jabatan farmasi hospital raja permaisuri bainun ipoh
TRANSCRIPT
JABATAN FARMASI
HOSPITAL RAJA PERMAISURI BAINUN IPOH
FOREWORD
Intravenous (IV) therapy is considered an essential component of current
healthcare delivery, with over 90% of hospitalized patients receiving some form
of infusion therapy. Errors involving IV medications can occur in all phases of the
medication use process and can be particularly dangerous based on the drug’s
properties and the complexity of its therapeutic action. IV medications are
clinically advantageous due to their immediate therapeutic effect and ability to
support plasma drug levels that reach an early target effect. At the same time,
harm can easily result from IV drug administration due to the immediate
bioavailability of intravenously administered drugs, the narrow therapeutic dose
range of many IV medications, as well as the limitations in reversing systemic
effects after IV administration.
Therefore,to promote and ensure the quality use of medication involving
Intarvenous Therapy, Adult Medication Dosing Protocol have been implemented.
We believe it be a good source of providing continuous training and education
amongst health personnel. Nevertheless, dilution of medications is an essential
part to ensure that patients receive the optimum therapy. It is important that the
concentration of medication dilution is correct to minimize the side effects. Besides,
stability of the preparation is essential to ensure safety, quality and efficacy of the
drugs
I would like to convey my heartfelt gratitude to the core editorial team, which
compromised our Ward Pharmacist, physicians and other health care personnels,
without whom this document would not have come true. i would particularly like to
thank Puan Norma bt Abdullah and her team of pharmacists for their patience,
perseverance and commitment in collating and producing this guideline.
Thank You
Dr. Teo Gim Sian Pengarah Hospital Hospital Raja Permaisuri Bainun Ipoh (HRPB)
FOREWORD
Intravenous drugs (I.V. drugs) are double-edged sword of pharmacology, potent, fast-acting and lifesaving, yet more apt to cause severe harm or even death when used in error. Undeniably, I.V. drugs are indispensable for many patients. Their near-instant onset of action is crucial in cardiac emergencies, trauma, and other life or death situations that demand rapid drug infusion.
However, mistakes with I.V. drugs can be catastrophic. Unsafe I.V. drug administration practices include failing to dilute the drug properly, failing to administer it properly, using the wrong I.V. bolus technique, overriding the proper administration rate, and calculating patient weights or dosages incorrectly.
Hence, Medical Dosing Protocol was developed to facilitate the healthcare staffs in preparing the dilutions and administrations of I.V. drugs which are available in this hospital. Each drug is listed with information on dose, dilution and comprehensive infusion rate table. This protocol is intended to be user-friendly in providing readily accessible information to be used at the bedside.
I appreciate the thought and planning of the ward pharmacists that went into creating this protocol. I would like to take this opportunity to thank the ward pharmacist team for their unwavering time and dedication in contributing to this protocol. Also, special thanks to consultants / specialists from various disciplines and head of clinical departments who review and contribute to the protocol. I sincerely hope our nurses and the healthcare workers will find this protocol useful in their daily practice.
Thank you.
Norma bt Abdullah Chief Pharmacist HRPB
DISCLAIMER
This guide is intended to serve as a quick guide to drug dilution and administration and not a complete reference.
The guide covers commonly used intravenous drugs that are administered as continuous infusion. It does not cover all available drugs at the Ministry of Health Malaysia.
Drug information is fast evolving because of constant ongoing researches. Although so, research in this setting is relatively scarce. Authors have used available recent information in preparing this
guide, the users are advised that authors, reviewers, contributors are not responsible for continued currency of information or for any errors, omissions or the application of this information or for any consequences arising therefrom. Therefore, due the dynamic growth of drug information, users are advised to make decisions regarding the drugs dilution and infusion based on current information and practice.
Contributors:
Doris George Visuvasam Foong Wai Keng Choo Choy Yuen Chai Chung Wei Ho Chee Wah Lee Pooi Mun Ng Wei Yee Wong Hong Yean Lim Kim Khee Ding Wern Jing Siti Nur Sharida Ng Chee Fong
Reviewers:
Dato Dr. K. Chandran Senior Consultant Physician
Dato Dr. K. Sothy Senior Consultant Physician
Dr. Asri Ranga Consultant Cardiologist
Dr. Padmini Menon General Physician of Internal Medicine and Clinical Hematology
Dr Ker Hong Bee Consultant Infectious Disease Physician, Hospital Raja Permaisuri Bainun
Dr Foong Kit Weng Consultant Intensivist, Hospital Raja Permaisuri Bainun
Dr Siti Rohayah binti Sulaiman Consultant Intensivist, Hospital Raja Permaisuri Bainun
Dr Loh Chek Long Consultant Nephrologist, Hospital Raja Permaisuri Bainun
Mr Yan Yang Wai General Surgeon, Hospital Raja Permaisuri Bainun
Dr. Adi Bin Osman Emergency Physician, Hospital Raja Permaisuri Bainun
Pn. Norma Binti Abdullah Chief Pharmacist, Hospital Raja Permaisuri Bainun
Contents
Abciximab …………………………………………………….…………..………….27
Adrenaline (Medical)…………………………………………………………………12
Adrenaline* (Anaes)………………………………………………………………….13
Amphotericin B Injection (Conventional)……………………………………………33
Antibiotic Lock Solutions…………………………………………………………….37
Cosmofer(Iron (Iii)-Hydroxide Dextran Complex)…………………………………..35
Dexmedetomidine…………………………………………………………………….14
Dobutamine (Medical) - Single Strength………………………………………………2
Dobutamine (Medical) - Double Strength……………………………………………..3
Dobutamine*(Anaes) - Single Strength………………………………………………..4
Dobutamine* (Anaes) - Double Strength……………………………………………...5
Dopamine (Medical) - Single Strength………………………………………………...8
Dopamine (Medical) - Double Strength…………………………………………….....9
Dopamine* (Anaes) - Single Strength………………………………………………..10
Dopamine* (Anaes) -Double Strength………………………………………………..11
Frusemide…………………………………………………………………………….18
Heparin……………………………………………………………………………….31
Inj. Factor Viii And Factor Ix………………………………………………………...22
Iron Injection…………………………………………………………………………35
Isoprenaline -Single Strength………………………………………………………...15
Isoprenaline -Double Strength……………………………………………………….16
Isosorbide Dinitrate…………………………………………….…………………….17
IV Human Normal Immunoglobulin…………………………………………………24
Labetalol……………………………………………………………………………...19
Lignocaine……………………………………………………………………………29
Noradrenaline (Medical)……………………………………………………………….6
Noradrenaline*(Anaes)……………………………………………………………...…7
Rituximab (Mabthera)………………………………………………………………...21
Salbutamol…………………………………………………………………………….20
Streptokinase………………………………………………………………………….30
Tirofiban………………………………………………………………………………28
Venofer (Iron Sucrose)………………………………………………………………..36
(Medical)
DOBUTAMINE (250mg/20ml)
Dose:
2 - 20mcg/kg/min
Dilution: 3 x Weight (kg) In 50ml Sodium Chloride 0.9% (or Dextrose 5%)
SINGLE STRENGTH
Infusion Rate:
1ml/hour = 1mcg/kg/min
Dilution Table
Weight 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100
(kg)
Dose (mg) 90 105 120 135 150 165 180 195 210 225 240 255 270 285 300
Volume of 7.2
8.4
9.6
10.8
12
13.2
14.4
15.6
16.8
18
19.2
20.4
21.6
22.8 24
Dobutamine
(mls)
Make into a Total Volume of 50mls
Infusion Rate (ml/hour) Table
Dose 2
2.5
3
3.5
4
4.5
5
7.5
10
12.5
15
17.5
20
(mcg/kg/min)
Infusion Rate
2
2.5
3
3.5
4
4.5
5
7.5
10
12.5
15
17.5
20
(ml/hour)
Precautions: Dobutamine must be diluted before administration.
