Embed Size (px)
Citation preview
PharmacyTraining Materials
ColoradoALTO Project
Our Partners
Table of ContentsIntroduction: Colorado ALTO Project Pharmacy Toolkit ................................................................................................. 2
ED Opiate-Free Pain Options by Indication in the ED ..................................................................................................... 3
ED Opiate-Free Pain Options by Indication at Discharge from the ED ............................................................................ 4
SAMPLE HANDOUT: High-Alert Med Adminstration ...................................................................................................... 5
SAMPLE HANDOUT: Procedural Sedation .................................................................................................................... 15
SAMPLE HANDOUT: Guidelines for Medications Used in Sedation/Analgesia .............................................................. 20
ColoradoALTO Project
All 10 EDs successfully completed the opioid pilot, achieving a reduction in opioid administration rates of more than double the 15 percent goal on average.
In addition, the 10 EDs increased their use of ALTOs by more than 31 percent, with ALTO administration surpassing opioid administration near the end of the six-month pilot.
CHA partnered with key stakeholders to develop and roll out the pilot program:
QUALITY & PATIENT SAFETY
To learn more about the Colorado ALTO Project visit www.cha.com/opioid.
© 2018 CHA
ED-Specific Percent Change in Opioid MEU (2016 vs 2017)
-50%
-40%
-30%
-20%
-10%
0%
ED 10ED 9ED 8ED 7ED 6CohortED 5ED 4ED 3ED 2ED 1
-46% -45%-41%
-39%-36% -36%
-34% -33% -32% -32% -31%
GOAL
Percent Change from Baseline in MEUs per 1,000 ED Visits
Perc
ent C
hang
e fr
om
Base
line
Aver
age
Number of Treated Pain Visits per 1,000 ED Visits
Baseline Project
150
200
250
300
350
400392 396 396
371
345
350
251264 257
238 242
197
236255
243
233237231200202185
172165166
November 2017
October 2017
September 2017
August 2017July 2017
June 2017
November 2016
October 2016
September 2016
August 2016July 2016
June 2016
n Alto n Opioid
The Colorado Opioid Safety Pilot demonstrated the feasibility and effectiveness of using an ALTO approach as a first-line treatment for acute pain in the ED before turning to opioids. Based on this success, CHA will roll out this program statewide in 2018 through the Colorado ALTO Project.
In 2017, Colorado Hospital Association (CHA) partnered with 10 hospital emergency departments (EDs) on a six-month pilot program with the goal of reducing the administration of opioids in the ED by 15 percent. This would be achieved by changing prescribing guidelines and using new protocols for alternatives to opioids (ALTOs) as first-line treatments for pain management, administering opioids sparingly or only as rescue medications.
Introduction:Colorado ALTO Project | Pharmacy ToolkitCourse Overview Thank you for participating in the Colorado ALTO Project. The Colorado ALTO Project Pharmacy Toolkit provides information and resources to assist in the education of pharmacists in the following areas:
Colorado’s opioid crisis Use of alternative to opioids (ALTOs), procedures Opioid crisis and pharmaceutical companies and pain pathways The Colorado Chapter of the American College of Evidenced-based ALTO research
Emergency Physicians 2017 Opioid Prescribing Policy changes & Treatment Guidelines Data
The Colorado Opioid Safety Pilot Pharmacy ALTO Training CurriculumThe pharmacy ALTO training curriculum has three main components: training sessions, handouts and podcast links.
Pharmacy ALTO Training SessionsThe pharmacy ALTO training session is generally presented in one, in-person 90-minute session, a PowerPoint presentation by your organization’s identified trainer or a recorded webinar.
HandoutsThe pharmacy ALTO training kit includes multiple sample handouts:
Sample high-risk medication and procedural policies ALTO pathway discharge prescribing document ED ALTO order sets Pain pathway indication algorithm
Podcast LinksThe pharmacy ALTO training kit offers a variety of podcasts from Emergency Medical Minute that can be accessed at the convenience of the clinician. For additional opioid-related podcasts, visit Emergency Medical Minute.https://emergencymedicalminute.com/opioid-miniseries/
Listen to Part I: Medicine's Greatest Folly from Emergency Medical Minute in Podcasts. Dr. Don Stader describes how opioids became medicine's drug of choice for pain, documenting the dubious science and market forces that helped create the opioid epidemic. https://itunes.apple.com/us/podcast/emergency-medical-minute/id1210879676?mt=2&i=1000386294042
Listen to Part II: Limiting Opioids in the Emergency Department from Emergency Medical Minute in Podcasts. Dr. Don Stader and Dr. Erik Verzemniks discuss COACEP 2017 Opioid Prescribing & Treatment Guidelines recommendations to limiting opioids in the ED, including in-depth discussion of keys to limiting opioids and speaking with patients about opioids. https://itunes.apple.com/us/podcast/emergency-medical-minute/id1210879676?mt=2&i=1000386312411
Listen to Part III: Alternative to Opioids from Emergency Medical Minute in Podcasts. Pharmacist Rachael Duncan reviews ALTO medications, how they are used and tips to using ALTOs safely and effectively. https://itunes.apple.com/us/podcast/emergency-medical-minute/id1210879676?mt=2&i=1000386312410
Listen to Part IV: Harm Reduction from Emergency Medical Minute in Podcasts. Dr. Don Stader and Harm Reduction Action Center Executive Director Lisa Raville discuss harm reduction and keys to speaking with patients with opioid use disorder and IV drug use – emphasizing points on how to keep these patients safe. https://itunes.apple.com/us/podcast/emergency-medical-minute/id1210879676?mt=2&i=1000386331460
For more information on the Colorado ALTO Pharmacy Training toolkit, contact Diane Rossi MacKay at [email protected].
Page 2
ED Opioid-Free Pain Options by Indication in the EDMusculoskeletal Pain: • No IV access – Intranasal ketamine 50 mg – 100mg/mL product• Acetaminophen 1000 mg PO• Ibuprofen 600 mg PO or Ketorolac 15 mg IV/IM• Trigger Point injection - Lidocaine 1% 2-3 mL IM at each trigger point• Cyclobenzaprine 5 mg PO or diazepam 5 mg PO/IV• Dexamethasone 8 mg PO/IV • Ketamine 0.2 mg/kg (50mg/5mL syringe) IVP over 10 min - ± 0.1 mg/kg/hr gtt (100 mg/50 mL) until pain is tolerable• Lidoderm patch to most painful area, MAX 3 patches • Gabapentin 300 mg PO (neuropathic component of paint)
Recurrent Primary Headache/Migraine:• Acetaminophen 1000 mg PO • Ibuprofen 600 mg PO or Ketorolac 15 mg IV/IM• 1 L 0.9% NS bolus • Sumatriptan 6 mg SC • Cervical or Trapezius Trigger Point Injection with lidocaine 1% 1-2 mL IM• Metoclopramide 10mg IV • Promethazine 12.5 mg IV OR prochlorperazine 10 mg IV• Magnesium 1 gm IV over 60 minutes • Valproic Acid 500 mg/50 mL NS IV over 20 min • Levetiracetam 1000 mg/100 mL NS IV over 15 min• Dexamethasone 8 mg IV (Migraine only) • Haloperidol 2.5-5 mg IV over 10 min • Lidocaine 1.5 mg/kg in 100 mL NS over 10 min (max 200 mg)
If tension component:• Cyclobenzaprine 5 mg OR Diazepam 5 mg PO/IV
Extremity Fracture or Joint Dislocation:Consider regional anesthesia: e.g. nerve blocks: wrist, ankle, ulnar, radial, hip, femur, etc.
Immediate therapy (steps 1-3 while setting up for block)• Ketamine intranasal 50 mg– concentration 100 mg/mL• Nitrous Oxide titrate as needed (MAX 70%) • Tylenol 1000 mg PO
Followed by setting up for:• Ultrasound Guided Regional Anesthesia - Joint Dislocation and Extremity Fracture - Lidocaine 0.5-1% peri-neural infiltration (MAX 4 mg/kg)
If unable to do ultrasound guided regional anesthesia:• Ketamine 0.2 mg/kg in (50mg/5mL syringe) IVP over 10 min - ± 0.1 mg/kg/hr gtt (100 mg/50mL) until pain is tolerable
Abdominal Pain: Gastroparesis-associated or chronic functional abdominal pain:• Metoclopramide 10 mg IV• Diphenhydramine 25 mg IV• Prochlorperazine 10 mg IV• Dicyclomine 20 mg PO/IM• Lidocaine 1.5 mg/kg in 100 mL NS over 10 min (max 200 mg)• Haloperidol 2.5-5 mg IV• Ketamine 0.2 mg/kg (50mg/5mL syringe) IVP over 10 min ± 0.1 mg/kg/hr gtt (100 mg/50 mL) until pain is tolerable• Capsaicin 0.025% topical (cannabinoid hyperemesis syndrome)
Renal Colic:• Acetaminophen 1000 mg PO• 1 L 0.9% NS• Ketorolac 15 mg IV• Lidocaine 1.5 mg/kg IV in 100 mL NS over 10 min (max 200 mg)• Desmopressin 40 mcg IN• Ketamine 50 mg IN (100 mg/mL product)
Page 3
ALTO Order sets created by Rachael Duncan, PharmD BCPS BCCCP, Swedish Medical Center.
