ROYAL PERTH HOSPITAL

NURSING PRACTICE STANDARD

FOR

Glyceryl Trinitrate Intravenous

Infusion Management
Relevant NSQHS Standards for this NPS

1. Governance for Safety and Quality in Health Service Organisations

2. Partnering with Consumers

3. Preventing and Controlling Healthcare Associated Infections

4. Medication Safety

5. Patient Identification and Procedure Matching

6. Clinical Handover

9. Recognising and Responding to Clinical Deterioration in Acute Health Care

Version 4 Compiled: May 2006

Title: Glyceryl Trinitrate Intravenous Infusion Management NPS
Document Owner: Nursing Director Service 1
Endorsed by NPC: 16th April 2015
Authorised by: A/Director of Nursing Robyn Kovac 8th May 2015
 Contents

Legislative Requirements ..................................................................................................... 4

Mandatory Requirements ..................................................................................................... 5

General Information.............................................................................................................. 6
GTN Pharmocokinetics ............................................................................................... 6
Drug Interactions ......................................................................................................... 6
Indications for Use ...................................................................................................... 6
Adverse Effects ........................................................................................................... 7

Preparation ........................................................................................................................... 8
Patient ......................................................................................................................... 8
Equipment ................................................................................................................... 8

Preparation and Administration of GTN Infusion .................................................................. 9

Infusion Administration ....................................................................................................... 10

Haemodynamic Observations Post-Commencement and after Rate Change of GTN

Infusion ............................................................................................................................... 10

Patient Activity with GTN Infusion in Progress ................................................................... 11

Weaning GTN..................................................................................................................... 11

Patient Education ............................................................................................................... 11

Documentation ................................................................................................................... 11

Appendix I: Table of GTN Concentrations .......................................................................... 12

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Endorsed by A/Director of Nursing Robyn Kovac: 8th May 2015
 Introduction
This Nursing Practice Standard (NPS) and associated Quiz reflect the current best available
evidence in the management of the patient with an intravenous (IV) glyceryl trinitrate (GTN)
Infusion at Royal Perth Hospital (RPH). Relevant standard components should be applied in
accordance with the needs of the individual patient.

The Evidence
RPH has adopted the definition for Levels of Evidence as identified by the Joanna Briggs
Institute (JBI) for Evidence Based Nursing & Midwifery. In developing this NPS the feasibility,
appropriateness, meaningfulness and effectiveness of evidence is considered.
Level I: Evidence obtained from a systematic review of all relevant randomised controlled
trials.
Level II: Evidence obtained from at least one properly designed randomised controlled
trial.
Level III: Evidence obtained from well designed pseudo-randomised controlled trial
Evidence obtained from comparative studies with concurrent controls and
allocation not randomised (cohort studies), case-control studies or interrupted
time series with a control group.
Evidence obtained from comparative studies with historical control, two or more
single arm studies, or interrupted time series without a parallel control group.
Level IV: Evidence obtained from case series, either post-test or pre-test and post-test,
expert committee reports or opinions and/or clinical experiences of respected
authorities.
Level IVB: Evidence obtained from local expert opinion (used only in the absence of higher
levels of evidence)
Available from URL: http://joannabriggs.org/jbi-approach.html#tabbed-nav=levels-of-Evidence

The logos represent the description and are used to replace the text within the NPS.

Logo Description
Follow the 6 Rights of Medication Administration:
1. Patient/individual 4. Route
2. Right medication 5. Time
3. Dose 6. Documentation
Refer to Medication Administration NPS.
Hand hygiene, which includes the use of an alcohol handrub OR
a soap and water handwash, must be performed as per the 5
moments of hand hygiene:
5 1. Before touching a patient
2. Before a procedure
3. After a procedure or body fluid risk
4. After touching a patient
5. After touching a patient’s surroundings
Refer to RPH Infection Control Manual on SOL.
Documentation required. Refer to Documentation NPS.

Page 3 of 12 Title: Glyceryl Trinitrate Intravenous Infusion Management NPS

Endorsed by A/Director of Nursing Robyn Kovac: 8th May 2015
 Original Authors:
Margaret Black – Bed Manager/Discharge Nurse (Shenton Park Campus)
Trevor Cherry – Clinical Nurse Specialist (CNS) CCU/4F
Santiago Higgins – Registered Nurse 6G
Sarai Le – Clinical Nurse CCU/4F
Sally Simpson – Staff Development Nurse (SDN) CCU/4F
Nicole Slavin – Acting Staff Development Nurse CCU/4F
Julia Turnell – SDN Ward 5B
Ann Berwick- Pharmacist

Review Authors:
Trevor Cherry – CNS CCU/4F Service 4
Lauren Gibb – CN CCU/4F Service 4

Facilitator:
Sally Simpson - SDE EBP, The Education Centre

Approved by the RPH Drug and Therapeutics Committee: 10th February 2015

The following 2 authors – or those holding the position at that time will coordinate a full
review of the literature relating to the management of the patient with an intravenous
glyceryl trinitrate infusion in October 2017. All new evidence will then be fully evaluated and
this NPS amended as appropriate for implementation in May 2018.