IV infusion preferred to be given into central IV route.
If higher concentration is used, > 500mg dobutamine in 50ml diluents of infusion, it should protect from light and administer through central line.
Stability: Stability of parenteral admixture at room temperature is 24 hours.
References: 1. Micromedex Healthcare Series 2010. 2. Lexi-Comp’s Drug Information Handbook,12th edition, Charles F, Lacy,et al. 2004
2
(Medical)
DOBUTAMINE (250mg/20ml)
Dose:
2 - 20mcg/kg/min
Dilution:
6 x Weight (kg) In 50ml Sodium Chloride 0.9% (or Dextrose 5%)
DOUBLE STRENGTH 3
Infusion Rate:
1ml/hour = 2mcg/kg/min
Calculation for infusion rate:
Infusion rate (ml/hour) = Patient’s dose (mcg/kg/min) 2
Dilution Table
Weight
(kg) 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100
Dose (mg)
180 210
240
270
300
330
360
390
420
450
480
510
540
570
600
Volume of
14.4 16.8
19.2
21.6
24
26.4
28.8
31.2
33.6
36
38.4
40.8
43.2
45.6 48
Dobutamine
(mls)
Make into a Total Volume of 50mls
Infusion Rate ( ml/hour) Table
Dose 2 2.5 3 3.5 4 4.5 5 7.5 10 12.5 15 17.5 20
(mcg/kg/min)
Infusion Rate
1
1.3
1.5
1.8
2
2.3
2.5
3.8
5
6.3
7.5
8.8
10
(ml/hour)
Precautions:
Dobutamine must be diluted before administration.
IV infusion preferred to be given into central IV route.
If higher concentration is used, > 500mg dobutamine in 50ml diluents of infusion, it should protect
from light and administer through central line.
Stability: Stability of parenteral admixture at room temperature is 24 hours.
References: 1. Micromedex Healthcare Series 2010. 2. Lexi-Comp’s Drug Information Handbook,12th edition, Charles F, Lacy,et al. 2004
3
(Anaes)
DOBUTAMINE* (250mg/20ml)
Dose: 2 - 20mcg/kg/min
Dilution:
250mg (1 vial) in 50 ml of 0.9% Sodium Chloride (or Dextrose 5%).
SINGLE STRENGTH
Infusion Rate (ml/hour) Table
Weight 30 35 40 45 50 55 60 65 70 75 80 85 90
(kg)
mcg/kg/min
2.5 0.9 1.1 1.2 1.4 1.5 1.7 1.8 2.0 2.1 2.3 2.4 2.6 2.7
5.0 1.8 2.1 2.4 2.7 3.0 3.3 3.6 3.9 4.2 4.5 4.8 5.1 5.4
7.5 2.7 3.2 3.6 4.1 4.5 5.0 5.4 5.9 6.3 6.8 7.2 7.7 8.1
10.0 3.6 4.2 4.8 5.4 6.0 6.6 7.2 7.8 8.4 9.0 9.6 10.2 10.8
12.5 4.5 5.3 6.0 6.8 7.5 8.3 9.0 9.8 10.5 11.3 12.0 12.8 13.5
15.0 5.4 6.3 7.2 8.1 9.0 9.9 10.8 11.7 12.6 13.5 14.4 15.3 16.2
17.5 6.3 7.4 8.4 9.5 10.5 11.6 12.6 13.7 14.7 15.8 16.8 17.9 18.9
20.0 7.2 8.4 9.6 10.8 12.0 13.2 14.4 15.6 16.8 18.0 19.2 20.4 21.6
Precautions: Dobutamine must be diluted before administration.
IV infusion preferred to be given into central IV route.
If higher concentration is used, > 500mg dobutamine in 50ml diluents of infusion, it should protect from light and administer through central line.
Stability: Stability of parenteral admixture at room temperature is 24 hours.
References:
1. Micromedex Healthcare Series 2010.
2. Lexi-Comp’s Drug Information Handbook,12th edition, Charles F, Lacy,et al. 2004
4
(Anaes)
DOBUTAMINE* (250mg/20ml)
Dose:
2 - 20mcg/kg/min
Dilution:
500mg (2 vials) in 50 ml of 0.9% Sodium Chloride (or Dextrose 5%).
