February 2009 1

Pharmaceutical Aspects of IV Medicine Administration

September 2009

February 2009 2

Contents of Session

The 5 Rights of Medicines Administration The 5 Components of Medicines

Administration Practitioner Responsibilities

February 2009 3

The Five Rights of Medicine Administration

1. Right patient2. Right medicine3. Right route4. Right dose5. Right time

……everytime!

February 2009 4

The Five Components of Medicine Administration

1. Selection2. Prescribing3. Preparation4. Administration5. Monitoring

February 2009 5

Why IV?

Oral or other route of administration not suitable or available eg vomiting, diarrhoea, malabsorption, resting gastro-intestinal tract, low muscle mass

Where rapid effect or high/predictable concentrations essential

Medicine not effective via other routes eg gentamicin, benzylpenicillin

February 2009 6

Advantages of IV

Medicine gets into the circulation quickly Rapid effect achieved Predictable concentrations achieved i.e. 100%

reaches systemic circulation Some medicines cannot be given by another

route eg gentamicin

February 2009 7

Prescribing Prescription is clear, unambiguous and legal Medicine is essential and appropriate for

patient The patient is not allergic to medicine Dose, route and rate essential and appropriate Medicine is compatible with flush and infusion

fluid

February 2009 8

Medicines Characteristics

Cytotoxics, TPN – outsourced or made in pharmacy Diazepam – must only be administered with extreme

caution and competence IV paracetamol reduced dose in patients weighing less

than 50Kgs (dose 15mg/Kg in 40kg patient = 600mg)

February 2009 9

Dose, Route and Rate

Is route suitable for medicine?eg vincristine given intrathecally causing death, cytotoxics given peripherally causing severe extravasation and loss of limbs

Is route suitable for required rate?

Properties of the medicine? eg osmolarity, pH

What routes are available?

February 2009 10

Concentration Check that the concentration of the drug is within the

recommended range for safety and efficacyeg erythromycin must be between 1-5mg/ml

Diluent and Vehicle Not always the same! Check!

eg clarithromycin must be reconstituted with water but diluted in sodium chloride 0.9%

Concentration, Diluent and Vehicle

February 2009 11

Instability – modification of the preparation due to storage conditions resulting in unsuitable product

Incompatibility – two or more products mixed with resulting preparation unsuitable for administration

Results: product becomes toxic, precipitates or ineffective

Never add medicines to fluid unless compatibility assured Never mix medicines together unless compatibility assured

Compatibility and Stability

February 2009 12

Compatibility and stability

• Heparin / Aminoglycosides• Hydrocortisone / flucloxacillan• Co-amoxiclav - stability when

reconstituted

February 2009 13

Factor Effect Action Example

Light rate of degradation

Ensure appropriate storage

TPN, Pabrinex®

Temperature rate of degradation / microbial growth

Ensure appropriate storage

Aciclovir, insulin, TPN

pH rate of degradation

Add buffer Amphotericin

Concentration Less stable at changes in concentration

Check volume Amiodarone, amphotericin

Adsorption Drug loss into plastic/glass

Avoid or minimise contact

GTN, insulin

3. Preparation: Factors Affecting Stability

February 2009 14

Displacement volume volume of fluid displaced by a powder when reconstituted Important when part-vials are used Mainly only relevant to paediatricspH Most medicines are stable at a specific pH Rate of degradation often pH dependent

eg amphotericin requires glucose pH>4.2

Displacement Volumes and pH

February 2009 15

All products must be labelled fully Complete label before preparing injection A record must be kept of all injections

prepared and administered (kardex, infusion chart or both)

Bolus drugs …must be administered immediately on preparation, do not prepare in advance!

Labelling

February 2009 16

Sources of Information

IV Drug Monographs/ Medusa website BNF/BNFC Product Information Leaflet Medicines Information Pharmacist On-call Pharmacist University College London Hospitals

Injectable Medicine Administration Guide

February 2009 17

Red Man Syndrome

February 2009 18

Rate of Administration

Most IV bolus injections over at least 3-5 minutes Ensure device is capable of accurate delivery and desired

infusion rate 95% of IV bolus injections given too fast

Systemic damage Furosemide ototoxicity Phenytoin arrhythmias Ranitidine bradycardia Vancomycin red man

Local damage Pain Extravasation Phlebitis

February 2009 19

IV Error Potential Article in BMJ 2003 - Errors identified in 49% of doses surveyed - 8% wrong diluent/solvent - 3% wrong dose prepared - 3% of doses omitted - 38% of bolus doses given too fast - 3% incompatibility

February 2009 20

Professional Responsibility

Prescriber and Administrator Prescription is clear, unambiguous and legal Medicine is essential and appropriate Dose, route and rate is essential and appropriate Medicine is compatible with infusion fluid Appropriate monitoring requirements are in place

eg ECG machine for potassium infusions

February 2009 21

Professional Responsibility

Nurse Must have completed IV Medicines Training Package,

be certified competent and be aware of own limitations Training must be recognised by NHSGGC Must not administer a drug if doubtful about any aspect

of IV medicine prescription / calculation / preparation / compatibility / administration / monitoring

Must ensure that appropriate and current information sources used

February 2009 22

Professional Responsibility

Pharmacist Specialist knowledge Access to specialist information Can advise and provide support on any aspect of IV

medicine use ie dose, calculations, method and rate of administration, diluents, stability and incompatibilities

Can provide advice 24 hours a day via ward pharmacist, medicines information or on-call pharmacist

February 2009 23

Remember

If in doubt, don’t administer!

Most important consideration is the PATIENT

They have to suffer the consequences