Medication Administration Policy

Section II Parenteral Medication Administration Guidelines This section can be copied and kept for reference at bedside.

• Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

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Click a letter to quickly navigate the list: A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Medication Generic - (Brand)

How Supplied

IV Push Conc / Rate

SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time

Precautions / Comments Stability / Storage Limitations / Restrictions

ABCIXimab (Reopro) Antiplatelet IIb/IIIa

2mg/ml 5 ml vial

Yes 2 mg/ml Give bolus over 1 minute

Percutaneous Coronary Intervention: 0.25 mg/Kg bolus followed by 0.125 mcg/Kg/min infusion (up to max 10mcg/min = 7.2 mg) x 12 hours System Standard Concentration: 7.2 mg/ 250 ml NS (28.8 mcg/ml)

Preprinted order set available Monitor Hgb/Hct, platelets, PT, PTT 6 hours after admin and 24 hrs after administration

Do not shake solution or transport via tube system.

Administer in separate IV line 0.22 micron filter must be used in preparation!!

AcetaZOLAMIDE (Diamox) Diuretic

500 mg Vial

Yes 100 mg/ml at max rate of 250 mg/min.

IV Push Preferred ** Verify dose to be given. Discard vial after drawing up correct dose. ** May cause thrombophlebitis

Reconstitute vial with sterile water only.

Acetylcysteine, N-acetylcysteine (Acetadote) Antidote – acetaminophen overdose

200 mg/ml 30 ml vial

NO Acetaminophen overdose: (Prescott Trial Protocol) Loading dose: 150 mg/kg IV over 60 minutes Maintenance dose: 50 mg/kg IV over 4 hours x 1 then 100 mg/kg IV over 16 hours Traditional dosing protocol may be used to dose IV rescue – Loading Dose: 140mg/kg IV over 60minutes; Maintenance dose: 70mg/kg IV Q4h x 17 doses. N-acetylcysteine should continue until liver function improves!! Pediatric patients: recommended conc is 40 mg/ml to avoid hyponatremia and seizures.

Caution with use in patients with asthma and/or history of bronchospasm Common adverse effects: rash, urticaria and pruritus Urticaria and pruritus may be treated with antihistamine (i.e. diphenhydramine) with physician order.

Administer in separate IV line Solution may turn pink/lavender in color – still ok to use

Acyclovir (Zovirax) Antiviral

5 mg/ml 10ml and 20 ml vials

NO Up to 350 mg in 50 ml NS or D5W 351-700 mg in 100ml NS or D5W Infuse doses over at least 60 min. Max conc: 7 mg/ml

Renal tubular damage with infusions <60min. Phlebitis if conc.>7mg/ml Dose reduction recommended for CrCl < 50 ml/min

Do NOT refrigerate – precipitate may form.



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How Supplied

IV Push Conc / Rate



Adenosine (Adenocard) Anti-arrhythmic

3 mg/ml 2 ml vial, 3 mg/ml 2 ml and 4 ml syringe

Yes, 6 mg rapidly over 2 seconds followed with saline flush. May then give 12mg 1-2 min later, followed by another 12 mg 1-2 min later if needed.

IV Push Preferred Dyspnea, flushing and heart-block (asystole) not uncommon with rapid resolution as half-life is only 10 seconds Reflex tachycardia may occur if given too slowly

Follow rapid IV push dose with 20 ml NS flush If given into IV line, use closest port to insertion site and follow with NS flush. Elevate extremity

* See footnote Continuous ECG, BP monitoring recommended during administration

Albumin, Human Serum Plasma Expander

5% - 250ml 25% - 50ml bottles

NO Dose and rate of administration based upon patient condition. Recommended max rate of infusion: 5% at 10 ml/min 25% at 3 ml/min

Administer with IV tubing provided by pharmacy.

If diluting 25% albumin, NS is preferred. D5W may be used for limited volumes. DO NOT dilute with sterile water!

Allopurinol (Aloprim) Xanthine oxidase inhibitor

500mg/30 ml Vial

NO Intermittent Infusion – 200-400mg/M²/day (Max of 600mg) diluted in 100ml NS/D5W Give over 30 minutes

Do not mix with other solutions

Limited Indication: Hyperuricemia associated with chemotherapy Dose reduction recommended for CrCl < 20 ml/min

Stable only 10 hours after dilution at room temp Do NOT refrigerate

Reconstitute vial with sterile water only! Further dilute with NS or D5W

Alprostadil (PGE1) Vasodilator/ Prostaglandin

500 mcg/ml 1 ml vial

NO Usual dose range for treatment of pulmonary hypertension: 1-150 nanograms/kg/min System Standard Concentration: 1000 mcg/100 ml NS (10 mcg/ml)

System “Concentrated” Concentration: 2000 mcg/100 ml NS (20 mcg/ml) Max conc: 20 mcg/ml

Very short half-life necessitating continuous infusion administration Common side effects in adults include: flushing, nausea, abd cramps, tachycardia, hypotension, and edema. Monitor respiratory and cardiac status May cause thrombophlebitis – recommend central line administration

Stable x 24 hours at room temperature

* See footnote



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How Supplied

IV Push Conc / Rate



Alteplase (Activase, TPA, Cathflo)

*HIGH ALERT MEDICATION*

Do not confuse with other thrombolytic

medicines Thrombolytic

100 mg/ 100 ml (1 mg/ml) vial & 2mg Cathflo vials

Yes, Up to 15 mg over 2 min. (7.5 mg/min)

MI – Greater than 67kg: 15 mg over 2 min, 50 mg over 30min, 35 mg over next 60min. MI - 67kg or Less: 15mg over 2min, followed by 0.75mg/kg over 30min, then 0.5mg/kg over 60min. Total dose not to exceed 100mg. Ischemic stroke: 0.9 mg/Kg up to max 90Kg - Give 10% as bolus over 1min, then remainder over 60min Pulmonary Embolism: 100 mg over 2 hours Peripheral Vascular Thrombolysis: Per Interventional Radiology/Interventional Cardiology. Preprinted order sets available. Catheter Clearing: Metro: Give 0.5 ml of 1 mg/ml alteplase and dwell x 60 min. If still occluded, aspirate alteplase, instill 1 ml of 1 mg/ml alteplase and dwell 60 min. If still occluded, aspirate alteplase, instill 2 ml of 1 mg/ml alteplase and dwell 60 min. When patency is restored, withdraw 5-10 ml and discard then flush with 10 ml NS. If catheter capacity is greater than volume of alteplase, then follow dose with NS to fill catheter volume. If patency is not restored after 2 ml dose, contact physician for further orders. (Metro Nursing Clinical Policy MN-11) *Use 2 mg dose initially for hemodialysis catheters and fistulas *

Thrombolytic medication: Monitor for bleeding. Minimize potential risks for bleeding: Establish all IV’s prior to therapy. (Minimum of 2 peripheral IVs recommended in addition to thrombolytic infusion site.) Avoid unnecessary arterial/venous punctures, excessive blood sampling, or IM injections for at least 24 hr after d/c’d (malnourished patients 48 hr). Apply pressure dressings to all puncture sites.

Reconstitution must be with sterile water. Conc 0.01-1 mg/ml stable 24 hours (if diluent is NS after reconstitution) Avoid shaking reconstituted solution. Do not transport via tube system. Administer via separate IV line.

*See footnote for cardiopulmonary indications (i.e.: AMI, PE). Monitoring is at physician discretion for peripheral vascular indications. No restrictions for alteplase use for catheter clearance or administration of low doses per chest tube.

Amikacin (Amikin) Antibiotic/ Aminoglycoside

250 mg/ml 2 ml & 4 ml vials

NO Dilute in 100 ml D5W or NS Max conc: 5mg/ml

Infuse over 60 minutes

Aminoglycoside dosing and monitoring service available from pharmacy upon physician order. Monitor renal function.



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How Supplied

IV Push Conc / Rate



Aminocaproic Acid (Amicar) Hemostatic / Antifibrinolytic

250 mg/ml 20 ml Vial

NO Intermittent infusion: Typically 1 Gm in 50 ml NS/D5W Infuse over 60 minutes. Continuous infusion: System Standard Concentration: 5 gm/250 ml NS (20 mg/ml) Usual dose range: 1 – 1.25 Gm/hr Cardiac Surgery: Loading dose: 10 gm/40 mL drawn up in a syringe & administered IV over 20 minutes. Maintenance Drip: 2 gm/hr (40mL/hr) during surgery. (10 gram/40 mL added to 150mL NS; total volume 200 mL).

Hypotension, bradycardia, arrhythmia with too rapid infusion Recommended max dose: 30 Gm/24 hr

Expiration dating: 7 days refrigerated.

Aminophylline – See Theophylline

Amiodarone (Cordarone) Anti-arrhythmic

50 mg/ml 3 ml vial, ampule

Yes, V. fib or Pulseless V-tach: Give 300 mg undiluted over 30 seconds. Follow with 20ml NS flush. May give 150 mg after 3 –5 min if V.fib/pulseless V-tach persists

Bolus: 150 mg / 100ml D5W (PVC) System Standard Conc: 450 mg / 250 ml D5W (Excel Bag) (1.8 mg/ml) System “Concentrated” conc: 600 mg/88 ml D5W (total volume 100 ml) (Excel Bag) (6 mg/ml) Central line only! Usual starting dose: Bolus 150 mg in 100ml D5W over 10 min. then 60 mg/hr x 6 hours then 30 mg/hr x 18 hours via infusion.

Central Line Required if concentration exceeds 2 mg/ml Monitoring: Continuous EKG Monitoring BP - Monitor during loading

dose: Continuous or q15min x 3; then q4-6hr while stable on infusion.

Decreasing rate or stopping infusion may alleviate hypotension and/or bradycardia

Preprinted order set available for new onset A.Fib

Two-hour stability if mixed in Poly Vinyl Chloride (PVC) plastic container. Infusions running longer than 2 hrs require Excel or glass containers. Stable 24 hours after dilution with D5W in Excel or glass.

Use of in-line 0.22 micron filter required for infusions. Check with pharmacist for compatibility information.

* See footnote



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How Supplied

IV Push Conc / Rate



Amphotericin B (Fungizone) Anti-fungal

50 mg and 100 mg vials

NO Optional Test dose: 0.1 mg/kg up to 1 mg in 50 ml D5W. Infuse over 10-30 min Doses < 25 mg/250 ml D5W 26-50 mg/500 ml D5W Infuse over 3 hours

Test Dose no longer considered necessary & no longer recommended. Monitoring: VS q15 min x 1 hr then q 1 hr for at least 1 hr post-infusion. Administer any pre-medications 30 minutes prior to starting daily infusion – Premeds must be per physician order. Recommended pre-medications: Acetaminophen 500-1000 mg PO or 650 mg PR ; Diphenhydramine 25-50 mg PO/IV ; Hydrocortisone 25-50 mg IV (use only in pt history of severe rigors) Sodium loading recommended to prevent nephrotoxicity. 500 ml NS before and after infusion. Lower volume (i.e. 250 ml) may be consider in pt with cardiac compromise or develop HTN during NS infusion.

Use D5W only Protect from light. Do NOT filter

Amphotericin may cause renal wasting of K+, Mg+2, HCO3

- and Na+ Daily monitoring recommended. Supplementation may be required.

Amphotericin B Lipid Complex (Abelcet) Anti-fungal

100 mg vial NO 3 - 5mg / Kg / Day typical dose Dilute with D5W to final concentration of 2 mg / ml. Infuse over 2 hours

Monitor VS q15 min x 1 hr then q 1 hr for at least 1 hr post-infusion. Administer any pre-medications 30 minutes prior to starting daily infusion See Amphotericin B for recommended pre-meds.

Use D5W only

Gently agitate solution prior to beginning infusion and every 2 hours. Stable 6 hr at room temp –

Amphotericin B Liposomal (AmBisome) Anti-fungal

50 mg Vial NO 3 – 5 mg/Kg/Day typical dose Dilute with D5W to final concentration of 1-2 mg/ml Infuse over 2 hours

Monitor VS q15 min x 1 hr then q 1 hr for at least 1 hr post-infusion. Administer any pre-medications 30 minutes prior to starting daily infusion See Amphotericin B for recommended pre-meds.

Use D5W only Gently agitate solution prior to beginning infusion and every 2 hours. Stable 6 hrs after dilution at room temp

Ampicillin Antibiotic/ Beta-lactam

0.5, 1 & 2 Gm Vial

NO Up to 1 Gm 50ml NS 2Gm 100ml NS Infuse dose over 30 min

Penicillin derivative – check allergies



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How Supplied

IV Push Conc / Rate



Ampicillin / Sulbactam (Unasyn) Antibiotic/ Beta-lactam

1.5 & 3 Gm Vial (2/3 amp, 1/3 sulbactam)

Not advised <1.5 Gm/50 ml NS 1.6 to 3 Gm/100 ml NS Infuse dose over 30 minutes

Penicillin derivative – check allergies Dose reduction recommended for CrCl < 30 ml/min

Anidulafungin (Eraxis) Antifungal

50 mg vial Not advised Intermittent infusion: 50 mg in 100 ml NS or D5W 100 mg in 250 ml NS or D5W 200 mg in 500 ml NS or D5W MAX infusion rate 1.1 mg/minute

Histamine-mediated symptoms (rash, urticaria, flushing, pruritus, dyspnea, and hypotension) possible – infrequent when infusion rate < 1.1 mg/min

Reconstitute vials with accompanying diluent only

Anticoagulant Citrate Dextrose – A (ACD-A)


Anticoagulant

500 ml bags

NO Not for intravenous administration. Do NOT infuse directly into patient. Continuous infusion with Continuous Renal Replacement Therapy (CRRT) and Plasmapheresis Used as anticoagulant for the machines – not effective as anticoagulant for patient.

May cause hypocalcemia



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How Supplied

IV Push Conc / Rate



Anti-thymocyte globulin- Equine (Atgam, Lymphocyte Immune Globulin) Immunosuppressant

50mg/ml – 5ml Vial

NO Intermittent Infusion – Prevention/treatment transplant rejection: 5-15 mg/kg daily for 7-14 days. Frequency and duration may be modified in response to peripheral CD3 targets. Treatment of aplastic anemia: 15 - 20mg/kg daily for 5-8 days Dilute into 250-1000ml NS and infuse over at least 4 hours (Use concentrations of 4mg/ml or less)

Metro: Preprinted order set use is mandatory per P&T!! Test dose recommended prior to first dose of each cycle. Pre-medication with a corticosteroid, antihistamine and acetaminophen is recommended See preprinted physician orders for monitoring parameters. Moderate fever and chills common during infusion

Do not mix with other solutions Central line administration preferred.

Use NS – Do NOT use D5W due to possible precipitate formation Do not shake or transport via tube system Use 0.22 micron filter

Anti-thymocyte globulin- Rabbit (RATG, Lymphocyte Immune Globulin, Thymoglobulin) Immunosuppressant

5 mg/ml – 5ml Vial

NO Treatment acute rejection Dose: 0.75mg/kg - 1.5 mg/kg daily x 7-14 days Infuse initial infusion over 6 hours, subsequent infusions over 4-6 hr Dose will be rounded to the nearest vial size!

Monitor BP, HR, respiratory status continuously. Stop infusion and call PHYSICIAN stat if SBP < 70, HR > 150 or dyspnea, bronchospasm, cyanosis or febrile reaction occurs. Anaphylaxis may occur. Diphenhydramine 50mg IV and epinephrine 1 mg (1 ml) required at bedside. Pre-medication with a corticosteroid, antihistamine and acetaminophen 1 hr prior to infusion is recommended Moderate fever and chills common during infusion – decreasing rate may relieve

Do not shake or transport via tube system Do not mix with other solutions Central line administration preferred. Addition of hydrocortisone and heparin recommended if infusing peripherally. Use 0.22micron in-line filter Metro: preprinted order set available

*See footnote



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How Supplied

IV Push Conc / Rate



Argatroban


Anticoagulant

100 mg/ml 2.5 ml Vial

NO System Standard Conc: 250mg/ 250ml NS (1mg/ml) Treatment of Heparin Induced Thrombocytopenia: Start at 0.5-2 mcg/kg/min and titrate to achieve PTT of 50-80 seconds Argatroban preprinted order set available.

Monitor for signs of bleeding Check PTT 3 hrs after dose changes Argatroban increases INR measurement falsely.

Dose reduction recommended for pt w/ hepatic insufficiency, azole antifungals, amiodarone or hypotension.

Monitor platelets, Hgb/Hct daily Platelets < 150,000 – notify physician

Do not mix with other medications/solutions. Check with pharmacist for compatibility information.

Aripiprazole (Abilify) Anti-psychotic

7.5mg/mL vial

NO IM ONLY

NO Do not administer IV or SQ. For deep IM injection only.

Ascorbic Acid Antioxidant/ Nutritional supplement

500 mg/ml 50ml Vial

Yes, admin slowly over 3-5 minutes Also, may be given IM or SQ

Daily dose may be added to 1000ml volume D5W or NS and administered slowly over a few hours

May cause dizziness/faintness w/ rapid injection

Stability of opened vial questionable after 24 hours due to oxidation Protect from light

Atracurium (Tracrium)


Neuromuscular -blocker

10 mg/ml 5 and 10 ml vials

Yes, administer bolus doses rapidly

Initial bolus: 0.4-0.5 mg/Kg, Usual dose range: 2 – 20 mcg/kg/min System Standard Conc: 500 mg/50 ml NS (total vol=100 ml) (5 mg/ml)

Metro Nursing Clinical Policy – Neuromuscular blockade (MN-13) Metro: preprinted order set available for ICU neuromuscular blockade

Refrigerate vials Vials stable x 14 days at room temp but then must be discarded May give undiluted if necessary

Controlled airway and ventilation required; Critical Care only: ED, ICU, Surgery

Sedation must be administered prior to and during paralytic use!



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How Supplied

IV Push Conc / Rate



Atropine Anticholinergic (Antimuscarinic)

0.1 mg/ ml 10 ml vial/syringe 1 mg/ml 1 ml vial/syringe

Yes, give rapidly IV for bradycardia Slow IV injection may cause paroxysmal bradycardia

NO Bradycardia: 0.5 mg - may repeat every 3-5 min up to max dose of 0.04 mg/kg PEA/asystole: 1 mg every 3-5 min up to max of 3 mg total Pre-procedure medication: Usual dose is 0.4 – 0.6 mg IV/IM/SC x 1, 30-60 min prior to procedure

Follow dose with 20 ml NS flush – elevate extremity x 10-20 seconds Extremely large doses may be needed for treatment of organophosphate (nerve agent) poisoning.

* See footnote Pre-procedure use does not require cardiac monitoring.

AzaTHIOprine (Imuran) Immunosuppressant

100 mg Vial

Yes, 100 mg over 5 min (20 mg/min).

Dilute in 50 - 100 ml NS Infuse over 30 min

Avoid extravasation Protect from light

Azithromycin (Zithromax) Antibiotic/ Macrolide

500 mg Vial

NO Infuse over 60 minutes (2mg/ml Max Conc)

Aztreonam (Azactam) Antibiotic/ Monobactam

1 Gm Vial, Premix: 1 Gm/50 ml

NO < 1Gm/50 ml D5W over 30 min > 1 Gm /100 ml D5W over 60 min

Dose reduction recommended for CrCl < 30 ml/min

B1 – Vitamin See Thiamine

B6 - Vitamin See Pyridoxine

BASILIXimab (Simulect) Immunosuppressant

20mg Vial NO Intermittent Infusion – Typical dosing: 40 mg in 100 ml NS given over 30 minutes pre-op 1 hr prior to incision. Then 20mg in 50ml NS – infuse over 30 minutes given POD#4.

Do not mix with other solutions Do not shake solution or transport via tube system

Stable only 4 hours at room temp.

BeneFIX See Factor 9 - Recombinant

Betamethasone (Celestone) Corticosteroid

5mL vial (6mg/mL)

IM only Do NOT administer IV

NO

Betamethasone 12 mg IM q24h x 2 doses recommended for all pregnancies 24-34 weeks at risk for pre-term delivery.