DOUBLE STRENGTH
Infusion Rate (ml/hour) Table
Weight 30 35 40 45 50 55 60 65 70 75 80 85 90
(kg)
mcg/kg/min
2.5 0.5 0.5 0.6 0.7 0.8 0.8 0.9 1.0 1.1 1.1 1.2 1.3 1.4
5.0 0.9 1.1 1.2 1.4 1.5 1.7 1.8 2.0 2.1 2.3 2.4 2.6 2.7
7.5 1.4 1.6 1.8 2.0 2.3 2.5 2.7 2.9 3.2 3.4 3.6 3.8 4.1
10.0 1.8 2.1 2.4 2.7 3.0 3.3 3.6 3.9 4.2 4.5 4.8 5.1 5.4
12.5 2.3 2.6 3.0 3.4 3.8 4.1 4.5 4.9 5.3 5.6 6.0 6.4 6.8
15.0 2.7 3.2 3.6 4.1 4.5 5.0 5.4 5.9 6.3 6.8 7.2 7.7 8.1
17.5 3.2 3.7 4.2 4.7 5.3 5.8 6.3 6.8 7.4 7.9 8.4 8.9 9.5
20.0 3.6 4.2 4.8 5.4 6.0 6.6 7.2 7.8 8.4 9.0 9.6 10.2 10.8
Precautions: Dobutamine must be diluted before administration.
IV infusion preferred to be given into central IV route.
If higher concentration is used, > 500mg dobutamine in 50ml diluents of infusion, it should protect from light and administer through central line.
Stability: Stability of parenteral admixture at room temperature is 24 hours.
References:
1. Micromedex Healthcare Series 2010.
2. Lexi-Comp’s Drug Information Handbook,12th edition, Charles F, Lacy,et al. 2004
5
(Medical)
NORADRENALINE (4mg/4ml)
Dose:
0.01 - 2mcg/kg/min
Dilution:
4mg In 50ml Dextrose 5%
SINGLE STRENGTH
Infusion Rate (ml/hour) Table
Weight (kg)
30 35 40 45 50 55 60 65 70 75 80 85 90 95 100
mcg/kg/min
0.05 1.1 1.3 1.5 1.7 1.9 2.1 2.3 2.4 2.6 2.8 3 3.2 3.4 3.6 3.8
0.10 2.3 2.6 3 3.4 3.8 4.1 4.5 4.9 5.3 5.6 6 6.4 6.8 7.1 7.5
0.20 4.5 5.3 6 6.8 7.5 8.3 9 9.8 10.5 11.3 12 12.8 13.5 14.3 15
0.40 9 10.5 12 13.5 15 16.5 18 19.5 21 22.5 24 25.5 27 28.5 30
0.60 13.5 15.8 18 20.3 22.5 24.8 27 29.3 31.5 33.8 36 38.3 40.5 42.8 45
0.80 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60
1.00 22.5 26.3 30 33.8 37.5 41.3 45 48.8 52.5 56.3 60 63.8 67.5 71.3 75
1.20 27 31.5 36 40.5 45 49.5 54 58.5 63 67.5 72 76.5 81 85.5 90
1.40 31.5 36.8 42 47.3 52.5 57.8 63 68.3 73.5 78.8 84 89.3 94.5 99.8 105
1.60 36 42 48 54 60 66 72 78 84 90 96 102 108 114 120
1.80 40.5 47.3 54 60.8 67.5 74.3 81 87.8 94.5 101.3 108 114.8 121.5 128.3 135
2.00 45 52.5 60 67.5 75 82.5 90 97.5 105 112.5 120 127.5 135 142.5 150
Precautions: Noradrenaline must be diluted before administration
Do not dilute Noradrenaline in Sodium Chloride 0.9% (Normal Saline).
IV infusion preferred to be given into central IV route.
Stability: Stability of parenteral admixture at room temperature or refrigeration is 24 hours.
References:
1. Product Information (Levophed Injection) 2. Micromedex Healthcare Series 2010.
6
(Anaes)
NORADRENALINE* (4mg/4ml)
Dose:
0.01 - 2mcg/kg/min
Dilution:
4mg In 50ml Dextrose 5%
SINGLE STRENGTH
Infusion Rate (ml/hour) Table
30 35 40 45 50 55 60 65 70 75 80 85 90 95 100
Weight
(kg)
mcg/kg/min
0.05 1.1 1.3 1.5 1.7 1.9 2.1 2.3 2.4 2.6 2.8 3 3.2 3.4 3.6 3.8
0.10 2.3 2.6 3 3.4 3.8 4.1 4.5 4.9 5.3 5.6 6 6.4 6.8 7.1 7.5
0.20 4.5 5.3 6 6.8 7.5 8.3 9 9.8 10.5 11.3 12 12.8 13.5 14.3 15
0.40 9 10.5 12 13.5 15 16.5 18 19.5 21 22.5 24 25.5 27 28.5 30
0.60 13.5 15.8 18 20.3 22.5 24.8 27 29.3 31.5 33.8 36 38.3 40.5 42.8 45
0.80 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60
1.00 22.5 26.3 30 33.8 37.5 41.3 45 48.8 52.5 56.3 60 63.8 67.5 71.3 75
1.20 27 31.5 36 40.5 45 49.5 54 58.5 63 67.5 72 76.5 81 85.5 90
1.40 31.5 36.8 42 47.3 52.5 57.8 63 68.3 73.5 78.8 84 89.3 94.5 99.8 105
1.60 36 42 48 54 60 66 72 78 84 90 96 102 108 114 120
1.80 40.5 47.3 54 60.8 67.5 74.3 81 87.8 94.5 101.3 108 114.8 121.5 128.3 135
2.00 45 52.5 60 67.5 75 82.5 90 97.5 105 112.5 120 127.5 135 142.5 150
Precautions: Noradrenaline must be diluted before administration
Do not dilute Noradrenaline in Sodium Chloride 0.9% (Normal Saline).
IV infusion preferred to be given into central IV route.
Stability: Stability of parenteral admixture at room temperature or refrigeration is 24 hours.
References: 1. Product Information (Levophed Injection) 2. Micromedex Healthcare Series 2010.
7
4
(Medical)
DOPAMINE (200mg/5ml)
Dose:
2 - 20mcg/kg/min
Dilution:
3 x Weight (kg) In 50ml Sodium Chloride 0.9% (or Dextrose 5% )
SINGLE STRENGTH
Infusion Rate:
1ml/hour = 1mcg/kg/min
Precautions: Dopamine should be diluted before administration.
IV infusion preferred to be given into central IV route.
Stability:
Stability of parenteral admixture at room temperature or refrigeration is 24 hours.
