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Treprostinil (Remodulin) Administration (10.27)

Treprostinil (Remodulin) Administration (10.27) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Medications

10.27

NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
May 20, 2016
Amended:
July 29, 2016

Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 10.27A

Original
Revision

Page
1
of 6

Title: Treprostinil (Remodulin)
Administration (Adult)

I. PURPOSE

To provide a consistent method of infusion of treprostinil (Remodulin) for the
treatment of pulmonary arterial hypertension.

II. POLICY

A. Only registered nurses (RNs) who have been trained may administer or monitor
patients receiving treprostinil.
B. Patients receiving subcutaneous or intravenous treprostinil, who are
hemodynamically stable will only be admitted to D6/5, Acute
Medicine/Progressive Care IMC or D6/5 general care (subcutaneous only).
C. Patients receiving subcutaneous or intravenous treprostinil who are
hemodynamically unstable will only be admitted to TLC.
D. Patients receiving treprostinil who are seeking services as an outpatient (i.e.,
Radiology, ED), contact D6/5 Care Team Leader for further instructions.

III. GENERAL INFORMATION

A. Treprostinil therapy is administered by continuous infusion, either subcutaneously
or intravenously.
1. Inpatients receiving IV Treprosintil will have the medication 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 Treprostinil is to be
infused via the patient’s home pump. The ED may contact D6/5 with
any questions or concerns.
B. The half life of treprostinil is 3-6 hours. 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.
1. Intravenous treprostinil is administered as a continuous infusion via a
dedicated central venous access device (CVAD). Nothing will be
piggybacked into the IV treprostinil lumen nor will the lumen be used
to obtain blood samples (except blood culture) 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 treprostinil is infusing through as this

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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. Treprostinil infusion may
be stopped during lab collection by a trained RN.
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
treprostinil. All bags will be administered using the Alaris pump and
the Guardrails® drug library listing for treprostinil.
C. Subcutaneous and IV treprostinil 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 or the home supply agency and can be retrieved by
calling (866) 344-4874 (phone is answered 24/7). If ACCREDO does not supply
the medication contact the specific agency (i.e. CVS) for information.

IV. ADMINISTRATION OF IV Treprostinil

A. Admitted Patients
1. A patient admitted to UWHC on IV treprostinil therapy must continue
treatment with IV treprostinil upon admission to the hospital.
2. When a patient receiving IV treprostinil 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.
3. General Assessment Parameters
4. Telemetry monitoring according to physician order.
5. Assess blood pressure, pulse and oxygen saturation every 4 hours or
more frequently. Assess and document 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. Change the treprostinil solution and IV tubing at least every 48
hours. The solution needs to be changed every 48 hours due to
drug stability parameters
c. An abrupt withdrawal or reduction in dosage of treprostinil may
result in worsening of pulmonary hypertension symptoms and
should be avoided. To avoid potential interruptions in drug
delivery, the patient must have immediate access to a back-up
infusion pump, infusion sets, and medication when using own
pump.
d. Assess for and document signs of insufficient drug dosage: chest
pain, shortness of breath, fatigue, dizziness and syncope, cool
extremities, pallor and cyanosis, nausea, vomiting and abdominal
pain, back pain or headache, palpitations, diaphoresis, and cough.

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6. Assess for and document signs of excess drug dosage: chest pain,
shortness of breath, fatigue, dizziness, warm extremities or flushing,
nausea, vomiting and abdominal pain, back pain, headache or jaw
pain, diarrhea, or bradycardia and hypotension, and anxiety.

V. ADMINISTRATION OF SUBCUTANEOUS TREPROSTINIL

A. It is critical the patient has a back-up pump and supplies while on
subcutaneous treprostinil.
B. Never transition home subcutaneous pump to an alaris pump; must be
converted to IV infusion.
C. The goal is to stay on home subcutaneous pump, Notify the Advance
pulmonary service for possible need for transition,
D. Assessment
1. The RN will assess the infusion insertion site every 8 hours (site
erythema and warmth is expected).
a. Follow the patient’s previous pain management protocol for old
and existing subcutaneous sites. Obtain order if needed.
2. The RN will assess the infusion rate, reservoir volume, and will verify
that the pump is running every 8 hours. This is verified by two RNs.
3. Equipment Change
a. Tubing must be changed every 3 days
b. Pump must be changed every 3 days with tubing change
c. Site must be changed every 6-8 weeks
4. The 3 mL reservoir syringes are NOT compatible between the CADD
MS-3® and MiniMed 407C® pump.

VI. PROCEDURE FOR CHANGING INTRAVENOUS TREPROSTINIL TO
UWHC CONCENTRATION DELIVERED BY ALARIS® PUMP

A. Equipment:
1. Two (2) Alaris® Computer Programming Units (CPU) Two (2)
Alaris® pump modules
2. Alaris® primary tubing (Central Service [CS] Item Number 4009795)
3. Two bags of UWHC prepared treprostinil solution (one to be used and
the other to be stored in the unit medication refrigerator)
4. Two 1 mL syringes
5. Empty 10 mL syringe
6. 10 mL saline-filled syringe
B. Procedure
1. Two trained nurses are required to transition to UWHC alaris pump
a. Obtain treprostinil solution from the UWHC pharmacy MARK
THE SOLUTION BAG WITH THE TIME WHEN REMOVED
FROM THE MEDICATION REFRIGERATOR.
b. Prime the Alaris® pump with the treprostinil solution from the
UWHC pharmacy using standard Alaris® tubing, being careful to
remove all the air from the tubing.
c. With a 1 mL syringe, withdraw 1 mL of UWHC mixed treprostinil
solution from the Alaris® pump tubing from the injection port on