ED Opioid-Free Pain Options by Indication at Discharge from the EDHeadache:1,2
For acute attacks:• Sumatriptan 100 mg • Acetaminophen/Aspirin/Caffeine (Excedrin Migraine)• Acetaminophen 1000 mg every 6 hours• DHE 2 mg nasal spray• Naproxen 500-550 mg twice daily• Metoclopramide 10 mg every 6 hours• Ibuprofen 600 mg PO every 6 hours For prevention:• Propranolol 40 mg BID• Divalproex DR 250 mg twice daily OR ER 500 mg daily• Topiramate 25 mg at bedtime• Magnesium supplementation 600 mg daily Sore Throat:• Ibuprofen 600 mg every 6 hours• Acetaminophen 1000 mg every 6 hours• Dexamethasone 10 mg once• Viscous lidocaine Fibromyalgia:3,4
• Cardiovascular exercise• Strength training• Massage therapy• Amitriptyline 10 mg at bedtime• Cyclobenzaprine 10 mg every 8 hours• Pregabalin 75 mg twice daily Uncomplicated Neck Pain:5
• Acetaminophen 1000 mg every 6 hours• Ibuprofen 600 mg every 6 hours• Cyclobenzaprine 5 mg every 8 hours• Physical therapy• Lidocaine 5% patch Q12 hours Uncomplicated Back Pain:6,7
• Acetaminophen 1000 mg every 6 hours• Ibuprofen 600 mg every 6 hours• Lidocaine 5% patch Q12 hours• Diclofenac 1.3% patch TD twice daily• Diclofenac 1% gel 4 g four times daily PRN • Cyclobenzaprine 5 mg PO three times daily• Heat• Physical therapy• Exercise program Simple Sprains:• Immobilization• Ice• Ibuprofen 600 mg every 6 hours• Acetaminophen 1000 mg every 6 hours• Diclofenac 1.3% patch TD twice daily• Diclofenac 1% gel 4 g four times daily PRN
Contusions:8
• Compression• Ice• Ibuprofen 600 mg every 6 hours• Acetaminophen 1000 mg every 6 hours• Lidoderm 5% patch Non-Traumatic Tooth Pain:9
• Ibuprofen 600 mg every 6 hours AND• Acetaminophen 1000 mg every 6 hours (clove oil, other topical anesthetics)• Viscous Lidocaine topically Osteoarthritis:10
• Diclofenac 50 mg every 8 hours• Naproxen 500 mg twice daily• Celecoxib 200 mg daily• Diclofenac 1.3% patch TD twice daily• Diclofenac 1% gel 4 g four times daily PRN (topical NSAIDs, capsaicin) Undifferentiated Abdominal Pain:• Dicyclomine 20 mg every 6 hours• Acetaminophen 1000 mg every 6 hours• Metoclopramide 10 mg every 6 hours• Prochlorperazine 10 mg every 6 hours Neuropathic Pain:• Gabapentin 300mg every 8 hours• Amitriptyline 25 mg at bedtime• Pregabalin 75 mg twice daily
1 Marmura MJ, Silberstein SD, Schwedt TJ. The acute treatment of migraine in adults: the american headache society evidence assessment of migraine pharmacotherapies. Headache. 2015 Jan;55(1):3-20. 2 Matchar DB et. al. Evidence-Based Guidelines for Migraine Headaches in the Primary Care Setting: Pharmacological Management of Acute Attacks. American Academy of Neurology.3 Chinn S, Caldwell W, Gritsenko K. Fibromyalgia pathogenesis and treatment options update. Curr Pain Headache Rep. 2016; 20-25.4 Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA. 2004 Nov 17;292(19):2388-95. 5 Schnitzer, TJ. Update on guidelines for the treatment of chronic musculoskeletal pain. 25 (Suppl 1), Clin Rheumatol. 2006;25 Suppl 1:S22-96 McIntosh G, Hall H. Low back pain (acute). Clin Evid (Online). 2011;05:1102.7 Hayden JA, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst Rev. 2005;(3).8 Jones P, Dalziel SR, Lamdin R, Miles-Chan JL, Frampton C. Oral non-steroidal anti-inflammatory drugs versus other oral analgesic agents for acute soft tissue injury. Cochrane Database Syst Rev. 2015 Jul 1.9 Moore PA, Hersh EV. Combining ibuprofen and acetaminophen for acute pain management after third-molar extractions. JADA. 2013; 898-908.10 da Costa, Bruno R et al. Effectiveness of non-steroidal anti-inflammatory drugs for the treatment of pain in knee and hip osteoarthritis: a network meta analysis The Lancet. 2016. 2093-2105.
Page 4
Purpose: To establish standards for the safe administration and additional monitoring of high alert/narrow therapeutic index medications in order to prevent and minimize potential injury to the patient.
Scope: Registered Nurses (RNs), Pharmacists, Physicians (MDs), Licensed Independent Practitioners (LIPs)
Policy:The Patient Safety and Pharmacy and Therapeutics committees will establish and maintain a list of high risk medications. This list may include a class or category of medications as well as specific medications. The list will be based on external (Institute for Safe Medication Practices, (ISMP), published reports and sentinel events) and internal (Swedish Medical Center (SMC) medication errors, sentinel events, and other) data. New drugs added to the formulary will be evaluated for potential risk.
For each drug/drug category identified, specific strategies should be identified and implemented. Strategies will include selection and procurement, storage, ordering and transcribing, preparing and dispensing, administration and monitoring.
Definitions:High Alert medication: Medications that have a relatively small difference between therapeutic and toxic dosages and/or when administered intravenously have the potential to cause life-threatening effects such as dysrhythmia or circulatory collapse.
Guidelines:1. The Medication Safety Committee and Pharmacy and Therapeutics committee will identify high risk medications based on the criteria above.
2. Strategies used include but are not limited to: limited access to these medications, standardizing ordering and concentrations, computer alerts, and double checks performed by pharmacists and nurses. In addition, care areas are assigned where medications can be given with proper monitoring.
These areas are:• Critical Care: Intensive care when patient has an
unstable condition and requires advanced and/or invasive monitoring along with aggressive therapies, medication management and specialized equipment (includes but not limited to: Cardiac Cath Lab, Critical Care Unit, Pediatric Intensive Care Unit, Emergency Department, Neonatal Intensive Care Unit, Interventional Radiology, Post Anesthesia Care Unit and Labor and Delivery)
• Intermediate Care: Patients that are hemodynamically stable but may need monitoring of a previously unstable condition (includes but not limited to: Ambulatory Care Unit, Progressive Care Unit)
• Medical/Surgical Care: Patients with general treatment and medication needs. These patients may or may not be on telemetry (includes but not limited to: all units not specifically listed above).
3. Staff members and physicians involved in the use of these medications will adhere to the strategies and policies identified.
4. Depending on the individual clinical situation a patient on a drug listed in this policy may require more or less intense monitoring than specified in this policy. If there is a question about the requirement for safe administration and monitoring of intravenous drug therapy or a question about exception to this policy, the unit director or nursing supervisor should be contacted to determine appropriate precautions.
5. Other policies that pertain to parenteral drug administration not addressed in this policy include but are not limited to: general intravenous (IV) policy#, Chemo Policy #, total parenteral nutrition (TPN) policy#FAC.PC.1001, Emergency Measures Protocol and Sedation/Analgesia Policy#FAC.PC.1016.
Page 5
TITLE: High-Alert Med AdminstrationCATEGORY: Patient Care Check one: List department if department specific:
HOSPITAL-WIDE DEPARTMENT-SPECIFIC FOR g
POLICY NUMBER: RESOURCE PERSON:
SAMPLE
a
6. As a group pediatric orders are given special consideration for safety. All pediatric drug dosages are calculated using mg/kg units where applicable as outlined in the Rocky Mountain Hospital for Children (RMHC) Pediatric Medication Orders Policy RMHC.PC.5301.
• Patients aged 0-17 are considered “Pediatric” for the purposes of double checks. • Pediatric medication orders entered by a prescriber via Electronic Physician Order Management (ePOM) may be verified by a single pharmacist acting as the independent verification step. In the event clarification must be obtained and the order is altered by the pharmacist or the original order is generated in any way other than ePOM (Verbal, Written, Protocol, etc.) a second pharmacist must perform an independent verification of the following medications: • IV Antibiotics • IV Opiates • IV Benzodiazepines • Epidurals • Anticoagulants • Narrow Therapeutic Index Medications - Aminophylline - Carbamazepine - Lithium - Phenytoin - Theophylline - Valproic Acid and its derivatives - Warfarin • Independent verification requires review of: Indication, Dose, Dose Volume, Frequency, Order Type, Concentration, Rate of Administration and Dose Delivery System (syringe vs. mini-bag). • Prior to dispensing medications from the pharmacy, two licensed individuals (at least one must be a pharmacist) should perform a check of the medication against the drug label. A single pharmacist may not pull an item from the shelf or prepare a product and send to the floor prior to having another individual verify the product with them. • Prior to administration two nurses, or respiratory therapist with nurse, will verify: Right Medication, Right Dosage, Right Time, Right Route, Right Patient, Right Documentation (“The 6 Rights”). Liquid preparations should have the dose checked by confirming the concentration and volume provide the correct dose ordered. When utilizing smart pump technology two practitioners must check that the correct drug/concentration are selected from the pump library.
