IV drug preparation Open heart

IV Drug Preparation & Administration Tips

:الصيدلي األول مدير وحدة الصيدلة اإلكلينيكية:

د/محمد عبد الحي /ريهام سميرد

JANUARY 26, 2016

Prepared by:

Mohammed Adel B.Sc., PharmD

Clinical Pharmacist

المستشفى: مدير

/محمد رشادد

1 | P a g e Prepared by: Mohammed Adel B.Sc, PharmD

Index

Inotropes:

o Adrenaline ……………………………..Page 2

o Noradrenaline…………………………Page 3

o Dopamine……………………………….Page 4

o Dobutamine (Dobutrex®)………..Page 5

o Milrinone (Primacor®)……………..page 5

Antibiotics

o Imipenem/Cilastatin (Tienam®)……Page 7

o Levofloxacin (TAvanic®)……………….Page 8

o Ciprofloxacin (Cipro®)……….………….Page 8

o Penicillin G (Parenteral/Aqueous)..Page 8

o Ampicillin/Sulbactam (Unasy®)…….Page 9

o Ceftriaxone………………………………..Page 10

o Vancomycin……………………………….Page 12


Index

Other IV Agents

o Potassium Chloride…..……………….Page 13

o Calcium gluconate………………….…Page 14

o Magnesium sulfate.……………….…..Page 16

o Aminophylline.…………………………..Page 17

o Amiodarone (Cordarone®)………….Page 18

o Regular Insulin……………………………Page 19

o Morphine.………………………………….Page 21

o Midazolam (Dormicum®)……………Page 21

o Protamine………………………………….Page 21

o Tranexamic acid (Kapron®)…………Page 22

o Ethamsylate (Dicynone®)…………..Page 22

o Phenytoin (Ipanotine®)………………Page 22

o Rantidine (Zantac®)……………………Page 24


Inotropes:

1. Adrenaline: Preparation for Administration

Dilution in dextrose containing solutions (provides protection against significant loss of potency by oxidation) and dilution in NS alone is not recommended, dilution in NS has been reported to be physically compatible (Trissel 2014).

Usual Infusion Concentrations: Adult IV infusion: 1 mg in 250 mL (concentration: 4 mcg/mL) or 4 mg in 250 mL (concentration: 16 mcg/mL) of D5W or NS; 1 mg in 1,000 mL (concentration: 1 mcg/mL) in D5W or D5NS

Administration: IV When administering as a continuous infusion,

central line administration is preferred. IV infusions require an infusion pump. If central line not available, as a temporary measure, may administer through a large vein. Avoid use of ankle veins (due to potential for gangrene), leg veins in elderly patients, or leg veins in those suffering from occlusive vascular diseases (eg, diabetic endarteritis, Buerger’s disease, arteriosclerosis, and atherosclerosis).

Vesicant; ensure proper needle or catheter placement prior to and during infusion; avoid extravasation.

Extravasation management: If extravasation

occurs, stop infusion immediately and Disconnect


(leave cannula/needle in place); gently aspirate

extravasated solution (do NOT flush the line);

remove needle/cannula; elevate extremity. Initiate phentolamine (or alternative antidote). Apply dry warm compresses (Hurst 2004). o Phentolamine: Dilute 5 to 10 mg in 10 to 15

mL NS and administer into extravasation site as soon as possible after extravasation (Peberdy 2010).

o Alternatives to phentolamine: Nitroglycerin topical 2% ointment

(based on limited case reports in neonates/infants): Apply 4 mm/kg as a thin ribbon to the affected areas; may repeat after 8 hours if needed (Wong 1992) or apply a 1-inch strip on the affected site (Denkler 1989).

Terbutaline (based on limited case reports): Infiltrate extravasation area using a solution of terbutaline 1 mg diluted to 10 mL in NS (large extravasation site; administration volume varied from 3 to 10 mL) or 1 mg diluted in 1 mL NS (small/distal extravasation site; administration volume varied from 0.5 to 1 mL) (Stier 1999).