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the tubing, using aseptic technique. LABEL THIS SYRINGE
“UWHC”.
d. Stop the “Home” treprostinil infusion and clamp the CVAD.
e. Disconnect the “Home” tubing from the CVAD and attach an
empty 1 mL syringe (without the needle) to the CVAD.
f. 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.
g. Apply the clamp to the CVAD, remove the syringe and set it aside.
h. Attach an empty 10 mL syringe to the tip of the CVAD and
unclamp the catheter. Aspirate 10 mL of blood and re-apply the
clamp to the CVAD.
i. Remove the blood-filled syringe and set aside. Attach the 10 mL
saline-filled syringe, unclamp the catheter, and instill the saline
slowly.
j. Re-clamp the CVAD.
k. Waste the excess amount of UWHC treprostinil solution from the 1
mL syringe so the amount of solution left in the syringe is equal to
the amount that was withdrawn from the CVAD.
m. Remove the emptied 10 mL syringe from the CVAD and attach the
syringe with the UWHC treprostinil solution (without the needle)
to the CVAD and open the clamp.
n. Slowly inject the UWHC treprostinil solution. This injection
should take one minute. Monitor closely for signs and symptoms
of a treprostinil bolus (see above).
o. Clamp the CVAD and remove the syringe. Connect the Alaris®
treprostinil pump tubing and start the infusion on the Alaris®
pump.
p. Discard “Home” solution, tubing, and syringes.
q. Document the procedure using the appropriate smart text in a
progress note

VII. PROCEDURE FOR CHANGING INTRAVENOUS TREPROSTINIL TO
HOME CONCENTRATION AND PUMP WHEN PATIENT IS DISCHARGED
FROM UWHC

A. Equipment
1. Two “Home” Computerized Ambulatory Drug Delivery (CADD)
pumps
2. One bag of ACCREDO or home supply agency-prepared IV
treprostinil (Two 1 mL syringes)
3. Empty 10 mL syringe
4. 10 mL saline-filled syringe
B. Procedure
1. Two trained nurses are required to transition to home pump
a. Prime the “Home” CADD pumps with the treprostinil solution
from the ACCREDO or home supply agency pharmacy using the
supplied CADD tubing. The concentrated vial used to prepare

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home infusion cassette must be stored out of sight after the
cassette has been prepared
b. With a 1 mL syringe, withdraw 1 mL of ACCREDO or home
supply agency mixed treprostinil solution from the treprostinil vial
using aseptic technique. LABEL THIS SYRINGE “ACCREDO”.
c. Stop the Alaris® UWHC treprostinil infusion and clamp the
CVAD.
d. Disconnect the Alaris® tubing from the CVAD and attach an
empty 1 mL syringe (without the needle) to the CVAD.
e. 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.
f. Apply the clamp to the CVAD, remove the syringe and set it aside.
g. Attach an empty 10 mL syringe to the tip of the CVAD, aspirate 10
mL of blood and re-apply the clamp to the catheter.
h. Remove the blood-filled syringe and set aside. Attach the 10 mL
saline-filled syringe, unclamp the catheter, and instill the saline
slowly.
i. Re-clamp the catheter.
j. Waste the excess amount of ACCREDO treprostinil solution from
the syringe so the amount of solution left in the syringe is equal to
the amount withdrawn from the CVAD.
k. Remove the emptied 10 mL syringe from the CVAD and attach the
syringe with the ACCREDO treprostinil solution (without the
needle) to the CVAD and open the clamp.
l. Slowly inject the ACCREDO treprostinil solution. This injection
should take one minute. Monitor closely for signs and symptoms
of a treprostinil bolus (see above).
m. Clamp the CVAD and remove the syringe. Quickly connect the
“Home” CADD treprostinil pump tubing and start the infusion on
the “Home” CADD pump.
n. Discard the UWHC treprostinil solution, tubing, and syringes.
o. Document the procedure using the appropriate smart text in a
progress note

VIII. UWHC CROSS REFERENCES

A. Nursing and Patient Care Policy 1.56 AP, Central Vascular Access Device Use,
Maintenance and Removal (Adult & Pediatric).
B. Procedure for MiniMed 407C® Pump Reservoir Change (see Related Resources)
C. Procedure for Reservoir Change, Verification Rate, and Rate Change for
Subcutaneous Treprostinil Using the CADD MS-3 (see Related Resources)
D. Procedure for Site Change for Subcutaneous Treprostinil (see Related Resources)
E. Treprostinil Adult Inpatient Clinical Practice Guideline

IX. REFERENCES
A. Subcutaneous Remodulin Therapy with CADD-MS3 and Soft Set: Pump and
Setup Operation formulated by Accredo Therapeutics (2008). Retrieved May

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2008 from Accredo Therapeutics.
B. Subcutaneous Remodulin Therapy with MiniMed: Pump and Setup Operation
formulated by Accredo Therapeutics (2008). Retrieved May 2008 from Accredo
Therapeutics.
C. Widlitz, A. C., McDevitt, S., Ward, G. R., & Krichman, A. (2007). Practical
aspects of continuous intravenous treprostinil therapy. Critical Care Nurse, 27(2),
41-50.

X. WRITTEN/REVIEWED BY

Clinical Nurse Specialist, Acute Med/Prog Care D6/5
Clinical Nurse Specialist, Trauma/Critical Care
Nurse Manager, Acute Med/Prog Care D6/5
Pharmacist, Critical Care
Physician, Medicine-Pulmonary (UWMF)
Nursing Patient Care Policy and Procedure Committee, May 2016

SIGNED BY

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