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21.5 Pentamidine isetionate administration

Essential equipment

  • Salbutamol nebulizer kit (SideStream with blue chamber and mask)
  • Pentamidine nebulizer kit (Filta‐Guard with purple chamber and mouthpiece)
  • Non‐sterile gloves, goggles (sealed if wearing contact lenses) and disposable apron
  • Facemask FFP3 (particulate filter respirator and surgical mask)
  • Upright chair designed for patient comfort
  • Completed prescription chart
  • Pharmaceutical/chemotherapy disposal bin
  • Red bag/alginate bag

Medicinal products

  • Pentamidine solution 300 mg (pre‐prepared into syringe in pharmacy)
  • Salbutamol solution 2.5 mg
  • Compressed medical air or oxygen outlet with flow meter. Use air or oxygen that meets specifications for medical breathing use. (Choice dependent upon patient's condition)

Pre‐procedure

ActionRationale

  1. 1.
    Ensure pentamidine isetionate is prescribed on prescription chart.
    To comply with medicines management regulations and Trust policy (NMC [85], C).
  2. 2.
    Explain and discuss the procedure with the patient. This must include:
    • details of the drugs and equipment
    • why the procedure is necessary
    • the possible side‐effects.
    To ensure that the patient understands the procedure and gives their valid consent (DH [30], C; NMC [86], E).
    The routine of obtaining verbal consent from patients undergoing pentamidine administration represents good clinical practice (MHRA [76], C).
  3. 3.
    Gain consent and assess patient's current condition.
    To ensure the patient has no underlying medical problems and is suitable to undergo the procedure. E
  4. 4.
    Ensure the patient is wearing a wristband correctly labelled with their name, hospital number and date of birth.
    To identify correct patient and prevent patient safety incidents and near misses relating to missing or incorrect wristbands (NPSA [87], C).
  5. 5.
    Obtain a baseline blood pressure and record on the observation chart.
    To monitor the effect of pentamidine administration on blood pressure as it is known to cause hypotension in some patients (Joint Formulary Committee [62], C).
  6. 6.
    Consult the patient's prescription chart to ascertain the following:
    • drug
    • dose
    • date and time of administration
    • route and method of administration
    • diluent as appropriate
    • validity of prescription
    • signature of doctor.
    To ensure that the patient is given the correct drug in the prescribed dose using the appropriate diluent and by the correct route (NMC [85], C).