Do not administer sodium bicarbonate (or any alkaline solution) through an IV line containing norepinephrine;


Stable in dextran 6% in dextrose, dextran 6% in NS, D5LR, D51/4NS, D51/2NS, D5NS, D5R, D2.5W, D5W, D10W, D10NS, LR, NS, Ringer's injection.

2. Noradrenaline Preparation for Administration

Dilute with D5W, D5NS, or NS; dilution in NS is not recommended by the manufacturer; however, stability in NS has been demonstrated (Tremblay, 2008).

Usual Infusion Concentrations: Adult IV infusion: 4 mg in 250 mL (concentration: 16 mcg/mL) or 8 mg in 250 mL (concentration: 32 mcg/mL) of D5W or NS

Administration: IV Administer as a continuous infusion with the

use of an infusion pump. Dilute prior to use. Administration via central line recommended (may cause severe ischemic necrosis if extravasated).

Do not administer sodium bicarbonate (or any alkaline solution) through an IV line containing norepinephrine; inactivation of norepinephrine may occur.


Extravasation management: If extravasation

occurs, stop infusion immediately and disconnect (leave cannula/needle in place); gently aspirate


extravasated solution (do NOT flush the line);

remove needle/cannula; elevate extremity. Initiate phentolamine (or alternative) antidote. Apply dry warm compresses (Hurst, 2004). o Phentolamine: Dilute 5 to 10 mg in 10 to 15

mL NS and administer into extravasation site as soon as possible after extravasation (Peberdy 2010).

o Alternatives to phentolamine: Nitroglycerin topical 2% ointment

(based on limited case reports in neonates/infants): Apply 4 mm/kg as a thin ribbon to the affected areas; may repeat after 8 hours if needed (Wong 1992) or apply a 1-inch strip on the affected site (Denkler 1989).

Terbutaline (based on limited case reports): Infiltrate extravasation area using a solution of terbutaline 1 mg diluted to 10 mL in NS (large extravasation site; administration volume varied from 3 to 10 mL) or 1 mg diluted in 1 mL NS (small/distal extravasation site; administration volume varied from 0.5 to 1 mL) (Stier 1999).


3. Dopamine

Usual Infusion Concentrations: Adult

IV infusion: 400 mg in 250 mL (concentration:

1600 mcg/mL) or 800 mg in 250 mL

(concentration: 3200 mcg/mL) of D5W or NS

Administration: IV

Administer as a continuous infusion with the use of an infusion pump. Administer into large vein to prevent the possibility of extravasation (central line administration); monitor continuously for free flow; use infusion device to control rate of flow; when discontinuing the infusion, gradually decrease the dose of dopamine (sudden discontinuation may cause hypotension). Vials (concentrated solution) must be diluted prior to use.


Extravasation management: If extravasation occurs, stop infusion immediately and disconnect (leave cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line); remove needle/cannula; elevate extremity. Initiate phentolamine (or alternative) antidote. Apply dry warm compresses (Hurst 2004).

Stable in D5LR, D51/2NS, D5NS, D5W, D10W, LR,

1/2NS, NS, mannitol 20%;

Incompatible with sodium bicarbonate 5%


4. Dobutamine

Usual Infusion Concentrations: Adult.

IV infusion: 250 mg in 500 mL (concentration:

500 mcg/mL), 500 mg in 250 mL (concentration:

2000 mcg/mL), or 1000 mg in 250 mL

(concentration: 4000 mcg/mL) of D5W or NS

Administration: Always administer via infusion device; administer into

large vein.

Stable in D5LR, D51/2NS, D5NS, D5W, D10W, LR,

1/2NS, NS, mannitol 20%;

Incompatible with sodium bicarbonate 5%

5.Milrinone

Preparation for Administration Loading dose (optional): May administer undiluted;

diluting to a rounded total volume of 10 or 20 mL may

simplify the visualization of the injection rate.