References:
1. Micromedex Healthcare Series 2010. 2. Lexi-Comp’s Drug Information Handbook,12th edition, Charles F, Lacy,et al. 2004
Weight 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100
(kg)
Dose (mg) 90 105 120 135 150 165 180 195 210 225 240 255 270 285 300
Volume of 2.3 2.6 3 3.4 3.8 4.1 4.5 4.9 5.3 5.6 6 6.4 6.8 7.1 7.5
Dopamine
(mls)
Make into a Total Volume of 50mls
Infusion Rate ( ml/hour) Table
Dose 2
2.5
3
3.5
4
4.5
5
7.5
10
12.5
15
17.5
20
(mcg/kg/min)
Infusion Rate
2
2.5
3
3.5
4
4.5
5
7.5
10
12.5
15
17.5
20
(ml/hour)
8
(Medical)
DOPAMINE (200mg/5ml)
Dose:
2 - 20mcg/kg/min
Dilution:
6 x Weight (kg) In 50ml Sodium Chloride 0.9% (or Dextrose 5% )
DOUBLE STRENGTH
Infusion Rate:
1ml/hour = 2mcg/kg/min
Calculation for infusion rate:
Infusion rate (ml/hour) = Patient’s dose (mcg/kg/min)
2
Dilution Table
Weight 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100
(kg)
Dose (mg)
180
210
240
270
300
330
360
390
420
450
480
510
540
570
600
Volume of
Dopamine
4.5
5.3
6
6.8
7.5
8.3
9
9.8
10.5
11.3
12
12.8
13.5 14.3 15
(mls)
Make into a Total Volume of 50mls
Infusion Rate ( ml/hour) Table
Dose 2 2.5
3
3.5
4
4.5
5
7.5
10
12.5
15
17.5
20
(mcg/kg/min)
Infusion Rate
1
1.3
1.5
1.8
2
2.3
2.5
3.8
5
6.3
7.5
8.8
10
(ml/hour)
Precautions: Dopamine should be diluted before administration.
IV infusion preferred to be given into central IV route.
Stability:
Stability of parenteral admixture at room temperature or refrigeration is 24 hours.
References:
1. Micromedex Healthcare Series 2010. 2. Lexi-Comp’s Drug Information Handbook,12th edition, Charles F, Lacy,et al. 2004
9
(Anaes)
DOPAMINE* (200mg/5ml)
Dose:
2 - 20mcg/kg/min
Dilution:
200mg (1 ampoule) in 50 ml of 0.9% Sodium Chloride (or Dextrose 5%).
SINGLE STRENGTH
Infusion Rate (ml/hour) Table
Weight 30 35 40 45 50 55 60 65 70 75 80 85 90
(kg)
mcg/kg/min
2.5 1.1 1.3 1.5 1.7 1.9 2.1 2.3 2.4 2.6 2.8 3.0 3.2 3.4
5.0 2.3 2.6 3.0 3.4 3.8 4.1 4.5 4.9 5.3 5.6 6.0 6.4 6.8
7.5 3.4 3.9 4.5 5.1 5.6 6.2 6.8 7.3 7.9 8.4 9.0 9.6 10.1
10.0 4.5 5.3 6.0 6.8 7.5 8.3 9.0 9.8 10.5 11.3 12.0 12.8 13.5
12.5 5.6 6.6 7.5 8.4 9.4 10.3 11.3 12.2 13.1 14.1 15.0 15.9 16.9
15.0 6.8 7.9 9.0 10.1 11.3 12.4 13.5 14.6 15.8 16.9 18.0 19.1 20.3
17.5 7.9 9.2 10.5 11.8 13.1 14.4 15.8 17.1 18.4 19.7 21.0 22.3 23.6
20.0 9.0 10.5 12.0 13.5 15.0 16.5 18.0 19.5 21.0 22.5 24.0 25.5 27.0
Precautions: Dopamine should be diluted before administration.
IV infusion preferred to be given into central IV route.
Stability:
Stability of parenteral admixture at room temperature or refrigeration is 24 hours.
References:
1. Micromedex Healthcare Series 2010. 2. Lexi-Comp’s Drug Information Handbook,12th edition, Charles F, Lacy,et al. 2004
10
(Anaes)
DOPAMINE* (200mg/5ml)
Dose:
2 - 20mcg/kg/min
Dilution:
400mg (2 ampoules) in 50 ml of 0.9% Sodium Chloride (or Dextrose 5%).
DOUBLE STRENGTH
Infusion Rate (ml/hour) Table
Weight 30 35 40 45 50 55 60 65 70 75 80 85 90
(kg)
mcg/kg/min
2.5 0.6 0.7 0.8 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7
5.0 1.1 1.3 1.5 1.7 1.9 2.1 2.3 2.4 2.6 2.8 3.0 3.2 3.4
7.5 1.7 2.0 2.3 2.5 2.8 3.1 3.4 3.7 3.9 4.2 4.5 4.8 5.1
10.0 2.3 2.6 3.0 3.4 3.8 4.1 4.5 4.9 5.3 5.6 6.0 6.4 6.8
12.5 2.8 3.3 3.8 4.2 4.7 5.2 5.6 6.1 6.6 7.0 7.5 8.0 8.4
15.0 3.4 3.9 4.5 5.1 5.6 6.2 6.8 7.3 7.9 8.4 9.0 9.6 10.1
17.5 3.9 4.6 5.3 5.9 6.6 7.2 7.9 8.5 9.2 9.8 10.5 11.2 11.8
20.0 4.5 5.3 6.0 6.8 7.5 8.3 9.0 9.8 10.5 11.3 12.0 12.8 13.5
Precautions: Dopamine should be diluted before administration.
IV infusion preferred to be given into central IV route.
Stability:
Stability of parenteral admixture at room temperature or refrigeration is 24 hours.
References:
1. Micromedex Healthcare Series 2010. 2. Lexi-Comp’s Drug Information Handbook,12th edition, Charles F, Lacy,et al. 2004
11
(Medical & Anaes)
ADRENALINE (1mg/ml)
Indication:
REFRACTORY HYPOTENSION
Dose:
1 - 10mcg/min
Dilution:
1mg In 250ml Sodium Chloride 0.9% (or Dextrose 5%)
(4mcg/ml)
Dose Infusion Rate
(mcg/min) (ml/hour)
1 15
2 30
3 45
4 60
5 75
6 90
7 105
8 120
9 135
10 150
Precautions:
Adrenaline must be diluted before administration IV infusion preferred to be given into central IV route.