High Risk/High Alert Drugs:• Adrenergic Agonists (dopamine, epinephrine, norepinephrine, phenylephrine, vasopressin)• Adrenergic Antagonists, injectable (labetalol, metoprolol, propranolol)• Aldesdesleukin, IL-2• Amphotericin B (liposomal, traditional) • Anesthetic Agents (general, inhaled, injectable)• Antiarrhythmics, injectable (amiodarone, diltiazem, lidocaine)• Anticoagulants (argatroban, bivalirudin, dalteparin, enoxaparin, fondaparinux, heparin, dabigatran, rivaroxaban, apixaban, warfarin)• Benzodiazepines• Blood factor products (Factor VII, Factor IX)• Chemotherapy, injectable and oral• Concentrated electrolytes (Calcium chloride/gluconate, magnesium sulfate, sodium chloride/phosphate, potassium chloride/phosphate)• Epidural medications• Fibrinolytics (alteplase, tenecteplase)• Glycoprotein IIb/IIIa inhibitors (abciximab, eptifibatide)• Intotropes (digoxin, dobutamine, milrinone)• Insulin• Intrathecal medications• Neuromuscular blocking agents (atracurium, cisatracurium, pancuronium, rocuronium, succinylcholine, vecuronium)• Opiates• PCA• Phenytoin and fosphenytoin, injection• Phytonadione injection• Promethazine• Sterile water for injection (in amounts of 100 mL or more)
Page 6
SAMPLE
Page 7
Use
of H
igh-
Aler
t/Hi
gh-R
isk
Med
icat
ions
by
Area
*CC=
Criti
cal C
are
Mon
itorin
g (in
clud
es b
ut n
ot li
mite
d to
: Car
diac
Cat
h La
b, C
ritica
l Car
e U
nit (
CCU
), Pe
diat
ric In
tens
ive
Care
Uni
t (PI
CU),
Emer
genc
y De
part
men
t (ED
), N
eona
tal I
nten
sive
Care
Uni
ts (N
ICU
), In
terv
entio
nal R
adio
logy
(IR)
, Pos
t Ane
sthe
sia C
are
Uni
t (PA
CU),
and
Labo
r and
Del
iver
y (L
D))
IntC
= In
term
edia
te C
are
Mon
itorin
g (in
clud
es b
ut n
ot li
mite
d to
: Am
bula
tory
Car
e U
nit (
ACU
), Pr
ogre
ssiv
e Ca
re U
nit (
PCU
)) M
S= M
ed/S
urg
Care
M
onito
ring
(incl
udes
but
not
lim
ited
to: o
ther
pati
ent c
are
area
s in
the
hosp
ital n
ot li
sted
abo
ve)
**In
trav
enou
s car
diac
med
icati
ons m
ay b
e ad
min
ister
ed fo
r acu
te c
ondi
tions
out
side
inte
nsiv
e ar
e or
inte
rmed
iate
car
e se
tting
s to
stab
le p
atien
ts
with
out m
ajor
org
an p
atho
logy
if a
utom
ated
non
inva
sive
bloo
d pr
essu
re m
onito
ring
is m
aint
aine
d an
d ap
prop
riate
rate
of a
dmin
istra
tion
is ob
serv
ed.
If co
nditi
on p
ersis
ts, c
onsid
er tr
ansf
er to
an
inte
rmed
iate
car
e un
it. F
or tr
eatm
ent o
f chr
onic
con
ditio
ns m
aint
enan
ce d
oses
may
be
adm
inist
ered
to
patie
nts o
n m
ed/s
urg
units
who
can
not t
ake
oral
med
icati
ons w
ith a
ppro
pria
te p
reca
ution
s for
rate
of a
dmin
istra
tion
and
freq
uent
non
-inva
sive
bloo
d pr
essu
re c
heck
s dur
ing
and
for o
ne h
our a
fter d
rug
adm
inist
ratio
n.
***C
entr
al v
enou
s acc
ess i
s req
uire
d if
two
or m
ore
vaso
pres
sors
are
infu
sing
at th
e sa
me
time.
Med
icati
onAr
eas A
llow
edCo
mm
ents
, Sto
rage
Phar
mac
y N
otes
Nur
sing
Not
es
Abci
xim
abCC
, Int
CCC
U, P
CU o
nly
Aden
osin
eCC
, Int
CIf
used
on
floor
mus
t hav
e co
de c
art i
n ro
om, b
e on
con
tinuo
us c
ardi
ac
mon
itorin
g an
d M
D pr
esen
t
Alde
sleuk
in, I
l-2CC
, Onc
olog
yTw
o qu
alifi
ed R
Ns w
ill re
view
the
phys
ician
’s or
der;
the
med
icati
on re
ceiv
ed fr
om th
e ph
arm
acy,
and
doub
le-c
heck
s the
dos
age
calc
ulati
ons p
rior t
o ad
min
istra
tion.
Pl
ease
refe
r to
the
Swed
ish M
edic
al C
en-
ter C
CU S
tand
ard
of C
are
for I
nter
leuk
in-2
, IL
-2 p
roto
col a
vaila
ble
on th
e CC
U in
tran
et
page
for d
etai
led
info
rmati
on o
n to
xici
ty
man
agem
ent.
Alte
plas
eCC
(ful
l dos
e) In
tC,
MS
(cat
h cl
eara
nce)
Al
tepl
ase
for c
athe
ter c
lear
ance
may
be
used
in a
ll ar
eas
Amio
daro
ne in
jCC
, Int
CCC
U, P
CU o
nly
Cent
ral li
ne re
quire
d if
the
expe
cted
dur
ation
of
ther
apy
is gr
eate
r tha
n 24
hou
rs.
Amph
oter
icin
, Am
phot
eric
in IV
lip
id-c
ompl
ex
CC, I
ntC,
MS
Conc
ern
if w
rong
form
of a
mph
oter
icin
is
disp
ense
d an
d ad
min
ister
ed. R
enal
fu
nctio
n ne
eds t
o be
mon
itore
d.
Doub
le c
heck
on
all o
rder
ent
ry. A
lert
s in
ord
er e
ntry
syst
em to
ver
ify p
rodu
ct
sele
cted
. Usu
al d
osin
g fo
r eac
h pr
oduc
t pr
ovid
ed fo
r ref
eren
ce. P
harm
acist
mon
itors
re
nal f
uncti
ons.
Revi
ew m
edic
ation
and
dos
e pr
ior t
o ad
min
istra
tion.
SAMPLE
Med
icati
onAr
eas A
llow
edCo
mm
ents
, Sto
rage
Phar
mac
y N
otes
Nur
sing
Not
es
Antic
oagu
lant
s-
apixa
ban,
arg
atro
ban,
da
biga
tran,
dal
tepa
rin,
enox
apar
in,
fond
apar
inux
, he
parin
(wei
ght
base
d pr
otoc
ols)
, tin
zapa
rin,
rivar
oxab
an,
war
farin
CC, I
ntC,
MS
Reco
mm
ende
d m
onito
ring:
Unf
racti
onat
ed H
epar
in (U
FH) a
nd
arga
trob
an: b
asel
ine
PT, I
NR,
aPT
T, C
BC,
plat
elet
cou
nt. A
ll w
eigh
t bas
ed d
osin
g sh
ould
use
app
rove
d pr
otoc
ols.
LM
WH
and
fact
or X
a in
hibi
tors
: bas
elin
e CB
C, se
rum
cre
atini
ne, p
late
let c
ount
. CB
C, p
late
let c
ount
eve
ry 3
day
s, se
rum
cr
eatin
ine
ever
y ot
her d
ay.
War
farin
: bas
elin
e IN
R. C
urre
nt IN
R us
ed
to a
djus
t the
rapy
.
• Do
uble
che
ck o
n al
l ord
er e
ntry
(not
re
quire
d fo
r pro
phyl
actic
dos
e of
sub-
q LM
WH
or H
epar
in) o
f the
rape
utic
antic
oagu
lant
s. D
oubl
e ch
eck
requ
ired
for a
ll Fa
ctor
Xa
inhi
bito
r ord
ers.
• Di
rect
Thr
ombi
n In
hibi
tors
- Onl
y on
e pr
emix
ed c
once
ntra
tion
of a
rgat
roba
n av
aila
ble-
1m
g/m
l.•
UFH
: Onl
y on
e pr
emix
ed c
once
ntra
tion
of h
epar
in fo
r inf
usio
n is
perm
itted
: 50
units
/ml.
The
only
stre
ngth
s of
hepa
rin a
vaila
ble
in p
atien
t car
e ar
eas a
re 1
000
units
/ml,
5000
uni
ts/
ml O
R 50
00 u
nits
/0.5
ml.
All
othe
r co
ncen
trati
ons w
ill b
e di
spen
sed
from
th
e ph
arm
acy
purs
uant
to sp
ecifi
c pa
tient
ord
er.
• W
arfa
rin: O
nly
unit
dose
war
farin
pr
oduc
ts u
sed
whe
n av
aila
ble.
Sta
ndar
d ad
min
istra
tion
time
1700
. Use
P&
T ap
prov
ed p
olic
y fo
r Pha
rmac
y to
dos
e w
arfa
rin.
• IV
pum
p re
quire
d fo
r all
Unf
racti
onat
ed
Hepa
rinU
FH, d
irect
thro
mbi
n in
hibi
tor
infu
sions
• Al
l inf
usio
n ra
te c
hang
es a
nd b
olus
do
ses f
or U
FH a
nd d
irect
thro
mbi
n in
hibi
tors
shal
l be
doub
le-c
heck
ed b
y a
seco
nd n
urse
and
doc
umen
ted
in
EMAR
. In
addi
tion
a do
uble
che
cked
w
ill b
e pe
rfor
med
whe
n a
new
bag
is
hung
or w
hen
the
pum
p is
chan
ged.
Se
cond
nur
se is
resp
onsib
le fo
r ch
ecki
ng th
e pr
epar
ation
labe
ling
and
antic
ipat
ed a
dmin
istra
tion
only
and
is
not p
erfo
rmin
g a
revi
ew o
f the
initi
al
phys
icia
n or
der o
r sub
sequ
ent p
atien
t as
sess
men
t.
Atro
pine
CC, I
ntC
Benz
odia
zepi
nes
CC, I
ntC,
MS
See
P&P:
Pro
cedu
ral S
edati
on/A
nalg
esia
#8
711.
601
Chem
othe
rapy
(in
ject
able
)Se
e P&
P: A
dmin
istra
tion
and
Hand
ling
of C
hem
othe
rapy
and
Bio
ther
apy
#861
4.14
2)•
The
Chem
othe
rapy
Ord
er F
orm
w
ill b
e uti
lized
by
pres
crib
ers f
or a
ll in
ject
able
che
mot
hera
peuti
c or
ders
. Cl
arifi
catio
ns o
f che
mot
hera
py o
rder
s do
not
requ
ire th
e re
writi
ng o
f the
en
tire
orde
r. Cl
arifi
catio
ns m
ay b
e w
ritten
on
regu
lar p
hysic
ian
orde
r fo
rms a
nd m
ay a
lso b
e ta
ken
as v
erba
l or
ders
per
the
verb
al o
rder
pol
icy.