Maintenance dose: For a final concentration of 0.2

mg/mL: Dilute 1 mg/mL (20 mL) with 80 mL diluent

(final volume: 100 mL) of 1/2NS, NS or D5W. May

also dilute 1 mg/mL (10 mL) with 40 mL diluent

(final volume: 50 mL)

Usual Infusion Concentrations: Adult 20 mg in 100 mL (total volume) (concentration:

200 mcg/mL) of D5W


Administration: Administer loading dose (optional) undiluted slowly

over 10 minutes. Infuse maintenance dose via

continuous infusion pump.

Stable in D5W, LR, 1/2NS, NS

ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ

Antibiotics:

6. Imipenem/Cilastatin (Tienam®)

Preparation for Administration IV: Prior to use, dilute dose into 100-250 mL of

D5W, D10W, Mannitol 5%, Mannitol 10% or NS. Imipenem is inactivated at acidic or alkaline pH. Final concentration should not exceed 5 mg/mL.

Administration: IV Do not administer IV push. Infuse doses ≤500

mg over 20-30 minutes; infuse doses ≥750 mg over 40-60 minutes.

Administration: Injectable Detail Vial contents must be transferred to 100 mL of

infusion solution. If nausea and/or vomiting occur during administration, decrease the rate of IV infusion. Do not mix with or physically add to other antibiotics; however, may administer concomitantly

Variable stability in D5W, D5LR, D51/4NS, D51/2NS, D5NS, D10W, mannitol 2.5%, mannitol 5%, mannitol 10%, NS, TPN.


7. Levofloxacin (Tavanic®)

Preparation for Administration Solution for injection: Single-use vials must be further

diluted in compatible solution to a final concentration of 5 mg/mL prior to infusion.

Administration: IV Infuse 250-500 mg IV solution over 60 minutes; infuse 750

mg IV solution over 90 minutes. Too rapid of infusion can lead to hypotension. Avoid administration through an intravenous line with a solution containing multivalent cations (eg, magnesium, calcium). Maintain adequate hydration of patient to prevent crystalluria or cylindruria.

Stable in D5LR, D5NS, D51/2NS with 20 mEq/L KCl, D5W, NS, Plasma-Lyte® 56 in 5% dextrose, sodium lactate (M/6); incompatible with mannitol 20%, sodium bicarbonate 5%.

8. Ciprofloxacin (Cipro®)

Preparation for Administration Injection, vial: May be diluted with NS, D5W, SWFI, D10W,

D51/4NS, D51/2NS, LR.

Administration: IV Administer by slow IV infusion over 60 minutes into a large

vein (reduces risk of venous irritation).

Stable in D51/4NS, D51/2NS, D5W, D10W, LR, NS, SWFI;


9. Penicillin G (Parenteral/Aqueous) Preparation for Administration

Intermittent IV: 5 million unit vial: Add 8.2 mL for a final concentration of 500,000 units/mL; add 3.2 mL for a final concentration of 1,000,000 units/mL. Dilute further to 50,000-145,000 units/mL prior to infusion.

Continuous IV infusion: 20 million unit vial: Add 11.5 mL for a final concentration of 1,000,000 units/mL. Dilute further in 1-2 L of infusion solution and administer over a 24-hour period.

Administration IV: Usually administered by intermittent infusion.

In some centers, large doses may be administered by continuous IV infusion. Note: The 20 million unit dosage form may be administered by continuous IV infusion only.

Intermittent IV: May be dissolved in small amounts of SWFI, NS, D5W and administered peripherally as a 50,000-100,000 unit/mL solution. In fluid-restricted patients, 146,000 units/mL in SW results in a maximum recommended osmolality for peripheral infusion. Infuse over 15-30 minutes.

Continuous IV infusion: Determine the volume of fluid and rate of its administration required by the patient in a 24-hour period. Add the appropriate daily dosage of penicillin to this fluid. For example, if the daily dose is 10 million units and 2 L of fluid/day is required, add 5 million units to 1 L and adjust the rate of flow so the liter will be infused over 12 hours (83 mL/hour).


