INS –India Announces 5th National Conference at Hyderabad
  • INS –India City Chapters 2016
  • Infusion Nurses Society-India Announces 5th National Conference
  • Best Practices in Peripheral IV Cannulation
  • Standards of Practice – Infusion Therapy
  • Contrast Extravasation- A Clinical Practice and Management
  • Policies, Procedures & Pharmacokinetics

INS India– Kerala Central Zone Chapter UDHYAN - 1st IV Nurse Leaders’ Summit 2016
AIMS- Kochi, 7th MAY 2016
UDHYAN - IV Nurse Leaders’ Summit 2016 held at Amrita Institute of Medical Sciences, Kochi is the first event organized by INS India– Central Zone chapter. It marked the beginning of new cycle of events by INS India – Central Zone chapter. The summit brought together 27 Nurse Leaders from various hospitals in and around Cochin.

The one day event was opened by Bri. Sai Bala Nursing Director, Governing Council Member and Member of Policy & Education Committee, INS-India. By welcoming the gathering she shared the journey of INS – India and the launch of INS India – Central Zone chapter.

Dr. Beena, Senior Administrator and Consultant in Public Health, in her inaugural address appreciated the efforts put forward by INS India in setting the bench marks in standards of Nursing. She stressed that Nursing is an integral part in NABH.

Mr. Sivaramakrishnan, in his motivational talk ‘Looking life differently’ discussed what is life, how to live happily and how to improve job environment. All the delegates found it interesting and interactive.

Plenary session started with the session on “Becoming a Change Agent” by Bri. Sai Bala, explained how she evolved as a leader and the challenges faced by her as a change agent.

Mrs. Soumya M. N., Clinical Nurse Specialist AIMS, detailed how to make and work as a team in Quality and importance of Audits. She also explained the activities undertaken by Nursing Quality Division in Amrita Institute.

Dr. Sanjeev K. Singh, Medical Superintendent –AIMS through his stress free hands on session made the most complicated quality improvement tools very palatable and easy for everyone to use it in their respective clinical settings.

Dr. Vasudev, BD India Ltd in his session on EPINET – a tool to standardize the NSI reporting, talked how effective is Epinet and how it can reduce the workload of ICNs in auditing and data analysis.

The afternoon was dedicated in interactive sessions such as IV complications – as a Quality Indicator, reporting and analysis by Sr. Berthlomea Nursing Superintendent, Lourdes Hospital in which the participants were divided in small groups to discuss. It was followed by the session “How happy are you as a Nurse Leader”, by Bri. Sai Bala, where she stressed on how to utilize opportunities and distributed self assessment questionnaires to assess the physical health, emotional health, personal well being, family health wellness, work place wellness, social health assessment and dharmic standards.

Bri. Sai Bala wrapped up by appreciating the effort put by everyone to organize and attend the session and wished everyone a better and happy life, and invited all for the second event of INS India- Central Zone, Kochi city chapter to be held in July 2016 at Lourde's Hospital, Kochi.
INS-India, Kerala Central zone Chapter Launch 2016
The INS India, Kerala Central Zone: Cochin City Chapter was conceptualised and a pre launch meeting was conducted on 7th November 2015 at AIMS, Cochin.

The Managing Council members for the chapter were selected. A brief introduction to INS India, its mission , vision and activities was done by Bri. Sai Bala, M, Nursing Director of AIMS. The Managing Council consists of Rev.

Sr. Berthlomea (NS-Lourdes Hospital. Cochin), Ms. Akanksha Dicholkar (Chief Nursing Officer-Aster Medicity, Cochin), Mrs. Shyni K. George (SNM- Renai Medicity, Cochin), Mrs. Visalakshi P. (DNO-AIMS, Cochin). The official launch of this chapter was planned to be conducted in Aster Medicity along with IV Nurses Day Celebration on 22nd January 2016.