Ex
cepti
on fo
r met
hotr
exat
e fo
r ect
opic
pr
egna
ncy.
• Vi
ncris
tine/
Vinb
lasti
ne-w
ill b
e pr
epar
ed w
ith a
vol
ume
of n
o le
ss th
an
50 m
l to
avoi
d po
ssib
le in
trat
heca
l in
fusio
n.
• Al
l dos
e ca
lcul
ation
s, in
dica
tions
fo
r use
, dilu
tion,
and
rout
e, a
nd
prep
arati
on sh
all b
e do
uble
-che
cked
by
two
phar
mac
ists p
rior t
o di
spen
sing.
Ch
emot
hera
py o
rder
s are
pla
ced
in a
pen
ding
stat
us in
Med
itech
by
the
ente
ring
phar
mac
ist u
ntil t
he
doub
le c
heck
is p
erfo
rmed
. Afte
r co
mpl
eting
the
doub
le c
heck
the
seco
nd p
harm
acist
will
pla
ce th
e or
der
in a
ver
ified
stat
us. D
oubl
e-ch
eck
shal
l inc
lude
ver
ifica
tion
of c
alcu
latio
n an
d ap
prop
riate
ness
of d
ose.
Dos
e di
ffere
nces
gre
ater
than
5%
will
be
disc
usse
d w
ith th
e pr
escr
iber
. Pati
ent
profi
les s
houl
d be
revi
ewed
prio
r to
disp
ensin
g.
• Ph
arm
acy
will
prim
e al
l IV
tubi
ng.
• Al
l che
mot
hera
peuti
cs a
gent
s are
st
ored
in se
para
te a
nd id
entifi
able
are
a aw
ay fr
om o
ther
inje
ctab
le m
edic
ation
s.
• Th
ese
drug
s mus
t be
adm
inist
ered
on
ly b
y a
nurs
e w
ho is
che
mot
hera
py
qual
ified
. Th
e PI
CC te
am sh
ould
be
con
tact
ed if
a c
hem
othe
rapy
qu
alifi
ed n
urse
is n
ot a
vaila
ble.
In
th
e op
erati
ve/in
vasiv
e se
tting
, in
ject
able
che
mot
hera
py m
ay o
nly
be a
dmin
ister
ed b
y th
e pr
escr
ibin
g ph
ysic
ian.
•
Two
chem
othe
rapy
qua
lified
RN
s w
ill re
view
the
phys
icia
n’s o
rder
, th
e m
edic
ation
rece
ived
from
the
phar
mac
y, an
d do
uble
-che
ck d
osag
e ca
lcul
ation
s prio
r to
adm
inist
ratio
n.
Both
RN
s will
doc
umen
t thi
s dou
ble
chec
k on
the
phys
icia
n pr
ogre
ss n
otes
. In
pro
cedu
ral a
reas
the
doub
le c
heck
m
ay b
e pe
rfor
med
by
the
phys
icia
n an
d RN
.
Page 8
SAMPLE
Med
icati
onAr
eas A
llow
edCo
mm
ents
, Sto
rage
Phar
mac
y N
otes
Nur
sing
Not
es
Chem
othe
rapy
(ora
l) •
All o
ral c
hem
othe
rapy
are
stor
ed
in d
istinc
tly c
olor
ed b
ins a
nd a
re
sepa
rate
d fr
om o
ther
ora
l uni
t dos
e m
edic
ation
s.
Ora
l cyt
otox
ic m
edic
ation
s may
be
adm
inist
ered
by
a no
n-ch
emot
hera
py
qual
ified
nur
se.
Prop
er c
hem
othe
rapy
pr
ecau
tions
and
use
of p
erso
nal
prot
ectiv
e eq
uipm
ent)
will
be
empl
oyed
. A
doub
le c
heck
with
ano
ther
nur
se w
ill b
e pe
rfor
med
and
doc
umen
ted
on th
e M
AR
or e
lect
roni
cally
in e
MAR
.
Conc
entr
ated
el
ectr
olyt
es:
Calc
ium
chl
orid
e/gl
ucon
ate,
Mag
nesiu
m su
lfate
,Po
tass
ium
chl
orid
e/ph
osph
ate,
Sod
ium
ch
lorid
e /p
hosp
hate
CC, I
ntC,
MS
The
Insti
tute
for S
afe
Med
icati
on
Prac
tices
(ISM
P), t
he P
harm
acy
and
Ther
apeu
tics C
omm
ittee
and
the
Depa
rtm
ent o
f Pha
rmac
y al
l disc
oura
ge
the
prac
tice
of a
ddin
g lid
ocai
ne to
IV
infu
sions
.
Calc
ium
chl
orid
e an
d ca
lciu
m g
luco
nate
•
Phys
icia
n or
ders
mus
t cle
arly
iden
tify
the
calc
ium
salt
desir
ed a
nd th
e sp
ecifi
c do
se in
mEq
, mg
or g
ram
s (ca
lciu
m
gluc
onat
e =
4.65
mEq
cal
cium
/gra
m,
calc
ium
chl
orid
e =
13.6
mEq
cal
cium
/gr
am).
• Sh
all n
ot b
e in
the
floor
stoc
k of
any
nu
rsin
g un
it, e
xcep
t in
emer
genc
y ca
rts.
Di
lute
d pr
emix
ed b
ags m
ay b
e st
ored
in
auto
mat
ed d
ispen
sing
cabi
net.
Mag
nesiu
m S
ulfa
te:
• Sh
ould
be
orde
red
base
d on
the
num
ber o
f gra
ms t
o be
adm
inist
ered
, no
t by
volu
me
or p
erce
ntag
e.
• Sh
all n
ot b
e in
the
floor
stoc
k of
any
nu
rsin
g un
it, e
xcep
t in
emer
genc
y Co
de
cart
s. D
ilute
d pr
emix
ed b
ags m
ay b
e st
ored
in a
utom
ated
disp
ensin
g ca
bine
t.•
The
stan
dard
mag
nesiu
m IV
co
ncen
trati
on fo
r SM
C La
bor a
nd
Deliv
ery
depa
rtm
ent i
s 10
gram
s in
250m
lSo
dium
chl
orid
e/ph
osph
ate:
• Vi
als o
f NaC
l with
a c
once
ntra
tion
> 0.
9% a
re st
ored
onl
y in
pha
rmac
y an
d ar
e st
ored
sepa
rate
ly fr
om 0
.9%
NaC
l in
the
phar
mac
y.
• Ph
osph
ate
salts
are
nor
mal
ly o
rder
ed in
m
illim
iole
s (m
mol
). So
dium
pho
spha
te
cont
ains
4 m
Eq o
f sod
ium
and
3 m
mol
of
pho
spha
te p
er 1
ml.
Pota
ssiu
m C
hlor
ide/
Phos
phat
e:•
The
conc
entr
ation
of p
otas
sium
in
an in
trav
enou
s sol
ution
is d
epen
dent
on
the
type
of I
V ac
cess
(cen
tral
or
perip
hera
l lin
e).
The
adm
inist
ratio
n ra
te o
f int
rave
nous
pot
assiu
m so
lutio
ns
is de
pend
ent o
n th
e ab
ility
to p
rovi
de
conti
nuou
s car
diac
mon
itorin
g.
Calc
ium
chl
orid
e an
d ca
lciu
m g
luco
nate
•
Infu
se 1
gm
/hr
Mag
nesiu
m S
ulfa
te:
• In
fuse
1 g
m/h
r all
area
s exc
ept:
• U
p to
6 g
ram
load
ing
dose
ove
r 30
min
utes
in L
&D,
follo
wed
by
infu
sion
of
up to
4 g
ram
s/ho
ur,
• U
p to
5 g
ram
load
ing
dose
ove
r 45
min
utes
in C
C ar
eas f
or H
ypot
herm
ia
Post
Car
diac
Arr
est P
roto
col,
follo
wed
by
infu
sion
of 1
gra
m/h
our,
• U
p to
4 g
ram
s inf
used
ove
r 1 h
our f
or
elec
trol
yte
repl
acem
ent i
n CC
are
as,
• Ra
pid
IV p
ush
in C
C ar
eas O
NLY
und
er
dire
ct p
hysic
ian
supe
rvisi
on fo
r acu
te
bron
chos
pasm
or o
ther
resp
irato
ry/
card
iac
emer
genc
y.So
dium
Chl
orid
e:•
Solu
tions
mor
e co
ncen
trat
ed th
an 0
.9%
N
aCl r
equi
re a
pum
p fo
r adm
inist
ratio
n•
If an
ticip
ated
use
is 4
8 ho
urs o
r les
s,
3% N
aCl m
ay b
e ru
n vi
a pe
riphe
ral l
ine.
If
antic
ipat
ed o
r act
ual u
se is
gre
ater
th
an 4
8 ho
urs,
a c
entr
al li
ne sh
ould
be
plac
ed.
• If
adm
inist
erin
g pe
riphe
rally
, any
m
aint
enan
ce fl
uids
shou
ld b
e ru
n vi
a Y-
site
with
the
3% N
aCl i
nfus
ion.
•
3% N
aCl i
nfus
ion
may
be
used
in n
on-
criti
cal c
are
area
s onl
y at
a ra
te o
f 30
mL/
hour
or l
ess (
max
imum
rate
doe
s no
t app
ly to
criti
cal c
are
area
s).
The
48-
hour
rule
app
lies f
or p
erip
hera
l ver
sus
cent
ral a
cces
s.
• Br
ain
inju
ry p
atien
ts w
ith e
leva
ted
ICPs
re
quiri
ng h
igh
rate
3%
NaC
l inf
usio
n or
AN
Y 23
.4%
NaC
l bol
us re
quire
cen
tral
ve
nous
acc
ess.
