Patient Group Direction For Use Within NHS Grampian ... · prominences, large underlying muscles,...

Patient Group Direction For Use Within NHS Grampian, Highland, Orkney, Shetland, Tayside and Western Isles

UNCONTROLLED WHEN PRINTED Review Date: April 2021 Identifier: NoS/PGD/EOLC_C19/MGPG1091 - i - PGD For The Administration Of Medicines in the EOLC C19 PGD Formulary - Version 1 Template Version NoS v4

Revision History: Reference and approval date of PGD that has been adapted and/or superseded

New PGD

Date of change

Summary of Changes

Section heading

April 2020 New PGD Formulary

NoS Identifier: NoS/PGD/EOLC_C19/MGPG1091 Keyword(s): PGD Patient Group Direction Buscopan Hyoscine

Butylbromide Midazolam Levomepromazine end of life EOLC palliative Morphine

Policy Statement: It is the responsibility of the individual healthcare professionals and their line managers to ensure that they work within the terms laid down in this PGD and to ensure that staff are working to the most up to date PGD. By doing so, the quality of the services offered will be maintained, and the chances of staff making erroneous decisions which may affect individual, staff or visitor safety and comfort will be reduced. Supervisory staff at all levels must ensure that staff using this PGD act within their own level of competence. The lead author is responsible for the review of this PGD and for ensuring the PGD is updated in line with any changes in clinical practice, relevant guidelines, or new research evidence. Review date: The review date for a PGD needs to be decided on a case-by-case basis in the interest of safety. The expiry date should not be more than 3 years, unless a change in national policy or update is required. This PGD is intended for use during the COVID-19 pandemic and may be withdrawn by NoS PGD group, or by individual boards, prior to its review date. Document: Drafted: April 2020 Completed: April 2020 Approved: April 2020 (published – April 2020) Amended:

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UNCONTROLLED WHEN PRINTED Review Date: April 2021 Identifier: NoS/PGD/EOLC_C19/MGPG1091 - 1 - PGD For The Administration Of Medicines in the EOLC C19 PGD Formulary - Version 1 Template Version NoS v4

Patient Group Direction For The Administration Of Medicines Included In The COVID-19 End Of Life Care PGD Formulary By Approved Healthcare Professionals Working Within NHS Grampian, Highland, Orkney, Shetland, Tayside And Western Isles Clinical indication to which this PGD applies Definition of situation/ Condition

This Patient Group Direction (PGD) will authorise approved healthcare professionals as detailed in the characteristics of staff authorised to work under this PGD to administer as included in the End of Life Care (EOLC) PGD Formulary Appendix 3 to individuals with suspected or confirmed COVID-19 in the last days of life, and where no prescriber is available to issue a prescription. This PGD should be used in conjunction with the recommendations in the current British National Formulary (BNF), the individual Summary of Product Characteristics (SmPC),the Scottish Palliative Care Guidelines – End of Life Care, Scottish Palliative Care Guidelines - Care in the Last Days of Life and the Scottish Palliative Care Guidelines - End of Life Care Guidance when a Person is Imminently Dying from COVID-19 Lung Disease.

Inclusion criteria Individuals aged 16 years and over where the oral route is NOT available or inappropriate, e.g. the individual cannot swallow, has persistent nausea and vomiting, or where there are concerns regarding absorption. Prior to the administration of the medicine, valid consent to receiving treatment under this PGD must be obtained. Consent must be in line with current individual NHS Boards consent policy.

Exclusion criteria Individuals may be administered a medicine(s) specified in Appendix 3 under this PGD unless; • They are less than 16 years of age • They have previously experienced an anaphylactic reaction

to the medicine(s) • They meet any exclusion criteria listed in the individual

monographs • Where there is no valid consent.

Precautions and special warnings

It is the responsibility of the designated, authorised healthcare professional using this PGD to ensure that treatment with the medicine(s) detailed in this direction is appropriate. If in any doubt, advice should be sought and recorded before the medicine is administered.

https://www.bnf.org/products/bnf-online/

https://www.medicines.org.uk/emc/

https://www.palliativecareguidelines.scot.nhs.uk/guidelines/end-of-life-care.aspx


https://www.palliativecareguidelines.scot.nhs.uk/guidelines/end-of-life-care/Care-in-the-Last-Days-of-Life.aspx


https://www.palliativecareguidelines.scot.nhs.uk/guidelines/symptom-control/end-of-life-care-guidance-when-a-person-is-imminently-dying-from-covid-19-lung-disease.aspx





Action if excluded from treatment

Medical advice must be sought – refer to relevant medical practitioner. Document the reason for exclusion under the PGD and any action taken in the individual’s appropriate clinical records.

