Injectable Drugs Monographs v2

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This procedure is adopted for PCH staff from:

Notice to staff using a paper copy of this guidance The policies and procedures page of Intranet holds the most recent version of this guidance. Staff must ensure they are using the most recent guidance. Author: Advanced Specialist Clinical Pharmacist Adults and Older People Asset Number: 385

Plymouth Community Healthcare CIC

Procedures for Administering Injectable

Drugs Version No 2

of 201

Procedures for Administering Injectable Drugs

Date Version December 2013 Issue 9

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 PHNT StaffNet 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 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),

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Version History Issue 6 November 2010 Issue 7 December 2011 Issue 8 December 2012 Issue 9 December 2013

Appendix 1: protocol added for non-medical staff to assess a patient and administer IM adrenaline without a prescription to an adult or child with anaphylaxisis.

Alteplase monograph(for acute myocardial infarction):Concurrent use of IV heparin clarified. Enoxaparin no longer needs monitoring of platelet count at Day 4-7 & Day 10-14. Botulinum toxin: vial sharing in clinincs/day-case has been risk-assessed and sanctioned by

the Medicines Governance Committee. Stipulations in the monograph must be followed. Ergocalciferol Injection: New monograph providing advice on using green B.Braun syringe. DigiFab replaces Digibind which is now discontinued. Do not give DigiFab via a filter. Ferinject: Added to the Formulary. New monograph inserted. Filgrastim (Zarzio): Added to the Formulary. New monograph inserted. Folinic acid monograph re-inserted. Instructions for preparing and giving 3g IV ceftazidime and 1g vials of Fosfocina

(Fosfomycin) added to the respective monographs. Glucose 10% with Actrapid to treat hyperkalaemia: Need to use 29 gauge Magellan 12.7mm

Insulin Safety Syringe to penetrate the rubber port on the bag of glucose. Insuman and Apidra insulin monographs inserted. Intravenous Iron preparations: All monographs amended to include instruction to observe

closely for signs of hypersensitivity during and for at least 30 minutes after each injection or infusion.

Venofer (Iron Sorbitol): Test dose no longer recommended. Ketamine for post-op analgesia: Rate reduced to 1-2ml/hour (100-200mcg/kg/hr). Metoclopramide IV bolus is now recommended over at least 3 minutes. Ondansetron: Due to the risk of QT-interval lengthening and subsequent Torsade-de-

Pointes, 8mg dose must be infused over 15 minutes in patients aged 65 and older, and 16 mg dose (by infusion only) is only allowed for patients younger than 75.

Piperacillin/Tazobactam: Slow IV bolus is no longer recommended or licensed. Infuse this over 30 minutes to achieve optimal MICs.

Epoprostenol: Monograph now makes reference to the ICU protocol. Additional route (subcutaneous injection) added for alemtuzumab post kidney

transplantation. CSM Black Triangle status has been removed from a number of injectable medications.

Last Approval Due for Review December 2013 December 2014

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

An electronic version of this document is available on PHNT StaffNet > Departments > Clinical support Services > Pharmacy > Injectable Medicines > Procedures for Administration of Injectable Drugs Alternatively copy the link into your internet browser: http://StaffNet.plymouth.nhs.uk/Portals/1/Documents/Department%20Documents/Surgery/Critical%20Care/Monographs%20for%20IV%20Drug%20Administration%20Version%208%202012%20June%202013.pdf

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Contents

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.

Section Page1.1 Injectable Drug Monographs 7 Chart of Injectable Drug Compatibilities 184 PHNT Analgesic ladder 185 PHNT Protocol for administering IV morphine to adults in Acute Care Areas 186 PHNT Protocol for administering IV morphine to adults in the Emergency Dept. 187 1.2 Management of Anaphylaxis 188 Appendix 1 Protocol for administering intramuscular adrenaline 1:1000 (1mg/ml) for treating

anaphylaxis, when there is no prescription available

A1.1 Legislation 189 A1.2 Persons who can be treated under this protocol 189 A1.3 Anaphylaxis 190 A1.4 Assessing the patient 190 A1.5 Explanation of treatment to the patient 191 A1.6 Patient consent 191 A1.7 Exclusions from treatment under this protocol 191 A1.8 Contra-indications to administration of adrenaline to treat anaphylaxis 191 A1.9 Immediate treatment 191 A1.10 Source of adrenaline 191 A1.11 Dosage of adrenaline 192 A1.12 Adverse Effects 192 A1.13 Follow up 192 A1.14 Documentation 192 A1.15 References 192 A1.16 Anaphylaxis algorithm 193 Appendix 2 Choice of Infusion device A2.1 Introduction 194 A2.2 Choice of Infusion device 194 A2.3 Additional Information 196 A2.4 References 196 Appendix 3 Copy of PHNT Policy for maintenance of patency, flushing and locking of

intravascular lines catheters or devices

A3.1 Introduction 197 A3.2 Policy 197 Appendix 4 Document accountability, responsibility and dissemination A4.1 Accountability 199 A4.2 Overall Responsibility for These Policies and Guidelines 199 A4.3 Dissemination and Implementation 199

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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.

