Procedures for Administering Injectable Drugs - WB1/0 for Injectable Drug... · 1 1.1 Injectable...

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Procedures for Administering Injectable Drugs

Date Version

December 2012 Issue 8

Purpose

The purpose of this document is to inform Trust staff of the correct and safe methods of preparation

and administration of injectable drugs. It includes information on the use of infusion devices.

Who should read this document?

All staff working for or on behalf of Plymouth Hospitals NHS Trust who prepare and administer fluids and drugs by injection or infusion.

Key messages

Staff working for or on behalf of Plymouth Hospitals NHS Trust who prepare and administer fluids and drugs by injection or infusion must do so in accordance with these procedures.

Accountabilities

Production Peter Gray, Pharmacist

Review and approval Medicines Governance Committee

Ratification Medicines Governance Committee

Dissemination Peter Gray, Pharmacist

Compliance Medicines Governance Committee

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Links to other policies and procedures

Pharmacy documents available on Plymouth Healthnet via

http://nww.picts.nhs.uk/PHNetLive/DesktopDefault.aspx?tabid=1715

• PHNT Medicines Management Policy

• SOPs for preparing and administering intravenous medicines and fluids.

• SOPs for the management of phlebitis, infiltraton, air embolism, speedshock and extravasation.

• SOPs for the safe handling and administration of injectable cytotoxic drugs.

• SOP for setting up and maintaining variable rate intravenous insulin infusions.

PHNT Vascular Access Documents:

• Administration of Medication through a Central Venous Catheter (CVC)

• Removal of a Central Line

• PHNT Central Vascular Access Guidelines

http://www.plymouthhospitals.nhs.uk/ourservices/clinicaldepartments/Pages/VascularAccessTeam.aspx

PHNT Infection Control Documents:

• Guidelines for the Management of Peripheral Intravenous Devices

• Guidelines for the Management of Central Intravenous Catheters

• Hand Hygeine Guidelines

• Guidelines for Aseptic Technique

• Safe Disposal of Sharps Policy

Other Documents:

• Royal College Nursing Standards for Infusion Therapy, 2010

• Department of Health High Impact Intervention Care Bundles for-

• Central venous catheter care

• Peripheral intravenous cannula care

• Renal haemodialysis

• Cleaning and decontamination

• Blood Cultures

• The Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance (published 14 Dec 2010),

Version History

Issue 6 November 2010

Issue 7 December 2011

• Pages of text from other existing PHNT policies were removed and replaced with the links to other PHNT documents above.

• Early review of all sections including all drug monographs. Many existing drug monographs were amended to reflect new recommendations, additional routes, changes to the product licence and new hospital department guidelines. Several injectable medicines were newly approved for use in PHNT in the 12 months since Issue No.6 of this policy. Monographs for these were written.

Issue 8.1 December 2012

• Sections of PHNT policy (which staff can give IV drugs, flushing and line-locks, and Strong Potassium Chloride) have been removed and relocated in the PHNT Medicines Management Policy.

• Sections relating to venepuncture and giving drugs through various cannulae types have been removed and will be relocated in Trust Folders for Combined Laboratories and Vascular Access respectively.

• Several existing monographs required updating and monographs for new injectable medications have been written.

• Copy of an IV compatibility chart produced originally for ICU has been included.

• Copy of the new IV morphine protocol for the Emergency Department has been included.

Last Approval Due for Review

December 2012 December 2013

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• PHNT is committed to creating a fully inclusive and accessible service.

• Making equality and diversity an integral part of the business will enable us to enhance the

services we deliver and better meet the needs of patients and staff.

• We will treat people with dignity and respect, actively promote equality and diversity, and

eliminate all forms of discrimination regardless of (but not limited to) age, disability, gender

reassignment, race, religion or belief, sex, sexual orientation, marriage/civil partnership and

pregnancy/ maternity. An electronic version of this document is available on Plymouth Healthnet. Use the A-Z drop down menu to select the “Pharmacy Dept.” section where this document is held. Alternatively use the link: http://nww.picts.nhs.uk/PHNetLive/DesktopDefault.aspx?tabid=1715

Larger text, Braille and Audio versions can be made available upon request.

Contents

Section Page

1.1 Injectable Drug Monographs 7 Chart of Injectable Drug Compatibilities 184 PHNT Analgesic ladder 185 PHNT Protocol for administering intravenous morphine to adults in acute care

areas 186

PHNT Protocol for administering intravenous morphine to adults in the Emergency Department

187

1.2 Management of Anaphylaxis 188

Appendix 1 Choice of Infusion device A1.1 Introduction 190 A1.2 Choice of Infusion device 190 A1.3 Additional Information 192 A1.4 References 192 Appendix 2 Copy of PHNT Policy for maintenance of patency, flushing and locking of

intravascular lines catheters or devices

A2.1 Introduction 193 A2.2 Policy 193 Appendix 3 Document accountability, responsibility and dissemination A3.1 Accountability 195 A3.2 Overall Responsibility for These Policies and Guidelines 195 A3.3 Dissemination and Implementation 195

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1.1 Injectable Drug Monographs

All monographs contained in this section are the current versions as of the time of going to print and are listed in alphabetical order according to generic name. Detailed guidance for the administration of cytotoxic drugs is not given in the monographs, but should be obtained from the appropriate ward or unit protocol.

Unlicensed use of medications

Where in the monographs the use of a drug is noted to be unlicensed, this either refers to the drug formulation itself not having a UK product licence or where the indication, dosage, dilution or rate of administration fall outside of the UK product licence.

When an unlicensed medication is administered to a patient or a licensed medication is administered in an unlicensed manner the prescribing doctor takes full responsibility for any adverse consequences. Important notes

• Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. This includes infusions such as Patient Controlled Analgesia (PCA) and sliding-scale insulin.

• Unless described in the drug monograph as “Multidose” all injectable products, including bags of sodium chloride 0.9% and 5% glucose must be treated as single use only and disposed of immediately after use.

• Any infusion containing drug(s) or potassium or any other additive must be administered using an infusion pump.

• Dosiflows or other gravity-fed administration sets must only be used for administering crystalloid infusions (eg. Sodium chloride infusion or glucose infusion) containing no potassium or other additives.

• For patients on a sliding-scale insulin infusion and glucose infusion, the glucose must be infused using a volumetric pump.

• Always read the label on the ampoule, syringe or box. Do not rely on familiar colours or shapes of packaging to correctly identify medication.

• Always label an IV container or syringe containing drug or added electrolytes for infusion with a completed “IV Additive Label”.

• All syringes containing drawn-up medication or flushing solution must be labelled with name of medicine or flushing solution and the dose/strength, unless the risk of doing so (eg contaminating a sterile field) is perceived by the individual practitioner to outweigh the risk of mis-identifying un-labelled syringe(s). The individual practitioner is then responsible for ensuring that any un-labelled syringes are not mis-identified. Labels for this purpose (Code QC31) can be ordered from Pharmacy.

• Drug solutions that have been drawn up or prepared in clinical areas must be administered immediately after preparation or drawing up.

• All the intravenous medications listed in the Section 4 monographs may be given via a peripheral cannula or a central venous cannula, unless the monograph specifically says that a particular drug or drug concentration must only be given via a central venous cannula.

• If you require information on intravenous compatibilities; contact Pharmacy Drug Information on Ext. 39976.

1 • ♠ Groups of staff allowed to administer injectable medications which are referred to in the

monographs:

Group 1

o Registered and Provisionally Registered Medical Practitioners. It is recommended that IV drugs are checked by a second person either another medical practitioner or a registered healthcare professional before administration.

Group 2

o Registered Nurses, Midwives and Operating Department Practitioners (ODP’s) who have undertaken the Plymouth Hospitals NHS Trust IV drug administration training (or satisfy the criteria for new employees from outside the Trust), and have been assessed as competent. Group 2 can administer to adult patients only. Another Registered healthcare professional should check all aspects of the administration with this Nurse or Midwife. Cytotoxic IV drugs are NOT to be administered by this group.

o Exceptions are methotrexate are cyclophosphamide, which can be administered by this group if the practitioner has previous experience of administering parenteral cytotoxics.

Group 3

o Nurses who qualify for Group 2, working in identified specialist areas, and have undertaken additional training and assessment to administer cytotoxic IV drugs.

Group 4

o A Registered Sick Children's Nurse (RSCN) or Registered Nurse (Part 15 - Child Branch) working in the paediatric field who qualifies for inclusion in Group 2.

o The exception is for staff who work regularly in the Emergency Department, Intensive Care Unit, Theatres, Maternity and Neonatal Intensive Care Unit, who can administer Group 2 drugs to paediatric patients, providing they are familiar with the drug and the calculation (if any) required.

Group 5

o Nurses who qualify for Group 4 and have undertaken additional training and assessment to administer cytotoxic drugs.

Group 6

o Named Individual Radiographers/Sonographers who have completed and passed an accredited training programme in the administration of IV drugs may administer named contrast media, Hyoscine Butylbromide, Sodium Chloride 0.9% and Glucagon via the IV route according to the department’s authorised and signed patient group direction.

Group 7

o Named and authorised technical, scientific and delegated medical staff of the department of Nuclear Medicine who have the appropriate training required by IR(ME)R 2000 to administer radiopharmaceuticals and who have completed an accredited course in IV drug administration or equivalent. Such individuals may administer named drugs and radiopharmaceuticals by IV route according to the department’s authorised and signed patient group direction (PGD).

o All Registered healthcare professionals must be assessed as competent in the methods

required for administration as advised in section 4 monographs. If they have not been assessed as competent with the administration method, e.g. using a central line, or aseptic non-touch technique they must not proceed.

o All training and assessment of competency to administer intravenous medication should

include training and assessment of aseptic non-touch technique and administration via central vascular access devices. For more information or training please contact the Learning and Development Facilitator.

1 Abbreviations used in the drug monographs

(C) Continuous (I) Intermittent IV Intravenous IM Intramuscular SC Subcutaneous N/S Sodium Chloride 0.9% G Glucose 5% G/S Glucose 4% and sodium chloride 0.18%. Other

combinations of glucose and sodium chloride may not be compatible with the drugs listed in Section 4 – contact Pharmacy for advice on ext.39976.

H Compound sodium lactate (Hartmann’s) Hep/S Heparin 10 units in 1ml sodium chloride -

heparinised sodium chloride (e.g. Hepsal) W Water for Injection (preservative free)

• Intravenous fluids and drug solutions must be changed every 24 hours unless otherwise specified in the drug monograph.

• Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded immediately after use.

• For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines http://nww.swretrieval.nhs.uk/DI_ALL.htm - for drug monographs click on “Intravenous Drug Administration Guide”), current BNF For children (www.bnfc.org) or the Neonatal Formulary.

• For more detailed information refer to the current BNF (www.bnf.org ). For full details of the licensed indications, dosage, contraindications and side effects refer to www.medicines.org.uk

Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 8.1, December 2012

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DRUG

METHOD WHO MAY GIVE

ADMINISTER OVER INSTRUCTION FOR DILUTION AND SUITABLE DILUENT

COMMENTS

Abatacept

(Orencia®)

(I) IV infusion ♠ Groups 1 and 2

Infuse all doses over 30 minutes

Infusion to be prepared by Pharmacy. Telephone Ext. 31083.

Monitor blood pressure (increase in BP is common), pulse and temperature. Monitor for allergic reactions (rare) and rash (common).

Check LFTs (ALT and AST commonly raised).

If any serious allergic or anaphylactic reaction occurs discontinue the infusion immediately and initiate appropriate therapy.

Do not mix with any other drug solutions.

Flush with N/S.

Abciximab

Initial IV bolus ♠ Groups 1 and 2

1 minute

Inject 5ml of air into the vial before withdrawing the solution. Use the 20ml syringe to draw up sufficient volume for both the bolus and 12-hour infusion. Connect the 0.2 or 0.22 micron filter and connector provided. Draw the volumes necessary for the bolus dose and infusion into two separate syringes through the connector.

(C) IV infusion via pump immediately following initial IV bolus.

♠ Groups 1 and 2

4ml/hour for 12 hours (50ml syringe driver) or 19ml/hour for 12 hours (250ml infusion bag)

See Filter Pack for nomogram. Either dilute the volume drawn up for infusion with N/S or G to make 50ml or add the drawn up volume to 250ml of N/S or G.

For stabilisation of unstable angina, bolus dose followed by the infusion is started up to 24 hours prior to PCI and concluded 12 hours after PCI. For other patients bolus is given 10-60 minutes prior to PCI followed by the infusion for 12 hours.

Do not shake unused vials.

Flush: N/S or G.

Do not infuse with any other drugs.

Acetazolamide IV bolus

♠ Groups 1 and 2

Suggested maximum 100-500mg/minute

Reconstitute each 500mg with at least 5ml W.

Flush with N/S or G. Extravasation may cause tissue damage.






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DRUG

METHOD WHO MAY GIVE


COMMENTS

(C) IV infusion Infusion pump is required.

♠ Groups 1 and 2

Treatment of paracetamol overdosage: three consecutive infusions as detailed in the table below (For treating children <40kg follow the instructions on the next 2 pages).

Acetylcysteine

(C) IV infusion via central line Infusion pump is required.

♠ Groups 1 and 2

On ICU or HDU acetylcysteine may be infused in smaller volumes of G or undiluted if necessary (unlicensed - see page 1) via a central IV line. However the hourly infusion rate (ml/hour) will be different to the figure in the table below.

A change in colour of solutions of acetylcysteine to light purple is insignificant.

Flush with G or N/S.

Sodium content 12.78mmol/10ml .

Adult Dosage Table for Treating Paracetamol Overdose

Regimen First Infusion Second Infusion Third Infusion

Infusion Fluid 200ml G (or 200ml N/S if G is unsuitable) 500ml G (or 500ml N/S if G is unsuitable) 1000ml G (or 1000ml N/S if G is unsuitable)

Duration of Infusion

1 hour 4 hours 16 hours

Drug Dose 150mg/kg 50mg/kg 100mg/kg

Patient’s weight (kg)

1 Grams of

acetylcysteine to prescribe

Volume (ml)2 of

acetylcysteine to add to 200ml fluid

Infusion rate (ml/hour)

Grams of acetylcysteine to

prescribe

Volume (ml)2 of


Infusion rate

(ml/hour)

Grams of acetylcysteine to prescribe

Volume (ml)2 of


Infusion rate

(ml/hour)

40 - 49 6.8 34 234 2.4 12 128 4.6 23 64 50 - 59 8.4 42 242 2.8 14 129 5.6 28 64 60 - 69 9.8 49 249 3.4 17 129 6.6 33 65 70 – 79 11.4 57 257 3.8 19 130 7.6 38 65 80 – 89 12.8 64 264 4.4 22 131 8.6 43 65 90 – 99 14.4 72 272 4.8 24 131 9.6 48 66

100 – 109 15.8 79 279 5.4 27 132 10.6 53 66

≥ 110 16.6 83 283 5.6 28 132 11 55 66 1 Dose calculations are based on the weight in the middle of each band. If the patient weighs less than 40kg use the paediatric dosage table.

2 Ampoule volume has been rounded up to the nearest whole number.






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Acetylcysteine for treating paracetamol overdose in Children

Children are treated with the same doses and regimen as adults. However, the quantity of intravenous fluid used has been modified to take into account age and weight, as fluid overload is a potential danger. Doses should be administered sequentially using an appropriate infusion pump. Preparation and administration of paediatric infusions

• Weigh the child to determine the correct weight band.

• Read off the table (on the next page) the total infusion volume required for each dose according to the weight of the child and make up the solutions according to the directions below.

First Infusion

• Prepare the appropriate volume for the weight of the child.

• Prepare a 50 mg/mL solution by diluting acetylcysteine (200 mg/mL) with glucose 5% (preferred) or sodium chloride 0.9% as follows: Weight 1-14kg add 10mls of acetylcysteine to 30ml of diluent Weight 15-24kg add 20mls of acetylcysteine to 60ml of diluent Weight 25-39kg add 30mls of acetylcysteine to 90ml of diluent

• The dose is infused over 1 hour at the infusion rate stated in the table (equiv to 3ml/kg/hour). Second Infusion

• Prepare the appropriate volume for the weight of the child.

• Prepare a 6.25 mg/mL solution by diluting acetylcysteine (200 mg/mL) with glucose 5% (preferred) or sodium chloride 0.9% as follows: Weight 1-9kg add 8mls of acetylcysteine 200mg/ml to a 250ml bag Weight 10-19kg add 16mls of acetylcysteine 200mg/ml to a 500ml bag Weight 20-39kg add 32mls of acetylcysteine 200mg/ml to a 1000ml bag

• The dose is infused over 4 hours at the infusion rate stated in the table (equiv to 2ml/kg/hour). Third Infusion

• Use the solution prepared under second infusion above.

• The dose is infused over 16 hours at the infusion rate stated in the table (equiv to 1ml/kg/hour). For example for a child weighing 12 kg, the first infusion would be 38 mL infused at 38 mL/h over 1 hour,the second infusion would be 100 mL infused at 25 mL/h over 4 hours and the third infusion is 208 mL infused at 13 mL/h over 16 hours.






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• Weigh the child and prepare the infusion as instructed on the previous page.

Paediatric Dosage Table for Treating Paracetamol Overdose

Regimen First Infusion Second Infusion Third Infusion

Infusion 50mg/ml for 1 hour 6.25mg/ml for 4 hours 6.25mg/ml for 16 hours

Infusion rate 3ml/kg/hour 2ml/kg/hour 1ml/kg/hour

Patient’s weight1

(kg)

Dose of acetylcysteine to prescribe

Total infusion volume

(ml)




(ml)




(ml)


1 150mg 3 3 50mg 8 2 100mg 16 1 2 300mg 6 6 100mg 16 4 200mg 32 2 3 450mg 9 9 150mg 24 6 300mg 48 3 4 600mg 12 12 200mg 32 8 400mg 64 4 5 750mg 15 15 250mg 40 10 500mg 80 5 6 900mg 18 18 300mg 48 12 600mg 96 6 7 1.05g 21 21 350mg 56 14 700mg 112 7

8 1.2g 24 24 400mg 64 16 800mg 128 8 9 1.35g 27 27 450mg 72 18 900mg 144 9

10-14 1.9g 38 38 625mg 100 25 1.3g 208 13 15-19 2.65g 53 53 875mg 140 35 1.8g 288 18 20-24 3.4g 68 68 1.125g 180 45 2.3g 368 23 25-29 4.15g 83 83 1.375g 220 55 2.8g 448 28 30-34 4.9g 98 98 1.625g 260 65 3.3g 528 33 35-39 5.65g 113 113 1.875g 300 75 3.8g 608 38

1 Dose calculations based on the weight in the middle of each band. If the patient weighs more than 40kg use the adult dosage table. Figures have been rounded up to

the nearest whole number.






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DRUG

METHOD WHO MAY GIVE


COMMENTS

Aciclovir

(Ready-diluted brands)

(I) IV infusion

Infusion pump is required.

♠ Groups 1,2,3,4 and 5

1 hour Dilute each 250-500mg in a 100ml bag N/S, G/S or H. For doses between 500mg and 1000mg use two 100ml bags or one 250ml bag. The concentration should not exceed 5mg/ml. Shake the prepared infusion well before use.

Aciclovir

(Powder for reconstitution)

(I) IV infusion



1 hour Reconstitute each 250mg with 10ml of W or N/S to produce a solution containing 25mg/ml. Dilute further with N/S, G/S or H to a concentration not exceeding 5mg/ml. For fluid restricted patients the reconstituted solution may be infused without further dilution via a central IV line.

Flush with N/S, G/S or H. Sodium content approx 1mmol/250mg. Discard infusion if any visible turbidity or crystallisation appears. Extravasation may cause tissue damage. Patient should be adequately hydrated.

Actrapid® See Insulin Section page

IV bolus ♠ Group 1 2 seconds If given into an IV line, inject as proximally as possible and follow with a rapid N/S flush. Cardiac monitoring and resuscitation equipment should be available for immediate use. Sodium content 0.154mmol/3mg.

Adenosine

(I) IV infusion for cardiac stress testing Infusion pump is required.

♠ Group 1 and Group 7

6 minutes

Can be diluted with N/S if necessary.

Administer in accordance with the Nuclear Medicine Department protocol.






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DRUG

METHOD WHO MAY GIVE


COMMENTS

Adrenaline

(Epinephrine)

(I) IV infusion


.

♠ Groups 1 and 2

Adjust rate according to response.

Usual local practice is to use 1:10,000 adrenaline in a 50ml syringe (5mg in 50ml). Adrenaline may be diluted with N/S, G, G10%, G/S or H.

Protect infusion from light. If G used as diluent pH must be below 5.5 (pH of G stocked in this Trust is between 4-4.2). Infuse through a large vein if possible. (I) IV infusion requires continuous blood pressure monitoring. Replace giving set - do not flush. Extravasation may cause tissue damage. Note that 1mg ampoules are only licensed for IM or SC use. However, they are suitable for preparing an IV infusion.

Emergency use in CPR: IV bolus

♠ Group 1 1 - 2 seconds Use 1:10,000 (1mg in 10ml) prefilled syringe.

Emergency use in anaphylaxis

IM Injection using 1:1,000 injection

♠ Groups 1 and 2

Refer to the Marsden Manual for guidance on IM injection.

Emergency use in anaphylaxis –

IV route is only used in an acute hospital setting by an experienced practitioner for a patient with immediately life-threatening profound shock.

♠ Group 1

Only anaesthetists and senior clinicians working in intensive care, theatre or the Emergency Department.

Specialist use only: Adults: 0.5ml of dilute 1:10,000 adrenaline IV over 1 minute with continuous ECG monitoring, pulse oximety and frequent blood pressure measurements. Repeat dose as necessary according to response

Use 1:10,000 injection or dilute 0.5ml of 1:1,000 adrenaline to 5ml with N/S or G to make a 1:10,000 solution.

Refer to the protocol for the management of suspected life-threatening anaphylaxis on page 188. IM is the usual route.






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DRUG

METHOD WHO MAY GIVE ADMINISTER OVER

INSTRUCTION FOR DILUTION AND SUITABLE DILUENT

COMMENTS

Ajmaline

(Unlicensed- see page 4)

For diagnosis of Brugada Syndrome

Slow IV bolus

♠ Group 1: junior doctors trained in the technique and with UK ALS accreditation, or a consultant cardiologist

No greater than 5mg/minute. Maximum dose is 1mg/kg

Undiluted For detailed instructions it is essential to read the Ajmaline Protocol (Copies on Torcross and Bickleigh wards)

Patient to be nil-by-mouth for at least 4 hours before the test.

Continuous 12-lead ECG monitoring required during administration. Cardiac rhythm monitoring required for 4 hours following administration.

Check the blood pressure at 5 minute intervals during administration and for 10 minutes afterwards.

Alcohol See Ethanol monograph






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DRUG

METHOD WHO MAY GIVE

ADMINISTER OVER


COMMENTS

Alemtuzumab

(MabCampath®)

for treating MS (unlicensed product – see page 4)

(I) IV infusion via an infusion pump

♠ Groups 1 and 2

See administration schedule below.

Alemtuzumab is prepared only by Pharmacy (Tel. 31083).

Dilution supplied is 12mg in 100ml N/S

Premedication: see administration schedule below.

Protect the infusion from light: Cover with infusion bag with the plastic bag supplied from Pharmacy. No need to cover the line.

During the infusion monitor for urticaria, rash, hypotension, nausea, rigors and fever. Serious but rare reactions include: respiratory distress, bronchospasm, syncope, MI and cardiac arrest. Refer to the full Alemtuzumab Prescribing Guidelines held on the Planned Investigation Unit (PIU). The guidelines are also available on Plymouth Healthnet under Clinical Guidelines.

Premedication prior to alemtuzumab for treating Multiple Sclerosis

(Allow 30 minutes for oral paracetamol to take effect).

• Paracetamol 1gram PO

• Chlorphenamine 10mg IV

• Methylprednisolone 1gram IV daily for the first 3 days immediately prior to administartion of alemtuzumab

1st Course of alemtuzumab:

Alemtuzumab 12mg IV daily for 5 consecutive days

2nd Course of alemtuzumab (Given 12 and 24 months after the 1st course)

Alemtuzumab 12mg IV daily for 3 consecutive days

Administration Schedule for premedication (treating Multiple Sclerosis)

Day 1 – 3:

Administer 1g methylprednisolone IV over 1 hour

Administer chlorphenamine 10mg IV and paracetamol 1gram PO

Administer alemtuzumab 12mg in 100ml N/S over 4 hours

Day 4 (1st course only):



Day 5 (1st course only):



Alemtuzumab

(MabCampath®)

Post kidney transplantation (unlicensed product – see page 4)


♠ Groups 1 and 2

2 hours Alemtuzumab is prepared only by Pharmacy (Tel. 31083). Dilution supplied is 30mg in 100ml N/S.

Protect the infusion from light: Cover with infusion bag with the plastic bag supplied from Pharmacy. No need to cover the line.

During the infusion monitor for urticaria, rash, hypotension, nausea, rigors and fever. Serious but rare reactions include: respiratory distress, bronchospasm, syncope, MI and cardiac arrest. Refer to the Renal Unit protocol for premedication instructions






15

DRUG

METHOD WHO MAY GIVE

ADMINISTER OVER


COMMENTS

Alfacalcidol IV bolus ♠ Groups 1 and 2

Approximately 30 seconds

Shake the ampoule for a minimum of 5 seconds before use. Give undiluted.

For patients undergoing haemodialysis the injection should be given into the return line from the haemodialysis machine at the end of dialysis.

Monitor serum calcium regularly during treatment.

Staff prescribing, administering and/or screening prescriptions for opioid medications should be familiar with the PHNT Policy for Reducing Errors with Opioid Medicines in Adults (Network Drive :Groups (G) > Trust Documents > Documents > Medicines Management folder). The PHNT Analgesic Ladder and equivalent dosages of different opioids can be found on page 185.

Alfentanil

IV bolus

using the

500 microgram/ml injection

♠ Groups 1 and 2

Approximately 30 seconds in spontaneously breathing patients.

Can be diluted with N/S, G or H.

Ampoules of Alfentanil 5mg/ml are 5000 micrograms/ml and must be diluted as below before administration by infusion.

(C) or (I) IV infusion with assisted ventilation. Infusion pump is required.

♠ Groups 1 and 2

Dilute with N/S, G or H to a usual concentration of 0.5mg/ml.

Occasionally concentrations of 1mg/ml or more have been used.

Flush : N/S, G or H Anaesthesia : Adequate plasma levels will only be achieved rapidly if the infusion (0.5-1 micrograms/kg/minute) is preceded by a loading dose of 50-100 micrograms/kg given as a bolus or fast infusion over 10 minutes.

SC injection ♠ Groups 1,2,3,4 and 5

Refer to the Marsden Manual for guidance on SC injection.

(C) SC infusion via syringe driver for use in palliative care


Dilute with W when 2 or more drugs are being mixed in the same syringe.

W or N/S may be used when the syringe only contains this drug.

Follow the PHNT Care of the Dying Pathway in Advance Kidney Disease and the PHNT Syringe Driver Policy. For combinations of 2 or 3 drugs in the same syringe refer to the compatibility charts in the pump kit or contact Pharmacy on ext. 39976 for advice. Alfentanil is unlicensed by the SC route and for use in palliative care (See page 4).






16

DRUG

METHOD WHO MAY GIVE


COMMENTS

Alglucosidase alfa

(Mycozyme®)

(I) IV infusion


♠ Groups 1,2 and 3

Initial rate of 1mg/kg/hour. Gradually increased by 2mg/kg/hour every 30 minutes if there are no reactions to the infusion, until a maximum rate of 7mg/kg/hour is reached.

Remove the required number of vials from the fridge and allow them to reach room temperature (may take about 30 minutes). Reconstitute each 50mg vial with 10.3ml W. Add the W by slow drop-wise addition down the side of the vial and not directly in to the powder. Tilt and roll each vial gently. Do not invert, swirl or shake the vials. The reconstituted volume is 10.5ml containing 5mg of enzyme/ml, and appears as a clear colourless to pale yellow solution which may contain particles in the form of thin white strands or translucent fibres. If on immediate inspection foreign particles other than those described above are observed, or if the solution is discoloured, do not use. Dilute the drawn up dose of alglucosidase alfa with N/S to a final alglucosidase alfa concentration of 0.5mg/ml to 4mg/ml (Remove the same volume of N/S from the bag first). Remove airspace from within the bag. Mix with gentle massage on inversion of the bag. Do not shake or agitate the bag. Infuse the solution via a 0.2micron low protein-binding in-line filter.

Suitable filters include PALL 0.22 micron, Braun Sterifix 0.2 micron, Technopharm codan 0.2 micron filters. These filters should be ordered through ORACLE.

Instructions for dosing and administration of alglucosidase alfa will usually be included in the patient’s treatment plan

(Recommended dosage for Pompe Disease is 20mg/kg once every 2 weeks)

During the infusion monitor for allergic reactions, monitor blood pressure, pulse, temperature, respiratory rate and for difficulty in breathing.






17

DRUG

METHOD WHO MAY GIVE


COMMENTS

Alprostadil

(Prostin VR®)

(C) IV infusion


♠ Groups 1 and 2

Initial rate:

5 nanograms/kg/minute = 0.1ml/hour of the prepared dilution.

Dilute 150micrograms/kg weight of baby to a final volume of 50ml with G, N/S or G10%.

(Note that after dilution with G10% the product is unlicensed. See page 1)

If using a burette avoid direct contact of the undiluted injection with the wall of the plastic burette. If this happens the appearance of the burette chamber may change and a hazy solution may develop requiring the solution to be discarded and the burette to be changed. Monitor arterial blood pressure, heart rate, SaO2 pO2 pH and respiratory rate

Alprostadil

(Caverject®)

Intracavernosal injection

(See comments)

♠ Group 1 Fit the 22 gauge needle to the syringe. Inject the 1ml of diluent into the vial, and shake to dissolve the powder entirely. Withdraw slightly more than the required dose of Caverject solution, remove the 22 gauge needle, and fit the 30 gauge needle. Adjust volume to the required dose for injection.

Using a half inch, 27 to 30 gauge needle is generally recommended. The intracavernosal injection must be done with aseptic technique. The site of injection is usually along the dorsolateral aspect of the proximal third of the penis. Visible veins should be avoided. Both the side of the penis that is injected and the site of injection must be alternated. Prior to the injection, the injection site must be cleansed with an alcohol swab.






18

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COMMENTS

If a special pre-programmed alteplase pump is unavailable then refer to the guidance on pages 43 and 44 Alteplase (TPA) to treat:

Acute myocardial infarction

Initial IV bolus dose then (I) IV infusion

using the special pre-programmed alteplase pump (Available in the Emergency Dept. and on Torcross ward).

♠ Groups

1 and 2

Accelerated regimen initiated within 6 hours of symptom onset administer over:

90 minutes

Initiated between 6 and 12 hours after symptom onset administer over:

3 hours

Reconstitute two 50mg vials each with the 50ml of W provided using the transfer needles supplied. Agitate gently until the contents of the vials have dissolved. Do not shake.

When using the special pre-programmed alteplase pump, draw up the contents of both vials (100ml) into a 100ml syringe.

ECG and haemodynamic monitoring required. Sodium content nil. Flush with N/S.

Alteplase and heparin infusions are not compatible. They should be infused through separate IV catheters.

Initial IV bolus dose

♠ Group 1 1 – 2 minutes Alteplase (TPA) to treat:

Pulmonary embolism

Followed by (I) IV infusion

using the special pre-programmed alteplase pump (Available in the Emergency Dept. and on Torcross ward)

♠ Groups

1 and 2

2 hours

Reconstitute two 50mg vials each with the 50ml of W provided using the transfer needles supplied. Agitate gently until the contents of the vials have dissolved. Do not shake.

Draw up the 10mg (10ml) bolus in a 10ml syringe for the doctor to inject over 1-2 minutes.

When using the special pre-programmed alteplase pump, draw up the remainder of the total dose into a 100ml syringe.

ECG and haemodynamic monitoring required. Sodium content nil. Flush with N/S.

Alteplase and heparin infusions are not compatible. They should be infused through separate IV catheters.






19

Alteplase to treat Acute Myocardial Infarction within 6 hours of symptom onset (Accelerated Regimen)

Suggested method when a pre-programmed alteplase pump is not available: Reconstitute two 50mg vials each with 25ml of the W provided using the transfer needles provided to make a 2mg/ml solution. Draw up the 50ml (100mg) of solution into a 50ml syringe. Then using a syringe pump set the infusion rate as follows: Bolus of 15mg over 2 minutes for patients of all weights (Set the pump at 225ml/hour for 2 minutes) then:

Patient weight

Further doses and infusion rates

≥≥≥≥ 65kg 50mg over 30 minutes. Set the pump at 50ml/hour for 30 minutes then 35mg over 60 minutes. Set the pump at 17.5ml/hour for 60 minutes

64kg 48mg over 30 minutes. Set the pump at 48ml/hour for 30 minutes then 32mg over 60 minutes. Set the pump at 16ml/hour for 60 minutes

62kg 46.5mg over 30 minutes. Set the pump at 46.5ml/hour for 30 minutes then 31mg over 60 minutes. Set the pump at 15.5ml/hour for 60 minutes














20

Alteplase to treat Acute Myocardial Infarction between 6 and 12 hours after onset of symptoms

Suggested method when a pre-programmed alteplase pump is not available: Reconstitute two 50mg vials each with 25ml of the W provided using the transfer needles provided to make a 2mg/ml solution. Draw up the 50ml (100mg) of solution into a 50ml syringe. Then using a syringe pump set the infusion rate as follows: Bolus of 10mg over 2 minutes for patients of all weights.: set the pump at 150ml/hour for 2 minutes, then: 50mg over 1 hour for patients ≥≥≥≥ 40kg: set the pump at 25ml/hour for 1 hour, then:

Patient weight Dose and infusion rate

≥≥≥≥ 65kg 40mg over 2 hours. Set the pump at 10ml/hour for 2 hours

60 - 64kg 30mg over 2 hours. Set the pump at 7.5ml/hour for 2 hours

53.4 -63.9kg 20mg over 2 hours. Set the pump at 5ml/hour for 2 hours

46.7 – 53.3kg 10mg over 2 hours. Set the pump at 2.5ml/hour for 2 hours

40 – 46.6kg No additional alteplase

Alteplase to treat Pulmonary Embolism

Suggested method when a pre-programmed alteplase pump is not available: Reconstitute two 50mg vials each with 25ml of the W provided using the transfer needles provided to make a 2mg/ml solution.

Draw up the Bolus of 10mg (5ml) in a 5 ml or 10ml syringe for the doctor to inject over 1 -2 minutes Then draw up the remainder of the total dose in a 50ml syringe. Then using a syringe pump set the infusion rate as follows:

Patient weight Dose and infusion rate

≥≥≥≥ 65kg 90mg over 2 hours. Set the pump at 22.5ml/hour for 2 hours

< 65kg For patients less than 65kg the total prescribed dose (including bolus dose) should not exceed 1.5mg/kg.

Following the bolus dose of 10mg, the infusion rate = Total prescribed dose (mg) – Bolus dose (10mg) ml/hour for 2 hours 4






21

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COMMENTS

Total dose is 900 micrograms/kg (Maximum dose 90mg). 10% of this dose (90micrograms/kg) given as a bolus over 2 minutes IV bolus ♠ Group 1 1 – 2 minutes Reconstitute one or two 50mg vials

each with 50ml of the W provided to make 1mg/ml solution. For the bolus dose, draw up 10% of the total dose (see table below) and inject using a 10ml syringe.

(I) IV infusion ♠ Groups

1 and 2

1 hour From the solution above, draw up the remainder of total dose (see table below) into one or two 50ml syringes.

It is essential to follow the detailed instructions in the PHNT Acute Ischaemic Stroke Protocol (Copy in the Emergency Department).

Unless the patient or companion knows their recent weight, estimate to the nearest 5kg. Take 2 initial blood pressure readings at 15 minute intervals. Record in both arms initially to exclude aortic dissection.

Weight(Kg) Weight (Imperial) Total dose 900micrograms/kg (Maximum 90mg)

Bolus dose (ml)

Inject over 1 -2 minutes

Infusion dose infused over 1 hour

45 7st 1lb 40 4 36

50 7st 12lb 45 4.5 40.5

Use 1 x 50mg vial

55 8st 9lb 49 4.9 44.1

60 9st 6lb 54 5.4 48.6

65 10st 3lb 58 5.8 52.2

70 11st 0lb 63 6.3 56.7

75 11st 11lb 67 6.7 60.3

80 12st 8lb 72 7.2 64.8

85 13st 5lb 76 7.6 68.4

90 14st 2lb 81 8.1 72.9

95 14st 13lb 85 8.5 76.5

Alteplase

to treat

Acute Ischaemic Stroke

Use 2 x 50mg vials

≥100 15st 10lb 90 9 81






22

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COMMENTS

Amikacin IM injection ♠ Groups 1,2,3,4 and 5

Do not dilute. Refer to the Marsden Manual for guidance on IM injection.

Slow IV bolus

(For large once daily doses see (I) IV infusion below)


2 – 3 minutes Undiluted

(I) IV infusion

For once daily doses of 15mg/kg or greater. Infusion pump is required


30 – 60 minutes A common dilution for adults is with 100ml of N/S or G.

For most infections the intramuscular route is preferred, but the IV route may be used for life threatening infection or when IM injection is not feasible.

Once diluted for infusion use immediately. Patient should be well hydrated during amikacin therapy.

Irrigation ♠ Groups 1,2,3,4 and 5

Dilute the required dose with N/S to a concentration of 2.5mg/ml.

Sterile irrigation of amikacin may be used in abscess cavities, the pleural space, peritoneum or in the cerebral ventricles.






23

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METHOD WHO MAY GIVE


COMMENTS

Aminophylline (I) IV infusion (initial loading dose) Infusion pump is required.

♠ Groups 1, 2 3 and 7

Minimum 20 minutes. Dilute further with 100ml N/S, G, G/S or H. However, the loading dose can be diluted to a smaller volume e.g. 50ml or given undiluted (25mg/ml) if necessary.

Flush with N/S, G or G/S.

Do not give loading dose if patient previously taking theophylline.

(I) or (C) IV infusion (after loading dose). Infusion pump is required.