Repeat steps (5 million units/L at 83 mL/hour) for the remaining 12 hours.

Penicillin G potassium: Stable in dextran 6% in dextrose, dextran 6% in NS, D5LR, D51/4NS, D51/2NS, D5NS, D5W, D10W, LR, 1/2NS, NS, hetastarch 6%; incompatible with dextran 70 6% in dextrose, dextran 40 10% in dextrose; variable stability in fat emulsion 10%, peritoneal dialysis solutions.

Penicillin G sodium: Stable in dextran 40 10%; incompatible with fat emulsion 10%; variable stability in D5W, NS, peritoneal dialysis solution.

10. Ampicillin/Sulbactam (Unasyn®) Preparation for Administration

Direct IV administration and IV infusion: Reconstitute with sterile water for injection (SWFI). Sodium chloride 0.9% (NS) is the diluent of choice for IV infusion use.

Administration: IV Administer around-the-clock to promote less

variation in peak and trough serum levels. Administer by slow injection over 10 to 15 minutes or as an IV infusion over 15 to 30 minutes. Ampicillin and gentamicin should not be mixed in the same IV tubing.

Some penicillins (eg, ampicillin, carbenicillin, ticarcillin, and piperacillin) have been shown to inactivate aminoglycosides in vitro. This has been observed to a greater extent with tobramycin and


gentamicin, while amikacin has shown greater stability against inactivation. Concurrent Y-site administration should be avoided.

Intermittent IV infusion: Solutions made in NS are stable up to 72 hours when refrigerated whereas dextrose solutions (same concentration) are stable for only 4 hours

11. Ceftriaxone Preparation for Administration

IV infusion: Infusion is prepared in two stages: Initial reconstitution of powder, followed by dilution to final infusion solution.

Vials: Reconstitute powder with appropriate IV diluent (including SWFI, D5W, D10W, NS) to create an initial solution of ~100 mg/mL. Recommended volume to add:

250 mg vial: 2.4 mL 500 mg vial: 4.8 mL 1 g vial: 9.6 mL 2 g vial: 19.2 mL

Note: After reconstitution of powder, further dilution into a volume of compatible solution (eg, 50-100 mL of D5W or NS) is recommended.

Piggyback bottle: Reconstitute powder with appropriate IV diluent (D5W or NS) to create a resulting solution of ~100 mg/mL. Recommended initial volume to add:

1 g bottle:10 mL

2 g bottle: 20 mL


Note: After reconstitution, to prepare the final infusion solution, further dilution to 50 mL or 100 mL volumes with the appropriate IV diluent (including D5W or NS) is recommended.

Administration: IV Do not coadminister with calcium-containing

solutions. Infuse as an intermittent infusion over 30 minutes. IV push administration over 1 to 4 minutes has been reported in children ≥12 years, adolescents, and adults (concentration: 100 mg/mL), primarily in patients outside the hospital setting (Baumgartner 1983; Garrelts 1988; Poole 1999), although a 2 g dose administered IV push over 5 minutes resulted in tachycardia, restlessness, diaphoresis, and palpitations in one patient (Lossos 1994). IV push administration in young infants may also have been a contributing factor in risk of cardiopulmonary events occurring from interactions between ceftriaxone and calcium (Bradley 2009).

Stable in D5W with KCl 10 mEq, D51/4NS with KCl 20 mEq, D51/2NS, D5W, D10W, NS, mannitol 5%, mannitol 10%, sodium bicarbonate 5%, bacteriostatic water, sterile water for injection


12. Vancomycin Preparation for Administration

Injection: Reconstitute 500 mg vial with 10 mL SWFI, 750 mg vial with 15 mL SWFI, 1 g vial with 20 mL SWFI, 5 g vial with 100 mL SWFI (final concentration: 500 mg/10 mL), and 10 g vial with 95 mL SWFI (final concentration: 1 g/10 mL). The reconstituted solution must be further diluted with at least 100 or 200 mL of a compatible diluent per 500 mg of vancomycin prior to parenteral administration.