A meeting of the Executive members was held on 4th DEC ’15 and fixed the activities for the year 2016. It is a great privilege to say that by the inauguration of “The Central Zone Cochin city chapter” KERALA has become the only state in India to have 2 INS CITY CHAPTERS. The day started with a poster competition (Theme: “Infusion Therapy is our passion”) participated by 9 hospitals, followed by a Quiz competition with participants from 10 hospitals. A total of 140 Nurses were present for the inauguration function representing around 18 hospitals from in-and –around Cochin City. The Central Zone Chapter was inaugurated at 3.00 pm by Smt. Prasanna Kumari (DDNE, Kerala State) followed by lighting of the lamp by all the dignitaries. The Chief Guest of the event Smt. Prasanna Kumari, DDNE, Kerala in her address, appreciated INS in its efforts towards training nurses and implementing best practices through establishment of standard practices in health care systems across India.

Bri. Sai Bala ( GC member, INS-India & Nursing Director, AIMS) in her address summarised the journey of INS so far and enlisted the achievements which are great milestones of nursing profession. She acknowledged and thanked the industry partners for taking initiative in bringing nursing experts together to build such a platform and supporting their great venture. Dr. Sanjeev K. Singh (Medical Director, AIMS) said that upgrading of nursing standards and providing quality care is the utmost priority in today’s health care system.

Other special dignitaries were Mr. Harish Pillai (CEO, Aster Group of Hospitals), Mr. Ramesh Kumar (COO, Aster Group of Hospitals), Ms. Akansha (Secretary- central zone Chapter & ND, Aster Medcity), Sr. Berthlomea (President –INS Central Zone Capter, Cochin & NS, Lourde Hospital).

The prizes for the Quiz and Poster Competions were also distributed. The first prize for quiz competition was secured by Lourdes Hospital, second by PVS Memorial Hospital, and third by Sunrise Hospital. For Poster competition first prize was bagged by Lourdes Hospital, second by KIMS Hospital and third by Amrita Institute of Medical Sciences.
Conference Highlights
INS-INDIA, the Infusion Nurses Society-India, An international affiliate of INS-US was formed in year 2010.
The vision is to exceed the public's expectations of excellence by setting the standard for infusion care, developing and disseminating standards of practice, providing professional development opportunities and quality education, advancing the specialty through evidence-based practice and research, supporting professional certification and advocating for the public, in alignment with the vision and mission of the Infusion Nurses Society - US.
NS- India 5th National Conference, Organizing Committee

Col. Binu Sharma
President, INS-India

Lt. Col. Saravjeet Kaur
General Secretary, INS-India

Shubhada Sakurikar
Organizing Secretory, INS-India 2016


Lt. Col. Anitha Philip
Organizing Committee, Hyderabad, INS-India 2016

Debra Joseph
Organizing Committee, Hyderabad, INS-India 2016

Meera Augustine
Organizing Committee, Hyderabad, INS-India 2016

Josephine Cyrill
Organizing Committee, Hyderabad, INS-India 2016

April 2012
1st National Conference, Bangalore

September 2013
2nd National Conference, Delhi

November 2014
3rd National Conference, Amrita Institute - Kochi, Kerala

October 2015
4th National Conference, National Library - Kolkata

More than 1000 professionals will gather together at this mega event of INS-INDIA 5th National conference. These two days will be exhilarating with educational sessions, competitions, exhibitions, interactive discussions and cultural event.

Professional development learn Infusion therapy best practices and clinical advance from the abstract posters and presentations.

Network with colleagues and Infusion Experts from across the country meet infusion professionals face-to-face, connect and learn from them at hands-on clinical sessions.

Standardization of practices in infusion therapy know about the set forth standards on best practices and developing patient-centered plans of care in order to provide safer patient care. Specially designed to assist you with challenges you face each day.

Industrial Exhibitions, Panel discussions, poster presentations, workstations, competitions and much more...