Trevor Cherry
Clinical Nurse Specialist CCU/4F
Service 4
Royal Perth Hospital
Wellington Street Campus
Tel: +61 8 9224 3111 Pager: 3111
E-mail: trevor.cherry@health.wa.gov.au

Lauren Gibbs
Clinical Nurse CCU/4F
Service 4
Royal Perth Hospital
Tel: +61 8 9224 2244
Email: lauren.gibbs@health.wa.gov.au

Legislative Requirements
• Health Practitioner Regulation National Law (WA) Act 2010
• Australian Health Practitioner Regulation Agency (AHPRA) Code of Ethics for Nurses
August 2008
• AHPRA Code of Professional Conduct for Nurses August 2008
• Poisons Act 1964, Poisons Regulations 1965 and Poisons Amendment Regulations 2010
• The Occupational Health, Safety and Welfare Act 1984
• Carers Recognition Act 2004

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Endorsed by A/Director of Nursing Robyn Kovac: 8th May 2015
 The Standard
The Registered Nurse and Enrolled Nurse (under the supervision of a Registered Nurse)
will provide nursing interventions appropriate to the needs of the individual patient while
reassessing the clinical status of the patient in response to all interventions and disease
processes and in accordance with medical instructions. Additionally practice should:
• Apply the Australian Nursing & Midwifery Council (ANMC) Decision Making Framework
(DMF) N.B: Nurse Practitioners to comply with legislation and their scope of nursing
practice
• Consider cultural, ethical and communication requirements for the patient. Utilise
interpreter as required
• Ensure information about the specific treatment or procedure is provided prior to
intervention and patient consent is obtained. Refer to SMHS Consent Policy
• Maintain standard precautions at all times including the use of personal protective
equipment (PPE). In particular, change PPE between different care activities for the same
patient to prevent cross contamination. Hand hygiene must be performed according to the
RPH Hand Hygiene policy
• Ensure risk to self and others is assessed and appropriate strategies to minimise risk are
implemented
• Ensure all findings are documented according to RPH Documentation Nursing Practice
Standard and communicate to relevant staff
• Comply with Single Use / Single Patient Use Medical Devices Policy
• Comply with SMHS Chaperone Policy
• Comply with RPH Aseptic Technique Policy

Mandatory Requirements
• As a minimum, all inpatients must be correctly identified using the core patient identifiers
(family name/given name, unit medical record number (UMRN), and date of birth) as
outlined on the patient identification band 1 [Level IV]
• DO NOT abruptly cease GTN infusion 2 [Level IV]. Wean as prescribed by medical officer
(MO)
• Ensure an infusion control device is used in the administration of an IV GTN infusion
2
[Level IV]
• GTN is not for direct intravenous injection – it must be diluted in dextrose 5% or sodium
chloride 0.9% prior to infusion 2 [Level IV]
• Intravenous (IV) sodium chloride 0.9% (5-30mL) may be administered without prescription
to maintain venous access patency and flushing, prior to and post prescribed medication.
Consider compatible diluents

No. Reference Details

1 Safety and Quality Improvement Guide Standard 5: Patient Identification and
Procedure Matching. Australian Commission on Safety and Quality in Health Care.
October 2012.
2 Glyceryl Trinitrate. Royal Perth Hospital e-MIMS; Nov 2014. Accessed 11/12/14.

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Endorsed by A/Director of Nursing Robyn Kovac: 8th May 2015
 General Information
GTN administration is a first line treatment for patients with cardiac related chest pain and may
be used for its vasodilatory and pain reducing qualities in patients with acute coronary
syndrome (ACS). It may also be used for patients with heart failure and acute pulmonary
oedema 2 [Level IV]. It is an organic nitrate which acts by relaxing the smooth muscle
vasculature of veins and arteries, reducing total peripheral vascular resistance 1,3 [Level IV].
GTN produces a dose-related dilation of both arterial and venous blood vessels. Venous
dilation predominates over arterial dilation 2 [Level IV].
GTN is not for direct intravenous injection – it must be diluted in dextrose 5% or sodium
chloride 0.9% prior to infusion 1 [Level IV].
DO NOT abruptly cease GTN infusion 2 [Level IV]. Wean as prescribed by medical officer (MO)

A major concern with a continuous infusion of GTN is the development of nitrate tolerance
that occurs in most patients within 24 hours 2 [Level IV]. This limits the efficacy of the
treatment and increased dosages may be required.
40-80% of GTN can be lost to adsorption or absorption when using PVC tubing, especially
during early infusion. It is increased in longer tubing and with slower infusion rates
1,3
[Level IV].