Administration: IV Administer vancomycin with a final

concentration not to exceed 5 mg/mL by IV intermittent infusion over at least 60 minutes (recommended infusion period of ≥30 minutes for every 500 mg administered). Not for IM administration.

Red man syndrome may occur if the infusion is too rapid. It is not an allergic reaction, but may be characterized by hypotension and/or a maculopapular rash appearing on the face, neck, trunk, and/or upper extremities. If this should occur, slow the infusion rate to over 11/2 to 2 hours and increase the dilution volume. Reactions are often treated with antihistamines and steroids.

Irritant; ensure proper needle or catheter placement prior to and during infusion. Avoid extravasation.


Extravasation management: If extravasation occurs, stop infusion immediately and disconnect (leave cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line); remove needle/cannula; elevate extremity. Apply dry cold compresses (Hurst, 2004).

Stable in D5NS, D5W, D10W, LR, NS

Other IV Agents:

13. Potassium Chloride Preparation for Administration

Parenteral: Potassium must be diluted prior to parenteral administration. The concentration of infusion may be dependent on patient condition and specific institution policy. Some clinicians recommend that the maximum concentration for peripheral infusion is 10 mEq/100 mL and 20-40 mEq/100 mL for central infusions.

Administration: IV Potassium must be diluted prior to parenteral

administration. Do not administer IV push. In general, the dose, concentration of infusion and rate of administration may be dependent on patient condition and specific institution policy. Some clinicians recommend that the maximum concentration for peripheral infusion is 10 mEq/100 mL and maximum rate of administration for peripheral infusion is 10 mEq/hour (Kraft, 2005). ECG monitoring is recommended for


peripheral or central infusions >10 mEq/hour in adults (Kraft, 2005). Concentrations and rates of infusion may be greater with central line administration. Concentrations of 20 to 40 mEq/100 mL at a maximum rate of 40 mEq/hour via central line have been safely administered (Hamill, 1991; Kruse, 1990).

Vesicant/irritant (at concentrations >0.1 mEq/mL); ensure proper needle or catheter placement prior to and during IV infusion. Avoid extravasation.

Extravasation management: If extravasation occurs, stop infusion immediately and disconnect (leave needle/cannula in place); gently aspirate extravasated solution (do NOT flush the line); initiate hyaluronidase antidote; remove needle/cannula; apply dry cold compresses (Hurst, 2004); elevate extremity.

Stable in D5LR, D51/4NS, D51/2NS, D5NS, D5W, D10W, D20W, LR, 1/2NS, NS

14. Calcium gluconate Preparation for Administration

IV: Observe the vial for the presence of particulates. If particulates are observed, place vial in a 60°C to 80°C water bath for 15 to 30 minutes (or until solution is clear); occasionally shake to dissolve; cool to body/room temperature before use. Do not use vial if particulates do not dissolve. Note: Due to the potential presence of


particulates, American Regent, Inc recommends the use of a 5 micron filter when preparing calcium gluconate-containing IV solutions (Important Drug Administration Information, American Regent, 2013); a similar recommendation has not been noted by other manufacturers. Usual concentrations: 1 g/100 mL D5W or NS; 2 g/100 mL D5W or NS. Maximum concentration in parenteral nutrition solutions is variable depending upon concentration and solubility (consult detailed reference).

Administration: IV Administer slowly (~1.5 mL calcium gluconate

10% per minute; not to exceed 200 mg/minute except in emergency situations) through a small needle into a large vein in order to avoid too rapid increases in the serum calcium and extravasation. Note: Due to the potential presence of particulates, American Regent, Inc recommends the use of a 0.22 micron inline filter for IV administration (1.2 micron filter if admixture contains lipids) (Important Drug Administration Information, American Regent, 2013); a similar recommendation has not been noted by other manufacturers. Not for IM administration.

