# An adult with septic shock receives continuous norepinephrine and regular insulin infusions through a central venous catheter. Which actions promote safe administration? Select all that apply.

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> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## Question

An adult with septic shock receives continuous norepinephrine and regular insulin infusions through a central venous catheter. Which actions promote safe administration? Select all that apply.

1

Titrate norepinephrine to the prescribed initial mean arterial pressure target near 65 mmHg and use continuous arterial pressure monitoring when available

2

For sustained norepinephrine and insulin infusions, use a 22-gauge peripheral catheter in the hand even when safer central or proximal peripheral access is available

3

Use smart-pump dose-error reduction software and follow facility policy for an independent verification of the medication, concentration, dose, and pump programming

4

Check blood glucose hourly until stable or at the interval required by the insulin protocol, and titrate while monitoring for hypoglycemia

5

When possible, dedicate and clearly label a separate lumen and tubing for each continuous high-alert infusion to prevent interruption, unintended bolus delivery, and incompatibility

6

Allow the continuous norepinephrine infusion bag to empty before preparing the replacement because a brief interruption is unlikely to affect blood pressure in septic shock

## Explanation

Titrate norepinephrine to the ordered MAP target and use invasive arterial pressure monitoring when available for a client in shock (Choice 1). Use smart-pump safeguards and complete independent verification as required by facility policy (Choice 3). Monitor glucose and titrate insulin at protocol-defined intervals, commonly hourly until stable (Choice 4). Dedicated, labeled lumens and tubing reduce interruptions, unintended boluses, and incompatibility risk (Choice 5). If a vasopressor must begin before central access is available, current guidance supports short-term peripheral administration with close monitoring; a small distal hand vein is not the preferred site for sustained therapy (Choice 2). Prepare the next bag before the current bag empties because interruption can cause abrupt hypotension (Choice 6).

## In-depth explanation

High-Alert Medications (ISMP)
Carry heightened risk of significant harm when used in error. Examples: vasopressors (norepinephrine, epinephrine, vasopressin), insulin (continuous IV especially), heparin, opioids (PCA), neuromuscular blockers, chemotherapy, concentrated electrolytes (KCl, hypertonic saline).

Universal Safeguards
1. Smart pump with drug library + DERS
2. Two-RN independent verification at start, bag change, dose change
3. Standardized concentrations
4. Clear tubing labeling proximal + distal
5. Limited access; pharmacy preparation when feasible
6. Dedicated lumen per continuous high-alert infusion when possible

Vasopressor Specifics
- Central line preferred for sustained therapy (peripheral only as brief bridge through proximal large vein with continuous monitoring)
- Titrate to MAP target (typically ≥65 mmHg in septic shock)
- Arterial line preferred for accuracy in shock
- Plan bag changes with primed backup ready; avoid interruption (immediate severe hypotension)
- Monitor for extravasation; phentolamine antidote for norepinephrine

Insulin Drip Specifics
- Capillary glucose every 1 hr initially, then per protocol
- Hypoglycemia surveillance (diaphoresis, tachycardia, altered mental status, glucose <70)
- D50 ready
- Coordinate with TPN, dextrose-containing fluids, and feedings
- Transition to subcutaneous insulin with overlap when stable

Memory Tip
"Smart Pump + Two-RN + Central Line + Don't Stop + Watch Sugar"

## Clinical scenario

Scenario
ICU client with septic shock on norepinephrine drip + insulin drip via central line.

Care Bundle
1. Smart pump + DERS + two-RN verification at start, bag/dose change
2. Norepinephrine titrate to MAP ≥65 with continuous arterial monitoring
3. Glucose q1h on insulin drip; hypoglycemia surveillance
4. Dedicated lumen per high-alert drip; tubing labels at both ends
5. Plan bag changes with primed backup; never disconnect briefly

Avoid
- Sustained vasopressor through peripheral 22 G in hand
- Brief disconnection of vasopressor
- Single-RN verification of high-alert program
- Skipping glucose checks

## Key concepts

- **High-Alert Medications (ISMP)** — Medications that bear heightened risk of significant client harm when used in error. ISMP maintains the canonical list including vasopressors (norepinephrine, epinephrine, vasopressin), continuous IV insulin, heparin, neuromuscular blockers, chemotherapy, opioid PCA, concentrated electrolytes (KCl, hypertonic saline), and others. Institutional safeguards include smart pumps with drug library and dose-error reduction software, two-RN independent verification, standardized concentrations, and clear labeling.
- **Vasopressor Continuous Infusion Safety** — Sustained vasopressor therapy (norepinephrine, epinephrine, vasopressin, phenylephrine) is administered via central venous catheter; peripheral access is acceptable only as a brief bridge through a proximal large vein with continuous monitoring for extravasation. Titrate to MAP target (typically ≥65 mmHg in septic shock) with continuous arterial pressure monitoring (arterial line preferred). Plan bag changes with a primed backup ready; brief interruption causes immediate severe hypotension. Phentolamine local infiltration is the antidote for norepinephrine extravasation.
- **Insulin Continuous Infusion Safety** — Continuous IV regular insulin requires capillary blood glucose monitoring at least hourly while titrating, with protocol-based dose adjustment. Watch for hypoglycemia (diaphoresis, tachycardia, altered mental status, glucose <70 mg/dL); D50 should be readily available. Coordinate with concurrent TPN, dextrose-containing fluids, and feedings — interruption of these without insulin adjustment causes hypoglycemia. Transition to scheduled subcutaneous insulin with overlap when the client is stable to avoid rebound hyperglycemia.

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