Action if treatment is declined

Ensure the individual is aware of the implications of declining treatment. Inform/refer to the relevant medical practitioner if individual declines treatment. Document that the administration was declined, the reason and advice given in appropriate clinical records.

Description of treatment available under the PGD Name form and strength of medicine

See individual medicine monographs.

Legal status

The medicines referred to in this PGD are all Prescription-only Medicines (PoMs). Additionally Midazolam is a Controlled Drug (Schedule 3) and Morphine Sulfate is a Controlled Drug (Schedule 2).

Dosage/Maximum total dose


Frequency of dose/Duration of treatment


Maximum or minimum treatment period


Route/Method of administration

Subcutaneous injection.

Prior to injection ensure the chosen injection site is clean and free of infection, skin lesions, scars, birthmarks, bony prominences, large underlying muscles, blood vessels, nerves, oedema, ascites, skin folds and has not been irradiated previously.



As the amount of subcutaneous fat varies between individuals, individual assessment is vital before carrying out the procedure. It is important to avoid inadvertently injecting the medicine into muscle, as intramuscular injection can affect drug absorption. The usual method for subcutaneous medicines to be given is via an indwelling subcutaneous device, e.g. Saf-T-IntimaTM. Following administration of medicines via a device subcutaneously, water for injections must be used to flush any remaining irritating solution away from the line, and ensure that the individual receives the full dose of the medication. Subcutaneous injections can also be given directly using a syringe and needle with the needle straight in at a 90 degree angle or at a 45 degree angle. Give the injection at a 90 degree angle if you can grasp 2 inches of skin between your thumb and first finger. If you can grasp only 1 inch of skin, give the injection at a 45 degree angle. There is no requirement to use a flush of water for injections following administration of medicines via this method. N.B. If this method of injection is used releasing the skin too quickly before the injection is completed or lifting the skin incorrectly can increase the risk of inadvertent intramuscular injection.

Quantity to be administered


Storage requirements


Follow-up (if applicable)

Individuals should be referred/discussed with a medical practitioner if treatment proves to be ineffective in relieving symptoms. If this is necessary a recommended treatment plan may be discussed and agreed and the medical practitioner can give verbal instruction to the healthcare practitioner regarding the medicines and doses to be administered in the individual situation. This instruction would be issued as a Patient Specific Direction (PSD) and not covered under this PGD.

Advice (Verbal) Advise individual what to expect and what to do for minor and major reactions.



Advice (Written) The Patient Information Leaflet (PIL) contained in the medicine(s) should be made available to the individual. Where this is unavailable, or unsuitable, sufficient information should be given in a language and way that they can understand.

Identifying and managing possible adverse reactions

See individual medicine monographs. This list of adverse effects in each medicine monograph is not exhaustive. Please also refer to current BNF and manufacturers SmPC for details of all potential adverse reactions. BNF: https://www.bnf.org/products/bnf-online/ SmPC/PIL/Risk Minimisation Material: https://www.medicines.org.uk/emc/ http://www.mhra.gov.uk/spc-pil/index.htm https://www.medicines.org.uk/emc/rmm-directory If an adverse reaction does occur give immediate treatment and inform relevant medical practitioner as soon as possible. Report any severe reactions using the Yellow Card System. https://yellowcard.mhra.gov.uk/

Facilities and supplies required

The following are to be available at sites where the medicine is to be supplied/administered: • Appropriate storage facilities • An acceptable level of privacy to respect individual’s right to

confidentiality and safety • Immediate access to Epinephrine (Adrenaline) 1 in 1000

injection • Access to a working telephone • Another competent adult, who can summon urgent

emergency support if required should ideally be present • Access to medical support (this may be via the telephone) • Approved equipment for the disposal of used materials • Clean and tidy work areas, including access to hand

washing facilities or alcohol hand gel • A copy of this current PGD in print or electronically.



http://www.mhra.gov.uk/spc-pil/index.htm

https://www.medicines.org.uk/emc/rmm-directory

https://yellowcard.mhra.gov.uk/



Characteristics of staff authorised to administer medicine(s) under PGD Professional qualifications

Registered nurses as recognised by the Nursing and Midwifery Council (NMC). Registered paramedics as recognised by the Health and Care Professionals Council (HCPC).