Usual starting rates:

0.5-0.7mg/kg/hour for adults and children aged 12 years and older.

0.3mg/kg/hour for the elderly.

1mg/kg/hour for children aged under 12 years.

To avoid excessive dosage in obese patients, the dose should be calculated on ideal body weight.

Adjust the rate according to plasma theophylline levels.

Remove 20ml from a 500ml bag of N/S, G, G/S or H then add 500mg (20ml) aminophylline to make a concentration of 1mg/ml.

Can be diluted to higher concentrations than 1mg/ml or given undiluted (25mg/ml) through a central line, but take care with the calculation and prescription of the infusion rate.

Do not infuse aminophylline down the same central line lumen or peripheral line as salbutamol.

Take blood to check theophylline levels 4-6 hours after commencing the aminophylline infusion.






24

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COMMENTS

Amiodarone (C) or (I) IV infusion. Infusion pump is required.

♠ Groups 1,2

and 3

5mg/kg loading dose (usually 300mg) over 20 minutes - 2 hours. This may be followed by repeat infusion up to 1.2g per 24 hours. Adjust rate according to response

Recommended dilution: 5mg/kg loading dose (Usually 300mg) diluted in 250ml G. Repeat infusion (usually 900mg over next 23 hours) diluted in 500ml G.

For fluid-restricted patients the dose (e.g. 300mg, 900mg or 600mg) may be diluted in 50, 100 or 250ml G.

Stability is concentration dependent - do not over dilute. Do NOT add 300mg to more than 500ml G or 600mg to more than 1 litre G.

IV bolus Emergency use

♠ Group 1 During Advanced Life Support for VF/VT give as a fast bolus. Otherwise give over a minimum of 3 minutes. Do not repeat dose for at least 15 minutes.

Dilute each 150-300mg with 10-20ml G.

Pre-filled syringe contains 300mg ready diluted in 10ml G.

Cardiac monitoring required. Flush with G. Repeated or continuous infusion via peripheral veins may lead to local discomfort and inflammation. Infusion concentrations greater than 2mg amiodarone per ml must be infused via a central venous catheter. When repeated or continuous infusion of any concentration is anticipated, administration via a central venous catheter is recommended. Sodium content nil.

As soon as an adequate response has been obtained, oral therapy should be initiated concomitantly at the usual loading dose (i.e. 200mg three times a day). Intravenous amiodarone should then be phased out gradually.






25

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COMMENTS

Amoxicillin IV bolus

(Usual method)


Inject doses up to 1g over 3 - 4 minutes.

Inject 2g doses slowly over 6 - 8 minutes or give by infusion (see below).

Reconstitute each 500mg with 10ml W.

Displacement 0.4ml/500mg. Add 9.6ml W to 500mg to produce 50mg/ml.

Flush with N/S.

Use infusion within 90 minutes of preparation.

(I) IV infusion. Infusion pump is required.

30 - 60 minutes Reconstitute as above then dilute with N/S or G to 100ml. Alternatively each 500mg amoxicillin may first be reconstituted with 5ml of the diluent (N/S or G).

Sodium content: 1.65mmol/500mg

(Avoid Intrathecal administration)

IM Injection ♠ Groups 1,2,3,4 and 5

Reconstitute a 500mg vial with 2.5ml W and shake vigorously (Final volume is 2.9ml). Reconstitute a 250mg vial with 1.5ml W and shake vigorously (Final volume is 1.7ml). Refer to the Marsden Manual for guidance on IM injection.

For Amoxil® brand only : If pain is experienced on IM injection, lidocaine 1% or procaine 0.5% injection may be used instead of W to reconstitute the vial.

Amphotericin

(Fungizone® )

For AMBISOME see next page

(I) IV infusion Infusion pump is required.


2-4 hours.

Up to 6 hours if poorly tolerated.

Displacement is negligible. Add 10ml diluent for 50mg in 10ml. Reconstitute vial with 10ml W, then dilute dose required with 50 times as much G to produce a maximum concentration of 100micrograms/1ml. Add 1ml of buffer solution supplied by Pharmacy to each 500ml G before adding amphotericin.

Concentrations up to a maximum of 500micrograms/1ml can be given using a central line (unlicensed use - see page 1).

A test dose must be given at start of each new course of treatment; Infuse the first 1mg of the first infusion over 20-30 minutes and observe for signs of anaphylactic reaction for at least a further 30 minutes. If no reaction then give the remainder of the first infusion. Flush with G before and after administration. Protect infusion from light. May cause thrombophlebitis; change infusion site frequently. Sodium content 0.25mmol/50mg.






26

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COMMENTS

Liposomal Amphotericin

(AmBisome )

For Fungizone®

See previous page



30-60 minutes Add 12ml W (2-8oC), shake vigorously for at least 15 seconds. Resulting amphotericin concentration 4mg/1ml. Dilute dose required with between 1 and 19 parts by volume G, using 5 micron filter provided, to give a final concentration of 200micrograms-2mg/1ml.

Administration of a test dose is advisable before a new course: Give 1mg of prepared infusion over 10 minutes, stop infusion and observe patient for 30 minutes.

Protect infusion from direct sunlight. Flush before and after administration with G. Do not infuse with any other drugs or infusion fluids.

Sodium content less than 0.5mmol/vial.

Anti-thymocyte immunoglobulin rabbit (ATG rabbit)

(I) IV infusion into a large vein. Infusion pump is required.


8-12 hours Infusion to be prepared by Pharmacy. Telephone Ext. 31083. Doctor to prescribe dose in 250 – 500ml N/S.

A test dose is usually given. Give an IV antihistamine 1 hour before. Flush with N/S. Do not infuse with any other drugs.

Anidulafungin ▼▼▼▼ This product is being intensively monitored by the CHM and MHRA. Please report all suspected reactions (including non-serious ones) using a Yellow Card from the BNF



Infuse the 200mg dose over at least 3 hours. Infuse the 100mg dose over at least

1½ hours.

Reconstitute each 100mg vial with 30ml WFI. Reconstitution can take up to 5 minutes. For the 200mg dose, remove 50ml from a 250ml bag of N/S or G, then add 60ml (2 x 100mg in 30ml) of reconstituted solution (Final volume 260ml). For the 100mg dose, add the 30ml of reconstituted solution to a 100ml bag of N/S or G (final volume 130ml).

Do not infuse with any other drugs or infusion fluids.

If the un-reconstituted vials are accidentally left out of the fridge, as long as the period at room temperature does not exceed 96 hours, they can be returned to the fridge and are ok to use.

Flush with N/S.






27

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COMMENTS

IV bolus (initial loading dose)

♠ Group 1 Maximum rate 10ml/minute

Aprotinin This drug is unlicensed – see page 4


♠ Groups 1 and 2

20-50ml/hour

Provided ready diluted. Flush with N/S. Initial 1ml (10,000 KIU) should always be given at least 10 minutes prior to treatment to test for possible allergic and anaphylactic reactions. Sodium content 7.7mmol/50ml. Do not infuse with any other drugs including heparin. Patient must be in the supine position during the administration of aprotinin.






28

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COMMENTS

Argatroban (I) IV infusion via infusion pump.

♠ Groups 1 and 2

Initial infusion rate in patients without hepatic impairment is 2micrograms/kg/minute. For critically ill or hepatically impaired patients the initial infusion rate is 0.5micrograms/kg/minute. See tables at foot of monograph for setting the initial infusion rate The maximum rate is 10micrograms/kg/minute

Add the 250mg in 2.5ml from the vial to a 250ml bag of N/S or G. Mix the solution for 1 minute by repeated inversion of the prepared infusion. There may be some brief haziness of the solution that clears upon mixing.

Obtain a baseline APTT. The target APTT is 1.5-3.0 times the baseline value, but not more than 100 seconds. Check the APTT 2 hours after starting the infusion or after a change of rate, and at least once a day thereafter (For critically ill or hepatically impaired patients, check the APTT 4 hours after starting infusion or changing the rate).

Standard dosing schedule

Initial Infusion Rate 2 micrograms/kg/minute Critically Ill/Hepatically impaired patients Initial infusion rate 0.5 micrograms/kg/minute

APTT (s) Infusion Rate change Next APTT Infusion Rate change Next APTT

< 1.5 times baseline Increase by 0.5 mcg/kg/min. 2 hours Increase by 0.1 mcg/kg/min. 4 hours

1.5-3.0 times baseline (not exceeding 100 s)

No change 2 hours; after 2 consecutive APTT's within target range, Check at least once per day

No change 4 hours; after 2 consecutive APTT's within target range, Check at least once per day

> 3.0 times baseline or > 100 s Stop infusion until the APTT is 1.5-3.0 times baseline; Resume at half of the previous infusion rate.

2 hours Stop infusion until the APTT is 1.5-3.0 times baseline; Resume at half of the previous infusion rate.

4 hours

2micrograms/kg/min 0.5micrograms/kg/min 2micrograms/kg/min 0.5micrograms/kg/min

Body weight (kg) Infusion rate (ml/hour) Infusion rate (ml/hour) Body weight (kg) Infusion rate (ml/hour) Infusion rate (ml/hour)

50 6 1.5 100 12 3

60 7 1.8 110 13 3.3

70 8 2.1 120 14 3.6

80 10 2.4 130 16 3.9

90 11 2.7

140 17 4.2






29

DRUG



COMMENTS

Argipressin See vasopressin Atenolol IV bolus ♠ Groups 1 and 2 Maximum rate

1mg/minute Can be diluted with N/S or G to any convenient volume e.g.10ml.

(I) Infusion Infusion pump is required.

♠ Groups 1 and 2 20 minutes Dilute with N/S or G to a suggested volume of 50ml or 100ml.

Severe bradycardia and hypotension may occur; monitor heart rate and blood pressure. Can cause conduction defects; monitor ECG. Infusing quickly increases incidence of side effects. Flush with N/S or G. Sodium content : approximately 1.3-1.8mmol/5mg

Atosiban Step 1: IV bolus loading dose using 7.5mg/ml Solution For Injection

0.9ml (6.75mg) over 1 minute immediately followed by Step 2

Step 2: (I) IV loading infusion. Infusion pump is required.

24ml (18mg)/hour for 3 hours followed by Step 3

Step 2: (I) IV infusion Infusion pump is required.

♠ Groups 1 and 2

8ml (6mg)/hour for up to 45 hours

Withdraw 10ml from a 100ml bag of N/S or G. Replace it with 10ml of Atosiban 7.5mg/ml Concentrate Solution for Infusion from two 5ml vials to obtain a concentration of 75mg in 100ml

Total duration of treatment should not exceed 48 hours. The total dose given should preferably not exceed 330mg. The vials and infusions should be inspected visually for particulate matter and discolouration prior to administration. Do not mix with any other drug solutions.

Atracurium IV bolus ♠ Group 1 – must only be given by doctors proficient in advanced airway management. Also see comments.

Can be diluted with H, G, G/S or N/S.

(C) IV infusion. Infusion pump is required.

♠ Groups 1 and 2

300-600 micrograms/kg/ hour

A 0.5mg/ml dilution is stable for 4 hours in H, 8 hours in G or G/S and 24 hours in N/S. Flush with N/S. If the patient is ventilated IV bolus can be administered by Group 2 staff. Incompatibilities include: propofol.






30

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COMMENTS

Atropine IV bolus ♠ Groups 1 & 2 See comments If necessary atropine injection can be diluted with N/S.

SC injection ♠ Groups 1 and 2


IM Injection ♠ Groups 1 and 2


Give rapidly since slow IV administration may cause paradoxical slowing of the heart. ECG monitoring required. Flush with N/S. IV incompatibilities include bromides, iodides, noradrenaline, metaraminol and sodium bicarbonate. Premedication: IV immediately before induction. IM or SC 30-60 minutes before induction. Control of muscarinic side effects of neostimine: IV bolus.

Augmentin See Co-amoxiclav

(I) IV infusion (preferred method wherever possible). Infusion pump is required.

♠ Group 1 or Group 2 who have previous experience of administering intravenous cytotoxics. Or a Group 3 nurse.

30-60 minutes Azathioprine

IV bolus through tubing of a fast flowing N/S or G drip.

♠ Group 1 or Group 2 who have previous experience of administering intravenous cytotoxics. Or a Group 3 nurse.

Usually 3-5 minutes. Minimum 1 minute.

Azathioprine injection is reconstituted and diluted only by Pharmacy (Tel. 31083). Handle the prepared injection or infusion as for cytotoxic drugs (See Appendix 3).

Flush the IV bolus with at least 50ml N/S, G or G/S since very irritant. Extravasation may cause tissue damage. Sodium content 0.2mmol/vial. Do not infuse with any other drugs.






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COMMENTS

Aztreonam IV bolus ♠ Groups 1,2,3,4 and 5

3-5 minutes Reconstitute vial contents with 6 - 10ml W and shake well. Displacement 0.8ml/1g. Add 9.2ml to 1g vial for 100mg/ml

Development of slight pink colour on standing does not affect potency. Flush with N/S or G. Sodium content nil.



20-60 minutes Reconstitute each 1 gram with at least 3ml W and shake well .Then dilute each 1 gram with at least 50ml N/S, G or H.

IM injection ♠ Groups 1,2,3,4 and 5

Reconstitute a 1gram vial with at least 3ml W or N/S and shake well.


Give by deep injection into a large muscle mass such as the upper quadrant of the gluteus maximus or the lateral part of the thigh. For doses higher than 1g, or for septicaemia, meninigitis, localised parenchymal abcess, peritonitis or other severe systemic or life-threatening infections, use the IV route as above.

Baclofen (C) Intrathecal infusion or

Intrathecal bolus

♠ Group 1 or Group 2*

Prepare and administer in accordance with the Pain Management Centre procedures.

* Restricted to those persons who are trained and competent to administer medication via the intrathecal route.

For regular intravenous benzylpenicillin see next page

Benzathine benzylpenicillin

(Extencillin®)

2.4 megaunit vial

(Unlicensed product – see page 4)

Deep IM injection ♠ Groups 1,2,3,4 and 5

Shake the vial to loosen the powder inside. Reconstitute the vial contents with the 8ml of W provided in the unlabelled ampoule.


Do not inject this formulation intravenously.






32

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COMMENTS

Benzylpenicillin

(Regular benzylpenicillin 600mg and 1200mg vials)

IV bolus

(Usual method)


3-5 minutes. Maximum rate for doses exceeding 1.2g: 300mg/minute.

Reconstitute each 600mg with 3.6-10ml W or N/S. Displacement 0.4ml/600mg. Add 3.6ml of W or N/S for 600mg in 4ml.

Administration faster than the recommended rate may cause seizures and CNS toxicity. Incompatibilities include: gentamicin.



30-60 minutes Reconstitute each 600mg with 10ml N/S or W .Can be further diluted if necessary with N/S or G (Suggested volume 100ml).

Flush with N/S or G.

Sodium content 1.68mmol/600mg.

1 mega unit = 600mg.


Reconstitute each 600mg vial with 1.6ml to 2ml W. Refer to the Marsden Manual for guidance on IM injection.

Doses greater than 1.2g should be given by the IV route.

Basiliximab Preferred method:



20-30 minutes Reconstitute 10mg vial with 2.5ml of the W supplied in the accompanying ampoule. Reconstitute 20mg vial with 5ml of the W supplied in the accompanying ampoule. Then dilute each 10mg to a volume of 25ml or greater with N/S or G. To avoid foaming mix by gently inverting – do not shake.

Use immediately and complete administration within 4 hours of reconstitution. Do not mix or infuse with other drugs in the same lumen or IV line. Anaphylactic reactions can occur rarely

IV bolus


Reconstitute 10mg vial with 2.5ml of the W supplied in the accompanying ampoule. Reconstitute 20mg vial with 5ml of the W supplied in the accompanying ampoule.







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COMMENTS

Beriplex P/N® Only prescribe after consultation with a Consultant Haematologist Available on request from the Blood Bank

(I) IV Infusion using an infusion pump


Each 500 IU in 20ml W over 10-15 minutes So set the infusion pump rate at 80-120ml/hour

Follow the nine steps illustrated below and continued on the next page for reconstituting the vials. Using the transfer device provided, reconstitute each 250 IU vial with the 10ml of W provided. Using the transfer device provided, reconstitute each 500 IU vial with the 20ml W provided. The concentration is 25 IU/ml. Do not further dilute the reconstituted solution.

The Consultant Haematologist will advise on the dosage to be given, and the monitoring to be performed. Do not administer down the same lumen or catheter as other drugs and fluids. May be flushed with N/S.

Take care that no blood enters the syringe filled with product, as there is a risk that the blood could coagulate in the syringe and fibrin clots would therefore be administered to the patient.

Store Beriplex P/N® in the fridge. Use reconstituted Beriplex® within 8 hours

Instructions for reconstituting Beriplex P/N®

1

1. Open the Mix2Vial package by peeling away the lid.

3

3. Carefully remove the package from the Mix2Vial set. Make sure that you only pull up the package and not the Mix2Vial set.

2

2. Place the diluent vial on an even, clean surface and hold the vial tight. Take the Mix2Vial together with the package and push the blue end straight down through the diluent stopper.

4

4. Place the product vial on an even and firm surface. Invert the diluent vial with the Mix2Vial set attached and push the transparent adapter straight down through the product vial stopper. The diluent will automatically flow into the product vial.

Instructions continued on the next page






34

Instructions for reconstituting Beriplex P/N® continued

5

5. With one hand hold the product-side of the Mix2Vial set, hold the diluent-side with the other hand and unscrew the set into two pieces.

Discard the diluent vial with the blue part attached

8

8. While keeping the syringe plunger pressed, invert the system upside down and draw the concentrate into the

syringe by pulling the plunger back slowly.

6

6. Gently swirl the product vial until the substance is fully dissolved. Do not shake.

9

9. Now that the concentrate has been transferred into the syringe, firmly hold on to the barrel of the syringe (keeping the syringe plunger facing down) and disconnect the Mix2Vial set from the syringe.

7

7. Draw air into an empty, sterile syringe. While the product vial is upright, connect the syringe to the Mix2Vial's Luer Lock fitting. Inject air into the product vial.






35

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COMMENTS

Rapid Initial IV bolus Patients undergoing PCI, including primary PCI : 0.75 mg/kg

Patients with unstable angina/non-ST segment elevated myocardial infarction: 0.1 mg/kg


Suggestion:

2 seconds

Bivalirudin

(C) IV infusion immediately following the IV bolus


Patients undergoing PCI, including primary PCI : 1.75mg/kg/hour = 0.35ml/kg/hour of the 5mg/ml infusion during the procedure and for up to 4 hours post PCI if necessary. Then 0.25mg/kg/hour = 0.05ml/kg/hour for 4- 12 hours if necessary.

Patients with unstable angina/non-ST segment elevated myocardial infarction:

0.25 mg/kg/hour = 0.05ml/kg/hour of the 5mg/ml infusion for up to 72 hours.

Add 5 ml W to one vial of 250mg bivalirudin and swirl gently until completely dissolved and the solution is clear. Withdraw 5 ml from the vial, and further dilute to 50 ml with G or N/S to give a final bivalirudin concentration of 5

mg/ml. Mix thoroughly. The reconstituted/diluted solution will be a clear to slightly opalescent, colourless to slightly yellow solution.

Incompatible with alteplase, amiodarone, amphotericin B, chlorpromazine, diazepam, prochlorperazine, reteplase, streptokinase and vancomycin.

Activated Clotting Time (ACT) values 5 minutes after bivalirudin bolus average 365 +/- 100 seconds. If the 5-minute ACT is less than 225 seconds, a second bolus dose of 0.3 mg/kg should be administered. Once the ACT value is greater than 225 seconds, no further monitoring is required provided the 1.75 mg/kg infusion dose is properly administered.






36

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COMMENTS

IM injection into specific muscles to treat spasticity

♠ Group 1 Reconstitute the 500unit vial with 1ml of W to make a 500unit/ml solution.

Reconstitute the 300unit vial with 0.6ml of W to make a 500unit/ml solution.

Botulinum toxin (Dysport®)

SC injection into specific facial sites to treat blepharospam and hemifacial spasm.

♠ Group 1 Reconstitute the 500unit vial with 2.5ml of W to make a 200unit/ml solution.

Reconstitute the 300unit vial with 1.5ml of W to make a 200unit/ml solution.

IV bolus ♠ Groups 1 and 2

Suggestion: 1 minute

Give undiluted.

Flush with N/S. Leave a gap of 20 minutes between repeat bolus doses.


♠ Groups 1 and 2

30-60 minutes Dilute 2 – 5mg with 500ml of G, N/S or G/S. Alternatively dilute to 1mg/10ml with G, N/S or G/S (unlicensed dilution- see page 1)

Protect infusion from light and discard if cloudiness develops. Sodium content 0.007mmol/1ml.

Bumetanide








37

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METHOD WHO MAY GIVE

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COMMENTS

All epidural administration sets and epidural catheters must be labelled “Epidural” when in use (NPSA/2007/21) Bupivacaine (epidural)

Adults:

0.167%

(with or without Fentanyl)

Paediatric:

0.125%

Epidural infusion via a McKinley epidural pump, using a yellow coloured line which must be labelled “Epidural”

♠ Groups 1and 2*

Adult patients: Epidurals: Protocol “A” PCEA or “B” CEA. Modified epidural protocols are very rarely prescribed by Anaesthetists

Pre-made bags are supplied from Pharmacy.

*Staff administering and monitoring epidural infusions must have received training from the Acute Care Team and demonstrated their competency at administering and monitoring epidural infusions. Follow the PHNT Epidural Protocols. Additional clinician boluses may be administered by Pain Nurses if required as per epidural protocol.

Bupivacaine Infusion for local infiltration 0.167% 0.125% 0.0625%

For specialist use: local infiltration at other sites i.e. near nerves, wound, joint, body cavity (e.g. interpleural, paravertebral) Via a dedicated, grey McKinley 595 pump, using a grey coloured line which must be labelled with the route.

♠ Groups 1and 2

Refer to Acute Care Team Guidelines

Pre-made bags are supplied from Pharmacy.

Refer to the PHNT protocol for Continuous Local Anaesthetic Infusions.

Buprenorphine IV bolus ♠ Groups 1 and 2

3-5 minutes Can be diluted with N/S or G. Flush with N/S. Sodium content nil.








38

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COMMENTS

Caffeine and sodium benzoate For treating low CSF pressure headache


1-2 hours Dilute 500mg caffeine sodium benzoate in 1 litre of N/S.

Record a resting ECG before administration. Monitor for possible side effects: tachycardia, cardiac arrythythmias, extra-systoles, restlessness, agitation, nausea, diuresis, hypoglycaemia, and hyperglycaemia. Note that caffeine and sodium benzoate injection is unlicensed (See page 1





Allow the ampoule or vial to reach room temperature before SC or IM injection. When in use the 400unit in 2ml multidose vial can be stored at room temperature. Record date of first use. Discard the remaining contents of the 400unit in 2ml multidose vial 1 month after first use. Ampoules of calcitonin are for single use only.

For hypercalcaemia of malignancy IV injection*


Suggestion: 1-2 minutes

May be given by IV injection for hypercalcaemia of malignancy after previous rehydration.* Do not use the calcitonin from the multiple dose 400unit in 2ml vial for bolus injection (As it contains phenol).

Calcitonin

(I) IV infusion for severe or emergency cases of hypercalcaemia of malignancy only.


At least 6 hours Dilute 10units/kg in 500ml N/S. Some adsorption of calcitonin to the plastic of the infusion set will occur so monitor the patient’s response to treatment.






39

DRUG

METHOD WHO MAY GIVE


COMMENTS

IV bolus Emergency use

or for severe acute hypocalcaemia

♠ Groups 1 and 2

Maximum adult rates:

1ml of 14.7%/minute

1-1.5ml of 10%/minute

1ml of 13.4%/minute

If 10% Calcium Chloride Minijets are not available then in cardiac arrest give 6.8ml of 14.7% calcium chloride undiluted which is 6.8mmol Ca2+ (equivalent to a 10% Calcium Chloride Minijet)

Calcium chloride

(I) or (C) IV infusion. Infusion pump is required.

♠ Groups 1 and 2

Adults: Maximum rate 1mmol/minute.

May be diluted with N/S, G or G/S to any suitable volume. However, concentrations greater than 10ml of 14.7% calcium chloride in each 100ml diluent will be irritant to peripheral veins and should ideally be given via a central IV line.

Very irritant; always administer slowly. Extravasation may cause tissue irritation and necrosis. Flush with N/S. Calcium chloride 10% contains 6.8mmol calcium/10ml.

Calcium chloride 13.4% contains 9.12mmol calcium/10ml.

Calcium chloride 14.7% contains 10mmol calcium/10ml.

IV bolus Emergency use or for severe acute hypocalcaemia

♠ Groups 1 and 2

Adults: Each 10ml ampoule preferably over 5 minutes, minimum 3 minutes.

If 10% Calcium Chloride Minijets are not available then in cardiac arrest give 30ml of 10% calcium gluconate undiluted which is 6.6mmol Ca2+ (approximately equivalent to a 10% Calcium Chloride Minijet)

(I) or (C) infusion using plastic ampoules of calcium gluconate

♠ Groups 1 and 2

Adults: Maximum rate by infusion 200mg (0.44mmol Calcium)/minute

May be diluted with N/S, G or G/S to any suitable volume e.g. 100ml, 250ml, 500ml or 1 litre. However, concentrations greater than 10ml of 10% calcium gluconate in each 100ml diluent will be irritant to peripheral veins and should ideally be given via a central IV line.

Flush with N/S. Calcium gluconate 10% contains 2.2mmol calcium in 10ml.

Irritant; extravasation may cause tissue irritation and necrosis.

In severe acute hypocalcaemia or hypocalcaemic tetany, an initial slow intravenous injection of 10–20 ml of calcium gluconate

injection 10% (use the plastic ampoules) should be given, with plasma-calcium and ECG monitoring (risk of arrhythmias if given too

rapidly), and either repeated as required or, if only temporary improvement, followed by a continuous intravenous infusion to prevent recurrence. For infusion, dilute 100 ml of calcium gluconate 10%(Use the plastic ampoules) in 1 litre of glucose 5% or sodium chloride 0.9% (remove 100ml from the bag first) and give at an initial rate of 50 ml/hour adjusted according to response.

Calcium gluconate

Calcium gluconate injection in glass ampoules or vials is now contra-indicated for use as repeated or prolonged treatment, including as an IV infusion, in children younger than 18 years and in patients with renal impairment. This is to limit exposure of patients to aluminium which is leached from the glass by the calcium gluconate solution. (MHRA Drug Safety Update, August 2010).






40

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COMMENTS

‘Campath’ See Alemtuzumab

Caspofungin (I) IV infusion. Infusion pump is required.


1 hour Allow the vial to warm to room temperature. Reconstitute each 50mg and 70mg vial with 10.5ml W. For the 50mg dose withdraw 10ml from the reconstituted 50mg vial. For the 70mg dose withdraw 10ml from the reconstituted 70mg vial. For reduced dose in moderate hepatic impairment (35mg) withdraw 7ml from the reconstituted 50mg vial. Further dilute with 250ml N/S or H.

If the patient is fluid restricted the 50mg and 35mg doses may be diluted in 100ml N/S or H.

Flush with N/S.

Do not infuse caspofungin with any other drug solutions or infusions containing glucose.

Phebitis is commonly reported.

IV bolus preferred method.


3-5 minutes Reconstitute 500mg with 2ml, 1g with 4ml and 2g with 10ml W. Displacement 0.2ml for 500mg vial. Add 1.8ml of W for 500mg in 2ml. Displacement 0.5ml for 1g vial. Add 3.5ml W for 1g in 4ml. Displacement 1.2ml for 2g vial. Add 8.8ml W for 2g in 10ml.

Cefotaxime

Only to be prescribed when ceftriaxone is contra-indicated due to the risk of precipitation with calcium containing fluids and TPN.

(I) IV infusion via infusion pump


20-60 minutes Reconstitute as above then dilute 1-2g with 40-100ml N/S, G, G/S or H.

Flush with N/S, G or G/S. Sodium content 2.09mmol/1g.


Reconstitute as for IV bolus. For paediatric doses apply the same displacement values.


IV bolus preferred method


3-5 minutes Reconstitute the 2g vial with 10ml or 20ml W, N/S, G or G10%. Displacement is 1ml for the 2g vial. Shake to dissolve and let stand until clear.

Incompatible with aminoglycosides eg.gentamicin, tobramycin and amikacin.


Reconstitute the 2g vial with 4ml W. Displacement is 1ml for the 2g vial. Shake to dissolve and let stand until clear.

Inject into a large muscle mass, eg. gluteus maximus.

Cefoxitine

(Unlicensed product – see page 4)

(C) IV infusion via infusion pump


Reconstitute each 2g vial with 10ml W. Shake to dissolve and let stand until clear. Further dilute with a suitable volume (eg. 500ml or 250ml) of N/S, G, G10% or H.

Diluted solutions for IV infusion must be discarded 12 hours after preparation.






41

DRUG

METHOD WHO MAY GIVE


COMMENTS

Cefradine Cefradine injection is no longer commercially available.

IV bolus ♠ Groups 1,2,3,4 and 5

3-5 minutes Reconstitute 500mg with 5ml, 1g and 2g with 10ml N/S or G. Carbon dioxide is released; see package insert.



Maximum 30 minutes Reconstitute 2g vial with 50ml of N/S, G, G10%, G/S or H. (For Kefadim® brand reconstitute 2g with 100ml of W, N/S or G. For Sandoz brand reconstitute 2g with 40ml of W, N/S or G).

Flush with N/S, G or G/S. Sodium content 2.3mmol/1g. Displacement values vary between brands, and are not consistent. Refer to the SPC or package insert for the brand and vial size being used.

Ceftazidime


Reconstitute 250mg with 1ml, 500mg with 1.5ml and 1g with 3ml N/S or W. carbon dioxide is released, see package insert.

Doses exceeding 1g should be given IV – see above. When IM injection causes pain Lidocaine 1% injection may be used to reconstitute the vial instead of N/S or W.


2-4 minutes Reconstitute 250mg vial with 5ml W and 1g vial with 10ml. Displacement values vary between brands and are not consistent – refer to the package insert or SPC for the particular brand and vial size being used.

(I) IV infusion (doses of 2g and above). Infusion pump is required.


At least 30 minutes Reconstitute 2g vial with 40ml G, G 10%, or N/S.

Do not give with TPN or fluids containing calcium, even by different infusion lines (Cefotaxime is a suitable alternative for these patients). Sodium content: 3.6mmol/1g Flush with N/S or G For infants and children up to 12 years, doses of 50mg/kg or over should be given by slow IV infusion over at least 30 minutes. (For neonates the dose is given over 60 minutes).

Ceftriaxone


Reconstitute 250mg with 1ml, 1g with 3.5ml and 2g with 7ml of 1% lidocaine injection. Refer to the Marsden Manual for guidance on IM injection.

Give by deep IM injection. Doses greater than 1g should be divided and injected at more than one site.






42

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COMMENTS

IV bolus (Usual method)


3-5 minutes Reconstitute 250mg with at least 2ml, 750mg with at least 6ml and 1.5g with at least 15ml W. Shake gently to produce an opaque suspension.



Maximum 30 minutes

Reconstitute as above then dilute to 50 - 100ml with N/S or G.

Cefuroxime


Reconstitute 250mg with 1ml W and 750mg with 3ml W (750mg Sandoz brand may alternatively be reconstituted with 3ml 1% lidocaine). Shake gently to produce an opaque suspension. Refer to the Marsden Manual for guidance on IM injection.

Flush with N/S, G or G/S. Sodium content: 1.8mmol/750mg Cefuroxime can be added to an infusion bag of metronidazole. Displacement values vary between brands and are not consistent – refer to the package insert or SPC for the particular brand and vial size being used.

Cernevit and Decan (see page 47) are added daily, Monday to Friday, by Pharmacy to TPN. The TPN bags held as stock on Penrose Ward do not contain vitamins or trace elements. If TPN is commenced for a Penrose patient when Pharmacy is closed, Penrose staff should confirm whether the duty ICU consultant wants Cernevit and Decan given separately to the patient (Do not add Cernevit and Decan to the TPN bag on the ward).

Slow IV bolus ♠ Groups 1,2,3,4 and 5

At least 10 minutes

Reconstitute the vial with 5ml of W, N/S or G. Mix gently to dissolve the powder forming a yellow-orange coloured solution. Either give undiluted or dilute further with a small volume of N/S or G.

Dosage for adults and children aged over 11 years: 1 vial of 5ml per day. Cernevit does not contain Vitamin K. Cernevit may be administered via any type of intravenous cannula (including peripheral). Do not mix with any other drug solutions.

Cernevit (Water and fat-soluble vitamins)



At least 10 minutes

Reconstitute the vial with 5ml of W, N/S or G. Mix gently to dissolve the powder forming a yellow-orange coloured solution, then dilute further with N/S or G (e.g. up to 50ml).






43

DRUG

METHOD WHO MAY GIVE


COMMENTS

IV bolus

(Usual method)


At least 1 minute Reconstitute with W, N/S or G. See package insert. Suggested maximum concentration 100mg/1ml. Displacement 0.8ml/1g vial. Add 9.2ml diluent to 1g vial for 1g in 10ml (100mg in 1ml).

Flush with N/S. Sodium content 2.98/1g In order to ensure rapid attainment of high blood levels, chloramphenicol succinate is best administered by IV injection. Where this is not possible, however, IM injection may be used, although it should be borne in mind that absorption may be slow and unpredictable.

Chloramphenicol sodium succinate



Give slowly over 15 to 30 minutes

Reconstitute as above then dilute with N/S or G (suggested volume 100ml).

Clomethiazole Discontinued product

Chloroquine (C) IV infusion. Infusion pump is required.

♠ Group 1 Initially 10mg/kg of Chloroquine base over 8 hours then 5mg of base/kg for 3 more 8-hour infusions

Dilute with N/S to a suitable volume e.g. 50ml.

Oral therapy is started as soon as possible to complete the course. Flush with N/S.






44

DRUG METHOD WHO MAY GIVE

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COMMENTS

IV bolus


Minimum 1 minute May be diluted with N/S to a convenient volume e.g. 10ml.

IM injection

(Use the IV route if a rapid effect is required)



Chlorphenamine

SC injection

(Use the IV route if a rapid effect is required)



Flush with N/S (IV)

Extra care should be taken when preparing the injection for children under 1 year due to the small volumes that are required. Dilution of chlorphenamine injection with N/S should facilitate preparation. For example, diluting 0.2ml chlorphenamine injection to 2ml with N/S produces a solution containing chlorphenamine 1mg/ml. The diluted product should be used immediately.

Deep IM injection



(I) IV infusion via an infusion pump to treat hiccups when IM injection fails.


Slowly (Suggestion: 12 hours)

Dilute 25-50mg with 500ml-1 litre N/S.

Chlorpromazine

IV bolus (This method is unlicensed – see page 1).


Adults: Maximum 1mg/minute.

Dilute to a maximum concentration of 1mg/1ml with N/S.

IM injection can be repeated at 6 to 8 hour intervals if required. Substitute with oral chlorpromazine as soon as possible. Very irritant; avoid IV administration if possible. Do not administer via the SC route. Flush with N/S (IV). Sodium content 0.2mmol/2ml.

Hypotension can occur, especially with rapid administration: Keep the patient supine and monitor the blood pressure during and for 30 minutes after IM or IV administration.






45


ADMINISTER OVER


COMMENTS

Ciclosporin (I) IV infusion. Infusion pump is required.


2-6 hours Dilute to a concentration of each 50mg in 20-100ml of N/S or G.

Use infusion within 6 hours of preparation because the solution contains polyethoxylated castor oil which causes phthalate leaching from PVC containers and tubing.

Observe patient continuously for the first 30 minutes and at frequent intervals thereafter (Risk of anaphylactic reactions, acute respiratory distress, blood pressure changes). Flush with N/S.

Ciprofloxacin Not for general use. Refer to Trust Policy for Control of Infection.

(I) IV infusion. Infusion pump is required. Infusion into a large vein will reduce venous irritation (low pH)


Adults: 200mg over 30 minutes, 400mg over 60 minutes. For children, infuse the dose over 60 minutes.

Provided suitably diluted.

Flush with N/S. Sodium content 15.4mmol/100ml.






46



COMMENTS

Clarithromycin (I) IV infusion via a large peripheral vein (or central vein). Infusion pump is required.


60 minutes Reconstitute 500mg vial with 10ml W and shake to dissolve the contents. Further dilute to a concentration of 2mg/ml with N/S, G or H (Adult dose of 500mg = 10ml of reconstituted solution in 250ml N/S, G or H). For fluid restricted patients 500mg clarithromycin, reconstituted as above, may be diluted in 100ml of N/S and infused over 60 minutes via a central IV line (This dilution is unlicensed).

Do not give by IV bolus (can cause cardiac arrythmias). Do not give by IM injection. The reconstituted vial contains 500mg in 10ml (although the final volume in the vial will be 10.4ml). Use infusion within 6 hours of preparation. Flush with N/S or G. Sodium content: Less than 0.5mmol/500mg Incompatible with aminophylline, cefuroxime, furosemide, heparin, phenytoin, flucloxacillin and ceftazidime. Monitor infusion site for signs of inflammation, tenderness, phlebitis and pain.

(I) IV infusion Maximum 1.2g. Infusion pump is required.

♠ groups 1,2,3,4 and 5

300mg over at least 10 minutes, 600mg over at least 20 minutes, 900mg over at least 30 minutes, 1.2g over at least 40 minutes.

Dilute to a maximum concentration of 18mg/ml with N/S or G. Typically: For doses of 300mg, 600mg or 900mg, dilute in 50ml or 100ml N/S or G. Dilute 1200mg in 100ml N/S or G.

Flush with N/S. Sodium content: Nil.

(C) IV infusion Doses above 1.2g Infusion pump is required.


Rate not to exceed 30mg/minute.

Dilute to a maximum concentration of 18mg/ml with N/S or G.

Continuous intravenous infusion may begin with a single rapid infusion of the first dose (generally over 30minutes), followed by a continuous infusion of 0.75 to 1.25mg/minute.

Clindamycin



Single IM injections of greater than 600mg are not recommended.






47



COMMENTS

Clonazepam IV bolus

In to a large vein in the antecubital fossa.