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How Supplied

IV Push Conc / Rate



Bivalrudin (Angiomax)


Anticoagulant

250mg Vial Yes, May bolus 0.75 - 1mg/kg depending on indication

Continuous infusion, weight-based and indication specific. Dose Range for Therapeutic Anticoagulation: 0.1 – 0.25 mg/kg/hr and titrated to target PTT. Dose for PCI: Refer to orderset. Standard conc: 250 mg/50 ml NS (5 mg/ml)

Dose reduction recommended for CRCL < 30 ml/min Bleeding risk PTT & ACT affected by bivalrudin Pre-printed order sets for Cath Lab PCI & Therapeutic Anticoagulation in Heparin Allergic Patients

Bumetanide (Bumex) Diuretic

2, 4, & 10 ml Vial (0.25 mg / ml)

Yes, Give at max rate of 0.5 mg/min

Doses may be diluted in 25-50 ml D5W/NS and infused at max rate of 0.5 mg/min Continuous infusion – System Standard Conc: 10 mg/ 60 ml NS (total volume 100 ml) (0.1 mg/ml)

High doses have been associated with muscle stiffness and tenderness Monitor BP/ fluid status

Buprenorphine (Buprenex) Narcotic Analgesic

0.3 mg / ml Amp

Yes, Give 0.3 mg dose over 2 min.

IV Push or IM preferred Monitor for excess sedation, cardiovascular and respiratory status

** NOTE: Reversal may require higher doses of naloxone**

**After naloxone administration - monitor for risk of recurrent respiratory depression. **

May cause withdrawal in opioid / methadone dependent patients.

Butorphanol (Stadol) Narcotic Analgesic

1, 2 & 10 ml Vial (2 mg / ml)

Yes, Admin at 0.5 mg/min

IV Push or IM preferred Monitor for excess sedation, cardiovascular and respiratory status May cause withdrawal in opioid / methadone dependent patients.

Caffeine/Sodium Benzoate Stimulant/analgesic

250 mg/ml 2 ml vial

NO Postdural Puncture Headache: 500 mg x 1 –2 doses (Common dilution: 500 mg/L. Given over 60-90 min)

Monitor BP/HR – may cause hypertension/tachycardia

Do NOT refrigerate * See footnote

Calcitriol (Calcijex) Vitamin D Analog

1 mcg/ml 1 ml ampule

Yes, 2-3 mcg/min

Not advised Used in the treatment of hypocalcemia/secondary hyperparathyroidism in chronic renal failure patients.

Discard ampule after use. Stable 8 hr in syringe



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How Supplied

IV Push Conc / Rate



Calcium Chloride


Electrolyte

100 mg/ml (10%) 10 ml vial/syringe

Yes, Admin at 50mg/min (0.5 ml/min) in emergency only. For treatment of severe hyperkalemia, may give 5-10 ml over 2-5 min.

If on digoxin do NOT give calcium IV push!

Intermittent infusion: 1 Gm in 25 ml D5W – infuse over 30min 2 Gm in 50 ml D5W – infuse over 60min

IV push should be used ONLY in emergency situations!

Avoid extravasation- See PPO 5046 for general guidelines / management. Never give IM or SQ-Irritant and may cause tissue necrosis Adverse reactions that may occur with too rapid administration: bradycardia, sense of oppression, burning sensation at IV site

Incompatible with phosphate solutions Central line administration preferred 1 ml = 27.3 mg = 1.36 mEq elemental calcium Calcium chloride is 3 times as potent as calcium gluconate.

* See footnote

Calcium Gluconate


Electrolyte

100 mg/ml (10%) 10 ml Vial

Yes, Administer into large vein at max rate of 1.5 ml/min Infusion preferred! If on digoxin do NOT give calcium IV push!

Intermittent infusion: 1 Gm in 25 ml D5W – infuse over 15 min 2 Gm in 50 ml D5W – infuse over 30 min

Avoid extravasation Central line administration preferred. SQ/IM administration not recommended Avoid Extravasation – see PPO 5046 for general guidelines / management Adverse reactions: same as calcium chloride

Incompatible with phosphate solutions 1 ml = 9.3 mg = 0.46 mEq elemental calcium

Caspofungin (Cancidas) Antifungal

50 mg, 70 mg vials

NO Indicated for treatment of invasive candidiasis & aspergillosis Intermittent Infusion: Infuse over 60 min 50 mg/250 ml NS or 70 mg/250 ml NS

Phlebitis common.

NS only!! Do not mix with any other medications/solutions!

CeFAZolin (Kefzol/Ancef) Antibiotic/ Cephalosporin

1 & 2 Gm Vials 1 Gm/ 50 ml D5W premix

May be given IV push over 3-5 min (i.e. hemodialysis patients) Routine use of IV push is not recommended

May be given IM

Up to 1 Gm /50 ml D5W -- Infuse over 15 min > 1 Gm/100 ml D5W -- Infuse over 30 min

Contraindicated in patients with prior hypersensitivity to cephalosporins Check allergies Dose reduction recommended with CrCl < 30 ml/min.



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How Supplied

IV Push Conc / Rate



Cefepime (Maxipime) Antibiotic/ Cephalosporin

0.5, 1 & 2 Gm Vials

Not advised Infuse doses over 30 minutes Contraindicated in patients with prior hypersensitivity to cephalosporins Check allergies Dose reduction recommended with CrCl < 60 ml/min

Cefotaxime (Claforan) Antibiotic/ Cephalosporin

1 & 2 Gm Vials


Up to 1 Gm/50 ml NS Infuse over 15 minutes > 1 Gm/100ml NS Infuse over 30 minutes

Contraindicated in patients with prior hypersensitivity to cephalosporins Check allergies Dose reduction recommended with CrCl < 50ml/min.

Cefoxitin (Mefoxin) Antibiotic/ Cephalosporin

1g & 2 g vials, Premix: 1g /50 ml

May be given IV push over 3-5 min (i.e. hemodialysis patients) Max rate: 1 gm/3 min Routine use of IV push is not recommended

Infuse over 15-30 minutes Contraindicated in patients with prior hypersensitivity to cephalosporins Check allergies Dose reduction recommended with CrCl < 50 ml/min.

Ceftazidime (Fortaz) Antibiotic/ Cephalosporin

1 g & 2g vials


Infuse over 30 minutes Contraindicated in patients with prior hypersensitivity to cephalosporins Check allergies Dose reduction recommended with CrCl < 50 ml/min.

CefTRIAXone (Rocephin) Antibiotic/ Cephalosporin

250 mg, 500 mg, 1 & 2 g vials. Premix: 1g/50 ml

NO Infuse over 30 minutes Contraindicated in patients with prior hypersensitivity to cephalosporins Check allergies Do NOT co-administer with IV calcium products.

Cefuroxime (Zinacef) Antibiotic/ Cephalosporin

0.75 & 1.5 Gm Vials, Premix: 1.5 g/50 ml

May be given IV push over 3-5 min (i.e. hemodialysis patients) Max rate: 750 mg/3 min Routine use of IV push is not recommended

Infuse over 15 to30 minutes Contraindicated in patients with prior hypersensitivity to cephalosporins Check allergies Dose reduction recommended with CrCl < 20 ml/min.



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How Supplied

IV Push Conc / Rate



Chloramphenicol Antibiotic

1 g vial Yes over at least 1min (100mg/mL)

Usual dose is 50 mg/kg/day divided Q 6 hr - infuse over 15-30 min Maximum concentration for infusion: <20mg/mL

May cause idiosyncratic aplastic anemia. May cause dose related bone marrow suppression. Monitor CBC.

Stable in NS and D5W

Do NOT administer IM.

Chlorothiazide (Diuril) Thiazide Diuretic

500 mg vial Yes, Slowly give 500mg over 10 minutes (50mg/min) Usual dose: 0.25 – 1 gm daily to twice daily

May be diluted with D5W or NS and given as infusion over 10 min

May cause hypokalemia, hyponatremia, and hypochloremic alkalosis – monitor electrolytes Monitor BP, fluid status

Do NOT give SC/IM – avoid extravasation!! Reconstitute each 500mg vial with 18 ml sterile water – use immediately

ChlorproMAZINE (Thorazine) Antipsychotic

25mg/ml vial (1 & 2mLs)

Yes, Dilute with NS to conc of 1 mg/ml (Dilute 1 ml with 24 ml NS) Max rate of admin is 1 mg/min May be given IM

Up to 50 mg/25 ml D5W infused slowly over at a rate of 0.5-1mg/min

Slow rate of administration if extra-pyramidal symptoms develop (dystonia, motor restlessness, Parkinson-like symptoms) – may be treated with diphenhydramine 50mg IV per physician order

May cause hypotension (esp. in elderly or given IV) BP, HR monitoring recommended w/ IV administration

Avoid mixing with alkaline solutions

SQ administration not recommended.



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How Supplied

IV Push Conc / Rate



Cidofovir (Vistide) Antiviral

375 mg Vial (75 mg/ml)

NO 5 mg/Kg dose in 100ml NS. Infuse over 60 minutes – Administered every 1-2 weeks. Maximum recommended concentration is 5 mg/ml

To minimize potential nephrotoxicity, probenecid and IV saline pre-hydration must be ordered with each infusion

Give 2gm probenecid 3 hours prior to cidofovir dose and 1gm at 2 and 8 hours after infusion Infuse 1 L NS over 1-2 hours immediately before each cidofovir dose. Patients who can tolerate additional fluid should receive a second liter either at the start of the cidofovir infusion or immediately afterwards and infused over a 1-3 hour period Monitor renal function. Contraindicated with CrCl<55mL/min or SrCr>1.5

Pharmacy to prepare dose using chemotherapy precautions Administer and discard using chemotherapy precautions.

Ciprofloxacin (Cipro) Antibiotic/ Fluoroquinolone

Premix: 400 mg/200 ml D5W (2 mg/ml) 20ml Vial (10 mg/ml)

NO 400mg/200ml in D5W premixed Infuse over 60 minutes Max conc: 2 mg/ml

Dose reduction recommended with CrCl < 50 ml/min.

CISatracurium (Nimbex)


Neuromuscular- blocker

2 mg/ml 5, 10 ml vials 10 mg/ml 20 ml vial

Yes, Admin bolus doses rapidly – 0.2 mg/Kg

Continuous infusion: Usual dose range: 0.5 – 10 mcg/kg/min System Standard Conc: 200 mg/ 80 ml NS (total volume 100 ml) (2 mg/ml)

Metro Nursing Clinical Policy on Neuromuscular Blockade (MN-13)

Refrigerate vials Vials stable x 21 days at room temp but then must be discarded. May give undiluted if necessary

Controlled airway and ventilation required; Critical Care only: ED, ICU, Surgery Sedation must be administered prior to and during paralytic use!



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How Supplied

IV Push Conc / Rate



Clindamycin (Cleocin) Antibiotic

6 ml Vials (150mg/ml) Premix: 300 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml

NO Doses < 300 mg, infuse over 15 min Doses > 300 mg, infuse over 30 min Max conc: 18mg/ml

Contraindicated for patients with allergy to lincomycin (Lincocin)

Codeine Narcotic Analgesic

15 mg/ml, 30 mg/ml and 60 mg/ml syringes

NO IM or SQ administration preferred

NO IV administration may lead to severe hypotension. Do not give IV.

Monitor respiratory status – may cause respiratory depression or distress

Reverse effects with naloxone (Narcan)

Colistimethate/colistin (Coly-Mycin M) Antibiotic

150 mg vial Yes, Slowly over 3-5 min

Intermittent infusion preferred: Dilute in 50 ml NS and infuse over 30 minutes

Monitor renal function – may cause/exacerbate acute renal failure Dose reductions recommended with decrease renal function Monitor neuro status – may cause neurotoxicity.



16


How Supplied

IV Push Conc / Rate



Conivaptan (Vaprisol) Vasopressin antagonist

20 mg/ 4 ml ampule

NO Loading dose: 20 mg in 100 ml D5W infused over 30 minutes Continuous infusion over 24hours: 10mg/250mL D5W or 20 mg in 250 ml D5W or 40 mg in 250 ml D5W Total duration of therapy not to exceed 4 days.

Indicated for the treatment of euvolemic symptomatic hyponatremia Overly rapid correction of sodium (>8-12 mEq/L/24 hrs) may result in serious sequelae. VASCULAR IRRITANT! Peripheral infusion site must be rotated every 24 hours – infuse via large vein only! Serial serum sodium levels (recommended every 6 hours) required with physician call back parameters (minimum: Call physician if increase in serum sodium > 8 mEq in 24 hours or >0.5mEq/L/hr). If levels and call back parameters not included in original order, physician must be contacted for order per Metro P&T

Dilute with D5W only! Infuse via separate line. Protect ampule from light.

Cosyntropin (Cortrosyn) Diagnostic – Adrenal function

250 mcg Vial

Yes, 250 mcg/ml in NS over 2 min. (125 mcg/min)

Intermittent infusion: 250mcg/250 ml NS or D5W Infuse over 6 hours

250 mcg = 25mg corticotropin (ACTH)

Infusion stable 12 hr



17


How Supplied

IV Push Conc / Rate



CycloSPORINE (Sandimmune) Immunosuppressant

50 mg Amp (10 mg/ ml)

NO Intermittent Infusion – typically q 12 hr For doses < 12.5 mg, give over 60 min For doses > 12.5 mg, Infuse over minimum of 2 hours. Concentration must be 0.4 – 2 mg/ml Continuous infusion – Change bag daily at 1800 System Standard Conc: 250 mg/250 ml NS (Excel) (1 mg/ml) System “Concentrated” Conc: 250 mg/ 100 ml NS (Excel) (2.5 mg/ml)

Due to the risk of anaphylaxis, patients receiving cyclosporine IV should be under continuous observation for at least the first 30 minutes following start of the infusion and at frequent intervals during. Epinephrine should be available (UBC) during 1st 30 minutes

IV dose = 0.33 x PO dose

Monitor cyclosporine trough concentrations.

Use admin set provided by pharmacy (Non PVC tubing) Protect ampule from light

Cytomegalovirus (CMV) Immune Globulin (CytoGam) CMVIG/ IgG antibody to CMV

1 Gm and 2.5 Gm Vials

NO Usual Dose: 50-150mg/kg – doses up to 400mg/kg for severe CMV infection Initial Dose: 15 mg/kg/hr - May increase to 30 mg/kg/hr if no adverse reactions after 30 min. - May increase to max rate of 60 mg/kg/hr if no adverse reactions after a subsequent 30 min. Do NOT exceed 60 mg/Kg/hr!! Max volume = 75 ml/hr Subsequent Doses: 15 mg/kg/hr for 15 min, then 30 mg/kg/hr for 15 min, then 60 mg/kg/hr if no adverse reactions Do NOT exceed 60 mg/kg/hr!! Max volume = 75 ml/hr.

Monitor vital signs before, midway through, after infusion and before any change in rate. Potential adverse reactions: flushing, chills, muscle cramps, back pain, fever, nausea, vomiting, wheezing, and decreased blood pressure.

If patient develops minor side effects (nausea, back pain, flushing), slow the IV rate or temporarily interrupt the infusion. If anaphylaxis or hypotension occurs, discontinue the infusion and contact the physician.

Start infusion within 6 hr of entering vial. Complete infusion within 12 hr of entering vial. Administer through IV line with in-line 15micron filter. Administer using a separate IV line. May be "piggybacked" into pre-existing line of NS or D5W, however CMV-IG should not be diluted more than 50%.

Daclizumab (Zenapax) Immunosuppressant

5mg/ml – 5ml vial

NO Intermittent Infusion – 1mg/Kg diluted into 50ml NS. Infuse over 15 minutes via peripheral or central line.

5 doses define standard course of therapy. First dose before transplant and subsequent doses 14 days apart

Stable 24 hours after dilution refrigerated Stable 4 hr at room temp Do not mix with other solutions Do not shake solution or transport via tube system



18


How Supplied

IV Push Conc / Rate



Dalfopristin / Quinupristin (Synercid) Antibiotic

500mg Vial NO Usual dose: 7.5mg/Kg (in 250 ml D5W) q 8-12 hr Infuse over 60 minutes Concentrated solution in 100ml D5W – central line administration only

Flush IV lines before and after admin with D5W only, avoid NS Infusion site reactions common – pain, burning, itch – further dilute doses (500-750mL) if these occur Arthralgia & myalgia common

Do not shake

Dalteparin (Fragmin) Anticoagulant/ Low molecular weight heparin

Pre-filled syringes, multi-dose vial

NO SC administration only! Do NOT give IM

Not advised. SC administration only! Do NOT give IM

See syringe for manufacturer expiration date

Dantrolene (Dantrium) Malignant Hyperthermia Hotline (for contact with MH expert) 1-800-MH-HYPER (1-800-644-9737) Muscle relaxant

20 mg Vial Yes, Rapid admin advised for treatment of Malignant Hyperthermia (MH)

Malignant Hyperthermia (MH): Prevention: 2.5 mg/Kg infused over 60 minutes 1.25 hours prior to anesthesia. Treatment: 2.5 mg/Kg infusion given rapidly. Repeat dose every 5 min until symptoms subside or 10mg/Kg (recommended upper limit) has been reached (subsequent doses may be given as needed!) Then continue 1 mg/kg every 4-8 hr for 24 – 48 hrs.

Staff in areas where stored to periodically check expiration date on vials to insure use of in date medication when needed. Avoid extravasation – central line administration preferred. Do not withhold care if no central access available!! Monitor urine output Call Code 4 and/or pharmacy for assistance if treating MH

Dilute with STERILE WATER only – 60 ml per 20 mg = 0.33 mg/ml. Prepare immediately before administration. Six-hour stability at room temp. ** Powder in vials may take several minutes to dissolve **

DAPTOmycin (Cubicin) Antibiotic

250 mg, 500 mg vial

NO Dilute in 100 ml NS – Infuse over 30 min Usual dose: 4-6 mg/kg IV q24h Max concentration: 20mg/mL

Dose reduction recommended for CrCl < 30: q48 hr May cause elevated CPK levels – monitor for myopathy

**Not compatible in dextrose!! Stable 12 hr at room temp/48 hrs refrigerated Check with pharmacist for compatibilities



19


How Supplied

IV Push Conc / Rate



Darbepoetin alfa (Arenesp) Red cell stimulating hormone

Vials: 25 mcg/ml 40 mcg/ml 60 mcg/ml 100 mcg/ml 200 mcg/ml

Yes, SQ or IV bolus

Not necessary Monitor for injection site pain, headache, arthralgias, and myalgias. Hemoglobin <10 in chemotherapy-induced anemia. Hemoglobin < 12 mg/dl in chronic kidney disease / other indications.

Do not shake product or transport via tube system Refrigerate

Restricted to Outpatient administration only. Check hemoglobin prior to administration. Notify physician prn for dose reduction or interruption based on most recent hemoglobin.

Deferoxamine (Desferal) Iron Chelating agent

500 mg, 2000 mg Vials

NO IM administration preferred May be given SC

Dose varies with indication. Acute Iron Overload: IM route preferred unless pt in shock. Recommended dose is 1000 mg then 500 mg Q 4 hr x 2 doses. Subsequent doses may follow. Max dose = 6 Gm/24 hr. If given via IV infusion: Max rate = 15 mg/kg/hr for first 1000 mg then max rate of 125 mg/hr for subsequent doses.