Specialist competencies

Approved by the organisation as: • Competent to assess the individual’s capacity to

understand the nature and purpose of the medicine administration in order to give or refuse consent

• Aware of current treatment recommendations and be competent to discuss issues about the medicine with the individual

• Having undertaken appropriate training to carry out clinical assessment of individuals identifying that treatment is required according to the indications listed in the PGD

• Competent in administering medicines using subcutaneous injection using an aseptic technique

• Competent to work under this PGD.

Ongoing training and competency

All professionals working under this PGD must: • Have undertaken PGD training as required/set out by each

individual Health Board • Have attended basic life support training which is required

to be updated annually • Have undertaken NHS e-anaphylaxis training or equivalent

(including annual updates) which covers all aspects of the identification and management of anaphylaxis

• Maintain their skills, knowledge and their own professional level of competence in this area according to their Code of Professional Conduct

• Have knowledge and familiarity of the following; o SmPC for the medicine(s) to be administered in

accordance with this PGD o Scottish Palliative Care Guidelines.

Responsibilities of professional manager(s)

Professional manager(s) will be responsible for; Ensuring that the current PGD is available to all staff providing care under this direction. Ensuring that staff have received adequate training in all areas relevant to this PGD and meet the requirements above. Maintain up to date record of all staff authorised to administer the medicine(s) specified in this direction.


https://www.palliativecareguidelines.scot.nhs.uk/



Documentation Authorisation of administration

Nurses and paramedics working within NHS Grampian, Highland, Orkney, Shetland, Tayside and Western Isles can be authorised to administer the medicine(s) specified in this PGD by their Professional Line Manager/Consultant/Practice GP. All authorised staff are required to read the PGD and sign the Agreement to Administer Medicines Under PGD (Appendix 1). A Certificate of Authorisation (Appendix 2) signed by the authorising professional/manager should be supplied. This should be held in the individual health professional’s records, or as agreed within the individual Health Board.

Record of administration

An electronic or paper record for recording the screening of individuals and the subsequent administration, or not of the medicine(s) specified in this PGD must be completed in order to allow audit of practice. This should include as a minimum: • Date and time of administration • Individuals name and CHI • Exclusion criteria, record why the medicine was not

administered (if applicable) • Record that valid consent to treatment under this PGD was

obtained • The name, dose, form, route (batch number, expiry date

and site where appropriate for injectable medicines) of the medicine administered/supplied

• Advice given, including advice given if excluded or declined treatment under this PGD

• Signature and name in capital letters of the healthcare professional who supplied/administered the medicine

• Record of any adverse effects (advise individuals GP/relevant medical practitioner).

Depending on the clinical setting where administration is undertaken, the information should be recorded manually or electronically, in one (or more) of the following systems, as appropriate: • Consent forms • Individual’s GP records if appropriate • Secondary Care Medical Notes • Individual service specific systems.



Audit All records of the medicine(s) specified in this PGD will be filed with the normal records of medicines in each practice/service. A designated person within each practice/service where the PGD will be used will be responsible for annual audit to ensure a system of recording medicines administered under a PGD.

References

Electronic Medicines Compendium http://www.medicines.org.uk Medicine Date of

Revision Date Accessed

Hyoscine Butylbromide 20mg/mL Ampoule for Injection (Buscopan®)

25/11/19 02/04/20

Levomepromazine Hydrochloride 25mg/mL Solution for Injection (Wockhardt)

26/04/17 02/04/20

Midazolam10mg/2mL Solution for Injection (Hypnovel®)

01/08/19 02/04/20

Morphine Sulfate 10mg/mL Solution for Injection (Hameln Pharmaceuticals ltd)

03/03/20 02/04/20

Water for Injections BP (ADVANZ Pharma)

