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IV Epoprostenol (Veletri) Administration (Adult and Pediatric) (10.21AP)

IV Epoprostenol (Veletri) Administration (Adult and Pediatric) (10.21AP) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Medications

10.21AP

NURSING PATIENT CARE POLICY & PROCEDURE


I. PURPOSE

To provide a consistent method of infusion for intravenous (IV) epoprostenol for the
treatment of pulmonary arterial hypertension.

II. POLICY

A. Only registered nurses (RNs) who have been trained with unit-specific competencies
may administer IV epoprostenol.
1. For the Pediatric Intensive Care Unit (PICU), RNs will be monitoring the
patient with physician/provider supervision.
B. Patients receiving IV epoprostenol and who are hemodynamically stable will be
admitted to D6/5 IMC.
1. Pediatric patients requiring epoprostenol will be admitted to the PICU.
C. Patients receiving IV epoprostenol and who are hemodynamically unstable will be
admitted to TLC.
D. Patient receiving IV epoprostenol and are seeking services as an outpatient (i.e.,
Radiology), contact D6/5 Care Team Leader for further instructions.

III. GENERAL INFORMATION

A. IV epoprostenol therapy is administered as a continuous infusion via a dedicated
central venous access device (CVAD) lumen.
1. Inpatients receiving IV epoprostenol will have the medication infusion
changed from the patient’s home regimen to a medication solution prepared
by the UWHC pharmacy and administered via an UWHC Alaris® pump.
2. For patients in the Emergency Department, IV epoprostenol is to be infused
via the patient’s home pump. The ED may contact D6/5 with any questions or
concerns.
a. For pediatric patients, the ED may contact the PICU physician.
B. The half-life of epoprostenol is 3-5 minutes. Do not interrupt the infusion – even
during cardiopulmonary resuscitation. Abrupt withdrawal or sudden large dose
reductions or increases can precipitate worsening of PAH symptoms and must be
avoided. Abrupt interruption of epoprostenol is considered life-threatening and
rebound pulmonary hypertension may occur.




Effective Date:
September 25,
2015
Amended:
January 22, 2016
June 20, 2016

Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 10.21AP

Original
Revision

Page
1
of 6

Title: IV Epoprostenol (Veletri)
Administration (Adult & Pediatric)

Page 2 of 6

1. Nothing will be piggybacked into the IV epoprostenol lumen nor will
the lumen be used to obtain blood samples (except blood culture - see
Appendix A in the “Related” section on U-Connect). If more than one
lumen is present in the CVAD the non-dedicated lumen can be used
for normal IV therapy.
2. Never flush the lumen that IV epoprostenol is infusing through as this
would give the patient a large bolus of drug, which could be life
threatening. The CVAD should be labeled “Do Not Flush”.
3. Lab Draws: A peripheral stick should be used to obtain lab draws unless a
secondary lumen is present and labs can be completed within 3-5 minutes
out of the non-dedicated lumen
4. Trained nursing staff is responsible for checking IV tubing, catheter, and
infusion pump to avoid interruptions in therapy.
5. Trained Nursing staff is responsible for proper administration of IV
epoprostenol. All bags will be administered using the Alaris pump and the
Guardrails® drug library listing for epoprostenol.
C. IV epoprostenol dosing is based on the patient’s weight at the time the therapy is
initiated (dose weight). The dose weight will remain the same, despite fluctuations in
the patient’s weight. The dose weight is on file with ACCREDO Therapeutics by
calling (866) 344-4874 (phone is answered 24/7). If Accredo does not supply
medication contact specific agency (i.e. CVS) for information.

IV. ADMINISTRATION OF IV EPOPROSTENOL

A. Admitted Patients
1. A patient admitted to UWHC on IV epoprostenol therapy must continue
treatment with IV epoprostenol upon admission to the hospital.
2. When a patient receiving IV epoprostenol is admitted to UWHC, the
medication infusion will be changed over from the patient’s home medication
solution and pump to a medication solution prepared by the UWHC pharmacy
as soon as a bag of solution is available. The infusion will then be
administered via an UWHC Alaris® pump.
a. An abrupt reduction, withdrawal or increase in dosage of IV
epoprostenol may result in the worsening of pulmonary arterial
hypertension symptoms and must be avoided.
i. To avoid potential interruptions in drug delivery, there
must be a backup UWHC Alaris® pump in the patient’s
room at all times in case of pump failure. An extra bag of
IV epoprostenol solution must be in the unit based
pharmacy refrigerator. Must maintain patent peripheral IV
while admitted as an inpatient as backup for epoprostenol
ii. The medication solution mixed in the UWHC pharmacy;
refrigerated bags of epoprostenol (Veletri®) can be stored
for up to 8 days and administered over 24-48 hours
depending on the epoprostenol concentration. The nurse is
responsible for labeling the bag with the expiration time
when the bag is removed from the medication refrigerator.
iii. Nursing staff will order additional epoprostenol bags in
Health Link. The nurses will order a bag to ensure the next