Flushing, hypotension and shock have been reported with IV administration – slow infusion rate if this occurs. Chronic Iron Overload: 500 – 1000 mg daily IM 2000 mg IV with each unit of transfused blood – administered separately. Max rate = 15 mg/kg/hr. Max dose = 6 Gm/24 hr no matter amount of blood transfused. Dilute in 500 ml or 1000 ml NS

Reconstitute with STERILE WATER then dilute with NS Protect from light Do NOT Refrigerate

Desmopressin (DDAVP) Hormone – Vasopressin analog

1 ml Vial (4 mcg/ml)

Yes, for treatment of diabetes insipidus – may give 2-4 mcg/d Give at max rate of 4 mcg/min May be given subcutaneously

Usual Dose: 0.3 mcg/kg in 50 ml NS given over 15-30 min To stabilize hemostasis before surgery administer 30min prior to procedure. Children < 10 kg, -dilute in 10 ml NS

Monitor HR and BP during infusion and for 60 minutes after. When used to manage diabetes insipidus, monitoring of urine output every 8 hr recommended May cause hyponatremia – monitor Na+

Refrigerate vial Stable 12 hr after diluted refrigerated

Dexamethasone (Decadron) Corticosteroid

4 mg/ml 1, 5, 25 and 30 ml vials 24 mg/ml 5 ml vial

Yes, IV Push preferred – all doses over 2 min.

IV Push preferred. Doses may be diluted in NS or D5W IM injection used in OB – 6 mg IM q12h x 4 doses recommended as alternative to betamethasone for all pregnancies 24-34 weeks at risk for pre-term delivery.

Doses > 10 mg may be ordered as intermittent IV infusion Pt may complain about perianal itching/tingling with doses > 10 mg



20


How Supplied

IV Push Conc / Rate



Dexmedetomidine (Precedex) Sedative

200mcg/2ml vial

Loading dose of 1mcg/kg given over 10 min

After bolus, start at 0.4 mcg/kg/hr Increase 0.1 mcg/kg/hr q 10 minutes up to maximum of 0.7 mcg/kg/hr Usual dose range: 0.2 – 0.7 mcg/kg/hr System Standard Conc: 200 mcg/50 ml NS (4 mcg/ml) Usual duration of infusion < 24 hr

Hypotension in 30% of patients; Bradycardia may occur Monitor cardiovascular and respiratory status Potentiates effects of opioids & benzodiazepines. Anticipate dose reductions / titrate to effect. Agent lacks amnestic properties. Preprinted order set available

Critical Care only

Dextran-40 Solution Plasma volume expander

10% in NS or D5W – 500ml

Not advised For plasma volume expansion Total dose during first 24 hours should not exceed 20ml/Kg (2 Gm/kg) Therapy should not exceed 5 days

Observe for signs of allergic reaction.

Do not administered unless solution is clear Check bag for expiration

Dextrose 50% Solution Hypertonic glucose

25 Gm / 50ml (500mg/ml) vial/syringe

Yes, Administer at rate not > 5Gm/min or 10ml/min

Reversal of severe hypoglycemia when oral intervention is not possible.

Highly osmotic solution! Irritating to peripheral veins - give via central line whenever possible Avoid Extravasation – see PPO 5046 for general guidelines / management Preprinted inpatient hypoglycemic order set available.

DIAZepam (Valium) Sedative/ Benzodiazepine

5 mg/ml – 1 & 2 ml syringes, Vials

Yes, Admin at rate not > 5mg/min IM absorption erratic.

Do not dilute – precipitation

Avoid extravasation. Thrombophlebitis is common – give preferably into Y-site of running IV. Monitor cardiovascular and respiratory status. May cause respiratory depression. Reverse with flumazenil (Romazicon)

Incompatible with many medications and solutions – contact pharmacist



21


How Supplied

IV Push Conc / Rate



Diazoxide (Hyperstat) Diuretic

300mg/20ml (15mg/ml)

Yes, Give rapidly over 30 seconds

Dilution not advised If infused – give 15-30 mg/min

Avoid extravasation Use Central Line if available. Do not administer IM/SQ

Do not mix with other IV medications. Protect from light. Darkened solutions should not be used.

* See footnote

Digoxin (Lanoxin) Cardiovascular/ Positive inotrope

0.25mg/ml – 2ml Amp

Yes, undiluted & give slowly over at least 3-5min or diluted to 10ml NS & give slowly over at least 3-5 min

Slow IV Push recommended Check apical pulse prior to administration. If heart rate is less than 50 BPM or otherwise specified – HOLD dose & call physician

Digoxin Immune FAB (Digibind, Digifab) Digoxin antidote

38 mg Vial (Digibind) 40 mg vial (Digifab)

Yes, 10mg/ml -ONLY if Cardiac Arrest is imminent. Give over 5 min.

Diluted in 50ml NS. Infuse over 30 min. Metro: ** Dose rounded to nearest vial per P&T ** Preprinted order set available

Monitor vital signs & ECG Monitor for hypokalemia – obtain serial potassium levels especially during the hours after administration Digoxin serum level assay not accurate after digibind. Pharmacy will notify lab pt has received digoxin immune FAB

Use reconstituted product immediately. Use administration set provided by pharmacy which includes 0.22 micron filter

*See footnote



22


How Supplied

IV Push Conc / Rate



Dihydroergotamine (DHE) Antimigraine/ Ergot alkaloid

1mg/ml – 1ml amp

Yes, Give at max rate of 1mg/min May be given IM

Continuous infusion may be used in status migranosis

Total IV dose should not exceed 2 mg/day (3mg/day if continuous infusion). Total weekly dose should not exceed 6 mg (20mg over 7 days if continuous infusion). Monitor HR and BP. Contact physician immediately (and stop infusion if continuous infusion) if chest pain develops. Contact physician immediately if numbness/tingling of extremeties, nausea/vomiting unrelieved by antiemetics, leg cramping, or coldness of skin develops. Contraindicated in patients with hypersensitivity to ergot alkaloids – ergotamine. Contraindicated if ergotamine or triptan used within past 24 hours Contraindicated with multiple drug classes (i.e. MAO-Inhibitors, potent inhibitors of 3A4). Contraindicated in patients with ischemic heart disease.

Protect ampule from light



23


How Supplied

IV Push Conc / Rate



Diltiazem (Cardizem) Cardiovascular/ Calcium Channel Blocker

5mg/ml – 5 & 10 ml Vial, 5 ml syringe

Yes, Initial dose: 0.25 mg/kg over 2 min Second dose: 0.35 mg/kg over 2 min, give after 20 minutes if response to first dose is poor Or 15-20mg IV push over 5-10min; may repeat in 30min x 1 Administration through running IV line preferred

System Standard Conc: 125 mg/100 ml NS (total vol=125 ml) (1 mg/ml) System “Concentrated” Conc: 125 mg/25 ml NS (total volume 50 ml) (2.5 mg/ml) Usual dose range: 5 – 15 mg/hr Onset: 2-5 min Half-life: 3-9 hr

Increase infusion rate by 5 mg/hr every 60 min if HR remains > 100 beats per minute. Maximum Dose: 20mg/hr D/C infusion if HR < 60 BPM, 2nd or 3rd degree AV block, junctional rhythm or asystole. Monitoring: Continuous EKG Monitoring BP - Following initiation or

dose titration: Continuous BP or q15min x 3, then q4h x 4 then q4-6hrs while stable.

Pre-printed order set available for new onset A.Fib

Solution (vial) should be stored in refrigerator. Check with pharmacist regarding compatibility information.

* See footnote

DiphenhydrAMINE (Benadryl) Antihistamine

50mg/ml 1 & 10 ml Vial 1 ml Syringe

Yes, Max rate of 25 mg/min May be given IM

Usual dose: 25-50mg IV Push Preferred

Max single dose: 100 mg Max dose/day: 400 mg

Dilute to concentration of 25 mg/ml with NS or D5W

DOBUTamine (Dobutrex) Cardiovascular/ Positive inotrope

500mg in 250ml D5W Pre-mix Bag 12.5 mg/ml 20ml Vial

NO System Standard Conc: 500 mg/250 ml D5W Premix (2 mg/ml)

System “Concentrated” conc: 500 mg/60 ml NS (total volume 100 ml) (5 mg/ml) Usual dose range: 2 – 20 mcg/Kg/min Onset: 2 min Half-life: 2 min

Continuous EKG Monitoring Monitoring: Following initiation or dose titration - Continuous BP or q15min x 3, then q4-6hrs while stable. Monitor for ectopy, increase in heart rate Irritant to tissues –administer via large vein. Central line preferred. Avoid Extravasation – see PPO 5046 for general guidelines / management.

May have slight pink coloration which is normal

* See footnote if titrating dose. Not necessary for maintenance infusion for CHF



24


How Supplied

IV Push Conc / Rate



Dolansetron (Anzemet) Antiemetic/ 5HT3 receptor antagonist

20 mg/ml 0.625 ml ampule, 20mg/ml 5 & 25ml vials

Yes, Give 12.5 – 25 mg over 30 seconds

Dose may be diluted in 50 ml D5W/NS. Infuse over 15 min

May cause QT prolongation Do not mix with other medications.

Non-formulary. Autosubstitution to ondansetron

DOPamine (Inotrope) Vasopressor

400 mg/250 ml D5W Premix Bag 40 mg/ml- 5 & 10 ml Vial

80 mg/ml – 5 ml vial

NO System Standard Conc: 400 mg/250 ml D5W Premix (1.6 mg/ml)

System “Concentrated” Conc: 800 mg/250 ml NS (3.2 mg/ml) Usual dose range is 2 – 20 mcg/kg/min Onset: 5 min Duration of action: 10 min Half-life: 2 min

Monitoring - Following initiation or dose titration: Continuous BP or q15min x 3, then q4x 4 then q4-6h while stable. Dopaminergic effects: < 5 mcg/kg/min Beta effects (Improved Cardiac Output): 2-10 mcg/Kg/min

Alpha > Beta Effects (Vasoconstriction): > 10-15 mcg/Kg/min

Central Line Administration Required unless order obtained from physician for peripheral administration!! Check IV site every 30 minutes while dopamine is administered peripherally.

Consult pharmacist for compatibility information.

Avoid infiltration – Phentolamine (Regitine) intradermally /subcutaneously recommended for management Avoid Extravasation – see PPO 5046 for general guidelines / management

* See footnote Central Line Administration Required unless order obtained from physician for peripheral administration!! Midline access is not = to a central line. Check IV site every 30 minutes while dopamine is administered peripherally.

Doxercalciferol (Hectorol) Vitamin D Analog

2 mcg/ml 1 ml and 2 ml ampules

Yes, 2-4 mcg/min

Not advised Used in the treatment of secondary hyperparathyroidism in chronic renal failure patients.

Protect from light Discard ampule after use.

Doxycycline (Vibramycin) Antibiotic/ Tetracycline

100 & 200 mg Vial

NO Max conc = 1 mg/ml Infuse over minimum of 60 min

Avoid extravasation -Irritant to tissues

Stable 12 hr at room temp or 72 hr refrigerated Protect from light



25


How Supplied

IV Push Conc / Rate



Droperidol (Inapsine) Antiemetic

2.5mg/ml – 2, 5ml vials

Yes, Give at max rate of 2.5 mg/min May be given IM

May dilute dose to 50 ml in D5W or NS - administer over 15 min

Use with caution if cardiovascular disease is present.

May cause QT prolongation. Avoid in patients with prolonged baseline QT. Normalization of potassium and magnesium levels recommended.

Monitor for hypotension & tachycardia – monitor BP and HR.

Monitor for extrapyramidal effects

Contraindicated in Parkinson’s patients.

Drotrecogin alfa (recombinant activated Protein C, Xigris) Adjunctive treatment for severe sepsis

5mg & 20mg vials

NO Weight based dose rounding – 24mcg/kg/hr X 96 hours Standard Bags: (100mcg/ml) 5mg/50ml NS 10mg/100 ml NS 15mg/150 ml NS 20mg/200 ml NS 25mg/250 ml NS

Significant risk of bleeding Mandatory pre-printed physician order set to review indications, warnings and contraindications! Patient must meet criteria to be eligible to receive drug! Hold infusion x 2 hr prior to invasive procedure (procedure with inherent risk of bleeding). Restart infusion immediately for uncomplicated less invasive procedure. Hold for at least 12 hr after major invasive procedure/surgery.

Stable for 12 hr only.

Critical Care

Edetate CALCIUM Disodium (CaEDTA) – (Calcium Disodium Versentate)


Heavy metal chelator

200mg/mL 5 ml vial

NO IM route preferred for patients with cerebral edema or lead encephalopathy

Dose varies with indication. Usual Dose: 500-1000 mg/m2/day in 500 ml D5W/NS Infuse over at least 4 hrs – 8-12 hrs recommended

If given IM, add lidocaine 1% 1 ml for each 1 ml of CaEDTA Establish urine flow with adequate IV fluids prior to administration Dose reduction recommended for SCr > 2 mg/dl ***Caution: Do not confuse with Edetate Disodium (Endrate) – verify product & indication. Confusion of products has resulted in fatalities.***

Telemetry monitoring advised



26


How Supplied

IV Push Conc / Rate



Enalaprilat (Vasotec IV) Antihypertensive/ ACE inhibitor

1.25 mg/ml 1 & 2 ml vial

Yes, Max rate: 1.25 mg/ml over 5 min

May dilute in 50 ml NS – give over 10 min

Peak Blood Pressure reduction may be anticipated within 15 minutes of administration – Monitor BP

Enoxaparin (Lovenox) Anticoagulant/ Low molecular weight heparin

Pre-filled syringes and multi-dose vial

Yes, 30 mg for cardiac indications over 1 minute x 1 only Usually given SQ

NO Contraindicated in patients receiving heparin (increased bleeding risk) and heparin-induced thrombocytopenia. Preprinted order set available for DVT/PE Treatment Doses rounded to nearest 10mg

See syringe for manufacturer expiration date. Do not expel air bubble in syringe before administering dose. Dose reduction recommended for patients with CrCl < 30 ml/min

EPHEDrine Vasopressor

50 mg/ml, 1 ml amp.

Yes, Slowly at max rate of 25 mg/min

NO Usual Intermittent IV dose: 5-25mg repeated q5-10min as needed May be given IM/SQ

Monitor HR, BP every15 min and urine output every 1-2 h – Consider continuous ECG Recommended max of 150 mg/24 hr

Critical Care

EPINEPHrine Vasopressor

1 mg/ml, 1 ml amp & 30 ml vial

Yes, Usual dose is 1 mg Give rapidly & follow with NS flush

May be given IM/SQ in treatment of hypersensitivity reactions/ anaphylaxis/asthma

System Standard Conc: 4 mg/250 ml NS (16 mcg/ml) System “Concentration” Conc: 8 mg/100 ml NS (80 mcg/ml) Usual dose range: 1 – 10 mcg/min Dose may be given via ET tube if no IV access at 2 to 2 ½ x IV dose, diluted in 10 ml NS

Monitor BP, HR and rhythm every 15 min. Preferred measurement of BP per arterial line if possible. Monitor urine output every 1-2 hr Avoid Extravasation – see PPO 5046 for general guidelines / management Phentolamine intradermally /subcutaneously recommended for management

Central line administration advised!

Do not use discolored solutions Protect from light Incompatible with many meds and solutions – contact pharmacist

**Check label as not all epinephrine can be given IV **

Critical Care



27


How Supplied

IV Push Conc / Rate



Epoprostenol (Flolan) Vasodilator/ Prostaglandin

0.5 and 1.5 mg vials for reconstitution

NO Continuous infusion required. Upon admission, patients are converted from home infusion device to hospital IV infusion pump. Usual starting dose is 2 nanogram/ Kg/min. Titrate per physician orders. **Metro: preprinted order set available – use advised! **

Avoid interruptions of infusion ( half-life = 6 min) – loss of disease control could lead to death Monitor for hypotension, flushing, headache, N/V, anxiety & chest pain. A “Flolan Dosing Weight” is established and used throughout the patient’s therapy. The “Flolan Dosing Weight” should be used when calculating infusion rate.

Dilute only with manufacturer-supplied diluent!

Protect from light

** Metro: Bag must be changed every 8 hr even if bag not empty **

* See footnote

Eptifibatide (Integrelin) Antiplatelet IIb/IIIa

2mg/ml – 10ml Vial for loading doses & 0.75mg/ml100ml Vial for maintenance infusions

Yes, 180mcg/Kg bolus over 1-2 minutes. ACS – x 1 PTCA - Repeat bolus in 10 min

Continuous Infusion – Acute Coronary Syndrome/PTCA: 0.5 - 2 mcg/Kg/min (max 15 mg/hr) System Standard Conc: 75 mg/ 100 ml Premix (0.75 mg/ml)

Pre-printed order set available for ACS/PTCA Monitor for bleeding. Recommended to decrease infusion rate to 1 mcg/kg/min for pt with SrCr 2 –4 mg/dl

Compatible with heparin Use vented set to administer undiluted eptifibatide

Ertapenem (INVanz) Antibiotic/ Carbapenem

1 Gm vial NO May be given IM

1 Gm/50 ml NS Infuse over 30 min

Caution with PCN allergy – check allergies Dose reduction recommended for CrCl < 30 ml/min

Stable 6 hr at room temp or 24 hr refrigerated – use within 4 hr after removal from refrigerator Stable in NS only!

Restricted indications per P&T

Erythromycin Antibiotic/ Macrolide

500 & 1000mg vials

NO Up to 500 mg in 100ml NS 501 - 1000 mg in 250ml NS (Max Concentration = 500mg/100ml NS) Infuse all doses over 60 min.

Slow infusion rate if vein irritation occurs Avoid Extravasation – see PPO 5046 for general guidelines / management

Stable 24 hours refrigerated, 8 hours at room temp after dilution



28


How Supplied

IV Push Conc / Rate



Erythropoietin, epoetin alfa (Epogen, Procrit) Red cell stimulating hormone

2,3,4,10, 20 & 40 thousand units/ml vials

20,000 unit/2 ml Multi-dose vial

Yes Give SQ or IV Push over 30-60 seconds

Dilution not advised Chronic Renal Failure: Recommended initial dose: 50 – 100 units/kg SQ or IV 3 times per week. SQ may be administered weekly

Monitor for hypertension, fever, headache, arthralgias & nausea Goal: Hemoglobin <10 in chemotherapy-induced anemia. Hemoglobin < 12 mg/dl in chronic kidney disease / other indications.

Do not shake product or transport via tube system Refrigerate vials

Check hemoglobin prior to administration. See EMAR for Hold parameters. Notify physician prn for dose reduction or interruption based on most recent hemoglobin.

Esmolol (Brevibloc) Cardiovascular/ Beta-Blocker

10mg/ml 10 ml Vial Premix: 2.5 Gm/250 ml

Yes, IV push loading doses (500 mcg/Kg) over 60 seconds

System Standard Conc: 2.5 gm/250 ml NS Premix (10mg/ml) System “Concentrated” Conc: 2000mg/100 ml NS (20 mg/ml) Central Line Only

Dose range: 50 – 200 mcg/Kg/min (Titrate in 50 mcg/Kg/min increments every 5 min to desired response)

Onset: immediate Peak response: 5 min Duration: 10-30 min Half-life: 9 min

Monitor BP and Heart Rate/Rhythm every 5-15 min during dose initiation and titration. Doses > 200 mcg/kg/min do not have increased benefits Contraindications: 2nd/3rd degree AV block, sinus bradycardia, cardiogenic shock

Telemetry / Critical Care Advised * See footnote

Esomeprazole (Nexium IV) Proton Pump Inhibitor

20 mg, 40 mg vials

Yes, 5 ml over 3 minutes Reconstitute vial with 5 ml NS

System Standard Concentration: 80 mg/ 250 ml NS (0.32 mg/ml) Usual dose for GI bleeds: 80 mg (in 100ml NS) bolus over 30 minutes then 8 mg/hr continuous infusion

Continuous infusion duration should not exceed 72 hr

Reconstitute vial with 5 ml NS. Use within 1 hour of reconstitution. Diluted solution stable for 12 hours (NS) Do not administer with other medications/fluids – check with pharmacist for compatibility information



29


How Supplied

IV Push Conc / Rate



Estrogens, Conjugated (Premarin IV) Hormone - Estrogen

25 mg vial Yes, 5mg/min at 5 mg/ml conc.

Not advised Usual intermittent dose -slow IV push Abnormal uterine bleeding: 25mg Uremic bleeding: 0.6mg/kg/day

Slow rate of administration if body/facial flushing occurs Used for treatment of abnormal uterine bleeding. Also used for uremic bleeding. ** Verify dose to be given. Discard vial after drawing up correct dose. **

Refrigerate before and following reconstitution. Do not use darkened solution. Do not shake vial!!