Emergency use


Adults: Maximum rate 0.25 - 0.5mg/minute Infants & children:

50microgram/kg (maximum 1mg) over at least 2 minutes

Immediately before use dilute each 1mg in 1ml with 1ml W (diluent supplied), to produce a 1mg in 2ml solution.




Neonates and children 1 month to 18 years:

10 – 60 micrograms/Kg/hour = 0.83 – 5ml/kg/hour of the 12microgram/ml dilution.

Dilute up to 3mg in 250ml of N/S, G, G10% or G/S(2.5%/0.45%).

On Neonatal ICU dilute to a maximum concentration of 300micrograms in 25ml or 600micrograms in 50ml (12 micrograms/ml) with G10%. In fluid restricted infants concentrations up to 100micrograms/ml have been used.

Resuscitation equipment must be readily available.

EEG, respiratory function and blood pressure should be monitored. Flush with N/S, G or G10%. Sodium content: Nil If using a PVC bag and/or a PVC line begin the infusion immediately and infuse over a period no longer than 2 hours. Alternatively dilute to 12 micrograms/ml with N/S in a 50ml Terumo or BD syringe using a PVC-free extension set. The following are available to be ordered from NHS Supplies: Codan PVC-free extension set 71.4001, order code FKA064 Alaris G30302M line, order code FKA058 Using this method the solution will be stable for 12 hours.






48



COMMENTS

IV bolus ♠ Groups

1 and 2

Give slowly preferably over 10-15 minutes to avoid transient pressor effect.

Can be diluted with N/S or G to any suitable volume.

(C) IV infusion for sedation/ withdrawal from sedation in critical care areas only. Infusion pump is required.

♠ Groups

1 and 2

Usual rate: 0.5 - 1 micrograms/kg/hour.

Rates up to 2 microgram/kg/hour have been used.

Dilute 750 micrograms to 50ml with N/S or G.


(C) IV infusion is unlicensed (See page 4).

Monitor for bradycardia and hypotension.

Withdraw gradually to avoid rebound tachycardia, hypertension, agitation and sweating. Very little compatibility data – infuse through a dedicated lumen or line. May be infused via a peripheral or central IV line.

Clonidine

(C) Intrathecal infusion or

Intrathecal bolus


Prepare and administer in accordance with the Pain Management Centre procedures







49


ADMINISTER OVER


COMMENTS

IV bolus

Usual method.


3-4 minutes Reconstitute each 600mg with 10ml W. For doses requiring part of a vial Displacement values:

Bowmed brand:

0.4ml for the 600mg vial and 0.7ml for the 1.2g vial.

Augmentin® and Wockhardt brands:

0.5ml for the 600mg vial and 0.9ml for the 1.2g vial.

PLIVA(TEVA) brand:

Insignificant (=0ml) for the 600mg vial and 0.25ml for the 1.2g vial.

Co-amoxiclav



30-40 minutes Reconstitute as above then dilute each 600mg with 50ml N/S.

Flush with N/S. Complete infusion within 4 hours of reconstitution. Sodium content 2.7mmol/1.2g. Potassium content 1mmol/1.2g.

For bolus injection use within 20 minutes of reconstitution.

Do not dilute Co-amoxiclav with G.

Not suitable for IM injection.

Example: How to give 900mg

Using a 20ml syringe, reconstitute a 1.2g vial with 15ml WFI. Draw up the entire vial contents into the syringe then draw up more W to the 20ml mark. Mix the syringe contents. Then administer 15ml (contains 900mg) and discard 5ml.



30 minutes Reconstitute all vial strengths with 10ml W or N/S. Roll vial in hand to dissolve. Do not shake to avoid foam formation, then dilute further with N/S to 50ml.

Colistimethate (Colistin)

(Colomycin ®)

Patients with a Totally Implantable Venous Access Device (TIVAD) may tolerate a slow IV bolus of up to 2 million units


Via TIVAD only: Minimum 5 minutes

Reconstitute all vial strengths with 10ml W or N/S. Roll vial in hand to dissolve. Do not shake to avoid foam formation.

Flush with N/S. Do not infuse with any other drugs.

Sodium content: less than 0.5mmol per 500,000 unit and 1,000,000 unit vials

The powder for injection is also licensed for use via a nebuliser. To nebulise dissolve dose in 2-4ml of W or N/S. The output from the nebuliser may be vented to the open air or a filter may be fitted. Nebulisation should take place in a well ventilated room.






50


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COMMENTS

Collagenase Clostridium histolyticum

▼▼▼▼ This product is being intensively monitored by the CHM and MHRA. Please report all suspected reactions (including non-serious ones) using a Yellow Card from the BNF

0.58mg per injection into a palpable Dupuytren's cord

♠ Group 1 Remove the vial from the fridge and allow to stand at room temperature for at least 15 minutes and no longer than 60 minutes. Reconstitute the vial with the solvent supplied according to the table below. Use only the supplied solvent as it contains calcium required to activate the medication. Inject the appropriate volume (see below) of the solvent slowly into the sides of the vial. Do not invert or shake the solution. Slowly swirl to ensure dissolution. The final solution must be clear and colourless.

Each vial is for single use only.

When injecting a cord affecting a proximal interphalangeal joint of the fifth finger, the needle insertion must not be more than 2 to 3 mm in depth and not more than 4 mm distal to the palmar digital crease.

Sodium injected per joint:

Metacarpophalangeal joints: 0.9mg

Proximal interphalangeal joints: 0.7mg

Volumes needed for reconstitution and administration of Collagenase Clostridium histolyticum

Joint to be treated Solvent required for reconstitution Injection volume to deliver 0.58 mg dose*

Metacarpophalangeal joints 0.39ml 0.25ml

Proximal interphalangeal joints 0.31ml 0.20ml

* Note that injection volume for delivery of a 0.58 mg dose is less than the total volume of solvent used for reconstitution.






51



COMMENTS

Co-trimoxazole



The dilution of Septrin brand for PJP (Formerly known as PCP) – each 5ml with 75ml G – should be given over no longer than 1 hour. Other dilutions should be given over no longer than 90 minutes, but this should be balanced against the patient’s fluid requirements

For patients with Pneumocystis jirovecii (formerly known as Pneumocystis carinii) pneumonitis

Septrin brand: Dilute each 5ml with at least 75ml G. Other infections dilute each 480mg (5ml) with 125ml, 960mg (10ml) with 250ml, 1440mg (15ml) with 500ml or an equivalent dilution with N/S, G or G/S. These infusions must be administered within 6 hours

Do not infuse with any other drugs.

Flush with N/S. Monitor all infusions carefully for turbidity and crystallization. Commence the infusion within half an hour of preparation. High doses have been given undiluted via a central line and syringe pump over 1.5 - 2 hours; not recommended by manufacturer. Sodium content 1.64mmol/480mg. Extravasation : may cause tissue damage.






52



COMMENTS


3-5 minutes Can be diluted with N/S or G if necessary to a convenient volume e.g. 5ml. If diluted with N/S, visually check the dilution. Discard if there is any crystallization, precipitation or haziness. Otherwise use immediately.

Flush with 5 ml of N/S or G. Sodium content nil.



Cyclizine

(C) SC infusion via syringe driver in palliative care


Continuous over 24 hours

Dilute with W.

(C) SC injection for use in palliative care



Follow the PHNT Care of The Dying Pathways and the PHNT Syringe Driver Policy. Cyclizine may precipitate if the concentration in W exceeds 10mg/ml. Precipitation occurs if mixed with N/S. For combinations of 2 or 3 drugs in the same syringe, refer to the Syringe Driver Drug Compatibility chart provided in the pump kit. Contact Pharmacy on ext. 39976 for further compatibility advice if necessary. Cyclizine is not licensed via the SC route (See page 124).

Cyclophosphamide When cyclophosphamide is prescribed to treat conditions including multiple sclerosis, glomerular kidney disease or rheumatoid

arthritis, it may be administered by Group 2 ♠ practitioners who have previous experience of administering parenteral cytotoxics. Read Appendix 3 for guidance on the handling of cytotoxic drugs. On the Planned Investigation Unit, refer to the Unit protocol.






53


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COMMENTS

Danaparoid IV loading dose injected over 30 seconds followed by (C) IV infusion to treat thrombo-embolism in patients with

Heparin- Induced Thrombocytopenia (HIT). Infusion pump is required.


See comments Dilute with N/S, G or G/S. The volume of diluent is not critical and can be adjusted to the fluid needs of the patient.

One suggested dilution: Draw up the contents of six 750 unit ampoules (6x750 units = 4500 units) into a 50ml syringe and dilute to 45ml with N/S or G to make a 100unit/ml dilution.

However, if the maintenance infusion rate is less than 187 units/hour the above dilution will waste danaparoid (expensive). In this case draw up the contents of three 750 unit ampoules (3x750units = 2250 units) into a 50ml syringe and dilute to 45ml with N/S or G to make a 50unit/ml dilution.

Seek advice of Consultant Haematologist as the Consultant Haematologists have different regimens for different indications.

Dantrolene IV bolus ♠ Group 1 Give rapidly Reconstitute 20mg with 60ml W. Shake the vial until the solution is clear.

Due to high pH (9.5) avoid extravasation. Sodium content 2mmol/20mg vial. Each 20mg vial also contains 3g mannitol. Protect from light. Incompatible: do not give with any other drugs or infusion fluids including G and N/S.






54

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COMMENTS


2 minutes Reconstitute the 500mg vial with 10ml N/S or the 350mg vial with 7ml N/S Do not use W to reconstitute. Gently rotate the vial to ensure complete wetting of the product and then allow to stand for 10 minutes. The vial should then be gently rotated/swirled for a few minutes as needed to obtain a clear reconstituted solution. Vigorous shaking/agitation should be avoided to prevent foaming of the product. The concentration of the reconstituted solution is 50mg/ml (No displacement)

Daptomycin

May only be initiated on the advice of a consultant microbiologist


(I) IV infusion ♠ Groups 1,2,3,4 and 5

30 minutes Reconstitute and dissolve as above. Further dilute to 50ml or 100ml N/S.

Contains negligible sodium (<0.05mmol/vial).

Treatment should be discontinued if the CPK level reaches greater than 5 times upper limit of normal in the presence of unexplained muscle symptoms.

Store vial in a refrigerator at 2-8oC.

If clotting profiles are required during treatment, samples should be taken pre-dose.

Compatible with: Aztreonam, ceftazidime, ceftriaxone, dopamine, fluconazole, gentamicin, heparin, levofloxacin, lidocaine.

Incompatible with Glucose solutions.

Flush with N/S.

Cernevit (See page 35) and Decan are added daily, Monday to Friday, by Pharmacy to TPN. The TPN bags held as stock on Penrose Ward do not contain vitamins or trace elements. If TPN is commenced for a Penrose patient when Pharmacy is closed, Penrose staff should confirm whether the duty ICU consultant wants Cernevit and Decan given separately to the patient (Do not add Cernevit and Decan to the TPN bag on the ward).

Decan (Trace elements)



Suggestion: 1 hour

Via a peripheral IV cannula, 40ml Decan must be diluted to at least 250ml with N/S, or to at least 500ml with G. Via a CVC or PICC line, 40ml Decan may be diluted in a smaller volume of N/S or G or given undiluted if necessary.

Dosage for adults: 1 vial of 40ml per day. Contra-indicated in children, patients weighing less than 40kg and in patients with pronounced cholestasis (serum bilirubin > 140micromol/l). Do not mix with any other drug solutions.






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Treatment of acute iron poisoning: 15mg/kg/hour, reduced as soon as the situation permits (usually after 4-6 hours). Total IV dose not to exceed 80mg/kg in any 24 hour period

Chronic iron overload:

20 – 60mg/kg/day

Reconstitute each 500mg with 5ml W and each 2g vial with 20ml W then dilute with N/S, G or G/S. to any suitable volume (e.g. 500ml, 1000ml or 250ml).

Example for treating acute iron poisoning: Reconstitute 5 x 2g vials each with 20ml W, remove 100ml from a 500ml bag of N/S and add the contents from the 5 x 2g vials to the bag then to produce 10g desferrioxamine in 500ml(=20mg/ml). The initial rate for will be 0.75ml/kg/hour (= 15mg/kg/hour). Displacements: 0.4ml/500mg Desferal® vial, 0.3ml/500mg Hospira vial and 1.5ml/2g vial (both brands).

Desferrioxamine

SC infusion using a portable ambulatory pump


Chronic iron overload:

20 – 60mg/kg/day.

Infuse the dose over 8 to 24 hours

Suggestion: Reconstitute as above then either dilute with N/S or give without further dilution.

Discard infusion if opalescent. Flush with N/S.

May be infused into the blood line through a “Y” adaptor located near to the venous site of injection.

For use in children with chronic iron overload follow the protocol on CYPOD (Childrens’ and Young Persons Outpatient Department).

Desferrioxamine is incompatible with heparin solutions.

If giving by SC infusion, monitor for irritation or discomfort at the site of administration.






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Suggestion: 1 minute Undiluted

Flush after IV bolus with N/S.

After repeated doses monitor for fluid overload; restrict fluid intake and check body weight regularly

Desmopressin 4mg in 1ml

(I) IV infusion

(Haemophilia and Von Willibrands). Infusion pump is required.


20 minutes Dilute the dose to 50ml with N/S but see comments.

Tachycardia, hypotension and facial flushing may occur during infusion; monitor blood pressure continuously during infusion.

For (I) IV infusion 100ml N/S can be used (unlicensed) if necessary but the 20 minute infusion time should be adhered to.

Do not mix with other fluids or drugs

SC injection ♠ Groups 1and 2


Desmopressin 15micrograms in 1ml

(OCTIM Brand)

For specialist use in Birch Outpatients or Haematology Outpatients

(I) IV infusion


♠ Groups 1 and 2

20 minutes Dilute the dose to 50ml with N/S but see comments.

Tachycardia, hypotension and facial flushing may occur during infusion; monitor blood pressure continuously during infusion.

Do not mix with other fluids or drugs.

Restrict fluid intake and check body weight regularly.

Continued monitoring of Factor VIII levels is recommended.






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IV bolus or (I) IV infusion. Infusion pump is required.


Organon brand:

Give 4mg over 1 minute.

Give large doses over several minutes.

Hospira brand:

For a 4mg dexamethasone dose give 1.2ml over 1 minute.

Give large doses over several minutes.

May be diluted with N/S, G or H to any convenient volume.

IM injection ♠ Groups 1,2,3,4, 5


Organon brand contains a quantity of dexamethasone phosphate equivalent to 4mg/ml dexamethasone.

Hospira brand contains a 8mg in 2ml of dexamethasone phosphate equivalent to 6.6mg dexamethasone in 2ml (3.3mg/ml).

Flush IV doses with N/S. Anaphylactic reactions can occur.

(For treatment of anaphylaxis see page 38).

The IV and IM routes of administration of dexamethasone should only be used where acute illness or life-threatening situations exist. Oral therapy should be substituted as soon as possible.

Note that absorption will be slower after IM injection.

Intra-articular ♠ Group 1 Prior to intra-articular injection, the joint fluid should be examined to exclude a septic process. Administer under strictly aseptic conditions.

Soft tissue infiltration (Intralesional)

♠ Group 1 Licensed sites include: bursae, tendon sheaths and ganglia.

Dexamethasone sodium phosphate

Intrathecal

(Use Hospira brand vials)

(Unlicensed route)


Administer in accordance with the Pain Management Centre procedures or current anaesthetic practice.

*Restricted to those persons who are trained and competent to administer medication via the intrathecal route. Use Hospira brand dexamethasone as it does not contain glycerol or disodium edetate.






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COMMENTS

Dexrazoxane

(Cardioxane®)

(I) IV infusion


15 minutes Infusion to be prepared by Pharmacy. Telephone Ext. 31083.

Administer about 30 minutes before anthracycline (e.g. doxorubicin or epirubicin) administration. Handle as for cytotoxics. Wear gloves and safety glasses when handling – See Appendix 3. Avoid handling drug if pregnant. Store the prepared infusion in the fridge and use within 6 hours of pharmacy preparation.

Dexrazoxane

(Savene®)

(I) IV infusion

into a large vein in extremity/area other than the one affected by the extravasation


1 – 2 hours Infusion to be prepared by Pharmacy. Telephone Ext. 31083.

The first infusion should be initiated as soon as possible and within the first six hours after the accident. Cooling procedures such as ice packs should have been removed from the area at least 15 min before the Savene administration in order to allow sufficient blood flow. Treatment Day 2 and Day 3 should start at the same hour (+/- 3 hours) as on the first day. Refer to the Guidelines for the administration of Savene(dexrazoxzane) for the treatment of extravasations caused by anthracyclines.






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COMMENTS



Maximum rate 1mg/minute

Usually reconstitute 5mg, 10mg , 30mg and 100mg ampoules with 1ml W. Use a minimum of 2ml W to reconstitute 500mg ampoule. Can be diluted with N/S or G.

Observe respiratory rate (especially with IV bolus doses). Naloxone and resuscitation equipment should be available. For acute pain the IV dose will be a quarter to half of the corresponding IM dose. For elderly and frail patients reduce the usual dose by half. Flush with N/S or G. Sodium content nil.


Reconstitute as above. Refer to the Marsden Manual for guidance on IM injection.


Reconstitute as above. Refer to the Marsden Manual for guidance on SC injection.

For use in palliative care follow the PHNT Care of The Dying Pathways




Reconstitute as above. Dilute further with W when 2 or more drugs are being mixed in the same syringe. W or N/S may be used where the syringe only contains diamorphine.

Follow the PHNT Care of The Dying Pathways and the PHNT Syringe Driver Policy. For combinations of 2 or 3 drugs in the same syringe, refer to the Syringe Driver Drug Compatibility chart provided in the pump kit. Contact Pharmacy on ext. 39976 for further compatibility advice if necessary. In chronic pain, the total daily dosage of IM or SC diamorphine is about one third of the equivalent total daily dosage of oral morphine.

Diamorphine

Epidural or spinal injection

♠ Group 1 Administer in accordance with standard anaesthetic practice.

All syringes containing solution for epidural administration should be labelled “For Epidural Use Only” (NPSA/2007/21)






60



COMMENTS

All epidural administration sets and epidural catheters must be labelled “Epidural” when in use (NPSA/2007/21) Diamorphine 50 micrograms/ml with bupivacaine 0.167% epidural infusion for adults

Epidural infusion via McKinley pump

♠ Groups 1and 2*

Background rate of 0 -10 ml/hour with additional Patient-Controlled Epidural Analgesia (PCEA) of 5ml boluses with a lock-out time of 30 minutes, if prescribed.

Pre-made bags supplied by Pharmacy. When these are not available the anaesthetist may prepare the infusion in theatre, with the bag labelled “For Epidural Use Only”.

*Staff administering and monitoring epidural infusions must have received training from the Acute Care Team and demonstrated their competency at administering and monitoring epidural infusions. Follow the Acute Care Team Protocols. Additional clinician boluses may be administered by Pain Nurses if required as per epidural protocol.


Maximum rate: 5mg (1ml) per minute.

Do not dilute. Flush with G (do not use N/S). Diazepam emulsion (Diazemuls) (This is the preferred diazepam formulation for IV injection)

(I) IV infusion. Infusion pump is required. .


Titrate dose to response.

Dilute 2-8ml with 100ml G or G10%, to produce a concentration between 100-400micrograms/1ml.

Use infusion within 6 hours. Diazepam is adsorbed by plastic infusion equipment.

It can be injected into the infusion tubing during an ongoing infusion of N/S, G or G10%.


Suggestion for adults: Maximum rate 5mg (1ml) per minute

Undiluted

(C) or (I) IV infusion. Infusion pump is required.


Titrate dose to response.

Dilute with N/S or G to a concentration not exceeding 40mg in 500ml.

Elderly or debilitated patients should be given not more than half of the usual dose.

Flush with N/S or G. Give IV injections into a large vein to reduce local reactions (thrombophlebitis and thrombosis).

It is recommended that patients should remain under medical supervision and in a supine position for at least one hour after administration. Resuscitation equipment should be available. Use infusion within 6 hours. Diazepam is adsorbed by plastic infusion equipment.

Diazepam



The IM route should only be used when IV or oral administration is not possible.






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(C) or (I) Infusion. Do NOT give as IV bolus. Infusion pump is required.

♠ Groups 1 and 2

Treatment of post-op pain: 75mg over 30 minutes - 2hours. Prevention of post-op pain: 25-50mg over 15 minutes - 1 hour then (C) IV infusion at 5mg/hour.

First add 0.5ml of 8.4%, or 1ml of 4.2% sodium bicarbonate solution to 100-500ml N/S or G with then add the contents of one ampoule (75mg diclofenac in 3ml).

Only use if solution is clear. Once prepared, use infusion immediately. Maximum daily dosage is 150mg. Parenteral administration should not exceed 2 days. Flush with N/S or G. Sodium content: negligible. Do not infuse with any other drugs.

Diclofenac

IM injection ♠ Groups 1 and 2

Give undiluted.


By deep intragluteal injection into the outer quadrant. If a second IM injection of diclofenac is needed, it is advised that the other buttock is used.

Dicobalt edetate IV bolus. ♠ Group 1 Adults: Each 300mg dose over 1 minute, or in less severe poisoning over 5 minutes.

Give undiluted.

Each dose may be followed immediately with 50ml G 50%. 100% oxygen should be administered

concurrently with Dicobalt Edetate. When the patient is fully conscious, it is unlikely that the extent of poisoning warrants the use of Dicobalt Edetate Injection.






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30 minutes Reconstitute each vial with 4 ml W. Mix gently. The reconstituted solution may be further diluted to any convenient volume with N/S. Infuse the final solution via a 0.22 micron filter

Digibind ®

Bolus only if cardiac arrest seems imminent

♠ Group 1 Reconstitute as above.

Can rarely cause anaphylaxis, allergic or febrile reactions.

Resuscitation equipment should be available.

Monitor blood pressure & body temperature.

Monitor ECG continuously during and for at least 24 hours after Digibind.

Hypokalaemia can develop- sometimes rapidly. Monitor serum potassium level carefully during and after Digibind.

Suitable filters to administer Digibind diluted in N/S include PALL 0.22 micron, Braun Sterifix 0.2 micron, Technopharm codan 0.2 micron filters. A filter can be obtained from Pencarrow ward

Digoxin (I) IV infusion. Infusion pump is required.


Emergency Loading Dose of 500micrograms to 1mg infused over at least 2 hours (see comments) Maintenance dose (when patient unable to take by mouth or enteral feeding tube) infused over 1 hour.

Adults: Dilute loading and maintenance doses to 50-100ml with N/S.

ECG monitoring required. Flush with N/S. Emergency Loading Dose depends on age, lean body weight and renal function. Consider giving a reduced dose if digoxin has been taken within the last 2 weeks. Note that 500micrograms of IV digoxin is equivalent to 750micrograms of digoxin in tablet form. For plasma monitoring, take blood at least 6 hours after a dose.

Dihydro-ergotamine

For the use of IV dihydroergotamine to treat migraine or cluster headache, follow a copy of the protocol from the Planned Investigation Unit (PIU). The protocol may also be found on Plymouth Healthnet > Depts > Pharmacy. Note that dihydroergotamine injection is an unlicensed product (see page 4).






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Disopyramide Regimen 1

Slow IV bolus

♠ Groups 1 and 2

Adults: 2mg/kg (maximum 150mg) over at least 5 minutes

Either give undiluted or dilute further with any suitable volume of N/S or G.

ECG monitoring is necessary. Monitor for ventricular arrythmias, widening of QRS complex and lengthening of QT interval, hypotension, hypoglycaemia, myocardial depression, AV block and antimuscarinic side effects. Stop administration of disopyramide if width of QRS-complex or QT-interval increase by more than 25%, or hypogylaemia occurs. If cardioversion occurs during the injection, stop injecting the remainder of the dose. If cardioversion is achieved (usually within 10-15 minutes after the first injection) but the arrhythmia recurs, a second dose of 2mg/kg (maximum 150mg) may be given by slow IV injection over at least 5 minutes (maximum of 300mg in the first hour, maximum of 800mg disopyramide by any route in 24 hours). Flush slowly with N/S.

Slow IV loading dose

♠ Groups 1 and 2

Adults: 2mg/kg (maximum 150mg) over at least 5 minutes

Either give undiluted or dilute further with any suitable volume of N/S or G.

Disopyramide Regimen 2 This regimen should be used for patients who are unable to take disopyramide by mouth or who have serious arrhythmias being treated in critical or coronary care areas.

(C) IV maintenance infusion

♠ Groups 1 and 2

Adults: 0.4mg/kg/hour Maximum 30mg/hour. Maximum total 800mg in 24 hours.

Suggested dilution: Remove 50ml from a 500ml bag of N/S or G. Then add 500mg = 50ml of disopyramide injection into the bag to make a 1mg/ml dilution.

ECG monitoring is necessary. Monitor for ventricular arrythmias, widening of QRS complex and lengthening of QT interval, hypotension, hypoglycaemia, myocardial depression, AV block and antimuscarinic side effects. Stop administration of disopyramide if width of QRS-complex or QT-interval increase by more than 25%, or hypogylaemia occurs.






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(C) IV infusion Infusion pump is required. Administration via a central IV line is recommended* as solutions of dobutamine have a low pH.

♠ Groups 1 and 2


Dilute 250mg to at least 50ml with N/S or G (If no central IV access available see below*) Concentrations of up to 10mg/1ml have been used via a central IV line but this is outside the manufacturer's recommendations. *In circumstances where a central venous catheter is not available and the infusion is going to be run for more than a couple of hours, use a solution of 1mg in 1mL (250mg in 250ml N/S) and administer via a large peripheral vein.

Do not flush - replace giving set. Infusion may turn a harmless pink colour. Haemodynamic monitoring required. Sodium content: 0.046mmol/vial. An alternative dilution: For administration via a central IV line draw up milligrams of dobutamine equal to six times the patient’s body weight in kilograms, and dilute to 100ml with N/S or G (or milligrams of dobutamine equal to three times the patient’s body weight in kg in 50ml). The infusion rate set in ml/hour will equal micrograms/kg/minute.

Pump rate (ml/hour) = Prescribed rate (mcg/kg/min) x weight(kg) x 60(minutes in an hour) 1000 x concentration(mg/ml) Rate (mcg/kg/min) = Pump rate(ml/hour) x concentration(mg/ml) x 1000 60 x weight(kg)

Dobutamine

(I) IV infusion using infusion pump for cardiac stress testing. Infusion pump is required.

♠ Group 1 or Group 7

See comments Calculate the required amount of dobutamine and dilute to 50ml with N/S.

Infuse at 10mcg/kg/min for 4 minutes, then 20mcg/kg/min for 4 minutes, then 30mcg/kg/min for 4 minutes, then 40mcg/kg/min.






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(C) IV infusion. Infusion pump is required. Administration via a central IV line is preferred as solutions of dobutamine have a low pH. If no central IV access is available the maximum concentration for infusion through a peripheral vein is 1.6mg/ml.

♠ Groups 1 and 2

Rate dependent on indication and response.

For administration via a central IV line draw up milligrams of dopamine equal to six times the patient’s body weight in kilograms, and dilute to 100ml with N/S, G, G10%, G/S or H (or milligrams of dopamine equal to three times the patient’s body weight in kg in 50ml). The infusion rate set in ml/hour will equal micrograms/kg/minute. Alternatively for administration via a central IV line dilute 200mg dopamine to 50ml with N/S, G, G10%, G/S or H and infuse at the calculated rate. For administration via a peripheral IV line add 400mg dopamine to 250ml N/S and infuse at calculated rate.

ECG monitoring usually required. Do not flush - replace giving set. For peripheral administration use a dilute solution and a large vein. Use a central venous line for concentrations over 1.6mg/ml. Extravasation causes local vasoconstriction; irrigate affected area with 5-10mg phentolamine in 10-15ml N/S. Sodium content 0.52mmol/200mg.

Dopamine

Pump rate (ml/hour) = Prescribed rate (mcg/kg/min) x weight(kg) x 60(minutes in an hour) 1000 x concentration(mg/ml) Rate (mcg/kg/min) = Pump rate(ml/hour) x concentration(mg/ml) x 1000 60 x weight(kg)

Dopexamine (C) IV infusion. Infusion pump is required.

♠ Groups 1 and 2


Dilute with N/S, G, G/S or H to a maximum concentration of 4mg/ml via a central IV line or a maximum concentration of 1mg/ml via a large peripheral vein.

Infuse via a central vein or a large peripheral vein. Monitor BP, heart rate, ECG, urine flow and where possible cardiac output. Infusion may turn a harmless pink colour.






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IV bolus ♠ Group 1 Minimum 30 seconds Ampoule can be diluted with N/S, G or G10%.

Doxapram



Adults: 1.5 – 4mg/minute = 45 – 120ml/hour using the 1g in 500ml infusion, increasing the rate gradually.

Adults: Dilute 1g doxapram in 500ml G.

Flush with N/S or G. IV bolus dose may be repeated at one hour intervals if necessary. Monitoring of blood pressure, heart rate and deep tendon reflexes is recommended to prevent overdosage. Check arterial blood gases (ABGs) frequently (every 30 minutes suggested) after starting infusion. If no improvement increase infusion rate in suggested increments of up to 1 mg/min (to a maximum of 4 mg/min)

Eculizumab ▼▼▼▼ This product is being intensively monitored by the CHM and MHRA. Please report all suspected reactions (including non-serious ones) using a Yellow Card from the BNF


♠ Groups 1 and 2

25 – 45 minutes For example, to give 900mg in 180ml N/S over 30 minutes, set the infusion pump at 360ml/hour. To give 1200mg in 240ml over 30 minutes, set the pump at 480ml/hour.

Infusion to be prepared by Pharmacy. Telephone Ext. 31083. Doctor to prescribe each dose as an infusion in N/S at a concentration of 5mg/ml, eg. prescribe 900mg eculizumab in 180ml N/S Prescribe 1200mg eculizumab in 240ml N/S.

Patients should be monitored for one hour following infusion. If an adverse event occurs during the administration of eculizumab, the infusion may be slowed or stopped at the medical team’s discretion. If the infusion is slowed, the total infusion time must not exceed two hours in adults and adolescents (aged 12 years to under18 years) and four hours in children aged less than 12 years. Flush with N/S. Sodium content: 5mmol/300mg eculizumab.

Edrophonium IV bolus ♠ Group 1 Can be diluted with W, but maintenance of stability cannot be guaranteed.

Have atropine available to counteract possible severe cholinergic reactions. In case of cholinergic crisis resuscitation equipment should be available.






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Enoxaparin Pre-filled syringes

SC injection For dose banding and guidance on choice of syringe strength(s) and volumes to inject see the table below


See section 12 for further general guidance on SC injection.

Do not press the plunger before injecting to expel the air bubble. Hold the syringe so that the needle is pointing downwards (vertically at a 900 angle). Insert the full length of the needle into the skin fold. To avoid bruising, do not rub the injection site after giving the injection.

Enoxaparin VTE Dosing Guidance Treatment Dose

Continue for at least 5 days AND until two consecuive INRs >2.0 Separate protocol applies to pregnant women

Prophylactic Dose

Weight (kg)

GFR > 30ml/minute (≈1.5mg/kg) GFR < 30ml/minute (≈1mg/kg) GFR > 30ml/minute GFR < 30ml/minute

40 – 49 60mg Daily 40mg Daily 20mg Daily 50 – 59 80mg Daily 60 – 74 100mg Daily

60mg Daily

75 – 89 120mg Daily 80mg Daily 90 – 99

40mg Daily

20mg Daily

100 – 109

150mg Daily

100mg Daily

110 – 120 180mg Daily 120mg Daily 121 – 150 Contact Consultant Haematologist

40mg TWICE Daily

40mg Daily

• For patients over 150kg or complex cases, advice may be obtained from a Consultant Haematologist. • For patients requiring treatment doses who are morbidly obese (BMI> 35mg/m2), pregnant, or have significant renal impairment (eGFR <30ml/minute)

monitor anti-Xa levels. Take the first anti-Xa level 3 hours after the 3rd dose and state time dose was administered and time of level take on blood form. Thereafter, repeat level if patient’s condition changes or advised by Haematology.

• For ACS patients, use fondaparinux unless patient’s eGFR < 30ml/minute, then use enoxaparin ≈1mg/kg daily as above.

Monitoring: Check baseline platelet count and then every 2-4days until day 14. As a minimum for extended prophylaxis post-discharge check once between 4-7days and then again after 10-14 days of enoxaparin treatment. If platelets fall by greater than 50% of baseline stop enoxaparin and discuss with haematology.






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Enoximone

(C) or (I) IV infusion via a pump.

♠ Groups 1 and 2

Initial rate: 90 micrograms/ kg/minute for 10-30 minutes until the required haemodynamic response is achieved (This is 2.16ml/kg/hour using an infusion of 2.5mg/ml) then Maintenance rate: 5-20 micrograms/kg/minute. (This is 0.12ml/kg/hour to 0.48ml/kg/hour using an infusion of 2.5mg/ml)

Dilute with an equal volume of W or N/S (i.e. dilute to a concentration of 2.5mg/ml).

Flush with N/S. Extravasation will cause tissue damage. Do not administer unless diluted product is a clear yellow solution. Monitor blood pressure, heart rate, ECG and CVP. Incompatible: do not infuse with any other drugs including G and furosemide.

Ephedrine IV bolus ♠ Group 1 3-5 minutes Must be diluted prior to administration with N/S (suggested dilution: 3mg in 1ml).

Flush with N/S.

Epoprostenol (C) IV infusion via a pump.


See package insert. Withdraw about 10ml of the diluent provided, inject into the vial of epoprostenol and shake gently to dissolve the powder. Then draw up the reconstituted epoprostenol and re-inject via the filter into the remainder of the diluent Mix well. This concentrated solution (10,000nanograms/ml) may be used undiluted or further diluted with N/S such that each 1 part of concentrate should be diluted with a maximum of 6 parts N/S e.g. 50ml of concentrate with a maximum of 300ml N/S. Displacement is negligible.

Cardiac and blood pressure monitoring required until dose is titrated. Do not stop infusion for more than a few minutes. Replace giving set; do not flush. On the Derriford Hospital Critical Care Unit the prepared solution is used for up to 24 hours. This is unlicensed but cost-saving. A drop in blood pressure is possible when renewing an infusion that’s been made up longer than 12 hours. Sodium content 2.5mmol/reconstituted vial. Incompatible: do not infuse with any other drugs including G and G/S.






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Ertapenem May only be initiated on the advice of a consultant microbiologist



30 minutes Reconstitute the contents of the 1g vial with 10ml W or N/S to give a solution of approximately 100mg/ml. Shake well to dissolve. Dilute further with N/S to a final concentration of 20mg/ml or less (e.g.1g in 100ml N/S).

Use the infusion within 6 hours of preparation. The product information suggests using a 50ml bottle or bag of N/S but these are not stocked in this Trust. Sodium content: 6mmol/1g



20-60 minutes Reconstitute each 1g with 20ml W to produce 50mg/1ml then further dilute to a maximum concentration of 5mg/ml with N/S, G or G/S. If G or G/S are used add 5ml sodium bicarbonate 8.4%/litre as a buffer. Displacement is allowed for. Addition of 20ml W to 1g vial gives 1g in 20ml (50mg in 1ml).



Reconstitute as above then dilute as above to a concentration of 1mg/ml to 5mg/ml (1mg/ml is recommended).

Extravasation is hazardous. IV infusion may cause thrombophlebitis, particularly concentrations exceeding 5mg/1ml. Flush with N/S. Sodium content nil. 125mg erythromycin used as prokinetic for GI tract(Unlicensed use - see page 1) should be diluted in 25ml N/S and given over 5 minutes. Prepare a fresh infusion every 8 hours.

Erythromycin

(I) IV infusion via a central line. Infusion pump is required.

♠ Groups 1,2,3,4and 5

Minimum 60 minutes

Reconstitute as above then dilute 1g to 100ml with N/S.

In addition to the above points, this is an unlicensed use for use in fluid restricted patients. Cardiac monitoring necessary.






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Esmolol (I) IV infusion via an infusion pump. Preferably administer via a central line to avoid potential venous irritation as the preparation has a low pH. If this is not possible, use a large peripheral vein

♠ Groups 1 and 2

Follow the dosage titration flow chart in the package insert.

Vials containing 100mg esmolol in 10ml (10mg/ml) are used without further dilution.

Treatment of supraventricular tachycardia: After achieving adequate control of heart rate introduce alternative oral agent and gradually reduce esmolol infusion rate - see package insert for instructions. Monitor the blood pressure frequently. Caution: Flushing the line will administer a bolus dose. However 5ml N/S has been used as a flush following loading doses, given at the same slow rate as the loading dose.

10mg/ml IV infusion of esmolol for supraventricular tachycardia or post-operative tachycardia and/or hypertension

Elapsed Time (Minutes)

Loading dose given before each titration step to produce rapid onset of action, infused over 1 minute (pump setting)

Maintenance Infusion (pump setting)

0 – 1 500micrograms/kg (=3ml/kg/hour)

1 – 5 50micrograms/kg/minute (=0.3ml/kg/hour)

5 – 6 500micrograms/kg (=3ml/kg/hour)

6 – 10 100micrograms/kg/minute (=0.6ml/kg/hour)

10 – 11 *500micrograms/kg (=3ml/kg/hour)

11 – 15 *150micrograms/kg/minute (=0.9ml/kg/hour


16 – 20 *200micrograms/kg/minute (=1.2ml/kg/hour)

20 - 21 *500micrograms/kg (=3ml/kg/hour)

21 – 25 *250micrograms/kg/minute (=1.5ml/kg/hour)


26 - 30 *300micrograms/kg/minute (=1.8ml/kg/hour)

*As the desired heart rate or endpoint (eg. Lowered blood pressure) is approached, omit the loading dose and reduce the incremental increases in infusion rate to 25micrograms/kg/minute (0.075ml/kg/hour to 0.15ml/kg/hour). The interval between titration steps may be increased from 5 to 10 minutes. Once the desired clinical endpoint is reached continue the maintenance infusion at that rate.