25/03/19 14/04/20

British National https://www.bnf.org/products/bnf-online/ accessed 02/04/20. Resuscitation Council (UK) Emergency Treatment of Anaphylactic Reactions Guidelines for Healthcare Providers (2008). Scottish Palliative Care Guidelines – End of Life Care (December 2020) Scottish Palliative Care Guidelines - End of Life Care Guidance when a Person is Imminently Dying from COVID-19 Lung Disease (April 2020)

http://www.medicines.org.uk/







Appendix 1 Healthcare Professional Agreement to Administer Medicine(s) Under

Patient Group Direction I:

(Insert name)

Working within:

e.g. Area, Practice

Agree to administer the medicine(s) contained within the following Patient Group Direction: Patient Group Direction For The Administration Of Medicines Included

In The COVID-19 End Of Life Care PGD Formulary By Approved Healthcare Professionals Working Within NHS Grampian, Highland,

Orkney, Shetland, Tayside And Western Isles I have completed the appropriate training to my professional standards enabling me to administer the medicine(s) under the above direction. I agree not to act beyond my professional competence, nor out with the recommendations of the direction. Signed:

Print Name:

Date:

Profession:

Professional Registration number/PIN:


Appendix 2

Healthcare Professionals Authorisation to Administer Medicine(s) Under Patient Group Direction

The Lead manager/Professional of each clinical area is responsible for maintaining records of all clinical areas where this PGD is in use, and to whom it has been disseminated.

The Senior Nurse/Professional who approves a healthcare professional to administer the medicine(s) under this PGD is responsible for ensuring that he or she is competent, qualified and trained to do so, and for maintaining an up-to-date record of such approved persons.

The Healthcare Professional that is approved to administer the medicine(s) under this PGD is responsible for ensuring that he or she understands and is qualified, trained and competent to undertake the duties required. The approved person is also responsible for ensuring that administration is carried out within the terms of the direction, and according to his or her individual code of professional practice and conduct.

Patient Group Direction For The Administration Of Medicines Included In The COVID-19 End Of Life Care PGD Formulary By Approved Healthcare

Professionals Working Within NHS Grampian, Highland, Orkney, Shetland, Tayside And Western Isles

Local clinical area(s) where the listed healthcare professionals will operate under this PGD:

Name of Healthcare Professional

Signature

Date

Name of Manager

Signature

Date


Patient Group Direction For The Administration Of Medicines Included In The COVID-19 End Of Life Care PGD Formulary By Approved Healthcare

Professionals Working Within NHS Grampian, Highland, Orkney, Shetland, Tayside And Western Isles

Name of Healthcare Professional

Signature

Date

Name of Manager

Signature

Date


Appendix 3

End of Life Care PGD Formulary Medicines Hyoscine Butylbromide 20mg/mL Ampoule for Injection (Buscopan®) (Administer) . 12

Levomepromazine Hydrochloride 25mg/mL Solution for Injection (Administer)........ 14

Midazolam10mg/2mL Solution for Injection (Administer) .......................................... 16

Morphine Sulfate 10mg/mL Solution for Injection (Administer) ................................. 18

Water for Injections BP (Administer) ......................................................................... 20

End of Life Care PGD Formulary


Hyoscine Butylbromide 20mg/mL Ampoule for Injection (Buscopan®) (Administer)

Legal Status PoM N.B. The use of hyoscine butylbromide for respiratory secretions is outside the terms of the marketing authorisation and constitutes an off-label use of the medicine. However, the dosing regimen is in accordance with Scottish Palliative Care Guidelines.

Indication Individuals approaching end of life and identified as requiring treatment for respiratory secretions or colic according to Scottish Palliative Care Guidelines - Care in the Last Days of Life and the Scottish Palliative Care Guidelines - End of Life Care Guidance when a Person is Imminently Dying from COVID-19 Lung Disease, and where no prescriber is available to issue a prescription.

Inclusion Criteria As per main PGD inclusion criteria. Exclusion Criteria As per main PGD exclusion criteria.

N.B. There are no absolute contraindications to the use of hyoscine butylbromide injection in EOLC. Medical advice should be sought immediately for any individual who is excluded from the PGD.

Dose/Maximum total dose

20mg (1mL) as a single dose. Maximum dose under this PGD is three doses (60mg) before a prescription/review by a medical practitioner is required.


As required for respiratory secretions or colic. DO NOT repeat the dose within ONE hour.


See Dose/Maximum total dose section above.

Route/Method of Administration

Subcutaneous injection. Following administration via a subcutaneous device water for injections 0.5mL must be used as a flush to ensure the individual receives the full dose of the medicine.