Stability:
Stability of parenteral admixture at room temperature or refrigeration is 24 hours.
References:
1. Lexi-Comp’s Drug Information Handbook,12th edition, Charles F, Lacy,et al. 2004 2. Micromedex Healthcare Series 2010
*For patient with fluid restriction and high dosage requirement. Adrenaline can be reconstituted as:
5mg in 50ml 0.9% Sodium Chloride (or Dextrose 5%)
(A Guide to Intravenous Administration, Bradford Teaching Hospital, NHS)
12
(Anaes)
ADRENALINE* (1mg/ml)
Indication:
REFRACTORY HYPOTENSION
Dose:
1 - 10mcg/min
Dilution:
5mg In 50ml Sodium Chloride 0.9% (or Dextrose 5%)
(100mcg/ml)
Dose Infusion Rate
(mcg/min) (ml/hour)
1 0.6
2 1.2
3 1.8
4 2.4
5 3
6 3.6
7 4.2
8 4.8
9 5.4
10 6
Precautions: Adrenaline must be diluted before administration
IV infusion preferred to be given into central IV route.
Stability: Stability of parenteral admixture at room temperature or refrigeration is 24 hours.
References:
1. A Guide to Intravenous Administration, Bradford Teaching Hospital, NHS 2. Lexi-Comp’s Drug Information Handbook,12th edition, Charles F, Lacy,et al. 2004 3. Micromedex Healthcare Series 2010
13
Dexmedetomidine HCl (PrecedexTM)
(200mcg/2ml)
Dose:
0.2 to 1 mcg/kg/hour
Dilution:
200 mcg (2 ml) of Dexmedetomidine HCl added to 48 ml of Sodium Chloride
0.9%
to a total volume of 50 mL
(Final Concentration: 4 mcg/ml)
Infusion Rate (ml/hour) Table
Weight
(Kg)
Dose
(mcg/kg/hour)
50 55 60 65 70 75 80 85 90 95 100
0.2 2.5 2.8 3 3.3 3.5 3.8 4 4.3 4.5 4.8 5
0.3 3.8 4.1 4.5 4.9 5.3 5.6 6 6.4 6.8 7.1 7.5
0.4 5 5.5 6 6.5 7 7.5 8 8.5 9 9.5 10
0.5 6.3 6.9 7.5 8.1 8.8 9.4 10 10.6 11.3 11.9 12.5
0.6 7.5 8.3 9 9.8 10.5 11.3 12 12.8 13.5 14.3 15
0.7 8.8 9.6 10.5 11.4 12.3 13.1 14 14.9 15.8 16.6 17.5
0.8 10 11 12 13 14 15 16 17 18 19 20
0.9 11.3 12.4 13.5 14.6 15.8 16.9 18 19.1 20.3 21.4 22.5
1 12.5 13.8 15 16.3 17.5 18.8 20 21.3 22.5 23.8 25
Precaution:
Must be diluted prior to administration.
Should be administered using a controlled infusion device (eg. IV or syringe pump).
Administration duration should not exceed 24 hours.
Dexmedetomidine HCl dosing should be individualized. The rate of maintenance infusion should be adjusted from
0.2- 1mcg/kg/hour to achieve desired effect.
Stability:
Prior to use, may store the diluted dexmedetomidine HCl solution for up to 4 hours at room temperature or
up to 24 hours at 2 to 8 oC.
Discard unused portion.
Reference:
1. Product Information (Dexmedetomidine HCl, PrecedexTM Injection).
14
Infusion Rate (ml/hour) Table
Dose (mcg/min)
Infusion Rate (ml/hour)
2 30
3 45
4 60
5 75
6 90
7 105
8 120
9 135
10 150
References:
1. Product Information Isuprel.
2. Micromedex Healthcare Series 2010.
3. Lexi-Comp’s Drug Information Handbook,12th edition, Charles F, Lacy,et al. 2004.
ISOPRENALINE Indication:
HEART BLOCK Dose:
2 - 10mcg /min
Dilution: 2mg In 500ml Dextrose 5%
SINGLE STRENGTH
15
Infusion Rate (ml/hour) Table
Dose
(mcg/min)
Infusion Rate
(ml/hour)
2 15
3 22.5
4 30
5 37.5
6 45
7 52.5
8 60
9 67.5
10 75
References:
1. Product Information Isuprel.
2. Micromedex Healthcare Series 2010.
3. Lexi-Comp’s Drug Information Handbook,12th edition, Charles F, Lacy,et al. 2004
ISOPRENALINE Indication:
HEART BLOCK
Dose:
2 - 10mcg /min
Dilution:
4mg In 500ml Dextrose 5%
DOUBLE STRENGTH
16
Infusion Rate (ml/hour) Table
Dose
(mg/hr)
1
mg/hr
2
mg/hr
3
mg/hr
4
mg/hr
5
mg/hr
6
mg/hr
7
mg/hr
8
mg/hr
9
mg/hr
10
mg/hr
Infusion
Rate (ml/hour)
2
ml/hr
4
ml/hr
6
ml/hr
8
ml/hr
10
ml/hr
12
ml/hr
14
ml/hr
16
ml/hr
18
ml/hr
20
ml/hr
Precautions:
Isosorbide dinitrate absorbed to some extent by PVC infusion containers. Preferably use glass or polyethylene
containers or give via a syringe pump.
Stability:
The diluted solution should be administered within 24 hours.
References:
1. Product information. ( Isoket® 0.1% Injection)
2. BNF, September 2008, Edition 58.
3. Lexi-Comp’s Drug Information Handbook 12th edition, Charles F. Lacy.et.al, 2004
Isosorbide Dinitrate (Isoket® 0.1%) (10mg/10ml)
DOSE:
1mg/hour – 10mg/hour
Note: Dose employed according to the patient’s response.