10mg/ml IV infusion of esmolol for intra-operative immediate control of tachycardia and/or hypertension

80 mg (approximately 1 mg/kg) bolus dose over 15 to 30 seconds followed by a 150 mcg/kg/min infusion (0.9ml/kg/hour), if necessary. Adjust the infusion rate as required up to 300 mcg/kg/min (1.8ml/kg/hour) to maintain desired heart rate and/or blood pressure.






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COMMENTS


At least 3 minutes Reconstitute 40mg vial with 5ml N/S. Esomeprazole



10 – 30 minutes Reconstitute as above then further dilute up to 100ml with N/S.

The reconstituted solution is clear and colourless to very slightly yellow. Revert to omeprazole capsules orally as soon as possible. Alternatively revert to dispersible lansoprazole Fastabs via PEG/NG/NJ as soon as possible. Use infusion in N/S within 12 hours. Incompatible: do not infuse with any other drugs.

IV Loading dose of 80mg


80mg in 100ml N/S over 30 minutes

For each 40mg vial, withdraw 5ml of N/S from a 100ml bag and use to reconstitute the vial. Then inject the reconstituted esomeprazole into the bag. Do not add more than 80mg esomeprazole to 100ml of diluent.

Esomeprazole For the specialist treatment of endoscopically controlled bleeding peptic ulceration.



After loading dose, infuse at 8mg/hour for 70 hours* (This is 10ml//hour with each 80mg in 100ml N/S)

Reconstitute and dilute each 40mg vial as above.

Use infusion in N/S within 12 hours. Incompatible: do not infuse with any other drugs. * The Gastroenterologists have agreed to a 70-hour treatment (rather than 72 hours). A pre-printed prescription is available.






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COMMENTS

Ethanol (Alcohol) (Unlicensed product- see page 4)

(C) IV infusion. Infusion pump is required. .


For ethylene glycol or methanol overdose: Refer to the Toxbase Website for details of the infusion rates.

Dilute to 5 or 10% with G. For a 5% solution: Remove 56ml from a litre bag of 5% glucose. Then add 56ml of 90% ethanol injection into the bag. For a 10% solution: Remove 111ml from a litre bag of 5% glucose. Then add 111ml of 90% ethanol injection into the bag.

Flush with N/S or G. 10% solutions of ethanol are hyperosmolar and irritant to veins and are best given by central venous catheter. Some references recommend discontinuing gradually over 24-48 hours to avoid a possible major secondary withdrawal reaction. For ethylene glycol overdose adjust infusion rate to achieve blood ethanol conc. of 1- 1.5g/L. Monitor blood glucose level. Always refer to the Toxbase website for more detailed instructions in the case of ethylene glycol or methanol overdose.

Etomidate IV bolus ♠ Group 1 30 – 60 seconds May be diluted with N/S or G. Pain can occur after injection into veins of the dorsum of the hand. Use of larger veins reduces pain on injection. Incompatible with Hartmann’s. Flush with N/S or G. Can reduce serum cortisol levels during induction so no longer kept in Main Theatres






73



COMMENTS


IV bolus (Theatre Recovery)

♠ Groups 1 and 2

Follow the algorithm from Recovery 2

Dilute 200 micrograms fentanyl to 10ml with N/S

Monitor the patient in accordance with the algorithm from Recovery 2.

Fentanyl

IV bolus

♠ Groups 1 and 2

Can be diluted with N/S, G, G/S or H.

For sedation in conscious adult patients follow the Sedation Guidelines on Plymouth Healthnet (under Clinical Guidelines). All healthcare practitioners involved directly or participating in sedation techniques must have the necessary knowledge, skills and competences required. Flush with N/S.

Patient Controlled Analgesia (PCA)


1000 micrograms fentanyl (20ml of injection) diluted to 50ml with N/S.

PCA: 20 microgram (1ml) bolus, 5 minute lock- out period. Follow the Acute Pain/Care Service Protocols.


♠ Groups 1 and 2

Sodium content 0.3mmol/1ml.

All epidural administration sets must be labelled “Epidural” when in use (not just the epidural catheter) NPSA/2007/21 Fentanyl 2micrograms/ml with bupivacaine 0.1% epidural infusion

Epidural infusion via McKinley pump

♠ Groups 1and 2*

Background rate of 7 – 15ml/hour with additional Patient-Controlled Epidural Analgesia (PCEA) of 5ml boluses with a lock-out time of 30 minutes.

Pre-made bags supplied by Pharmacy.

*Staff administering and monitoring epidural infusions must have received training from the Acute Care Team and demonstrated their competency at administering and monitoring epidural infusions. Follow the Acute Care Team Protocols. Additional clinician boluses may be administered by Pain Nurses if required as per epidural protocol.






74



COMMENTS

Ferumoxytol


IV Bolus ♠ Groups 1,2,3,4 and 5

Maximum rate 1ml/second (i.e. the contents of each 17ml vial over at least 17 seconds).

Do not dilute further. Follow the administration with a slow flush of N/S to clear the line. Monitor the patient for signs of hypotension and hypersensitivity reactions for at least 30 minutes after giving the injection. The maximum dose for a course of treatment is 2 vials, but these must not be given at the same time (The second injection should be given 2 to 8 days after the first injection).

Flebogamma® See Immunoglobulin Human Normal

IV bolus Adults: 2mg/kg Maximum 150mg

♠ Groups 1 and 2

In an emergency or for rapid effect, give over at least 10 minutes. Minimum 30 minutes for patients with cardiac failure or ventricular tachycardia.

Can be diluted with G and given as a mini-infusion (e.g. 50ml or 100ml of G).

Flecainide


♠ Groups 1 and 2

Adults: Loading dose over 30 minutes as above followed by IV infusion at 1.5 mg/kg/hour for the first hour then 0.1-0.25 mg/kg/hour thereafter. Using a 300mg in 50ml dilution, this is 0.25ml/kg/hour for the first hour then 0.017 – 0.042ml/kg/hour thereafter.

Suggested dilution for maintenance infusion: Dilute 300mg to 50ml with G.

Flush with G. Continuous ECG monitoring required for bolus doses. It is recommended that the maximum duration by infusion is 24 hours. The maximum cumulative dose in the first 24 hours should not exceed 600mg. Switch to oral treatment as soon as possible. If infusion in N/S or H is necessary 150mg flecainide must be diluted in at least 500ml.






75



COMMENTS

IV bolus Usual method


Inject doses up to 1g over 3-4 minutes Inject 2g doses slowly over 6-8 minutes or give by infusion (see below).

Reconstitute 250-500mg with 5-10ml and 1g with 15-20ml W. Can be diluted with N/S or G. Displacement volumes: Bowmed Ltd: 0.15mL for 250mg, 0.3mL for 500mg, 0.6mL for 1g. Wockhardt Ltd: 0.2mL for 250mg, 0.4mL for 500mg, 0.7mL for 1g. Genus Pharmaceuticals: 0.2mL for 500mg, 0.4mL for 1g.



30-60 minutes Reconstitute as above then dilute with N/S or G to 100ml.


Add 1.5ml of water for injections to 250mg vial contents or 2ml of water for injections to 500mg vial contents. Refer to the Marsden Manual for guidance on IM injection.

Intrapleural ♠ Group 1 Dissolve 250mg in 5 to 10ml of water for injections.

Flucloxacillin

Intra-articular ♠ Group 1 Dissolve 250 to 500mg in up to 5ml of water for injections or 0.5% lidocaine hydrochloride solution for injection.

Flush with N/S. Sodium content 0.57mmol/250mg.

For IV administration: The following drugs are incompatible with flucloxacillin: amiodarone, atropine sulphate, buprenorphine, calcium gluconate, chlorpromazine hydrochloride, ciprofloxacin, diazepam, dobutamine hydrochloride, erythromycin lactobionate, gentamicin sulphate, metoclopramide hydrochloride, morphine sulphate, netilmicin sulphate, ofloxacin, papaveretum, pethidine hydrochloride, prochlorperazine edisylate, promethazine hydrochloride, tobramycin and verapamil hydrochloride.






76

DRUG METHOD WHO MAY GIVE ADMINISTER OVER


COMMENTS

Fluconazole (I) IV infusion. Infusion pump is required.


10-20mg/minute. Set the pump at 300 – 600ml/hour

Provided ready diluted (2mg/ml). Flush with N/S. Fluconazole is well absorbed from the gut so consider an early switch to oral/NG/PEG treatment. Sodium content 15mmol/200mg (100ml bottle).

Flucytosine (I) IV infusion. Infusion pump is required.


20-40 minutes Provided ready diluted. Can be administered concurrently with N/S, G or G/S.

Flush with N/S. Must be stored at 18oC to 25oC. Sodium content 34.5mmol/250ml. Infusion must not be used as a multidose container. Incompatible: do not infuse with any other drugs except N/S, G, or G/S.

Flumazenil IV bolus

♠ Group 1 Minimum 15 seconds

Can be diluted with N/S or G to any suitable volume.

Flush with N/S. Give (I) IV infusion if drowsiness recurs after initial IV bolus.



100-400 micrograms/ hour

Flumazenil infusion should be used within 3 hours of preparation. Incompatible: do not infuse with any other drugs.

Fluorescein IV bolus ♠ Group 1 or F grade Group 2 with ENB346 or relevant ophthalmic qualification

Test dose in 5ml N/S then 3-5ml of 10%-20% fluorescein injection followed by N/S flush.

Follow the REI Fluorescein Angiograhy Guidelines






77



COMMENTS

Folic acid IV bolus ♠ Groups 1,2,3,4 and 5

Suggestion: 1 minute Can be diluted with N/S Flush with N/S. Flush with N/S.

Fondaparinux For the treatment of Acute Coronary Syndrome

Deep SC injection. Alternate sites between the left & right anterolateral and left & right posterolateral abdominal wall. Insert the whole length of the needle at right angles into the skin.


To avoid the loss of fondaparinux solution, do not expel the air bubble from the pre-filled syringe before injection.

2.5mg once daily initiated as soon as possible following diagnosis and continued for up to 8 days. The medical team can stop the treatment once the patient has had no chest pain for 48 hours. For patients with ACS and an eGFR less than 30ml/minute, prescribe 1mg/kg enoxaparin once daily instead. Refer to the Marsden Manual for guidance on SC injection.

(I) IV infusion. Initial loading dose. Infusion pump is required.


Foscarnet sodium

(C) IV infusion Maintenance therapy.



Rate determined by renal function, see data sheet. Minimum infusion time of 1 hour.

Infusion to be prepared by Pharmacy. Telephone Ext 31083.

Can be infused undiluted via a central line. Flush with N/S or G. Sodium content 15.6mmol/1g. Incompatible: do not infuse with any other drugs.

Peripheral administration may lead to local irritation and thrombophlebitis.

DO NOT administer by rapid intravenous injection.

Wear gloves, gown and safety glasses when handling. Avoid handling drug if pregnant.






78



COMMENTS

Fosfomycin (Fosfocina®) N.B. This brand is unlicensed



Infuse all doses over 1 hour

Reconstitute the 4g vial with 20ml of W or G. Upon dissolving, the vial will become slightly warm. Remove 50ml G from a 250ml bag of G. Add the reconstituted fosfomycin (4g) into the bag containing 200ml G.

Incompatible with the following drug solutions: Erythromycin, gentamicin and rifampicin. Compatible with H and 10%G.

Fosfomycin (Infectofos®)



Infuse all doses over 30 minutes

Reconstitute the 2g bottle with 40ml to 60ml W and begin infusion immediately. Reconstitute the 3g and 5g bottles with 100ml W. Reconstitute the 8g vial with 200ml W. Begin the infusion immediately after reconstitution. During reconstitution the solution may get warm. If necessary G or G10% may be used instead of W to reconstitute the bottles (volumes as for W). Do not further dilute.

Sodium content 14.5mmol/1g fosfomycin Monitor serum electrolytes, in particular serum sodium, potassium and creatinine. Monitor patient for phlebitis at the infusion site. Safe to be given to patients with allergies to any other commonly used antibiotics including penicillins, cephalosporins, levofloxacin, tetracyclines, trimethoprim and erythromycin. On storage the bottles should be protected from light (Keep in original box)

IV bolus

Furosemide


♠ Groups 1,2,3,4,5 and 7

Adults: The rate should not usually exceed 4mg/minute, however single doses of up to 80mg may be given more quickly.

Either dilute with N/S (a common dilution is 1mg/ml) or give undiluted.

Flush with N/S. Sodium content 0.14mmol/1ml for 20mg/2ml and 50mg/5ml; 0.04mmol/1ml for 250mg/25ml. Rapid administration may damage the hearing. Furosemide precipitates in glucose solutions.

Fusidic Acid See Sodium Fusidate

Gallamine IV bolus ♠ Group 1 Flush with N/S.

Gammanorm® See Immunoglobulin Human Normal Gammapex® See Immunoglobulin Human Normal






79

DRUG



COMMENTS

Ganciclovir (I) IV infusion. Infusion pump is required.


Minimum 60 minutes

Infusion to be prepared by Pharmacy. Telephone Ext. 31083. Doctor to prescribe dose (see comments) in 100ml N/S or G.

To facilitate accurate measurement of the dose, the prescribed dose in milligrams (rounded up or down if necessary) divided by 50 should have no more than one decimal figure. Wear gloves, gown and safety glasses when handling. Avoid handling drug if pregnant. Do not infuse with any other drugs. Preferably infuse through a large vein. Flush with N/S or G.

Gelatin

(Gelofusine)


Volume and rate depend upon patient’s condition

Sodium content: 154mmol/L


3-5 minutes (minimum 3 minutes)

Either give undiluted or dilute with N/S or G (usually 10-20ml).

(I) IV infusion for once-daily dosing (>200mg). Infusion pump is required.


30 minutes Dilute with 50ml or 100ml N/S or G.

Administration by (I) IV infusion once a day is current Trust policy, although this use is outside of the manufacturer’s recommendations. Flush with N/S. Sodium content negligible Incompatibilies include benzylpenicillin and teicoplanin.

Intraperitoneal ♠ Groups 1 and 2

Follow the Renal Services Directorate Peritoneal Dialysis Peritonitis Protocol

Gentamicin

Refer to the Plymouth Healthnet Clinical Guidelines/ Infection Control for the use and current dosage of gentamicin, teicoplanin and vancomycin.

IM injection

Discuss further with a Consultant Microbiologist if unable to give gentamicin via the IV route



Glargine insulin See Insulin Section page






80

DRUG

METHOD WHO MAY GIVE


COMMENTS

SC Injection ♠ Groups 1,2,3,4,5 and 6

Reconstitute with diluent provided (1ml W) and shake gently until the glucagon has dissolved and the solution is clear. The resulting solution is 1mg/ml. Do not further dilute. Refer to the Marsden Manual for guidance on SC injection.

Intravenous glucose must be given if the patient fails to respond to Glucagon within 10 minutes.

IM Injection ♠ Groups 1,2,3,4,5 and 6


Intravenous glucose must be given if the patient fails to respond to Glucagon within 10 minutes.

IV bolus

(For diagnostic testing)

♠ Groups 1,2,3,4,5 and 6

Reconstitute as above. However, for doses > 2mg reconstitute each vial with 1ml G instead of the diluent provided, to avoid administration of large amounts of preservative.

Flush with N/S.

Treatment of cardiogenic shock caused by beta-blocker poisoning

Glucagon

IV bolus (Loading dose)

followed by (I) IV infusion.



Loading dose of 2 -10mg (Child: 50 – 150 microgram/kg, max. 10mg) by slow IV bolus over 3 – 5 minutes

followed by IV infusion of 50 micrograms/kg/hour:

Using 1mg/ml glucagon for infusion:

50micrograms/kg/hour

= 0.05ml/kg/hour

Using a dilution of 10mg in 100ml for infusion:

50micrograms/kg/hour

= 0.5ml/kg/hour

For loading doses > 2mg reconstitute each vial with 1ml G instead of the diluent provided, to avoid administration of large amounts of preservative.

Suggestion for the infusion for an adult: Reconstitute 10 x 1mg vials, each with 1ml G (Do not use the diluent provided as the patient will get a large dose of preservative).

Using syringe pump

Draw up the reconstituted glucagon into a 50ml syringe and either infuse undiluted (1mg/ml) or dilute further with G.

Using a volumetric pump

Draw up the reconstituted glucagon and dilute further with G. (suggestion for an adult: 10mg glucagon diluted to a volume of 100ml with G. 10ml G from the bag can be used to reconstitute the 10 vials of glucagon).

(I) IV infusion is an unlicensed use (See page 1) to treat cardiogenic shock from beta blocker poisoning.






81

DRUG

METHOD WHO MAY GIVE

ADMINISTER OVER


COMMENTS


Glucose infusions can be diluted with W if the concentration required is unavailable.

Glucose 5-10%

N.B All bags of glucose are for single use only. (C) or (I) IV

infusion via infusin pump


G5% is iso-osmotic with blood and can be infused through a peripheral line.

If G10% is administered peripherally use a large vein and preferably alter the injection site daily.

Glucose 20-50% (C) or (I) IV infusion


Concentrations greater than 20% should be infused through a central line to prevent venous irritation and thrombophlebitis.

Glucose 5% to treat severe hypoglycaemia

Fast IV infusion


Fast IV infusion 200ml of 5% glucose

or Glucose 10% to treat severe hypoglycaemia

Fast IV infusion via a large vein


Fast IV infusion 100ml of 10% glucose

(PHNT Hypoglycaemia Guideline 2011)

Glucose 50% to treat severe hypoglycaemia

IV bolus via a central vein.


20ml of 50% glucose over 1-2 minutes

20ml of 50% glucose over 1-2 minutes is very irritant and potentially damaging to peripheral veins.

Glucose 10% to treat hyperkalaemia

(I) IV infusion via a large vein


500ml of 10% glucose over 30 minutes

Add 10 units of Actrapid insulin into the 500ml of 10% glucose using a 29 gauge Magellan 12.7mm (1.3cm) Insulin Safety Syringe available from Thrushel, Tavy or ED (NHS order code: FTR1276)

Monitor U&E’s every 2 hours until the serum potassium is stable and less than 6mmol/L. Monitor blood glucose every 30 minutes during the infusion of glucose with Actrapid, and for 2 hours after the infusion

For patients at risk from heart failure or fluid overload :

Glucose 50% to treat hyperkalaemia

(I) IV infusion via a large vein


50ml of 50% glucose over 15 minutes

Add 10 units of Actrapid insulin into the 50ml of 50% glucose.

Monitor U&E’s every 2 hours until the serum potassium is stable and less than 6mmol/L. Monitor blood glucose every 30 minutes during the infusion of glucose with Actrapid, and for 2 hours after the infusion






82

DRUG

METHOD WHO MAY GIVE

ADMINISTER OVER


COMMENTS

Glucose 5% (C) SC infusion

Only use gravity-feed administration sets. Never use an infusion pump for SC infusions.


Usual rate is 500ml over 8 hours (21 drops per minute). Maximum rate is 500ml over 4 hours (40 drops per minute)

Maximum concentration of glucose for SC infusion is 5%

Maximum of 2 litres of glucose 5% in 24 hours. The needle and giving set should preferably be changed every 72 hours. However, infusion sets can be left in place for up to 5-7 days if there are no complications. Refer to potassium chloride monograph for SC potassium.

Due to the acidic pH of glucose 5%, monitor the infusion site regularly for early signs of inflammation and irritation.

(C) or (I) IV infusion via pump

♠ Groups 1 and 2

0.6 - 12 mg/hour

Up to a maximum of 24 mg/hour depending on indication.

Use the 50mg in 50ml ready-made vials. If these are not available dilute with G to 1mg/ml. Can be diluted with N/S instead.

Give via a syringe driver and either a polyethylene-lined PVC extension set or a PVC-free extension. The following extension sets are suitable and are available to order from NHS Supplies: Codan PVC-free extension set 71.4001, order code FKA064. Alaris G30302M line, order code FKA058 Vygon PE-lined extension set 6222.151, order code FSB147. BMS PE-lined extension set 30-7200, order code FSB646. Other suitable sets include the Vygon 71100.15 PE extension set and the Vygon 0832.211R PE-lined extension set. Do not flush - replacing giving set. Monitor blood pressure and pulse during infusion.

Glyceryl trinitrate

Intra-coronary in Cardiac Catheter Labs.

♠ Group 1 Follow Cardiac Catheter Laboratory procedures.






83

DRUG

METHOD WHO MAY GIVE

ADMINISTER OVER


COMMENTS


Rapid IV bolus May be diluted with N/S or G if needed.




SC injection to reduce secretions in palliative care



Glycopyrronium

(Glycopyrrolate)

(C) SC infusion via syringe driver to reduce secretions in palliative care



Dilute with W when 2 or more drugs are being mixed in the same syringe. W or N/S may be used where the syringe only contains glycopyrromium.

Follow the PHNT Care of The Dying Pathways and the PHNT Syringe Driver Policy. For combinations of 2 or 3 drugs in the same syringe, refer to the Syringe Driver Drug Compatibility chart provided in the pump kit. Contact Pharmacy on ext. 39976 for further compatibility advice if necessary. Glycopyrronium is not licensed via the SC route (See page 124).






84

DRUG

METHOD WHO MAY GIVE


COMMENTS

Glypressin See Terlipressin.

Gonadorelin IV bolus or SC Injection (for pituitary function test)

♠ Group 1 Reconstitute HRF brand 100micrograms with 1ml diluent provided.



Minimum 30 seconds Dilute each 1mg with 5ml with N/S. Flush with N/S.

Granisetron Only if patient cannot tolerate ondansetron

(I) IV infusion (Adults). Infusion pump is required.

5 minutes Dilute each 3mg with 20-50ml N/S, H, G or G/S.

Sodium content 1.17mmol/3mg vial, 0.15mmol/1mg vial.


Oral treatment should succeed IM administration as soon as practicable. Oral bioavailability is about 60% of that from the IM route so adjustment of the dosage may be necessary.


1-2 minutes, longer if possible. Maximum 5mg/minute.

Do not dilute to give by IV route. Flush with N/S. Note that haloperidol injection is no longer licensed by the IV route in the UK. This is not due to any new safety concerns about IV haloperidol. The manufacturer has only taken this action to standardise the license across all global markets.

SC injection for use in palliative care



Haloperidol




Dilute with W when 2 or more drugs are being mixed in the same syringe. W or N/S may be used where the syringe only contains haloperidol.

Follow the PHNT Care of The Dying Pathways and the PHNT Syringe Driver Policy. For combinations of 2 or 3 drugs in the same syringe, refer to the Syringe Driver Drug Compatibility chart provided in the pump kit. Contact Pharmacy on ext. 39976 for further compatibility advice if necessary. Haloperidol is not licensed by the SC route (See page 4).






85

DRUG

METHOD WHO MAY GIVE


COMMENTS

IV bolus loading dose followed by (C) below.


3 – 5 minutes 5,000 units = 5ml of 1,000 unit/ml solution with no further dilution. (Or 10,000 units = 10ml of 1,000 unit/ml solution with no further dilution for severe pulmonary embolism – see prescription).

(C) IV infusion Immediately following the loading dose. Infusion pump is required.


Initial infusion rate 15 units/kg/hour = 0.015ml/kg/hour of 1,000 unit/ml infusion. Alter rate according to APTTR (Check before commencing heparin therapy, then 4-6 hours after commencing the infusion, 4-6 hours after every infusion rate change, and at least once daily thereafter.

Take a 20ml ampoule containing 20,000 units of heparin. Draw up the 20ml into a 50ml syringe. Do not dilute this any further

Use of a PVC-free or PE-lined extension set will avoid adsorption of heparin to the line. The following extension sets are suitable and are available to order from NHS Supplies: Codan PVC-free extension set 71.4001, order code FKA064. Alaris G30302M line, order code FKA058 Vygon PE-lined extension set 6222.151, order code FSB147. BMS PE-lined extension set 30-7200, order code FSB646. Other suitable sets include the Vygon 71100.15 PE extension set and the Vygon 0832.211R PE-lined extension set. Prepare a fresh infusion every 24 hours.




1,000 units per litre of dialysis fluid Follow the PHNT Renal Services Directorate Procedures

Heparin

Heparin may only be used for locking or flushing IV lines, cannulae or devices in accordance with PHNT policy – see Appendix 5, page 215

Hizentra® See Immunoglobulin Human Normal Humalog® Humalog Mix® Humulin®

See Insulin Section






86

DRUG

METHOD WHO MAY GIVE

ADMINISTER OVER


COMMENTS

With S/C infusion of fluid (Hypodermoclysis) Either give 1,500iu by S/C injection into the site before the infusion is set up, or iniect 1,500iu into the tubing of the infusion set about 2cm back from the needle at the start of the infusion.


Reconstitute 1,500iu of hyaluronidase with 1ml of N/S or W.

1,500iu hyaluronidase is sufficient for the administration of 500-1000ml of most fluids. Compatible fluids include: N/S, G, G/S(4%/0.18%), G/S(2.5%/0.45%).

With S/C and I/M injections


1,500iu to be dissolved directly in the solution to be injected.

Compatible when mixed with: morphine, diamorphine, hydrmorphone, chlorpromazine, metoclopramide, dexamethasone and very low concentrations of adrenaline. Incompatible with: heparin, moderate to high concentrations of adrenaline, furosemide, phenytoin and benzodiazepines.

With local anaesthetics ♠ Group 1 (Other Groups only in accordance with specific PGDs)

1,500iu mixed with the quantity of local anaesthetic solution to be used. In ophthalmology 15iu hyaluronidase per ml is the recommended concentration.

Hyaluronidase

Extravastion where dispersal rather than localisation is indicated. Administer by S/C infiltration


Reconstitute 1,500 iu of hyaluronidase with 1ml of N/S or W.

Follow the PHNT protocol for managing extravasation – See Section 2.8.6

Haematoma By S/C infiltration


Reconstitute 1,500 iu of hyaluronidase with 1ml of N/S or W.






87

DRUG

METHOD WHO MAY GIVE


COMMENTS

Slow IV bolus


Over at least 5 minutes to avoid over-rapid reduction in blood pressure.

Reconstitute with 1ml W then dilute with 10ml with N/S.

Flush with N/S. If necessary, a repeat injection can be given after an interval of 20-30 minutes. Sodium content nil.

(C) IV infusion via an infusion pump


Adults: Initial rate of 200-300micrograms/minute Usual maintenance rate of 50-150micrograms/minute Adjust rate according to patient's blood pressure response and tolerance.

Reconstitute as above then dilute 20mg with 500ml of N/S to give 40 micrograms/ml. However, for fluid restricted patients 60mg hydralazine may be diluted to 60ml with N/S to make a 1000microgram/ml solution, and infused via a central IV line. (This dilution is unlicensed).

Monitor heart rate and blood pressure. Incompatible with glucose solutions.

Hydralazine

Pump rate (ml/hour) =Prescribed rate(micrograms/minute) x 60(minutes in an hour) Concentration of the infusion(micrograms/ml)

IV bolus (Usual method)


Manufacturer recommends injection over 1 - 10 minutes

Reconstitute each 100mg with not more than 2ml W and shake before drawing up.

Flush with N/S or G. Sodium content 0.5mmol/100mg.

(C) or (I) IV infusion via an infusion pump


Reconstitute as above then dilute to 100-1000ml with N/S or G (maximum concentration of 1mg/1ml).

Hydrocortisone sodium succinate


Reconstitute as for IV bolus. Refer to the Marsden Manual for guidance on IM injection.

The preferred method for initial emergency use is IV injection.






88

DRUG

METHOD WHO MAY GIVE

ADMINISTER OVER


COMMENTS

Slow IV bolus ♠ Groups 1,2,3,4,5 and 6

3-5 minutes Can be diluted with G or N/S. Flush with N/S or G.

Give “slowly” as in rare cases it has caused a marked drop in blood pressure or even shock.

IM injection ♠ Groups 1,2,3,4,5 and 6


Hyoscine butylbromide

(Buscopan®)




Dilute with W when 2 or more drugs are being mixed in the same syringe. W or N/S may be used when the syringe only contains this drug.

Follow the PHNT Care of The Dying Pathways and the PHNT Syringe Driver Policy. For combinations of 2 or 3 drugs in the same syringe, refer to the Syringe Driver Drug Compatibility chart provided in the pump kit. Contact Pharmacy on ext. 39976 for further compatibility advice if necessary. Hyoscine butylbromide is not licensed via the SC route (See page 124).

IM injection as premedication



SC injection as premedication



IV bolus as premedication (For acute use)


3-5 minutes




Hyoscine hydrobromide





Follow the PHNT Care of The Dying Pathways and the PHNT Syringe Driver Policy. For combinations of 2 or 3 drugs in the same syringe, refer to the Syringe Driver Drug Compatibility chart provided in the pump kit. Contact Pharmacy on ext. 39976 for further compatibility advice if necessary. Hyoscine hydrobromide is not licensed for use in palliative care (See page 124).






89

DRUG

METHOD WHO MAY GIVE


COMMENTS

For prevention of skeletal events in patients with breast cancer and bone metastases:

(I) IV infusion


♠ Groups 1 and 2

At least 15 minutes.

If GFR<50ml/minute then infuse dose over 1 hour.

Add the dose to 100ml N/S or G.

If GFR<50ml/minute then add the reduced dose to 500ml N/S or G.

Treatment of tumour-induced hypercalcaemia:

(I) IV infusion


♠ Groups 1 and 2

2 hours Add the dose to 500ml N/S (or G).

Treatment of post-menopausal osteoporosis:

Ibandronic acid

(Ibandronate)

IV bolus using the prefilled syringes

♠ Groups 1 and 2

15-30 seconds

Do not mix with calcium containing solutions.

Extravasation can lead to tissue damage.

Patient should be adequately rehydrated with N/S prior to treatment for tumour-induced hypercalcaemia.

The contents of the prefilled syringes may be injected into an existing IV line through which N/S or G is running.

Ibuprofen

(Pedea®)

(I) IV infusion


♠ Groups 1 and 2

15 minutes Preferably do not dilute further. If necessary, the injection volume may be adjusted with either N/S or G.

A course of therapy is defined as three intravenous injections of Pedea given at 24-hour intervals. The first injection should be given after the first 6 hours of life.

1st injection:10 mg/kg, 2nd and 3rd injections: 5 mg/kg.

If anuria or manifest oliguria occurs after the first or second dose, the next dose should be withheld until urine output returns to normal levels.

If the ductus arteriosus does not close 48 hours after the last injection or if it re-opens, a second course of 3 doses may be given.






90

DRUG

METHOD WHO MAY GIVE


COMMENTS

(I) IV infusion via a syringe pump.

Preferred method. Infusion pump is required.

♠ Groups 1 and 2

6 hour infusion (once each day).

Dilute 50 micrograms(0.5ml) to 25ml with N/S or G. For patients who require more than 50 micrograms during the 6 hour infusion dilute 100 micrograms(1ml) to 50ml with N/S or G.

Obtain written administration instructions from Pharmacy or from Braunton Ward.

Iloprost injection is not licensed in the UK (See page 124).

Iloprost


Dilute 50 micrograms(0.5ml) to 250ml with N/S or G. For patients who require more than 50 micrograms during the 6 hour infusion dilute 100 micrograms(1ml) to 500ml with N/S or G.

Immunoglobulin human normal

(FlebogammaDIF) 50mg/ml = 5% Supplied by Pharmacy



Initially 0.6 – 1.2ml/kg/hour for 30 minutes. If well tolerated, the rate may be gradually increased to a maximum of 6ml/kg/hour

Provided ready diluted. If side effects occur reduce rate or interrupt infusion until symptoms subside then restart at lower tolerated infusion rate. Have adrenaline available in case of anaphylactoid reactions. Monitor vital signs and observe patient during infusion and for 20 minutes afterwards (for 1 hour after the first infusion, or after the first infusion after a long interval in treatment eg. Several weeks). Do not infuse with other drugs or fluids.






91

DRUG

METHOD WHO MAY GIVE


COMMENTS


(FlebogammaDIF) 100mg/ml = 10% Supplied by Pharmacy




Initially 0.6ml/kg/hour for 30 minutes. If tolerated, advance to 1.2ml/kg/hour for the second 30 minutes. Again, if tolerated, advance to 2.4ml/kg/hour for the third 30 minutes. It the patient tolerates the infusion well, additional increments of 1.2ml/kg/hour may be made at 30 minute intervals up to a maximum of 4.8ml/kg/hour.







92

DRUG

METHOD WHO MAY GIVE


COMMENTS

Subcutaneous infusion via syringe driver for home treatment.

If Gammanorm is accidentally administered into a blood vessel, the patient could develop shock.

♠ Groups 1,2,3,4 and 5 Also administered by patient or patient’s guardian.

Initial infusion rate: 10ml/hour per syringe driver. The infusion rate may be gradually increased by 1ml/hour per syringe driver every three to four weeks. The maximum dose administered has been 40 ml/hour using two syringe drivers simultaneously.

Provided ready diluted Instruct the patient in the use of a syringe driver, infusion techniques, the keeping of a treatment diary and measures to be taken in case of severe adverse events. When large doses are given, it is advisable to administer them in divided doses at different sites. Monitor vital signs and observe patient during infusion and for 20 minutes afterwards. Sodium content: 100mg/40ml

Immunoglobulin Human Normal

(Gammanorm) 16.5%=165mg/ml Supplied by Pharmacy ▼▼▼▼ This product is being intensively monitored by the CHM and MHRA. Please report all suspected reactions (including non-serious ones) using a Yellow Card from the BNF

IM Injection-Only in exceptional cases where subcutaneous administration is not possible


Provided ready diluted






93

DRUG

METHOD WHO MAY GIVE


COMMENTS


(Gammaplex) 50mg/ml = 5% Supplied by Pharmacy ▼▼▼▼ This product is being intensively monitored by the CHM and MHRA. Please report all suspected reactions (including non-serious ones) using a Yellow Card from the BNF



Infuse at an initial rate of 0.6 - 1.2 ml/kg/hour for 15 minutes. If well tolerated, the rate of administration may be increased to 2.4ml/kg/hour for 15 minutes, then to 3.6ml/kg/hour for 15 minutes, followed by a maximum of 4.8ml/kg/hour for the remainder of the infusion.







94

DRUG

METHOD WHO MAY GIVE


COMMENTS


(Hizentra) 200mg/ml = 20% Supplied by Pharmacy ▼▼▼▼ This product is being intensively monitored by the CHM and MHRA. Please report all suspected reactions (including non-serious ones) using a Yellow Card from the BNF

Subcutaneous infusion via syringe driver for home treatment. Suitable sites of administration include the abdomen, thigh, upper arm and lateral hip.

If Hizentra is accidentally administered into a blood vessel, patients could develop shock.

♠ Groups 1,2,3,4 and 5 Also administered by patient or patient’s carer.

The recommended initial infusion rate depends on individual needs of the patient and should not exceed 15 ml/hour/site. If well-tolerated, the infusion rate can then gradually be increased

to 25 ml/hour/site.

Up to 4 infusion sites can be used simultaneously, provided that the maximum infusion rate for all sites combined does not exceed 50 ml/hour. Injection sites should be at least 5cm apart.

Provided ready diluted Instruct the patient or carer in the use of a syringe driver, infusion techniques, the keeping of a treatment diary and measures to be taken in case of severe adverse events. If side effects occur reduce rate or interrupt infusion until symptoms subside then restart at lower tolerated infusion rate. Have adrenaline available in case of anaphylactoid reactions. Monitor vital signs and observe patient during infusion and for 20 minutes afterwards (for 1 hour after the first infusion, or after the first infusion after a long interval in treatment eg. several weeks). Do not infuse with other drugs or fluids. Hizentra® is essentially sodium-free.






95

DRUG

METHOD WHO MAY GIVE


COMMENTS


(Kiovig) 10%=100mg/ml Supplied by Pharmacy

(I) IV infusion via pump.


Initially 0.5ml/kg/hour for 30 minutes. If well tolerated, the rate may be gradually increased to a maximum of 6ml/kg/hour

Provided ready diluted. If side effects occur reduce rate or interrupt infusion until symptoms subside then restart at lower tolerated infusion rate. Have adrenaline available in case of anaphylactoid reactions. Monitor vital signs and observe patient during infusion and for 20 minutes afterwards (for 1 hour after the first infusion, or after the first infusion after a long interval in treatment eg. several weeks). Do not infuse with other drugs or fluids.






96

DRUG

METHOD WHO MAY GIVE


COMMENTS


(Octagam) 5%=50mg/ml Supplied by Pharmacy



Initially 1ml/kg/hour for 30 minutes, If well tolerated, the rate of administration may gradually be increased to a maximum of 5 ml/kg/hour.



(Octagam) 10%=100mg/ml Supplied by Pharmacy ▼▼▼▼ This product is being intensively monitored by the CHM and MHRA. Please report all suspected reactions (including non-serious ones) using a Yellow Card from the BNF



Initially 0.6ml/kg/hour for 30 minutes. If well tolerated, the rate of administration may gradually be increased to a maximum of 7.2ml/kg/hour.







97

DRUG

METHOD WHO MAY GIVE


COMMENTS


(Privigen) 10%=100mg/ml

Supplied by Pharmacy



Initially 0.3ml/kg/hour. If well tolerated, the rate may be gradually increased to 4.8ml/kg/hour. In patients with Primary Immunodeficiency who have tolerated 4.8ml/kg/hour well, the rate may be further increased gradually to 7.2ml/kg/hour

Provided ready diluted. However, if dilution prior to infusion is required Privagen® 100mg/ml may be diluted with an equal volume of G to make a 50mg/ml solution.

Have adrenaline available in case of anaphylactoid reactions. Monitor vital signs and observe patient during infusion and for 20 minutes afterwards (for 1 hour after the first infusion, or after the first infusion after a long interval in treatment eg. Several weeks). In all patients, IV immunoglobulin administration requires:

• adequate hydration prior to the initiation of the infusion of IV immunoglobulin.

• monitoring of urine output

• monitoring of serum creatinine levels

• avoidance of concomitant use of loop diuretics.

In case of adverse reaction, either the rate of administration must be reduced or the infusion stopped. Privigen® is essentially sodium-free.






98

DRUG

METHOD WHO MAY GIVE


COMMENTS

Subcutaneous infusion via syringe driver for home treatment, preferentially administered into the abdominal wall, thigh and/or buttocks.

If Subcuvia is accidentally administered into a blood vessel, patients could develop anaphylactic shock or thromboembolic events.