20mg (1mL) up to a maximum of three doses (60mg).









Hyoscine Butylbromide 20mg/mL Ampoule for Injection (Buscopan®) (Administer)

Potential Adverse Reactions

The most common adverse effects of subcutaneous administration are injection-site reactions, including local swelling, redness, itching, soreness and induration. Common side effects: Tachycardia, dizziness, dry mouth. Refer to BNF for other side-effects.

Advice Explain to the individual/family or carer the reason for giving the injection, the expected benefit, and potential adverse effects particularly blurred vision, gritty eyes and dry mouth. Encourage good oral care (See Scottish Palliative Care - Mouth Care Guideline). Delays or difficulty in passing urine should be reported as soon as practicable to the healthcare provider responsible for the individual’s EOLC.

Follow up (If applicable)

Individuals should be referred to a medical practitioner if treatment proves to be ineffective in relieving symptoms.

Storage Store below 30°C.

https://www.palliativecareguidelines.scot.nhs.uk/guidelines/symptom-control/Mouth-Care.aspx

https://www.palliativecareguidelines.scot.nhs.uk/guidelines/symptom-control/Mouth-Care.aspx



Levomepromazine Hydrochloride 25mg/mL Solution for Injection (Administer)

Legal Status PoM

Indication Individuals approaching end of life and identified as requiring treatment for nausea and vomiting or agitation and delirium according to Scottish Palliative Care Guidelines - Care in the Last Days of Life and the Scottish Palliative Care Guidelines - End of Life Care Guidance when a Person is Imminently Dying from COVID-19 Lung Disease, and where no prescriber is available to issue a prescription.


N.B. There are no absolute contraindications to the use of levomepromazine injection in EOLC. Medical advice should be sought immediately for any individual who is excluded from the PGD.


2.5mg (0.1mL) as a single dose for nausea and vomiting. 10mg (0.4mL) as a single dose for agitation and delirium. Maximum dose under this PGD is three doses (7.5mg) for nausea and vomiting before a prescription/review by a medical practitioner is required. Maximum dose under this PGD is three doses (30mg) for agitation and delirium before a prescription/review by a medical practitioner is required.


As required for nausea and vomiting or agitation and delirium. DO NOT repeat the dose within ONE hour.






2.5mg (0.1mL) up to a maximum of 3 doses (7.5mg) for nausea and vomiting. 10mg (0.4mL) up to a maximum of 3 doses (30mg) for agitation and delirium.







Levomepromazine Hydrochloride 25mg/mL Solution for Injection (Administer)

N.B. For single dose use only. Discard any unused solution immediately and safely.


The most common adverse effects of subcutaneous administration are injection-site reactions, including local swelling, redness, itching, soreness and induration. Common side effects: Dry mouth, somnolence, hypotension, asthenia and QT Prolongation. Refer to BNF for other side-effects.

Advice Explain to the individual/family or carer the reason for giving the injection, the expected benefit and potential adverse effects particularly sleepiness. Emphasise the significance of having any important communication prior to administration.



Storage Store below 30°C.



Midazolam10mg/2mL Solution for Injection (Administer)

Legal Status PoM and Controlled Drug (Schedule 3 – record of administration not required in Controlled Drug register). N.B. The use of midazolam for anxiety, agitation or breathlessness is outside the terms of the marketing authorisation and constitutes an off-label use of the medicine. However, the dosing regimen is in accordance with Scottish Palliative Care Guidelines.

Indication Individuals approaching end of life and identified as requiring treatment for anxiety, agitation or breathlessness according to Scottish Palliative Care Guidelines - Care in the Last Days of Life and the Scottish Palliative Care Guidelines - End of Life Care Guidance when a Person is Imminently Dying from COVID-19 Lung Disease, and where no prescriber is available to issue a prescription. N.B. It is important to ensure the cause of the acute anxiety or agitation is not pain - if pain is suspected as the cause, this must be treated before considering the administration of Midazolam.


N.B. There are no absolute contraindications to the use of midazolam injection in EOLC. Medical advice should be sought immediately for any individual who is excluded from the PGD.


2mg (0.4mL, if 10mg/2mL injection used) as a single dose. Midazolam 10mg/2mL is the most appropriate strength of ampoule for use in palliative care. Maximum dose under this PGD is three doses (6mg) before a prescription/review by a medical practitioner is required.