Vesicant; ensure proper needle or catheter placement prior to and during IV infusion. Avoid extravasation.

Extravasation management: If extravasation occurs, stop infusion immediately and disconnect (leave needle/cannula in place); gently aspirate extravasated solution (DO NOT flush the line);


initiate hyaluronidase antidote; remove needle/cannula; apply dry cold compresses (Hurst, 2004); elevate extremity.

Stable in D5LR, D51/4NS, D51/2NS, D5NS, D5R, D5W, D10W, D20W, LR, NS; incompatible in fat emulsion 10%

15. Magnesium sulfate

Preparation for Administration IV: Dilute to a ≤20% solution for IV infusion.

Administration: IV Must be diluted to a ≤20% solution for IV infusion and may

be administered IV push, IVPB, or continuous IV infusion. When giving IV push, must dilute first and should generally not be given any faster than 150 mg/minute; may administer over 1 to 2 minutes in patients with persistent pulseless VT or VF with known hypomagnesemia (Dager, 2006). ACLS guidelines recommend administration over 15 minutes in patients with torsade de pointes (ACLS, 2010). In patients not in cardiac arrest, hypotension and asystole may occur with rapid administration. In patients with asthma (acute severe exacerbation) (off-label use), may administer single dose over 20 minutes to 60 minutes (GINA 2015; NAEPP 2007).

Maximal rate of infusion: Up to 50% of an IV dose may be eliminated in the urine, therefore, slower administration may improve retention (maximum rate: 1 g/hour in asymptomatic patients). For doses <6 g, infuse over 8 to 12 hours and for larger doses infuse over 24 hours if


patient is asymptomatic. If patient is severely symptomatic (or has conditions such as preeclampsia or eclampsia) more aggressive therapy (≤4 g over 4 to 5 minutes) may be required; patients should be closely monitored (Kraft, 2005).

Stable in D5W, D10W, D51/4NS, D5NS, LR, NS, R; incompatible with fat emulsion 10%.

16. Aminophylline Usual Infusion Concentrations: Adult

IV infusion: 250 mg in 250 mL (concentration: 1 mg/mL) of D5W or NS

Administration: IV IV: For IV administration only (IM use is not

recommended). Loading doses should be administered IV over 30 minutes. Infusion rate should not exceed 21 mg/hour (equivalent to theophylline 17 mg/hour) in patients with cor pulmonale, cardiac decompensation, liver dysfunction, patients >60 years of age, or patients taking medications which reduce theophylline clearance.

For reversal of adenosine-, dipyridamole-, or regadenoson-induced adverse events during nuclear cardiac stress testing, administer IV undiluted over 30-60 seconds, repeat as necessary. Since adenosine-induced side effects are short lived after discontinuation of the infusion, aminophylline administration is only very rarely required.



Extravasation management: If extravasation occurs, stop infusion immediately and disconnect (leave needle/cannula in place); gently aspirate extravasated solution (do NOTflush the line); initiate hyaluronidase antidote; remove needle/cannula; apply dry cold compresses (Hurst, 2004); elevate extremity.

Stable in dextran 6% in D5W, dextran 6% in NS, D5LR, D5NS, D51/2NS, D51/4NS, D5W, D10W, D20W, LR, 1/2NS, NS;

17. Amiodarone (Cordarone®) Usual Infusion Concentrations: Adult

IV infusion: 450 mg in 250 mL (concentration: 1.8 mg/mL) of D5W or NS

Administration: IV For infusions >1 hour, use concentrations ≤2

mg/mL unless a central venous catheter is used;

Use only volumetric infusion pump; use of drop counting may lead to under dosage.

Administer through an IV line located as centrally as possible. For continuous infusions, an in-line filter has been recommended during administration to reduce the incidence of phlebitis. During pulseless VT/VF, administering undiluted is preferred (Dager 2006; Skrifvars 2004). The Handbook of


Emergency Cardiovascular Care (Hazinski 2015) and the ACLS guidelines do not make any specific recommendations regarding dilution of amiodarone in this setting.