GTN Pharmocokinetics
• Half-life of 1-4 minutes
• Therapeutic effect is apparent within 1-2 minutes of intravenous administration
• Duration of action following a single intravenous dose of GTN is about 3-5 minutes
1
[Level IV]
• Monitoring of haemodynamic parameters (e.g. blood pressure, heart rate, central venous
pressure, pulmonary artery and pulmonary capillary wedge pressure as appropriate) must
be performed to observe for the desired physiological effects and side effects of GTN
administration 4 [Level IV]
Drug Interactions
• Concomitant administration of GTN with vasodilators (e.g. sildenafil [Viagra®], vardenafil,
tadalafil) are contraindicated as they may potentiate the vasodilatory effects of GTN
resulting in severe hypotension 1 [Level IV]
• The pharmacological effects of heparin may be decreased by GTN infusions and the
anticoagulation status may need to be monitored when commencing and ceasing GTN
infusions 1,5 [Level IV]
Indications for Use
• Congestive heart failure
• Acute coronary syndrome (ACS)
• Blood pressure control in peri-operative hypertension especially cardiovascular procedures
• Severe systemic hypertension
• Production of controlled hypotension during neurosurgical and orthopaedic surgical
procedures
1
[Level IV]

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Endorsed by A/Director of Nursing Robyn Kovac: 8th May 2015
 Adverse Effects
• Adverse reactions are generally dose related with the majority of reported reactions
occurring as a result of the vasodilatory effect of GTN 1 [Level IV]
Cardiovascular
• Flushing of the face
• Tachycardia/bradycardia
• Hypotension
• Syncope
Central Nervous System
• Headache (severe)
• Dizziness
• Blurred vision
Gastrointestinal
• Nausea/vomiting
Neuromuscular and Skeletal
• Parasthesia
• Weakness
Respiratory
• Hypoxaemia
• Dyspnoea
• Pharyngitis
Contraindications
Contraindicated in the presence of 1 [Level IV]:
• Pre-existing or severe hypotension (systolic blood pressure below 90mmHg or drop of
20mmHg or more below baseline)
• Extreme bradycardia (below 40bpm)
• Obstructive cardiomyopathy
• Pericardial tamponade
• Uncorrected hypovolaemia
• Increased intracranial pressure
• Severe anaemia
• Glaucoma
• Cerebral haemorrhage
• Aortic or mitral valve stenosis
• Concomitant sildenafil (Viagra®) administration
Follow MO instructions if emergency use is required with these conditions.
Use with caution
• In the presence of hypovolaemia
• In patients with known sensitivity to GTN
• In patients with acute myocardial infarction
• Arterial hypoxaemia
• Constrictive pericarditis
• Pregnancy
• Mitral prolapse or stenosis
• In the presence of severe renal or liver disease
1
[Level IV]

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Endorsed by A/Director of Nursing Robyn Kovac: 8th May 2015
 Preparation
Patient
• Check for contraindications to GTN administration
• Liaise with MO if contraindications present
• Ensure patent intravenous (IV) access
• Check all drug compatibilities prior to administration
• Compatible infusions may be infused via same IV access port using a ‘Y’ connector
• Educate patient prior to initial administration of GTN infusion as clinical condition permits.
Refer to Patient Education section