As required for anxiety or agitation. DO NOT repeat the dose within ONE hour.




Subcutaneous injection.









Midazolam10mg/2mL Solution for Injection (Administer)

Following administration via a subcutaneous device water for injections 0.5mL must be used as a flush to ensure the individual receives the full dose of the medicine.


2mg dose up to a maximum of three doses (6mg). N.B. For single dose use only. Discard any unused solution immediately, safely and in-line with Board policy relating to controlled drugs after initial use.


The most common adverse effects of subcutaneous administration are injection-site reactions, including local swelling, redness, itching, soreness and induration. Common side effects: Ataxia (more common in elderly); confusion (more common in elderly); dizziness; drowsiness; dysarthria; fatigue; gastrointestinal disorder; headache; hypotension; mood altered; muscle weakness; nausea; respiratory depression. N.B. Paradoxical anxiety or agitation may be caused as a result of administering midazolam. Refer to BNF for other side-effects.

Advice Explain to the individual/family or carer the reason for giving the injection, the expected benefit and potential adverse effects particularly sleepiness. Emphasise the significance of having any important communication prior to administration.



Storage Do not store above 25°C.



Morphine Sulfate 10mg/mL Solution for Injection (Administer)

Legal Status Controlled Drug (Schedule 2 – record of administration MUST be made in the Controlled Drug register).

Indication Individuals approaching end of life and identified as requiring treatment for pain or shortness of breath according to NHS Scottish Palliative Care Guidelines - Care in the Last Days of Life and the Scottish Palliative Care Guidelines - End of Life Care Guidance when a Person is Imminently Dying from COVID-19 Lung Disease, and where no prescriber is available to issue a prescription.


N.B. Individuals on a regular opioid, equivalent to more than 40mg of oral morphine per day, will require higher doses which are out with the scope of this PGD. Seek advice to calculate dose equivalents if required. Such individuals may already have an appropriate “as required” opioid prescribed. N.B. There are no absolute contraindications to the use of morphine injection in EOLC. Medical advice should be sought immediately for any individual who is excluded from the PGD.


2mg (0.2mL of the 10mg/1mL injection) as a single dose. Maximum dose under this PGD is three doses (6mg) before a prescription/review by a medical practitioner is required.


As required for pain or shortness of breath. DO NOT repeat the dose within ONE hour.






2mg dose up to a maximum of three doses (6mg). N.B. For single dose use only. Discard any unused solution immediately, safely and in-line with Board policy relating to controlled drugs after initial use.








Morphine Sulfate 10mg/mL Solution for Injection (Administer)


The most common adverse effects of subcutaneous administration are injection-site reactions, including local swelling, redness, itching, soreness and induration. Very common side effects: Nausea, vomiting, constipation, respiratory depression (not associated with breathlessness), sedation, drowsiness, itching, disorientation, hallucinations, dysphoria, euphoria, tolerance. N.B. It is important to monitor individuals for signs of morphine toxicity. Symptoms include persistent sedation, vivid dreams/hallucinations, shadows at the edge of the visual field, delirium, muscle twitching/myoclonus/jerking and abnormal skin sensitivity to touch. If there any concerns seek immediate medical advice Refer to BNF for other side-effects.

Advice Explain to the individual/family or carer the reason for giving the injection, the expected benefit and potential adverse effects particularly the possibility of subtle hallucinations



Storage Do not store above 25°C. Protect from light.



Water for Injections BP (Administer)

Legal Status PoM

Indication Individuals approaching end of life and identified as requiring treatment under this PGD where the medicine(s) for subcutaneous administration requires water for injections to flush any remaining irritating solution away from the line, and ensure that the individual receives the full dose of the medication.


Medical advice should be sought immediately for any individual who is excluded from the PGD.


The standard dose to be used as a flush post administration of a subcutaneously administered medicine(s) is 0.5mL. (N.B. the BD saf-t-intima™ device has a dead space of 0.2mL).


N/A


N/A


To be used as a flush following the administration of medicine(s) via subcutaneous injection.


0.5mL per flush.


Water for Injections is hypotonic and it should not be administered alone, because it may cause haemolysis. Refer to BNF for other side-effects.

Advice Administer the flush slowly.


N/A

Storage Do not store above 25°C.

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