Procedure

  1. 7.
    Take the prepared dose to the patient and check the patient's identity by asking them to verbally identify themselves (where possible) and check against the patient's identification wristband. Also ask about and check allergy status.
    To prevent error and confirm patient's identity (NMC 2005, C; NPSA [88], C; [87], C).
  2. 8.
    Assess the patient to ensure they are capable and competent to switch from the salbutamol to pentamidine.
    To ensure patient understanding and safety of staff (COSHH [24], C).
  3. 9.
    Treat all patients receiving pentamidine in a negative‐pressure room designated only for the administration of pentamidine.
    As pentamidine is classed as a substance hazardous to health, exposure needs to be reduced to as low a level as is reasonably practicable (COSHH [24], C).
  4. 10.
    The door must be kept closed at all times with a visible DO NOT ENTER: PENTAMIDINE ADMINISTRATION IN PROGRESS sign on the door.
    To minimize unnecessary exposure (COSHH [24], C).
  5. 11.
    Due to the teratogenic effects of the drug, ask all staff and relatives to leave the room prior to and while pentamidine is being administered unless there is a clinical need.
    To minimize unnecessary exposure (COSHH [24], C).
  6. 12.
    Wash hands using a bactericidal handrub.
    To minimize the risk of infection (Loveday et al. [73], C).
  7. 13.
    Apply goggles, gloves and a plastic apron to administer the pentamidine.
    Pentamidine is classed as a substance hazardous to health. Exposure needs to be reduced to as low a level as is reasonably practicable (COSHH [24], C).
  8. 14.
    Sit the patient in an upright chair in a negative‐pressure room where they can be observed from the outside.
    To minimize dyspnoea and allow maximum lung expansion in order to ensure medication reaches the bronchioles. This aids gravitational sedimentation (settling), and diffusion (Gardenhire et al. [43], E).
  9. 15.
    Ensure the patient can be observed and a nurse call bell is easily accessible in the event of the patient seeking assistance. Observe the patient intermittently throughout the procedure.
    To react quickly to any deterioration in the patient (NPSA [88], C).
  10. 16.
    Wherever possible, the patient should be instructed to switch on the nebulizer themselves.
    This allows the nurse to leave the room.
    To ensure patient understanding and safety of staff (COSHH [24], C).
  11. 17.
    Instruct the patient in the use of the nurse call system and ensure the bell is within easy reach.
    To react quickly to any deterioration in the patient (NPSA [88], C).
  12. 18.
    Administer salbutamol first.
    • Put prescribed salbutamol into the reservoir of the salbutamol nebulizer and secure.
    • Attach the oxygen tubing to one end and connect the other end to the oxygen/medical air outlet.
    • Secure the mask safely and securely on the patient's face and adjust straps to fit to ensure there is no leakage.
    To dilate the bronchus and minimize the risk of bronchospasm from the pentamidine (Joint Formulary Committee [62], C).
  13. 19.
    Turn on oxygen/medical air to flow at 6 litres per minute. Instruct the patient to breathe normally until all of the solution of salbutamol has been inhaled (this takes approximately10 minutes).
    To ensure at least 65% of the droplets are of a size that enables drug penetration into the distal airways (Downie et al. [37], E).
  14. 20.
    On completion dispose of nebulizer in clinical waste bin.
    To comply with safe management of healthcare waste (DH [32], C).
  15. 21.
    To change the salbutamol over to the pentamidine inhalation the nurse should ensure that they put on their PPE (facemask, goggles and gloves).
    Pentamidine is classed as a substance hazardous to health. Exposure needs to be reduced to as low a level as is reasonably practicable (COSHH [24], C).
  16. 22.
    Place the syringe of prescribed pentamidine solution into the reservoir and secure.
    To ensure correct administration (manufacturer's instructions, C).
  17. 23.
    Attach the reservoir with mouthpiece to the Filta‐Guard breathing filter at the clear plastic end.
    To ensure correct administration (manufacturer's instructions, C).
  18. 24.
    Attach one end of the tubing to the reservoir and the other end to the oxygen/medical air outlet.
    As pentamidine is classed as a substance hazardous to health, exposure needs to be reduced to as low a level as is reasonably practicable (COSHH [24], C).
    To ensure correct administration (manufacturer's instructions, C).
  19. 25.
    Instruct patient to place lips firmly on the mouthpiece.
    To ensure correct administration (manufacturer's instructions, C).
  20. 26.
    Turn oxygen/medical air on to 10 litres per minute.
    To ensure correct administration (manufacturer's instructions, C).
  21. 27.
    Instruct patient to breathe in slowly.
    After inspiration, the patient should pause briefly before exhaling.
    To promote greater disposition of medication in the airways (Perry [93], E).
  22. 28.
    Leave the room and dispose of aprons and gloves into orange clinical waste bin.
    To ensure safety of staff (COSHH [24], C).
  23. 29.
    This should continue until the nebulized medication is completely administered (this takes approximately 10 minutes).
    To ensure correct administration (manufacturer's instructions, C).
  24. 30.
    Instruct the patient to remain in the room for 30 minutes after the procedure has completed.
    This allows for adequate ventilation, thereby minimizing the risk of pentamidine inhalation by staff/relatives before the room is used again (COSHH [24], C).

Post‐procedure

  1. 31.
    Ensure all equipment is disposed of in the cytotoxic/cytostatic (purple‐topped) waste bins.
    To comply with the safe management of healthcare waste (DH [32], C).
  2. 32.
    Check and record blood pressure once the patient has completed the 30 minutes post procedure.
    To monitor the effect of pentamidine administration on blood pressure as it is known to cause hypotension in some patients (Joint Formulary Committee [62], C).
  3. 33.
    Document and sign administration has been completed on prescription chart and in relevant nursing notes.
    To comply with medicines management regulations (NMC [85], C).
    There must be a clear, accurate and immediate record of all medicine administered, intentionally withheld or refused by the patient, ensuring the signature is clear and legible (NMC [85], C).
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