Adjust administration rate to urgency (give more slowly when perfusing arrhythmia present). Slow the infusion rate if hypotension or bradycardia develops. Infusions >2 hours must be administered in a non-PVC container (eg, glass or polyolefin). PVC tubing is recommended for administration regardless of infusion duration.

Incompatible with heparin; flush with saline prior to and following infusion. Note: IV administration at lower flow rates (potentially associated with use in pediatrics) and higher concentrations than recommended may result in leaching of plasticizers (DEHP) from intravenous tubing. DEHP may adversely affect male reproductive tract development. Alternative means of dosing and administration (1 mg/kg aliquots) may need to be considered.

18. Regular Insulin Preparation for Administration

For IV infusion: o Humulin R: May be diluted in NS or D5W to

concentrations of 0.1-1 unit/mL. o Novolin R: May be diluted in NS, D5W, or

D10W with 40 mEq/L potassium chloride at concentrations of 0.05 to 1 unit/mL.


Usual Infusion Concentrations: Adult IV infusion: 100 units in 100 mL (concentration:

1 unit/mL) of NS

Administration: IV Do not use if solution is viscous or cloudy; use

only if clear and colorless. May be administered IV with close monitoring of blood glucose and serum potassium; appropriate medical supervision is required. Do not administer mixtures of insulin formulations intravenously. IV administration of U-500 regular insulin is not recommended.

IV infusions: To minimize insulin adsorption to IV tubing: Flush the IV tubing with a priming infusion of 20 mL from the insulin infusion, whenever a new IV tubing set is added to the insulin infusion container (Jacobi 2012; Thompson 2012).

Note: Also refer to institution-specific protocols where appropriate.

If insulin is required prior to the availability of the insulin drip, regular insulin should be administered by IV push injection.

Because of insulin adsorption to IV tubing or infusion bags, the actual amount of insulin being administered via IV infusion could be substantially less than the apparent amount. Therefore, adjustment of the IV infusion rate should be based on effect and not solely on the apparent insulin dose. The apparent dose may be used as a starting point for determining the subsequent SubQ dosing regimen (Moghissi 2009); however,


the transition to SubQ administration requires continuous medical supervision, frequent monitoring of blood glucose, and careful adjustment of therapy. In addition, SubQ insulin should be given 1 to 4 hours prior to the discontinuation of IV insulin to prevent hyperglycemia (Moghissi 2009).

Stable in D5W and NS.

Note: A universal sterile diluent, Sterile Diluent for Humalog, Humulin N, Humulin R, Humulin 70/30, and Humulin R U-500, is available from the manufacturer for SubQ administration

19. Morphine

Usual Infusion Concentrations: Adult IV infusion: 1 mg/mL

Administration: IV When giving morphine IV push, it is best to first

dilute with sterile water or NS for a final concentration of 1 to 2 mg/mL and then administer slowly over 4 to 5 minutes.

Stable in dextran 6% in dextrose, dextran 6% in NS, D5LR, D51/4NS, D51/2NS, D5NS, D5W, D10W, LR, 1/2NS, NS;

20. Midazolam (Dormicum®)

Usual Infusion Concentrations: Adult IV infusion: concentration: 1 mg/mL of D5W or

NS


Administration: IV Administer by slow IV injection over at least 2 to

5 minutes at a concentration of 1 to 5 mg/mL or by IV infusion. For induction of anesthesia, administer IV bolus over 5 to 30 seconds. Continuous infusions should be administered via an infusion pump.

Stable in D5NS, D5W, NS; incompatible with LR.

21. Protamine Administration: IV

For IV use only. Administer slow IV Push (50 mg over 10 minutes). Rapid IV infusion causes hypotension. Inject without further dilution over 1-3 minutes; maximum of 50 mg in any 10-minute period.

Stable in D5W, NS.