Make use of an opportunity to build your professionalism by participating in scientific sessions, activities etc.

INS –India offers you...

INS India is investing in creating a national data repository for:

  • "Infusion therapy complications"
  • "Occupational exposure to blood borne pathogens"

Infusion Nursing Standards of Practice

An invaluable guide for decision making and developing patientcentered plans of care in order to provide safer patient care.

Now available on Line
Log On to:

Membership Benefit:

  • Quarterly i-news
  • Access to website /E-courses/ e-library
  • Discount’s on scientific events, webinars, CME’s & many more...

E- Courses:

Infusion Therapy Basic Module - Being current and relevant is necessary in order to provide safe patient care.

Clinical Sessions

Key Note Presentations:

The evolution of INS - Past, Present & Future.
Launch of INS SOP 2016 – What is new for me?

General Sessions: IV Therapy Basics / Sharing Best Practices

The Journey to Standards of Practice, Core competencies for Infusion therapy to enhance healthcare outcome.

Platinum Showcases:

Additional educational opportunities during select hours of the meeting from industry experts provided by INS-INDIA Platinum corporate members.

Hot Topic Discussion: Infusion Therapy- Challenges / Managerial Issues

To address subject with current challenge, concerns with experts opinion through panel discussions.

Breakout Sessions: IV Therapy Advanced

Intended for all attendees who currently meet the infusion therapy needs of the specialty population viz. Pediatric, Oncology etc. with focus on safety, best practices and novel strategies to care for the unique need of these patient population.

Evidence Based Practices:

Scientific Paper Presentations [Four Best Papers will get opportunity to present].

Award Presentation:

Each year INS-India Announces Best Scientific Paper Presenters and Poster Competition.

Exciting Future Plan…
Online Registration Gateway Mobile APP
TOT- Certification Programme
INS-SOP Implementation Research Opportunity

Industry Exibition


Discover innovative products, emerging technology and scientific advances at the industries in the conference exhibit hall. While there, you can also stop by the INS membership booth. Meet with INS-INDIA Council Members at the INS booth to learn more about membership, Standards of practice Guidebook and voluntary participation.

Participate in Poster Competition & Scientific Paper Presentation
Send your Poster Design & Abstracts at E-mail:
For Participation Criteria Log on to: Website:


Best Practices in Peripheral IV Cannulation : Challenges and Impact

Sai Bala.M (MSN), Lakshmi Priya Ravi N (MSN), Sreeja Mohan (RN) Amrita Institute of Medical Sciences, Kochi

Peripheral intravenous cannulation is the most common procedure in any health care setting. Even though perceived as a safe method, several complications can arise from unsafe and improper practices. The risk is higher in pediatric population and more so in a cardiac surgical setting due to multiple physiological reasons related to age and cardiac conditions.

1. Aim
To identify the challenges and impact of implementing best practices in Peripheral IV Cannulation in Pediatric Cardiac Surgical Intensive Care Unit, AIMS, Kochi.

2. Methodology
This prospective study consisted observation of approximately 2500 total IV placements among patients in Pediatric Cardiac Surgery Intensive Care unit with bed strength of 11 over a period of three years from August 2012 to July 2015. Data was collected on individual cannulation, resulting complications and analyzed quarterly and yearly to find out areas for improvement. We followed the FADE model of Quality improvement.

3. Results
Goals were set for every year, taking one or two challenges to be addressed at a time. Important findings observed in quarterly analysis paved way to establishing guidelines and changes in practices.

