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Using Hospital Pharmacy Using Hospital Pharmacy Reference Tools in IV TherapyReference Tools in IV Therapy

Chuck DiTrapano, RPhPharmacy Supervisor

The Reading Hospital and Medical Center

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Transition to Transition to Hospital PharmacyHospital Pharmacy

• RetailRetail– Dispensing– Prescription order entry– Orals, topical, some injectables

….– Insurance issues– Customer service– Compounding?– Physician calls– Inventory management

• HospitalHospital– Dispensing – 24 hour

• Drug Formulary• Robotics, Automated

Dispensing Cabinets• BPCV (Barcode Verification)

– Medication order entry– Interaction with nursing / drug

administration issues– Same as retail + Injectable,

infusion therapy, specialty services (chemotherapy, NICU, Pediatrics)

– Stop order policy– Protocols– Clinical information systems– Clinical services– Drug Information Services– Physician Order Management

(POM)

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Transition to Transition to Hospital PharmacyHospital Pharmacy

Dispensing FunctionsDispensing Functions• Unit Dose (12 / 24 hour)

– Unit of use systems• Floor stock (Automated Dispensing Cabinets-

ADC)– SureMed, Omnicell, Pyxis

• Operating Room– Learn the acronyms (PACU, ED,

ECU,NICU,MICU,SICU,CCU,PICU) • Emergency Department (ED)• Infusion Therapy Services

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Omnicell MedicationOmnicell MedicationDispensing CabinetsDispensing Cabinets

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IV TherapyIV Therapy

• Common Injectable routes of administration– Subcutaneous (SubQ, SQ, SC)– Intramuscular (IM)– Intravenous

• IV Push• IV Intermittent Injection / Infusion• IV Infusion

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IV PushIV Push

• How fast is too fast for IV push medications?– IV Push should be defined by hospital policy– Concentration can effect IV rate

• Midazolam 1mg/mL vs 5 mg/mL

– Medications that carry risk from rapid administration should be designated by hospital policy as IV Intermittent Infusion (IVPB)

– Who can administer it?, How much drug can be administered? How fast can it be administered? Is there any monitoring required?

Source: ISMP

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IV Intermittent Injection / InfusionIV Intermittent Injection / Infusion

• Intermittent infusion is used when a patient requires medications only at certain times, and does not require additional fluid. It can use the same techniques as an intravenous drip (pump or gravity drip), but after the complete dose of medication has been given, the tubing is disconnected from the IV access device

• Typical Volumes– 25mL, 50mL, 100mL, 150mL

• Time of Infusion– 15 to 60 minutes; typically

• Heparin Flushing / Central Line– SASH

• Long administration times / impact on nursing• Policy on who can administer RN? LPN?• Compatibility / Stability / Light Protection

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IV InfusionIV Infusion

• Continuous Infusion• LVP – Large Volume Parenteral

– Typical volumes: 250mL, 500mL, 1000mL• Taper

– Many drugs require titration to clinical response of patient

• Infusion Lines– Peripheral Line– Central Line– PICC – Peripherally inserted central catheter

• Compatibility / Stability / Light Protection

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IV Infusion (2)IV Infusion (2)

• Central / Peripheral ?– Osmolarity

• Blood - 280 - 295 mOsm/kg• 0.9% Sodium Chloride - 308 mOsm/L. (Isotonic)• Dextrose 5% Water – 252 mOsm/L (Isotonic)• 0.45% Sodium Chloride – 154 mOsm/L

• Hypertonic: over 900 mOsm/L• Hypotonic – below 150 mOsm/L

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IV Therapy MathIV Therapy Math

Infusion Drip Rate

• Rx: Infusion of D5W 1,000 mL over 8 hours:1000 mL/hour ÷ 8 hours = 125 mL / HOUR

• Rx: Infusion of D5W at 50 mL/hour:1,000 mL ÷ 50 mL / hour = 20 hours / bag

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IV Therapy MathIV Therapy Math

mg / HOUR to mL / HOUR

• Rx: Diltiazem 10 mg/HOUR:

Standard Concentration = 125 mg/125 mL

(1 mg/mL)

10 mg / Hour ÷ 1 mg / mL = 10 mL / HOUR

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IV Therapy MathIV Therapy Math

mg / MINUTE to mL / HOUR

• Rx: Amiodarone 0.5 mg / MINUTE: Standard Concentration = 500 mg/250 mL

(2 mg/mL)

0.5 mg/MINUTE x 60 minutes = 30 mg / HOUR

30 mg / HOUR ÷ 2 mg / mL = 15 mL / HOUR

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IV Therapy MathIV Therapy MathWeight BasedWeight Based

mg / kg / HOUR to mL / HOUR

• Rx: Aminophylline: 0.51 mg/kg/HOUR –

pt wt: 80 kgStandard Concentration = 250 mg / 250 mL

(1 mg/mL)

0.51 mg/kg/hour x 80 kg = 40.8 mg / hour

40.8 mg / hour ÷ 1 mg / mL = 40.8 mL / hour• 41 mL / hour (rounded)

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IV Therapy MathIV Therapy MathWeight BasedWeight Based

mcg / kg / MINUTE to mL / HOUR

• Rx: DOPamine: 10 mcg / kg / minute – 80 kg patient

Standard Concentration =

200 mg / 250 mL (0.8 mg/mL)

10 mcg/kg/minute x 80 kg x 60 minutes = • 48,000 mcg / hour• 0.8mg/mL x 1,000 mcg per mg = 800 mcg/mL

