Noradrenaline Administration Protocol

  1. I am after information on the administration and safety strategies in place for noradrenaline. As far as I am aware, noradrenaline must be administered to a central line (which in my state the giving set is bright orange coloured) with a three-way tap and must not be flushed with NS after use. So how do you check IV line patency if you can not flush the line?

    I understand the logistics of not flushing a noradrenaline line as doing so can cause a bolus of medication to the patient which can be life-threatening. Is there any literature on the flushing of noradrenaline lines? Or incidences of medication errors involving noradrenaline?

    At nursing school, we are taught to flush before and after giving an IV medication as a given. However, this is not the case with noradrenaline? Should I also not flush IV lines for other high-risk medications e.g. insulin infusions?

    Thanks in advance.
  2. Visit cazrella profile page

    About cazrella

    Joined: Jun '15; Posts: 6

    11 Comments

  3. by   Esme12
    Hi!

    Are you a nurse already? Are you in the US? Are you working in a hospital? Do they have a specific policy for the administration of drugs? Are you in a critical care area or emergency?
  4. by   Esme12
    Quote from cazrella
    I am after information on the administration and safety strategies in place for noradrenaline. As far as I am aware, noradrenaline must be administered to a central line (which in my state the giving set is bright orange coloured) with a three-way tap and must not be flushed with NS after use. So how do you check IV line patency if you can not flush the line?

    I understand the logistics of not flushing a noradrenaline line as doing so can cause a bolus of medication to the patient which can be life-threatening. Is there any literature on the flushing of noradrenaline lines? Or incidences of medication errors involving noradrenaline?

    At nursing school, we are taught to flush before and after giving an IV medication as a given. However, this is not the case with noradrenaline? Should I also not flush IV lines for other high-risk medications e.g. insulin infusions?

    Thanks in advance.
    Where I have worked we call it Norepinephrine or levophed. It is also, usually, administered via a central line...which would be a triple lumen/multilumen, Swan Ganz/pulmonary artery catheter. These lines are verified position by chest x ray and blood return.

    The care of these lines are dictated by hospital policy. The infusion of these medicines are also dictated by policy. As a general rule you do not "flush" these lines and are usually infused in a dedicated port where nothing else is infused to there would be no reason to flush for patency.
  5. by   Esme12
  6. by   cazrella
    Hi Esme12,

    I am a nursing student and thus do not have access to the hospital policies unless I am on placement. I am in Australia and focusing on the ICU setting.

    I am trying to find literature on this "general rule" that you do not flush a noradrenaline line. I do not feel there is enough safety measures and education about "accidental drug boluses". I have noticed elsewhere in the world, there are "do not bolus" IV line labels.

    We had an incident of an accidental noradrenaline bolus.

    I can not find much information about aspirating blood back from the IV line and reasons why we do this. If we are to finish a noradrenaline treatment (no more infusions), as we can't "flush" the line with NS we would aspirate blood back? This would allow us to check for patency and remove any blood clots? I have seen nurses do this as they have said they don't want to push meds through if they do not know what was in that line before.

    Thanks for your comments thus far.
  7. by   Esme12
    Quote from cazrella
    Hi Esme12,

    I am a nursing student and thus do not have access to the hospital policies unless I am on placement. I am in Australia and focusing on the ICU setting.

    I am trying to find literature on this "general rule" that you do not flush a noradrenaline line. I do not feel there is enough safety measures and education about "accidental drug boluses". I have noticed elsewhere in the world, there are "do not bolus" IV line labels.

    We had an incident of an accidental noradrenaline bolus.

    I can not find much information about aspirating blood back from the IV line and reasons why we do this. If we are to finish a noradrenaline treatment (no more infusions), as we can't "flush" the line with NS we would aspirate blood back? This would allow us to check for patency and remove any blood clots? I have seen nurses do this as they have said they don't want to push meds through if they do not know what was in that line before.

    Thanks for your comments thus far.
    If you check the links I gave you one of them is from Australia and Norepinepherine specific. If you had an "incident" of an accidental bolus that would indicate to me that you would have access to policies.

    In the US I have not seen "Do not bolus" labels. We do label lines with what they are infusing at the injection port to try to prevent accidental bolus. In the US when a drug is weaned A new bag and tubing are hung and replace the infusion at the same low rate (remember you have weaned the drug) and the infusion infuses at the last rate the Levophed was infusing.

    It is not necessary to check the patency of a central line during infusions. Here in the US we document at what point the line is secured and if that stays consistent you do not have to check for placement. Central lines are sutured into place. If there was an infusion infusing there is no danger of clotting (there is always a danger of clots with any invasive line but you do not have to routinely flush to prevent them.