The recommended initial rate is 10 ml/hour per syringe driver. The infusion speed can be increased by 1 ml/hour per syringe driver every subsequent infusion. The recommended maximum speed is 20 ml/hour. More than one pump can be used simultaneously.

Provided ready diluted Instruct the patient in the use of a syringe driver, infusion techniques, the keeping of a treatment diary and measures to be taken in case of severe adverse events. The infusion site should be changed every 5-15ml. Monitor vital signs and observe patient during infusion and for 20 minutes afterwards (for 1 hour after the first infusion, or after the first infusion after a long interval in treatment eg. several weeks).


(Subcuvia) 16%=160mg/ml Supplied by Pharmacy

IM Injection- Only in exceptional cases where subcutaneous administration is not possible.


Provided ready diluted In exceptional cases where IM administration is necessary, cumulative monthly dose should be divided up into weekly or bi-weekly applications, in order to keep the injected volume low. To further minimize the discomfort for the patient, each single dosage may need to be injected at different anatomic sites.






99

DRUG

METHOD WHO MAY GIVE


COMMENTS

Subcutaneous infusion via syringe driver for home treatment.

If Subgam is accidentally administered into a blood vessel, patients could develop shock.


Initially the infusion rate should be no more than 10ml/hour for each syringe driver. If well tolerated it can be increased at weekly intervals by 2ml/hour per syringe driver to a maximum of 20ml/hour. The administration can be performed at two or more different sites simultaneously to reduce infusion time.

Provided ready diluted Instruct the patient in the use of a syringe driver, infusion techniques, the keeping of a treatment diary and measures to be taken in case of severe adverse events. Monitor vital signs and observe patient during infusion and for 20 minutes afterwards (for 1 hour after the first infusion).


(Subgam) 16%=160mg/ml Supplied by Pharmacy

IM Injection- Only in exceptional cases where subcutaneous administration is not possible.


Provided ready diluted In exceptional cases where IM administration is necessary, cumulative monthly dose should be divided up into weekly or bi-weekly applications, in order to keep the injected volume low. To further minimize the discomfort for the patient, each single dosage may need to be injected at different anatomic sites.






100

DRUG

METHOD WHO MAY GIVE


COMMENTS


(Vigam) 5%=50mg/ml Supplied by Pharmacy

(I) IV infusion via pump. Infuse via an IV infusion set fitted with a 15 micron filter


Initially: 0.6 – 1.2ml/kg/hour for 30 minutes. Increase gradually up to 2.4ml/kg/hour (Maximum of 180ml/hour).

Provided ready diluted.

If side effects occur, reduce rate or interrupt infusion. Have adrenaline available in case of anaphylactoid reactions. Monitor vital signs and observe patient during infusion and for 20 minutes afterwards (for 1 hour after the first infusion, or after the first infusion after a long interval in treatment eg. several weeks). Careful consideration needed before giving to diabetic patients (contains sucrose). Flush with G or N/S.

Indometacin (Indocid PDA®) Single use vials


20 – 30 minutes Either reconstitute the 1mg of powder with 1ml of N/S or W to produce a concentration of 100micrograms in 0.1ml, or reconstitute the 1mg of powder with 2ml N/S or W to produce a concentration of 50micrograms in 0.1ml. Do not further dilute.

Do not reconstitute with glucose solutions. If anuria or marked oliguria (urinary output <0.6ml/kg/hour) is evident at the time of the scheduled second or third dose, further doses must not be given until laboratory studies indicate that renal function has returned to normal. If the ductus reopens, a second course of treatment may be given.

Infliximab (I) IV infusion. Infusion pump is required.


Not less than 2 hours. (Infusion rate not more than 2ml/minute for 250ml infusion). In carefully selected patients who have tolerated three 2-hour infusions, subsequent infusions may be given over not less than 1 hour.

Reconstitute each 100mg vial with 10ml W to make a 10mg/ml solution. Direct the stream of W to the glass wall of the vial and gently swirl the solution. Avoid vigorous agitation and do not shake as foaming is common. Allow the reconstituted solution to stand for 5 minutes. First remove from a 250ml bag of N/S a volume equal to the volume of infliximab being added then add in the required dose of infliximab. Mix gently.

Observe patients for at least 1-2 hours after the infusion for anaphylactic reactions. Equipment and medication to treat anaphylaxis must be immediately available. Use an infusion set with an in-line sterile non-pyrogenic, low protein-binding filter (pore size 1.2 micrometre or less). PIU (Planned Investigation Unit) use these filters routinely to administer infliximab and will know where to obtain them. The displacement value is insignificant.






101

Insulin Section Important notes for all insulins

• When prescribing and administering insulin refer to the patient’s Insulin Passport to confirm the brand of insulin and type of injection device.

• Only use Insulin syringes to draw up insulin. Do not use intravenous syringes to draw up or measure insulin (Even for IV sliding scale infusion).

• Subcutaneous administration should be in the upper arms, thighs, buttocks, or abdomen.

• When administered subcutaneously, care should be taken when injecting to ensure that a blood vessel has not been entered (inject into a lifted skin-fold). Keep the needle under the skin for at least 6 seconds to ensure that the entire dose is injected. After injection, the site of injection should not be massaged.

• Patients must be educated to use the proper injection techniques.

• Before first use store all insulin products in the refrigerator (2 – 80C). Do not freeze.

• If the package insert is missing, refer to the SPC on www.medicines.org.uk for instructions on how to use the various devices.

• Patients’ own insulin pens containing insulin do not need to be kept in a fridge when they are in current use.

DRUG

METHOD WHO MAY GIVE


COMMENTS

Insulin neutral (e.g. Human

Actrapid,

Humulin S) Multidose Vial

(C) IV infusion Infusion pump is required.


In accordance with the sliding-scale instructions.

Inspect product before use: Actrapid and Humulin S injection should be clear and colourless. Dilute with N/S to 1unit/1ml. See the guidelines for setting up and maintaining I.V Sliding Scale Insulin Infusion in Section 8.

Follow the appropriate PHNT protocols/pre-printed prescriptions for the control of blood glucose:

• Peri-operative/Fasting/Unstable Adults

• Adult patients with an acute MI

• Hyperglycaemic Emergencies in diabetic adults

• Critical Care Unit insulin protocol Loss of drug into bag, plastic syringe or giving set may occur. If an infusion bag is used ensure insulin is not injected into dead space of injection port. Compatible with IV glucose infusion/injection and N/S or G containing potassium chloride for infusion.

SC Injection ♠ Groups 1,2,3,4 and 5

Inspect product before use: Actrapid and Humulin S injection should be clear and colourless.

Refer to the Marsden Manual for guidance on SC injection. Actrapid: Discard vial 6 weeks after first use Humulin S: Discard vial 4 weeks after first use Record the date of first use on the vial.






102

DRUG

METHOD ADMINISTRATION COMMENTS

Humalog® (Insulin Lispro)

Humalog Mix 25

Humalog Mix 50

SC Injection

by ♠ Groups 1,2,3,4 and 5


Give Humalog very close to mealtimes. Give Humalog Mix (25 or 50) shortly before meals. When necessary, Humalog Mix® (25 or 50) can be given soon after meals. Humalog should not be mixed with insulin produced by other manufacturers or with animal insulin preparations. Expiry after cartridge insertion, or after first use (vial and prefilled pen): 28 days. After cartridge insertion or first use (pre-filled pen) store below 30°C. Do not refrigerate. The pen with the inserted cartridge and the pre-filled pen should not be stored with the needle attached.

Humulin I® (Isophane)

Humulin M3®

SC Injection



Vials containing Humulin I or the Humulin M3 formulations should be rotated several times in the palms of the hands before use to completely resuspend the insulin, until it appears uniformly cloudy or milky. Cartridges and pre-filled pens containing Humulin I and Humulin M3 formulations should be rolled in the palms of the hands ten times and inverted 180° ten times immediately before use to resuspend the insulin until it appears uniformly cloudy or milky. If not, repeat the above procedure until contents are mixed. Cartridges contain a small glass bead to assist mixing. Do not shake vigorously Expiry after insertion of the cartridge in the pen or first use of a vial: 28 days. Do not use beyond this period. When in use, the cartridges and vials should be stored below 30°C.

Lantus® (Insulin Glargine)

SC Injection


Inspect the cartridge, pen or vial before use. It must only be used if the solution is clear, colourless, with no solid particles visible, and if it is of water-like consistency

If the Lantus has been in the refrigerator, it should ideally be taken out 1 to 2 hours before injection to allow it to warm up as cold insulin is more painful to inject.

After first use, Lantus may be kept for a maximum of 4 weeks at a temperature below 25°C. Record the date of first use on the vial.






103

DRUG

METHOD ADMINISTRATION COMMENTS

Levemir® (Insulin Detemir)

SC Injection


Inspect the Levemir injection: it must not be used if it does not appear clear and colourless. Refer to the Marsden Manual for guidance on SC injection.

Shelf life after first opening: A maximum of 6 weeks when stored below 30°C.

Each Penfill cartridge, Flexpen or Innolet must only be used for a single patient.

NovoMix 30® Refer to the Marsden Manual for guidance on SC injection.

Allow the NovoMix30 to warm up to room temperature (Makes mixing easier). Alternate rolling the pen 10 times horizontally in your palm with tilting to get the glass ball to roll from one end to the other several times until the suspension of insulin appears uniformly white and cloudy. When stored at room temperature (less than 300C) the expiry date of a vial, Penfill or Flexpen is 4 weeks from the date of first use. Each Penfill cartridge or Flexpen must only be used for a single patient

Novorapid® (Insulin Aspart)

SC Injection


Inspect product before use: Novorapid injection should be clear and colourless. Refer to the Marsden Manual for guidance on SC injection.

NovoRapid should generally be given immediately before a meal. When necessary NovoRapid can be given soon after a meal. When stored at room temperature (less than 300C) the expiry date of a vial, Penfill or Flexpen is 4 weeks form the date of first use. Each Penfill cartridge or Flexpen must only be used for a single patient.






104

DRUG

METHOD WHO MAY GIVE


COMMENTS

Intralipid® 20% For the treatment of cardiac arrest due to toxic intravenous concentrations of local anaesthetic

IV bolus and IV infusion

♠ Group 1 Follow the Association of Anaesthetists of GB and Ireland guidelines. The Intralipid is located on the crash trolleys in Theatre, along with a laminated copy of the guideline. 1. Give IV bolus of 1.5ml/kg over 1 minute and start IV infusion at

15ml/kg/hour. 2. After 5 minutes give a maximum of two repeat IV boluses of 1.5ml/kg if:

• adequate circulation has not been restored or

• an adequate circulation deteriorates. Leave 5 minutes between boluses. A maximum of three boluses can be given (including the initial bolus).

3. Continue the infusion at the same rate, but double the rate to 30ml/kg/hour at any time after 5 minutes if:

• cardiovascular stability has not been restored or

• an adequate circulation deteriorates. 4. Continue the infusion until stable and adequate circulation restored or the

maximum cumulative dose of Intralipid has been given. Do not exceed a maximum cumulative dose of Intralipid of 12ml/kg

• Continue CPR throughout treatment with Intralipid®.

• Recovery from local anaesthetic induced cardiac arrest may take more than 1 hour.

• Propofol is not a suitable substitute for Intralipid®.

• Lidocaine should not be used as an anti-arrythmic therapy.






105

DRUG

METHOD WHO MAY GIVE


COMMENTS

First test dose before administration of Cosmofer® to all new patients

Slow IV bolus


Test dose (25mg = 0.5ml) over 1-2 minutes. Monitor the patient closely. If no adverse reactions occur after 60 minutes give the remainder of the very first dose as below.

Preferred method:



Infuse the first 25mg over 15 minutes before each subsequent infusion. If no adverse effects during this time infuse the remaining solution at maximum rate of 100ml/30 minutes.

Dilute 100-200mg iron (2 – 4ml) in 100ml of N/S or G.

Hospital Use Only:Total Dose IV Infusion. Infusion pump is required.


Infuse the first 25mg of the infusion over 15 minutes. If no adverse effects during this time infuse the remaining solution over 4 – 6 hours. The rate of infusion may be increased progressively to 135-180ml/hour.

For Total Dose Infusion add the required dose (determined by the dosage table or calculation in the product leaflet) to 500ml N/S or G.

Iron dextran (Cosmofer®) Each ml contains 50mg Iron(III)

IV bolus (or injection into the venous limb of the dialyser during haemodialysis)


Administer the first 25mg over 1-2 minutes before each subsequent slow bolus. Wait 15 minutes and monitor for adverse effects. If no adverse effects give remainder of each dose at 10mg/minute (0.2ml/minute)

Dose of 100-200mg iron (2-4ml) preferably diluted in 10-20ml N/S or G.

Consult the Haematology Cosmofer protocol. Monitor patient closely in case of anaphylaxis. Resuscitation equipment should be available. Stop the infusion or injection immediately if any signs of hypersensitivity or intolerance occur. Observe the patient closely during iron administration and for at least 1 hour after IV administration (Especially after Total Dose Infusion to monitor for delayed hypersensitivity-like reactions). Do not infuse with any other drugs or fluids. Flush with N/S. Cosmofer® may alternatively be given by deep IM injection – refer to the SPC for further instructions (www.medicines.org.uk) Do not give Cosmofer® to patients with a history of asthma, allergic eczema or other atopic allergy by the IV route (For these patients IM is the preferred route for Cosmofer®). For use on the Planned Investigation Unit, follow the PIU Cosmofer® Pathway.






106

DRUG

METHOD WHO MAY GIVE


COMMENTS

IV bolus (or injection into the venous limb of the dialyser during haemodialysis )


Test dose (1ml) over 1-2 minutes. Remainder of first dose and subsequent doses at 1ml/minute (5ml ampoule over 5 minutes).

Undiluted First 1ml of first dose is the Test Dose. Monitor for possible anaphylaxis. If no adverse effects occur within 15 minutes after the test dose then give remainder of first dose. Do not give Venofer by IM injection.

Iron sucrose (Venofer®) Each ml contains 20mg Iron



Test dose (25mg)- infuse over 15 minutes. Remaining solution and subsequent infusions at maximum rate of 200mg/hour.

Dilute each 5ml ampoule to a maximum of 100ml with N/S. Two 5ml ampoules should not be diluted to more than 200ml with N/S

First 25mg of first infusion is the Test Dose. Monitor patient closely in case of anaphylaxis. Resuscitation equipment should be available. Do not infuse with any other drugs or fluids. Extravasation may cause tissue damage.

Isoniazid IV bolus ♠ Groups 1,2,3,4 and 5

Give slowly. Suggestion: 3-5 minutes

Recommended to administer undiluted but can be further diluted with W if needed.

Isophane insulin

Isophane insulin should be prescribed by brand. See Insulin Section page






107



COMMENTS


Preferably administer via a central venous catheter to avoid potential venous irritation as the preparation has a low pH


For severe bradycardia: Dose range 0.5 – 10

micrograms/minute

Adjust rate according to response

Via a central IV line (or large peripheral vein if central access is not available) dilute 2mg or 2.25mg isoprenaline sulphate (depending on the brand of ampoule available) in 500ml G.

In fluid restricted patients 2mg or 2.25mg isoprenaline sulphate (depending on the brand of ampoule available) may be diluted to 50ml with G and given via a central line.

ECG monitoring required.

Pump rate (ml/hour) =Prescribed rate(micrograms/minute) x 60(minutes in an hour) Concentration of the infusion(micrograms/ml)

Infusion using 2mg isoprenaline sulphate in 500ml G: 0.5 – 10micrograms/minute = 7.5 – 150ml/hour

Infusion using 2.25mg isoprenaline sulphate in 500ml G: 0.5 – 10micrograms/minute = 6.7 – 133ml/hour

If patient is fluid restricted then via a central line:

Infusion using 2mg isoprenaline sulphate in 50ml G: 0.5 – 10micrograms/minute = 0.75 – 15ml/hour

Infusion using 2.25mg isoprenaline sulphate in 50ml G: 0.5 – 10micrograms/minute = 0.67 – 13.3ml/hour

Isoprenaline

IV bolus ♠ Group 1 Using the 100microgram in 2ml ampoule, dilute 2ml (100micrograms) to 5ml with N/S or G.






108



COMMENTS

(C) or (I) IV infusion via pump

♠ Groups 1 and 2

Usually 2-12mg/hour. Up to 20mg/hour if needed.

This equates to 4 -24 ml/hour (Max 40ml/hour) of 0.05% (25mg in 50ml) solution.

The manufacturer recommends dilutions that are not practical as PVC-free 500ml containers are not routinely available.

Dilute 25mg of isosorbide dinitrate to 50ml with N/S or G in a 50ml syringe.

Use a plastic syringe with a PVC-free or PE-lined extension set. The following extension sets are suitable and are available to order from NHS Supplies: Codan PVC-free extension set 71.4001, order code FKA064. Alaris G30302M line, order code FKA058 Vygon PE-lined extension set 6222.151, order code FSB147. BMS PE-lined extension set 30-7200, order code FSB646. Other suitable sets include the Vygon 71100.15 PE extension set and the Vygon 0832.211R PE-lined extension set.

Flush with N/S or G. Monitor blood pressure and pulse during infusion.

Isosorbide dinitrate

(Isoket®)

Intra-coronary

♠ Group 1 1mg bolus given prior to balloon inflation

Manufacturer recommends dilution to 0.5mg/ml with N/S or G.

Further doses may be given, not exceeding 5mg within a 30 minute period.






109



COMMENTS

Itraconazole (I) IV infusion. Infusion pump is required.


Administer 60 ml (200mg) over 1 hour

Stop the infusion when 60ml (200mg) has been administered

(About 15ml will remain in the bag and infusion set to be discarded)

Following the package insert instructions remove the outer wrap from the 50ml bag of N/S provided. Inject 250mg itraconazole (25ml) into the bag in a slow single action (up to 60 seconds) and agitate gently.(The bag now contains 250mg in 75ml). Close the infusion set clamp then push the pin of an infusion set into the flexible port of the infusion bag. Then prime the infusion set in the usual manner. Connect the infusion set to the two-way stop cock of the extension line and open the clamp to allow all the air to be expelled from the infusion set and extension line.

To avoid incompatibility problems, after infusing the itraconazole flush the extension line with 15-20ml N/S at the two-way stop cock, just before the 0.2 micron in-line filter as directed in the package insert instructions.

Do not infuse any other drug solutions together with itraconazole down the same line/lumen.

Protect prepared infusion from direct sunlight.

Do not administer if the solution is a milky white colour that does not disappear after gentle mixing.






110

DRUG METHOD WHO MAY GIVE ADMINISTER OVER INSTRUCTION FOR DILUTION AND SUITABLE DILUENT

COMMENTS

Induction & maintenance of anaesthesia

IV bolus

♠ Group 1 Minimum 60 seconds 50mg/ml is the recommended maximum concentration.

Flush IV bolus with N/S or G.

Low dose as premedication prior to invasive or painful procedures

IV bolus

♠ Groups 1 and 2 3-5 minutes 50mg/ml is the recommended maximum concentration.


♠ Group 1

Can be given by Group 2 staff to a ventilated patient in level 3 critical care.

Can be diluted to 1mg/1ml with G or N/S or infused as 10mg/ml or 50mg/ml (undiluted product).

Ketamine

Induction & maintenance of anaesthesia

IM Injection

♠ Group 1 Refer to the Marsden Manual for guidance on IM injection.


Monitor cardiac and respiratory functions.

Ketamine is chemically incompatible with barbiturates and diazepam because of precipitate formation. Therefore, these should not be mixed in the same syringe or infusion fluid.

Post-operative

(C) IV Infusion.

Use a locked infusion pump designated for ketamine.

Only to be prescribed by an anaesthetist or the Acute Care Team.

Group 2 staff can administer.

1 – 4ml/hour via anti-siphon/reflux line. Titrate to response.

Draw up 0.1ml/kg of ketamine 50mg/ml injection. Dilute this to 50ml with N/S.

Monitor the patient in accordance with the PHNT Acute Pain protocols.

Kidney perfusion solution (Soltran)

Kidney perfusion via kidney transplant catheter

♠ Group 1 or Group 2 trained in the use of the LifePort system

Chill to 4oC then rapidly perfuse kidney with 8 litres, followed by slower perfusion of 75-100ml/minute

Do not further dilute. Not for Intravenous Infusion

Follow the operating instructions for the LifePort system.






111



COMMENTS

Kiovig® See Immunoglobulin Human Normal

IV bolus

♠ Groups 1 and 2

50mg bolus over at least 1 minute. Lower doses are used during anaesthesia.

Labetalol



Usual maximum rate 120mg/hour

Dilute to 1mg/1ml with G or G/S. Suggested volume 200ml. For patients in critical care areas who are fluid restricted undiluted labetolol injection (5mg/ml) may be given by IV infusion via a central IV line -this method is unlicensed (See page 4)

IV bolus can be repeated every 5 minutes to a maximum dose of 200mg. ECG and blood pressure monitoring required. The patient should remain supine for at least 3 hours after administration. Flush with G.

Lantus ® See Insulin Section page



30 minutes Using the 19G needle provided, reconstitute with the 1.05ml W provided and agitate gently to ensure complete dissolution (do not shake vigorously). Dilute with N/S or G up to 50ml/vial for Granocyte-13 or up to 100ml/vial for Granocyte-34.

Flush with N/S. Lenograstim

SC Injection ♠ Groups 1,2,3,4 and 5

Reconstitute as above using the 19G needle. Keep the19G needle and the syringe attached to the vial and withdraw the required volume of reconstituted solution from the vial. Replace the needle used for reconstitution and fit the syringe with the 26G needle provided for subcutaneous injection.







112



COMMENTS

Levemir® See Insulin Section page Levetiracetam (I) IV infusion.



Give all doses over 15 minutes

Dilute all doses with 100ml N/S or G.

IV and oral dosage (dose and frequency) are the same. No adjustment is needed when switching between these routes. Flush with N/S or G. Sodium content: 1.5g dose contains 25mmol sodium. The SPC states that there is no experience with administration of IV levetiracetam for longer than 4 days.

Levobupivacaine Epidural injection Local Infiltration Intrathecal injection Peripheral nerve block Peribulbar block

♠ Group 1 Administer in accordance with standard anaesthetic practice

All syringes containing solution for epidural administration should be labelled “For Epidural Use Only” (NPSA/2007/21)

Levofloxacin (I) IV infusion. Infusion pump is required.


250mg over at least 30 minutes. 500mg over at least 60 minutes.

Provided ready diluted. Flush with N/S or G. Sodium content : 15.4mmol/100ml bottle. Rarely, profound hypotension may occur during infusion. If this happens halt the infusion immediately. Levofloxacin is well absorbed from the GI tract so consider an early switch to the oral route. The bag should only be removed from the outer covering at the time of infusion as the shelf life reduces to 7 days once this outer covering is removed.






113


ADMINISTER OVER


COMMENTS


3-5 minutes Dilute with at least an equal volume of N/S before administration.

Protect infusion from light. Discard injection if pink or yellow colouration occurs. Flush with N/S. Postural hypotension can occur, particularly in patients over 50; monitor blood pressure. Sodium content: 0.037mmol/1ml




Follow the PHNT Care of The Dying Pathways.

Levomepromazine





Follow the PHNT Care of The Dying Pathways and the PHNT Syringe Driver Policy. For combinations of 2 or 3 drugs in the same syringe, refer to the Syringe Driver Drug Compatibility chart provided in the pump kit. Contact Pharmacy on ext. 39976 for further compatibility advice if necessary.






114

DRUG

METHOD WHO MAY GIVE ADMINISTER OVER INSTRUCTION FOR DILUTION AND SUITABLE DILUENT

COMMENTS

Slow IV bolus ♠ Groups 1 and 2

2 – 3 minutes

Loading Dose (Slow IV bolus as above) followed by (C) or (I) IV infusion. Infusion pump is required.

♠ Groups 1 and 2

Infusion for adults: 4mg/minute for 30 minutes then 2mg/minute for 2 hours than 1mg/minute.

Dilute with N/S or G. Usual concentration of 1mg/ml or 2mg/ml but concentrations up to 8mg/ml have been used in fluid restricted patients.

ECG monitoring required. Flush with N/S. 50mg bolus dose for patients who have gross circulatory impairment or low body weight. Use reduced dosage for patients with CCF, hepatic failure and cardiac surgery. If an IV infusion is not immediately commenced, the slow bolus may be repeated once or twice at intervals of at least 10 minutes. 1gram Lidocaine in 500ml G (2mg/ml) ready-made infusion available from Pharmacy.

Lidocaine (Lignocaine)

Anaesthesia: Infiltration Regional IV Nerve blocks

♠ Group 1 (Other Groups only in accordance with specific PGDs)

Administer in accordance with standard anaesthetic practice

Linezolid



♠ Groups 1 and 2

30 to 120 minutes Provided ready diluted

With the new FreeFlex bag containing linezolid, the spike of the giving set should be pushed into the blue port, after twisting off the cap marked with a down-ward pointing arrow. The white port is not intended to be used.


Linezolid is a reversible non-selective inhibitor of Monoamine Oxidase (MAOI) and may theoretically enhance increases in blood pressure produced by sympathomimetics (e.g. dopamine, noradrenaline, adrenaline). Theoretically it may cause serotonin syndrome with serotonin re-uptake inhibitors e.g. SSRI’s (fluoxetine etc).

Sodium content 5mmol/600mg.






115

DRUG

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ADMINISTER OVER


COMMENTS

Liothyronine

20micrograms


3-5 minutes Reconstitute the 20microgram vial with 1 to 2ml W and shake gently until the powder has dissolved. Displacement 0.2ml/20micrograms. (For example, to give 10micrograms, reconstitute with 1ml W which expands to 1.2ml. Then withdraw 0.6ml = 10micrograms)

Flush with N/S. Sodium content 1.49mmol/1g.

IV bolus (Preferred route)


Usual maximum rate 2mg/minute except in control of status epilepticus where rapid injection is required.

Can be diluted 1:1 with N/S or W. Lorazepam

IM injection (Give IV to treat status epilepticus)


For IM administration the injection must be diluted 1:1 with N/S or W. Refer to the Marsden Manual for guidance on IM injection.

Absorption from an IM injection is too slow for a rapid effect, and no more rapid than oral administration.


Suggestion: 2 – 3 minutes

Immediately before use, reconstitute the contents of each 500mg vial with the 5ml of W provided to make a 100mg/5ml solution.

(I) infusion ♠ Groups 1,2,3,4 and 5

Suggestion: 30 minutes

Reconstitute as above then dilute the dose (500mg or 1g) with N/S or G – suggested volume 100ml.

Do not mix with other injectable products in the same line.

Minimum interval between doses is 4 hours.

(DL)-Lysine acetyl salicylate (Aspegic®) (product – see page 4)

Deep IM injection



MabCampath® See Alemtuzumab






116

DRUG

METHOD WHO MAY GIVE


COMMENTS

Arrythmias: 2g (8mmol Mg2+) over 10-15 minutes repeated once if necessary. Treatment of hypomagnesaemia: 2g (8mmol Mg2+) over a minimum of 30 minutes or 5g (20mmol Mg2+) over a minimum of 1 hour Prevention of Re-Feeding Syndrome: 0.2mmol/kg (0.05g/kg) over a minimum of 1 hour

10% (1g in 10ml) magnesium sulphate injection may be given undiluted. Dilute 50% (5g in 10ml) magnesium sulphate injection to a maximum concentration of 200mg/1ml with N/S or G (e.g. 2g (4ml of 50% injection) diluted to at least 10ml). For patients requiring rehydration or larger volumes of fluid, the magnesium replacement dose may be diluted with 500ml or 1L of N/S or G.

Flush with N/S. Monitor blood pressure and pulse. Also monitor for signs of Mg overdose which include weakness, nausea, drowsiness & slurred speech.

Magnesium sulphate 2g (8mmol Mg2+) magnesium sulphate= 20ml of 10%(1g in 10ml) injection or 4ml of 50%(5g in 10ml) injection. 4g (16mmol Mg2+) magnesium sulphate= 40ml of 10%(1g in 10ml) injection or 8ml of 50%(5g in 10ml) injection. 5g (20mmol Mg2+) magnesium sulphate= 50ml of 10%(1g in 10ml) injection or 10ml of 50%(5g in 10ml) injection.



Treatment of seizures and and prevention of recurrence in Eclampsia: 4g loading dose over 20 minutes. Maintenance infusion: 1g/hour. Using 5g in 50ml dilution set pump at 10ml/hour.

Loading dose: Draw up 4g (8ml of 50% magnesium sulphate injection). Dilute to 20ml in a 50ml syringe with N/S. Mix well. Maintenance infusion: Draw up 5g (10ml of 50% magnesium sulphate injection). Dilute to 50ml in a 50ml syringe with N/S. Mix well.

Continue the infusion for at least 24 hours after the seizure or delivery, whichever is later. If seizure recurs, increase the infusion rate to 1.5-2g/hour or give an additional IV bolus of 2g over 5 minutes (Dilute 4ml of 50% magnesium sulphate injection to 10ml with N/S). Monitor the patellar reflex and oxygen saturation levels hourly during administration of magnesium sulphate (including overnight) to exclude signs of toxicity.






117

DRUG

METHOD WHO MAY GIVE


COMMENTS

IM Injection, only if IV access is not possible or impractical


For adults, administer the dose using 50% (1g in 2ml) injection undiluted, or dilute to 25% (1g in 4ml) with N/S. For children a maximum recommended concentration for IM injection is 20% (200mg/ml) eg. For a 500mg dose, dilute 1ml of 50% magnesium sulphate injection to 2.5ml with N/S.

IM injection of magnesium sulphate is painful. Refer to the Marsden Manual for guidance on IM injection.

Magnesium sulphate (Continued from previous page)

SC infusion, only if no other route is possible or practical


Keep the concentration as low as possible, preferably not greatly exceeding the isotonic concentration of 6.3% w/v in Water For Injections (6.3g =25.2mmol in 100ml Water For Injections). Discuss and check dose/concentration/route with a Pharmacist.

There is little published data to support administration of magnesium sulphate by the S/C route. There are isolated case reports of between 2 and 4mmol magnesium sulphate added to 500ml - 1 litre of N/S being tolerated by S/C infusion. Administration via the S/C route is not licensed in the UK (See page 124).

Mannitol (I) IV infusion. Infusion pump is required.


Reduction of intracranial pressure: 0.25g -0.5g/kg over 30-60 minutes. Can be repeated as necessary. Urgent reduction of intra-ocular pressure before eye surgery: Up to 500ml of 20% mannitol given by slow IV infusion until the intra-ocular pressure has been satisfactorily reduced.

500ml of ready-to-use 10% (50g in 500ml) mannitol is routinely stocked. (If using 20% mannitol, infuse through an administration set incorporating a filter*).

Flush with N/S Infusion may crystallise at low temperatures; redissolve by warming. Extravasation causes inflammation and thrombophlebitis. 20% mannitol should preferably be administered via a central IV line or at least through a large peripheral vein due to its high osmolarity.

*Suitable filters to administer mannitol are PALL 0.22 micron, Braun Sterifix 0.2 micron, Technopharm codan 0.2 micron filters. These filters should be ordered via ORACLE.






118

DRUG

METHOD WHO MAY GIVE


COMMENTS

Meropenem IV bolus for doses up to 1g


5 minutes Reconstitute each 250mg meropenem with 5ml W. This provides an approximate concentration of 50mg/ml.

Flush with N/S or G. Sodium content: 4mmol/gram.

(I) IV infusion. Infusion via pump

♠ Groups 1,2,3,4, 5

15-30 minutes Reconstitute and dilute to 50-200ml using N/S or G.

The preferred method for administering doses greater than 1g is intermittent IV infusion.

(I) IV infusion when ifosfamide or cyclophosphamide are given as an (I) infusion over 1-2 hours or as IV bolus, or cyclophosphamide has been given orally


15-30 minutes Dilute the required dose of mesna (Usually 20% of the dose of cyclophosphamide or ifosfamide) to 50ml or 100ml with N/S.

When protection against urothelial toxicity is required, three doses of mesna are typically given with each dose of cyclophospamide or ifosfamide. The first dose of mesna is usually IV and given just prior to the dose/infusion of cyclophosphamide or ifosfamide. Intravenous second and third doses are given at 4 hours and 8 hours (after the end of an infusion). Alternatively, the second and third doses of mesna can be given orally, in which case each oral dose is 40% of the dose of cyclophosphamide or ifosfamide given, given at 2 hours and 6 hours (after the end of an infusion), using mesna injection by the oral route.

Mesna

(C) IV infusion ♠ Groups 1,2,3,4 and 5

Typically, for the duration of a (C) infusion of ifosfamide, and then for a further 12 hours afterwards.

Dilute with N/S or G to any convenient volume

On occasions Pharmacy Technical Services add the required dose of Mesna into the bag containing ifosfamide.

Example shown for 2 hour infusion of cyclophosphamide: IV mesna over 15-30 minutes

IV mesna over IV mesna over 15-30 minutes 15-30 minutes

IV mesna over 15-30 minutes

Oral mesna Oral mesna (40% of the cyclophos. dose) (40% of the cyclophos. dose)

2 hr Cyclophos infusion

OR 2 hr Cyclophos infusion

0

2 4

Hours 6 8 10 0 2 4 6 8 10

Hours






119

DRUG

METHOD WHO MAY GIVE


COMMENTS

IV bolus Emergency use only.

♠ Groups 1 and 2

Undiluted. Bolus dose: 0.5 – 5mg (0.05 – 0.5ml) Flush with N/S or G. Sodium content : 0.087mmol/ml.


0.5 – 1ml over a few seconds via a large peripheral vein or a central vein.

Dilute 10mg in 1ml with 19ml of N/S to make 10mg in 20ml.

Follow each bolus dose with a 20ml flush of N/S. The bolus dose of 0.5 – 1ml of the prepared dilution may be repeated every 1 – 5 minutes as indicated by the mean arterial pressure (MAP) and patient response.

Metaraminol


♠ Groups 1 and 2


Dilute 15-100mg in 500ml N/S or G. The volume may be varied depending on the rate of administration and the patient's fluid needs.

Metaraminol injection from Torbay Manufacturing Unit is unlicensed (See page 4).

When methotrexate is prescribed to treat conditions including multiple sclerosis, glomerular kidney disease, severe psoriasis or rheumatoid arthritis, it may be administered by Group 1 or 2 « practitioners who have previous experience of administering parenteral cytotoxics. Read Appendix 3 for guidance on the handling of cytotoxic drugs. Explicitly inform the patient of the once a week dosing schedule for ongoing therapy and determine a fixed weekday as the day of injection. This should be stated on the prescription.

IV bolus injection (Not for children or adolescents)

Group 1 or 2 «

SC bolus injection

Group 1 or 2 «


Methotrexate For use in haematology and oncology refer to chemotherapy protocols

IM injection Group 1 or 2 «


Consider folic acid supplementation. Refer to the SPC for Metoject® on www.medicines.org.uk for details of the recommended monitoring to detect signs of toxicity (Mouth and throat examinations, full blood counts, liver function tests, renal function etc). Refer to specific protocols as appropriate: IM methotrexate for ectopic pregnancy (EPU and Monkswell).






120

DRUG

METHOD WHO MAY GIVE

ADMINISTER OVER


COMMENTS

(I) IV infusion. Infusion pump is required. .

♠ Groups 1 and 2

15 – 60 minutes Dilute to a suggested concentration of 1mg/ml with G.

Methylene Blue To treat hypotension refractory to fluids and vasopressors in septic shock


♠ Groups 1 and 2

0.25-2 mg/kg/hour Dilute to a suggested concentration of 1mg/ml with G.

Dose to treat hypotension in septic shock refractory to fluids and vasopressors is 1-2mg/kg over 15-60 minutes. May be repeated as required, alternatively after 2 hours set up a continuous infusion. Do not infuse down the same lumen/line as any other drugs. Do not dilute with N/S. Extravasation can cause tissue damage. The use of methylene blue to treat hypotension in septic shock is unlicensed (See page 4)

IV bolus (doses up to 250mg)


Give slowly minimum 5 minutes.

Reconstitute with diluent provided. Methyl-prednisolone sodium succinate (Solu-Medrone)

(I) IV infusion (doses over 250mg) via pump


Minimum 30 minutes Reconstitute as above then dilute with G, N/S or G/S to any suitable volume (e.g. 50-250ml).

Flush with N/S, G or G/S. Sodium content: 2mmol/g. For Acute Spinal Cord Injury refer to protocol on Pencarrow.


Reconstitute with diluent provided. Refer to the Marsden Manual for guidance on IM injection.


Inject deeply into the gluteal muscle.


Methyl-prednisolone acetate (Depo-Medrone)

Intra-articular Peri-articular Intrabursal Intralesional Into tendon sheaths

♠ Group 1 Prior to intra-articular injection the joint fluid should be examined to exclude a septic process. Administer under strictly aseptic conditions. Do not give via the intrathecal route (potentially neurotoxic) or the IV route.






121

DRUG

METHOD WHO MAY GIVE


COMMENTS

IV bolus


1-2 minutes Give undiluted.

Flush with N/S or G. Sodium content 10mg/2ml = 0.26mmol.






Follow the PHNT Care of The Dying Pathways.

Metoclopramide 10mg in 2ml

(C) SC infusion for us in palliative care




Follow the PHNT Care of The Dying Pathways and the PHNT Syringe Driver Policy. For combinations of 2 or 3 drugs in the same syringe refer to the compatibility charts in the pump kit or contact Pharmacy on ext. 39976 for advice. If an infusion containing metoclopramide becomes discoloured it should be discarded.

Metoprolol IV bolus ♠ Groups 1,2,3,4 and 5

Cardiac arrhythmias: 1-2 mg/minute During anaesthesia: 2-4mg injected “slowly” Further injections of 2mg up to a maximum overall dose of 10mg may be given

Give undiluted Early intervention post MI: 5mg every 2 minutes up to a maximum of 15mg total as determined by blood pressure and heart rate. Monitor blood pressure, heart rate and ECG. Flush with N/S or G.

Metronidazole (I) IV infusion. Infusion pump is required.


Adults: 300ml/hour (5ml/minute) will deliver the 100ml infusion over 20 minutes.

Provided ready diluted. Flush with N/S, G or G/S. Cefuroxime can be mixed into an infusion of metronidazole. Sodium content: 13.5mmol/500mg infusion.