3.1 2012 August to 2013 July

  • Demand for focused attention to IV line maintenance
  • Under reporting and hesitation to report
  • Nurses incompetent to discriminate the stages of phlebitis
  • Difficulty in completing the Peripheral IV complication reporting form Goal
  • Goal improve incident reporting and building awareness through education


  • Nurse in charge took up the role of IV champion as the institutional IV team became active
  • Session on Hospital Incident reporting system in Orientation program was modified to include the need and importance of prompt reporting
  • IV cannulation workshops started once in a month
  • Revised Peripheral IV complication form to make reporting easier and comprehensive
  • Auditing by IV team


  • Only one late in 7 incidents reported between Aug 2012- Aug 2013, (no late reporting there after)
  • Phlebitis Stage I – 1 in 2
  • Phlebitis Stage II – 1 in 2
  • Infiltration reporting started -5
  • Better identification of complications (infiltration vs extravasation)
  • IV audit for best practices: 2013 first half 95%

3.2 2013 August to 2014 July

  • Complications while administering high risk medicine (Milrinone and Dobutamine)
  • Maintenance fluid was started before morning care without flushing resulting in infiltration
  • Identified need for mandatory certification program to be made as a part of Orientation program


  • Identify areas for improvement


  • Mandatory carrier fluid along with high risk medicines
  • Central lines retained for TPN, Cordarone and potassium
  • Femoral lines for hypertonic solution in absence of central line
  • Emphasized the importance of flushing practices before morning care
  • Auditing by IV
  • Mandatory IV Cannulation certification program with skill training


  • No error or late reporting
  • Phlebitis Stage I – 1 in 2
  • Phlebitis Stage II – 1 in 2
  • Infiltration Stage I – 4 in 6
  • Infiltration Stage II – 2 in 6
  • IV audit for best practices 2013 second half -96%
  • IV audit for best practices 2014 first half -100%


  • Monitoring standards of practice
  • Encouraging and facilitating feedback
  • Tracking all IV placements
  • Measuring the effectiveness of IV workshop


  • Ensuring use of transparent dressing at all levels
  • Established feedback system for addressing issues related to materials used in IV therapy
  • Appreciation letters for prompt feedback and appraisals of issues
  • Product change, 3 way extension replaced by bifusate
  • Distributed posters on IV cannulation sites
  • Mandatory bed side IV audit in each shift
  • Well established data tracking system for all peripheral IV cannulation
  • Analysis of effectiveness of certification program by pretest and posttest comparison


  • IV audit for best practices:
    • 2014 second half- 96%
    • 2015 first half- 97.5%
  • Early identification and prompt reporting of complications
  • Phlebitis Stage I – 2 in 3
  • Phlebitis Stage II – 1 in 3
  • Infiltration Stage I – 4 in 4
  • 100% nurses working in the unit were certified in IV Cannulation program
  • Mean difference between pretest score and post test score of 37 nurses from the unit was 8.19 , paired t test showed a t value of 18.12 with a two tailed p value <0.0001 indicating highly significant improvement

4. Implications

  • Structured, focused and continuous training is key in maintaining best practices
  • Audit and feedback reinforces best practices
  • Best practices reduces the complication resulting in reduced cost of care, length of stay, patient and parent discomfort and distress
  • Empowered nurses facilitate implementation of change and introduction of innovative ideas

5. Conclusion
Though implementation and sustenance of best practices is a challenge, it is not unachievable. An interested team of enthusiastic nurses can foster change to positively influence patient care outcomes through collaboration and team work.

6. References

  1. INS. (2011). Infusion Nursing Standards of practice. Infusion Nurses Society. Massachusetts. USA.
  2. INS. (2014). Infusion Nursing Standards of practice. Infusion Nurses Society. India.

Standards of Practicet

Michelle Berreth, RN, CRNI, CPP
Nurse Educator: INS-US

Standards of practice along with scope of practice, code of ethics, regardless of practice setting. Standards of practice, not to be confused with standards of care, “focus on the provider of care and clearly state the acceptable levels of practice in patient care delivery”.

The Foundation of Professional Nursing

The origins of nursing standards of practice likely began with Florence Nightingale. She believed that "well educated women, using scientific principles ... could dramatically improve the care of sick patients," Nightingale kept detailed records of the results she observed when patients received care from trained nurses. She continually analyzed data and was able to show a significant drop in the mortality of injured and sick soldiers who received "standardized care."