Page 9
SAMPLE
Med
icati
onAr
eas A
llow
edCo
mm
ents
, Sto
rage
Phar
mac
y N
otes
Nur
sing
Not
es
• Co
ncen
trati
on L
imits
:
- Per
iphe
ral l
ine-
10
meq
/100
ml
- C
entr
al li
ne -2
0 m
Eq p
er 1
00 m
L.•
Dose
Lim
its:
-
40 m
Eq d
oses
are
the
max
imum
sing
le
dose
size
that
will
be
disp
ense
d fo
r a
patie
nt in
a C
ritica
l Car
e m
onito
red
patie
nt.
-
Dose
s will
onl
y be
disp
ense
d in
10
mEq
incr
emen
ts fo
r non
-Criti
cal C
are
mon
itore
d pa
tient
s.•
Rate
Lim
its:
-
For n
on-C
ritica
l Car
e m
onito
red
patie
nts:
10
mEq
/hou
r max
imum
rate
.
- Fo
r Criti
cal C
are
mon
itore
d pa
tient
s:
20 m
Eq/h
our m
axim
um ra
te a
nd
patie
nt sh
ould
hav
e co
ntinu
ous c
ardi
ac
mon
itorin
g.
-
Rate
lim
its in
clud
e al
l pot
assiu
m b
eing
ad
min
ister
ed th
roug
h m
aint
enan
ce IV
flu
ids +
pig
gyba
ck a
dmin
istra
tion.
Pota
ssiu
m C
hlor
ide/
Phos
phat
e:•
Pota
ssiu
m w
ill n
ot b
e gi
ven
by IV
pus
h or
und
ilute
d fo
rm•
Pota
ssiu
m in
fusio
ns w
ill b
e ad
min
ister
ed v
ia a
n IV
pum
p
Dexm
edet
omid
ine
CC
Digo
xin
CC, I
ntC,
MS*
*Se
e ab
ove,
lim
its o
n us
e ou
tsid
e of
CC,
In
tC
Digo
xin
Imm
une
Fab
CC, I
ntC
Dilti
azem
CC, I
ntC,
MS*
*Se
e ab
ove,
lim
its o
n us
e ou
tsid
e of
CC,
In
tC
Dobu
tam
ine
CC, I
ntC
CCU
or P
CU (fi
xed
dose
s) o
nly
Dopa
min
e***
CC, I
ntC
CCU
or P
CU( fi
xed
dose
less
than
10
mcg
/kg/
min
) onl
yCo
nsid
er c
entr
al v
enou
s acc
ess f
or
infu
sions
>5
mcg
/kg/
min
for 1
2-24
hou
rs
Enal
april
atCC
, Int
C, M
S**
See
abov
e, li
mits
on
use
outs
ide
CC, I
ntC
Epid
ural
m
edic
ation
sSe
e P&
P: P
atien
t Con
trol
led
Anal
gesia
#8
614.
143
and
Epid
ural
Pai
n M
anag
emen
t #86
14.1
40.
• D
oubl
e ch
eck
on a
ll ord
er e
ntry
requ
ired.
• M
ake
sure
anti
coag
ulan
t dos
e ar
e
app
ropr
iate
for c
oncu
rren
t epi
dura
l
adm
inist
ratio
n
Ephe
drin
eCC
Ephe
drin
e m
ay b
e ad
min
ister
ed b
y an
an
esth
esio
logi
st, o
r nur
se a
nest
hetis
t; se
e P&
P M
edic
al S
cree
ning
of t
he
Obs
tetr
ic p
atien
t Cl
assifi
ed a
s con
trol
led
subs
tanc
e an
d st
ored
in th
e CI
I saf
e.
May
onl
y be
disp
ense
d th
ru P
yxis
or
dire
ctly
to a
phy
sicia
n.•
Ephe
drin
e m
ust b
e di
lute
d an
d ad
min
ister
ed in
5-1
0 m
g in
crem
ents
. •
Ephe
drin
e m
ay a
lso b
e ad
min
ister
ed
by a
CCU
nur
se u
nder
the
dire
ction
of
a p
hysic
ian
for p
ost-i
ntub
ation
hy
pote
nsio
n.
Page 10
SAMPLE
Med
icati
onAr
eas A
llow
edCo
mm
ents
, Sto
rage
Phar
mac
y N
otes
Nur
sing
Not
es
Eptifi
batid
eCC
, Int
CCC
U, P
CU o
nly
Esm
olol
CC
Epin
ephr
ine*
**CC
Infu
sions
requ
ire c
entr
al v
enou
s acc
ess
Fact
or V
IICC
Asso
ciat
ed w
ith ri
sk fo
r thr
ombo
sisPr
oper
dos
ing
shal
l be
verifi
ed b
y th
eph
ysic
ian
and
phar
mac
ist.
Fact
or IX
Com
plex
CC
Asso
ciat
ed w
ith ri
sk fo
r thr
ombo
sis.
Prop
er d
osin
g sh
all b
e ve
rified
by
the
phys
icia
n an
d ph
arm
acist
.
Fent
anyl
PCA
CC, I
ntC,
MS
Fent
anyl
inje
ction
CC, I
ntC,
MS
(see
not
e)In
tC, M
S-Si
ngle
dos
e of
100
mcg
or l
ess
for a
pro
cedu
re (e
xcep
tion
for o
ncol
ogy
and
5 Ea
st).
Onc
olog
y an
d 5
East
: Int
erm
itten
t dos
ing
is al
low
ed fo
r pai
n an
d pa
lliati
ve c
are
patie
nts.
Onc
olog
y –
dose
s of 1
00 m
cg o
r les
s for
patie
nts w
ith h
istor
y of
opi
ate
use
and
seve
re p
ain
asso
ciat
ed w
ith c
ance
r.CC
-Inte
rmitt
ent d
osin
g or
infu
sion
for p
ain
Onc
olog
y an
d 5
East
– A
dmin
istra
tion
requ
ires o
xyge
n sa
tura
tion
and
resp
irato
ryra
te m
onito
ring.
Hydr
alaz
ine
CC, I
ntC,
MS*
*Se
e ab
ove,
lim
its o
n us
e ou
tsid
e CC
, Int
C
Ibut
alid
eCC
, Int
CCC
U, P
CU o
nly
Insu
linCC
, Int
C, M
S (iv
,su
b-q)
CC, L
D(iv
drip
)
• M
ultip
le d
ose
insu
lin v
ials
avai
labl
e as
flo
or st
ock.
• Th
e st
anda
rd in
sulin
drip
con
cent
ratio
n is
100
uni
ts/1
00m
l (1
unit
per 1
ml).
Dr
ips m
ay o
nly
be in
fuse
d in
CCU
and
LD
.•
Bloo
d gl
ucos
e le
vels
will
be
chec
ked
prio
r to
initi
ation
of a
sing
le d
ose
or in
fusio
n an
d at
regu
lar i
nter
vals
ther
eafte
r.
• Al
l ins
ulin
dos
es sh
all b
e do
uble
-ch
ecke
d by
a se
cond
nur
se a
nd th
is do
uble
che
ck is
doc
umen
ted
in th
e el
ectr
onic
MAR
or o
n th
e M
AR.
• Al
l ins
ulin
drip
s are
pre
pare
d by
ph
arm
acy,
requ
ire a
pum
p fo
r ad
min
istra
tion,
and
mus
t hav
e th
e ra
te
doub
le-c
heck
ed b
y a
seco
nd n
urse
(c
hart
ed o
n th
e M
AR).
• Th
e se
cond
nur
se p
erfo
rmin
g th
e do
uble
che
ck is
resp
onsib
le fo
r che
ckin
g th
e pr
epar
ation
labe
ling
and
antic
ipat
ed
adm
inist
ratio
n on
ly. T
he se
cond
nur
se
is no
t per
form
ing
a re
view
of t
he in
itial
ph
ysic
ian’
s ord
er o
r sub
sequ
ent p
atien
t as
sess
men
t.
Page 11
SAMPLE
Med
icati
onAr
eas A
llow
edCo
mm
ents
, Sto
rage
Phar
mac
y N
otes
Nur
sing
Not
es
Intr
athe
cal
med
icati
onCC
CCU
or O
R on
ly•
Intr
athe
cal (
IT) d
oses
will
be
labe
led
usin
g ap
prop
riate
rout
e of
ad
min
istra
tion
auxi
liary
labe
ls.
• Ph
arm
acy
will
pre
pare
IT d
oses
acc
ordi
ng
to a
pplic
able
dep
artm
ent P
&Ps
.•
Phar
mac
y pe
rson
nel w
ill h
and
carr
y do
ses t
o th
e pa
tient
’s nu
rse
or
phys
icia
n.
• Ad
min
istr
ation
is re
stric
ted
to th
e ph
ysic
ian.
Eac
h pr
ovid
er (p
harm
acist
, ph
ysic
ian,
nur
se) w
ill v
erify
the
rout
e of
ad
min
istra
tion.
Keta
min
e CC
, Int
C, M
SKe
tam
ine
use
is do
se-d
epen
dent
. Ke
tam
ine
may
be
used
for a
nalg
esia
at
dose
s les
s tha
n or
equ
al to
0.2
5 m
g/kg
via
slow
IVP
or 0
.1 m
g/kg
/hr i
nfus
ion
and
may
be
give
n on
the
floor
. Do
ses
that
exc
eed
thes
e lim
its, o
r dos
ing
for
seda
tion
mus
t be
give
n in
CC
area
s.Fo
r pro
cedu
ral s
edati
on, r
efer
ence
8711
.601
• Ad
min
istra
tion
requ
ires c
ontin
uous
ox
ygen
satu
ratio
n an
d re
spira
tory
rate
m
onito
ring
Labe
talo
lCC
, Int
C, M
S**
See
abov
e, li
mits
on
use
outs
ide
CC, I
ntC
Lido
cain
eCC
, Int
C, M
SDo
ses l
ess t
han
or e
qual
to 1
.5 m
g/kg
give
n ov
er 1
0 m
inut
es m
ay b
e gi
ven
onth
e flo
or (m
axim
um o
f 200
mg
per d
ose)
. Do
ses t
hat e
xcee
d th
is m
ust b
e gi
ven
in C
CU o
r Int
C ar
eas.