122

DRUG

METHOD WHO MAY GIVE


COMMENTS

IV bolus for sedation in conscious adult patients


Administer over at least 30 seconds an initial dose of midazolam guided by:

• Age

• Weight

• Other medications

• Medical history and co-existing disease

• Planned procedure Assess the level of sedation after 2-5 minutes and repeat as necessary (minimum of 2 minutes between subsequent doses). During the procedure, additional doses may be given.

Dilution not recommended.

IV bolus for induction of anaesthesia


Induction of anaesthesia and loading dose for ICU sedation for adults: Each increment over 20-30 seconds allowing 2 minutes between successive increments.

Dilution not recommended.

Midazolam (Monograph continues on the next page)

(I) or (C) IV infusion following initial loading dose via infusion pump

♠ Groups 1 and 2

Dilute with N/S, G or G/S. Usual dilution is 50mg in 50ml. (Pharmacy stocks 50mg in 50ml vials).

For sedation in conscious adult patients follow the Sedation Policy on Plymouth Healthnet (under Clinical Guidelines). All healthcare practitioners involved directly or participating in sedation techniques must have the necessary knowledge, skills and competences required Flush with N/S. Respiratory depression and arrest have occurred when doses were given too rapidly. Naloxone, Flumazenil and resuscitation equipment must be immediately available.






123

DRUG

METHOD WHO MAY GIVE


COMMENTS

Slow IV bolus for Carotid Artery Rupture

♠ Groups 1 and 2

2.5 – 5mg over 1-2 minutes repeated at 2 minute intervals if sedation is not adequate.

Use the 5mg in 5ml pre-filled syringe prepared by Pharmacy and kept in the patient’s bedside locker. If a pre-filled syringe is not available use a 5mg in 5ml ampoule.

For the Management of Carotid Artery Rupture (Carotid Blow Out) follow the specific additional guideline on Lynher ward.

SC injection for terminal restlessness and agitation



Midazolam (Continued)

(C) SC infusion via syringe driver for terminal restlessness and agitation


Continuous over 24 hours Dilute with W when 2 or more drugs are being mixed in the same syringe. W or N/S may be used when the syringe only contains this drug.

Follow the PHNT Care of The Dying Pathways and the PHNT Syringe Driver Policy. For combinations of 2 or 3 drugs in the same syringe, refer to the Syringe Driver Drug Compatibility chart provided in the pump kit. Contact Pharmacy on ext. 39976 for further compatibility advice if necessary.






124

DRUG


COMMENTS

Milrinone (I) or (C) IV infusion. Infusion pump is required.

♠ Groups 1 and 2 Loading dose (50microgram/Kg) over 10 minutes followed by infusion at 0.375-0.75 microgram/kg/minute according to haemodynamic response (For help setting the infusion pump rate see table below).

Dilute to 200 microgram/ml with N/S or G (e.g. 10mg ampoule diluted to 50ml). However solutions of different concentrations may be used according to the patient’s fluid requirements.

Monitor blood pressure, heart rate, ECG, fluid balance and renal function. Do not mix with other drugs. Flush with N/S or G. Using a 200microgram/ml dilution the recommended maintenance infusion rate is 0.11-0.22ml/kg/hour.

Milrinone 10mg in 50ml G dilution eGFR >50ml/minute

For patients with renal impairment (eGFR < 50ml/minute) using Milrinone 10mg in 50ml G dilution

Maintenance infusion rate: Titrate from 0.375 to 0.750 micrograms/kg/minute

Infusion pump rate ml/kg/hour

eGFR ml/minute/1.73m2

Initial maintenance infusion rate micrograms/kg/minute (titrate according to haemodynamic response).

Initial Infusion pump rate ml/kg/hour (titrate according to haemodynamic response).

0.375 0.11 5 0.20 0.06

0.400 0.12 10 0.23 0.07

0.500 0.15 20 0.28 0.08

0.600 0.18 30 0.33 0.10

0.700 0.21 40 0.38 0.11

0.750 0.22 50 0.43 0.13

IV bolus ♠ Group 1 – must only be given by doctors proficient in advanced airway management

Doses up to 150micrograms/kg over 5-15 seconds. Higher doses over 30 seconds. See comments

Mivacurium


♠ Groups 1 and 2 8-10 micrograms/kg/ minute

Can be administered undiluted or diluted to 500 micrograms in 1ml with N/S, G, G/S or H.

Give IV bolus over 60 seconds to patients with cardiovascular disease, those with increased sensitivity to histamine (eg. asthmatics) and those who may be unusually sensitive to falls in arterial blood pressure (eg. those with cardiovascular disease). Monitor blood pressure. Flush with N/S.






125

DRUG

METHOD WHO MAY GIVE


COMMENTS


IV bolus (Theatre Recovery)

♠ Groups 1 and 2

Follow the algorithm from Recovery 2

Dilute 10mg morphine to 10ml with N/S

Flush with N/S, G or G/S. Sodium content negligible.

IV bolus (Acute Care Areas)

♠ Groups 1 and 2

Follow the IV Morphine Protocol for Adults in Acute Areas (Copy on page 186)

Dilute 10mg morphine to 10ml with N/S

IV bolus (Emergency Department)

♠ Groups 1 and 2

Follow the IV Morphine Protocol for Adults in the Emergency Department (Copy on page 187)

For monitoring required when IV morphine is given in the Emergency Department, see the protocol on page 187.

(C) or (I) IV infusion in Critical Care areas via infusion pump.

♠ Groups 1 and 2

Vials of ready-diluted morphine 50mg in 50ml N/S are available from Pharmacy).

Monitor blood pressure, heart rate, respiratory rate. Have naloxone and resuscitation equipment available.

Patient Controlled Analgesia (PCA)


See comments Vials of ready-diluted morphine 50mg in 50ml N/S are available from Pharmacy).

Adult PCA: Usual bolus dose 1mg. Usual lock-out period is 5 minutes. Refer to Acute Pain/Care Service Protocols. Background morphine infusion may only be prescribed by a member of the Acute Pain/Care Team. Nurse-led Controlled Analgesia via the PCA pump is available – seek advice from the Acute Pain/care Team.



Morphine



SC injection not suitable for oedematous patients






126

DRUG

METHOD WHO MAY GIVE


COMMENTS

Morphine 40mg in 1ml preservative-free (Unlicensed)

(C) Intrathecal infusion or

Intrathecal bolus


Prepare and administer in accordance with the Pain Management Centre protocols.


Mycophenolate (I) IV infusion ♠ Groups 1,2,3,4 and 5

2 hours.

Infusion to be prepared by Pharmacy. Telephone Ext. 31083. Doctor to prescribe dose in 100ml G.

Avoid direct contact of the drug solution with skin or mucous membranes. If such contact occurs, wash thoroughly with soap and water. Commence the infusion immediately after preparation.

Mycozyme® See Alglucosidase alfa






127

DRUG

METHOD WHO MAY GIVE


COMMENTS

IV bolus for: Reversal of opiate induced respiratory depression in adults prescribed opiates as part of their palliative, chronic pain or peri-operative care


Adults: Bolus dose of 100 micrograms may be repeated at intervals of not less than 2 minutes to achieve desired response.

Dilute to a concentration of 100micrograms/ml with N/S. If repeated bolus doses are insufficient a continuous infusion may be required using an infusion pump – Dilute 2mg naloxone with 500ml N/S or G (Resulting concentration 4micrograms/ml). Starting rate is 60% of the initial IV bolus infused over 1 hour then titrate to response.

IV bolus followed by (C) infusion to treat PCA or epidural opiate-induced pruritis


40microgram IV bolus (=0.1ml of 400mg/ml injection) followed by 200micrograms infused over 6 – 8 hours.

For the infusion, dilute 200micrograms in 1 litre N/S infused over 6 – 8 hours.

IV boluses to treat Acute opiate overdose/poisoning

♠ Groups 1 and 2

400 micrograms – 2000 micrograms (2mg) over 2-3 minutes. If no response then repeat every 2-3 minutes to a maximum of 10mg (then review the diagnosis).Further doses may be required if respiratory function deteriorates.

IV infusion to treat Acute opiate overdose/poisoning

♠ Groups 1 and 2

Initially the rate may be set at 60% of initial resuscitive IV bolus infused over 1 hour, then adjusted according to respiratory rate and level of consciousness.

Dilute 10mg in 50ml N/S or G.

IM Injection only if IV administration is not possible



Naloxone

SC injection only if IV administration is not possible



Use infusions within 12 hours. Monitor for possible hypotension, hypertension, ventricular tachycardia and fibrillation and withdrawal syndrome. Flush with N/S or G. Note that 4mg in 20ml is an unlicensed dilution (see page 1). When using a continuous infusion to treat opiate induced respiratory depression in adults prescribed opiates as part of their palliative, chronic pain or peri-operative care do not suddenly stop the infusion. Once the patient is stabilised and it is deemed appropriate, the naloxone infusion should be titrated down rather than just turned off. Close monitoring is essential at this stage for the possibility of opioid toxicity recurring again especially when it is due to long acting opioids.






128

DRUG

METHOD WHO MAY GIVE


COMMENTS

Natalizumab (Tysabri®) ▼▼▼▼ This product is being intensively monitored by the CHM and MHRA. Please report all suspected reactions (including non-serious ones) using a Yellow Card from the BNF



Approximately 1 hour Check that the solution is clear and free of particles. Draw up 15 ml from the vial and add to 100ml N/S. Gently invert the bag to mix completely. Do not shake. Visually inspect the diluted product for particles or discolouration prior to administration. Flush the line with N/S when the infusion has finished. Do not mix with any other drugs or diluents.

Observe the patient during the infusion and for 1 hour after the completion of the infusion for signs and symptoms of hypersensitivity reactions. Do not administer as a bolus injection. Equipment and medication to treat anaphylaxis must be immediately available. Discontinue administration of natalizumab and initiate appropriate therapy at the first symptoms or signs of hypersensitivity.






129

DRUG

METHOD WHO MAY GIVE


COMMENTS


Minimum 3-5 minutes. However, for reversal of neuromuscular block, administer over 1 minute.

Give undiluted. Flush with N/S. Protect from light. Have atropine or glycopyrollate available to counteract possible cholinergic reactions. For use in Critical Care for acute colonic pseudo-obstruction, follow the Critical Care Bowel Management Protocol (Use for this indication is unlicensed - see page 1).

(I) or (C) IV infusion to treat severe constipation in Critical Care

♠ Groups 1 and 2

Start at 0.4mg/hour (4ml/hour). If no response after 8 hours increase to 0.8mg/hour (8ml/hour)

Dilute 5mg neostigmine to 50ml with N/S to make a concentration of 0.1mg/ml.

Use atropine or glycopyrronium if necessary to treat bradycardia, and for patients with spinal cord lesions. Follow the Critical Care Bowel Management Protocol (Use for this indication is unlicensed - see page 1). The only confirmed Y-Site compatibilities are with heparin, hydrocortisone and potassium chloride.

SC Injection ♠ Groups

1 and 2


Neostigmine

IM injection ♠ Groups

1 and 2


When treating Myaesthenia Gravis, 500micrograms of neostigmine metilsulfate by intravenous injection is equivalent in effect to about 1 to 1.5mg of neostigmine metilsulfate by intramuscular or subcutaneous injection, and to about 60mg of oral pyridostigmine

Nimodipine (I) IV infusion via a central IV line. Infusion pump is required.

♠ Groups 1 and 2

500micrograms-2mg/ hour =2.5 – 10ml/hour

Provided ready diluted (10mg in 50ml).

Draw up solution into 50ml syringe and use the polyethylene line provided in the box. Administer via a central catheter through a Y-piece connector into an infusion of N/S, G, H, Dextran 40, human albumin 5% or mannitol 10% running at 40ml/hour. Protect infusion from direct sunlight. Flush with N/S or G. Incompatible with PVC

Nitroprusside See Sodium Nitroprusside






130

DRUG

METHOD WHO MAY GIVE

ADMINISTER OVER


COMMENTS

(C) or (I) IV infusion via a central IV line. Infusion pump is required.

♠ Groups 1 and 2


Usual dilutions in this Trust: “Single Strength” 4ml (4mg noradrenaline base) diluted to 50ml with G (or G/S) = 80micrograms/ml. “Double strength” 8ml (8mg noradrenaline base) diluted to 50ml with G (or G/S) = 160micrograms/ml. “Quadruple Strength” 16ml (16mg noradrenaline base) diluted to 50ml with G (or G/S)= 320micrograms/ml.

Infuse via a central venous catheter. Loss of potency occurs if diluent is N/S. Discard infusion if brown colour develops. Flush with G or N/S. Protect infusion from direct sunlight. Haemodynamic monitoring required.

Noradrenaline (Norepinephrine) base 1mg/1ml (=Noradrenaline tartrate 2mg/ml)

Rate (micrograms/kg/minute) = Pump rate (ml/hour) x concentration (micrograms/ml) Patient’s weight (kg) x 60 Pump rate (ml/hour) =Prescribed rate(micrograms/kg/minute) x 60(minutes in an hour) x Patient’s weight (kg) Concentration of the infusion(micrograms/ml)

Novomix 30® Insulin

Novorapid® Insulin (Insulin aspart)

See Insulin Section, page






131

DRUG

METHOD WHO MAY GIVE

ADMINISTER OVER


COMMENTS

Octagam® See Immunoglobulin Human Normal




3-5 minutes Dilute each 1ml octreotide injection with a minimum of 1ml and a maximum of 9ml of N/S.

Subcutaneous injection is preferred method of administration. ECG monitoring necessary with IV injection (Not with SC injection). Flush after IV injection with N/S. It is not recommended to use G to dilute octreotide (except for treatment of variceal bleeding below). The rubber caps of the Multidose vials should not be punctured more than 10 times.

Octreotide

(C) SC infusion via syringe driver in palliative care. (Unlicensed – see page 1)




Follow the PHNT Care of The Dying Pathways and the PHNT Syringe Driver Policy. For combinations of 2 or 3 drugs in the same syringe refer to the compatibility charts in the pump kit or contact Pharmacy on ext. 39976 for advice.

Octreotide Depot (Sandostatin LAR®) IM injection by

♠ Groups 1 and 2

Instructions for IM injection of Sandostatin LAR for deep intragluteal injection only

1. Remove the cap from vial containing Sandostatin LAR. Ensure that the powder is settled at the bottom of the vial by lightly tapping the vial. Remove the cap from the vehicle syringe. Attach one of the supplied needles to the vehicle syringe.

2. Insert needle through centre of rubber stopper of the Sandostatin LAR vial. 3. Without disturbing the Sandostatin LAR powder, gently inject the vehicle into the vial by running the vehicle down the inside wall of the

vial. Do not inject the vehicle directly into the powder. Withdraw any excess air present in the vial. 4. Do not disturb the vial until the vehicle has wetted the Sandostatin LAR powder for suspension. Once complete wetting (approximately 2-5

minutes) has occurred, the vial should be moderately swirled until a uniform suspension is achieved. Do not vigorously shake the vial. 5. Immediately draw 2ml of air into the syringe and re-insert the needle through the rubber stopper. Inject the 2ml of air into the vial and then,

with the bevel down and the vial tipped at approximately 45 degree angle, slowly draw the entire contents of the vial containing the suspension into the syringe. Immediately change the needle (supplied).

6. Gently invert the syringe as needed to maintain a uniform suspension. Eliminate air from syringe and disinfect the injection site. Insert needle into right or left gluteus and draw back to ensure that no blood vessel has been penetrated. Immediately inject IM by deep intragluteal injection.

7. Sandostatin LAR must be given only by intragluteal injection, never IV If a blood vessel has been penetrated, select another injection site.






132

DRUG

METHOD WHO MAY GIVE

ADMINISTER OVER


COMMENTS

Omalizumab ▼▼▼▼ This product is being intensively monitored by the CHM and MHRA. Please report all suspected reactions (including non-serious ones) using a Yellow Card from the BNF

SC injection in the deltoid region of the arm. Alternatively, the injections can be administered in the thigh if there is any reason precluding administration in the deltoid region.

♠ Groups 1 and 2

Available in pre-filled syringes.






133

DRUG

METHOD WHO MAY GIVE


COMMENTS

When intravenous omeprazole is not available, intravenous esomeprazole should be prescribed – refer to the esomeprazole monograph

Omeprazole


♠ Group 1,2 and 3

20-30 minutes Reconstitute each 40mg with approximately 5ml N/S or G. Dilute each 40mg to 100ml with N/S or G.

Flush with N/S. Sodium content 0.1mmol/40mg vial. Revert to omeprazole capsules orally or omeprazole dispersible tablets via PEG/NG/NJ as soon as possible. Use infusion in N/S within 12 hours, 3 hours if in G. Incompatible: do not infuse with any other drugs.

IV Loading dose of 80mg


80mg in 250ml N/S over 60 minutes

For each 40mg vial, withdraw 5ml of N/S from a 250ml bag and use to reconstitute the vial. Then inject the reconstituted omeprazole into the bag. Do not add more than 80mg omeprazole to 250ml of diluent.

Omeprazole For the specialist treatment of endoscopically controlled bleeding peptic ulceration. (C) IV infusion.



After loading dose, infuse at 8mg/hour for 70 hours* (This is 25ml//hour with each 80mg in 250ml N/S)

Reconstitute and dilute each 40mg vial as above.

Use infusion in N/S within 12 hours. Omeprazole infusion must not be infused through the same venflon or line lumen as any other drug solution. Each bag is for single use only and must be used immediately after preparation. * The Gastroenterologists have agreed to a 70-hour treatment (rather than 72 hours). A pre-printed prescription is available.

Ondansetron IV bolus Usual method


3-5 minutes Either give undiluted or dilute to any convenient volume of N/S or G.




15 minutes Dilute with N/S or G to any suitable volume.



1mg/hour








134

DRUG

METHOD WHO MAY GIVE


COMMENTS

(C) infusion. Infusion pump is required.

♠ Groups 1 and 2

Increase the rate every 30 minutes until contractions are satisfactory (4 – 5/10)

Dilute 3 units of oxytocin (3 units = 0.6ml of the 5 units/ml injection) to 50ml with N/S.

Using the 3 unit in 50ml dilution:

Time from start of infusion (Minutes)

Infusion rate (milliunits/minute)

Infusion rate (ml/hour

0 1 1

30 2 2

60 4 4

90 8 8

120 12 12

150 16 16

180 20 20

Only increase the rate beyond this point following review and at the discretion of the specialist registrar or consultant.

210 24 24

240 28 28

Oxytocin

270 32 32

For detailed instructions it is essential to read the PHNT Guidelines for Augmentation of Labour

Continuous electronic fetal monitoring during administration is required.

Stop the infusion during a prolonged deceleration or definite fetal distress (if CTG is abnormal perform FBS first).

Do not infuse through the same line as blood or plasma.

Optiray 300® ♠ Group 1 or Group 6

50ml from prefilled syringe

Do not dilute. Monitor for possible anaphylaxis or other allergic reactions. Resuscitation equipment must be immediately available. Flush catheter frequently

Orencia® See Abatacept






135

DRUG

METHOD WHO MAY GIVE


COMMENTS


SC bolus ♠ Groups 1,2,3,4 and 5


Oxycodone

(C) SC infusion via syringe driver for use in palliative care.


24 hours Dilute with W when 2 or more drugs are being mixed in the same syringe.

W or N/S may be used when the syringe only contains this drug.

Follow the PHNT Care of the Dying Pathway in Advance Kidney Disease and the PHNT Syringe Driver Policy. For combinations of 2 or 3 drugs in the same syringe refer to the compatibility charts in the pump kit or contact Pharmacy on ext. 39976 for advice.

Pabrinex ® IV high potency injection

(I) IV infusion (Preferred method). Infusion pump is required.

♠ Groups 1 and 2

15 to30 minutes The contents of the pair(s) of ampoules should be diluted with 50 to 100ml N/S or G. (Up to 3 pairs of 5ml ampoules can be diluted with 50-100ml N/S or G).

Flush with N/S or G. Mild allergic reactions are warning signs that further doses may cause anaphylactic shock


10 minutes Mix contents of one 5ml Ampoule No.1 and one 5ml Ampoule No.2 (Maximum volume 10ml) in a single syringe immediately before use.

Facilities for treating anaphylaxis must be available.

Pabrinex ® IM high potency injection


The contents of one ampoule number 1 and one ampoule number 2 of Pabrinex Intramuscular High Potency (total 7ml) are drawn up into a syringe to mix them just before use, then injected slowly high into the gluteal muscle, 5cm below the iliac crest.

Do not give the IM formulation via the IV route. Refer to the Marsden Manual for guidance on IM injection. Mild allergic reactions are warning signs that further doses may cause anaphylactic shock. Facilities for treating anaphylaxis must be available.






136

DRUG

METHOD WHO MAY GIVE


COMMENTS

Pamidronate (I) IV infusion. Infusion pump is required.


Maximum 1mg/minute. A dose of 90 mg should normally be administered as a 2-hour infusion. In renally impaired patients the maximum recommended rate is 20mg/hour.

For some brands the vials contain solution that requires further dilution. For vials that contain powder needing reconstitution before further dilution: reconstitute each 15mg vial with 5ml W. Reconstitute each 30mg and 90mg vial with 10ml W. Further dilution is necessary: Dilute 30mg to at least 125ml with N/S Dilute 60mg to at least 250ml with N/S Dilute 90mg to at least 375ml with N/S

Flush with N/S. Sodium content 0.11mmol/15mg. Monitor serum electrolytes, calcium and phosphate. Aredia® and Medac® brands state that they should not be given if eGFR<30 unless the hypercalcaemia is life-threatening and the benefit outweighs the risk. In order to minimise local reactions at the infusion site, the cannula should be inserted carefully into a relatively large vein.

Pancuronium IV bolus preferably via a central IV line or through tubing of flowing N/S or G drip.

♠ Groups 1 and 2

. Flush with N/S or G.






137

DRUG

METHOD WHO MAY GIVE


COMMENTS

Pantoprazole is non-formulary and should only be used if both intravenous omeprazole & esomeprazole are unavailable


2 minutes Reconstitute 40mg vial with 10ml N/S.



15 minutes Reconstitute as above then further dilute with 100ml with N/S or G.

The reconstituted solution is clear and yellowish. Revert to omeprazole capsules orally as soon as possible. Alternatively revert to dispersible lansoprazole Fastabs via PEG/NG/NJ as soon as possible. Use infusion in N/S within 12 hours. Incompatible: do not infuse with any other drugs.

Pantoprazole (C) infusion is unlicensed (See page 4) and is for specialist use after endoscopic treatment of bleeding peptic ulceration.



After loading dose*, infuse at 8mg/hour for 72 hours (This is 20ml//hour with each 40mg in 100ml)

Reconstitute each 40mg vial with 10ml N/S and dilute up to 100ml with N/S or G. (Do not add the contents of more than one vial to larger bags of N/S)

*The loading dose is 2 x 40mg doses, each diluted in a 100ml bag of N/S and infused over 15 minutes each, one after the other.

Intravenous paracetamol must only be used when a patient cannot take any medicines by mouth and paracetamol cannot be given via an enteral feeding tube. Peri-operative patients able to take sips of water can take paracetamol orally with a little water.

Paracetamol



15 minutes Provided ready-diluted Can be flushed with N/S. Each bottle is for single use only.


Rapid bolus directly into a vein or into an existing line through which N/S, G or H is running.

Reconstitute 40mg vial with 2ml N/S (can be reconstituted with 2ml G instead of N/S if necessary). Dissolve the powder with a gentle swirling motion.

Do not administer parecoxib together with opioids in the same syringe. Do not reconstitute with Hartmann’s as this will cause precipitation.

Parecoxib

Deep IM injection








138

DRUG

METHOD WHO MAY GIVE

ADMINISTER OVER


COMMENTS



Adults: Each bag should run over no longer than 24 hours

Do not infuse with any other drugs. See back of Pharmacy TPN order form for required monitoring of electrolytes, and LFT’s etc.

Parenteral nutrition (TPN)

1. TPN must be ordered by 12 noon on the day it is required. Ensure that biochemistry results are available before the TPN is prescribed. It is advised to “Red Spot” the samples to speed the results.

2. All patients (except those on Penrose or Pencarrow) should be referred to the Nutrition Support Team (NST). If you wish to contact or refer a patient to the NST contact Dr Stephen Lewis Consultant Gastroenterologist on bleep 89756, Dr Andrew Latchford Consultant Gastroenterologist on bleep 89149, Nutrition Nurse Specialist bleep 89755 or 89760, Dietitian on Ext 52266 or Pharmacy Technical Services on Ext 53429.

3. For patients on ICU please follow the ICU TPN protocol. 4. The protocol for connecting TPN bags and monitoring should be followed with meticulous attention. 5. TPN should not be commenced out-of-hours on weekdays (Between 5pm and 9am). On a Saturday, Sunday or Bank Holiday TPN

is only available after discussion with the on-call Gastroenterologist. Once the on-call Gastroenterologist has agreed on the commencement of TPN, then he will contact the on-call pharmacist for a supply. This applies to all wards other than Penrose and Pencarrow (TPN bags are no longer available from the Pharmacy Night Cupboard).

(I) IV infusion with patient supine, via an infusion pump, for the treatment of Pneumocystis jirovecii (formerly known as Pneumocystis carinii) pneumonia, or Trypanosomiasis


Minimum 1 hour Flush with N/S or G. Sodium content nil. Blood pressure must be closely monitored. To reduce the risk of severe, sudden hypotension, patient should be supine. Do not infuse with any other drugs.

Pentamidine (Pentamidine isethionate)

IM injection for the treatment of Leishmaniasis or Trypanosomiasis

♠ Groups 1 and 2

Pharmacy must prepare this. Contact Ext. 31083







139

DRUG

METHOD WHO MAY GIVE


COMMENTS



Pethidine


2 - 5 minutes Can be diluted with N/S or G.



Flush after IV bolus with N/S or G Monitor blood pressure, heart rate and respiratory rate. Have naloxone and resuscitation equipment available. Sodium content nil.

Phenobarbitone IV bolus ♠ Groups 1,2,3,4 and 5

For status epilepticus in adults: 10mg/kg at a rate of no more than 100mg/minute. Maximum dose 1g.

Dilute to 10 times its own volume with W.

Flush with N/S. Sodium content 0.79mmol/200mg. The injection is highly alkaline and may produce local tissue damage. Extravasation may cause tissue damage. Monitor sedation score, respiratory rate, heart rate and blood pressure.

IV bolus To treat hypertensive episodes due to phaeochromocytoma

♠ Group 1 May be diluted with N/S if required.

Flush with N/S or G. Monitor blood pressure and ECG. Protect from light. Use with care in asthmatics: monitor for hypersensitivity reactions.

Phentolamine mesylate

Rapid IV bolus or IM injection for

Diagnosis of phaeochromocytoma - Rogitine blocking test

♠ Group 1 See section 12 for general guidance on SC and IM injection.

Refer to the product SPC for details of how to perform the test and the monitoring required.

(C) IV infusion ♠ Group 1 0.2-2mg per minute titrating the dose to the desired blood pressure response

Dilute with a suitable volume of N/S or G.

Note that IV infusion of phentolamine is unlicensed.






140

DRUG

METHOD WHO MAY GIVE


COMMENTS

IV bolus ♠ Group 1 100-500micrograms slowly over 3-5 minutes, repeated if necessary after at least 15 minutes.

Dilute to 1mg in 1ml with N/S.


♠ Groups 1 and 2

Adults: Maximum initial rate 180micrograms/ minute reduced according to response to 30 – 60 micrograms/minute

Add 10mg to 500ml of N/S or G.



Phenylephrine



Flush IV bolus with N/S or G.

Extravasation may cause tissue damage. Monitor blood pressure and heart rate.

When an IV infusion is discontinued, slow the infusion rate gradually; do not stop it abruptly

Phenytoin sodium

Slow IV bolus or (I) IV infusion into a large vein. A pump is required for infusion.



Give undiluted. ECG and blood pressure monitoring essential. Monitor for possible respiratory depression. Flush with N/S before and after administration of each injection or infusion to avoid venous irritation.

(I) IV infusion through a large vein. Infusion pump is required.



Children: up to 1mg/kg/minute. Maximum 50mg/minute.

After dilution: Use immediately, complete infusion within 1 hour.

An in-line 0.22-0.5 micron filter should be used to administer phenytoin injection diluted in N/S. If a suitable in-line filter is not available then give as undiluted injection via a syringe driver as above. If a suitable filter is available dilute in 50-100ml N/S to a final concentration not exceeding 10mg/1ml. Do not use if solution is hazy or contains precipitate.

Sodium content 0.91mmol/250mg.

Incompatible: Do not infuse with any other drugs.


Suitable filters to administer phenytoin diluted in N/S include PALL 0.22 micron,

Braun Sterifix 0.2 micron, Technopharm codan 0.2 micron filters. These filters should be ordered through ORACLE.






141

DRUG

METHOD WHO MAY GIVE


COMMENTS

Phosphate Polyfusor

(I)infusion via peripheral or central IV line. Infusion pump is required.


Infuse over 6 – 12 hours.

Maximum rate: 150ml/hour

Incompatible with other solutions containing calcium or magnesium, Hartmann’s solution, Ringer’s solution, ciprofloxacin, dobutamine and TPN

Provided ready-diluted. Do not further dilute.

Dosage: Serum phosphate 0.5-0.7mmol/L infuse 1 - 2ml/kg. Serum phosphate <0.5mmol/L infuse 2 – 5ml/kg. Maximum dose 500ml per infusion. Infusion can be repeated if necessary.

To treat Re-feeding Syndrome, 500ml (50mmol phosphate) is typically infused over 12 hours. This dose may be repeated depending on serum phosphate levels.

Consider reduced dosage in the elderly or patients with impaired renal function. Monitor serum electrolytes including phosphate and calcium (frequently in renal impairment). Monitor renal function, ECG and fluid balance.

Pain and phlebitis may occur at the infusion site.

Sodium content 162mmol/L

Potassium content 19mmol/L

Phosphate content 100mmol/L

Flush with N/S.

Phytomenadione (Konakion MM® vitamin K) 10mg in 1ml


Over at least 30 seconds, usually 3-5 minutes per 10mg.

May be given undiluted.

Alternatively, draw up the required dose from the ampoule then dilute further with a small volume (eg. 10-20ml) of G.

Do not dilute the 10mg in 1ml with G and take the fraction of the diluted injection corresponding to the required dose, as the MM formulation does not distribute evenly in the diluent.

Product has been reformulated without polyethoxylated castor oil, however there is still a risk of anaphylaxis with rapid IV administration. Protect infusion and giving set from light. Flush with G.

The contents of the 10mg in 1ml ampoules can be given by mouth, but this use is unlicensed (See page 4)

Do not administer via the IM route.






142

DRUG

METHOD WHO MAY GIVE


COMMENTS

IV bolus.

The dose may be injected into the lower part of an infusion set containing 5% dextrose or 0.9% sodium chloride running at 0.7ml/minute


Do not further dilute.

Product has been reformulated without polyethoxylated castor oil, however there is still a risk of anaphylaxis with rapid IV administration. Flush with G.

The contents of the 2mg in 0.2ml ampoules are also licensed to be given by mouth.

Phytomenadione (Konakion MM® Paediatric

vitamin K) 2mg in 0.2ml


IM injection ♠ Groups 1,2 and 4

For neonatal use following the protocols on NICU

Further neonatal information can be found in the Neonatal Formulary 6th Edition.

Konakion MM Paediatric must be administered by IV injection when used as an antidote to anticoagulant drugs such as warfarin & phenindione, as IM injections may result in significant bleeding in these patients.






143

DRUG

METHOD WHO MAY GIVE

ADMINISTER OVER


COMMENTS

Piperacillin/

Tazobactam


Slow IV bolus of this medication is no longer recommended or licensed.


30 minutes Reconstitute each 2.25g with 10ml and each 4.5g with 20ml of W, or N/S. Swirl until dissolved. When swirled constantly reconstitution should occur within 10 minutes.

Displacement ranges 1.5 – 1.7ml per 2.25g.

Dilute further to at least 50ml with N/S or G (adding to a 100ml bag is ok).

In paediatrics, the maximum concentration for infusion is 90mg/ml.

Flush with N/S. Sodium content: 4.7 - 5.58mmol/2.25g vial and 9.4 – 11.2mmol/4.5g vial. Incompatible with all aminoglycosides. Do not mix with or give through the same line at the same time as gentamicin, amikacin, tobramycin etc. If only one line available separate the doses and flush well with N/S before and after each dose. Do not give through the same line as Hartmann’s

Pitressin ® See vasopressin






144

DRUG

METHOD WHO MAY GIVE

ADMINISTER OVER


COMMENTS

Potassium chloride ready prepared infusion bags

containing 20mmol/L

or 40mmol/L potassium in N/S, G or G/S.

Can be kept as stock by all wards and departments.

Ready-made bags containing

80mmol/litre are also available



Adults: Maximum rate 20mmol potassium/hour.

If a concentration of potassium other than 20, 40 or 80mmol/litre is prescribed contact the ICU pharmacist or the on-call pharmacist.

Pain or phlebitis may occur during peripheral administration of solutions containing 30mmol or more potassium/litre. Solutions containing more than 40mmol/litre potassium should ideally be given via a central line. However, in cases of serious hypokalaemia with no central access up to 80mmol/litre potassium may be tolerated peripherally if given via a large vein (e.g. femoral vein).

Extravasation will cause tissue damage.

ECG monitoring essential and resuscitation equipment must be available when administering more than 20mmol potassium/hour to adults.

Administration of IV potassium at a rate

Potassium chloride 15% injection

May only be stocked by Critical Care areas


♠ Groups 1 and 2

Adults: Usual maximum rate 20mmol potassium/hour.

Children:

Usual maximum rate

0.2mmol/kg/hour

Critical care areas only may give undiluted 2mmol/ml potassium injection via a central line with ECG monitoring, or dilute to the required concentration with N/S, G , G/S or H with thorough mixing.

exceeding 40mmol/hour poses a serious risk of asystole.

Flush with N/S.

For instructions on the use of potassium chloride injection during cardiopulmonary bypass refer to the Blood Cardioplegia Management section of the Clinical Perfusion policy.






145

DRUG

METHOD WHO MAY GIVE

ADMINISTER OVER


COMMENTS

Potassium chloride ready prepared infusion bags

containing 20mmol/L potassium in N/S, G or G/S.

(C) SC infusion



Adults: maximum rate 20mmol potassium/hour.

Use the ready-made infusion bags containing 20mmol/L potassium chloride available from Pharmacy.

There is anecdotal evidence that up to 40mmol/L potassium can be given by SC infusion. However, SC potassium infusion can cause ulceration and the risk is greater at 40mmol/L than at 20mmol/L.

Monitor the infusion site regularly for early signs of irritation and inflammation.

Potassium chloride 15% injection

Intra-cardiac for feticide

♠ Group 1

To be administered in accordance with procedures for feticide on the Early Pregnancy Unit or the Emergency Gynaecology Unit.

A single ampoule may be ordered as a Controlled Drug by these Units. Records of receipt and administration are as for Controlled Drugs.






146

DRUG

METHOD WHO MAY GIVE

ADMINISTER OVER


COMMENTS

Potassium phosphate (Dipotassium hydrogen phosphate) injection *May only be stocked by Critical Care areas.

(I) infusion. Infusion pump is required.

♠ Groups 1 and 2

Adult patients on a critical care unit: Usual maximum rate 20mmol potassium/hour (30mmol phosphate over 3 hours) It is suggested that general wards ask the doctor to prescribe a dose of Phosphate Polyfusor instead (See page 182)

Critical care areas only may give undiluted potassium phosphate injection via a central line with ECG monitoring. For administration via a peripheral line dilute with N/S, G or G/S to a usual maximum concentration of 40mmol potassium/litre.

Flush with N/S Up to 0.3 – 0.6mmol/kg/day of phosphate may be required during the treatment of Refeeding Syndrome. Dipotassium phosphate 17.42 % injection contains 1mmol phosphate/ml and 2 mmol potassium/ml.

Privigen® See Immunglobulin Human Normal

Deep IM injection ♠ Groups 1 and 2


Prochlorperazine

IV bolus

♠ Groups 1 and 2

Maximum rate 6.25mg/minute

Dilute 1 part with 5 parts N/S before administration.

Flush IV bolus with N/S. Prochlorperazine is unlicensed (See page 4) by the IV route. IV administration can cause hypotension and venous irritation.

Procyclidine IV bolus ♠ Groups 1 and 2

Suggestion: over 3 minutes

Dilution is not recommended.






147

DRUG

METHOD WHO MAY GIVE


COMMENTS

Propofol IV bolus ♠ Groups 1 and 2*

Do not dilute. Can be administered through tubing (close to the injection site) of infusions of N/S, G or G/S.

Monitor ECG and blood pressure. Also monitor for airway obstruction and oxygen saturation. Resuscitation equipment should be available. *Boluses of propofol may only be given by Group 2 nurses to ventilated patients in level 3 critical care.

(C) IV infusion. ♠ Groups 1 and 2

Dependent on indication.

Infuse undiluted or dilute with G to a concentration of not less than 2mg/1ml. B.Braun Propfol-Lipuro can be diluted with G, N/S or G/S to a concentration of not less than 2mg/1ml. If diluted in a PVC bag withdraw a volume of infusion fluid and replace it with an equal volume of propofol 1%.

Administer immediately after preparation of the syringe or infusion. Anaesthetics Directorate policy: Administer propofol within 30 minutes of drawing up into syringe. Use propofol diluted with G, N/S or G/S within 6 hours of preparation. When using B.Braun (Propofol –Lipuro), Generics UK and Fresenius kabi brands of propofol in bottles for infusion, the bottle and line should be changed at least every 12 hours. To reduce pain on injection 20ml 1% propofol may be mixed with up to 1ml of 1% lignocaine immediately before use. Flush with N/S.

Propranolol IV bolus Emergency use.

♠ Group 1 Adults: 1mg over 1 minute. May be repeated at 2-minute intervals until desired response observed or until maximum dose*

Can be diluted with N/S or G. ECG monitoring required. Flush with N/S. Sodium content nil. If IV used as temporary substitute for oral propranolol 1mg IV = 10mg orally. *Maximum dose of 10mg in conscious patients or 5mg in patients under anaesthesia.