Also known as the "Lady with the Lamp: Florence Nightingale taught nursing with the intention that graduate nurses would "teach nursing to the entire world" Over the next several years, training programs and schools for nursing increased. Hospitals provided the setting for many of the schools, where students were expected to work in exchange for an education. Having students provide care saved hospitals money.

Clinical experiences were limited, related either to the size of the hospital or the specialty, e.g., sanatoriums for tuberculosis or state mental hospitals." The length of training programs ranged from several months to three years; there were no standards regarding the education of professional nurses. This lack of standardization resulted in the formation of one of the first national organizations related to nursing. The American Society of Superintendents of Training Schools of Nursing was charged with the task of "elevating the standards of nursing education." The association continues its work to this day as the National League for Nursing. In the late 1800s, 90 percent of people in the United States who cared for the sick did not receive much, if any, hospital training. Concerned for public safety, as well as the image of nursing, nurse leaders of the time sought to unify nurses in an effort to bolster the nursing profession. The Nurses' Associated Alumnae of the United States and Canada, now known as the American Nurses Association (ANA), was organized "with the intent of achieving licensure for nurses." In addition to nurse licensure, ANA's goals included the "establishment of a code of ethics, promotion of the image of nursing, and provision of attention to the financial and professional interests of nursing,"! Individual states formed their own nursing associations that contributed to the passage of nurse registration acts. Nursing practice could now be regulated and a code of ethics and scope of practice established, and nurses received a license and the title of registered nurse."

Building on the Foundation
Another important part of the foundation of the Model of Professional Nursing Practice Regulation' is standards of practice. ANA established standards of professional nursing practice and describes them as follows:
". .. a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process. The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. Accordingly, the nursing process encompasses significant actions taken by registered nurses and forms the foundation of the nurse's 7 decision - making. "

ANA's standards of nursing practice apply to all nurses across all practice settings, defining "criteria relative to nursing accountability and professional competency' The standards are the foundation each nurse uses to develop and build a strong personal and professional practice. Standards of nursing practice, just as the practice of nursing itself, constantly change and are remodeled based on research, legal guidelines, and evidence affecting nursing practice. Continuing nursing education, maintaining competencies, and seeking professional certification demonstrate that "nurses, individually and collectively, are responsible and accountable for their practice" Specialty nursing organizations, such as INS, speak "for nurses and nursing, based on their mission and vision statements that are specific to their specialty interests, goals, and purposes." Many nursing organizations develop and maintain standards of practice specific to their specialty. INS' most recent revision of the Standards supports a piece of its mission statement of "developing and disseminating standards of practice."

At the beginning of this article, it was noted that standards of practice "focus on the provider of care and clearly state the acceptable levels of practice in patient care delivery'? The focus for standards of care is the recipient of the care, the health care consumer, the patient. According to The Joint Commission, "standards of care must be developed within the (health care) organization." Standards of care are statements of outcome, or what the end results of patient care should be.

These standards, which contribute to an organizations policies and procedures, vary from location to location. Standards of practice often contribute to the development of standards of care.

With a focus on evidence-based practice, safety, and quality, the standards of practice developed by ANA provide a solid foundation for the profession of nursing. The Standards developed by INS adds to this foundation, providing the specialty of infusion nursing with materials to build a nursing practice that exceeds “the public's expectations of excellence by setting the standard for infusion care”.