5
• Perform baseline observations pre initial administration of GTN infusion
• Respiratory rate (RR)
• Peripheral oxygen saturations
• Pulse (heart rate [HR] and rhythm if cardiac monitored)
• Blood pressure (BP)
• Central venous pressure (CVP) if clinically indicated
• Pulmonary systemic pressure and pulmonary artery wedge pressure (PAWP) if pulmonary
artery catheter in situ
Inform MO if:
• Systolic blood pressure <90mmHg and/or 20mmHg or more below baseline
• Heart rate <40bpm or >140 bpm
• Impaired conscious state
• Patient complains of syncope (feeling dizzy/faint)
Equipment
• IV GTN as prescribed by MO on Fluid Treatment Chart
• Compatible diluent solution
• Sodium chloride 0.9% or glucose 5% 1 [Level IV]
• A glass infusion bottle is recommended 1 [Level IV]
• 10mL syringe and drawing up needle (21 gauge)
• Drug additive label
• Change tubing date sticker
• 1% chlorhexidine and 70% isopropyl alcohol swab (alcohol swab)
• Volumetric pump or (syringe driver for high acuity areas only)
• Administration set appropriate for the volumetric pump/syringe driver. 40-60% of GTN can
be lost to adsorption or absorption when using PVC tubing, especially during early
infusion. It is increased in longer tubing and with slower infusion rates 1,3 [Level IV]
• Securing tape as required
• Y connector as required

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Endorsed by A/Director of Nursing Robyn Kovac: 8th May 2015
 Preparation cont’d
Equipment for Syringe Driver
• Three way tap
• 10 mL syringe
• Drawing up needle
• 50mL Leur lock syringe. 50mL syringe is made of polypropylene plastic, which is suitable
for GTN infusion
• Syringe driver giving set
Preparation and Administration of GTN Infusion
5
Use aseptic technique at all times.
In Glass Bottles
• Two nurses to prepare infusion.
• Check IV prescription
• Check content, dose and expiry date on GTN ampoule. Refer to Medication
Administration NPS
• Swab injection port of compatible diluent solution alcohol swab. Allow to air dry
• Avoid skin contact with the concentrated GTN solution
• Using 10mL syringe and 21G needle remove volume from diluent, equivalent to the
amount of GTN concentrate solution to be added and discard (e.g. if 50mg GTN is
prescribed in 10mL remove 10mL from diluent)
• Using drawing up needle, draw required volume of GTN concentrate in 10mL syringe
• Add GTN concentrate to compatible diluent
• Invert the prepared solution several times to ensure uniform dilution of GTN 1 [Level IV]
Affix completed drug additive label to the prepared solution
• GTN infusion is commenced at rate as prescribed by MO
• Both nurses to sign Fluid Treatment Chart
• Record time infusion commenced
Utilising Syringe Driver
This may be utilised for fluid restricted patients in the critical care setting. It is recommended
to be administered via central access only, to enable rapid dilution in the bloodstream.

• Two nurses to prepare infusion

• Check prescribed IV drug order
• Check content, dose and expiry date on GTN ampoule. Refer to Medication
Administration NPS
• Calculate the amount of compatible diluent required to make up total 50mL volume
• Swab injection port of compatible diluent solution with alcohol swab. Allow to air dry
• Using 50mL syringe remove required volume from diluent solution (e.g. 40mL)
• Using drawing up needle, draw required volume of GTN concentrate in 10mL syringe
• Add GTN concentrate to compatible diluent in 50mL syringe
• Invert syringe several times to ensure uniform dilution of GTN 1 [Level IV]
Affix completed drug additive label to the syringe containing the prepared solution
• GTN infusion is commenced at rate as prescribed by MO (liaise with MO for titration
parameters)
• Both nurses to sign Fluid Treatment Chart
• Record time infusion commenced
Page 9 of 12 Title: Glyceryl Trinitrate Intravenous Infusion Management NPS
Endorsed by A/Director of Nursing Robyn Kovac: 8th May 2015
 Preparation and Administration of GTN Infusion cont’d
If GTN Concentration is Adjusted
• Draw up adjusted concentration of GTN as prescribed
• Prime new IV infusion line with the adjusted concentration of GTN – including lines to the IV
access devices (e.g. Y connector) to avoid delay to patient receiving adjusted prescription
• Disconnect previous GTN concentration and IV infusion line
• Promptly connect new GTN concentration and line directly to venous access
• Titrate rate of infusion as ordered by MO (liaise with MO for titration parameters)

Infusion Administration
General Information
• Titrate infusion as prescribed by MO (liaise with MO for titration parameters)
• Ensure GTN infusion is not interrupted - dose is titrated to achieve desired level of
haemodynamic function and symptom control 2 [Level IV]
Ensure GTN infusion is continuous:
• When replacing infusion bottle/syringe
• When infusion bottle/syringe completed
• Ensure GTN prepared solution is changed within 24 hours as a minimum 1 [Level IV]