148

DRUG

METHOD WHO MAY GIVE


COMMENTS

Reversal of IV heparin infusion

IV bolus


Slow injection over 10 minutes. Maximum rate 5mg/minute

Can be diluted with N/S. Flush with N/S.

Monitor APTT coagulation tests.

Reversal of SC heparin:

Dose: 1mg protamine per 100 units heparin. Give 25-50mg of this dose by slow IV bolus followed by (C) IV infusion of the remainder of the calculated protamine dose via an Infusion pump.


Slow IV injection (maximum rate 5mg/minute) followed by infusion of the remainder of the calculated protamine dose over 8-16 hours

Dilute to a suitable volume with N/S or G.

Too rapid administration of protamine sulphate may cause severe hypotension and anaphylactoid reactions. Facilities for resuscitation and treatment of shock should be available.

Protamine sulphate

Partial (60% maximum) reversal of enoxaparin

Within the first 8 hours after enoxaparin administration: 1mg protamine per 1mg enoxaparin (maximum dose 50mg protamine) by slow IV bolus


Maximum rate 5mg/minute

Can be diluted with N/S. Decisions regarding the necessity and dose of subsequent protamine injections should be based on clinical response rather than measurement of anti Xa or anti XIIa results. The physician should also consider that the amount of enoxaparin in the body drops to 50% after 8 hours and 33% or less after 12 hours. The dose of protamine should be adjusted depending on the length of time

since enoxaparin was administered.






149

DRUG

METHOD WHO MAY GIVE


COMMENTS

Protirelin IV bolus ♠ Group 1 Suggestion: Over 30-60 seconds

Do not dilute. Diagnostic test.

Quinine dihydrochloride


♠ Groups

1 and 2

4 hours Dilute required dose in 250ml or 500ml N/S or G.

However, in fluid restricted patients a maximum dilution of 30mg/ml may be infused via a central IV line,

Flush with N/S Quinine may cause hypoglycaemia. Therapy should be changed to oral as soon as possible. Sodium content: negligible.

Ranitidine IV bolus ♠ Groups 1,2,3,4 and 5

Adults: at least 2 minutes*

Children: at least 3 minutes*

May be diluted further with G or N/S (20ml for example)



2 hours at 25mg/hour Add 50mg ranitidine to 100ml N/S or G.

(C) IV infusion following initial IV bolus. Infusion pump is required.


125-250 micrograms/ kg/hour

Dilute 150mg ranitidine to 250ml with N/S or G.



Flush with N/S, G or G/S. Sodium content 0.12mmol/2ml.

*A slower bolus over 5 minutes is recommended by some references because of the risk of causing bradycardia on administration.






150

DRUG

METHOD WHO MAY GIVE


COMMENTS

Radio- Pharmaceuticals

♠ Group 1 and Group 7

Refer to Group Protocols/PGD’s within the Department of Nuclear Medicine.

Rasburicase (I) IV infusion ♠ Group 1 and Group 2

30 minutes Rasburicase infusion is prepared in Pharmacy. Tel. ext. 31083.

The prescribed dose will be diluted to 50ml with N/S.

Infuse through a different line to that used for chemotherapy agents. If this is not possible, flush between the chemotherapy agents and rasburicase with N/S.

Rasburicase is not cytotoxic.

Rasburicase is not compatible with glucose solutions.

Remifentanil IV bolus infusion at induction of anaesthesia.

(C) IV infusion during maintenance of anaesthesia or for sedation of ventilated patients in intensive care.


♠ Groups 1 and 2

If not using pre-programmed syringe pump see table on the next page

Reconstitute to a concentration of 1mg/ml with N/S, G, W or 0.45% saline. Further dilute to a concentration of 20-250 micrograms/ml with N/S, G or 0.45% saline. (20 -25 micrograms/ml is recommended for paediatric patients aged 1 year and over). For TCI (Target Controlled Infusion) the recommended dilution is 20-50 micrograms/ml. However, 100 microgram/ml (eg 5mg in 50ml) is often used for TCI and for sedation of ventilated ICU patients.

IV bolus infusion not necessary if intubation is to occur more than 8-10 minutes after commencing remifentanil infusion.

IV bolus infusion is not recommended for induction in cardiac anaesthesia .Instead intubate at least 5 minutes after start of infusion. Bolus infusions are not recommended when infusing remifentanil for ICU sedation.

Monitor cardiovascular and respiratory functions.

Resuscitation equipment must be available.

Do not flush line. Sodium content: Nil.






151

REMIFENTANIL INFUSION RATES

Anaesthesia in adults

including cardiac anaesthesia

Anaesthesia in children

1 – 12 years of age

Sedation in Intensive Care

Concentration:

Bolus infusion

0.5 – 1 microgram/kg over at least 30 seconds.

Set pump at::

Continuous infusion 0.025 – 2 microgram/kg/minute (rate dependent on choice of general anaesthetic(s))

Set pump at:

Bolus infusion

1 microgram/kg over at least 30 seconds.

Set pump at:

Continuous infusion 0.05 – 1.3 microgram/kg/minute (rate dependent on choice of general anaesthetic(s))

Set pump at:

Starting rate 0.1 – 0.15 micrograms/kg/minute adjusting by 0.025 micrograms/kg/minute at intervals of at least 5 minutes

Set pump at:

100 micrograms/ml

(eg. 5mg in 50ml)

0.6 – 1.2 ml/kg/hour for 30 seconds

0.015 – 1.2 ml/kg/hour

1.2 ml/kg/hour for 30 seconds

0.03 – 0.78 ml/kg/hour

0.06 – 0.09 ml/kg/hour. Adjust by 0.015 ml/kg/hour

60 micrograms/ml

(eg. 3mg in 50ml)

1 – 2 ml/kg/hour for 30 seconds

0.025 – 2 ml/kg/hour 2 ml/kg/hour for 30 seconds

0.05 – 1.3 ml/kg/hour 0.1 – 0.15 ml/kg/hour. Adjust by 0.025 ml/kg/hour

50 micrograms/ml 1.2 – 2.4 ml/kg/hour for 30 seconds

0.03 – 2.4 ml/kg/hour 2.4 ml/kg/hour for 30 seconds

0.06 – 1.56ml/kg/hour


40 micrograms/ml 1.5 – 3 ml/kg/hour for 30 minutes

0.0375 – 3 ml/kg/hour

3 ml/kg/hour for 30 minutes

0.075 – 1.95 ml/kg/hour


25 micrograms/ml 2.4 – 4.8 ml/kg hour for 30 seconds

0.06 – 4.8 ml/kg/hour 4.8 ml/kg hour for 30 seconds

0.12 – 3.12 ml/kg/hour


20 micrograms/ml 3 – 6 ml/kg/hour for 30 seconds

0.075 – 6 ml/kg/hour 6 ml/kg/hour for 30 seconds

0.15 – 3.9 ml/kg/hour

0.3 – 0.45 ml/kg/hour. Adjust by 0.075ml/kg/hour






152

DRUG


COMMENTS

Rifampicin (I) IV infusion. Infusion pump is required.


2-3 hours Reconstitute with diluent provided (10ml) and shake vigorously for 30 seconds. Then dilute to a concentration of 600mg in 500ml N/S, G or G10%. If patient is fluid restricted 600mg may be diluted in 100ml G and given over 30 minutes.

Flush with N/S. Discard remaining infusion after 6 hours. Sodium content less than 0.5mmol/600mg. Displacement volume for a 600mg vial is 0.48ml. Do not infuse with any other drugs.

Rituximab The monograph for rituximab is on the next page.

Rapid IV bolus

♠ Group 1- must only be given by doctors proficient in advanced airway management. Also see comments

Rocuronium


♠ Groups 1 and 2 300-600 micrograms/kg/hour

No specific recommendations. Dilute to appropriate volume with N/S, H or G.

Flush with N/S or G. Compatible with G/S and H. Sodium content 0.72mmol/50mg. If the patient is ventilated IV bolus can be administered by Group 2 staff.






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COMMENTS

Read and print off the full guideline from the Royal College of Nursing: http://www.rcn.org.uk/__data/assets/pdf_file/0008/262385/Rituximab_protocol.pdf

Rituximab

For treating severe active Rheumatoid Arthritis in adults after failure of treatment with a TNF inhibitor


♠ Groups 1 and 2

(Premedication is required – see comments)

First infusion on Day 1:

50mg/hour (25ml/hour of 1g in 500ml dilution) for the first 30 minutes then

100mg/hour (50ml/hour of 1g in 500ml dilution) for the second 30 minutes,

then the rate can be increased by 50mg/hour (25ml/hour of 1g in 500ml dilution) every 30 minutes to a maximum rate of 400mg/hour (200ml/hour of 1g in 500ml dilution) providing no adverse reactions occur.

(Premedication is required – see comments)

Second infusion on Day 15:

100mg/hour (50ml/hour of 1g in 500ml dilution) for the first 30 minutes then

200mg/hour (100ml/hour of 1g in 500ml dilution) for the second 30 minutes,

then the rate can be increased by 100mg/hour (50ml/hour of 1g in 500ml dilution) every 30 minutes to a maximum rate of 400mg/hour (200ml/hour of 1g in 500ml dilution) providing no adverse reactions occur.

Although rituximab may be diluted with N/S to a concentration between 1mg/ml and 4mg/ml, the usual concentration is 2mg/ml. So the usual dilution of a 1g dose is 1g in 500ml N/S. Rituximab infusion should be prepared by Pharmacy. Telephone Ext. 31083.

Premdication: Dose of oral paracetamol 60 minutes before each rituximab infusion (not if paracetamol already given in the last 4 hours). Chlorphenamine 10mg IV 60 minutes before each rituximab infusion. Methylprednisolone 100mg in 100nl N/S infused over 30 minutes to be commenced 60 minutes before each rituximab infusion. Full resuscitation facilities must be immediately available. Monitoring: 1st hour – blood pressure, pulse, temperature and O2 sats every 15 minutes. Thereafter, every 30 minutes after increasing the infusion rate, and throughout the course of the infusion once maximum rate is reached. Possible reactions: Low grade fever, BP drop of <30mmHg from baseline: halve the infusion rate. Fever >38.50C, chills, mucosal swelling, dyspnoea, BP drop of > 30mmHg from baseline: stop the infusion and contact the doctor.






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DRUG

METHOD

1. Remove the plastic cap from Romiplostim powder vial and clean rubber stopper using the provided alcohol swab.

5. Holding the pre-filled syringe of

water for injections with one hand, bend the tip of the white plastic cover downward with your other hand. This will break the seal of the white plastic cover. Once the seal is broken, pull cover off to separate the grey rubber cap from the clear plastic syringe tip.

2. Attach vial adapter to Romiplostim vial by peeling off paper backing from vial adapter, keeping the vial adapter in its packaging. Keeping the vial on the bench, push the vial adapter down onto the centre of the vial until it is firmly in place.

6. Keeping the vial on the bench, attach the pre-filled syringe of water for injections to vial adapter: hold the outer edge of the vial adapter with one hand and twist the syringe tip clockwise onto the adapter with the other hand until you feel a slight resistance.

3. Remove and discard vial adapter packaging.

7. Very slowly and gently expel all water (0.72ml) into the 250 microgram powder vial. Water should flow slowly onto powder. GENTLY swirl the vial until all of the powder has dissolved and the fluid in the vial is clear and colourless. Do not shake or agitate vial

Romiplostim

(Nplate®)

SC Injection by

♠ Groups 1 and 2

Each vial is for single use only.

Do not mix with N/S or any drug solutions



4. Attach plunger rod to the pre-filled syringe of water for injections by twisting the plunger rod clockwise onto the syringe plunger, until you feel a slight resistance.

8. Visually inspect the reconstituted solution for particulate matter and/or discoloration. The reconstituted solution should be clear and colourless and should not be administered if particulate matter and/or discolouration are observed. Make sure solution is fully dissolved before removing syringe. Instructions continued on next page…






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DRUG

METHOD (Continued from previous page)

9. Remove the empty pre-filled syringe from the vial adapter.

10. Remove 1 ml administration syringe from package. Attach the 1 ml syringe to vial adapter of reconstituted solution by twisting the syringe tip onto the vial adapter until you feel a slight resistance.

13. Twist off administration syringe from vial adapter.

Attach safety needle to the filled administration syringe by twisting needle clockwise into syringe Luer lock tip.

11. Turn assembled syringe-vial unit upside down, so the vial of reconstituted product is above the syringe. Withdraw all of the medicinal product solution into the

administration syringe.

14. Prepare injection site with a new alcohol swab. Pull back on the pink safety cover toward the syringe and away from the needle. Remove clear needle shield from prepared needle by holding syringe in one hand and carefully pulling shield straight off with the other hand.

15. Administer subcutaneous injection following local protocols and good aseptic technique.

12. Ensure the correct amount of solution for the patient dose is in the administration syringe by expelling any excess solution back into the vial. 0.5ml of reconstituted solution contains 250micrograms

16. After injecting, activate the pink safety cover by pushing the cover forward using the same hand until you hear and/or feel it click/lock.

Romiplostim

(Nplate®)

SC Injection by

♠ Groups 1 and 2

(Continued)

17. Immediately discard syringe and needle into an approved Sharps Container






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COMMENTS

IV bolus

♠ Groups 1and 2

3-5 minutes Dilute 500micrograms in 1ml salbutamol injection with 9ml W, N/S or G to give a concentration of 50micrograms in 1ml.





Asthma:

3-20 micrograms/minute

= 18 -120ml/hour of the 5mg in 500ml dilution

Asthma: Dilute 5ml (5mg) of Ventolin Solution for Infusion to 500ml with G or N/S to make a concentration of 10micrograms/ml

(I) IV infusion using syringe pump.

♠ Groups 1 and 2

Premature labour: Dilute 10ml (10mg) of Ventolin Solution for Infusion to 50ml with G or N/S to make a concentration of 200 micrograms/ml

Salbutamol

(I) IV infusion. Using volumetric pump.

♠ Groups 1 and 2

Premature Labour: 10 micrograms/minute increasing the rate at 10 minute intervals to maximum rate of 45 micrograms/minute. Once uterine contractions have ceased the infusion rate should be maintained at the same level for one hour and then reduced by 50% decrements at six hourly intervals 10 – 45micrograms/minute = 3 -13.5ml/hour of the 10mg in 50ml dilution. 10 – 45micrograms/minute = 30 – 135ml/hour of the 10mg in 500ml dilution.

Premature Labour: Dilute 10ml (10mg) of Ventolin Solution for Infusion to 500ml with G or N/S to make a concentration of

20 micrograms/ml

Flush with N/S or G. ECG monitoring recommended. Sodium content 0.15 mmol/ml. If necessary in adult or paediatric intensive care salbutamol 5mg/5ml IV solution for infusion may be given undiluted via a central IV line (this method is unlicensed -see page 1) 3 – 20 micrograms/minute = 0.18 – 1.2ml/hour using this dilution.






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COMMENTS


For exocrine pancreatic function test inject over 1 – 2 minutes

Reconstitute each vial with the 10ml N/S provided making a concentration of 10 Clinical Units/ml. Draw up the prescribed dose.

Secretin pentahydrochloride

(Secrelux®)

(Secrelux® is an unlicensed product- see page 4)

(I) IV infusion.


♠ Groups 1 and 2

1 hour Reconstitute each vial with the 10ml N/S provided making a concentration of 10 Clinical Units/ml. Draw up the prescribed dose and infuse over 1 hour.

Can be given as infusion using a syringe pump depending on how the test is run. 1 Clinical Unit/kg dose = 0.1ml/kg of reconstituted secretin 2 Clinical Unit/kg dose = 0.2ml/kg of reconstituted secretin. Administer immediately after preparation.

Loading dose (I) IV infusion

♠ Groups 1 and 2

90 minutes Draw up 250mg/kg = 1.25ml/kg of injection and dilute in 5ml/kg of 10%G.

Sodium benzoate 2g in 10ml (Unlicensed product- see page 4)

Maintenance

(C) IV infusion ♠ Groups 1 and 2

24 hours Draw up 250mg/kg = 1.25ml/kg of injection and dilute in 5ml/kg of 10%G.

Follow the BRHC guidelines for the management of hyperammonaemia – http://nww.swretrieval.nhs.uk/DI_ALL.htm

Click on “Clinical Guidelines” then “Hyperammonaemia”






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DRUG

METHOD WHO MAY GIVE


COMMENTS

Sodium bicarbonate (C) IV infusion. Infusion pump is required.


IV bolus ♠ Group 1

Ready prepared infusions are available from pharmacy. Can be diluted with N/S or G.

Flush with N/S or G. Concentrations for IV infusion greater than 1.4% should be given via a central IV line

(C) or (I) IV infusion.


Ready prepared infusions are available from pharmacy.

Concentrations over 1.8% should be given via a central line. Sodium content of 0.9% injection is 150mmol/1 litre.

Sodium chloride

N.B. All bags of sodium chloride are for single use only.

IV bolus ♠ Groups 1,2,3,4,5,6 and 7

Can be diluted with G, G/S or H.

(C) SC infusion



Usual rate is 500ml over 8 hours (21 drops per minute). Maximum rate is 500ml over 1 hour (167 drops per minute)

Maximum concentration of sodium chloride by subcutaneous infusion is 0.9%.

Usual maximum of 2 litres in 24 hours. However, 3 litres may be given if necessary over 24 hours using two SC sites. The needle and giving set should preferably be changed every 72 hours. However, infusion sets can be left in place for up to 5-7 days if there are no complications. Refer to potassium chloride monograph for SC potassium.






159

DRUG

METHOD WHO MAY GIVE


COMMENTS

Sodium fusidate/

Fusidic acid

(I) IV infusion into a central venous line (preferred method). Infusion pump is required


2 hours Displacement is negligible. Add 10ml buffered diluent for 500mg in 10ml (50mg in 1ml).

Reconstitute with 10ml buffered diluent provided then dilute with 500ml N/S or G.

6 - 8 hours For fluid restricted patients reconstitute as above then dilute with 100ml N/S (unlicensed dilution - see page 1)

(I) IV infusion into wide bore peripheral vein. Infusion pump is required.


6 -8 hours Reconstitute and dilute with 500ml as above. Alternatively for fluid restricted patients dilute with 250ml N/S or G (unlicensed dilution - see page 1).

G can be used as diluent but opalescence may occur with more acidic samples (infusion must be discarded). Flush with N/S.

When reconstituted with 10ml buffer, preparation contains 3.1mmol sodium and 1.1mmol phosphate.

Sodium fusidate is well absorbed from the GI tract so consider an early switch to tablets or mixture.






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COMMENTS


♠ Groups 1 and 2

Increase rate slowly until desired effect occurs. The maximum rate is 8micrograms/kg/minute in order to avoid excessive levels of cyanide and thiocyanate and to lessen the possibility of a sudden drop in blood pressure.

Reconstitute 50mg with 2-3ml G (or the 5ml G provided in the case of the unlicensed Spanish Nitroprussiat fides brand) then further dilute with 500ml or 1000ml of G. Intensive care areas or Theatres only may use a dilution of 1mg/ml 50mg in 50ml) in G via a central IV line.

Intra-arterial blood pressure monitoring necessary. Protect infusion and administration set from light: Use the tin foil provided to wrap the bag and administration set, or the line. Use an amber syringe if giving by syringe pump. Discontinue infusion gradually over 15-30 minutes. Discard infusion solution if it is highly coloured. When using the Nitroprussiat fides brand the prepared infusion should be discarded after 4 hours. Do not flush - replace giving set. Sodium content 0.34mmol/50mg.

Using the 50mg in 50ml dilution for Intensive Care areas or Theatres:

Hypertensive crisis 0.5 – 8micrograms/kg/minute = 0.03 – 0.48ml/kg/hour

Maintenance of blood pressure at 30-40% lower than pre-treatment diastolic

20 – 400micrograms/minute (Lower doses if treated with other antihypertensives)

=1.2 – 24ml/hour

Controlled hypotension in surgery Up to a maximum of 1.5micrograms/kg/minute

=Up to a maximum of 0.09ml/kg/hour

Sodium nitroprusside (N.B Nitroprussiat fides brand is unlicensed – see page 4)

Heart failure 10 – 200micrograms/minute =0.6 – 12ml/hour






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DRUG

METHOD WHO MAY GIVE


COMMENTS

Loading dose (I) IV infusion

♠ Groups 1 and 2

About 90 minutes Draw up 250mg/kg = 1.25ml/kg of injection and dilute in 5ml/kg of 10%G.

Sodium phenylbutyrate 2g in 10ml (Unlicensed product- see page 4)

Maintenance (C) IV infusion

♠ Groups 1 and 2

24 hours Draw up 250mg/kg = 1.25ml/kg of injection and dilute in 5ml/kg of 10%G.

Follow the BRHC guidelines for the management of hyperammonaemia – http://nww.swretrieval.nhs.uk/DI_ALL.htm

Click on “Clinical Guidelines”, then “ALL” then “Hyperammonaemia”

For a ready-made phosphate infusion that can be given via a peripheral or central vein, see the monograph for Phosphate Polyfusor

Sodium Phosphate (Disodium Hydrogen Phosphate)

(I) or (C) IV infusion. Infusion pump is required


Adult patients on a critical care unit: Suggested maximum infusion rate of 10mmol phosphate per hour (30mmol phosphate in 50ml over 3 hours). It is suggested that general wards infuse the dose of phosphate over 12 hours or ask the doctor to prescribe a dose of Phosphate Polyfusor instead (See page 182)

Via a peripheral vein dilute dose with a suggested volume of 500ml N/S or G. Undiluted sodium phosphate injection may be infused via a central IV line using a syringe pump.

Flush with N/S. Up to 0.3 – 0.6mmol/kg/day of phosphate may be required during the treatment of Refeeding Syndrome. Disodium hydrogen phosphate 21.49% injection contains 6mmol phosphate in 10ml (30mmol phosphate in 50ml).






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COMMENTS



3 - 5 minutes.

Reconstitute with 4ml diluent provided. Due to the product displacement this produces a solution of 95mg/ml.



Divide total infusion volume by 24 to set the hourly rate on the pump

Reconstitute as above then dilute with N/S, G or G/S to any suitable volume of at least 50ml

Sodium valproate



1 hour Reconstitute as above then dilute with N/S, G or G/S to any suitable volume of at least 50ml

Flush with N/S, G or G/S. Sodium content 2.41mmol/400mg vial. Usually continue the patient’s current oral dosage as repeated slow bolus injections. Alternatively continue total usual oral daily dosage as a continuous IV infusion over 24 hours. For patient’s not previously treated with sodium valproate a slow bolus of 400 – 800mg depending on patient’s weight (up to 10mg/kg) is given followed by continuous infusion (Max. 2500mg per day). Do not infuse with any other drugs.

Streptokinase (C) or (I) IV infusion. Infusion pump is required.


Myocardial Infarction: 1.5 MU over 60 minutes. Embolism/thrombosis 250,000 units over 30 minutes followed by 100,000units/hour.

Streptase brand reconstitute all sizes with 5ml N/S. Further dilute 1.5 MU dose in 50-200mlN/S, G or H. Dilute other doses in any suitable volume of N/S or G e.g. 50-250ml.

ECG and blood pressure monitoring required. 1 MU= 1,500,000 units Flush with N/S. Duration of infusion: 72 hours for DVT or 24 hours for PE or 24-72 hours for arterial thrombosis or 12 hours for central retinal thrombosis.






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DRUG

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COMMENTS

Streptomycin (Unlicensed product – see page 4)

Deep IM injection Change the injection site each time.

♠ Groups 1 and 2


A 1g dose is usually dissolved in 2 -3ml W. The displacement volume is approximately 0.75ml So if you dissolve the powder with 3.25ml W the solution produced will be 250mg/ml

In the treatment of tuberculosis the usual dose for adults, and children 1month to 18 years is 15mg/kg up to a maximum of 1000mg, given daily or three times a week. For the elderly and adults over 40 years of age or less than 50kg body weight give 500mg-750mg once daily or 750mg three times a week.

Monitor serum levels, particularly in patients with renal impairment, and adjust dosage accordingly.

One hour (peak) levels should be 15 – 40mg/litre and pre-dose (trough) levels should be less than 5mg/litre (less than 1mg/litre in renal impairment or in those over 50 years).

Subcuvia® See Immunoglobulin Human Normal

Subgam® See Immunoglobulin Human Normal






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DRUG

METHOD WHO MAY GIVE


COMMENTS

Sugammadex Approved use in this Trust: Immediate reversal of neuromuscular block by rocurronium when intubation and ventilation have failed. It will also be effective in a similar emergency situation to reverse vecuronium.

▼▼▼▼ This product is being intensively monitored by the CHM and MHRA. Please report all suspected reactions (including non-serious ones) using a Yellow Card from the BNF.

Rapid IV bolus ♠ Group 1 Rapid injection within 10 seconds

Adult dose for immediate reversal of rocuronium block is 16mg/kg of undiluted 500mg in 5ml injection. 16mg/kg = 0.16ml/kg of the 500mg in 5ml injection

If sugammadex is administered via the same infusion line that is also used for other medicinal products, flush before and after sugammadex administration with N/S.

However, sugammadex can be injected into the intravenous line of a running infusion with the following intravenous solutions: N/S, G, H, and sodium chloride 0.45% and glucose 2.5%.






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DRUG


COMMENTS

Sulphadiazine (I) IV infusion. Infusion pump is required.


Minimum 30-60 minutes

Dilute dose with N/S to a maximum concentration of 50mg/1ml. Preferably dilute required dose to 500ml to 1 litre to reduce risk of crystallisation in the urine.

Flush with N/S. Sodium content approximately 4mmol/1g. To reduce the risk of crystallisation in the urine a high fluid intake (2.5-3.5 litres in 24 hours) should be maintained with urinary output of not less than half that amount. In addition the urine should be rendered alkaline.

Suxamethonium IV bolus ♠ Group - must only be given by doctors proficient in advanced airway management.

Ready diluted Flush with N/S or G.


♠ Groups 1 and 2 2.5 - 4mg/minute Infuse as a 1mg/ml to 2mg/ml solution diluted in N/S or G.

Infusion not usually recommended due to development of phase II neuromuscular block and likelihood of exceeding maximum dose.

Synacthen® See Tetracosactide.






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DRUG

METHOD WHO MAY GIVE

ADMINISTER OVER


COMMENTS

Tacrolimus Give by mouth or enteral feeding tube routes if at all possible.



Infuse daily dose in 48ml over 24 hours (Pump set at 2ml/hour)

Draw up the correct dose in a 1ml syringe (See table below). Transfer and dilute to 48ml with N/S or G in a 50ml Terumo or BD syringe. The final concentration should be between 4 and 100 micrograms/ml. Infuse through a PVC-free extension set (Codan PVC-free extension set 71.4001 available via ORACLE, order code FKA064 or Alaris G30302M line via ORACLE order code FKA058)

Tacrolimus is adsorbed to PVC and must be infused though a PVC-free or PE-lined extension set The following extension sets are suitable and are available to order from NHS Supplies: Codan PVC-free extension set 71.4001, order code FKA064. Alaris G30302M line, order code FKA058 Vygon PE-lined extension set 6222.151, order code FSB147. BMS PE-lined extension set 30-7200, order code FSB646. Other suitable sets include the Vygon 71100.15 PE extension set and the Vygon 0832.211R PE-lined extension set. Where the need is immediate and a PVC-free extension set has not been provided with the supply of IV tacrolimus a PVC-free extension set can be obtained from Neonatal ICU. Wear gloves when preparing the infusion Not Y-site compatible with ganciclovir or aciclovir. Flush with N/S or G.

Oral to IV tacrolimus conversion chart Oral to IV tacrolimus conversion chart (continued)

Total oral dose of tacrolimus in 24 hours

Approximately equivalent IV dose over 24 hours

Volume of tacrolimus injection (5mg in 1ml) to draw up for further dilution

Total oral dose of tacrolimus in 24 hours

Approximately equivalent IV dose over 24 hours

Volume of tacrolimus injection (5mg in 1ml) to draw up for further dilution

0.5mg 100micrograms 0.02ml 5.5mg 1.1mg 0.22ml

1mg 200micrograms 0.04ml 6mg 1.2mg 0.24ml








5mg 1mg 0.2ml 10mg 2mg 0.4ml






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DRUG

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ADMINISTER OVER


COMMENTS

Tazocin® See Pipercillin/Tazobactam



3 – 5 minutes for all doses.

Slowly reconstitute each 200mg or 400mg vial with the 3.2ml of W provided. Roll the vial gently until the powder has completely dissolved. Take care to avoid formation of foam. If it does foam, leave the vial to settle for 15 minutes until the foam subsides. Reconstituted in this manner you will be able to extract 200mg in 3ml from the 200mg vial and 400mg in 3ml from the 400mg vial.

Flush with N/S. Sodium content less than 0.5mmol/vial (200mg and 400mg). Incompatibile with aminoglycosides (eg. gentamicin). Teicoplanin solutions will precipitate when they come into contact with gentamicin – flush the catheter well with N/S between giving these two antibiotics.



30 minutes Reconstitute as above then dilute the required dose further with N/S, G, G/S or H (e.g. 50ml or 100ml).

Teicoplanin Refer to the Plymouth Healthnet Clinical Guidelines/Infection Control for the use and current dosage of gentamicin, teicoplanin and vancomycin.

IM injection of doses up to 400mg possible only when IV access cannot be established and after discussion with Microbiologist








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COMMENTS


3 – 4minutes Reconstitute each 1g with 10ml W and shake vigorously. The final volume is 10.7ml (i.e. displacement volume is 0.7ml)

(I) IV infusion



30-40minutes Reconstitute as above then add the dose to 100ml N/S.

Incompatible with aminoglycosides e.g. gentamicin, tobramycin & amikacin – if administering down the same IV line, flush with N/S between the temocillin and the aminoglycoside.

Temocillin


Reconstitute each 1g with 2ml W and shake vigorously. The final volume is 2.7ml (i.e. displacement volume is 0.7ml).

If pain is experienced at the site of IM injection each 1g can be reconstituted with 2ml of lidocaine 0.5% or 1% injection instead of W.







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IV bolus ♠ Groups 1and 2

About 10 seconds 1) Remove the flip-off cap from the vial. 2) Remove the tip-cap from the syringe. Then immediately screw the pre-filled

syringe onto the vial adapter and penetrate the vial stopper in the middle with the spike of the vial adapter.

3) Add the water for injections into the vial by pushing the syringe plunger down slowly to avoid foaming.

4) Reconstitute by swirling gently. 5) The reconstituted preparation results in a colourless to pale yellow, clear solution.

Only clear solution without particles should be used. 6) Directly before the solution will be administered, invert the vial with the syringe still

attached, so that the syringe is below the vial. 7) Transfer the appropriate volume of reconstituted solution of Metalyse into the

syringe, based on the patient's weight. 8) Disconnect the syringe from the vial adapter. 9) Alternatively the reconstitution can be performed with the included needle.

Do not inject into a line containing glucose. Compatible with N/S

Patient Weight Vial size to pick

Reconstitute with the W provided

Dose Volume to give

<60kg 40mg 8ml 30mg 6ml

>60kg to <70kg 40mg 8ml 35mg 7ml



Tenecteplase

Follow the protocol for the treatment of Acute Myocardial Infarction (See Plymouth Healthnet Clinical Guidelines)

>90kg 50mg 10ml 50mg 10ml






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COMMENTS






Suggestion: 3 – 5 minutes

SC and IM injection are usually preferable to slow IV bolus, but if slow IV bolus is necessary monitor the patient’s pulse.

(C) IV infusion for bronchodilation via a volumetric pump


Adult dosage:

30 – 60ml/hour for 8 – 10 hours

Dilute 3 – 5ml (1.5 – 2.5mg) of terbutaline injection in 500ml G, N/S or G/S.

(C) IV infusion for premature labour via syringe pump.

(Recommended method to avoid fluid overload)


Initially 3ml/hour (5microgram/minute) for 20 minutes. Titrate dosage in increments of 1.5ml/hour (2.5microgram/minute)

Dilute 10ml (5mg) of terbutaline injection to 50ml with G.

(C) IV infusion for premature labour via volumetric pump.


Initially 30ml/hour (5microgram/minute) for 20 minutes. Titrate dosage in increments of 15ml/hour (2.5microgram/minute)

Dilute 10ml (5mg) of terbutaline injection to 500ml with G (remove 10ml G from the bag first).

Titrate the hourly rate with reference to suppression of contractions, increase in pulse rate and changes in blood pressure, which are limiting factors. These parameters should be carefully monitored during treatment. A maternal heart rate of more than 135 beats/min should be avoided. In order to minimise the risk of hypotension associated with tocolytic therapy, special care should be taken to avoid caval compression by keeping the patient in the left or right lateral positions throughout the infusion.

Infusion via a syringe pump is preferable to keep the volume of fluid administered to a minimum and to avoid maternal pulmonary oedema.

The recommended diluent in premature labour is G. If it is necessary to use N/S monitor for maternal pulmonary oedema.

Terbutaline

SC infusion treating brittle asthma


Typical dose range:

5 – 15mg/24 hours

Can be infused undiluted or diluted with N/S to the required volume.

SC infusion of terbutaline is unlicensed – see page 1






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DRUG

METHOD WHO MAY GIVE


COMMENTS

Terlipressin


Suggestion: Each 1mg over 1 minute

For Variquel® brand: Slowly add the entire contents of the solvent ampoule (5ml) to the powder vial and roll the vial gently until the powder is completely dissolved. The powder should dissolve to form a colourless solution within 10 seconds. This may be further diluted to 10 ml with N/S if required. ForGlypressin® brand: Ready diluted (1mg in 8.5ml)

Monitor blood pressure, serum sodium and potassium and fluid balance. Flush with N/S.

Terlipressin to treat septic shock in critical care areas only, when vasopressin is unavailable

(C) infusion in Critical Care areas only via central IV line.

(Preceded by an IV bolus of 0.5mg or 1mg at the discretion of the consultant intensivist)

♠ Groups 1 and 2

1.3micrograms/kg/hour =0.065ml/kg/hour of a 1mg in 50ml G dilution.

(Infusion rate may be titrated to effect at the discretion of the consultant intensivist)

For Variquel® brand:

Reconstitute one 1mg vial as above and dilute the contents further to 50ml with G.

ForGlypressin® brand:

Dilute the contents of a 1mg ampoule further to 50ml with G.

This is an unlicensed regimen (see page 1) to reduce noradrenaline requirements in patients with septic shock based on the following reference: http://www.biomedcentral.com/content/pdf/cc799

0.pdf

N/S is not a suitable diluent for terlipressin infusion.

The suggested expiry for terlipressin in G infusion is 12 hours after preparation.


Suggestion: Give over 30 to 60 seconds

Ready diluted. Flush with N/S. Keep patient under observation for 30 minutes after the injection – hypersensitivity reactions are possible.

The Planned Investigation Unit (PIU) have copies of the “Short Synacthen test” protocol.

Tetracosactide

(Synacthen®)


Inject deep into the deltoid muscle







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DRUG

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COMMENTS

Thiopental

(Thiopentone)

IV bolus ♠ Group 1 Anaesthesia –induction:

100 –150mg over 10-15 seconds Longer in the elderly or debilitated) repeated after 1 minute if necessary.

Control of convulsions:

75 –125mg over 3-5 minutes Lowering raised intracranial pressure:

1.5 –3mg/kg over 3-5 minutes. Repeat as necessary.

Reconstitute 500mg vial with 20ml W to produce a 2.5% (25mg/ml) solution.

Flush with N/S.

Check for haze or precipitation before administering.

Extravasation causes local tissue necrosis and severe pain. This can be relieved by application of an ice pack and local injection of hydrocortisone. The reconstituted solution should be discarded after 7 hours.

(C) infusion via a central IV line Pump is required.

♠ Groups 1 and 2*

For the management of refractory intracranial hypertension or Status Epilepticus, refer to the appropriate critical care protocol.

Reconstitute three 500mg vials, each with 20ml W, making an infusion of 1500mg in 60ml (2.5% solution). In intensive care areas or Theatres only, the 2.5% (25mg/ml) solution may be infused without further dilution through a central line (local practice).

(C) IV infusion is not a licensed method of administration of thiopentone (See page 126) Sodium content: 2.31mmol/500mg Use the prepared solution within 7 hours. For the management of refractory intracranial hypertension or Status Epilepticus, refer to the appropriate critical care protocol. *Group 2 nurses may only administer prescribed additional boluses of thiopental to ventilated patients in level 3 critical care.






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ADMINISTER OVER


COMMENTS

Ticarcillin with clavulanic acid

See Timentin®

Tigecycline

May only be initiated on the advice of a consultant microbiologist

▼▼▼▼ This product is being intensively monitored by the CHM and MHRA. Please report all suspected reactions (including non-serious ones) using a Yellow Card from the BNF.



30 – 60 minutes Reconstitute the powder in the vial with 5.3ml N/S or G to make a 10mg/ml solution. Gently swirl to dissolve the powder. Then withdraw 5ml (50mg) from the vial and add to a 100ml bag of N/S or G. For the 100mg dose reconstitute two vials as above and add 10ml to a 100ml bag of N/S or G.


Tigecycline in N/S is compatible at a Y-Site with dobutamine, dopamine, gentamicin, lidocaine,morphine, potassium chloride, propofol, ranitidine and Hartmann’s

The solution should be inspected for the presence of particulate matter or green or black discolouration before use. Tigecycline should be yellow/orange in colour once reconstituted, if it is not, it should be discarded.






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COMMENTS

Timentin® (I) IV infusion Infusion pump is required.


30-40 minutes Reconstitute the 3.2g vial with 10ml W to form a pale straw-coloured solution. Heat is released when the powder dissolves. Further dilute 3.2g with 100 -150ml G.

Displacement value: 2.2ml for 3.2g of Timentin® so reconstitute 3.2g vial with 7.8ml W to get 3.2g in 10ml.

Incompatible with gentamicin and other aminoglycosides. Each 3.2g of Timentin® contains approximately 15.9mmol of sodium. Do not administer Timentin® by IV bolus or IM injection. Flush with N/S.

Tinzaparin

2,500units

3,500units

4,500units

Pre-filled syringes

Injection into the arterial limb of the dialyser at the start of haemodialysis

♠ Groups 1 and 2

No further dilution required. Follow the PHNT guidelines for the use of tinzaparin (sodium) for preventing clotting in the haemodialysis circuit.