6. References

  1. American Nurses Association. Model of professional nursing practice regulation. http://w'-A' Accessed December 15,2015.
  2. Alexander M, Corrigan A, Gorski L, Hankins J. Perucca R, eds. Infusion Nursing: An Evidence-Based Approach. 3rd ed. St. Louis, MO: Saunders Elsevier; 2010:32.
  3. Britannica Online Encyclopedia. Nursing. Accessed December 15, 2015.
  4. Hood L. Leddy & Pepper's Conceptual Bases of Professional Nursing. 8th ed. Kansas City, MO:Lippincott Williams & Wilkins; 2014:41,490.
  5. Egenes KJ. History of nursing. http://www.jblearning.comf samples/0763752258/52258_chOl_roux. pdf. Accessed December 15, 2015.
  6. The history of nursing as a profession. Villanova University. the- history-ofnursing-as-a- profession/a. VnBblsmPMok.
    Accessed December 15, 2015.
  7. American Nurses Association. Nursing: Scope and Standards of Practice. 2nd ed. Silver Spring, MD:; 2010:8-9.
  8. Matthews JH. Role of professional organizations in advocating for the nursing profession. Online J Issues Nurs. 2012; 17( 1). viewarticle/766817 _print. Accessed December 14, 2015. Login needed for this reference.
  9. Infusion Nurses Society. Mission, values. bylaws. http:/hlfWl.v,insl.orgIi4a/pages/index.cfm?pageid=3763.Accessed December 30, 2015.


Contrast Extravasation, A Clinical Practice & Management

In CT department, various types of patients comes for scan every day, such as brain, neck, chest, abdomen/pelvis angiograms, liver, peripheral angiograms. Among these patients, some may have undergone chemotherapy whose vein are very fragile and thrombosed. There are two ways of injecting contrast in the body:

  1. Manual- where contrast is given by hand
  2. Mechanical-where the power injector will inject contrast with certain pressure, according to patient’s weight. When this contrast is being injected in the fragile vein at a high pressure, the movement can cause extravasation which is very painful.

Mode of infusion of contrast:
Contrast should be injected through peripheral & central line since the contrast has high Osmolarity than blood. It should be given through proper gauge cannula. Contrast should not be given through Hickman’s catheter or port line, as it may block the opening of catheter and or extravasation can happen.

Contrast Extravasation:
Contrast extravasation is the accidental extravascular injection of intravascular contrast media caused by dislodgment of the cannula, contrast leakage from the vessel puncture site, or rupture of the vessel wall. Contrast extravasation is a well-recognized complication, with reported frequencies of 0.25% (56/22,254), 0.7% (475/69,657) and 0.9% (48/5,106) in three large CT series where power injectors were used. Extravasation usually causes some combination of immediate pain, erythema, and swelling, but fortunately these are usually self-limiting. However, severe skin and subcutaneous ulceration can occur, and subfascial extravasation may cause compartment syndrome (neurovascular signs and symptoms due to increased volume in the confined spaces formed by the deep fascia). These major complications may occur even with small volume (< 10cc) extravasations and non-ionic contrast media. Research shows that contrast extravasation is a rare problem that occurs in less than 1% of patients, and very rarely patient requires surgical intervention like fasciotomy for compartment syndrome.

Risk Factors and Prevention:
Small children, the elderly, and unconscious patients are at higher risk for extravasation, partially because of reduced reporting of injection site pain. Other risk factors are use of an injection site other than the antecubital fossa, use of an indwelling venous cannula that has been in place for over 24 hours, and multiple attempts at venous access. When extravasation does occur, complications are more severe in extremities with poor vascular or lymphatic circulation (e.g., on the side of a prior mastectomy with radiation or lymph node dissection) or when extravasation occurs on the dorsum of the hand or foot. Based on these considerations, and realizing that prevention is the key to avoiding contrast extravasation, the following practice guidelines are suggested:

  • Ensure the IV site is properly selected, placed, secured, and tested. Make sure the vein is not obstructed when repositioning the arm.
  • Consider a lower flow rate in patients at particular risk (while high flow rates do not seem to increase the risk of extravasation, they while result in a more rapid accumulation of extravasated contrast).
  • Warn the patient to report any unusual sensations at the IV site immediately.
  • Observation of the IV site by the technologist for the first 10-20 seconds of the injection.
  • STOP the injection if there is ANY concern or question of extravasation.
  • Below Documentation to be filled by Contrast Injector.