    Not flushing/infusing into lines with vasoactive drips is one of those "known" facts that critical care nurses know. I am not sure what you are getting at.
  8. by   Dodongo
    Let's say you have a triple lumen IJ CVC. The distal lumen is transducing CVP, the proximal lumen is infusing levophed (noradrenaline, norepinephrine) and the medial is a lock. I would aspirate and flush the medial to ensure patency. Same with the distal, which if you have a cvp transducing, is easy with the pressure tubing. And the proximal lumen I would leave alone. I'm not going to stop the vasopressor, aspirate back, flush, and then restart the med. It would be unnecessary and the patient wouldn't tolerate it. Now, if you titrate the levophed down and can turn it off, then you disconnect the tubing from the CVC lumen, aspirate 5-10cc back and discard (so you don't bolus the patient with pressor), and then flush.
  9. by   Here.I.Stand
    Noradrenaline/Levophed is given as a continuous infusion, and yes you are correct -- it is given through a central line. First of all, central lines don't infiltrate like PIVs can, and they are sutured into the pt's skin. So once that xray verifies placement, it is in the proper place (unless of course the pt is confused and rips it out. Ouch!)

    You don't need to check for patency or administer routine flushes with a continuous running IV -- if the drug is running with no occlusion alarm from the pump, the line is patent. As with any drug, if the desired drip rate is very low, say less than 10 ml/hr, I set up a 2nd pump with NS running at 10 ml/hr, and then attach the med line to the port closes to the pt -- that way you don't run the risk of the line occluding. You routinely administer an NS flush through unused ports.

    When stopping a vasoactive drip such as noradrenaline, you're correct you don't want to bolus the pt with the drug that was resting in his line. So yes as you asked, we take an empty syringe and aspirate. Along with the blood, the drug that was still in the line is aspirated out and into that syringe. Syringe is discarded, and then you flush the port with NS as usual.
  10. by   cazrella
    No, I don't have access as I am no longer on placement.

    The "do not bolus" labels were mentioned pg. 10 https://www.nuh.nhs.uk/handlers/downloads.ashx?id=61025

    As you mentioned, IV lines (for continuous infusions?) should be labelled with the name of the drug. I wonder what the rationale for NHS was for implementing a "do not bolus" label in addition to a label with the drug name on the IV line.

    Okay, so CVC line patency does not need to be checked 8 hourly (or per shift) if there is an infusion running through it. And, if I was to titrate the noradrenaline down and end treatment, then I aspirate blood out and flush with NS after.

    What other medication should we also aspirate blood out (to prevent a drug bolus) when that lumen of the CVC is used again? All potent continuous IV infusions (high-alert drugs e.g. insulin infusions)? I have heard of cases in the literature where patients have received accidental drug boluses with lots of different medications.

    I am trying to implement a safety initiative to prevent incidents of NS IV bags for flushes being connected to the wrong IV lines e.g. connected to lines with high-alert drugs like noradrenaline.

    Thanks all.
  11. by   Esme12
    Again...I would not be familiar with what is done in the UK. That link you provided is very detailed I would think it would be a good reference for you. I am sure the DO NOT FLUSH was an initiative that was instituted after a serious drug error occurred.

    What we do here in the US isn't going to be useful for you for your project. Are you a student?

    Here we would wean the drug then (if fluid is not a problem) hang a plain IV at the last rate. If necessary and fluid needs to be stopped....yes we would remove (aspirate) 10mls of blood then flush according to hospital Policy and procedure.

    Here in the US critical care nurses are specially trained for these area. Our hospitals formulate their own policies for care of vasoactive and other titrated drips.
  12. by   iluvivt
    A few pieces of information provided are incorrect.A central line,any type can have a secondary malposition and is not as uncommon as you would think. One I see a lot of is a flip up into the ipsilateral Internal Jugular.At least that type is a vein and not extravascular!A blood return on a CVAD is a great sign that it is in a vessel but not a guarantee it is in proper position thus the necessity of a chest radiograph or the use of a tip verification system and frequent assessment for signs and symptoms of malposition.If you are infusing the Levophed and you are not meeting any resistance and not having any downstream occlusions then you just keep infusing and do not let bags run dry.
  13. by   Esme12
    Quote from iluvivt
    A few pieces of information provided are incorrect.A central line,any type can have a secondary malposition and is not as uncommon as you would think. One I see a lot of is a flip up into the ipsilateral Internal Jugular.At least that type is a vein and not extravascular!A blood return on a CVAD is a great sign that it is in a vessel but not a guarantee it is in proper position thus the necessity of a chest radiograph or the use of a tip verification system and frequent assessment for signs and symptoms of malposition.If you are infusing the Levophed and you are not meeting any resistance and not having any downstream occlusions then you just keep infusing and do not let bags run dry.
    In my second post I mentioned the necessity of a CXR
    Quote from Esme12
    Where I have worked we call it Norepinephrine or levophed. It is also, usually, administered via a central line...which would be a triple lumen/multilumen, Swan Ganz/pulmonary artery catheter. These lines are verified position by chest x ray and blood return.
    .

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