(Firstly, prime the circuit with 1 litre N/S).

Tinzaparin 40,000units in 2ml

Multidose vial

(Non-Formulary)



Tinzaparin must not be administered by intramuscular injection due to the risk of haematoma. Do not administer intravenously.

Discard the vial 14 days after first use. Record the date of first use on the vial.






175

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COMMENTS

Tirofiban Loading dose followed by

(C) IV infusion via Infusion pump


See below for indication-specific infusion rates.

Withdraw 50ml from a 250ml bag of N/S or G and replace with 50ml of Tirofiban solution to make a concentration of 50 micrograms/ml. Mix well before use.

Intravenous infusion of unfractionated heparin (5,000unit IV bolus followed by IV infusion at initial rate of 1,000units per hour: target APTTR approximately 2) should be administered concurrently with Tirofiban and may be infused through the same catheter/Venflon as the Tirofiban.

For patients diagnosed with NSTE-ACS and managed with an invasive strategy undergoing angiography within 4 hours after the diagnosis, tirofiban is given IV initially by 25 microgram/kg bolus dose given over 3 minutes initiated at the start of PCI followed by a continuous infusion of 0.15 microgram/kg/min for 18-24 hours and up to 48 hours.

When administering the bolus dose, always pre-set the infusion pump with the total bolus volume to be administered

For NSTE-ACS patients managed with an early invasive strategy and not planned to undergo angiography for at least 4 hours and up to 48 hours after diagnosis, tirofiban is given IV at an initial infusion rate of 0.4 microgram/kg/min for 30 minutes. At the end of the initial infusion, tirofiban is continued at a maintenance infusion rate of 0.1 microgram/kg/min.

When administering the loading infusion, always pre-set the infusion pump with the total loading infusion volume to be administered.

Patient weight(kg) Bolus (ml) 3 minute bolus infusion rate (ml/hour)

Maintenance infusion rate (ml/hour)

Patient weight(kg) 30 minute loading infusion (ml)

30 minute loading infusion rate (ml/hour)

Maintenance infusion rate (ml/hour)

30 – 37 17 340 6 30 – 37 8 16 4

38 – 45 21 420 7 38 – 45 10 20 5

46 – 54 25 500 9 46 – 54 12 24 6

55 – 62 29 580 11 55 – 62 14 28 7

63 – 70 33 660 12 63 – 70 16 32 8

71 – 79 38 760 14 71 – 79 18 36 9

80 – 87 42 840 15 80 – 87 20 40 10

88 – 95 46 920 16 88 – 95 22 44 11

96 – 104 50 1000 18 96 – 104 24 48 12

105 – 112 54 1080 20 105 – 112 26 52 13

113 – 120 58 1160 21 113 – 120 28 56 14

121 – 128 62 1240 22 121 – 128 30 60 15

129 – 137 67 1340 24 129 – 137 32 64 16

138 – 145 71 1420 25 138 – 145 34 68 17

146 – 153 75 1500 27 146 – 153 36 72 18

In patients with an eGFR<30ml/min reduce the dosage by 50% In patients with an eGFR<30ml/min reduce the dosage by 50%






176

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COMMENTS


3 – 5 minutes

(I) IV infusion for once daily dosing in cystic fibrosis Infusion pump is required.


30 minutes 10mg/kg dose in Cystic Fibrosis diluted to 50ml or 100ml with N/S or G.

Tobramycin



Flush with N/S.

N.B. Current recommended dose of 10mg/kg once daily in Cystic Fibrosis patients exceeds the dose stated in the package insert.

Maximum once daily dose in Cystic Fibrosis is 660mg with trough levels measured before the 2nd and 8th doses (Target trough level <1mg/L. Modify dose interval if trough level >2mg/L.

TPN See Parenteral Nutrition



Slowly over 2 – 3 minutes

Undiluted


12 – 24mg/hour (=30 – 60ml/hour)

Dilute 200mg tramadol in 500ml N/S, G or H

Tramadol



Maximum total IV/IM dose in 24 hours is 600mg

IV infusion is incompatible with diazepam, diclofenac, indometacin, midazolam and piroxicam.

Tranexamic acid IV bolus ♠ Groups 1,2,3,4 and 5

100mg/minute Flush with N/S or G.



25-50mg/kg/24 hours

Can be diluted with any convenient volume of N/S or G (e.g.. 20-50ml for a bolus or more for an infusion) or given undiluted.

Tri-iodothyronine See Liothyronine

Trimethoprim Trimethoprim injection is a discontinued product






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COMMENTS

Triptorelin

(Decapeptyl®)


Draw up the mannitol diluent provided into the syringe provided using one of the injection needles and inject in to the vial containing the powder. Gently swirl the vial until a uniform suspension is formed, then draw the mixture back into the syringe without inverting the vial. The injection needle should then be changed and the second needle used to administer the injection. As the product is a suspension, the injection should be administered immediately after reconstitution to prevent sedimentation.

This is a single-use vial


Tysabri® See natalizumab






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COMMENTS

Lock for unblocking midlines and PICC lines (Adults)

♠ Groups 1and 2

Retain in the line for 1-2 hours

(or longer)

Reconstitute one 10,000unit vial of urokinase with 3ml of N/S. Instil 1.5ml (5,000units) of the reconstituted solution into each lumen of the catheter.

If the lumen is completely blocked do not force urokinase into the lumen.Refer to the full PHNT guidelines:

http://www.plymouthhospitals.nhs.uk/ourservices/clinicaldepartments/Pages/VascularAccessTeam.aspx

Catheter lock for unblocking haemodialysis CVC

(Adults)

♠ Groups 1and 2

• Reconstitute urokinase 25,000unit vial with N/S in a volume equal to the priming volume of both catheter lumen plus an additional 0.2mls (e.g. ‘A’ lumen = 1.7, ‘V’ lumen = 1.9, therefore 1.7 + 1.9 + 0.2 = 3.8 ml of N/S).

• Draw up solution into two syringes: one equal to arterial lumen volume + 0.1ml and one equal to venous lumen + 0.1ml (e.g. ‘A’ lumen syringe = 1.7 + 0.1 = 0.8 ml; ‘V’ lumen syringe = 1.9 + 0.1 = 2ml)

• All staff must be aware that any connection/disconnection to a haemodialysis CVC must be performed using aseptic technique

o Flush each lumen with 10ml of N/S o Inject 12,500unit urokinase into each lumen to the priming volume o Positively lock the lumen and place the red obdurate, then wait for 30 minutes o Aspirate 5mls from each lumen and flush with 10-20ml of N/S if flows have restored

• Commence dialysis treatment

Inter-dialysis infusion via the haemodialysis CVC

(Adults)

♠ Groups 1and 2

The decision to use an inter-dialysis infusion of urokinase must be agreed beforehand with one of the Trust consultant nephrologists each time it is used, and after assessment of any increased bleeding risk.

• Reconstitute two 100,000unit vials of urokinase each with 2ml N/S and add both vials to 100ml N/S (200,000unit urokinase in 100ml N/S).

• Draw up the urokinase solution into two 50ml luer-lock syringes.

• Attach the 50ml syringes to the lumens of the dialysis CVC.

• Using a syringe driver, infuse a 50ml syringe containing the urokinase solution (100,000iu in 50ml N/S) down each lumen over 90 minutes (34ml/hour).

• When the infusion is complete, flush each lumen with 10–20ml N/S to establish blood-flow.

• Commence haemodialysis.

Urokinase

Intraperitoneal catheter lock for unblocking the catheter.

♠ Groups 1and 2

Retain in catheter for 2 hours

Dilute 12,500 international units with 5ml N/S.

Follow the Renal Services Directorate Peritoneal Dialysis Protocols






179

DRUG

METHOD WHO MAY GIVE


COMMENTS

(I) IV infusion preferred method. Infusion pump is required.


Adults: 500mg over 1 hour. Doses over 500mg maximum rate 10mg/minute.

Vancomycin

Refer to the Plymouth Healthnet Clinical Guidelines/Infection Control for the use and current dosage of gentamicin, teicoplanin and vancomycin.



24 hours

Reconstitute 1g vial with 20ml W and 500mg vial with 10ml W. Dilute 500mg with at least 100ml N/S or G. Dilute 750mg with at least 150ml N/S or G. Dilute 1g with at least 200ml N/S or G. Dilute 1.5g with at least 300ml N/S or G. Dilute 2g with at least 400ml N/S or G.

Flush with N/S or G. In practice 1g in 100ml may be used in fluid restricted patients; but the use of such high concentrations may increase the risk of infusion related events when administered via a peripheral vein. Note that the current recommended target trough level is higher than that in the SPC and is therefore unlicensed (See page 4).

Example IV calculations

500mg vancomycin (in 10ml W) added to a 100ml bag N/S = 110ml over 1 hour

750mg vancomycin (in 15ml W) added to a 250ml bag N/S = 265ml over 1½ hours

1g vancomycin (in 20ml W) added to a 250ml bag N/S = 270ml over 2 hours

1.5g vancomycin (in 30ml W) added to a 500ml bag N/S = 530ml over 2½ hours

2g vancomycin (in 40ml W) added to a 500ml bag N/S = 540ml over 3⅓ hours (200 minutes)

Set pump rate at :

110ml/hour

177ml/hour

135ml/hour

212ml/hour

162ml/hour

Intrathecal Injection

♠ Group 1 Refer to the Neurosurgical Antibiotic Therapy Guidelines for Adults on Plymouth Healthnet (Under Clinical Guidelines)


Follow the Renal Services Directorate Peritoneal Dialysis Peritonitis Protocol






180

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COMMENTS

Vasopressin =Argipressin

For use in Critical Care to reduce noradrenaline requirements in patients with refractory septic shock.

Regent and Sandoz brands must be kept at room temperature

Pitressin ® - keep in the fridge


Administer via a central IV line.

♠ Groups 1 and 2

Dosage for use in critical care for refractory septic shock: 0.6–2.4 units/hour

(= 1.5 -6ml/hour using 20 units/50ml dilution)

Dilute 20 units to 50ml with G.

Flush with G.

Note that Regent and Sandoz brand vials are only labelled for IM and SC use. However, they are also suitable for IV use. Regent and Sandoz brands are unlicensed in the UK (see page 1).

Note that Sandoz brand vials are multidose 40units in 2ml. Part-used vials should be stored at room temperature and discarded 28 days after initial use.

(Unlicensed indication- see page 1).






181

DRUG


COMMENTS

IV bolus ♠ Group 1– must only be given by doctors proficient in advanced airway management. Also see Comments.

See Data Sheet Vecuronium


♠ Groups 1 and 2 Bolus of 40-100 micrograms/kg followed by 48 - 84 micrograms/kg/hour.

The 10mg vial can be reconstituted with 5ml W to produce 2mg/ml solution. Alternatively reconstitute the 10mg vial with 10ml W, G, N/S or H to produce a 1mg/ml solution. The reconstituted solution can be given undiluted or diluted further with N/S or G to a maximum dilution of 4mg/100ml.


The reconstituted solution can be injected or infused in to the line of a running infusion of Hartmann’s. If the patient is ventilated IV bolus can be administered by Group 2 staff.

Using a 2mg/ml dilution e.g. 100mg in 50ml 48 – 84micrograms/kg/hour = 0.024 – 0.042ml/kg/hour

Using a 1mg/ml dilution e.g. 100mg in 100ml 48 – 84micrograms/kg/hour = 0.048 – 0.084ml/kg/hour






182

DRUG

METHOD WHO MAY GIVE


COMMENTS

Verapamil IV bolus Emergency use.


2 minutes (elderly patients minimum 3 minutes)

Ready diluted. ECG and blood pressure monitoring necessary. Flush with N/S. Sodium content 0.15mmol/ml.

Vigam® See Immunoglobulin Human Normal

Vitamins B and C High Potency IV injection

See Pabrinex

Vitamin K See phytomenadione

Voriconazole (I) IV infusion. Infusion pump is required.


Over 1-2 hours. Maximum rate 3mg/kg/hour.

Add 19ml W to each 200mg vial. Resulting concentration is 200mg in 20ml (Displacement 1ml/200mg vial). Dilute the required dose with N/S, G, H or 0.45% saline to a final concentration of 0.5 to 5mg/ml.

Do not infuse concomitantly with other drug solutions through the same lumen/Venflon.

Xiapex® See Collagenase Clostridium histolyticum

X-ray Contrast Medium,

Non-ionic,

tri-iodinated

IV bolus ♠ Groups

1 and 6

According to X-ray Department protocol.

Do not dilute. Monitor for possible anaphylaxis or other allergic reactions. Resuscitation equipment should be immediately available.

X-ray Contrast Medium,

Gadolinium based.

IV bolus ♠ Groups

1and 6

According to X-ray Department protocol

Do not dilute Monitor for possible anaphylaxis or other allergic reactions. Resuscitation equipment should be immediately available.






183

DRUG

METHOD WHO MAY GIVE


COMMENTS

Zidovudine (I) IV infusion ♠ groups 1,2,3,4 and 5

1 hour Dilute the prescribed dose to 2mg/ml or 4mg/ml with G – see comments for examples.

Example: For a 63mg dose you would draw up 6.3ml of zidovudine injection(10mg/ml) and dilute to 31.5ml with G in a 50ml syringe to make a final concentration of 2mg/ml, and set the pump rate at 31.5ml/hour.

Example for doses > 100mg:

For a 130mg dose, you would draw up 13ml zidovudine injection(10mg/ml) and dilute to 32.5ml with G in a 50ml syringe to make a final concentration of 4mg/ml, and set the pump rate at 32.5ml/hour.

Do not give by IM injection.

Zoledronic acid

(Aclasta® 5mg in 100ml bags)

(I) IV infusion ♠ groups 1,2,3,4 and 5

Infuse all doses over at least 15 minutes.

Set the pump rate at a maximum of 400ml/hour

Ready diluted. Do not mix with magnesium or calcium containing solutions such as Hartmann’s.

(I) IV infusion ♠ groups 1,2,3,4 and 5

Infuse all doses over at least 15 minutes.

When diluted with 100ml N/S set the pump rate at a maximum of 400ml/hour

Draw up the prescribed dose (dependent on renal function – see below) and add to 100ml N/S or G.

Do not mix with magnesium or calcium containing solutions such as Hartmann’s.

For the treatment of tumour-induced hypercalcaemia ensure the patient is well hydrated before and after administration of zoledronic acid.

Dosing according to renal function

GFR > 60 4mg dose Draw up 5ml from the vial

GFR 50 – 60 3.5mg dose Draw up 4.4ml from the vial

GFR 40 – 49 3.3mg dose Draw up 4.1ml from the vial

Zoledronic acid

(Zometa® 4mg in 5ml vials)

GFR 30 -39 3mg dose Draw up 3.8ml from the vial

184

Alteplase 100mg in 100ml Water C

Acetylcysteine in 5% glucose

Aciclovir up to 5mg/ml in 5% glucose I

Adrenaline 1:10,000 undiluted (Central IV)

Aminophylline up to 25mg/ml in saline I or (empty box) = no data available therefore this combination cannot be recommended

Amiodarone in 5% glucose (Central IV) C I

Argatroban 1mg/ml in 0.9% saline I

Atracurium 10mg/ml (Undiluted) C I C

Ceftriaxone 2g in 40ml 0.9% saline C I

Clindamycin up to 18mg/ml in 5% glucose C I C I

Co-trimoxazole (Septrin) 480mg/75ml 5% glucose C C

Digoxin in 100ml 0.9% saline I

Dobutamine 250mg in 50ml 5% glucose I I C I C C C I

Dopamine 200mg in 50ml 5% glucose (Central IV) I I C C C C C

Dopexamine 50mg in 50ml 5% glucose I C C C

Doxapram 2mg/ml in 5% glucose I I I I C

Erythromycin 125mg in 25ml 0.9% saline C C C

Esmolol 10mg/ml in 5% glucose C C C C C C C C

Esomeprazole 40mg in 100ml 0.9% saline

Fentanyl 50micrograms/ml (Undiluted) C C C C C C C C

Fluconazole 2mg/ml (in 0.9% saline) C C C I I I I C C

Furosemide 10mg/ml (undiluted) or 1mg/ml in 0.9% saline I C I C I C I I I I I C I

Gentamicin up to 5mg/kg dose in 100ml saline C C C I C I I C I C C I

Glucose 10% C C C C C C C C C I I C

Glyceryl trinitrate 50mg in 50ml 5% glucose I I I C C C C C C C C I C I

Hartmann's C C C C I I C C C C C I C C C C

Heparin sodium 1,000 units/ml I C C C I I C C I I I I C C C I I C I

Insulin soluble 50 units in 50ml 0.9% saline I I I I C C C C C C

Isoprenaline sulphate 2.25mg in 50ml or 500ml 5% glucose I C C C I C C

Isosorbide dinitrate 25mg in 50ml 5% glucose I I I I I I I

Ketamine 10mg/ml or 50mg/ml in 0.9% saline I C

Labetalol 1mg/ml in 5% glucose or 5mg/ml undiluted C C I C C C C C C I C C I I

Levofloxacin 500mg in 100ml 0.9% saline (Ready diluted) I C C C C C C I C I I I C

Lidocaine 2mg/ml in 5% glucose C C C C C I C C C C C I C C C C C C C

Linezolid 600mg in 300ml 5% glucose (Ready diluted) C C I C I C C C I C C C C C C C C C C

Magnesium sulphate 5g in 100ml 0.9% saline C I I I C C C C C C C

Mannitol 10% C I C

Metaraminol in 0.9% saline C I C I

Methyl prednisolone in 0.9% saline C I I C I I C C I C I

Metronidazole 500mg in 100ml 0.9% saline C C C I C C C C I C C C C C

Midazolam 1mg/ml or 2mg/ml in 0.9% saline C I C C C I C I C C C C C I C C I C C I C C C

Milrinone 10mg in 50ml 5% glucose C C C C C C C C C C C I C C C C C C C C C C C

Morphine sulphate 50mg in 50ml (0.9% saline) I C I C C C C C C C C C C C C I C C C C I C C C C C C C C C C

Noradrenaline up to 16mg in 50ml 5% glucose C I C C C C C I C I C I C I C

Pabrinex up to 3 pairs of ampoules in 50 or 100ml 5% glucose I C

Phenytoin up to 10mg/ml in 0.9% saline using in-line filter I I I C I I I I I I I I I I

Potassium chloride 2mmol/ml undiluted (Central IV) C C C C C C C I C C C C C C C C C C C C C C I C I C C C I

Potassium phosphate 30mmol in 50ml (Central IV) I I C C I C I I

Propofol 10ml/ml undiluted C C I C I C C C C C C I C C C C C I C C I C C C I C C C C I

Remifentanil upto 250micrograms/ml in 5% glucose C C C C C C C C C C C C I C C C C C C C C C C C C C C C

Sodium bicarbonate 1.26% C I C I C I I I I I C I I C C I I I C I C I C I I C C C

Sodium bicarbonate 8.4% (Central IV) I I C I I I I I C I I C I I I C I I C I I C C

Sodium nitroprusside up to 1mg/ml in 5% glucose I C I I I C C I C C C C C C I C I C C C

Sodium phosphate 30mmol in 50ml undiluted (Central IV) I I

Thiopentone 25mg/ml in water I I I I I I I I I C I C I C I I I I I I I C I I C C I I

Tirofiban 50micrograms/ml in 5% glucose C C C C C C C C C C C

Vancomycin up to 5mg/ml in 5% glucose I C C I C C C C C I C C C C C C C C I C C

Vasopressin 20 units in 50ml 5% glucose C C I C C C C C I C

Vecuronium 2mg/ml in water C C C C C C C C C C I C C C C C I C C C C C C C C I C

Ve

cu

ron

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2m

g/m

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Th

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Tir

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Fe

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50

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up

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16

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Do not infuse the following drugs together

with any other drug solutions down the same

central line lumen or venflon:

Enoximone, Ambisome

Epoprostenol (Flolan)

Important warnings: The table below shows Y-site physical or visual (not chemical) compatibilities between drugs tested at specific concentrations

in specific diluents. The concentrations tested are often different to those used in practice on the ward which are shown in the table below.

This table gives information for two-drug combinations only. The information cannot be extrapolated to three-drug combinations. While the

indications of compatibility in the table are consistent with the best currently available advice, there is no absolute guarantee of compatibility

where the concentrations in the literature differ significantly from those shown below. Pay careful attention to the diluent(s) quoted for particular

drugs in the table below.

Ins

uli

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50

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50

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% g

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Mid

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0.9

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o 5

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line

Compatibilities of Injectable DrugsUpdated by Derriford Pharmacy December 2012

= Compatible but read the warnings above

= Incompatible

Flumazenil

Rifampicin, salbutamol

Sodium valproate

Po

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185

Derriford Hospital Analgesic Ladder for non-malignant acute pain

If pain unresolved:Identify type of pain and consider adjuvant medicationAlternative or parenteralopioidContact Team for reviewACT Nurse Specialist 0195

Opioid equivalence:10mg oral morphine•5 mg Morphine SC/IM•3mg Morphine iv•5mg oral Oxycodone•50mg oral Tramadol•120mg oral Codeine•200mcg sublingual BuprenorphineNB: Fentanyl patches are not to be used for

acute pain (consultant prescribing only)

�This guideline is to be used in conjunction with the BNF and PHNT joint formulary.�Ensure a full pain history is taken from all patients and regular analgesics are prescribed.�Be aware of the dose equivalence of opioids prescribed – particular care is needed with opioid patches.�Consider subcutaneous route rather than repeated im injections.�Be aware of the influence of renal impairment, age and opioid tolerance on opioid prescribing. Refer to opioid prescribing guidelines if unsure.

Pain is the “Fifth Vital Sign” and must be assessed and recorded alongside other vital signsAll staff involved in the prescribing, dispensing and administration of controlled drugs must be familiar with the characteristics of the drug

Mild painRegular Paracetamol 1g qds

(maximum paracetamoldosage 60mg/kg/day if weight

< 50kg.See drug chart for further advice)

eGFR ≥≥≥≥ 30ml/min

Consider PRN NSAID unless contraindicated (see drug chart

for further advice). Caution if eGFR < 60ml/min

Avoid non-steroidal drugs.

eGFR < 30ml/min

Moderate painRegular Paracetamol 1g qds

(maximum paracetamoldosage 60mg/kg/day if weight

< 50kg. See drug chart forfurther advice)

PlusRegular NSAID

unless contraindicated e.g. eGFR < 30ml/min

Caution if eGFR <60ml/minPlus

PRN intermediate opioid(eg:Codeine 30-60mg qds, Tramadol 50-100mg qds)

eGFR < 30ml/min

Avoid non-steroidal drugs.Caution with tramadol and

codeine – observe for opioid toxicity

Severe pain

Surgical PatientsPRN Oramorph 20-30mg

2 hourly

(adjust by age - see notes)

Medical PatientsRegular Oramorph 5mg 4

hourlyIncrease to 10mg 4 hourly if

necessary>75 years old reduce to 2.5mg

4 hourly Plus PRN Oramorph of the

same dose 4 hourly

eGFR ≥≥≥≥ 30ml/min

As for moderate painPlus

eGFR < 30ml/min

Surgical Patients:PRN Oramorph 20-30mg

2 hourly (adjust by age - see

notes)

Surgical PatientsPRN Oxynorm 10-15mg

2 hourly –observe for opioid toxicity

(adjust by age - see notes)

Medical PatientsRegular Oxynorm 2.5mg 4 hourly – observe for opioid

toxicity

Notes

Oxynorm dose PRN 2hrlyAge (years) Dose(mg)18-59 10-15mg60-69 5-10mg70-89 2.5-5mg>89 2.5mg

Surgical PatientsOramorph dose PRN 2hrlyAge (years) Dose(mg)18-59 20-30mg60-69 10-20mg70-89 5-10mg>89 2.5-5mg

187

Emergency Department Adult Intravenous Morphine Guideline

• This guideline is to be used in conjunction with BNF & PHNT joint formulary & Trust acute pain analgesic ladder.

• No intravenous morphine to be given in minors.

• Always take into account age, weight and co-morbidities – use with extreme caution in renal impairment. Give 1/2 or 1/3 of below doses in elderly and frail.

• Consider non-pharmacological methods of analgesia – eg splintage, LA blocks.

• Actively seek out times and doses of prior (including pre-hospital) analgesia.

• Patients with high pain scores should be asked if they require further pain relief. Only prescribe if the patient says they do.

• Seek senior advice for non-responsive pain.

Severe Pain = 8-10 Moderate Pain = 4-7

Mild Pain = 1-3 No Pain = 0

Author: Dr Mark Rockett 2012

Assess with pain score & consider IV morphine for moderate or severe pain.

Prescribe multi-modal analgesia (paracetamol +/-NSAIDs) to be given simultaneously.

Reassess at 20 minutes with observations including RR, conscious level & pain score

Prescribe IV morphine on STAT section of the drug chart 0.1mg/kg titrated to effect over 2-3 minutes but see above

Repeat up to above dose as required but no sooner than 20 mins If a second dose is given in ED apply monitoring – minimum of pulse oximetry

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1.2 Management of Anaphylaxis

For more information please contact the Resuscitation Department on 52851

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References

• The Electronic Medicines Compendium 2012 published by Datapharm Communications Ltd

(http://www.medicines.org.uk/emc/)

• The Injectable Medicines Guide produced by the network of UK hospital pharmacists, published by the Pharmacy Dept. Charing Cross Hospital, London, and endorsed by the UK

Medicines Information service (http://medusa.wales.nhs.uk/)

• The British National Formulary No.64 (September 2012) (http://bnf.org/bnf/bnf/current/)

• The British National Formulary for Children (2012-2013) (http://bnfc.org/bnfc/bnfc/current/

• UK Resuscitation Council Anaphylaxis Algorithm (http://www.resus.org.uk/pages/anaalgo.pdf)

190

Appendix 1

Choice of Infusion device

1.1 Introduction

All individuals that operate infusion devices within the remit of their role have a responsibility to ensure that they are competent to operate the equipment in a safe and effective manner, seek advice and training where necessary and complete relevant documentation with their assessor in line with the Trusts Policy and Procedure document for the ‘Training of Plymouth Hospitals NHS Staff in the Use of Medical Devices.’

It is the responsibility of the person administering the drug to select the appropriate infusion pump for the therapy required. Alterations to the pump setting may only be made and recorded by a person entitled to administer intravenous drugs. The volume of fluid administered must be recorded on the fluid chart. All pumps must be checked 2 hourly throughout the infusion and details of the infusion should be recorded on the relevant infusion chart. Infusion Devices must always be operated and serviced in accordance with the Manufacturers operating instructions and the MEMS Medical Equipment Users’ Guide. Every area should maintain a library of user manuals for commonly used equipment, which may be kept in the Ward Equipment File. Manuals for commonly used infusion devices can be found on the Medical Devices Training webpage on TrustNet. The MEMS Medical Equipment Users Guide is available on the Trust documents drive.

1.2 Choice of Infusion device

The choice of infusion device should be based upon the clinical application it is intended for, and the safety features incorporated within the device. Infusion devices may be grouped into the following categories: a. Volumetric pumps

• Pump of choice for medium and high flow rates, and large volume infusions.

• Pressure sensitivity of pump: Some pumps have selectable occlusion pressure alarm levels. Selecting low levels will help to prevent excessive delivery pressures and possible vein damage.

• Some may allow for the addition of piggyback or secondary infusions.

• The majority of volumetric pumps will perform satisfactorily at rates down to 5 ml/hr. Although the controls can set rates below 1ml/hr, these pumps are not considered appropriate for delivering drugs at such low rates.

• Once the infusion has been connected to the patient, the vertical position of the device should be altered as little as possible as an increase in height of the device above the infusion site may result in a bolus of infusate being delivered to the patient.

• Blood transfusions may be given through a Baxter Colleague Volumetric Pump safely if given with correct blood giving set.

• Most volumetric pumps also incorporate the following safety features: o Automatic alarm and stopping of infusion following detection of air in line,

upstream/downstream occlusion, and reservoir/bag empty alert. o Facility to pre-set volume to be infused (VTBI) and digital read out of total volume

infused. o Automatic switch to ‘keep vein open’ (KVO) rate towards end of infusion. o Automatic battery operations in the case of mains supply failure.

• PHNT has standardised on the Baxter Colleague pump as the volumetric pump of choice, although others may still be in service in some areas.

191

b. Syringe pumps

• The preferred choice for lower volumes and low rate infusions.

• Capable of delivering very low flow rates of < 1ml/hr.

• Operated by driving a syringe plunger forward at a controlled rate to deliver the infusate to the patient.

• The syringe is located and clamped within the device, with the plunger attached to a moving carriage.

• Users should be aware that the flow delivered at the start of an infusion might be considerably less than the rate set on the device. At low flow rates, the mechanical slack must be taken up before the set rate is achieved. Mechanical slack can be eliminated by operating the syringe pump to purge the line prior to connection to the patient.

• Some pumps have a selectable occlusion pressure alarm levels. Selecting low levels will help to prevent excessive delivery pressures and possible vein damage.

• Additional features may include: o In line pressure monitoring o Syringe barrel clamp alarm o Syringe plunger disengagement alarm o ‘Volume to be infused’ (VTBI) display o ‘Volume infused’ (VI) display o Automatic ‘keep vein open’ (KVO) rate facility o Patient history log o Drug name library

PHNT has standardised in the Alaris GH syringe pump of choice. Other syringe pumps may still be available in some areas.

c. Patient Controlled Analgesia pumps (IVPCA)

• Used specifically for the patient to administer a prescribed intravenous dose of opioid as required, by activating a demand button, which has a pre-set lockout interval.

• PCA pumps (the Alaris IVAC PCAM) contains a memory log, to enable the clinician to determine how frequently the patient has made a demand, and the total volume of drug infused over a given time.

• Monitoring of patients with PCA devices may only be performed by those individuals who have received formalised training from the Department of Pain Management or those that have already been deemed competent in the use of PCA.

d. Ketamine Infusions

• Ketamine is an anaesthetic agent with analgesic properties. A low dose Ketamine infusion can provide safe and effective analgesia. It is usually used with IVPCA to improve pain relief and reduce opioid side effects.

• The Graseby 3300 pump must always be used for these infusions. This is a locked pump. The responsibility of Ketamine infusions falls to the Acute Care Team / Anaesthetic team. Ward areas should not be the key holder unless under specific instructions of the Pain Team. In an emergency situation ward nurses should be aware of how to stop the infusion pump.

Specific guidelines / protocols are in place within the Trust on all Advanced Pain Management Systems and must be followed. Please refer to the Acute Pain Resource Manuals or on the Hospital Healthnet

192

e. Ambulatory pumps

• Allows for the mobility of the patient due to the small nature of the device.

• Preferred pump of choice for treatment in palliative care.

• Ambulatory pumps may be powered by electricity or by other means.

• The previously used Graseby MS26 has now been replaced, in this Trust, with the Mckinley T34 ambulatory syringe pump. The T34 is calibrated in ml/hr in common with other types of infusion device.

• The ‘Syringe Driver Infusion Chart’ should be used in conjunction with every infusion given via an ambulatory syringe driver device.

f. Gravity feed

• Gravity feed involves the control of infusion rate by means of the height of the infusion reservoir being sufficiently greater than the infusion site to allow a slow flow of the infusate. Control is further refined by use of a clamp on the infusion line.

• Generally suited to the delivery of fluids containing no added drugs or drugs with no potential for vaso-irritation or damage. This is due to the poor reliability of flow rate and pressure sensing in the delivery system.

• Provides a cheap and readily available delivery system.

1.3 Additional Information

• Only luer-lock syringes should be used within syringe pumps/drivers, PCA pumps. This is a standard instruction issued by all infusion device manufacturers, as there is a risk of the pressure generated in the infusion line causing the line to come apart from the syringe. Plymouth Hospital NHS Trust currently uses BD Plastipak syringes for this purpose.

• Anti-syphon lines must be used on all syringe pump infusions in all areas.

• Gravity lines may be used for administration of electrolytes and most antibiotics. If considered necessary however, an infusion device may be used.

1.4 References

Medical Devices Agency (2000) Equipped to Care CQC Essential Standards of Quality & Safety Medicines and Healthcare products Regulatory Agency (2008) Devices in Practice

193

Appendix 2

Copy of the PHNT Policy for maintenance of patency, flushing and locking of intravascular lines catheters or devices

2.1 Introduction

This appendix contains tables of instructions which have been copied from the PHNT Medicines Management Policy. The full ratified copy of this policy can be found on Plymouth Healthnet using the link: http://nww.picts.nhs.uk/PHNetLive/Portals/57ad7180-c5e7-49f5-b282-c6475cdb7ee7/prowsea_TRW.MMA.POL.265.6%20Medicines%20Management%20Policy.pdf These tables were produced following review of current local practice and extensive local consultation, and in response to the National Patient Safety Agency Rapid Response Alert No.2 (2008) “Risks with Intravenous Heparin Flush Solutions”.

2.2 Policy

• All flushes (Bolus and infusions) and line/catheter locks must be prescribed.

• Administration of all flushes and line/catheter locks must be recorded on the prescription chart.

• Always attempt to aspirate the heparin lock before use of the line. If unable to aspirate the heparin from the line, discuss with the duty consultant whether the heparin may be flushed into the patient.

• Heparin must not be used in a patient with recognised or suspected HIT, or at risk of HIT (Heparin-induced thrombocytopenia) without discussion with a Consultant Haematologist.

Type of intravascular line, catheter or device

Maintenance of Patency, Flushing and Locking

Short-term Peripheral Venous Catheters (Adults and children) � Cannula, venflon

Flush with 5 -10ml 0.9% sodium chloride

Arterial Lines (Adults and children)

Maintain patency with an infusion of 0.9% sodium chloride.

Central Venous Lines (Inpatient Adults)

� Tunnelled lines eg. Hickman or Broviac lines

� PICCs and Midlines

� Short-term CVCs

� Long Lines

Flush with 0.9% sodium chloride (at least 10ml for adult patients) and lock with 0.9% sodium chloride (volume stated on the line) using a positive pressure clamp technique.

Short-term Central Venous Catheters (Children)

All lines without a continuous infusion running should be flushed with 0.9% sodium chloride 6-hourly. To avoid blood flashing back into the lumen, “positive pressure” is applied at the end of the flush.

Above table continued on the next page

194

Table continued from the previous page

Type of intravascular line, catheter or device

Maintenance of Patency, Flushing and Locking

Long-term Central Venous Lines (Children)

• Hickman, Cook & Broviac Lines: Flush with 0.9% sodium chloride and lock with 3ml of 10 units/ml heparin.

• Groshong Lines: Flush with 0.9% sodium chloride and lock with 5ml sodium chloride 0.9%.

Long Lines (Children) Use 10 units/ml heparin to flush and lock Long Lines in children

Long Lines (Neonates) Maintain patency with an infusion of 0.9% sodium chloride. In the case of an extremely premature infant maintain patency with an infusion of 0.45% sodium chloride.

Umbilical Arterial Catheters (Neonates)

Maintain patency with an infusion of 1unit/ml heparin, prepared by diluting 10 units/ml heparin, according to the Neonatal ICU protocol.

Vascaths (In General and Cardiothoracic Intensive Care)

Lock the catheter with 1,000 units/ml heparin (volume as stated on the catheter lumen). Before use, aspirate the heparin from the catheter and flush with 10ml of 0.9% sodium chloride. If unable to aspirate the heparin, discuss with the duty consultant whether the heparin may be flushed into the patient.

Renal-type large bore lines (On Adult Renal and Haemodialysis Units, and in Adult Haematology patients) � Dialysis lines � Vascaths

Flush the line with at least 10ml 0.9% sodium chloride then lock the line/catheter with trisodium citrate 46.7% solution (If no allergy). The locking volume will be stated on the catheter. Before use, aspirate the trisodium citrate 46.7% solution from the line/catheter. If this is not possible, the trisodium citrate 46.7% solution may be slowly flushed into the patient. Then flush with at least 10ml 0.9% sodium chloride.

Ports (Adults and children) � Totally implantable venous

access devices eg. Portacaths

When in use with the needle in, flush with at least 10ml 0.9% sodium chloride. Lock the device with the appropriate volume of 10 units/ml heparin. Before the needle is removed, flush with at least 10ml 0.9% sodium chloride then lock the device with the appropriate volume of 100 unit/ml heparin.

Central Lumen of Intra-aortic Balloon Pump Catheter

Use Heparin Sodium 2000 units/L in 0.9% Sodium Chloride IV Infusion, 500mL bags, REF Baxter B0953, as a continuous flush of the central lumen of the Intra-Aortic Balloon Catheter, as per protocol.

Central Venous Lines (Outpatient or Day Case Adults)

� Tunnelled lines eg. Hickman or Broviac lines

Flush the line with at least 10ml 0.9% sodium chloride then lock the line/catheter with trisodium citrate 46.7% solution (If no allergy). The locking volume will be stated on the catheter. Before use, aspirate the trisodium citrate 46.7% solution from the line/catheter. If this is not possible, the trisodium citrate 46.7% solution may be slowly flushed into the patient. Then flush with at least 10ml 0.9% sodium chloride.

Line lock in patients receiving TPN who have had a previous line infection

Lock the line with the appropriate volume of Taurolock® (This contains taurolidine and sodium citrate).

195

Appendix 3

Document accountability, responsibility and dissemination

3.1 Accountability

Production Peter Gray, Pharmacist

Review and approval Medicines Governance Committee

Dissemination Peter Gray, Pharmacist

3.2 Overall responsibility for this document

The Director of Pharmacy has overall responsibility for the safe preparation and administration of medicines in this Trust, and therefore has overall responsibility for this document.

3.3 Dissemination and Implementation

• Following approval and ratification by the Medicines Governance Committee this eighth edition of the injectable drug monographs with appendices will be rolled out across the Trust.

• Publication of the eighth issue will be publicised in Vital signs and in the weekly staff news brief. The new edition will be held in the Pharmacy Dept. Section of Plymouth Healthnet and will be accessible using the link:

http://nww.picts.nhs.uk/PHNetLive/DesktopDefault.aspx?tabid=1715

• Paper copies will be printed by the hospital Print Room, and together with electronic copies for selected recipients, will be distributed according to a distribution list held in Pharmacy.

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