Contrast Agent Date and time Amount of contrast extravasated Amount of saline extravasated Site of extravasation

As soon as we see swelling or pain during the injection of contrast stop injection immediately try to aspirate it as much as you can and remove the I.V. line, do the proper dressing and apply ice pack, and inform the overseeing radiologist.

Immediately put ice pack on it, if the swelling is persistent, then MgSO4 dressing should be applied for certain period and elevation of hand should be done.

Wait and watch: if pain is persistent then analgesic and antibiotic should be administered as per physician’s order.

Advice patient for follow up after a week, if required.

  • If pain and swelling is persistent then refer patient to plastic surgery.
  • Check and ask patient to report any complication like blister formation discoloration of skin,tissueperfusion and changes of sensation.
  • It may lead to necrosis.

Patients with extravasation should be assessed and reassured, and referred to the Emergency Department if there is skin blistering, altered tissue perfusion, increasing pain, or change in sensation distal to the site of extravasation.

Scenario: Contrast Extravasation at CT department
A 44-year-old female was referred for contrast-enhanced CT. A catheter was placed into a vein in the metacarpal site, and approximately 50 mL of nonionic low-osmolar contrast medium was injected using a power injector. The patient complaint of pain after the injection, and the site of the injection was noted to be swollen and tender. The contrast medium has been extravasated into the skin and subcutaneous tissues around the injection site. An observation supported by the visible protrusion at site catheter placement. After observation from radiologist and further assessment, there was no risk of compartment syndrome, and immediate intervention was followed as per hospital protocol and swelling subsequently reduced over period of time. Patient has been sent home and advised for further follow up by the radiologist. The incidental documentation and reporting was required in this case.

So one has to be very careful while inserting an I.V. line; that it should be properly placed. One cannot take it easy. “This develops with the skill. Skill develops by practice and practice makes you perfect” in I.V. cannulation. Updating the knowledge and skill becomes important aspect of a nurses career hence participation in organizations/associations like Infusion Nurses Society - INS is very important!

Policies, Procedures, and Pharmacokinetics

Michelle Berreth, RN, CRNI, CPP
Nurse Educator: INS-US

There has been a noticeable questions regarding the policies and procedures. Common questions mainly pertain to obtaining the samples and interpreting the results. To answer those questions, a basic understanding of pharmacokinetics is helpful. This article will discuss aspects of IV drug pharmacokinetics that are relevant to infusion therapy, as well as how these aspects help ensure patients receive the most benefit from the IV medication.

The reasons for monitoring the amount of medication in a patient's system have evolved over the years. In the 1960s, studies of how medications were distributed, absorbed, metabolized, and excreted by the human body fueled the new clinical practice of therapeutic drug monitoring. At that time, pharmacokinetic studies introduced a connection 2 between “mathematical theories to patient outcomes:”

Pharmacokinetics and Infusion Therapy
Three aspects of pharmacokinetics are applicable to infusion therapy: drug distribution, therapeutic index, and plasma concentration. Drug distribution refers to the movement of an IV medication from the blood into the tissues of the body. In order for medication to have a therapeutic effect, it needs to reach the receptor site, the place where the drug performs its action. The time it takes for the drug to reach the tissue and appropriate receptor sites is dependent on how fast the blood can reach the tissue, how much tissue there is, and the permeability of the blood to the tissue. Once the amount of medication administered is equal to the amount eliminated, the medication has reached a "steady state." Plasma concentration represents this equilibrium between tissues and plasma.

Therapeutic index indicates a range in which an IV medication produces the desired therapeutic effects, but is not high enough to be toxic. Every medication has its own range, even within the same category of drugs.