Haemodynamic Observations Post-Commencement and

after Rate Change of GTN Infusion
Record pulse, BP and oxygen saturations:
• Every 5 minutes until titrated to final rate
• Then every 15 minutes for 1 hour and prn as determined by titration parameters
• Then 2-4 hourly unless patient’s clinical condition indicates more frequent
observations
This observation regime is to be followed at commencement of infusion and for any alteration
in rate or concentration of GTN infusion.
Haemodynamic Parameters
Liaise with MO if:
• Pulse rate is:
• Consistently varying by +/- 30 bpm pre-infusion pulse rate or
• < 40bpm
• > 140bpm
• Systolic BP is 20mmHg or more below pre infusion BP and/or fall of systolic BP below
90mmHg
• An episode of chest pain continues/persists for more than 15 minutes
• Activate Medical Emergency Team (MET) call as per MET criteria. Refer to Management
of Medical Emergencies and Cardiorespiratory Arrest CPS
• Assess venous access site, if extravasation occurs or loss of IV access, stop infusion
immediately and inform MO
• Prepare for insertion of new venous access and resume GTN infusion as soon as
possible. Monitor patient’s haemodynamic observations whilst infusion stopped

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Endorsed by A/Director of Nursing Robyn Kovac: 8th May 2015
 Patient Activity with GTN Infusion in Progress
Patient is to remain rest in bed until:
• Infusion dose stable and the haemodynamic observations are unchanged for 2 hours
• Or in consultation with MO or Shift Coordinator in critical care areas
• No symptoms of dizziness, fainting, chest pain or tachycardia present
Record BP, pulse and HR prior to ambulation
If any change in patients clinical condition occurs during ambulation:
• Return patient to bed
• Perform haemodynamic observations
• Inform MO and Shift Coordinator
• Activate MET or cardiac arrest as per CPS criteria

Weaning GTN
• Wean IV GTN infusion as prescribed by MO (liaise with MO for titration parameters)
• Monitor observations a minimum of 5 minutes after each change in infusion rate and as
clinically indicated
• DO NOT abruptly cease GTN infusion as it may induce rebound vasoconstriction
1
[Level IV]. Wean as prescribed by medical officer (MO)
Document time GTN infusion ceased in patient integrated notes.

Patient Education
• Patient is to be educated on the benefits, titration, side effects and contraindications of
being prescribed intravenous GTN therapy (as applicable)

Documentation
Document in patient integrated notes:
• Rate of administration
• Titration
• Adverse events such as tachyarrhythmias, hypotension
• Time GTN infusion ceased
Haemodynamic observations pre and during administration are recorded on the Observation
Chart or Unit Specified Observation Chart (e.g. CCU or ICU Chart).

No. Reference Details

1 Glyceryl Trinitrate. Royal Perth Hospital e-MIMS; Nov 2014. Accessed 11/12/14.
2 Reeder GS. Nitrates in the management of acute coronary syndrome. UpToDate.
2014. Available from: URL: www.uptodate.com. Accessed 11/12/14
3 Chu V. Glyceryl Trinitrate (GTN) Infusion: Clinician Information. The Joanna Briggs
Institute. 01/07/2014.
4 Jayasekara R. Glyceryl Trinitrate (GTN) Infusion: Clinician Information. The Joanna
Briggs Institute. 01/11/2011.
5 No author. UpToDate. Nitroglycerin (glyceryl trinitrate): Drug information. 2012.
Lexicomp, Inc. Available from: URL: www.uptodate.com. Accessed December 2014.

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Endorsed by A/Director of Nursing Robyn Kovac: 8th May 2015
 Appendix I: Table of GTN Concentrations
The following concentrations are calculated utilising GTN concentrate injection ampoule
50mg/10mL.
500 micrograms/mL GTN concentration (most common dilution prescribed)
Remove 10mL glucose 5% from bottle.
Add 50mg (10mL) glyceryl trinitrate to 90mL glucose 5%.
50mg in 100mL = 500micrograms/mL.

DOSAGE (micrograms/min) FLOW RATE (mL/hr)

5 0.6
10 1.2
15 1.8
20 2.4
25 3
30 3.6
1000 micrograms/mL GTN concentration (used in critical care areas only)

This may be utilised for fluid restricted patients in the critical care setting. It is recommended
to be administered via central access only, to enable rapid dilution in the blood stream.

Add 50mg (10mL) glyceryl trinitrate to 40mL glucose 5% or sodium chloride 0.9% in a syringe
50mg in 50mL = 1000 micrograms/mL or 100mg in 100mL in glass bottle.

DOSAGE (micrograms/min) FLOW RATE (mL/hr)

5 0.3
10 0.6
15 0.9
20 1.2
25 1.5
30 1.8

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Endorsed by A/Director of Nursing Robyn Kovac: 8th May 2015