Met
hyld
opa
CC, I
ntC,
MS*
*Se
e ab
ove,
lim
its o
n us
e ou
tsid
e CC
, Int
C
Met
opro
lol
CC, I
ntC,
MS*
*Se
e ab
ove,
lim
its o
n us
e ou
tsid
e CC
, Int
C
Milr
inon
eCC
, Int
CCC
U o
r PCU
( fixe
d do
se le
ss th
an10
mcg
/kg/
min
) onl
y
Neu
rom
uscu
lar
Bloc
king
age
nts:
Atra
curir
um,
cisa
trac
uriu
m,
panc
uron
ium
,ro
curo
nium
,su
ccin
ylch
olin
e,ve
curo
nium
CCPa
tient
s mus
t be
in C
ritica
l Car
e M
onito
red
area
s onl
y.•
Patie
nts o
n ne
urom
uscu
lar b
lock
ing
infu
sions
mus
t hav
e re
gula
rly sc
hedu
led
dose
s or a
con
tinuo
us in
fusio
n of
a
seda
tive
agen
t.•
Patie
nts o
n ne
urom
uscu
lar b
lock
ing
infu
sions
mus
t hav
e re
gula
rly sc
hedu
led
dose
s or a
con
tinuo
us in
fusio
n of
a
narc
otic
anal
gesic
age
nt.
• Pa
tient
s rec
eivi
ng d
oses
of
neur
omus
cula
r blo
ckin
g dr
ugs m
ust
have
a p
rote
cted
airw
ay (i
ntub
ated
, m
echa
nica
l ven
tilati
on).
• Re
com
men
ded
mon
itorin
g fo
r pati
ents
on
neu
rom
uscu
lar b
lock
ing
infu
sions
in
clud
es u
se o
f a p
erip
hera
l ner
ve
stim
ulat
or to
mon
itor r
espo
nse
and
avoi
d ov
erdo
se.
Page 12
SAMPLE
Med
icati
onAr
eas A
llow
edCo
mm
ents
, Sto
rage
Phar
mac
y N
otes
Nur
sing
Not
es
Nic
ardi
pine
CC
Nitr
ogly
cerin
CC, I
ntC
Nitr
opru
ssid
eCC
Nor
epin
ephr
ine*
**CC
Infu
sions
requ
ire c
entr
al v
enou
s acc
ess
Opi
ates
CC, I
ntC,
MS
See
P&P
Seda
tion/
Anal
gesia
#87
11.6
01•
Use
dos
e fr
actio
natio
n w
hen
appr
opria
te.
Nar
cotic
frac
tiona
tion-
adm
inist
erin
g le
ss
than
the
dose
ord
ered
by
the
phys
icia
n at
a g
iven
tim
e. D
ose
may
be
repe
ated
w
ithin
the
orde
red
time
fram
e as
long
as
the
cum
ulati
ve d
oses
do
not e
xcee
d th
e in
itial
dos
e.
Phen
ylep
hrin
e***
CCIn
fusio
ns >
100
mcg
/min
ute
requ
irece
ntra
l ven
ous a
cces
s
Phen
ytoi
nCC
, Int
C, M
SPh
enyt
oin
and
fosp
heny
toin
hav
epa
rticu
larly
nar
row
ther
apeu
tic m
argi
ns,
whi
ch m
ay p
ut p
atien
ts a
t risk
for t
oxic
ity.
The
dilu
ent i
n ph
enyt
oin
may
also
cau
se
toxi
c sid
e eff
ects
ther
efor
e, th
is pr
oduc
tis
non-
form
ular
y.
• By
usin
g ph
enyt
oin
sodi
um m
illig
ram
eq
uiva
lent
s (m
g PE
), ph
ysic
ians
will
no
t hav
e to
mak
e do
sing
adju
stm
ents
w
hen
conv
ertin
g fr
om p
heny
toin
so
dium
to fo
sphe
nyto
in o
r vic
e ve
rsa.
Fos
phen
ytoi
n sh
ould
alw
ays b
e pr
escr
ibed
and
disp
ense
d in
phe
nyto
in
sodi
um m
illig
ram
equ
ival
ents
(mg
PE).
• M
onito
r for
neu
roto
xici
ty (n
ysta
gmus
, di
plop
ia) a
nd c
ardi
ovas
cula
r effe
cts
(hyp
oten
sion
and
dysr
hyth
mia
) du
ring
and
imm
edia
tely
follo
win
g IV
fo
sphe
nyto
in a
dmin
istra
tion.
• Pa
tient
s with
hist
ory
of c
ardi
ac d
iseas
e,
and
patie
nts w
ith a
n ar
rhyt
hmia
shou
ld
have
con
tinuo
us E
KG m
onito
ring
whi
le
rece
ivin
g do
ses o
f fos
phen
ytoi
n.
• Th
e m
axim
um ra
te o
f adm
inist
ratio
n fo
r fos
phen
ytoi
n is
100
mg
PE/m
in.
Patie
nts i
n Cr
itica
l Car
e m
onito
ring
area
s may
rece
ive
fosp
heny
toin
at 1
50
mg
PE/m
in fo
r man
agem
ent o
f sta
tus
epile
pticu
s•
Fosp
heny
toin
is n
ot a
ves
ican
t and
may
be
giv
en IM
.
Phyt
onad
ione
CC, I
ntC,
MS
Intr
amus
cula
r and
subc
utan
eous
rout
esof
adm
inist
ratio
n fo
r phy
tona
dion
e do
ses
shou
ld n
ot b
e ro
utine
ly u
sed.
Phyt
onad
ione
for i
ntra
veno
us u
se m
ust
be d
ilute
d in
a 5
0 m
L IV
pig
gyba
ck a
ndad
min
ister
ed o
ver 3
0-60
min
utes
(max
imum
1m
g pe
r min
ute)
.
Mon
itor b
lood
pre
ssur
e, h
eart
rate
, and
resp
iratio
ns e
very
5 m
inut
es x
3 th
enev
ery
15 m
inut
es x
3 fo
r sym
ptom
s of
anap
hyla
xis o
r sho
ck fo
llow
ing
IVad
min
istra
tion
of p
hyto
nadi
one.
Proc
aina
mid
eCC
, Int
C
Page 13
SAMPLE
Med
icati
onAr
eas A
llow
edCo
mm
ents
, Sto
rage
Phar
mac
y N
otes
Nur
sing
Not
es
Prom
etha
zine
CC, I
ntC,
MS
Prom
etha
zine
has b
een
iden
tified
as
a ve
sican
t whi
ch m
eans
it h
as th
e po
tenti
al to
cau
se ti
ssue
irrit
ation
and
, in
som
e ca
ses,
nec
rosis
.
Initi
al d
oses
of p
rom
etha
zine
shou
ld
be in
the
6.25
– 1
2.5
mg
rang
e an
d it
is re
com
men
ded
that
dos
es b
e fr
actio
nate
d in
6.2
5 m
g in
crem
ents
.
• Pr
omet
hazin
e sh
ould
be
give
n in
to a
ru
nnin
g IV
line
at t
he p
ort f
urth
est f
rom
th
e pa
tient
’s ve
in.
• If
nece
ssar
y to
adm
inist
er p
rom
etha
zine
by IV
pus
h di
lute
pro
met
hazin
e in
10-
20 m
ls of
flui
d an
d gi
ve b
y se
cond
ary
infu
sion
over
10-
15 m
inut
es.
• M
onito
r pati
ent f
or a
dver
se re
actio
ns
and
educ
ate
patie
nt to
repo
rt a
ny
prob
lem
s with
pro
met
hazin
e
Prop
ofol
CC
Prop
rano
lol
CC, I
ntC,
MS*
*Se
e ab
ove,
lim
its o
n us
e ou
tsid
e CC
, Int
C
Qui
nidi
neCC
Rocu
roni
umCC
Ster
ile W
ater
Hypo
toni
c so
lutio
ns su
ch a
s ste
rile
wat
erfo
r inj
ectio
n sh
ould
not
be
used
for d
irect
IV a
dmin
istra
tion
due
to ri
sk o
f red
blo
odce
ll he
mol
ysis.
Phar
mac
y m
ay n
ot d
ispen
se h
ypot
onic
solu
tions
for I
V in
fusio
n su
ch a
s 0.2
25N
aCl (
quar
ter-n
orm
al sa
line,
1/4
nor
mal
salin
e).
For p
atien
t con
ditio
ns w
here
ahy
poto
nic
or lo
w so
dium
solu
tions
are
requ
ired
(suc
h as
hyp
erna
trem
ia),
the
Insti
tute
for S
afe
Med
icati
on P
racti
ces
(ISM
P) a
nd th
e Ph
arm
acy
Depa
rtm
ent
both
reco
mm
end
usin
g 0.
45%
NaC
l (ha
lfno
rmal
salin
e, 1
/2 n
orm
al sa
line)
whi
ch is
cons
ider
ed a
hyp
oton
ic so
lutio
n or
D5W
or D
51/4
NS
whi
ch b
oth
cont
ain
little
or n
oso
dium
.
Tene
ctep
lase
CC
Uro
kina
seCC
Vaso
pres
sinCC
Vera
pam
ilCC
, Int
C, M
S**
See
abov
e, li
mits
on
use
outs
ide
CC, I
ntC
Page 14
SAMPLE
Page 15
Policy:A. The purpose of this policy is to provide guidelines for
the care of patients receiving sedation/analgesia while undergoing invasive, manipulative, interventional or diagnostic procedures. Sedation/analgesia administration is directed by the Anesthesia Section, which establishes guidelines and makes recommendations to assure that sedation/analgesia is administered in a safe and appropriate manner. This will be achieved through continuous quality monitoring of sedation/analgesia administration by the involved department. Note: This policy is not meant to address pain management; sedation of patients on ventilators; or similar situations in which medications are administered for reasons other than to provide sedation/analgesia (i.e., routine preoperative PO/IM
medications). Pediatric patients less than 12 years of age, refer to Rocky Mountain Hospital for Pediatric Procedure/Analgesia Policy.