Do not mix with other solutions/medications

Ethacrynic acid (Edecrin) Diuretic

50 mg Vial Yes, Give over > 3 min Max of 100 mg per single dose

Slow IV push recommended Slow rate of administration if vein irritation occurs and/or consider different IV site No IM/SC administration!

Etidronate Disodium (Didronel IV) Inhibitor of bone metabolism

50mg/ml – 6ml Amp (300mg)

NO Usual dose for treatment of hypercalcemia: 7.5 mg/Kg/day x 3 days Diluted in 250ml NS – infuse over minimum of 2 hours (3 mg/ml max concentration)

Temporary taste loss not uncommon following IV etididronate Adequate hydration recommended prior to administration Too rapid administration may lead to renal insufficiency Dose decrease recommended in pt with SrCr 2.5 – 4.9 mg/dl. Not recommended in pt with SrCr > 5 mg/dl

Etomidate **HIGH ALERT MEDICATION** Sedative

2 mg/ml 10 ml vial, 20 ml vial/syringe

Yes 0.3 mg/Kg over 15-60 seconds

NO Monitor BP, HR and RR Pain at injection site common Transient myoclonic movement/seizure-like activity may occur. Nausea/vomiting common

Etomidate has no analgesic properties.

Critical Care



30


How Supplied

IV Push Conc / Rate



Exenatide (Byetta) **HIGH ALERT MEDICATION** Incretin mimetic/adjunctive therapy for diabetes

Pre-filled syringes

No SC administration ONLY

NO Not for use in Type 1 diabetics or for the treatment of diabetic ketoacidosis Common side effect: nausea

Refrigerate Do NOT mix with insulin!!

Non-formulary. Patient may use own supply if deemed necessary & appropriate by prescriber.

Factor VIIa - Recombinant (Novoseven) Blood factor

1mg, 2mg & 5 mg vials

Yes, give over 2-5 min Reconstitute with diluent provided to final concentration of 1mg/mL

Usual single dose: 15 - 100 mcg/kg Continuous infusion may be done –do NOT further dilute Factor VIIa or run into running IV line

Monitor Coagulation profile, PTT/PT Hgb/Hct, platelets May increase risk of thrombotic events Non-emergent indications: Confirm final coagulation results and Factor VIIa order with prescriber prior to administration.

Vial stable at room temperature for 2 years prior to reconstitution. Once reconstituted - administer within 3 hours.

Factor 8 – Human (Humate-P)

Vials – size varies based on pooled plasma source

Yes – Slow IV push at rate not to exceed 4mL/min

VonWillebrand Disease (VWD) – Usual Dose: 40-80 IU/kg** initial dose; for major bleeds or invasive procedures, continue with repeated doses of 25-30 IU/kg Q8- 12h

Infusions: Use diluent & filter provided with product. No additional (inline) filtration or dilution recommended.

***Caution: Product is labeled in Factor 8 units and von Willebrand factor:Ristocetin Cofactor (VWF:RCo) units. In VWD disease dose is based on VWF:RCo content. ***

Product is NOT typically used for Hemophilia A

**Use higher dose for patients with type 2 and 3 VWD

Use diluent provided Stability: 24hrs room temp or refrigerated

Factor 8 – Recombinant (Helixate)

250, 500, 1000,2000 units/vial

Yes - Slow IV push over 5-10min

Hemophilia A – Usual Dose: 50 IU/kg initial dose; for major bleeds or invasive procedures, continue with 25 IU/kg repeated Q12h

Multiple products in Hemophilia A available – this may be used as a “universal product” for urgent reconstitution. Life-threatening bleeds/ Major surgery: Target Factor 8 levels of 80-100%.

Use diluent provided Stability: 3hrs – Stability may be extended on a case-by-case basis – concentrations / dilutions must be considered.

Factor 9 – Recombinant (BeneFIX)

250, 500, 1000,2000 units/vial

Yes - Slow IV push over 5min

Hemophilia B – Usual Dose: 95 IU/kg to achieve a target Factor 9 level of 70-80%; Repeat doses at 12-24hr intervals at a dose of 40 IU/kg

Decreased Factor 9 recovery requires higher relative dose to achieve target Factor 9 levels. Dose = Target level x Pt wt x 1.3

Use diluent provided Stability: 3hrs Stability may be extended on a case-by-case basis. – concentrations / dilutions must be considered.



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IV Push Conc / Rate



Factor 9 Complex – Human (Profilnine SD)

Vial sizes vary based on pooled plasma source

Yes – 5-10mL/min Do not exceed 10mL/min – rates in excess of this may result in vasomotor reactions.

Warfarin reversal in life threatening bleeds – Usual dose: 50 units/kg or 4,000 units Doses may be repeated based on INR response (total dose range 25-100units/kg)

Product FDA approved for Hemophilia B. Contains Factors II, VII, IX, X – In life-threatening bleeds: coadministration with vitamin K & additional source of factor 7 (FFP or NovoSeven) is recommended.

Use diluent provided (SW)

Famotidine (Pepcid) H2 Receptor Antagonist

10mg/ml – 2 & 4 ml Vial

Yes, 10mg/ml – give over 1 min

Dilute with 5-10 ml NS or D5W

IV Push preferred Intermittent infusion: 20mg/50 ml NS – infuse over 15 min

Dose reduction recommended for pt with CrCl < 50 ml/min



32


How Supplied

IV Push Conc / Rate



Fat Emulsion (Intralipid, Liposyn) Local anesthetic toxicity

20% 500 ml bag

Yes 1.5 mL/kg IV bolus over 1 minute (for suspected local anesthetic toxicity); consider repeating bolus up to two more times q 3-5 minutes if adequate circulation not restored

Start continuous intravenous drip at 0.25 mL/kg/min upon initiation of first IV bolus. Increase infusion to 0.5 mL/kg/min if adequate circulation not restored/BP declines after second bolus. Continue lipid infusion until hemodynamic stability restored – recovery may take longer than an hour. A total cumulative dose of 8 mL/kg has been recommended.

Do not use propofol as lipid source. ACLS must be continued throughout fat emulsion administration! Achieving continuous infusion rate > 1200 ml/hr (0.25 mL/kg/hr for a 80 kg patient) may require infusion via multiple lines. ** No standard dosing has been established – contact Poison Control and/or see www.lipidrescue.org for further information **

Stored at room temperature. Recommended storage in L&D, OR, and other areas with high volume use of local anesthetics.

None

Fenoldopam (Corlopam) Antihypertensive

10 mg/ml – 5ml Amp

NO Continuous infusion recommended; Begin at 0.05 mcg/Kg/min and titrate up by 0.05mcg/Kg/min every 15 minutes to desired effect Usual dose range: 0.05 – 1.6 mcg/Kg/min System Standard Conc: 10 mg/ 250 ml NS (40 mcg/ml) System “Concentrated” Conc: 10 mg/100 ml NS (100 mcg/ml)

Monitor BP (preferably via arterial line if possible), HR q 15 min during dose initiation and titration. Half-life = 5 min. Effects quickly reversed with D/C of drip Doses > 1.5 mcg/kg/min rarely required Tachycardia may occur if drug started at rate > 0.1 mcg/kg/min or if titrated too quickly

Incompatible with many medications/solutions – contact pharmacist

Critical Care



33


How Supplied

IV Push Conc / Rate



FentaNYL (Sublimaze) **HIGH ALERT MEDICATION** Narcotic analgesic

50 mcg/ml – various sized amps/vials

Yes, Slowly over 3 – 5 minutes

Continuous infusion or PCA recommended Bolus dose range: 10–30 mcg Continuous IV dose range: 20 – 60 mcg/hr System Standard Conc for continuous infusion: 1250 mcg/250 ml NS Premix (5 mcg/ml) System “Concentrated “ Conc: 1000 mcg/ 100 ml NS (10 mcg/ml)

Monitor BP, RR

Too rapid administration may cause respiratory depression/distress

Reverse effect with naloxone (Narcan) Optimal dose determined by patient response

Metro: If PCA ordered, mandatory order set must be used

Ferrous Gluconate Complex (Ferrlecit) Iron Supplement

Amps 62.5mg/5 ml

Yes, Max 12.5mg/min Give 62.5 mg over 5 min Give 125 mg over 10 min IV push not recommended for doses > 125 mg

Intermittent infusion: 62.5 mg – 125 mg/100 ml NS Infuse over 30 - 60 min Doses greater than 125 mg require dilution Max dose per Metro P&T = 250 mg

Test dose not necessary

Monitor vital signs (BP) including orthostatic BP – Metro: For Outpatient Admin - Doses < 250 mg – monitor patient for 1 hour post-infusion per P&T Doses of 250 mg – monitor patient for 2 hours post- infusion per P&T

May cause hypotension or hypertension, chest, back or groin pain. Symptoms typically resolve 1-2 hours after infusion completed.

Unopened ampules good until expiration dating from manufacturer

Metro: max dose per infusion is 250 mg per P&T

Filgrastim (Neupogen) White cell stimulating hormone

300mcg/ 1 ml 480mcg/1.6ml Vials

SQ preferred Intermittent infusion: 300mcg/18ml D5W 480mcg/25ml D5W Infuse over 30 min

Refrigerate Do not shake product or transport via tube system

Dilute in D5W only!!

Fluconazole (Diflucan) Antifungal

Premix 200mg/200ml & 400mg/400ml

NO Intermittent administration recommended Infuse at max rate of 200 mg/hour




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How Supplied

IV Push Conc / Rate



Flumazenil (Romazicon)

**HIGH ALERT MEDICATION**

**Reversal Agent** Benzodiazepine (BZD) antagonist

5 & 10 ml vial 0.1 mg/ml

Yes, Give rapidly over 15-30 seconds preferably into large vein with running IV

To reverse benzodiazepine (BZD) effects – intermittent administration recommended: 0.2 mg IV repeated every 60 seconds to a total of 3mg/hr. Titrate to response using small IV doses. Most patients respond to total doses between 1 & 3 mg

Irritant, avoid infiltration Elim half-life = 60 min – much less than typical BZD’s and re-sedation following initial response is possible & not unusual May unmask BZD controlled seizures or precipitate BZD withdrawal in chronic BZD users.

Monitor BP, HR, RR

Folic Acid Vitamin/Nutritional supplement

5mg/ml – 10 ml vial

Yes, Give over 1-2 min May be given SQ, IM

Common component in “banana” bag. May dilute with NS or D5W and administered continuously via peripheral or central line

Dilution recommended for > 5 mg Methanol Poisoning: Cofactor in elimination - Higher dose folic acid (50-75mg) administered q4h x 24h or until resolution of acidosis.

Protect from light

Fomepizole (Antizol) Ethylene glycol and Methanol Antidote

1Gm/ml – 1.5 ml vials

NO Intermittent Infusion – 15mg/Kg load then 10mg/Kg every 12h x 4 then 15mg/Kg every 12h until serum ethylene glycol <20mg/dL and / or resolution of acidosis Dilute with 100ml NS and infuse over 30 minutes

Solution may solidify at temps < 77°F, run under warm water or hold in hands to liquify Monitor for signs of allergic reaction – shortness of breath, rash, hives, and pruritus. Do not wait for results of methanol/ethylene glycol blood levels to initiate therapy.

Dialyzable – dosing interval should be increased to every 4 hr during hemodialysis

Monitor ethylene glycol or methanol serum concentrations

Fondaparinux (Arixtra) Anticoagulant

Pre-filled syringes

NO Administer SC only! Do NOT give IM!

Administer SC only! Do NOT give IM! Contraindicated per manufacturer in patients w/ CrCl < 30 ml/min or body weight < 50 kg

See syringe for manufacturer expiration date. Do not expel air bubble in syringe before administering dose.



35


How Supplied

IV Push Conc / Rate



Foscarnet (Foscavir) Antiviral

24 mg/ml in 250 and 500ml bottles

NO Peripheral Line: Must be diluted to 12 mg/ml with NS or D5W Central line: May be given undiluted.

Induction Dose: rate not to exceed 1 mg/kg/min (minimum of 1 hour) every 8 hours. Maintenance Dose: 90-120 mg/kg/day given over 2 hours

Adequate hydration is recommended prior to and during treatment to minimize renal toxicity Dose reduction recommended in pt with decrease CrCl May cause thrombophlebitis

Do NOT refrigerate undiluted solution Incompatible with many medications and solutions, check with pharmacist

May administer undiluted through central line only!

Fosphenytoin (Cerebyx) Anticonvulsant

50 mg/ml 2 & 10 ml vial

Yes Dilute to total of 10mL (or max concentration of 25mg/mL) and administer at max rate of 150mg /min May be given IM undiluted

May dilute to 50 or 100ml with NS. Infuse not rate not faster than 150mg/min Rate reduction to 75 mg/min recommended in elderly and pt with coronary heart disease.

Prodrug of phenytoin - preferred product for IV/ IM administration. Automatically substituted for phenytoin. Monitor BP/HR/RR during infusion and 30-60 min after. Flushed feeling with IV admin. not uncommon - pruritus – commonly near groin area

Refrigerate vials

Furosemide (Lasix) Diuretic

10mg/ml vial and pre-filled syringes

Yes, Doses < 100 mg may be given IV push at max rate of 10 mg/min

Dilute doses 100-200 mg with NS/D5W and administered no faster than 10 mg/min. Doses > 200 mg must be diluted and given no faster than 4 mg/min. Continuous infusion usual dose range 1 – 20 mg/hr. Higher doses may be been used in kidney failure. System Standard Conc: 250mg/250ml NS (1 mg/ml) System “Concentrated” Conc: 250 mg/100ml NS (total volume 125 ml) (2 mg/ml)

Do not use furosemide solutions that are yellow in color IV furosemide = 50% PO dose Monitor urine output/fluid status, BP

Do NOT refrigerate - may crystallize with refrigeration



36


How Supplied

IV Push Conc / Rate



Ganciclovir (Cytovene) Antiviral

500mg vial Reconstitute with 10ml NS to 50mg/ml

NO Dilute dose to 100ml D5W. Infuse over 60 minutes Final concentrations greater than 10mg/ml not recommended for peripheral administration

Irritant - monitor for phlebitis and infusion site pain Dose reduction recommended for Cr Cl < 70 ml/min

Use chemotherapy precautions for preparation, administration & disposal

Gentamicin Antibiotic/ Aminoglycoside

10mg/ml and 40mg/ml in 2 & 20ml vials & premixed minibags in various doses

NO ** May be given undiluted intrathecally – using preservative free product **

Dilute all doses in 50 -100ml NS or D5w Infuse over 30-60 minutes Extended interval (7mg/kg) dosing infuse over 60min


Glucagon Hormone, Antihypoglycemic Agent

1 mg Vial Yes, 1mg/ml over 60 seconds May also be given IM or SQ

Continuous infusions may be used in treatment of calcium channel blocker or beta-blocker overdoses. Usual dose range: 1 – 5 mg/hr

Forms precipitate when mixed with chloride solutions, NO NS – Dilute with sterile water or D5W

Tx of hypoglycemia: usually awakens pt within 15 min

Use immediately after reconstitution.

Granisetron (Kytril) Antiemetic/ 5HT3 receptor antagonist

1mg/ml Vial

Yes, Undiluted over 30 seconds

IV Push preferred.

Intermittent infusion: Dilute in 25 to 50 ml NS or D5W - Infuse over 5 minutes

Give dose 30 minutes prior to chemotherapy to prevent nausea/vomiting.

Haloperidol (Haldol) Antipsychotic/ Anxiolytic

5mg/ml Vial and syringe

Yes, Give at max rate of 5mg/min Use only the lactate salt of haloperidol for IV Push – NOT Decanoate salt May be given IM

Prefer intermittent IV Push

Titrate dose to desired effect

Use with caution if cardiovascular disease is present.

May cause QT prolongation. Normalization of potassium and magnesium levels recommended.

Monitor for hypotension and/or symptoms of angina. Also, monitor for extrapyramidal effects

Will NOT cause respiratory depression.

Contraindicated in Parkinson’s patients

Recommended to flush line with at least 2 ml NS before and after med admin



37


How Supplied

IV Push Conc / Rate



Helixate See Factor 8 - Recombinant

Heparin

**HIGH ALERT MEDICATION**

Recheck concentration of vial/bag before administering dose! Anticoagulant

Various concentra-tions vials and syringes Premix bag: 50 units/ml 500 ml

Yes, All doses administered over 10-20 seconds, undiluted Do NOT give IM!!

Continuous infusion –

Standard conc: 25000 units/500 ml D5W premix (50 units/ml)

See specific weight-based dosing protocols (PPOs) for Cardiac Indications and for Treatment of DVT/PE

Monitor platelets – may cause thrombocytopenia with any dose (even catheter flushing!)

Monitor for signs of bleeding

Monitor PTT 6 hours after any dose change or per orders

Per manufacturer on vials and syringes Multi-dose vials expire 28 days from initial opening.

Recheck concentration of vial/bag before administering dose!

Hetastarch (Hespan) Plasma expander

6% solution in 500ml NS

NO Intravenous infusion preferred. Not to exceed 1500ml/24 hours

Rare allergic reactions to hetastarch have been reported. Monitor for hypersensitivity reactions.

Monitor for plasma volume overload – (dyspnea, fluid in lungs, rapid increase in blood pressure)

Dose reduction recommended for severe renal insufficiency

Humate-P See Factor 8 - Human

HydrALAZINE (Apresoline) Antihypertensive

20mg/ml Vials

Yes, Give undiluted at a max rate of 5mg/min

Intermittent or continuous infusion NOT recommended

Exception – OB uses continuous infusions

50 mg/500 ml D5W or fluid per physician

Monitor for reflex tachycardia after each dose. Monitor BP every 5 min until stabile.

Maximal reduction in blood pressure seen 15-80 min after doses given

Metro: See MWH-19-MAT: Women’s Health Policy & Procedures – Hydralazine: Continuous Infusion

Incompatible with many medications and solutions, check with pharmacist



38


How Supplied

IV Push Conc / Rate



Hydrocortisone Corticosteroid

Various vial sizes 100mg/2ml 250mg/2ml 500mg/4ml 1000mg/8ml

Yes, Give undiluted doses over 30 –60 seconds

IV Push preferred. May dilute dose to 50ml in NS or D5W and give over several minutes.

Local infusion related adverse effects are rare.

Intrathecal administration: use preservative-free ONLY!!

Check vial/syringe for expiration date.

HYDROmorphone (Dilaudid)


Narcotic analgesic

2, 4, or 10mg/ml Vials and syringes

Yes, Give dose slowly over 2-3 min or max rate of 0.5 mg/min

Continuous infusion:

System Standard Conc: 50 mg/250 ml NS (0.2 mg/ml)

System “Concentrated” Conc: 50 mg/ 100 ml NS (0.5 mg/ml)

Reverse effects with naloxone (Narcan)

Monitor RR, HR, BP

Give lower doses to elderly, debilitated or patients on additional CNS depressants

Hydromorphone 1.5 mg IV = Morphine 10 mg IV

Very Potent opioid analgesic. High doses (IV >1mg or IM > 2mg) in opioid naïve patients must be verified with prescriber. IV dose = 1/3 to 1/5 PO dose.

Metro: If PCA ordered, mandatory PCA order set must be used

Hydroxocobalamin (Cyanokit) Antidote – cyanide poisoning

1 kit = 2 x 2.5 gm vials

NO 2.5 gm reconstituted with 100 ml NS – infuse over 7.5 minutes – repeat x 1 for total of 5 gm

2nd 5 gm dose may be given over 15 minutes to 2 hours depending on severity/clinical response for total dose of 10 gm

Urine and skin will turn red

May cause hypertension

Allergic reactions including anaphylaxis, pruritus, rash may occur

May interfere with various lab tests

Stable 6 hours

HydrOXYzine (Vistaril) Antihistamine

25 & 50mg/ml Vials & Syringes

NO IM preferred

Intermittent Infusion – Not advised; IM Preferred!