DILUTION:
Number of ampoules of
Isoket
Volume of diluents to be
added (ml)
Total Volume
(ml)
2 ampoules (20mg)
-20ml 20ml 40ml
Compatible Diluents:
Sodium Chloride 0.9% ( Normal Saline)
Dextrose 5%
(Final concentration : 0.5mg/ml)
Infusion Rate (ml/hr) = Dose ( mg/hr) × 2
17
Infusion Rate (ml/hour) Table
Dose
(mg/hr)
1
mg/hr
2
mg/hr
3
mg/hr
4
mg/hr
5
mg/hr
6
mg/hr
7
mg/hr
8
mg/hr
9
mg/hr
10
mg/hr
Infusion
Rate (ml/hour)
0.5
ml/hr
1
ml/hr
1.5
ml/hr
2
ml/hr
2.5
ml/hr
3
ml/hr
3.5
ml/hr
4
ml/hr
4.5
ml/hr
5
ml/hr
Frusemide (20mg/2ml) DOSE:
IV Infusion : Administer at a rate not more than 4mg/min
DILUTION:
Number of ampoules of
Frusemide
Volume of diluents to be
added (ml)
Total Volume
(ml)
5 ampoules (100mg)
-10ml 40ml 50ml
Compatible Diluents:
Sodium Chloride 0.9% ( Normal Saline)
(Final concentration: 2mg/ml)
Infusion Rate (ml/hr) = Dose (mg/hr)
2
Precautions:
Frusemide incompatible with glucose solution.2
Unstable in acidic media but very stable in basic media.
Do not use if solutions in yellow colour. Refrigeration may result in precipitation. However, resolubilization at
room temperature or warming may be performed without affecting the stability of frusemide.
Dilute in NS via peripheral IV route or undiluted via the central IV route ONLY.
Stability:
The stability data for diluted solution is not available.
References:
1. Product information Frusemide.
2. Micromedex Healthcare series vol 156, 2013.
3. BNF, September 2008, Edition 58.
4. Lexi-Comp’s Drug Information Handbook 12th edition, Charles F. Lacy.et.al, 2004.
18
Infusion Rate (ml/hour) Table
Dose
(mg/min)
0.25mg/min OR
15mg/hr
0. 5mg/min OR
30mg/hr
1 mg/min OR
60mg/hr
2 mg/min OR
120mg/hr
Infusion Rate
(ml/hour) 7.5ml/hr 15ml/hr 30ml/hr 60ml/hr
Labetalol (Trandate™) (25mg/5ml)
Dose:
Initial: 2mg/min, titrate to response up to 300mg total dose, if needed.
DILUTION:
Number of ampoules of
Labetalol
Volume of diluents to be
added (ml)
Total Volume
(ml)
4 ampoules ( 100mg) - 20ml 30ml 50ml
8 ampoules (200mg) - 40ml 60ml 100ml
Compatible Diluents:
Dextrose 5%,
Dextrose Saline
Sodium Chloride 0.9% ( Normal Saline)
( Final concentration : 2mg/ml)
Infusion Rate (ml/hr) = Dose (mg/hr)
2
Precautions:
Labetalol must not dilute with sodium bicarbonate injection BP 4.2% w/v and alkaline solution.
Stability:
Unused labetalol injection solution should be discarded 24 hour after preparation.
References:
1. Product information. ( Trandate ™ Injection)
2. Lexi-Comp’s Drug Information Handbook 12th edition, Charles F. Lacy.et.al, 2004.
19
Infusion Rate (ml/hour) Table
Dose
(mg/min) 1mcg/min 2mcg/min 3mcg/min 4mcg/min
Infusion Rate
(ml/hour) 1ml/hr 2ml/hr 3ml/hr 4ml/hr
Precautions:
Do not inject undiluted.
Avoid addition of other medications to infusion solution..
Stability:
Protect from light.4
After dilution, discard unused portion after 24 hours.4
References:
1. Product information ( Salbutamol, VentolinTM Injection)
2. Micromedex Healthcare series vol 156, 2013.
3. BNF, September 2008, Edition 58.
Lexi-Comp’s Drug Information Handbook 12th edition, Charles F. Lacy.et.al, 2004.
Salbutamol (Ventolin™) (5mg/5ml)
Initial: 5mcg/minute;
May increase up to 10-20mcg/minute at 15-30 minute intervals if needed.
DILUTION:
Number of ampoules of
Salbutamol
Volume of diluents to be
added (ml)
Total Volume
(ml)
3 ml ( 3mg) 47ml 50ml
Compatible Diluents:
Dextrose 5%,
Dextrose Saline
Sodium Chloride 0.9% ( Normal Saline)
( Final concentration : 60mcg/ml)
Infusion Rate ( ml/hr) = Dose (mcg/min)
20
RITUXIMAB (MABTHERA)
(A) PRE-MEDICATION
(30 mins prior to Rituximab Infusion)
NOTE
1) First infusion (C) (I) must be administered as in-patient.
If no infusion-related reaction occurs, subsequent
infusions (C) (II) can be administered as a day care
procedure.
2) The dosage is 375mg/m2 or 500mg, whichever is
feasible.
3) Rituximab should not be mixed or diluted with other
drugs.
4) Rituximab vials are stable at 2-8°C. Protect from light.
Do not shake or freeze.
5) Rituximab solution for infusion should not be stored 2-
8°C and is stable for 24 hours.
6) Throughout infusion:
- monitor patient for any signs of adverse reaction
- measure patient’s BP every 30 minutes
- an emergency trolley should be easily accessible if
required.
Drugs Date Time Given by
IV Chlorpheniramine 10mg
IV Hydrocortisone 100mg /
T Prednisolone
(as in chemo regimen)
Oral Paracetamol 1000g
(B) RECONSTITUTION
Withdraw 50ml (500mg) of Rituximab from the vial. Dilute in 450ml NS (total volume = 500ml at 1mg/ml)
GENTLY invert the infusion bottle to mix. DO NOT shakes vigorously.
DO NOT ADMINSTER AS AN IV PUSH OR BOLUS.
(C)(I) FIRST INFUSION (500mg IV Rituximab) Date:
3-hours Infusion Cycle:
Time (Duration) Rates
(mg/hr)
VOLUME
to be administered
Time of
administration
Administered/
Monitored by
0 → 0.5 hr (½ hr) 50 25 ml
0.5 → 1 hr (½ hr) 100 50 ml
1 → 1.5 hr (½ hr) 150 75 ml
1.5 → 2 hr (½ hr) 200 100 ml
2 → 3 hr (1 hr) 250 250 ml
** If an infusion reaction develops, the infusion should be temporarily slowed or withheld.
The infusion can be continued at ½ of the previous infusion rate upon improvement of symptoms.