22. Tranexamic acid (kapron®) Preparation for Administration

Tranexamic acid doses may be diluted in 50 to 250 mL of NS or D5W (Trissels 2015). According to the manufacturer, tranexamic acid may be mixed with most solutions for infusion such as electrolyte solutions, carbohydrate solutions, amino acid solutions, and dextran solutions.

Administration: IV May be administered by direct IV injection at a

maximum rate of 100 mg/minute; use plastic syringe only for IV push


In general, tranexamic acid loading doses are diluted in 50 to 250 mL of D5W or NS and are administered over 5 to 30 minutes.

Compatible with dextrose, saline, electrolyte, amino acid, or dextran solutions, heparin;

Incompatible with solutions containing penicillin.

23. Ethamsylate (Dicynone®) N/A

24. Phenytoin (Ipanotine®) Preparation for Administration

Hazardous agent; use appropriate precautions for handling and disposal.

IV: May be further diluted in NS to a final concentration (5-10 mg/mL); infusion must be completed within 4 hours after preparation. Do not refrigerate. Stable in NS

Administration: IV

Fosphenytoin may be considered for loading in patients who are in status epilepticus, hemodynamically unstable, or develop hypotension/bradycardia with IV administration of phenytoin. Although, phenytoin may be administered by direct IV injection, it is preferable that phenytoin be administered via infusion pump either undiluted or diluted in normal saline as an IV piggyback (IVPB) to prevent exceeding the maximum infusion rate


(monitor closely for extravasation during infusion). The maximum rate of IV administration is 50 mg/minute in adults. Highly sensitive patients (eg, elderly, patients with preexisting cardiovascular conditions) should receive phenytoin more slowly (eg, 20 mg/minute) (Meek 1999). An in-line 0.22 to 0.55 micron filter is recommended for IVPB solutions due to the potential for precipitation of the solution. Avoid extravasation. Following IV administration, NS should be injected through the same needle or IV catheter to prevent irritation.

Note: SubQ administration is not recommended because of the possibility of local tissue damage (due to high pH).


Extravasation management: If extravasation occurs, stop infusion immediately and disconnect (leave needle/cannula in place); gently aspirate extravasated solution (do NOT flush the line); remove needle/cannula; elevate extremity. There is conflicting information regarding an antidote; some sources recommend not to use an antidote (Montgomery 1999 [pediatric reference]), while other sources recommend hyaluronidase.


25. Rantidine (Zantac®) Preparation for Administration

Continuous infusion: Dilute in D5W or other compatible IV solution; for Zollinger-Ellison patients, dilute in D5W or other compatible IV solution to a maximum concentration of 2.5 mg/mL.

Intermittent bolus injection: Dilute in NS or other compatible IV solution to a maximum concentration of 2.5 mg/mL (20 mL).

Intermittent infusion: Dilute in D5W or other compatible IV solution to a maximum concentration of 0.5 mg/mL (100 mL).

Usual Infusion Concentrations: Adult IV infusion: 50 mg in 50 mL (concentration: 1

mg/mL) or 500 mg in 250 mL (concentration: 2 mg/mL) of D5W or NS

.Administration: IV IV must be diluted; may be administered intermittent bolus, intermittent IV infusion, or continuous IV infusion

Intermittent bolus: Manufacturer recommends a maximum rate of administration of 10 mg/minute (infuse over at least 5 minutes); however, in adults may also be administered at a maximum rate of 25 mg/minute (or over 2 minutes) if necessary (Coursin 1988; Goelzer 1988; Smith 1987).

Intermittent IV infusion: Administer over a maximum rate of 2.5 to 3.5 mg/minute (infuse over at least 15 to 20 minutes)


Continuous IV infusion: Administer at a rate of 6.25 mg/hour; for Zollinger-Ellison patients, administer at a rate of 1 mg/kg/hour (infusion rates as high as 220 mg/hour have been used).

Stable in D51/2NS, D5W, D10W, fat emulsion 10%, LR, NS, sodium bicarbonate 5%; for injection, do not add other medications to premixed bag;

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