Definitions of Sedation: A. MINIMAL SEDATION (anxiolysis) A drug-induced state during which patients respond
normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.
B. MODERATE SEDATION/ANALGESIA (“conscious sedation”) A drug-induced depression of consciousness during
which patients respond purposefully* to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.
C. DEEP SEDATION/ANALGESIA A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully* following repeated or painful stimulation. The ability to independently maintain ventilatory function maybe impaired. Patients may require assistance in maintaining a patent airway and spontaneous ventilation may be inadequate. Cardiovascular function is usually
maintained.
In those cases in which there is an intention for deep sedation using Etomidate or Propofol,
1. Adverse trends will be monitored in the Patient Safety Committee and in Peer Review.
2. CO2 monitoring will be used for patient monitoring.
D. GENERAL ANESTHESIA Consists of general anesthesia and spinal or major regional anesthesia. It does not include local anesthesia. General anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful
stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.
Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Hence, practitioners intending to produce a given level of
sedation should be able to rescue patients whose level of sedation becomes deeper than initially intended.
*Reflex withdrawal from a painful stimulus in NOT considered a purposeful response.
Qualifications/Training for Administering and Monitoring of Sedation/Analgesia: A. CREDENTIALING Practitioners prescribing/administering sedation/
analgesia must satisfy the credentialing requirements as stated by the Credentialing Committee. Personnel administering, and monitoring sedation/analgesia must have demonstrated competency in sedation/analgesia.
Competence includes, but is not limited to knowledge
of pulse oximetry; medication selection, usage and complications; airway management skills; and cardiac dysrhythmias.
TITLE: Procedural SedationCATEGORY: Patient Care Check one: List department if department specific:
HOSPITAL-WIDE DEPARTMENT-SPECIFIC FOR g
POLICY NUMBER: RESOURCE PERSON:
SAMPLE
a
B. QUALIFICATIONS FOR DEEP SEDATION The patient receiving deep sedation/analgesia may
descend into anesthesia and require rescue breathing and airway management. Deep sedation privileges are intended to be restricted to physicians who are trained and experienced in airway management and the rescue of patients from respiratory and cardiovascular events. The privilege for deep sedation, therefore, is limited. It is intended to be granted to only three categories of physicians in addition to anesthesiologists.
1. Physicians who are board certified in emergency medicine to facilitate the care of adult patients in need of emergent care in which more than moderate sedation is necessary for a very brief period of time, and without which deep sedation, the patient’s care could not be safely or effectively rendered. 2. Physicians who are board certified in critical care medicine for emergency airway management. These physicians may also administer propofol infusions for the sedation of patients who are mechanically ventilated; however, these guidelines do not apply to that situation. 3. Physicians who are board certified in pulmonology for the purpose of emergency airway management. These physicians may also administer propofol infusions for the sedation of patients who are mechanically ventilated; however, these guidelines do not apply to that situation. Please note: Pediatricians credentialed through and practicing in the Emergency Department may qualify for the administration of ketamine under these guidelines in addition to their moderate sedation privileges, but are NOT credentialed for the use of etomidate, methohexital, or propofol.
C. PHYSICIAN RESPONSIBILITIES 1. The physician with deep sedation privileges is responsible for rescue and although he may be assisted by others, should not delegate this responsibility to anyone other than another physician with deep sedation privileges, an anesthesiologist or a certified registered nurse anesthetist. 2. The physician with deep sedation privileges is responsible for attention to monitoring the patient’s cardiac and respiratory status and level of consciousness throughout the deep sedation. 3. The physician with deep sedation privileges is responsible for assuring that the patient is recovered from the deep sedation and that the
patient meets the criteria to be discharged from that recovery.
4. The standards of care and record keeping responsibilities for the non-anesthesiologist administering deep sedation are the same as those for an anesthesiologist or CRNA. Procedure: A. PROCEDURE TYPES 1. Deep sedation is intended only for those very brief emergent procedures in which the physician’s attention is not diverted from monitoring the patient’s physiological status and attending to rescue. These would include brief orthopedic procedures such as reduction of shoulder or hip dislocations as well as emergency airway management procedures. 2. Procedures performed under deep sedation in which the physician’s attention is diverted from continuous monitoring and rescue should generally involve the Anesthesia department and require the presence of an anesthesiologist or CRNA, or if unavailable, require the presence of another physician credentialed in deep sedation to attend to continuous monitoring and rescue of the patient. 3. Non-emergent procedures and procedures which are not anticipated to be brief, as well as procedures in which the physician’s attention is anticipated to be diverted from monitoring and the ability to immediately attend to rescue, should be scheduled with the Anesthesia department. B. The following protocol has been established in all
areas in which sedation/analgesia is administered at the moderate or deep level. Because sedation is a continuum, a patient intended to receive minimal sedation may be induced at a deeper level. Because of this, all the requirements and or equipment will need to be readily available.
1. Patient Selection is the responsibility of the physician prescribing sedation/analgesia. 2. Informed consent is required for the procedure and the administration of sedation/analgesia. This is a responsibility of the physician. Please see “informed consent for surgical-medical invasive procedures” policy for further details. 3. Hospital Locations/Departments: Deep sedation by non-anesthesia providers may be administered to emergent patients in the Critical Care Unit or Emergency Department and extended to limited areas such as the Medical Imaging Department where the emergent patient is under the immediate care of the emergency physician.
Page 16
SAMPLE
Page 17
Other areas where sedation/analgesia is administered including but not limited to the following: a. Endoscopy Dept. b. Critical Care c. Emergency Dept. d. Minor Procedure e. Cardiac Cath Lab f. PACU g. Operating Room h. Labor & Delivery i. Radiology j. Cardiovascular Testing 4. Only a physician is qualified to order and/or select the medication(s) to achieve sedation/analgesia. 5. Drug Administration: a. The prescribing physician will order the medication used to achieve sedation/analgesia. b. Personnel administering drugs to achieve sedation/analgesia will do so under the direct supervision of a physician who orders the drug, dose and route of administration. Physicians may also administer the medications. c. Personnel must wait the onset interval before re-administration. d. Documentation of drug, dose, route and time of administration will be recorded in the medical record. 6. Management and Monitoring Requirements: a. Intravenous access must be continuously maintained during the procedure and recovery phase for IV sedation/analgesia. For other forms of sedation/analgesia intravenous access is left up to the discretion of the physician prescribing. b. Monitoring the patient's physiological parameters involves continuous visual observation by personnel who have demonstrated competence in sedation/analgesia and assessment for behavioral and physiological changes. This includes monitoring for hypersensitivity reactions, cardiovascular depression, respiratory depression, central nervous system depression and toxicity. c. A designated individual, other than the practitioner performing the procedure, should be present to monitor the patient throughout procedures performed with sedation/analgesia. This individual may assist with minor, interruptible tasks.
d. The following minimal monitoring parameters are as follows: i. Monitor the blood pressure, level of consciousness, heart rate and respiratory rate. ii. Monitor continuous O2 saturation. iii. EKG monitoring should be readily available and is performed if clinically indicated. e. The following vital signs must be immediately reported to the directing/ordering physician: i. Respiratory rate less than 10/minute or greater than 20/minute. ii. Blood pressure variant of 30% of baseline.
iii. Heart rate variant of 25% of baseline. iv. Oxygen saturation lower than 90%. (or per physician direction relative to patient baseline) v. Level of consciousness in which the patient cannot communicate verbally or follow
verbal commands. f. The following emergency equipment will be immediately accessible to every location where sedation/analgesia is administered and includes at least the following: i. Defibrillator ii. Suction device iii. Oxygen iv. Airways v. Emergency drugs, i.e., Narcan and Romazicon vi. Ambu bag vii. Intubation equipment viii. EKG monitor 7. Documentation Requirements: Documentation during sedation/analgesia reflects continued assessment, planning, implementation and evaluation of the patient. 8. Pre-Procedure: a. A valid History & Physical will be on the chart. b. A physician shall perform a pertinent pre-procedural assessment immediately prior to the procedure to include: i. Abnormalities of the major organ systems ii. American Society of Anesthesia (ASA)/ Anesthesia sedation/analgesia classification iii. Verification of past and present medical and
drug history, previous anesthesia experience(s) iv. Focused physical examination including auscultation of the heart and lungs and evaluation of the airway/neck v. Assessment of pain status vi. A note indicating that the patient is an appropriate candidate for sedation/analgesia, including high-risk patients for sedation/
analgesia.
SAMPLE
High-risk patients are defined as those with: • A history of sleep apnea, airway trauma, or prior difficult intubation. • Morbid obesity. • Known abnormal airway. c. If there is not a valid H&P, the pre-sedation MD assessment will be completed, including the following: i. Abnormalities of the major organ systems ii. ASA/Anesthesia sedation/analgesia classification iii. Verification of past and present medical and drug history, previous anesthesia experience(s) iv. Focused physical examination including auscultation of the heart and lungs and evaluation of the airway v. Assessment of pain status vi. A note indicating that the patient is an appropriate candidate for sedation/
analgesia, including high-risk patients for sedation/analgesia. High risk patients are defined as those with: • A history of sleep apnea, airway trauma, or prior difficult intubation. • Morbid obesity. • Known abnormal airway. d. The physician shall also obtain consent for sedation/analgesia and the procedure to be performed. e. A clinician will collect the following data and document appropriately: i. Current medications and drug allergies ii. Time and nature of last oral intake/NPO (nothing by mouth) status, including
guidelines iii. History of tobacco, alcohol or substance abuse iv. Blood pressure, pulse, and respirations v. Level of consciousness and response vi. Pulse oximetry reading (room air oximetry should be greater than or equal to 90% saturation) vii. Any age specific education provided for the specific procedure and other relevant
health care needs. f. Document assessment of NPO status: NPO STATUS GUIDELINES: ADULT: NPO status - 2 hours clear liquids - 8 hours all other intake EXCEPTION: Emergency situations g. Document current weight in kilograms
(pediatrics).