OR
(C)(II) SUBSEQUENT INFUSION (500mg IV Rituximab) Date:
2-hours Infusion Cycle:
IF THE PATIENT DID NOT TOLERATE THE FIRST INFUSION,
PLEASE CONTINUE THE NEXT INFUSION USING THE INFUSION OF C(I)
Time (Duration) Rates
(mg/hr)
VOLUME
to be administered
Time of
administration
Administered/
Monitored by
0 → 0.5 hr (½ hr) 100 50 ml
0.5 → 1 hr (½ hr) 200 100 ml
1 → 1.5 hr (½ hr) 300 150 ml
1.5 → 2 hr (½ hr) 400 200 ml
21
INJ. FACTOR VIII AND FACTOR IX
FOR HEMOPHILIA PATIENTS
The formula for calculating clotting factor concentrates:
Factor VIII infusion:
Factor dose (IU) = (target factor level % - *current factor level%) x Weight (kg)
2
Repeat dosing every 8-12 hours (if necessary)
Factor IX infusion:
Factor dose (IU) = (target factor level % - *current factor level%) x Weight (kg)
2
Repeat dosing every 8-12 hours (if necessary)
*For severe haemophilia, the baseline level is assumed to be 0%.
The target of factor level (%) will depend on the site and severity of bleed.
Type of
hemorrhage
Hemophilia A Hemophilia B
Desired
level (%)
Duration (days) Desired
level (%)
Duration (days)
Joint 30 - 40 1-2 days, may be longer if
response is inadequate
30 - 40 1-2 days, may be longer
if response is inadequate
Muscle (except
iliopsoas)
30 - 40 2-3 days, may be longer if
response is inadequate
30 - 40 2-3 days, may be longer
if response is inadequate
Iliopsoas
Initial
Maintenance
80 – 100
30 – 60
1-2
3-5, sometimes longer as
secondary prophylaxis
during physiotherapy
60 – 80
30 – 60
1-2
3-5, sometimes longer as
secondary prophylaxis
during physiotherapy
CNS/ head
Initial
Maintenance
80 – 100
50
1-7
8 - 21
60 – 80
30 – 60
1-7
8 - 21
Throat and neck
Initial
Maintenance
80 – 100
50
1-7
8 - 21
60 – 80
30 – 60
1-7
8 - 21
Gastrointestinal
Initial
Maintenance
80 – 100
50
1-6
7-14
60 – 80
30 – 60
1-6
7-14
Renal 50 3-5 40 3-5
Deep laceration 50 5-7 40 5-7
Surgery (major)
Pre-op
Post-op
80 – 100
60 – 80
40 – 60
30 - 50
1-3
4-6
7-14
60 – 80
40 – 60
30 – 50
20 - 40
1-3
4-6
7-14
22
TYPE OF FACTOR CONCENTRATE AVAILABLE IN HRPB
Factor VII Recombinant
activated
Novoseven (Novo) 1mg
Factor VIII Plasma-derived
intermediate purity
virally-inactivated
*Alphanate (Grifols)
250ii
*Optivate (BPL)
250ii
Alleviate (CSL) 250ii
Hemofil M (Baxter) Contents variable per batch
Plasma-derived
high purity
virally-inactivated
Octanate (Octapharma) 250ii
Factor IX Plasma-derived *Alphanine (Grifols) 500ii
Replenine (BPL)
500ii
Combined factor
concentrates
Plasma-derived
Factor II, IX, X
*Prothrombinex 500ii
Plasma-derived
Factor II, VII, IX, X
Octaplex (Octapharma) 500ii
Beriplex 500ii
Factor II, IX, X &
activated Factor VII
*FEIBA 500ii
*Available in HRPB (updated 1st July 2017)
DOSE CALCULATION AND SUPPLY OF FACTOR CONCENTRATES
A haemophilia A patient weighing 70kg comes with left knee joint bleed. The factor concentrates dose needed
will be:
Referring to the above table, target factor level for knee joint bleed is 30-40%. Current factor level % is
assumed to be 0%.
Factor dose (IU) = (target factor level % - *current factor level%) x Weight (kg)
2
= (30-0) x 70 = 1050IU
2
No of vial of FVIII to supply will be = 1050/250
= 4.2 vials (round up to 5 vials)
Please make sure:
1. The prescription is ordered in unit and not number of vials.
2. Do not break the cold chain. Factor concentrates should be kept at a temperature of 2-8 °C and do not
freeze. Patients must bring their ice box with ice packs.
3. Supply patient with the same batch of factor concentrates.
4. Patient should get the consumables (needles, syringes, alcohol swab etc.) needed from A&E, wards or
day care.
5. Record the date of supply, patient’s name, number IC/ RN, no of vials supplied and batch number in
the bin card.
6. Prescription is kept and returned to pharmacy ward supply on the next working day.
23
IV HUMAN NORMAL IMMUNOGLOBUULIN (IVIg) 3g/ 50ml
The dose for each patient can be rounded up or down to the nearest full unit in which the IVIg is supplied,
in order to avoid discarding unused portions of this very costly therapy.
ADMINISTRATION
a) Refrigerated product should be warmed to room temperature prior to infusion.
b) Ensure solution is clear or slightly opalescent. Do not use solutions which are cloudy or have deposits.
c) Record all batch numbers of IVIG products used in each infusion in patient’s notes in order to facilitate
identification of problems with any products.
d) Some products require filtration; refer to individual product labeling.
e) May be infused undiluted.
f) Adequately hydrate prior to the initiation.
g) Should be administered separately from other IV fluids/ medications the patients might be receiving.
The line may be flushed with sodium chloride 0.9% following infusion.
h) Titration up of infusion rate as below. A rate of infusion which is too rapid may cause flushing and
changes in HR and BP
First Infusion
Infusion rate (ml/hr) Duration (mins) Volume infused (ml)
30 30 15
60 30 30
90 30 45
120 30 60
150* 30 75
180 30 90
*Consider remaining at 150 mL/hr if
a) the patient is unwell or
b) has a low body mass or
c) where there is a large loading dose prescribed.
24
24
.
Subsequent infusions
Infusion rate (ml/hr) Duration (mins) Volume infused (ml)
60 15 15
120 15 30
180 15 45
240 15 60
Administration rates for patients who have tolerated the 1st infusion with no adverse effects.