Page 3 of 6

scheduled bag is prepared and on the unit approximately
two hours prior to the anticipated hang time.
iv. Do not hang a new bag until an extra bag of solution is
available on the unit.
v. Tubing and filter must be changed every 24 hours or less,
preferably with a bag change. The new tubing should be
primed before pausing the current infusion.
3. Intravenous epoprostenol (Veletri) must be infused using an in-line 0.2 filter.
a. The in-line filter should be placed proximal to the lumen Veletri is
infusing.
b. If pump beeps “occlusion” the in-line filter should be replaced and
primed with current infusion.
c. DO NOT attempt to flush filter this will cause bolus of
epoprostenol which could lead to life threatening event
d. If unsuccessful with in-line filter change stop infusion and switch
to backup PIV with filter attached (Notify Advance Pulmonary
team)
4. A nurse trained in the administration of IV epoprostenol must accompany the
patient when transported off unit for procedures. When taking patient off unit
always take the extra epoprostenol bag with to prevent interruption of
infusion
B. General Assessment Parameters
1. Telemetry monitoring according to physician order.
2. Assess blood pressure, pulse and oxygen saturation every 4 hours or more
frequently Assessment and documentation every 8 hours and PRN:
a. Assess the CVAD for signs and symptoms of infection according to
UWHC Nursing and Patient Care Policy 1.56 AP, Central Vascular
Access Device Use, Maintenance and Removal (Adult & Pediatric).
b. Assess the backup PIV for patency and blood return for emergency
use.
c. Assess lung sounds, respiratory rate and rhythm and patient reports of
decreased or increased shortness of breath.
d. Assess for signs of insufficient drug dosage: chest pain, shortness of
breath, fatigue, dizziness, syncope, cool extremities, pallor, cyanosis,
nausea, vomiting, abdominal pain, back pain, headache, palpitations,
diaphoresis or cough.
e. Assess for signs of excess drug dosage: chest pain, shortness of
breath, fatigue, dizziness, warm extremities, flushing, nausea,
vomiting, abdominal pain, diarrhea, back pain, headache, jaw pain,
diarrhea, bradycardia, hypotension, anxiety and diarrhea.
C. Use caution when troubleshooting pump alarms. Always check the tubing, catheter
and pump to avoid an inadvertent bolus or interruption in therapy.

V. PROCEDURE FOR CHANGING IV EPOPROSTENOL CONCENTRATIONS OF
THE DRUG AND PUMP WHEN ADMITTED TO UWHC

A. Equipment:
• Two (2) Alaris
®
Computer Programming Units (CPU)
• Two (2) Alaris
®
pump modules

Page 4 of 6

• Alaris® primary tubing (Central Service [CS] Item Number 4009795)
• Two (2) bags of UWHC prepared IV epoprostenol solution (one to be used and
the other to be stored in the unit’s Pharmacy refrigerator)
• Two (2) 1 mL syringes
• Empty 10 mL syringe
• 10 mL saline-filled syringe
B. BE AWARE THAT THIS PROCEDURE MUST BE ACCOMPLISHED IN LESS
THAN FIVE (5) MINUTES BECAUSE THAT IS THE UPPER LIMIT OF THE
MEDICATION’S HALF-LIFE.
C. Obtain IV epoprostenol solution from the UWHC pharmacy (an extra bag of solution
must be in the unit Pharmacy’s refrigerator before initiating the infusion). MARK
THE SOLUTION BAG WITH THE TIME REMOVED FROM THE
REFRIGERATOR.
D. Prime Alaris® tubing with the IV epoprostenol solution from the UWHC pharmacy,
being careful to remove all the air from the tubing and Y-sites (tap when priming the
tubing to eliminate all air from the line). Load medication primed tubing into the
Alaris® pump.
E. With a one (1) mL syringe, withdraw one (1) mL of UWHC mixed IV epoprostenol
solution from the Alaris® pump tubing utilizing the injection port on the bag. LABEL
THIS SYRINGE “UWHC” or Clean
F. Stop the “Home” IV epoprostenol infusion and clamp the CVAD.
G. Disconnect the “Home” tubing from the CVAD and attach an empty one (1) mL
syringe to the CVAD.
H. Unclamp the CVAD and withdraw the solution slowly until blood is visible in the tip
of the syringe. BE AWARE THAT THIS IS A VERY SMALL AMOUNT AND IT
IS THE VOLUME OF THE CATHETER. NOTE THIS AMOUNT.
I. Apply the clamp to the CVAD and remove the syringe. Set it aside.
J. Attach an empty 10 mL syringe to the tip of the CVAD and unclamp the catheter.
Aspirate 10 mL of blood and re-clamp the CVAD.
K. Remove the blood-filled syringe and set aside. Attach the 10 mL saline-filled syringe.
Unclamp the CVAD and instill the saline slowly to clear the line of blood.
L. Re-clamp the CVAD.
M. Waste the excess amount of UWHC/clean IV epoprostenol solution from the one (1)
mL syringe so the amount of solution left in the syringe is equal to the amount that
was withdrawn from the CVAD. This is witnessed by another trained RN.
N. Remove the flushed 10 mL syringe from the CVAD and attach the one (1) mL
syringe with the UWHC/clean IV epoprostenol solution to the CVAD. Open the
clamp.
O. Slowly inject the UWHC IV epoprostenol solution over one minute. Monitor closely
for signs and symptoms of an IV epoprostenol bolus.
P. Clamp the CVAD and remove the syringe. Connect the Alaris® IV epoprostenol
pump tubing and start the infusion on the Alaris® pump.
Q. Discard “Home” solution, tubing and syringes.
R. Document the procedure using the appropriate smart text in a progress note