9. Intra-Procedure: a. The first evaluation of level of consciousness (LOC), blood pressure (B/P), pulse, respirations, CO2, oximetry and pain scale must be prior to sedation and at a minimum of every five minutes. b. O2 saturation is documented at a minimum of every five minutes. High-risk patients (see G.1.a) should have oxygen administered continually. If oxygen saturation cannot be maintained at or above 90% during the procedure, anesthesia consultation or assistance should be considered. c. Medications/fluids, including drug, dosage (bolus and maintenance), route, time(s) and person administering them are documented. d. Any unusual occurrences and their management (i.e. hypersensitivity) are documented. e. EKG monitoring. 10. Immediate Post-Procedure: Document the following: a. Patient's tolerance to sedation and procedure, and physiologic and psychological status. b. Place location transferred to and name of person receiving the patient. c. B\P, pulse and respirations. d. Continuous pulse oximeter reading. e. Level of consciousness and response. f. Assessment and management of pain 11. Performance Improvement: All use of reversal agents will be referred to pharmacy for internal review by a multidisciplinary committee that convenes quarterly. An occurrence report and reversal tool will be completed within 24 hours. a. Documentation review will be completed on a quarterly basis by the departments in which sedation/analgesia is administered. Action is required at the department level for significant deficiencies. Findings and action taken are sent to the Quality Management Department for compiling of statistics on a quarterly basis. 12. Post-Procedure: a. Post procedure monitoring should take place at least every fifteen minutes until stable. Vital signs should include but are not limited to LOC, B/P, pulse, respirations, assessment and management of pain, and pulse oximeter reading. Vital signs (VS) must be stable as compared to baseline readings taken pre-procedure
(+ 30% of pre-procedure). Minimum recovery period is 30 minutes after time of last sedation given.
Page 18
SAMPLE
SAMPLE
Page 19
13. Discharge for Outpatients: a. Patients should meet the discharge criteria for the department to include but not limited to: i. Patients should be alert and oriented; infants and patients whose mental status was initially abnormal should have returned to their baseline. Practitioners must be aware that pediatric patients are at risk for airway obstruction should the head fall forward while the child is secured in a car seat. ii. Vital signs should be stable and within 30% of pre-procedure. iii. If reversal agents are given, sufficient time (2 hr) should have elapsed after the last administration to ensure that patients do not become resedated after reversal effects have abated. Monitoring will continue during this time. iv. Patient and/or responsible adult have received verbal and written instructions relative to the post-procedure, medications, activities, signs and symptoms of complications with course of action to take if complications develop. b. Outpatients who receive sedation or narcotic analgesia shall not be allowed to drive themselves home. c. Outpatients who are not accompanied by an adult and do not meet discharge criteria shall be admitted for extended recovery per order of the attending physician. d. Any exception to the above shall require discharge confirmation from the physician. 14. Evaluation of Program: The Anesthesia Department, in collaboration with the Pharmacy and Therapeutics’ Committee monitors,
evaluates and reviews the program and quality improvement on a yearly basis.
Medications Used for Sedation/Analgesia Maximum dosages are not specified because sedation/analgesia is a continuum and an individual patient response is not always predictable. See table to follow.
Only a physician who is credentialed for deep sedation is qualified to order and/or select the medication(s) to achieve deep sedation. Medications that are categorized as deep sedation agents include propofol (Deprival) and etomidate (Amidate). Whenever these agents are used (except for sedation of mechanically ventilated patients) these deep sedation guidelines will apply. Etomidate (Amidate) is not recommended for deep sedation for children under ten years of age by non-anesthesiologists. Propofol (Deprival) is safe in children at least 3 years of age.
Ketamine (Ketalar) Ketamine is recognized as a unique dissociative agent and its use is restricted to physicians granted privileges for deep sedation administration as well as emergency room pediatricians covered under these guidelines. Specific monitoring requirements will be based on dosages administered. The guidelines for drug dosages can be found on Attachment A. It should be emphasized that the effects of ketamine are potentiated by all sedatives (i.e. midazolam and chloral hydrate) and all narcotics (i.e. fentanyl and morphine). Therefore ketamine dosages should be adjusted accordingly and titrated to effect. 1. Doses up to 5mg/kg IM or PO, 2mg/kg IV require continuous visual observation by a RN competent in sedation/analgesia administration and assessment for behavioral and physiologic changes. Additionally the presence of an appropriately privileged physician is required. a. Doses less than or equal to 1mg/kg IM or PO, 0.25mg/kg IV do not typically cause dissociative effects and therefore do not fall under the Procedural Sedation policy. 2. Doses over 5mg/kg IM or PO, 2mg/kg IV require an additional physician credentialed in deep sedation/analgesia or an anesthesiologist or CRNA to continuously monitor and provide cardiac and respiratory support as needed.
Drug Dosing Recommendations
Morphine
Page 20
2-10 mg IV (approx 0.1 mg/kg). Titrate to effect with 1-2 mg increments.
5 min 4-5 hrs Hypotension, bradycardia, respiratory depression, N/V
Onset Duration Complications Considerations
OPIOID ANALGESICS – do not give if respirations are less than 12 per minute. Use cautiously in patients with head injury, increased ICP, seizures, asthma, COPD, hepatic or renal disease.OPIOID ANALGESICS – do not give if respirations are less than 12 per minute. Use cautiously in patients with head injury, increased ICP, seizures, asthma, COPD, hepatic or renal disease.
Meperidine 25-100 mg (approx. 0.5-1 mg/kg) IV or IM. Titrate to effect with 12.5-25 mg increments.
5 min 1-3 hrs Hypotension, bradycardia, respiratory depression, N/V
Administer IV very slowly, preferable as a diluted solution. Contraindicated if patient has MAO inhibitors in last 2 days.
Fentanyl 25-100 mcg (approx. 0.5-1 mcg/kg/dose) IV. Titrate to effect.
3 min 60 min Hypotension, bradycardia, respiratory depression, N/V
Hydromorphone 0.5-2 mg IV or 0.01 mg/kg not to exceed 4 mg
15 min 2-3 hrs Hypotension, bradycardia, respiratory depression, N/V
BENZODIAZEPINES – potentiates the effects of narcotics and other sedatives. Decrease dose by 25% in elderly, debilitated, or chronically ill patient. If use with opiate, decrease dose by 30% in younger patients and 50% in elderly.
Diazepam 2.5-10 mg IV, may titrate up to 20 mg total or approx. 0.1 mg/kg
5 min 2-4 hrs Hypotension, bradycardia, respiratory depression
Do not mix with any other drug. Give in large vein.
Midazolam 0.5-2.5 mg IV, may titrate up to 20 mg total or approx. 0.1 mg/kg
2 min 1-2 hrs Hypotension, bradycardia, respiratory depression, apnea
Has beneficial amnestic effect which can diminish patient recall of events during the procedure.
Lorazepam 0.5-4 mg IV or 0.05 mg/kg
5 min 6-8 hrs Hypotension, bradycardia, respiratory depression
Infuse IV over 2-3 min not to exceed 2 mg/min.
Guidelines for Medications Used in Sedation/Analgesia
SAMPLE
Drug Dosing Recommendations
Propofol 1-2 mg/kg, may repeat dose at 0.5-1 mg/kg/min
10-30 sec 5-10 min Hypotension, bradycardia, pain on injection, respiratory depression, apnea
Use with patients with a history of severe cardiac or respiratory disease, seizures, increased ICP. Use lower doses in elderly, debilitated, or hypovolemic patients and ASA III or IV.
Onset Duration Complications Considerations
OTHER AGENTS
Etomidate 0.2-0.6 mg/kg IV over 30-60 sec. Repeat with small increments.
1-2 min 4-10 min Involuntary muscle movements, hypertension, hypotension, hyperventilation, hypoventilation, apnea, laryngospasm, N/V
Use with caution in patients with marked hypotension, severe asthma, or severe cardiovascular disease. Relatively minimal effects on cardiovascular and respiratory systems.
Ketamine 1-3 mg/kg IV, 3-5 mg/kg IM. Repeat increments of half initial dose.
30 sec 5-10 min Hypertension and tachycardia, psychological disturbances, enhanced skeletal muscle tone.
Give over at least 60 sec (faster may cause respiratory depression). Dilute with NS, D5W or SW to 50 mg/mL. Physiologic disturbance upon emergence less common in patients < 15 or > 65 years old. Contraindicated in head trauma and intracranial bleed or mass.
REVERSAL AGENTS
Flumazenil 0.2 mg IV over 15 sec. May repeat at 60 sec intervals up to 1 mg.
1-2 min 30 min Dizziness, N/V, seizures.
Administer as a series of small injections and not as a single bolus dose so that reversal can be controlled. Not for patients with coma of unknown origin, unknown or suspected mixed drug overdose, or history of seizure disorders. Patients who consume alcohol regularly or have received benzos for long-term therapy are especially at risk for seizure. Duration of benzo may be greater than that of flumazenil so repeated dose may be necessary.
Naloxone 0.1-2 mg IV, IM, or SC up to a total of 10 mg. Repeat doses at 2-3 min intervals. Titrate to effect.
2-3 min 30-90 min May cause hypertension, arrhythmias, pulmonary edema, ventricular fibrillation.
Duration or opioids may exceed that of naloxone so repeated doses may be necessary.
Page 21
SAMPLE
7335 East Orchard RoadGreenwood Village, Colorado 80111-2512www.cha.com
© 2018 CHA