48,000 mcg / hour ÷ 800 mcg / mL = 60 mL / hour

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Check IV CompatibilityCheck IV Compatibility

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Check IV CompatibilityCheck IV Compatibility

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Check IV CompatibilityCheck IV Compatibility

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Drug Information is Alphabetical

ContentsContents

Product InformationpH

OsmolarityAdministration

StabilityLight Sensitivity

FiltrationCompatibility Information by:

Mixed in various solutionsMixed with another drug in

solutionMixed together in syringe

Y-Site Compatibility

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Drug Information is Alphabetical

ContentsContents

ProperitiesSolubility

pHpKa

General Stability ConsiderationsStability Reports of Compounded

ProductsFormulations with compounding

directionsCommercial availability (if

applicability)

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Drugs Filed by Therapeutic Category

ContentsContents

•Dose & Administration•Uses

•Monitoring•Adverse Effects / Precautions

•Pharmacology•Special Considerations /

Preparation•Solution Compatibility

•Solution Incompatibility•Terminal Injection Site

Compatibility•Incompatibility

•Selected References

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Formulary SectionFormulary Section

Drugs listed alphabetical

Content Drug Monographs

Usual Dose (Adults)Usual Dose (Pediatrics)

Dose AdjustmentsDilution

CompatibilityRate of Administration

ActionsIndications and Uses

ContraindicationsPrecautions

Drug / Lab InteractionsSide Effects

Antidote

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BAXA COMPOUNDERBAXA COMPOUNDER

Automated Infusion Dispensing

Barcode Verification

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Specialty PopulationsSpecialty Populationsin Hospital Pharmacy in Hospital Pharmacy

• Pediatrics– Weight based dosing– Double Checks– Alternate drug concentrations– Dedicated reference sources– Standard Infusion Concentrations

• No “rule of 6 dosing”

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Specialty PopulationsSpecialty Populationsin Hospital Pharmacy in Hospital Pharmacy

• NICU– Weight based dosing– Double Checks– Alternate drug concentrations– Wide weight fluctuations in patients– Dedicated reference sources– Standard Infusion Concentrations

• No “rule of 6 dosing”

– Specialty Compounding for oral liquids

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Typical Pediatric OrderTypical Pediatric Order

• Rx: Gentimicin 4 mg/kg, weight= 10.5 kg q24h

1. 4 mg/kg x 10.5 kg = 42 mg

2. Standard Concentration -= 5 mg / mL

3. 42 mg/kg ÷ 5 mg/kg = 8.4 mL

4. Administer 8.4 mL (42 mg) over 30 minutes

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Formulary SectionFormulary Section

Drugs listed alphabetical

Content Drug Monographs

Usual Dose (Adults)Usual Dose (Pediatrics)

Dose AdjustmentsDilution

CompatibilityRate of Administration

ActionsIndications and Uses

ContraindicationsPrecautions

Drug / Drug InteractionsDrug / Lab Interactions

Side EffectsAntidote

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Formulary SectionFormulary Section

Drugs listed alphabetical

Content Drug Monographs

Therapeutic CategoryDosing for Neonates & Pediatrics

Adult DosingPharmacokinetic information

Contraindications

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Drugs listed alphabetical

Content Drug Monographs

Usual Dose (Pediatrics)Dose AdjustmentsMaximum dosing

IV Push InformationIntermittent InfusionContinuous Infusion

Maximum concentrationCautions related to IV

Administration

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Pediatric Medication OrderPediatric Medication OrderStandard Antibiotic OrderStandard Antibiotic Order

Patient: 3 years old, 16.7 kgPatient: 3 years old, 16.7 kgRx: Ceftriaxone 800 mg IV q12hRx: Ceftriaxone 800 mg IV q12h

• Order Verification: Dose Check– Dosing Guidelines: ASHP Pediatric Injectable Drugs:

• Mild to Moderate Infection: 50-75 mg/kg / DOSE every 12 hours• Severe Infections: 80-100 mg/kg / DOSE every 12 hours

– Patient: 800 mg / 16.7 kg = 47.9 mg/kg – OK

• Administration Information– Infuse over 10-30 minutes

• Dose Preparation Information– Single Dose Preparation

– Bulk Dose Preparation

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Drugs Filed by Therapeutic Category

ContentsContents

•Dose & Administration•Uses

•Monitoring•Adverse Effects / Precautions

•Pharmacology•Special Considerations /

Preparation•Solution Compatibility

•Solution Incompatibility•Terminal Injection Site

Compatibility•Incompatibility

•Selected References

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Specialty PopulationsSpecialty Populationsin Hospital Pharmacy in Hospital Pharmacy

• Chemotherapy– Safe Handling – High Alert / High Risk Drugs– Biological Safety Cabinet Operation– Administration Issues

• Filtration• Low absorption tubing / bags• Stability • Light Sensitivity

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Drugs Filed Alphabetically

ContentsContents

•Safe Handling of Chemotherapy•Extravasations

Procedures•Drug Monographs

•Y-Site Compatibility•Patient Education

•Patient Drug Monographs•Combination Regimens

•Patient Symptom Information

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Drug DosingDrug Dosing• Pharmacokinetics

– Antibiotic Dosing• Aminoglycosides• Vancomycin• Theophylline• Digoxin• Valproic Acid

• Renal Dosing– Antibiotic Dosing Adjustments

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Need Help?Need Help?

Chuck DiTrapano,RPh

The Reading Hospital and Medical Center

Pharmacy Department

ditrapanov@readinghospital.org

610-988-9328