What is the proper protocol for administering an IV (intravenous) push?

IV Push Administration Protocol

For most medications requiring IV push administration, inject slowly over 2-5 minutes through a patent IV line, followed by a saline flush, with continuous monitoring of vital signs and immediate access to emergency equipment. 1

General Administration Technique

Pre-Administration Requirements

• Verify IV line patency before administering any IV push medication to prevent extravasation injuries 2
• Use the most proximal IV site available when administering medications requiring rapid onset (e.g., adenosine) 1
• Establish continuous ECG monitoring for any medication with cardiac effects 1
• Have emergency equipment and defibrillator readily available at bedside 1, 3

Standard Push Technique

• Administer most medications slowly over 2-5 minutes to avoid transient excessive blood concentrations and adverse effects 1, 4
• Follow with immediate saline flush of 5-20 mL depending on patient size and medication (larger flush volumes up to 20 mL may be needed in older children/adults) 1
• Use a 2-syringe technique when rapid administration is critical—one syringe with medication, one with flush 1

Medication-Specific Protocols

Ultra-Rapid Push (Adenosine)

• Administer as rapidly as possible (over seconds, not minutes) followed by immediate rapid 5-20 mL saline flush 1
• This is the exception to slow administration—rapid delivery is required for efficacy 1

Standard Rapid Push (5 minutes or less)

• Midazolam: Order every 5 minutes as needed 1
• Fentanyl: Order every 5 minutes as needed 1
• Calcium gluconate: Administer over 5-10 minutes for most indications 1, 2
• Metoprolol: 2.5-5 mg IV bolus over 2 minutes, up to 3 doses 1, 5

Moderate Push (Over 2-5 minutes)

• Morphine/hydromorphone boluses: Order every 15 minutes as needed 1
• Diltiazem: 15-20 mg (0.25 mg/kg) IV over 2 minutes 1, 3
• Verapamil: 2.5-5 mg IV over 2 minutes 1

Slow Push/Short Infusion (Over 20-60 minutes)

• Amiodarone: 5 mg/kg over 20-60 minutes when patient has perfusing rhythm (rapid push only during cardiac arrest) 1
• Calcium gluconate: Infuse over 30-60 minutes for non-emergent hypocalcemia 2
• Phenytoin/fosphenytoin: Slow infusion necessary to minimize adverse events 1

Critical Safety Considerations

High-Risk Medications Requiring Central Access

• Calcium gluconate should be administered through central venous catheter when possible to prevent severe skin and soft tissue injury from peripheral extravasation 2
• Sustained infusions of concentrated dextrose (>10%) require central venous access 1
• Sustained calcium infusions require central venous access 1

Monitoring Requirements During Administration

• Continuous ECG monitoring for all antiarrhythmics, calcium, and medications affecting cardiac conduction 1, 2
• Frequent blood pressure measurement for vasodilators (calcium channel blockers, beta-blockers) 1, 3
• Monitor for hypotension which may occur 1-3 hours after administration of certain medications like diltiazem 3
• Serum ionized calcium monitoring during calcium infusions, avoiding levels greater than twice upper limits of normal 1, 2

Common Pitfalls to Avoid

• Never mix diltiazem with other drugs in the same container or co-infuse in the same IV line due to physical incompatibilities with multiple medications including acetazolamide, acyclovir, aminophylline, ampicillin, diazepam, furosemide, phenytoin, and sodium bicarbonate 3
• Avoid first-generation antihistamines (diphenhydramine) for infusion reactions as they can exacerbate hypotension, tachycardia, and shock 1
• Do not administer vasopressors through peripheral lines when central access is available, as some medications (calcium, amiodarone, procainamide, sympathomimetics) may be irritating 1
• Protect airway before administering glucagon in patients with CNS depression, as vomiting is common 1

Preparation Standards

Aseptic Technique Requirements

• Use aseptic technique for all medication preparation including reconstitution, compatibility assessment, and labeling 4
• Inspect all parenteral products visually for particulate matter and discoloration before administration 3
• Verify compatibility (physical, chemical, and therapeutic) before mixing or co-administering medications 4

Dilution Errors Prevention

• Dilutional errors during preparation cause 83% of major overdoses with push-dose vasopressors 6
• Use standardized concentrations rather than weight-based calculations when possible to reduce medication errors 1
• Double-check high-potency drug calculations (prostaglandins, vasoactive amines, nitroprusside, fentanyl) which are dosed in micrograms per kilogram 1

Efficiency Considerations

Time to Administration

• IV push reduces time to administration by approximately 70 seconds compared to IV piggyback for vasopressors 6
• Median time from order verification to administration: 12-35 minutes for IV push versus 38 minutes to 1 hour 49 minutes for IV piggyback 7, 8
• This time reduction is clinically significant in status epilepticus and acute seizure management 8

When IV Push is Preferred

• Emergency situations requiring rapid medication delivery (status epilepticus, acute seizures, hemodynamic instability) 9, 7, 8
• Medications with short half-lives requiring immediate effect 1
• Settings where IV piggyback preparation delays treatment 8