Page 5 of 6


VI. PROCEDURE FOR CHANGING IV EPOPROSTENOL CONCENTRATIONS OF
THE DRUG AND PUMP WHEN PATIENT IS DISCHARGED FROM UWHC

A. Equipment:
• Two (2) “Home” Computerized Ambulatory Drug Delivery (CADD)
pumps
• One (1) bag of ACCREDO or home supply agency-prepared IV
epoprostenol solution
• Two (2) 1 mL syringes
• One (1) empty 10 mL syringe
• 10 mL saline-filled syringe
B. ACCREDO will supply two (2) CADD pumps (one to be used and another for a
backup).
C. The ACCREDO nurse will bring the IV epoprostenol solution from the ACCREDO
pharmacy. The concentrated vial used to prepare home infusion cassette must be
stored out of sight after the cassette has been prepared.
D. Two trained nurses are required to transition to home pump. BE AWARE THAT
THIS PROCEDURE NEEDS TO BE COMPLETED IN LESS THAN FIVE (5)
MINUTES SINCE THAT IS THE UPPER LIMIT OF THE MEDICATION’S
HALF-LIFE.
E. Prime the “Home” CADD pump with the IV epoprostenol solution from the
ACCREDO pharmacy using the supplied CADD tubing. With a one (1) mL syringe,
withdraw one (1) mL of ACCREDO mixed IV epoprostenol solution from the CADD
pump tubing. LABEL THIS SYRINGE “ACCREDO/clean.
F. Stop the Alaris
®
UWHC IV epoprostenol infusion and clamp the CVAD.
G. Disconnect the Alaris
®
tubing from the CVAD and attach an empty one (1) mL
syringe to the CVAD.
H. Unclamp the CVAD and withdraw the solution slowly until blood is visible in the tip
of the syringe. BE AWARE THAT THIS IS A VERY SMALL AMOUNT AND IT
IS THE VOLUME OF THE CATHETER. NOTE THIS AMOUNT.
I. Clamp the CVAD. Remove the syringe and set it aside.
J. Attach an empty 10 mL syringe to the tip of the CVAD and unclamp the catheter.
Aspirate 10 mL of blood and re-clamp the CVAD.
K. Remove the blood-filled syringe and set aside. Attach the 10 mL saline-filled syringe.
Unclamp the CVAD and instill the saline slowly.
L. Re-clamp the CVAD.
M. Waste the excess amount of ACCREDO/clean IV epoprostenol solution from the
syringe so the amount of solution left in the syringe is equal to the amount that was
withdrawn from the CVAD. This is witnessed by another trained RN.
N. Remove the empty 10 mL syringe from the CVAD and attach the syringe with the
ACCREDO IV epoprostenol solution and unclamp.
O. Slowly inject the ACCREDO IV epoprostenol solution over one minute. Monitor
closely for signs and symptoms of an IV epoprostenol bolus.
P. Clamp the CVAD and remove the syringe. Connect the “Home” CADD IV
epoprostenol pump tubing and start the infusion on the “Home” CADD pump.
Q. Discard the UWHC IV epoprostenol solution, tubing and syringes.
R. Communicate the time the infusion was started to the patient and family.

Page 6 of 6

S. Document the procedure using the appropriate smart text in a progress note

VII. UWHC CROSS REFERENCES

A. Appendix A: Drawing Blood Cultures from a Central Venous Access Device When
IV Epoprostenol is Infusing
B. Hospital Administrative Policy 8.33, High Alert Medication Administration
C. Nursing and Patient Care Policy 1.56 AP, Central Vascular Access Device Use,
Maintenance and Removal (Adult & Pediatric).
D. UWHC Guidelines for the Use of Alteplase (t-PA) for Catheter Clot Clearance
E. UWHC Guidelines for the Use of Intravenous Epoprostenol (Flolan) (2006), Updated
2009

VIII. REFERENCES

A. Micromedex (n.d.). Epoprostenol sodium. Retrieved from
http://www.micromedexsolutions.com/micromedex2/librarian/
B. GlaxoSmithKline (2011). Proscribing information: Flolan. Retrieved from
https://www.gsksource.com/gskprm/htdocs/documents/FLOLAN.PDF

IX. REVIEWED BY

Clinical Nurse Specialist, Acute Medical & Progressive Care Unit
Clinical Nurse Specialist, Pediatric Intensive Care Unit (PICU)
Clinical Nurse Specialist, Trauma Life Support Center
Nurse Manager, Acute Medical & Progressive Care Unit
Pharmacy Manager, Inpatient Services
Physician, Pulmonary
Nursing Patient Care Policy and Procedure Committee, September 2015

SIGNED BY

Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer