16.3 Infusion Pumps, Patient-Owned Devices & Medication Delivery Device Counseling

16.3 Infusion Pumps, Patient-Owned Devices & Medication Delivery Device Counseling

Infusion Devices in the ED

Two habits prevent many infusion errors. First, trace each line from the bag to the patient before starting or changing any infusion. Second, confirm that the secondary bag hangs above the primary and that clamps are open only where intended. Pump-EHR integration, where orders send rates directly to the pump, removes keystroke errors but does not replace the bedside check.

Patient-Owned Devices That Must Not Be Interrupted

Pulmonary Arterial Hypertension Infusions

Continuous IV epoprostenol has a half-life of about 6 minutes. If the pump fails or the catheter becomes dislodged, pulmonary pressures rebound within minutes and the patient can develop right ventricular failure and cardiac arrest.

• Restart the infusion immediately at the home rate, through a peripheral IV if the central line is unusable. Ask the patient or caregiver for their backup supplies and pump.
• Never flush the epoprostenol line and never draw blood from it, because flushing delivers a bolus.
• Contact the patient's pulmonary hypertension center and specialty pharmacy.

Subcutaneous or IV treprostinil has a longer half-life (about 4 hours), which allows a little more time but still requires prompt restoration.

Insulin Pumps and Automated Insulin Delivery

The 2026 ADA Standards of Care support continuing insulin pumps, including automated insulin delivery systems, in hospitalized patients when it is clinically appropriate and the institution has a protocol, supplies and trained staff. Personal continuous glucose monitors may also continue, with point-of-care glucose checks to confirm values before insulin dosing or hypoglycemia treatment.

Stop or remove the pump when the patient has altered mental status, DKA or HHS, critical illness, or will undergo MRI or certain procedures, or when the patient cannot manage the device. Because pumps deliver only rapid-acting insulin, start IV insulin or give subcutaneous basal insulin as the pump is stopped. With no insulin depot, ketoacidosis can begin within a few hours. Pump malfunction, such as a kinked cannula or empty reservoir, is itself a common trigger for DKA.

Intrathecal Baclofen Pumps

Intrathecal baclofen labeling carries a boxed warning about abrupt discontinuation, which can be fatal. Withdrawal follows a low reservoir, catheter kink or disconnection, or pump failure. Signs include:

• Pruritus without a rash (often early)
• Return of spasticity, high fever and altered mental status
• Autonomic instability, rhabdomyolysis, seizures and multiorgan failure

Management:

1. Restore intrathecal delivery as quickly as possible; the patient's pump team or neurosurgery can interrogate and refill the pump.
2. Give high-dose oral or enteral baclofen, which is absorbed unpredictably and works slowly.
3. Give IV benzodiazepines for spasticity and agitation, with cooling and supportive care.

Intrathecal opioid and ziconotide pumps raise similar problems, and accidental overdose during refills is a known hazard.

Medication Delivery Devices and Counseling

Inhaled Devices

An MDI with a spacer works as well as a nebulizer for most acute asthma in adults and children. Four to eight puffs of albuterol (90 mcg each) is commonly treated as equivalent to a 2.5 mg nebulized dose. Before discharge after an asthma exacerbation, check technique and make sure the patient leaves with an inhaled corticosteroid-containing controller (Section 7.2).

Epinephrine Products for Anaphylaxis

• Autoinjectors: inject into the outer thigh, through clothing if needed, and hold for the time stated on the device (about 3 seconds for EpiPen). Call emergency services, and give a second dose after 5 to 15 minutes if symptoms persist or return. Weight-based device strengths are listed in Section 7.3.
• Nasal epinephrine (neffy): 2 mg for patients 30 kg or more, 1 mg for those 15 to under 30 kg. If symptoms do not improve, a second dose is given with a new device in the same nostril after 5 minutes.
• Prescribe two devices, check expiration dates, avoid temperature extremes, and teach caregivers and schools.

Intranasal Atomizers

A mucosal atomization device turns a liquid dose into a fine mist that is absorbed through the nasal mucosa, avoiding a needle stick.

• Use the most concentrated product: midazolam 5 mg/mL, fentanyl 50 mcg/mL, ketamine 50 or 100 mg/mL.
• Give no more than about 1 mL per nostril, ideally 0.2 to 0.5 mL, and split the dose between both nostrils.
• Add about 0.1 mL for the device's dead space.
• Blood, mucus or vasoconstrictors reduce absorption.

Worked example: a 20-kg child having a seizure needs midazolam 0.2 mg/kg = 4 mg. With 5 mg/mL midazolam, the volume is 0.8 mL, given as 0.4 mL in each nostril.

Ready-to-Use Rescue Products

• Opioid overdose: naloxone 4 mg nasal spray (sold over the counter since 2023), naloxone 8 mg nasal spray, and nalmefene nasal spray and autoinjector. Nalmefene lasts longer than naloxone and can cause prolonged withdrawal in people physically dependent on opioids.
• Severe hypoglycemia: nasal glucagon 3 mg, ready-to-use glucagon autoinjectors and prefilled syringes, and dasiglucagon.
• Seizure clusters: rectal diazepam gel, diazepam nasal spray, and midazolam nasal spray (labeled for patients 12 years and older).

Injectables, Pens and Patches

• Insulin pens: prime 2 units before each dose and hold the needle in the skin for about 10 seconds. Never share a pen between patients, even with a new needle, because blood can flow back into the cartridge.
• Enoxaparin prefilled syringes: do not expel the air bubble from fixed-dose syringes, inject into the abdomen, rotate sites and do not rub.
• Weekly methotrexate: confirm the weekly schedule at every counseling contact, because daily dosing errors have been fatal.
• Fentanyl patches: heat from fever, heating pads or hot baths increases absorption. Remove the old patch, fold used patches sticky sides together before disposal, and keep them away from children.
• Metal-backed patches (some nicotine, clonidine, testosterone and other products) can cause burns during MRI and should be removed beforehand.
• Nitroglycerin patches need a daily patch-free interval of 10 to 12 hours to prevent tolerance.

Counseling That Works

Use teach-back: ask the patient to show or explain how they will use the device, rather than asking "Do you have any questions?" Demonstrate with a trainer device, give written instructions with pictures in the patient's preferred language, and include caregivers. Section 18.3 covers health literacy and access barriers.