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

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o Registered Nurses, Midwives and Operating Department Practitioners (ODPs) 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 departments 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 departments 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.

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%

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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 (Hartmanns) 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 9, December 2013

9

DRUG

METHOD WHO MAY GIVE

ADMINISTER OVER INSTRUCTION FOR DILUTION AND SUITABLE DILUENT

COMMENTS

Abatacept (Orencia)

(I) IV infusion via a pump. Infuse via a non-pyrogenic low protein binding filter (0.2-1.2 microns)

Groups 1 and 2

Infuse all doses over 30 minutes

Reconstitute each 250mg vial with 10ml W using the silicone-free syringe provided. Direct the stream of W down the inside wall of the glass vial. Minimise foam formation by rotating the vial slowly with gentle swirling to dissolve the powder. Do not shake. After dissolution, vent the vial with a needle to dissipate any foam that may be present. Remove a volume of N/S from a 100ml bag N/S equal to the volume of reconstituted vials. Slowly add the reconstituted solution from each vial to the infusion bag using the same silcone-free syringe. Gently mix.

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. 0.375mmol sodium per 250mg vial 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.

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. (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.

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.





10

DRUG

METHOD WHO MAY GIVE


COMMENTS

Acetylcysteine (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





11

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.





12

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 InfusionInfusion 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 Patients weight1

(kg) Dose of

acetylcysteine to prescribe

Total infusion volume

(ml)

Infusion rate (ml/hour)

Dose of acetylcysteine to prescribe


(ml)


Dose of acetylcysteine to prescribe


(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 34 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.





13

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.

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. Aciclovir (Powder for

reconstitution)



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.

Actrapid See Insulin Section page Adenosine

IV bolus Group 1 2 seconds Can be diluted with N/S if necessary. 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.

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

Group 1 and Group 7

6 minutes Administer in accordance with the Nuclear Medicine Department protocol.





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DRUG

METHOD WHO MAY GIVE


COMMENTS

Adrenaline (Epinephrine)

(I) IV infusion Infusion pump is required. .

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.

Refer to the algorithm for the management of suspected life-threatening anaphylaxis on page 193. IM is the usual route. If a patient is suffering an anaphylactic reaction, there is no prescription for adrenaline and there is no doctor immediately available to prescribe adrenaline, IM adrenaline can be given by a non-medical member of staff who has the skills to assess a patient and give IM injections. They should do this in accordance with the protocol in Appendix 1 (page 189)

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.





15

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 Alemtuzumab Post kidney transplantation (unlicensed product see page 4)

SC Injection in to the deltoid or anterior abdominal wall.

Groups 1 and 2

1-2 minutes Alemtuzumab is prepared only by Pharmacy. Contact the Renal Pharmacist on Bleep 0728 or the Pharmacy Screening Room on ext.32278 (send prescription chart to Pharmacy). Out of office hours, bleep the on-call pharmacist through Switchboard. For SC injection, Pharmacy will supply a 30mg in 1ml pre-filled syringe. For IV infusion, Pharmacy will supply 30mg in 100ml N/S.

Give the following pre-medication 30-60 minutes prior to giving alemtuzumab: Methylprednisolone 500mg IV prior to first dose, 250mg IV prior to second dose. Chlorphenamine 10mg IV and paracetamol 1g PO prior to first and second dose.

(I) IV infusion via an infusion pump

Groups 1 and 2

2 hours Additional information relating to IV infusion of alemtuzumab: Protect IV infusion from light: Cover with infusion bag with the plastic bag supplied from Pharmacy. No need to cover the line. During and after administration monitor for urticaria, rash, hypotension, nausea, rigors and fever. Serious but rare reactions include: respiratory distress, bronchospasm, syncope, MI and cardiac arrest.





16

DRUG

METHOD WHO MAY GIVE

ADMINISTER OVER


COMMENTS

Alemtuzumab 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): Administer chlorphenamine 10mg IV and paracetamol 1gram PO Administer alemtuzumab 12mg in 100ml N/S over 3 hours Day 5 (1st course only): Administer chlorphenamine 10mg IV and paracetamol 1gram PO Administer alemtuzumab 12mg in 100ml N/S over 2 hours





17

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.

Alfentanil 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. 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. 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.

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.

SC injection Groups 1,2,3,4 and 5

Refer to the Marsden Manual for guidance on SC injection.

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).

(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.





18

DRUG

METHOD WHO MAY GIVE


COMMENTS

Alglucosidase alfa (Mycozyme)


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 patients 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.





