Limited intravenous access is a common conundrum in the Emergency Department, with heavy implications for medication administration. Of particular concern, are the profoundly septic patients that necessitate multiple timely therapies, which require tying up a line – fluids, pressors, several antibiotics, etc. The shift away from less central line (i.e. triple lumen) placement for initial resuscitation, may serve to further exacerbate this issue.

The Problem

Since most of these septic patients will require more than one antimicrobial for empiric coverage, the exact timing of therapy and desired order of administration are details that may not be adequately communicated. How many times have you noticed after ordering vancomycin and cefepime, that vancomycin has been administered first, allowing several hours to go by without having received that broad-spectrum, gram-negative coverage with cefepime?

Despite these challenges, the Surviving Sepsis Campaign (SSC) guidelines currently recommend administration of appropriate empiric antibiotics within 1 hour after recognition of severe sepsis.1 This is largely based upon a retrospective analysis of 2,731 patients with septic shock, which demonstrated that administration of effective antibiotics within the first hour of documented hypotension was independently associated with increased survival to hospital discharge.2 Currently however, a lack of guidance exists regarding the best way to achieve this important aspect of the resuscitation bundle.

Trick of the Trade – IV Push Antibiotics

Administration of antibiotics via intravenous push (IVP) may be one approach to hasten antibiotic administration without tying up lines. Additionally, while communicating the desired order of administration is still important, when faced with limited IV access, nurses may be more inclined to initiate the IVP antibiotic first, due to shorter administration times. Further, IVP administration of antibiotics may be a more economically beneficial alternative as compared to more common methods.3 Through cost avoidance of both pharmacy preparation and nursing administration time, as well as eliminating the need for minibags and IV tubing, one study estimated savings of $184,000 per year.4

Listed below are various antibiotics that have been shown to be safe when given as an IVP to adults:5–8

Antibiotic Concentration*, Diluent Rate of Administration Osmolality (mOsm/L)** Cefazolin 1 g/10 mL, SWFI 1-2 min 340 Cefuroxime 750 mg/10 mL, SWFI 1-2 min 447 Cefoxitin 1 g/10 mL, SWFI 2-4 min 525 Cefotaxime 1 g/10 mL, SWFI 1-2 min 440 Ceftriaxone 1 g/10 mL, SWFI 1-2 min 423 Ceftazidime 1 g/10 mL, SWFI 1-2 min 435 Cefepime 1 g/10 mL, SWFI 2-4 min <400 Meropenem 1 g/10 mL, SWFI 3-5 min <500 Aztreonam 1 g/10 mL, SWFI 2-4 min 487 SWFI, sterile water for injection; * The concentrations stated above do not necessarily represent recommended doses; these should be used to determine the volume required for higher/lower doses (e.g. cefepime 2 g/20 mL SWFI) ** Substances with an osmolality less than 600 mOsm/L are generally acceptable for administration via a peripheral line9

Important Considerations

When implementing IVP antibiotics in your ED, standardize the process . This may require substantial changes in nursing practice, updating policies and procedures, departmental education, adjustments to electronic order sets, adjustments to product stocking and inventory, as well as implementing oversight for unforeseen adverse effects

. This may require substantial changes in nursing practice, updating policies and procedures, departmental education, adjustments to electronic order sets, adjustments to product stocking and inventory, as well as implementing oversight for unforeseen adverse effects It is important to note, that the use of sterile water for injection (SWFI) is to help minimize osmolality; reconstituting with NS or D5W may produce significant phlebitis, and increase the risk for extravasation injury. Read more information (extravasation injuries PDF) on this topic.

As with any IV preparation, remember to properly label your syringe. Refer to Dr. Bryan Hayes’ post on The Art of Syringe Labeling in the ED.

Beta-lactam antibiotics are often administered as prolonged infusions in order to take advantage of their pharmacokinetic/pharmacodynamic profiles (T > MIC). However, this is usually employed for subsequent maintenance doses, and is also not practical for initiation in the ED. Moreover, time to administration of the initial dose is a more important factor in septic patients.

The literature used to support the aforementioned IVP antibiotics did not include pediatric patients. Therefore, the safety and feasibility of implementing this practice within the pediatric population is uncertain.

Take-Home Points

Various beta-lactam antibiotics may be safely administered via IVP.

IVP administration may be one strategy to help facilitate timely administration of antibiotics, and to prevent tying up multiple lines.

To date, no published literature exists to support the potential benefits (i.e. improved time to administration; improved outcomes) of IVP antibiotics in the Emergency Department; future studies are warranted.

References

1. PubMed] Dellinger R, Levy M, Rhodes A, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med. 2013;39(2):165-228. 2. PubMed] Kumar A, Roberts D, Wood K, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34(6):1589-1596. 3. PubMed] Ambrose P, Quintiliani R, Nightingale C. Pharmacoeconomic analysis of administration of famotidine i.v. push vs.intermittent slow i.v. infusion. Ann Pharmacother. 1997;31(5):645. 4. PubMed] Garrelts J, Smith D, Ast D, Peterie J. A comparison of the safety, timing and cost-effectiveness of administering antibiotics by intravenous bolus (push) versus intravenous piggyback (slow infusion) in surgical prophylaxis. Pharmacoeconomics. 1992;1(2):116-123. 5. PubMed] Norrby S, Newell P, Faulkner K, Lesky W. Safety profile of meropenem: international clinical experience based on the first 3125 patients treated with meropenem. J Antimicrob Chemother. 1995;36 Suppl A:207-223. 6. PubMed] Garrelts J, Wagner D. The pharmacokinetics, safety, and tolerance of cefepime administered as an intravenous bolus or as a rapid infusion. Ann Pharmacother. 1999;33(12):1258-1261. 7. PubMed] Nowobilski-Vasilios A, Poole S. Development and preliminary outcomes of a program for administering antimicrobials by i.v. push in home care. Am J Health Syst Pharm. 1999;56(1):76-79. 8. PubMed] Garrelts J, Ast D, LaRocca J, Smith D, Peterie J. Postinfusion phlebitis after intravenous push versus intravenous piggyback administration of antimicrobial agents. Clin Pharm. 1988;7(10):760-765. 9. Intravenous Nurses Society. Position paper: midline and mid-clavicular catheters. J Intraven Nurs. 1997;20:175-178.