Hypotension, phlebitis and hemolysis reported following IV administration Intra-arterial administration has resulted in endarteritis, thrombosis and gangrene.

Do NOT give IV-push



39


How Supplied

IV Push Conc / Rate



Ibutilide (Corvert) Anti-arrhythmic

1mg/10ml NO 1 mg/50 ml NS Infused over 10 min Stop infusion when afib/aflutter terminated If < 60kg dose @ 0.01mg/Kg May repeat same dose 10 minutes after completion of initial dose if rhythm not converted Preprinted order set available

Continuous cardiac monitoring recommended for at least 4 hours after completion of infusion. Monitor for increased QT interval prolongation and ventricular arrhythmia potential Check potassium and magnesium levels: should be within normal limits at time of infusion

* See footnote bedside monitor & defibrillator recommended

Imipenem/Cilastatin (Primaxin) Antibiotic/ Carbapenem

500mg Vial NO < 500mg/100ml NS. Infuse over 30 minutes > 500 mg/250ml NS. Infuse over 60 minutes

Reduce rate of infusion if nausea/vomiting occur

Caution with penicillin allergy

Check allergies Dose reduction recommended for CrCl < 70 ml/min



40


How Supplied

IV Push Conc / Rate



Immune Globulin Intravenous (IVIG) Immune modulator

Various strengths & brands

Not advised Standard IVIG (Carimune) - contains sucrose

Initial Dose -Carimune: 3% solution recommended for previously untreated patients. First dose dispensed as partial dose ( 3% solution – usually 6g dose). If tolerated – after first bag – remainder of dose is provided as 6% solution. Solution may be further concentrated to 12% as needed. Initial Rate -Carimune 3% Solution: Initiate at 30-60mL/hr x 15-30min. If tolerated may increase rate every 15-30minutes to a maximum of 150mL/hr. Subsequent Doses – (Carimune 6% and 12% Solutions): After 1st dose of 3% solution, subsequent infusions (6% or 12%) may be administered at a higher concentration and higher rate (i.e. increasing q15-30 min). Infuse at a maximum rate of 2 mg/kg/min Sucrose-free IVIG 10% Solutions

Initial Dose-Gammagard & Privigen Initiate at 15-30mL/hr and increase as tolerated every 30min to maximum of 5mL/kg/hr (Gammagard) and 2.4mL/kg/hr (Privigen), respectively. Subsequent Doses: Higher rates may be possible for Privigen based on indication & tolerability (check with pharmacist).

Monitoring - Monitor BP every 15 minutes for first hour of every infusion, then every 30-60 min. for duration of the initial infusion. Monitor Blood Pressure every 30-60 min. during subsequent infusions if the patient has a history of intolerance to IVIG. Decrease rate or stop infusion if patient experiences adverse reactions. Consider premedication with acetaminophen +/- diphenhydramine

Refer to IVIG PPO - Monitor patient for signs and symptoms of anaphylaxis and have epinephrine available to treat.

- Monitor renal function

Adverse reactions include hypotension, headache, fatigue, change in pulse, flushing, tightness in chest, chills, fever, dizziness, nausea/vomiting, backache, leg cramps, uticaria, and diaphoresis

Standard (Sucrose-containing) IVIG is appropriate for most patients; however, IVIG has been associated with renal dysfunction, ARF, osmotic nephrosis, and death. Patients predisposed to ARF include patients with: 1) any degree of pre-existing renal insufficiency, 2) diabetes mellitus, 3) age > 65, 4) volume depletion, 5) sepsis, 6) paraproteinemia, 7) pts receiving known nephrotoxic drugs In these patients, IVIG should be administered at the minimum concentration and the minimum infusion rate that is practical. Sucrose-free IVIG may also be considered.

Filter not required for: Carimune, Privigen or Gammagard. Gammagard S/D requires filter – use provided administration set that includes 15 micron filter. If administration set not provided, contact pharmacy for filter! Reconstitute Carimune vials with sterile water

Unless clinically indicated (i.e. IgA deficiency) - requests for specific brands cannot be accommodated.

Indication required with all orders.

Pharmacists will provide ordered dose as 3%, 6% or 12% solution (Carimune) or a 10% solution (Gammagard, Privigen).

Pharmacist will round dose down to nearest vial (3, 5, 6 or 10g) depending on availability within 90% of calculated dose.



41


How Supplied

IV Push Conc / Rate



Inamrinone (Inocor) formerly – amrinone Cardiovascular/ Positive inotrope

20 ml amp (5 mg/ml)

Yes May give undiluted via central line or running IV. Give over 2-3 min.

Loading dose 0.75 mg/Kg Usual dose range: 5-10 mcg/Kg/min

Standard conc: 400 mg/250 ml NS (total vol=330 ml) (1.2 mg/ml) “Concentrated” conc: 500 mg/100 ml NS (total vol=200 ml) (2.5 mg/ml)

Maximum Concentration = undiluted (5 mg/ml)

Dose-related thrombocytopenia occurs in 2-3% within 48-72 hr after initiation. Reverses within one week upon d/c of med. Monitor BP, HR every 15 min Total cumulative dose should not exceed 10 mg/kg

Dilute with NS only Incompatible with many medications/solutions – check with pharmacist

* See footnote

Indomethacin (Indocin) Anti-inflammatory/ NSAID

1mg Vial Yes, Give 0.1 – 0.25 mg/Kg dose over 5-10 seconds

Not advised For closure of Patent Ductus Arteriosis in premature infants between 500 & 1750 Gram Weight.

See labeling for age specific dosing

Course of therapy involves 3 doses 12-24 hours apart

Prepare solution just prior to administration Do not dilute with agents containing benzyl alcohol. Use preservative-free sterile water or NS only!

Neonatal Intensive Care

InFLIXimab (Remicade) Monoclonal antibody

100 mg Vial

NO Infuse slowly over 2 hours Recommended Doses: Crohn’s: 5 mg/Kg Rheumatoid Arthritis: 3 mg/Kg

Concentration should be 0.4 - 4mg/ml

Monitor for allergic symptoms – shortness of breath, rash, hives, and pruritus. Premedication with acetaminophen and diphenhydramine recommended Preprinted order sets available

Administer within 3 hrs of preparation

Do NOT shake or transport solution through pneumatic tube system Use administration set provided by pharmacy (contains 1.2 micron filter)

Insulin- Human Regular Also see Section III


Recheck insulin name and dose before administering! Antidiabetic

100 units/ml 10 ml vial

Regular Insulin used for IV route. Give all doses over 15-30 seconds Also administered SQ – see section IV of guidelines

System Standard Concentration: 150 Units/150ml NS (1 unit/ml)

Waste 10-20 ml of diluted solution through the administration set to saturate binding sites in IV tubing before connection to infusion pump. Preprinted order sets available for insulin infusions in ICU patients, Adult Surgical/Medical Patients, and DKA/Hyperosmolar Nonketotic Coma Patients Monitor blood glucose

Vials are stable x 28 days after first use refrigerated or at room temp

Recheck insulin name and dose before administering!



42


How Supplied

IV Push Conc / Rate



Iron Dextran (INFed) Iron supplement

50 mg/ml-2ml Vial

Yes, Doses up to 200mg at max rate of 50 mg/min

Dose > 200mg = Total Dose Infusion (TDI) - dilute into 250-500 ml NS Max conc = 50 mg/ml Infuse over 2-6 hours May be given IM – IV infusion preferred over IM due to local complications and unpredictable absorption with IM admin

25 mg test dose IV-Push over 30 seconds to 5 min recommended before each total dose infusion Observe and monitor BP and HR every 15 min for 60 minutes after test dose before implementing infusion Have the following readily available during infusion: diphenhydramine 50 mg IV, epinephrine 1:1000 (1 mg/ml) and hydrocortisone 100mg/2ml Anaphylactoid/Hypotensive reactions possible.

Use NS – D5W has increased incidence of phlebitis/pain at injection site Lean body weight (or ideal body weight) not actual body weight should be used in calculating dose Incompatible with many medications/solutions, check with pharmacist

Iron Sucrose Complex (Venofer) Iron supplement

20mg/ml – 5ml vial

Yes, Undiluted up to 200mg at max rate of 20mg/min

50 mg IV in 50 ml NS over 15 min 100 mg IV in 50 ml NS over 30 min 200 mg IV in 50 ml NS over 60 min 300 mg IV in 100 ml over 2 hours Maximum Dose per P&T: 300 mg – no more frequently than once weekly

Hypotensive reactions may be possible Test dose not necessary.

Monitor vital signs (BP) including orthostatic BP – Metro: For Outpatients - Doses < 100 mg – monitor patient for 1 hour post-infusion per P&T Doses 200-300 mg – monitor patient for 2 hours post- infusion per P&T May cause hypotension or hypertension, chest, back or groin pain. Symptoms typically resolve 1-2 hours after infusion completed.

Isoniazid (Nydrazid®) Antimicrobial

100 mg / ml Vial – 10ml

Yes, Administer undiluted & slowly over 5 minutes

Dilution not advised.

Solution may cause local irritation

Slow rate if tingling sensation reported in extremities

Oral administration preferred. May be given IM via ventrogluteal site due to volume per dose.

Solution may crystallize at low room temperature. Warm slowly to re-dissolve



43


How Supplied

IV Push Conc / Rate



Isoproterenol (Isuprel®) Cardiovascular/ Chronotrope

0.2 mg / ml 5 ml amp

NO System Standard Conc: 1 mg/250 ml NS (4 mcg/ml) System “Concentrated” Conc: 2 mg/250 ml NS (8 mcg/ml) Usual dose range: 1-10mcg/min Decrease/temporarily stop infusion if HR > 110. Doses sufficient to increase HR > 130, may induce ventricular arrhythmias or angina.

Monitor ECG continuously; BP and HR every 15 min Monitor urine output every 1-2 hr May cause PVC’s

Cardiac transplant patients have little or no response to Atropine. Isoproterenol is considered first line drug for treatment of severe bradycardia in heart transplant patients

Incompatible with many meds/solutions – check with pharmacist

* See footnote

K – Vitamin K – See Phytonadione

Ketamine Analgesic-sedative/anesthetic

10 mg/ml 20 ml vial; 50 mg/ml 10 ml vial;

Yes, Slowly over 2-3 min (conc max 50mg/ml) May also be given IM

Usual dose for sedation: 0.2 – 1 mg/kg IV Continuous infusions may be used during surgery as general anesthetic. Infusion may be used as sedative / analgesic for refractory pain syndromes Infusion: Dilute dose in D5W or NS to final concentration of 1-2mg/mL (max: 2 mg/mL) ** Oxygen via nasal cannula at minimum w/continuous pulse oximetry/ECG monitoring recommended while sedated

Monitor RR, BP, HR and mental status. May cause – * respiratory depression with high doses or too rapid injection *cardiovascular stimulation (HTN, tachycardia) *hypersalivation / excessive secretions - may be managed with atropine/glycopyrolate. *Emergence phenomenon (vivid dreams, hallucinations, delirium, confusion) Benzodiazepines (eg. midazolam) may decrease/alleviate CV stimulation and emergence phenomenon

Protect from light Critical Care & prescriber experienced w/administration



44


How Supplied

IV Push Conc / Rate



Ketorolac (Toradol) Analgesic/ Anti-inflammatory/ NSAID

15 mg & 30 mg per ml syringe & vial

Yes, Give over 15-30 seconds

Give IV - push Pain with injection common-slow infusion if this occurs NSAID – check allergies

Recommended max dose is 120 mg/day Recommended max dose for CrCl < 50 ml/min or age > 65 y.o. is 60 mg/day Max recommended length of therapy is 5 days

Labetalol (Trandate, Normodyne) Antihypertensive

5 mg/ml 4 ml syringe, 20 ml vial

Yes, Give 10 mg over 2 minutes

Continuous infusion: Initial rate: 0.5 – 2 mg/min titrate to desired effect System Standard Conc: 250 mg/150 ml NS (total vol 200 ml) (1.25 mg/ml) System “Concentrated” Conc: 300 mg/40 ml NS (total vol 100ml) (3mg/ml) Undiluted 5mg/ml = max conc

Maximum anti-hypertensive effect apparent approximately 5 min after each dose Titrate to desired BP parameters May cause orthostatic hypotension. Administer to pt while in supine position if possible.

NOT compatible with alkaline solutions such as furosemide (Lasix) – check with pharmacist for compatibilities

* Continuous infusion - see footnote Intermittent doses - monitor VS. May cause hypotension and bradycardia

Lacosamide (Vimpat) Anti-seizure

10mg/mL single dose 20mL vial

NO Dilute all doses in 100mL NS and administer over 30min

IV dose = PO dose IV doses mixed in 0.9% NaCl are stable for 24 hours at room temperature.

Lansoprazole (Prevacid) Proton Pump Inhibitor

30 mg vial NO 30 mg in 50 ml NS Infuse over 30 min

IV dose = PO dose Vial must be reconstituted with Sterile Water and further diluted within 1 hr In-line filter must be used! Do not administer with other medications/fluids – check with pharmacist for compatibility information



45


How Supplied

IV Push Conc / Rate



Lepirudin (Refludan)


Anticoagulant

5 mg/ml 10 ml vial

Yes, Loading dose (0.4 mg/kg – max 44 mg)*: IV Push over 30 seconds

Maintenance infusion: 0.1 mg/Kg/Hr, titrate to target aPTT System Standard Conc: 50mg/ 100 ml NS (0.5 mg/ml) Preprinted order set available

Anticoagulant for use in patients with heparin associated thrombocytopenia Monitor for signs of bleeding!

Monitor therapy with aPTT (1.5-2.5 x baseline) 4 hours after beginning drip or change in the rate of a continuous infusion

*Adjust dose if CrCl < 60 ml/min, SrCr > 1.5, or if pt has received thrombolytic

Levetiracetam (Keppra) Anticonvulsant

500 mg/5 ml vial

NO Dilute in 100 ml NS and infuse over 15 minutes

Double check drug name IV Dose = PO Dose Dose reduction for patients with CrCl < 50 ml/min recommended.

Store at room temperature Compatible with NS, D5W, LR, lorazepam, diazepam and valproate

Levofloxacin (Levaquin) Antibiotic/ Fluoroquinolone

25mg/ml Vial. Premix: 500mg/100ml

NO Infuse 250 and 500 mg doses over 60 min Infuse 750 mg dose over 90 min

Dose reduction for patients with CrCl < 50 ml/min recommended

Levocarnitine (Carnitor) Nutritional supplement/Amino acid

200 mg/ml 2.5 ml ampule

Yes, Give over 2-3 min

May be given as intermittent infusion – diluted to conc of 0.5 to 8 mg/ml in NS or LR

May cause HTN – monitor VS May cause N/V – slow rate of infusion May cause hypercalcemia

Discard ampule immediately after use Use NS or LR – NOT D5W

Levothyroxine (Levothroid, Synthroid) Hormone - thyroid

200 mcg/5 ml vial

Yes, Give over 2 min

Slow IV push recommended

** Verify dose to be given. Discard vial after drawing up correct dose. ** IV dose = 50% of PO dose

Use immediately after reconstitution Use NS only to reconstitute Do not combine with other solutions



46


How Supplied

IV Push Conc / Rate



Lidocaine Anti-arrhythmic

100mg Syringes, 2Gm/500ml Premix

Yes, 50-100mg over 2 minutes at max rate of 50mg/min ** Do not use in WPW syndrome **

Continuous infusion required to maintain anti-arrhythmic effect Usual dose range: 1 – 4 mg / min System Standard Conc: 2000 mg/ 500 ml D5W Premix (4 mg/ml) System “Concentrated” Conc: 2000 mg/ 100 ml NS (total volume 200ml) (10 mg/ml) Can be given via ET tube: 2 – 2 ½ x IV dose

Continuous EKG Monitoring Do NOT exceed 300 mg/hour or 4 mg/min Cardiac signs of toxicity: Widening of QRS, bradycardia, increasing PVCs, hypotension, heart block Non-cardiac signs of toxicity: numbness of lips, tongue and face; tremors; paresthesias; diploplia; mental status changes, nausea/vomiting; confusion; slurred speech

Continuous ECG monitoring. Therapeutic serum lidocaine levels: 1.5 to 5 Toxic levels: > 5

* See footnote

Linezolid (Zyvox) Antimicrobial

Premix: 400mg/ 200ml NS, 600mg/ 300ml NS Premix bags

NO Max conc: 2 mg/ml Administer dose over 60 minutes

Weak MAO inhibitor – verify patient on low tyramine diet (in addition to ordered diet) Low tyramine diet to continue x 3 days after d/c of medication. Avoid co-administration with meds that may increase risk of serotonin syndrome (i.e. SSRIs, SNRIs, TCAs)

Compatible with NS, D5W and LR Incompatible with ceftriaxone Normally may exhibit a yellow color

Low tyramine restriction (in addition to ordered diet)

LORazepam (Ativan) Sedative/ Benzodiazepine

2 & 4 mg/ml syringe / Vial

Yes, Dilute with equal volume NS-Give at max rate of 2 mg/min

Continuous infusion System Standard Conc: 100 mg/ 50 ml D5W Excel or glass bottle (total volume 100 ml) (1 mg/ml)

Monitor respiratory and cardiovascular status May cause respiratory depression Reverse with flumazenil (Romazicon)

Vials stable 60 days at room temp Observe for crystals (may use 5 micron in-line filter).

Critical Care for continuous infusion Continuous infusion may be given unmonitored if used for comfort care/hospice pt



47


How Supplied

IV Push Conc / Rate



Magnesium


Electrolyte

Vials: 4 mEq/ml – multiple vial sizes Premix bags: 1 Gm/100 ml, 2 Gm/50 ml, 4Gm/100 ml, 6 Gm/ 50 ml & 20 gm/50 ml Premix

Yes, Bolus dose only for Torsades de Pointes Dilute with 10 ml NS/D5W for 1 gm dose; 20 ml NS/D5W for 2 gm dose. Give at max rate of 1Gm/min

Intermittent infusion: Magnesium supplementation - 1 – 2 Gm over 30 min Pre-eclampsia/eclampsia: Usual bolus dose is 4 grams given over 20-30 minutes Pre-term labor: Usual bolus dose is 6 grams given over 20-30 minutes Continuous Infusion: 1- 4 Gm/hr System Standard Conc: 20 grams/ 500 ml Sterile Water Premix (40 mg/ml)

1 Gm = 8.12 mEq Mg. Metro OB: Assess DTR, respirations, signs and symptoms of Mg toxicity (muscle weakness, ECG changes, hypotension, sedation, confusion), I&Os. Obtain Mg levels as order by physician May cause respiratory/cardiovascular collapse Antidote for Mg toxicity: calcium gluconate

**Metro OB: Mandatory use of order set for IV infusion

Mannitol (Osmitrol) Osmotic diuretic

Vial 25%- (12.5Gm/50ml) Premix: 20% (100 Gm/500 ml) 10% (50 Gm/ 500 ml)

Yes, 12.5 Gm/50 ml over 5 min or 1g/kg over no less than 10 min

Intermittent Infusion: Infuse over 30-60 min 12.5 gm = 62.5 ml of 20%, 50 ml 25% 25 gm = 125 ml of 20%, 100 ml 25% 50 gm = 250 ml 20%, 200 ml 25% Metro: Infusion bags from pharmacy contain extra volume for priming of tubing and filter.

Use 0.22 micron in-line filter

Inspect vials/bags for crystals prior to administration Hypertonic solutions – monitor venous site for irritation. Avoid Extravasation – see PPO 5046 for general guidelines / management

Common hold parameters: Na+ > 145 or Serum Osmolarity > 310

Do not refrigerate!!

