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Drug Delivery

Issues surrounding drug administration during critical care transfer.
Two syringe drivers without syringes are shown with the menue
© Dr Verity Blackburn, North Central London Adult Critical Care Transfer Service (NCL-ACTS) & Dr Soliana Bekele, North Central London School of Anaesthesia

Here we learn about the safe use of infusion devices in transfers and explore some of the issues that can arise with infusions during packaging and movement.

There are 4 types of system…

  • gravity feed
  • in-line piston
  • volumetric (peristaltic)
  • syringe drivers
A device suitable for delivering 100ml of saline per hour might not be suitable to deliver a fraction of noradrenaline per minute!
In practice, we use syringe drivers and volumetric pumps most commonly. Volumetric pumps are sensitive to the giving set diameter. Syringe drivers use different syringes with different bore sizes for the same size syringe, which affects infusion rate (drive rate mm/hr x syringe barrel cross sectional area) and so the driver must be compatible with the syringe.
Ensure you’ve had the training relevant to the pump system you’re using so you can correctly programme the infusion.
Resistance of the infusion system caused by filters, giving sets, anti-siphon and reflux valves, the cannulae and venous pressure itself has to be overcome for an infusion to be successfully delivered.
This equates to the device needing to generate normal infusion pressures of around 150mmHg in an adult and 50mmHg in neonates to deliver the infusion.
Remember your basic science – higher viscosity (e.g. propofol!), longer tubing lengths and higher infusion rates will all increase the pressure needed for drug delivery.
Learn more about the practical issues with infusions that you should be able to manage during transfer using this link

“Double-Pumping”

  • When transferring patients, you may have to switch an infusion from one syringe driver to another.
  • If the drug is short-acting, its effect may wear off during this transition. In the case of vasopressors, such as noradrenaline, this change could lead to a period of profound hypotension in highly-dependent patients.
This video demonstrates a technique known as “double-pumping”, which aims to prevent hypotension while switching syringe drivers

Controlled Drugs

Controlled drugs refer to medicines under special legislative regulation concerning their supply, handling and utilisation due to the potential for harm and misuse.
Using controlled drugs (CDs) between different hospitals, regions or even between countries is quite complicated. The rules and regulations are different in every country and laws have to be followed. Follow local legislation if you take controlled drugs into different countries.
In the UK, the Misuse Of Drugs Act 1971 provides a framework to regulate activities (including production, possession and supply) and classifies these drugs into three broad categories based on the potential level of harm if misused. – The Misuse Of Drugs Regulations 2001 has further outlined five schedules of drugs and the conditions which need to be met to supply these in a professional capacity.
The classification of drugs as controlled drugs differs from country to country, but in the UK most opiates and certain stimulants like ketamine fall under schedule 2 and are subject to full controlled drug governance. However, ketamine is not classified as a controlled drug in some countries like Tanzania, Kenya or Germany.

CDs In Transfer Practice…

The following is an example of good practice used in the UK but you should explore your own local policies and laws.
It is often under the remit of the referring hospital to ensure adequate CDs to cover the transfer, supplied from their stocks. Strict guidelines exist to ensure the secure execution of this process, largely directed by appointable officers within healthcare facilities and independent hospitals.
Commonly practised safety measures include:
  1. Restricted access.
  2. Meticulous documentation in consensus with at least two qualified healthcare professionals.
  3. Witnessed preparation immediately prior to administration.
Practitioners will routinely oversee the transfer of patients requiring administration of controlled drugs as part of their care. The practitioner leading the transfer should assume responsibility when taking custody of controlled drugs (infusions, pre-drawn syringes for emergency use and any spare ampoules) and this includes:
  1. Appropriate utilisation of these drugs under close observation at all times.
  2. Careful documentation on the transfer chart, including any boluses administered.
On reaching the receiving centre, any unused quantities should be carefully recorded then discarded – ideally witnessed by other members of the team and clearly documented
  • The receiving unit should continue administration of CDs as appropriate, in accordance with their own controlled drug policies, and will often prefer to prepare their own CD infusions from stock which can then be accurately documented in their records on site.
  • It is good practice to institute a system of incident reporting to highlight any untoward events.
  • Be aware of the limitations of the use of CDs in international travel which applies to the use in long haul transfers.
© Dr Verity Blackburn, North Central London Adult Critical Care Transfer Service (NCL-ACTS) & Dr Soliana Bekele, North Central London School of Anaesthesia
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