Plasma concentration provides a snapshot of the amount of medication in the plasma at any given time. A sample of blood obtained 30 to 60 minutes after administration of an IV medication will provide the highest level, or peak, of the medication at that time. A trough level is the lowest level of the medication. It is obtained just before the administration of the next dose of medication. Not all medications have the same requirements for peak and trough times. Be sure to follow your organization's policies and procedures or guidelines.

Factors Affecting Drug Monitoring and Interpretation
Various factors can affect the accuracy of drug monitoring, which, if inaccurate, can lead to inappropriate dosing of the IV medication.

  1. Each patient is different, and the differences influence various aspects of pharmacokinetics. Factors to consider include body surface area, gender, age, clinical status, and comorbidities.
  2. Timing of IV medication administration and blood sampling. In care settings with a laboratory available, communication between nursing and laboratory technicians is imperative to accurate blood sampling. Blood draws must be rescheduled when the administration of medication late or missed. A specimen obtained at the wrong time can lead to erroneous results. According to Kang and Lee, “Errors in the timing of the sample are likely responsible for the greatest number of errors in interpreting the results.”
  3. Blood samples obtained through central vascular access devices (CVADs). Before collecting a blood sample through a CVAD, review the risks and benefits of the procedure. Venipunctures cause increased patient anxiety if the patient has difficult vascular access, especially when frequent testing is required. However, samples obtained from a CVAD increase the risks associated with bloodstream infections and occlusion. Review results of lab tests carefully when samples and medication are drawn or given by means of the same CVAD. A venipuncture may be needed to verify results that lead to a dose change,”

Implications for the Infusion Nurse
Monitoring therapeutic levels of IV medications contributes to the best outcomes for the infusion therapy ordered. In addition, the clinical assessment and critical thinking skills of the infusion nurse help ensure the results of laboratory testing are as accurate as possible by:

  • Understanding how pharmacokinetics affects patients receiving IV medications.
  • Monitoring the patient's therapeutic response to the therapy.
  • Administering IV medications on time, and notifying laboratory technicians if the timing of lab work changes.
  • Using best practice when obtaining blood specimens from a CVAD.

And that brings us back to the original question: What are the policies and procedures for obtaining blood samples to monitor IV medications? Ultimately, the organization you work for develops and maintains policies and procedures, and you are responsible for following them. As the infusion nurse, you should be an active participant in the development and/or review of the policies. The policies and procedures reflect your state Board of Nursing's scope of practice, as well as the competencies required to perform the procedures and standards of 5 practice applicable to your nursing practice. To help ensure your patients receive the most benefit from their infusion therapy, communicate and collaborate with the pharmacy and laboratory departments, as well as the licensed independent practitioner.


  1. Ratain MJ, Plunkett WK Jr. Principles of pharmacokinetics. In: Kufe DW, Pollock RE, Weichselbaum RR, et al, eds, Holland-Prei Cancer Medicine. 6th ed. Hamilton, ON: Be Decker; 2003. http://w' Accessed September 30, 2015.
  2. Kang IS, Lee MH. Overview of thera- peutic drug monitoring. Korean J Intern Med. 2009;24(1}:1-10. doi:10.3904! kjim.2009.24.l.L
  3. Ladell LM, TenniesSA. Pharmacology applied to infusion therapy. In: Weinstein SM, Hagle ME eds. Plumer'sPrinciples and Practice of Infusion Therapy. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2014:532, 534.
  4. Le J. Drug distribution to tissues. Merck Manuals. http://www.merckmanuals. comI professionalJ clinicalpharmacology! harmacokinetics/drug-distribution- to-tissues. Updated May 2014. Accessed September 2015.
  5. Infusion Nurses Society. Infusion nursing standards of practice, J lnfusNun. 2011;34(suppll): S57 A,C.

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5th & 6th Floor, Signature Tower B,
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INS India’s Family Just Going Bigger!!!
A hearty welcome to all new members

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Ajitha P. S. | Dr. Annu Kaushik | Linta Issac
Nikita Mokal | Ujwala Raj Pal

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