Meperidine (Demerol)


Narcotic analgesic

25,50,75 & 100 mg/ml syringe, 50 mg/ml vial

Yes, Dilute dose to 10ml with NS and give at max rate of 10 mg per minute

Continuous infusion NOT advised PCA administration recommended System Standard Conc: 250 mg/ 250 ml NS (1 mg/ml) System “Concentrated” Conc: 250 mg/ 100 ml NS (2.5 mg/ml)

Not recommended for patients 65 years or older nor patients with poor renal function. Monitor for delirium, or other CNS toxicity

Monitor respiratory status – may cause respiratory depression or distress

Reverse respiratory depression with naloxone (Narcan)

PCA: Check syringe for expiration date




48


How Supplied

IV Push Conc / Rate



Meropenem (Merrem) Antibiotic/ Carbapenem

500 mg & 1 Gm vials


Intermittent Infusion – Usual Dose: 500mg/50mL –1g/100mL NS IV over 30min Extended infusions over 3 hours may be used for treatment of resistant pathogens.

Monitor for allergic reaction-rash, hives, and shortness of breath, pruritus.

Caution with penicillin allergy Check allergies!

Dose reduction recommended in pts w/ CrCl < 50 ml/min

Stable 24 hr after dilution with NS refrigerated Stable only 4 hr after dilution with D5W refrigerated

Methyldopate (Aldomet IV) Antihypertensive

50mg/ml – 5 & 10ml Vial

NO Intermittent Infusion Up to 250mg in 50ml D5W over 30min 251-500mg in 100ml D5W over 60min

Monitor BP / Orthostasis Uncommon anecdotal reports of paradoxical pressor response with IV methyldopate-blood pressure may increase

Methylene Blue Thiazone dye

1 % Solution (10mg/mL) 1 ml amp/vial 10 ml amp/vial

Yes, 1-2 mg/kg SLOWLY over 3-5 min

Continuous infusion: Methemoglobinemia: (converts methemoglobin to hemoglobin) 0.1 – 0.15 mg/kg/hr

Metro: Preprinted order set available for treatment of septic shock/refractory hypotension Loading dose 2mg/kg in 50mL NS over 30min followed by infusion of 0.5-2mg/kg/hr System Standard Conc: 500 mg/ 50 ml NS (total volume 100 ml) (5 mg/ml)

Urine and feces may turn blue-green. Skin discoloration may also occur.

Avoid extravasation – may cause necrotic abscesses

Total doses > 7 mg/kg may cause dyspnea, cyanosis, dysrhythmias, hypotension, CNS depression

Use with caution in pts w/ severe renal insufficiency or G-6-PD deficiency

Administer via Central Line only!

Pulse Ox reading may be artificially low during IV administration

Incompatible with many medications/solutions – contact pharmacist Use only NS for dilution

* See footnote



49


How Supplied

IV Push Conc / Rate



Methylergonovine (Methergine) Uterine Stimulant

0.2 mg/ml 1 ml amp

NO Give IM only 0.2 mg over 1 min

Usual dose: 0.2 mg IM q4 hr Monitor BP – do not administer if BP > 140/90

Do NOT give via IV administration due to increased risk of HTN and CVA. Intravenous administration in severe, life-threatening situations ONLY.

Discard discolored solutions

Methylnatrexone (Relistor) Opioid Antagonist

12mg / 0.6ml vial

NO SQ administration ONLY

Not recommended. Intermittent SQ administration ONLY.

Usual dose q48h – SQ in upper arm, abdomen or thigh only. Frequency not to exceed Q24h

Store at room temperature. Once drawn up in a syringe dose is stable at room temperature for 24hours

MethylPREDNISolone (Solu-Medrol) Corticosteroid

40, 125 & 500mg Vial, 1&2 Gm Vial

Yes – at max rate of 50 mg/min

IV Push preferred method of administration Intermittent Infusion 100-250mg in 50ml NS – give over 15 min > 250mg in at least 50ml NS – give over 60 min

Acute Spinal Cord Injury: Continuous Infusion -- Usual dose: 30 mg/kg bolus over 15 min then 5.4 mg/kg/hr x 23 (or 48) hours ** Depo-Medrol must be given IM – not IV **

Reconstitute vials with sterile water only. May further dilute with NS.

Critical Care recommended for continuous infusion

MetoCLOPramide (Reglan) Prokinetic/antiemetic

5mg/ml in 2,10, 20 & 30 ml Vial

Yes, Give at 5 mg/min

Intermittent Infusion Doses > 10mg, dilute in 50 ml. Infuse over 15 min

Slow rate if extra-pyramidal symptoms (dystonia, motor restlessness, parkinson-like symptoms) occur Reverse EPS with diphenhydramine (Benadryl) 50mg IV per physician order Contraindicated in Parkinson’s patients.

Contraindicated in patients with Parkinson’s disease.

MetoPROLOL (Lopressor) Cardiovascular/Beta Blocker

1mg/ml – 5ml Syringe & Amp

Yes, Give at max rate of 5mg/min

IV-push preferred Acute myocardial infarction: 5 mg IVP every 5 minutes x 3

Monitor HR and BP Administer undiluted * See footnote



50


How Supplied

IV Push Conc / Rate



MetroNIDAZOLE (Flagyl) Antibiotic

500 mg Vial, Premix: 500 mg/100 ml

NO Infuse over 60min Incompatible with many meds and solutions – check with pharmacist Avoid ETOH use during treatment and 72 hours post due to possible disulfiram like reaction

May form crystals if refrigerated, warm to room temperature to re-dissolve

Micafungin (Mycamine) Antifungal

50 mg, 100 mg vials

NO For treatment of candidemia, invasive candidiasis, aspergillus infections Intermittent infusion: 50-150 mg in 100 ml NS or D5W infused over 60 minutes

No dose adjustments required in renal/hepatic dysfunction

Dilute vials prior to reconstitution with NS (without bacteriostatic agent)

MIDAZolam (Versed) Sedative/ Benzodiazepine

1 & 5 mg/ml Vial & Syringes

Yes, 1 – 2.5 mg doses over 2 – 3 minutes. Titrate SLOWLY

Continuous infusion: Usual dose range: 0.5 – 10 mg/hr System Standard Conc: 50 mg/ 100 ml NS (0.5 mg/ml)

Titrate doses slowly especially in the elderly Monitor respiratory and cardiovascular status

Rapid and/or frequent administration may cause respiratory depression

Reverse effects with flumazenil (Romazecon)

*See footnote Critical Care for continuous infusion

Milrinone (Primacor) Cardiovascular/ Positive inotrope

200 mcg/ml-100ml Premix, 10 & 20 ml vial 1 mg/ml

Yes, Loading dose of 50 mcg/Kg over 10 minutes

Continuous Infusion: Usual dose range: 0.25 – 1 mcg/kg/min – titrate to response System Standard Conc: 20mg/100 ml D5W Premix (200 mcg/ml)

System “Concentrated” Conc: 20 mg/30 ml NS (total volume 50 ml) (400 mcg/ml) Half-life: 1-3 hr

Dose reduction recommended for decreased renal function Monitoring: Continuous EKG Monitoring Following initiation or dose

titration: Continuous BP or q15min x 3, then q1h x 4 then q4h x 2 then q4-6 hours while stable.

Incompatible with many meds – check with pharmacist

* See footnote



51


How Supplied

IV Push Conc / Rate



Morphine


Narcotic analgesic

Various concentra-tions, vials & syringes.

Yes, at max rate of 1 mg/min

Continuous Infusion – System Standard Conc: 50mg/250ml NS (0.2 mg/ml) System “Concentrated” conc: 50mg/100ml NS (0.5 mg/ml) Chronic pain management- maximum dose is effective dose

Hierarchy of effects analgesia sedation respiratory depression

Monitor respiratory and cardiovascular status – may cause respiratory depression/distress Titrate to dose that relieves pain without excessive sedation – avoid abrupt dose changes Lower doses advised in elderly, debilitated or in patients receiving other CNS depressants Reverse effects with naloxone (Narcan)

PCA: Check syringe for expiration date


Moxifloxacin (Avelox) Antibiotic/ Fluoroquinolone

400 mg/250 ml Premix

NO Infuse over 60 min

Multivitamin Vitamin/ Nutritional supplement

MVI-12 (adult) 10 ml vial

NO Common component of banana bag.

Manufacturer recommends minimum volume for infusions of 500 ml.

Common component of TPN.

Muromonab CD3 (Orthoclone OKT3) Immunosuppressant

1 mg/ml – 5 ml Amp

Yes, 5 mg over 60 seconds

NO Pre-dose corticosteroid, antihistamine and acetaminophen recommended Be aware of potential for cytokine release syndrome (CRS) & acute hypersensitivity (allergy) reactions with initial doses Dose is 5 mg IV daily x 10-14 days in adults


* See footnote



52


How Supplied

IV Push Conc / Rate



Mycophenolate mofetil (CellCept) Immunosuppressant

500mg Vial NO Infuse over 2 hours Each 500mg vial reconstituted with 14ml D5W Final concentration of solution should be 6 mg/ml Avoid direct contact with solution. If this occurs, thoroughly wash exposed area with soap and water –teratogen.


Nafcillin (Nafcil) Antibiotic/ Penicillin

1 & 2 Gm Vials 2 Gm/100 ml Premix

NO Intermittent Infusion < 2 Gm give over 30min > 2 Gm give over 60min

Penicillin derivative - check allergies Avoid Extravasation – see PPO 5046 for general guidelines / management Tissue damage reported with infiltration – prefer central line administration if available Slow rate or further dilute if phlebitis occurs

Nalbuphine (Nubain) Narcotic Analgesic

10mg/ml – 10ml Vial 20mg/ml – 10ml Vial

Yes, at max rate of 1 mg/min

Not Advised – Give IV Push 10 mg Nalbuphine = 10 mg IV Morphine Monitor respiratory status – may cause respiratory depression

Reverse with naloxone (Narcan) May cause withdrawal in opioid dependent patients.

NaLOXone (Narcan) REVERSAL AGENT Narcotic Antagonist/ Reversal agent for Narcotics

0.4 & 1 mg/ml, various size syringes & vials

Yes, 0.1 – 0.4 mg over 1 minute May repeat IV doses at 2-3 min intervals or per order

Not advised – Give IV Push Continuous infusion for epidural associated pruritis System Standard Conc: 1 mg/250ml NS (4mcg/mL) System “Concentrated” Conc: 2 mg/100 ml NS (20mcg/mL)

Used for reversal of narcotic agents Onset of action within 2 min If no response after 10 mg given, question narcotic overdose Reversal of opiod depression may cause nausea/vomiting, sweating, tremulous, tachycardia, and HTN.



53


How Supplied

IV Push Conc / Rate



NATALizumab (Tysabri) Monoclonal antibody for Multiple Sclerosis & Crohns Disease

300mg/15 ml vial

NO Intermittent infusion: 300 mg in 100 ml NS. Infuse over 1 hour.

Restrictions in administration apply – patient, physician, in fusion center and pharmacy must be registered with FDA. Preprinted order set available for administration in ASLMC CND and ASLMC ATC. May cause infusion-related/ hypersensitivity reactions. Monitor patient during and x 1 hour post-infusion. Emergency preprinted order set available.

Vials: Refrigerate and protect from light USE NS ONLY! Stable 8 hours after dilution refrigerated. Warm to room temp prior to infusion. Do NOT shake. Do NOT transport via tube system.

Must be only administered in FDA registered outpatient infusion areas – check with site (i.e. ASLMC – CND/ATC only; no inpatient areas)

Neostigmine (Prostigmin) Anticholinesterase

1 mg/ml = 1:1000 – 10 ml vial 0.5 mg/ml = 1:2000 – 1 ml amp/vial 0.25 mg/ml = 1:4000 – 1 ml amp

Yes, 0.5 – 2 mg. Give SLOWLY May give IM Usual max/total dose is 5 mg

NO Antidote for non-depolarizing neuromuscular blockade Metro: For Acute Colonic Pseudo-Obstruction (Ogilvie’s Syndrome): Per P&T --Bedside telemetry/RN presence required during administration. Give over 10 min. Patients must remain in monitored bed 4-6 hours after administration. Use with caution in renal dysfunction. Decrease dose for CrCl < 50mL/min

*See footnote (see Precautions/ Comments)

Nesiritide (Natrecor) Cardiovascular/ Vasodilator

1.5 mg vial Bolus dose: 2 mcg/kg IV push over 1 minute. Bolus not always given.

Continuous infusion: Usual dose = 0.01 mcg/kg/min. Drip may be increased by 0.01 mcg/kg/min q3h if needed to maximum dose of 0.03 mcg/kg/min. System Standard Conc: 1.5mg/250ml NS (6 mcg/ml)

Monitoring parameters and IV incompatibilities available on pre-printed order set For initiation or dose titration, monitor BP every 15 min x 4, every 30 min x 2, every 1hr x 2 hr then every 4 hr. Hold for BP < 90.

Flush tubing with approx. 25 ml prior to connecting to patient and prior to bolus if ordered. Incompatible with heparin, insulin, furosemide, bumetanide, enalaprilat, and hydralazine. Consult pharmacist for compatibility information.

* See footnote



54


How Supplied

IV Push Conc / Rate



NiCARdipine (Cardene) Cardiovascular/ Calcium Channel Blocker

2.5mg/ml – 10ml Amp

NO Continuous Infusion System Standard Conc: 25 mg/250 ml NS (0.1mg/ml) System “Concentrated” conc: 50 mg/80 ml NS (total vol 100 ml) (0.5 mg/ml) Usual dose range: 2.5 – 15 mg/hr Recommended titration: Initiate at 2.5-5mg/hr & increase infusion by 2.5 mg/hr Q15min until at BP goal (max of 15 mg/hr). Once desired effect reached, reduce to maintenance of 3 mg/hr.

Rate >3mg/hr: Continuous BP & EKG Monitoring Rate 1-3mg/hr: Continuous BP & HR or vitals q15min x 3, q30 x 2 then q4-6h while stable. Normally solution light yellow in color Incompatible with Lactated Ringers or bicarbonate solutions – contact pharmacist for compatibility information

Central line access advised! Manufacturer recommends changing IV site every 12 hours if run peripherally

Critical Care – See footnote*

NitroGLYcerin (Tridil) Cardiovascular/ Vasodilator

Vial 50mg/10ml Premix 50mg/500ml & 50mg/250ml

NO Continuous Infusion – Initial dose: 10 mcg/min then titrate by 10mcg increments q5min to desired BP goal Usual dose: 10-200 mcg/min

System Standard Conc: 50 mg/250 ml D5W Premix (glass bottle) (200 mcg/ml) System “Concentrated” conc: 100 mg/250 ml NS (glass bottle) (400 mcg/ml)

Monitoring - For initiation or dose titration: Continuous BP &HR or q5min x 3, then q15min x 3, then Q4-6hr while stable. Side effects include: hypotension, HA (common), tachycardia ** If IV tubing changes are needed, monitor pt every 15 min x 1 hr for possible NTG-retitration. IV tubing sets must be changed every 72 hr. **

Glass container only Use vented set Check with pharmacist regarding compatibility information.

* See footnote



55


How Supplied

IV Push Conc / Rate



NitroPRUSSide (Nipride) Cardiovascular/ Vasodilator

50mg/2 ml vial

NO Continuous Infusion: Usual dose range: 0.5 – 10 mcg/Kg/min

System Standard = 50 mg/250 ml NS (200mcg/ml) System “Concentrated” conc: 50 mg/100 ml NS (500mcg/ml)

Onset: 30-60 sec Peak effect: 1-2 min Duration: 1-10 min Half-life: 3-4 min Tachyphylaxis has been reported particularly with doses > 10 mcg/kg/min – d/c drug immediately if occurs!!

Monitor BP (via arterial line if possible) and HR every 15 min Monitor urine output every 1-2 hr

Excessive infusion may produce cyanide toxicity. Monitor for signs and symptoms of cyanide toxicity: mental status changes, dyspnea, HA, N/V, ataxia, absent reflexes, distant heart sounds, widely dilated pupils, shallow breathing, and coma. Increased risk of cyanide toxicity in pt with renal dysfunction or hepatic insufficiency. May need to check thiocyanate (renally cleared metabolite) levels. S/sx thiocyanate toxicity: fatigue, muscle weakness, tinnitus, confusion, psychosis, hallucinations, nystagmus, coma

Protect from light Sodium thiosulfate 500mg may be added to each nitroprusside infusion bag to decrease cyanide formation. Addition is recommended when nitroprusside dose is > 2 mcg/kg/min for more than one hour or for infusion duration > 72 hr ** Do not run infusion at 10 mcg/kg/min for longer than 5-10 min – if this high of dose needed, call physician for alternative**

Critical Care

Norepinephrine (Levophed) Vasopressor

1 mg/ml- 4 ml amp

NO Continuous Infusion: Usual dose range: 2 – 12 mcg/min

System Standard Conc: 4 mg/250 ml NS (16 mcg/ml) System “Concentrated” Conc: 8 mg/250 ml NS (32 mcg/ml) Onset: immediate Duration: 1-2 min

Central Line Advised! Avoid infiltration – Phentolamine (Regitine) SQ recommended for management of infiltration ( PPO 5046)

Monitor BP, HR every 5-15 min Monitor urine output every 1-2 hr

Check with pharmacist regarding compatibility information

Critical Care

Octreotide (SandoSTATIN) Hormone - Somatostatin

0.05 mg/ml 1 ml, 0.1 mg/ml 1 ml, 0.5 mg/ml 1 ml ampules; 0.2 mg/ml 5 ml, 1 mg/ml 5 ml vials

Yes, Give dose over 3 minutes May be given SQ

Intermittent Infusion – Dilute with 50ml NS – Infuse over 15 minutes Continuous IV/Subcutaneous Infusion System Standard Conc: 500 mcg/250 ml NS (2 mcg/ml) System “Concentrated” Conc: 1000 mcg/100 ml NS (10 mcg/ml)

Refrigerate undiluted product Multi-dose vial stable 14 days refrigerated after initial use



56


How Supplied

IV Push Conc / Rate



Ondansetron (Zofran) Antiemetic/ 5HT3 receptor antagonist

2mg/ml – 2 & 20ml Vials

Yes, 4 mg over 1-2 min for post-op nausea/vomiting

Intermittent Infusion – Chemotherapy 8, 12, 16, 20 or 24 mg in 50ml NS Infuse over 15 minutes Continuous infusion: Max of 32mg/day

Recommended max dose is 32 mg/day Flat dose response from 1-4mg.

Oxytocin (Pitocin)


Hormone – Uterine stimulant

10 units/ml 1 ml syringe/vial

NO Continuous Infusion – Induction of labor: 1-2 milli-units/min, increase by 1-2 milli-units every 15-30 minutes as needed System Standard Conc: 20 units/1000 ml NS (0.02 units/ml)

System “Concentrated” Conc: 40 units/ 1000 ml NS (0.04 units/ml) Postpartum Hemorrhage: Infusion titrated to absence of hemorrhage.

Metro: See MWH-11-MAT: Women’s Health Policy and Procedures – Maternal for Oxytocin: Induction and Augmentation of Labor Metro: Pre-printed order set available for Labor Induction/Stimulation See site specific administration policy Monitor VS – may cause hypotension, hypertension, bradycardia

Pamidronate (Aredia) Bisphosphonate

30 mg/10 ml and 90 mg/10 ml vials

NO Infuse over 3 to 24 hr Renal function should be assessed prior to each dose

Dose should not exceed 90 mg May cause HTN and bone pain Infusion site reactions possible – slow infusion rate if occurs

Pancuronium (Pavulon)


Neuromuscular blocker

1 mg/ml 10 ml vial, 2 mg/ml 2 ml and 5 ml vials/ syringes

Yes, 0.1 mg/Kg bolus given rapidly

Continuous Infusion – System Standard Conc: 100mg/50 ml NS (total volume 100 ml) (1 mg/ml)

Refer to Clinical Nursing Policies on Neuromuscular Blockade (i.e MN13) Refer to Preprinted order sets available for ICU neuromuscular blockade

Store undiluted product (vial) under refrigeration

Controlled airway and ventilation required; Critical Care only Sedation must be administered prior to and during paralytic use!