19

DRUG

METHOD WHO MAY GIVE


COMMENTS

Alprostadil (Prostin VR)

(C) IV infusion Infusion pump is required.

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.





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Alteplase (TPA) to treat: Acute myocardial infarction (AMI)

If a special pre-programmed alteplase pump is unavailable then refer to the guidance on pages 19 and 20. 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. When treating AMI, alteplase is given together with IV heparin. The IV heparin regimen is 5,000unit bolus followed by a continuous IV infusion for at least 48 hours, using the standard PHNT IV heparin prescription form. Alteplase and heparin infusions are not compatible. They should be infused through separate IV catheters. If IV access is a problem, the infusion of heparin can be commenced once the alteplase infusion has finished.

Alteplase (TPA) to treat: Pulmonary embolism

Initial IV bolus dose

Group 1 1 2 minutes 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.

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





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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 60kg 45mg over 30 minutes. Set the pump at 45ml/hour for 30 minutes then 30mg over 60 minutes. Set the pump at 15ml/hour for 60 minutes 58kg 43.5mg over 30 minutes. Set the pump at 43.5ml/hour for 30 minutes then 29mg over 60 minutes. Set the pump at 14.5ml/hour for 60 minutes 56kg 42mg over 30 minutes. Set the pump at 42ml/hour for 30 minutes then 28mg over 60 minutes. Set the pump at 14ml/hour for 60 minutes 54kg 40.5mg over 30 minutes. Set the pump at 40.5ml/hour for 30 minutes then 27mg over 60 minutes. Set the pump at 13.5ml/hour for 60 minutes 52kg 39mg over 30 minutes. Set the pump at 39ml/hour for 30 minutes then 26mg over 60 minutes. Set the pump at 13ml/hour for 60 minutes 50kg 37.5mg over 30 minutes. Set the pump at 37.5ml/hour for 30 minutes then 25mg over 60 minutes. Set the pump at 12.5ml/hour for 60 minutes 48kg 36mg over 30 minutes. Set the pump at 36ml/hour for 30 minutes then 24mg over 60 minutes. Set the pump at 12ml/hour for 60 minutes 46kg 34.5mg over 30 minutes. Set the pump at 34.5ml/hour for 30 minutes then 23mg over 60 minutes. Set the pump at 11.5ml/hour for 60 minutes





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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





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Alteplase to treat Acute Ischaemic Stroke

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.

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.

(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.

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

Bolus dose (ml) Inject over 1 -2

minutes

Infusion dose infused over 1 hour

Use 1 x 50mg vial

45 7st 1lb 40 4 36 50 7st 12lb 45 4.5 40.5 55 8st 9lb 49 4.9 44.1

Use 2 x 50mg vials

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

100 15st 10lb 90 9 81





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Alteplase (Low-Dose) to treat acute venous thrombosis (subclavian or ilio-femoral deep vein thrombosis) This indication for alteplase is unlicensed see page 4

(C) IV Infusion Groups 1,2,3,4 and 5

2.5ml/hour This will deliver 0.5mg alteplase per hour

Reconstitute 1 x 10mg alteplase with the 10ml of W provided. Further dilute the 10mg of reconstituted alteplase to 50ml with N/S.

The minimum stable concentration is 0.2mg/ml. Each prepared infusion is stable upto 8 hours at room temperature. Prepare a fresh syringe and change the infusion promptly, every 8 hours. After 8 hours, 30ml of solution will remain in the used syringe which must be discarded. Follow the Low-Dose Alteplase Protocol.

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

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

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.

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.

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.





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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.





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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. Where a lower volume is needed 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.

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.

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.





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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



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.





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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 1 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.





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Aprotinin This drug is unlicensed see page 4

IV bolus (initial loading dose)

Group 1 Maximum rate 10ml/minute

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.


Groups 1 and 2

20-50ml/hour





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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 12 360 7 1.8 110 13 3.370 8 2.1 120 14 3.680 10 2.4 130 16 3.990 11 2.7 140 17 4.2





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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.

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

(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.

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

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

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.

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

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

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

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

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

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.

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. (C) IV infusion. Infusion

pump is required. Groups 1 and 2

300-600 micrograms/kg/ hour





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

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.

SC injection Groups 1 and 2

Refer to the Marsden Manual for guidance on SC injection.

IM Injection Groups 1 and 2

Refer to the Marsden Manual for guidance on IM injection.

Augmentin See Co-amoxiclav Azathioprine (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 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.

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.





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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. Refer to the Marsden Manual for guidance on IM injection.

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. Refer to the Marsden Manual for guidance on IM injection.

Do not inject this formulation intravenously.





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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.

(I) IV infusion. Infusion pump is required.


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.

IM Injection Groups 1,2,3,4 and 5

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


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.

Flush with N/S or G.




www.medicines.org.uk Procedures for Administering Injectable Drugs, Pharmacy Department,

Injectable Drugs Monographs v2

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