Intravenous medicines

Last updated: Wednesday, March 23, 2016

The intravenous route provides a rapid way of administering drugs, fluids, blood products and parenteral nutrition. There are two basic methods:

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1.  Direct intravenous injection is the administration of a small volume of drug solution into an entry port sited in a vein such as a cannula or 'Venflon'. Direct injections can also be made via existing IV infusion administration lines (or ‘giving sets’). The technique of direct injection is sometimes called an ‘IV push’. The term ‘bolus’ is widely used but should be avoided as it implies that the injection can be given instantly over a few seconds, whereas most direct injections should normally be given over 2 to 5 minutes.

Direct injection gives therapeutic levels of a drug quickly (e.g. glucose 50% injection for hypoglycaemia), but there can be problems with this technique. For example, direct injection may damage a vein, particularly if the drug is irritant (e.g. phenytoin). In addition it is impractical if a drug needs to be given slowly or in a large volume.

2.  Infusion. This involves IV administration over a longer time period often using bigger volumes. Plastic tubing (‘IV line’ or ‘giving set’) connects the bag or syringe of drug solution to an entry point in a patient’s vein. The infusion may be intermittent (e.g. metronidazole 500mg in 100ml saline over 20 minutes every eight hours) or continuous over 24hours. Continuous infusion is indicated for drugs with a short half-life (e.g. glyceryl trinitrate) or when a constant therapeutic drug level is required (e.g. insulin). Infusions require a drug to be stable in the specified diluent for the duration of administration. They also require the drug to be compatible with the plastic used to make the IV line and infusion bag.

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The choice of intravenous administration method depends on the drug (e.g. indication, volume of infusion fluid, rate of administration, degree of irritancy, pharmacokinetics) and patient factors (e.g. age, availability of IV access, concurrent disease such as presence of heart failure). Some drugs may cause pain on injection because of their tonicity, pH or irritancy (e.g. erythromycin). The vein may become red and inflamed; this is called phlebitis.

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A Y-site is the point where two IV lines containing drug solutions join to run down the same line forming a ‘Y’ shape. One infusion may be described as being ‘piggybacked’ onto the other.

Intravenous injections and infusions may be given via peripheral or central veins. Peripheral lines are usually inserted in the hand or arm. They can become blocked or dislodged easily and, because the veins are quite narrow, they are not usually used for irritant drugs (e.g. amiodarone), concentrated solutions in fluid-restricted patients (e.g. potassium) and vasoconstricting drugs (e.g. epinephrine). Central lines are preferred for these situations and are inserted into larger veins such as the superior vena cava. Central lines can be used for any intravenous medicine.

Thrombophlebitis is a painful inflammation and swelling of the veins with a number of causes, including the administration of IV medicines. Preparations that are particularly liable to cause thrombophlebitis include those that are irritant, at extremes of pH, or with a high osmolarity. Many of these would ideally be given centrally, but often need to be given peripherally. In this situation, the peripheral line should go into as big a vein as possible – i.e. not a peripheral cannula placed in a small vein in the back of a hand.

Common clinical problems

  • The rate of administration of a drug (e.g. phenytoin).
  • The volume and infusion fluid that a drug needs to be diluted in (e.g. vancomycin).
  • How to administer an IV drug in fluid restricted patients (e.g. potassium).
  • Choosing between a peripheral or central intravenous line (e.g. dopamine, amiodarone).
  • Mixing drugs in the same syringe, bag or line (e.g. cefuroxime and metronidazole)