57


How Supplied

IV Push Conc / Rate



Pantoprazole (Protonix) Proton Pump Inhibitor

40mg /10ml vials

Yes, 40–80mg over 2min Dilute 40 mg vial with 10 ml NS

Continuous infusion: System Standard Conc: 80 mg/ 500 ml NS (0.16 mg/ml) System “Concentrated” Conc: 80 mg/ 100 ml NS (0.8 mg/ml)

Continuous infusion duration should not exceed 72 hr Run separately!! Do not infuse with any other medications!! Check with pharmacist for possible compatible medications.

Vial: stable at room temperature or refrigeration 24 hrs after reconstitution. Intermittent / Continuous Infusion (40mg-80mg/100mL): Stable for 24hrs room temp. Infusion (80mg/500mL NS): Stable for 12hrs at room temp. Filtration not required during preparation or administration.

Parenteral Nutrition (PN)

----------- No Route of administration: Central line

If no central line access, confirm with pharmacist that osmolality (< 900 millimoles) is appropriate for peripheral administration.

PN which includes lipids: change tubing every 24 hours. Use 1.2 micron filter for PN with lipids.

PN with no lipids: change tubing every 96 hours. Use 0.22 micron filter for PN without lipids.

Avoid Extravasation – see PPO 5046 for general guidelines / management

Do not administer any medications/solutions/blood products etc. with PN. If alternative IV access is a problem, contact the pharmacist for compatibility information.

Paricalcitrol (Zemplar) Vitamin D Analog

2 mcg/ml 1 ml, 5 mcg/ml 1 ml vials

Yes – 5 mcg/min

IV push preferred Used in the prevention and treatment of secondary hyperparathyroidism in chronic renal failure patients.

Discard vial after use.



58


How Supplied

IV Push Conc / Rate



Pegfilgrastim (Neulasta) White cell stimulating hormone

6mg/0.6ml syringe

NO Give 6 mg SQ as a 1 time dose only

Give only SQ!! Long acting filgrastim May cause bone pain

Refrigerate Do not shake product or transport via tube system

Penicillin G (sodium or potassium salt) Antibiotic/ Penicillin

1,5,10 & 20 Million Unit Vials Premix: 3 Million Unit/50ml container

NO Intermittent Infusion – Up to 3 Million Units/50 ml NS. Infuse over 30 minutes 3.1 - 5 Million Units/100 ml NS. Infuse over 60 minutes

Penicillin allergy precautions – Check allergies Avoid rapid infusions – seizures may result Dose reduction recommended for CrCl < 50 ml/min

Watch K+ -- 1 million units PCN G contains 1.7 mEq K+

Pentamidine (Pentam) Antiprotozoal

300mg vial NO Intermittent Infusion – 4 mg/Kg diluted into 250ml D5W – over 60 minutes Nebulized product also available.

Monitor BP every 15 min during 60 min infusion

Administer in supine position

Monitor blood glucose daily during therapy-hypoglycemia common Daily BUN/SCr, and LFTs recommended Metallic taste noted to be common

Do NOT refrigerate – crystallization may occur

Pentazocine (Talwin) Narcotic Analgesic

30 mg/ml 1 ml syringe and amp, 30 mg/ml 10 ml vial

Yes, Max rate of 5 mg/min

Not recommended Recommended max dose is 360 mg/24 hr Monitor respiratory status – may cause respiratory depression

Reverse with naloxone (Narcan)

Pentazocine 30 mg = Morphine 10 mg IV



59


How Supplied

IV Push Conc / Rate



PENTobarbital (Nembutal) *HIGH ALERT MEDICATION* Sedative/ Barbiturate

50mg/ml – 1 ml syringe, 20 & 50 ml Vials

Yes, Give slowly at max rate of 50 mg/min

System Standard Conc: 2000 mg/210 ml NS (total volume 250 ml) (8 mg/ml) Metro: Preprinted order set available for Barbiturate Coma for elevated ICP. Refer to ICP protocol (PPO 02974) – Loading /Bolus Doses: 2.5-10mg/kg over 15-60min, respectively. Continuous Infusion: Initiate at 1.5mg/kg/hr.

Undiluted solution is alkaline – avoid infiltration. Central line administration preferred.

With IV administration monitor respiration & cardiac function continuously Monitor pentobarbital levels. Goal levels: Hyponotic/sedation: 1–5 mcg/ml Coma: 10-50 mcg/ml

Incompatible with most medications/solutions – check with pharmacist Use 0.22 micron filter with infusion

Controlled airway and ventilation required – Critical care only!

Perphenazine (Trilafon) Antipsychotic Agent

5 mg/ml 1 ml amp

Yes – but only use IV if absolutely necessary Dilute 5 mg w/ 9 ml NS and give 0.5 mg/min IM administration recommended

Usual dose is 1 mg every 2-3 min Recommended max dose is 5 mg May cause contact dermatitis; Extrapyramidal symptoms (ie. Dystonia rxn) possible Postural hypotension may occur – monitor BP

PHENObarbital (Luminal) Anticonvulsant/ Sedative/ Barbiturate

60 mg/ml 1 ml, 130 mg/ml 1 ml syringes

Yes, Give slowly at max rate of 60 mg/min

Intermittent Infusion: Loading dose: 15mg/kg in 100 ml NS Infuse over 15-30 minutes Maintenance doses: 1-3mg/kg/day (divided doses) may be given slow IV push

Undiluted solution is very alkaline – avoid infiltration Monitor BP, HR, RR

With continuous IV administration monitor respiration & cardiac function continuously Too rapid administration may cause respiratory distress and hypotension

Incompatible with most medications/solutions – check with pharmacist

*See footnote Critical Care for continuous infusions



60


How Supplied

IV Push Conc / Rate



Phentolamine (Regitine) Vasodilator

5mg/ml – 1ml Vial

Yes, 5mg/10ml NS Give over 30 seconds SQ administration preferred

SQ administration preferred Administer within 12 hr of extravasation

Antidote for peripheral ischemia due to dopamine, dobutamine, norepinephrine, metaraminol, epinephrine , phenylephrine. See PPO 5046 SQ admin: dilute to 0.5-1 mg/ml and inject 0.5 ml in multiple sites to cover extravasation area (doses up to 50 mg have been used)

Use reconstituted solution immediately

Phenylephrine (Neosynephrine) Vasopressor

10 mg/ml – 1 & 5ml Vial

Yes, rarely. 0.1-0.5 mg given over at least 1 min Prep: add 1 ml of phenylephrine 10 mg/ml to 100 ml NS – final conc 0.1 mg/ml

Continuous Infusion System Standard Conc: 50 mg/250 ml NS (200 mcg/ml) System “Concentrated” Conc: 50 mg/ 100 ml NS (0.5 mg/ml) Usual dose range: 40-60 mcg/min is usually adequate

Avoid infiltration – Phentolamine (Regitine) SQ recommended for management of infiltration -see PPO 5046 for general extravasation guidelines / management Monitor BP, HR every 15 min Monitor urine output every 1-2 hr Central line advised!

Critical Care

PhenyTOIN (Dilantin) Anticonvulsant

50 mg / ml 2ml Syringe & 2 or 5ml vial

Yes, Max rate of 50 mg/min Rate of 25 mg/min recommended in elderly or presence of coronary artery disease.

Dilute with only NS to a concentration between 2 & 10 mg/ml. Recommended loading dose: 15-20 mg/kg Recommended maintenance dose: 5 mg/kg/day

Monitor BP Central line administration required for doses > 300mg. Fosphenytoin may be given peripherally. Watch for crystal formation. Alkaline solution – local burning upon administration is common – slow infusion if occurs

Avoid Extravasation – see PPO 5046 for general guidelines / management Fosphenytoin is preferred – refer to fosphenytoin entry.

Administer immediately after dilution. Stable only 4 hr.

Use in-line filter (0.22 micron)

Flush IV line with 10 ml NS before and after dose administered



61


How Supplied

IV Push Conc / Rate



Phosphate – Potassium or Sodium Salts


Electrolyte

5 & 10 ml Vial 3 mMol (Millimoles) Phosphate & 4.4 mEq K or 4 mEq Na per ml

NO Infuse slowly as dilute solutions Recommended infusion rates: 5 mMol Phos/100 ml D5W over 1 hr 10 mMol Phos/150 ml D5W over 2 hr 15 mMol Phos/250 ml D5W over 3 hr 20 mMol Phos/250 ml D5W over 4 hr 30 mMol Phos/250 ml D5W over 6 hr

Lower dose recommended with concomitant hyper-calcemia Recommended dose range is 0.08 – 0.24 mMol/Kg

Sodium Phosphate or Potassium Phosphate should always be ordered in millimoles (mMol)

Not compatible with calcium solutions

Physostigmine (Antilirium) Cholinergic

1mg/ml – 2ml Amp

Yes, at max rate of 1mg/min

NO For reversal of anti-cholinergic toxicity Recommended max dose is 4 mg in 30 min

Too rapid administration may cause bradycardia and respiratory distress

*See footnote Do not confuse with pyridostigmine. Atropine readily available (UBC)

Phytonadione (Vitamin K –Aquamephyton) Vitamin/ Reversal of Anticoagulation

1 mg/0.5 ml amp/ syringe 10 mg/ml amp 50mg/5 ml vial

NO

Intermittent infusion- Usual Dose: 5-10mg/50 ml NS over 30-60minutes, respectively. May be administered over 15min in emergency reversal (ICH).

Severe anaphylactoid reactions have occurred – usually during / immediate following infusions. Fatal reactions have been reported.

Monitor closely for signs of flushing, weakness, tachycardia, SOB, abdominal pain, and hypotension; discontinue infusion. Consider fluids, diphenhydramine, epinephrine, corticosteroids & supportive therapy.

Use immediately after dilution. Protect from light.

IV route restricted to Critical Care, OR & ED administration.

Outside of these areas: physician administration only.

Piperacillin (Pipracil) Antibiotic/Penicillin

2, 3, and 4 gm vials

NO IM administration recommended

Dilute in 100 ml NS/D5W and infuse over minimum of 30 minutes Penicillin derivative – Check

allergies

Slow infusion rate if vein irritation occurs




62


How Supplied

IV Push Conc / Rate



Piperacillin/Tazo-bactam (Zosyn) Antibiotic/ Penicillin

2/0.25, 3/0.375 & 4/0.5 Gm Vial and Premix 2/0.25 in 50 ml, 3/0.375 in 50 ml, 4/0.5 in 100 ml

NO Infuse over minimum of 30 min Penicillin derivative – Check allergies

Slow infusion rate if vein irritation occurs


Extended infusions over 3 -4 hours may be used for treatment of resistant pathogens.

Potassium Chloride


Electrolyte

Vials – 2mEq/ml Premix bags: 10mEq/ 50 & 100ml, 20mEq /50 & 100ml

NEVER GIVE IV PUSH!!

Maximum concentration: • Intermittent infusion, peripheral

line: 20 mEq/100 ml • Intermittent infusion, central line:

20 mEq/50 ml • LVP/IV fluids: 80 mEq/L Administration rate: • Usual: 10 mEq/hr (20 mEq/hr for

20 mEq/50 ml) • Max admin rate without

telemetry: 20 mEq/hr • Max. admin rate with telemetry:

40 mEq/hr (exceeding 40mEq/hr for severe, life-threatening, symptomatic hypokalemia requires cardiac monitoring & physician presence)

Avoid extravasation – see PPO 5046 for general guidelines / management.

Slowing potassium infusion rate, increasing maintenance fluid rate, or increasing SVP volume may reduce stinging if encountered with peripheral administration. If these measures fail, lidocaine 10-50 mg may be added for peripheral administration upon MD order. Greater than 100 mg/day not recommended.

* See footnote if rate of infusion exceeds 20mEq/Hr

Pramlintide (Symlin)


Synthetic analog of amylin/ adjunct treatment of diabetes

No, SC administration only!

Not advised Used as adjunct to mealtime insulin in Type I & Type 2 DM.

Can cause severe hypoglycemia when used with insulin – monitor for s/sx of hypoglycemia

Caution: Product labeled in mg/mL. Dosed in mcg. Administered using insulin syringes labeled in units.

Do NOT mix with insulin!! Unopened vials: refrigerate/protect from light. See vial for expiration date. Opened vials: Discard after 28 days

Metro: Pramlintide will NOT be dispensed for inpatients per P&T. See Metro Pharmaceutical Services P&P 3.55 (06/06)



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How Supplied

IV Push Conc / Rate



Procainamide (Pronestyl) Cardiovascular/ Anti-arrhythmic

100 mg/ml 10 ml vials 500 mg/ml 2 ml vials for IM injections

Yes, Diluted to 20mg/ml and give at 20-50 mg/min Up to total dose of 1 Gm

Continuous Infusion: Usual dose range: 2 – 6 mg/min System Standard Conc: 1 Gm/250 ml NS (4mg/ml) System “Concentrated” Conc: 1 Gm/100 ml NS (10 mg/ml)

Monitor BP every 2-3 min during loading dose then every 15 min until stable during initial infusion.

Continuous ECG monitoring.

Elimination half-life extended in renal failure.

Check with pharmacist regarding compatibility information.

* See footnote

Prochlorperazine (Compazine) Antiemetic

5mg/ml, syringes and Vials

Yes, 5 mg per minute maximum rate

Intermittent Infusion – 10mg in 50ml NS over 15min

Do not exceed 40 mg in 24 hours

Slow rate if extra-pyramidal symptoms (dystonia, motor restlessness, parkinson-like symptoms) occur

Monitor for hypotension – recommend patient lay down or sit for 30 min after dose

Protect diluted solutions from light

Contraindicated in patients with Parkinson’s disease

Profilnine SD See Factor 9 Complex - Human

Promethazine (Phenergan) Antihistamine/ antiemetic

25 & 50mg/ml - Vials

Yes, max of 25 mg/min For IV admin: Dilute to 10-20 ml with NS and admin via running IV line IM Preferred

Not advised – IM Preferred Monitor for hypotension, tachycardia.

Avoid extravasation --Apply warm compresses for 20-30 minutes 4-6 times a day for 1-2 days.

Extravasation – see PPO 5046 for general guidelines / management

Metro: Promethazine injection is not available due to safety concerns including extravasation.



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How Supplied

IV Push Conc / Rate



Propofol (Diprivan)


Sedative

10mg/ml – 20ml Amp, 50 & 100ml bottles – fat emulsion

Yes, Give slowly over 3-5 min.

Continuous Infusion – ICU sedation 5mcg/kg/min with additional 5-10 mcg/kg/min increments every 5 minutes to sedation level desired. Usual dose range: 5-50 mcg/kg/min System Standard Conc: 1000 mg/100 ml Premix (10 mg/ml)

Do not mix with other solutions or infuse if emulsion appears separated Propofol contains 1.1 Kcal/ ml Monitor closely for hypotension, bradycardia, and respiratory depression For infusions > 72 hours, recommend checking triglycerides Avoid Extravasation – see PPO 5046 for general guidelines / management

Discard unused solutions after 12 hours Change tubing every 12 hours Do not filter

Critical Care for continuous infusion; IV push mode limited to areas that can provide respiratory monitoring and prompt intubation

Propranolol (Inderal) Cardiovascular/ Beta-Blocker

1mg/ml – vial

Yes, 0.5mg then 1mg/min every 5-10 min to max of 0.1mg/Kg Max rate: 1 mg/min

NO BP every 5 min during titration, then q 15min until stable Monitor Heart Rate-bedside monitor + defibrillator IV maintenance dose may be given every 4 hrs

May dilute w/ 10 ml D5W or give undiluted

* See footnote

Protamine Heparin antagonist

10mg/ml – 5 and 25ml Vials

Yes, 10mg/ml given over 1-3 minutes. Max dose: 50mg in any 10 minute period

NO Monitor for hypotension & bradycardia 1 mg protamine for approx 100 units USP Heparin

Pyridostigmine (Mestinon) Cholinergic

5 mg/ml 2 ml amp, 5 mg/ml 5 ml vial

Yes Max rate of 5 mg/min

NO Used in pt with myasthenia gravis May be used to reverse effects of non-depolarizing neuromuscular blockers. Other agents preferred.

Incompatible with many medications/solutions – check with pharmacist

Monitored bed recommended. Do not confuse with physostigmine.



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How Supplied

IV Push Conc / Rate



Pyridoxine (Vitamin B-6) Vitamin/ Nutritional Supplement

100mg/ml in 10 & 30ml vials

Yes, 50 – 100 mg/min

Intermittent Infusion – 5 Gm in 50ml NS over 30min 50-100mg in 50mL NS over 30min

Antidote: Isoniazid poisoning or overdose - Give equivalent amounts of pyridoxine as ingested Isoniazid. Antidote: Ethylene glycol toxicity – administer 50-100mg q6h until ethylene glycol levels undetectable / resolution of acidosis

Ranitidine (Zantac) H2Receptor Antagonist

25mg/ml – vial and syringe

Yes, Dilute 50mg dose up to 5ml with NS and give over 2-3 minutes

Slow IV-Push preferred

Continuous Infusion: System Standard Conc: 150mg/250ml NS (0.6 mg/ml)

Remifentanil (Ultiva)


Narcotic Analgesic

Powder for Injection: 1mg,2mg, 5mg vials

Yes, over 30-60 seconds by Anesthesia or with continuous airway support

Slow IV push or via continuous infusion Continuous Infusion: System Standard Conc: 2mg/100mL (20mcg/mL). Dose range 0.025-2mcg/kg/min

Risk of apnea / respiratory depression.

Anesthesia / Anesthesia Consult Only

Reteplase (r-PA, Retevase)



medicines. Thrombolytic

1 unit/ml 10 ml vial

Yes, For AMI: 10 units over 2 min. Repeat 10 units after 30 min Flush with minimum of 30-50 ml NS or D5W

May be used for treatment of Peripheral Arterial Occlusion (PAO)

Thrombolytic medication: Monitor for bleeding. Minimize potential risks for bleeding: Establish all IV’s prior to therapy. (Minimum of 2 peripheral IVs recommended in addition to thrombolytic infusion site.) Avoid unnecessary arterial/venous punctures, excessive blood sampling, and IM injections for at least 24 hr after d/c’d (malnourished patients 48 hr).

Apply pressure dressings to all puncture sites.

Do not shake or transport via tube system. Incompatible with heparin!! Check compatibilities with pharmacist Do not mix with any meds/solutions.

*See footnote for cardiopulmonary indications (ie: AMI, PE). Monitoring is at physician discretion for peripheral vascular indications.



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How Supplied

IV Push Conc / Rate



RifAMPIN (Rifamycin) Antibiotic

600mg Vial for Injection

NO Intermittent Infusion – Up to 600mg diluted into 100ml D5W or NS over 30 minutes

May cause a reddish-orange discoloration of urine, saliva, tears, sweat and stool Permanent discoloration of soft contact lenses may occur. Avoid infiltration = local irritation and inflammation. If this occurs, the infusion should be discontinued and started at another site.

Protect from light Expires 4 hours after preparation.

Rocuronium (Zemuron)



10mg/ml – 5ml Vial

Yes, intubation dose 0.6 mg/Kg rapidly

Continuous Infusion: Usual dose range: 5-20 mcg/Kg/min

Refer to Nursing Clinical Policies on Neuromuscular Blockade (i.e. MN-13)

Refrigerate vials. Unopened vial stable at room temp x 60 days but then must be discarded.

Controlled airway and ventilation required; Critical Care only: ED, ICU, Surgery Sedation must be administered prior to and during paralytic use!

Sargramostim (GM-CSF – Leukine) Colony Stimulating Factor

500mcg/ml vial

NO Intermittent infusion: 25 ml NS Infuse over 2 hours

Do not filter solution Use only NS to dilute Monitor BP – syncope may occur especially after 1st dose

Concentrations less than 10mcg/mL require albumin 0.1% added to solution to prevent adsorption.

Sodium Bicarbonate Electrolyte

8.4% solution 1mEq/ml & syringe Neonatal: 4.2% solution 0.5 mEq/ml 10 ml syringe

Yes, 50 mEq (50 ml) over 1-2 minutes Neonates: avoid admin of 10 ml/min or greater

Sodium bicarbonate may be added to IV fluids – check with pharmacist for compatibility/stability information

Do not mix with other medications – Check with pharmacist Neonates: Flush w/ 10-20 ml NS before after administration Avoid extravasation!! Central line administration advised when ever possible. (See PPO 5046)



67


How Supplied

IV Push Conc / Rate



Sodium Chloride 3%


Hypertonic solution

500 ml bag Not advised Rate and infusion duration variable.

Hypertonic (3%) saline is non-physiologic and is only indicated in neurosurgical patients or patients with severe (Na+ < 120) or symptomatic hyponatremia. Chronic Hyponatremia: Risk associated with rapid sodium correction (greater than 0.5mEq/L/hr or 8 mEq/24 hr) includes osmotic demyelination and permanent neurologic damage. Periodically hypertonic saline is used at low rates for short periods of times s/p urological surgeries, etc. – the limitations/restrictions need not apply in such instances.

Do not mix with any medications/solutions. Contact pharmacist for compatibility information. Central line administration and Critical Care admission advised.

Metro: Mandatory PPO with serial sodium levels (minimum q 4 hr) and mandatory call parameters (minimum order to call if Na+ correction exceeds 8 mEq/24 hr) – if not included in original order, physician must be contacted per P&T.

Sodium citrate, 4% Anticoagulant

500 ml bags

NO NOT to be infused directly intravenously.

May be used as an alternative to capping with heparin (ex. PICC lines, Mahukar lines, etc.)

StreptoMYCIN Antimicrobial

1g vial (powder)

NO Intermittent IV Infusion - usual dose: 500-1000mg in 100mL NS over 30-60min May administer via deep IM injection

Dose adjustment in elderly / reduced renal function. Monitor hearing, renal function & serum concentrations as indicated.



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How Supplied

IV Push Conc / Rate



Succinylcholine



20mg/ml 10ml Vial

Yes, prior to intubation 0.6mg/kg slowly over 30 seconds

Other medications preferred as continuous infusions

Contraindicated in patients with personal or family history of malignant hyperthermia or history of skeletal muscle myopathy!!

Refer to Nursing Clinical Policies - Neuromuscular Blockade (i.e. MN-13) Too rapid administration may cause bradycardia May cause hyperkalemia – increased risk with use in patients with burns, severe trauma, stroke, spinal cord injury, muscular dystrophy, multiple sclerosis, tetanus, Parkinson’s disease. May cause rhabdomyolysis

Refrigerate

Controlled airway and ventilation required; Critical Care only: ED, ICU, Surgery.


Tacrolimus (Prograf) Immunosuppressant

5mg/ml – 1ml Amp

NO Continuous Infusion – Usual dose: 0.05 – 0.1 mg/Kg/Day Standard conc: 5 mg/250 ml NS (Excel) (20 mcg/ml) Intermittent infusion (q12h) – run over 4 hr Conc must be 0.004 – 0.02 mg/ml

*NOTE: Sublingual administration preferred due to risk of allergic reaction with IV product* Monitor for allergic reaction especially during initial 30 minutes of first infusion – anaphylaxis Monitor for hyperkalemia, hyperglycemia and elevated BP Monitor trough tacrolimus levels

Use admin set provided by pharmacy IV = ¼ PO Dose

Tenecteplase (Tnkase)



medicines. Thrombolytic

50mg vial Yes, Weight based bolus dosing (15 - 50mg depending on weight) Give dose over 5 seconds into running NS line

Acute Coronary Syndrome/Acute Myocardial Infarction: Preprinted order set available Peripheral Vascular Thrombolysis: Per Interventional Radiology. Preprinted order set available

Thrombolytic medication: Monitor for bleeding. Minimize potential risks for bleeding: Establish all IV’s prior to therapy. (Minimum of 2 peripheral IVs recommended in addition to thrombolytic infusion site.) Avoid unnecessary arterial/venous punctures, excessive blood sampling, and IM injections for at least 24 hr after d/c’d (malnourished patients 48 hr). Apply pressure dressings to all puncture sites.

May precipitate in IV lines with D5W. Flush line with NS before and after administering. Do not mix with other medications/solutions.

*See footnote for cardiopulmonary indications (ie: AMI, PE). Monitoring is at physician discretion for peripheral vascular indications.



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How Supplied

IV Push Conc / Rate



Terbutaline (Brethine) Sympathomimetic

1 mg/ml ampule

NO

SQ administration preferred – 0.25 mg SQ x 1, may repeat x 1 after 15-30 min. Max dose of 0.5 mg in 4 hr recommended.

Continuous infusion: Used to inhibit pre-term labor contractions (tocolysis). Titrate to contractions >/= 15 minutes or absence of contractions Uterine relaxation: 0.25 mg in 5 ml NS – given IV push

Monitor for s/sx pulmonary edema in pt on continuous infusion Monitor HR (maternal and fetal), BP, ECG, I&Os See site specific administration policy Metro: See MWH-17-MAT: Women’s Health Policies & Procedures – Terbutaline sulfate: Administration for Tocolysis

Protect ampule from light

* See footnote

Theophylline Bronchodilator

Premix bags: 800mg/500ml

NO Intermittent Infusion – 5mg/kg theophylline loading dose over 30 min Continuous Infusion – 0.4mg/Kg/hr theophylline System Standard Conc: 800mg/500ml Premix (1.6 mg/ml)

Theophylline serum level monitoring is recommended periodically during IV infusion Monitor HR, BP (Note: Aminophylline is 80% theophylline: 500mg aminophylline = 400mg theophylline)

Thiamine (Vitamin B-1) Vitamin/ Nutritional supplement


Yes, Administer via large vein over at least 3 min with running IV fluids. Also may be given IM

A common component in a “banana bag” – 1000 ml bag. May also be given as intermittent infusion: 100 mg/50 ml D5W. Infuse over 15 – 30 min.

** Verify dose to be given. Discard vial after drawing up correct dose. ** Pain at IV site noted at times.

Thiopental (Pentothal) Sedative/ Barbiturate

400 mg & 500 mg syringes

Yes, Over 10-15 seconds

Avoid infiltration – may treat affected area with lidocaine 1% Central line administration preferred

Monitor respiration & cardiac function continuously Contraindicated in patient with porphyria

Controlled airway and ventilation required – Critical care only!



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How Supplied

IV Push Conc / Rate



Tigecycline (Tygacil) Antibiotic

50 mg/5 ml vial

NO Intermittent infusion: 100 mg in 100 ml D5W or NS then 50 mg in 100 ml D5W or NS. Infuse over 30-60 minutes Max conc = 1 mg/ml

Dose reduction needed for patients w/ hepatic impairment

Diluted solution is yellow/orange in color Stable 6 hrs at room temp/ 24 hrs refrigerated after dilution Contact pharmacist for compatibility information

Tirofiban (Aggrastat) Antiplatelet IIb/IIIa

12.5 mg/ml 50 ml vial, 12.5mg/250 ml premix bag

Yes, 25 mcg/Kg over 3 minutes in PTCA

Continuous Infusion – PTCA: 0.15mcg/Kg/min Unstable Angina: 0.4 mcg/Kg/min x 30min then 0.1 mcg/Kg/min Standard Conc: 12.5mg/250ml NS (50mcg/ml)

Pre-printed orders for unstable angina or PTCA applications are available Monitor for signs of bleeding!! Monitor VS every 15 min Dose reduction to 0.05mcg/kg/min recommended for pt with CrCl < 30ml/min Monitor APTT, Hgb/Hct, PT/INR, and platelets daily while receiving tirofiban

Tobramycin (Nebcin) Antibiotic/ Aminoglycoside

10mg/ml & 40mg/ml – Vial

NO Intermittent Infusion – All doses diluted into 50 - 100ml NS or D5W and infused over 30-60 minutes


Torsemide (Demadex) Loop Diuretic

10mg/ml – 2 & 5ml Amps

Yes, Max 5 mg/min

May be given as continuous infusion. System Standard Conc: 100 mg/100 ml NS (1 mg/ml)

Recommended max single dose is 200 mg

Tranexamic acid (Cyclokapron) Antifibrinolytic

100mg/ml – 10ml Amps

NO IV infusion during cardiac surgery. Refer to PPO as needed.

Do not mix with penicillin



71


How Supplied

IV Push Conc / Rate



Treprostinil (Remodulin) Cardiovascular/ Vasodilator

1, 2.5, 5, and 10 mg/ml 20 ml vials

NO Subcutaneous or intravenous continuous infusion *** Metro: Use of preprinted order set advised ***

Avoid infusion interruptions – loss of disease control could lead to death Monitor for hypotension, flushing, headache, N/V, anxiety & chest pain. A “Remodulin Dosing Weight” is established and used throughout the patient’s therapy. The “Remodulin Dosing Weight” should be used when calculating infusion rate.

SC: Stable 28 days after initial use if refrigerated; 14 days at room temp

SC administration: Only use syringe pump provided by home health care agency. IV: 1 mg in 100ml NS stable 48 hr at room temp.

* See footnote

Trimethoprim & Sulfamethoxazole (Cotrimoxazole) (Bactrim, Septra) Antibiotic/ Sulfonamide

80mg TMP + 400mg SMX per 5ml vial

NO Intermittent Infusion – PCP (Pneumocystis Carinii Pneumonia): 15-20mg/kg/day into 4 doses (q 6h) Each 80mg (5ml) TMP diluted into 100ml D5W Infuse dose over 90min

Flush line before and after Cotrimoxazole with D5W Do not mix with any other medications/solutions – contact pharmacist

5 ml in 100 ml D5W Stable 4 hours 5 ml in 75 ml D5W Stable 2 hours

Sulfa derivative – check allergies!!

Urokinase (Abbokinase)


Thrombolytic

250,000 unit vial

Varying doses depending on indication – consult external reference or pharmacist. Give over 10 min

Varying continuous infusions depending on indication – consult external reference or pharmacist System Standard Conc: 1 million units/250 ml NS (4000 units/ml)

Thrombolytic medication: Monitor for signs of bleeding. Minimize potential risks for bleeding: Establish all IV’s prior to therapy. (Minimum of 2 peripheral IVs recommended in addition to thrombolytic infusion site.) Avoid unnecessary arterial/venous punctures, excessive blood sampling, and IM injections for at least 24 hr after d/c’d (malnourished patients 48 hr). Apply pressure dressings to all puncture sites. Thrombin time elevated

Critical Care for continuous infusion Monitoring is at physician discretion for peripheral vascular indications.



72


How Supplied

IV Push Conc / Rate



Valproate Sodium (Depacon) Anticonvulsant


NO Intermittent Infusion – Loading dose: 15 mg/Kg in 50-100 ml NS or D5W over 10-15 minutes Maintenance dose: 2-5 mg/kg q6-8h in 50-100 ml NS or D5W Infusion rate may be up to 3 mg/kg/min (total dose </= 15 mg/kg)

Dosing and monitoring service available from pharmacy per physician order.

Vancomycin Antibiotic/Glycopeptide

500mg & 1Gm vial, Premix bag: 500mg /100ml

NO Intermittent Infusion – <500mg in 100ml NS/D5W > 500 mg in 250ml NS/D5W Infuse doses < 500 over 60 minutes Infuse doses < 1 gm over 90 minutes Infuse doses > 1 gm over 120 minutes

Slow rate of infusion if hypotension or flushing occur

Avoid extravasation – Refer to PPO 05046 Aminoglycoside dosing and monitoring service available from pharmacy upon physician order.

Monitor renal function.

Vasopressin (Pitressin) Hormone

20 units/ml –1 & 10ml vial

Yes, For persistent VF/pulseless VT or asystole/PEA 40 units IV push x 1 – after flush w/ 10 ml NS

Continuous Infusion – Usual dose range: 0.2-1.0 units/min (GI bleeds) 0.02- 0.1 units/min (Shock) System Standard Conc: 100 Units/ 100ml NS (1 unit/ml)

Avoid extravasation/infiltration – central line advised.

Monitor BP, HR every 15 min Monitor urine output every 1-2 hr Monitor fluid and electrolyte status Bradycardia and hypertension are early signs of toxicity

Critical Care

Vecuronium (Norcuron)



10 & 20 mg vials (powder)

Yes, intubation dose 0.1 mg/Kg rapidly

Continuous Infusion: Usual dose range: 1-2 mcg/Kg/min System Standard Conc: 50 mg/50 ml NS (total vol=100 ml) (0.5 mg/ml)

Refer to Nursing Clinical Policies on Neuromuscular Blockade (i.e. MN-13) Preprinted order set available for ICU neuromuscular blockade

Controlled airway and ventilation required; Critical Care only: ED, ICU, Surgery.




73


How Supplied

IV Push Conc / Rate



Verapamil (Isoptin) Cardiovascular/ Calcium Channel Blocker

2.5mg/ml – 2 & 4ml vial

Yes, 5-10 mg over 2 minutes (max rate of 5 mg/min) Slower in elderly patients – max rate of 2 mg/min

Continuous Infusion: Usual dose range: 5-20 mg/hr Standard conc: 125 mg/150 ml NS (total vol=200 ml) (0.625 mg/ml) “Concentrated” conc: 125 mg/50 ml NS (total vol=100 ml) (1.25 mg/ml)

Not compatible with bicarbonate solutions Avoid mixing with other medications/solutions – check with pharmacist

* See footnote

Vitamin K – See Phytonadione

Voriconazole (Vfend) Antifungal

10 mg/ml 20 ml vial

NO Recommended dose: 6 mg/kg IV every 12 hr x 2 doses then 4 mg/kg IV every 12 hr Dilute in 250 ml NS Infuse over 2 hr

Refer to preprinted order set (PPO 2627) for dose, indications & contraindications

IV formulation contraindicated in pt with CrCl < 50 ml/min. PO formulation not contraindicated in pt with renal insufficiency nor is any dose reduction recommended Dose reduction recommended in pt with hepatic insufficiency/drug-drug interactions Transient visual disturbances may occur

Warfarin (Coumadin) Anticoagulant

5 mg vial Yes, Give dose over 1-2 minutes IM administration NOT advised!

NO ** Verify dose to be given. Discard vial after drawing up correct dose. ** Monitor INR

Use only sterile water for reconstitution Once reconstituted, use within 4 hours Keep vial in carton until use Do NOT refrigerate



74


How Supplied

IV Push Conc / Rate



Ziconotide intrathecal infusion (Prialt)


due to intrathecal administration!!

Non-opioid analgesic

100 mcg/ml 1 & 5 ml vials, 25 mcg/ml 20 ml vial

Intrathecal administration only!!

Indicated for the management of severe chronic pain in patients whom intrathecal therapy is warranted, and who are intolerant of or refractory to other treatments.

Approved only for use in Medtronic SynchroMed EL, SynchroMed II Infusion Systems and Simms Deltec CADD Micro External Microinfusion Device and Catheter. Expiration once placed in infusion pump: Initial fill: 25 mcg/ml undiluted = 14 days Refill of pump: 25 mcg/ml & 100 mcg/ml undiluted = 60 days 100 mcg/ml diluted = 40 days

Refrigerate Dilute only with preservative free NS Protect from light

Zidovudine Antiviral

10 mg/ml 20 ml vial

NO Intermittent infusion: Infuse over 30-60 min L&D: 2mg/kg IV bolus over 1hour followed by 1mg/kg/hr IV infusion until cord clamped, then PO regimen for infant(s).

May cause anemia or neutropenia 100 mg PO zidovudine every 4 hr = 1 mg/kg IV every 4 hr

Stable after dilution: 8 hr at room temp 24 hr refrigerated Vial: Protect from light Do not mix with other medications/solutions

Zoledronic Acid (Zometa / Reclast) Bisphosphonate

4 mg vial 5mg premixed solution

NO Hypercalcemia / Bone Metastases: 4 mg/100ml NS or D5W over a minimum of 15 minutes X 1 dose Repeat prn usually every 3-4 weeks, but no more than once per week Paget’s Disease / Osteoporosis: 5mg/100mL premixed solution over minimum of 15minutes once yearly. Doses given over < 15 minutes increase risk of renal toxicity!

Assess baseline renal function, serum calcium and vitamin D levels prior to administration. Monitor renal function (I/O, SCr) Dose reduction recommended for patients with CrCl < 60 ml/min. Not recommended if CrCl <30ml/min

Hypotension in 10% of patients Bone pain common Mild fever and flu-like symptoms

Restricted to outpatient use. Mandatory System-wide orders required for use.

Reference: Aurora Health Care - Department of Pharmacy Services – March 2009

Insulin & Parenteral Antiglycemic Agents Aurora Hospitals

Rapid-Acting Insulin Apidra; Insulin Glulisine Onset: 5 minutes Duration: 2-4 hours May be mixed with Novolin N (NPH) only 1 unit Apidra ≈ 1 unit regular human insulin Give within 15 minutes before a meal or within 20

minutes after starting a meal In hospital: administer only when meal tray

available Therapeutically equivalent to insulin aspart / lispro. Note: peak & duration extended in T2DM

Rapid-Acting Insulin Novolog; Insulin Aspart *

Onset: 5-15 minutes Duration: 3-5 hours May be mixed with Novolin N (NPH) Therapeutically equivalent to Lispro (Humalog) In hospital: administer only when meal tray available

Short-Acting Insulin Novolin R; Regular Insulin * Onset: 30-60 minutes Duration: 5-8 hours May be mixed with: Novolin N (NPH) Therapeutically equivalent to Humulin R

Intermediate-Acting Insulin Novolin N; NPH Insulin * Onset: 2-4 hours Duration: 14-18 hours May be mixed with Novolog and Novolin R Therapeutically equivalent to Humulin N

Long-Acting Insulin Lantus; Insulin Glargine* Onset: 1.5-2 hours Duration: 20-24 hours Can not be mixed with any other insulins Administered once daily in most patients.

Long-Acting Insulin Levemir®; Insulin Detemir * Onset: 3-14 hours Duration: 6-24 hours Can not be mixed with any other insulins Administered once or twice daily

Insulin Aspart Mix Novolog Mix 70/30 Onset: More rapid than regular insulin mixes - administer with meals Peak effect: 1-4hours Duration: up to 24hours Administered once or twice daily. Do not mix with other insulin products. Shake prior to use – must appear uniformly white & cloudy.

Premixed 70/30 Insulin Novolin 70/30 * Onset: 30-60 minutes Duration: 14-18 hours Premixed with 70% NPH and 30% Regular Cannot be mixed with any other insulin

Symlin®; Pramlintide Amylin Analog - augments effects of insulin and reduces prandial insulin requirements by ≈ 50%

Should not be started in hospitalized patients due to high risk of nausea, vomiting, & hypoglycemia.

Do not mix with insulin products.

Do not use pramlintide if the patient is NPO, likely to skip a meal/not eat enough, hypoglycemic, or has gastroparesis

Give SQ immediately prior or within 15 min before each major meal, do not give after meals.

Byetta®; Exenatide Glucagon-like Peptide-1 Analog (GLP-1) used in

Type 2 DM only, as an alternative to insulin Peak response: 2-3 hours Duration: up to 5 hours Hold if NPO.

Twice daily SQ injection, before breakfastand supper.

Dose anytime within 1 hour before meals.

Formulary Insulins & Antiglycemics are indicated with an asterix (*). Insulin Product Ordered AHC Formulary Substitution

Insulin Glulisine (Apidra) Equivalent number of units of Insulin Aspart (Novolog)

Insulin Lispro (Humalog) Equivalent number of units of Insulin Aspart (Novolog)

Humulin 50/50 50% of the ordered dose as NPH and 50% of ordered dose as Insulin Aspart (Novolog)

Humalog (Lispro Mix) 75/25 Equivalent number of units of Insulin Aspart Mix 70/30 (Novolog Mix 70/30)

Humalog (Lispro Mix) 50/50 50% of the ordered dose as NPH and 50% of the ordered dose as Insulin Aspart (Novolog)

Novolin 70/30 Equivalent number of units of Insulin Aspart Mix 70/30 (Novolog Mix 70/30)

Note: Formulary Substitutions as of April 2009. Contact your pharmacist with questions regarding substitutions as necessary.

Parenteral Antigylcemic Agents – These are not Insulin Products

Documents

Medication Administration Policy