Consider maximum rates of 150 – 180 ml/hr in patients who have experienced mild to
moderate systemic effects with a previous infusion.
ADVERSE REACTIONS
a) Monitor patients for any changes in vital signs regularly throughout the infusion.
b) Emergency equipment should be readily available in case of adverse reactions.
c) Adverse reactions (flushing, changes in HR & BP): related to the infusion rate and more likely
during the 1st hour of the infusion.
d) ADR occurring with 1st infusion may return with further infusion and do not usually worsen with
long-term IVIG therapy.
Common Mild ADR Actions
Muscle/joint pain
Weakness / Fatigue
Abdominal pain
Diarrhea
Dizziness
Drowsiness
Headache
Fever / Chills
Flushing
Changes in BP/ HR
Itchy, raised rash
Nausea
Slow or stop infusion.
Inform the doctor of this action.
Give paracetamol for fever/headaches.
Oral or intravenous anti-histamine and hydrocortisone be given
as prescribed for such situations.
The patient should be closely observed for the worsening of
symptoms.
Restart infusion as per protocol when patient improves
clinically and gradually increase the infusion rate when
symptoms have resolved.
If symptoms persist, stop the infusion and refer doctor-in-
charge.
25
Severe ADR Actions
Anaphylactic
reaction (urticarial,
angioedema,
bronchospasm or
hypotension)
Asthma exacerbation
/ acute respiratory
distress syndrome
Seizure
Stop infusion
Inform the doctor of this action.
If necessary, administer supportive drugs adrenaline, oxygen,
antihistamine and steroids.
References:
1. Immune globulin: Drug information.1978-2016 Lexicomp, Inc.
2. Micromedex Healthcare Series 2010.
3. Product information (Intragam® P – CSL Biotherapies)
4. Rosman Z, Shoenfeld Y, Zandman-Goddard G. Biologic therapy for autoimmune diseases: an update. BMC
Medicine. 2013;11:88
5. Katz, U., Achiron, A., Sherer, Y., & Shoefield, Y. (2006) Safety if intravenous immunoglobulin (IVIG) therapy.
Autoimmunity reviews 6 (2007) 257 – 259.
26
ABCIXIMAB 10 mg / 5ml (ReoPro®) INDICATION
In the setting of Percutaneous Coronary Intervention (PCI)
DOSE
Bolus : 0.25 mg/kg IV Push (undiluted)
Maintenance : 0.125 mcg/kg/min up to max 10 mcg/min
DILUTION
9 mg (4.5ml) add in 250ml of Sodium Chloride 0.9% (or Dextrose 5%)
Final Volume : 250 ml
Final Concentration 36 mcg/ml
DILUTION TABLE
Patient’s
Weight (kg) Bolus
IV PUSH over 1 minute
(Undiluted)
Maintenance Infusion
0.125 mcg/kg/min
(Max 10 mcg/min)
30 3.8 ml 6.3 ml/hour
35 4.4 ml 7.3 ml/hour
40 5 ml 8.3 ml/hour
45 5.6 ml 9.4 ml/hour
50 6.3 ml 10.4 ml/hour
55 6.9 ml 11.5 ml/hour
60 7.5 ml 12.5 ml/hour
65 8.1 ml 13.5 ml/hour
70 8.8 ml 14.6 ml/hour
75 9.4 ml 15.6 ml/hour
80 10 ml 16.7 ml/hour (MAX infusion rate)
85 10.6 ml 16.7 ml/hour
90 11.3 ml 16.7 ml/hour
95 11.9 ml 16.7 ml/hour 100 12.5 ml 16.7 ml/hour
Bolus – 10 – 20 minutes prior to PCI, followed by 12 hours of infusion.
Precaution
Do not shake vials.
Abciximab can be infused in same line as heparin, nitroglycerin, dobutamine, dopamine, noradrenaline,
lidocaine and streptokinase. Separate IV line whenever possible.
Contraindicated in severe renal failure requiring hemodialysis.
Vials are SINGLE USE only. Discard any unused portion in the vial.
Reference :
1. Product Leaflet of ReoPro®
27
TIROFIBAN 12.5mg / 50ml (Aggrastat®) INDICATION
STEMI : In the setting of angioplasty / atherectomy ONLY
DOSE
Bolus : 25 mcg/kg over 3 minutes
Maintenance : 0.15mcg/kg/min for 36 hours
DILUTION
1 vial (50ml) add in 200ml of Sodium Chloride 0.9% (or Dextrose 5%)
Final Volume 250ml
Final Concentration 50mcg/ml
DILUTION TABLE Patient’s
Weight
(kg)
Normal Renal Function Severe Renal Impairment CrCl
< 30ml/min
Bolus
Over 3
mins
Maintenance
Infusion 0.15mcg/kg/min
Bolus
Over 3
mins
Maintenance
Infusion 0.075mcg/kg/min
30 7 ml 5.4 ml/hour 4 ml 2.7 ml/hour
35 8 ml 6.3 ml/hour 4 ml 3.2 ml/hour
40 10 ml 7.2 ml/hour 5 ml 3.6 ml/hour
45 12 ml 8.1 ml/hour 6 ml 4.1 ml/hour
50 13 ml 9 ml/hour 7 ml 4.5 ml/hour
55 15 ml 9.9 ml/hour 8 ml 5 ml/hour
60 17 ml 10.8 ml/hour 9 ml 5.4 ml/hour
65 18 ml 11.7 ml/hour 9 ml 5.9 ml/hour
70 20 ml 12.6 ml/hour 10 ml 6.3 ml/hour
75 22 ml 13.5 ml/hour 11 ml 6.8 ml/hour
80 23 ml 14.4 ml/hour 12 ml 7.2 ml/hour
85 25 ml 15.3 ml/hour 13 ml 7.7 ml/hour
90 26 ml 16.2 ml/hour 13 ml 8.1 ml/hour
95 28 ml 17.1 ml/hour 14 ml 8.6 ml/hour 146 - 153 30 ml 18 ml/hour 15 ml 14 ml/hour
Precaution
Tirofiban MUST be diluted before administration
NOT to be administered in the same IV line as diazepam (immediate percipitation)
Discard any unused intravenous solution.
Reference :
1. Product Leaflet of Aggrastat®
28
Lignocaine (1% - 50mg/5ml, 2% - 100mg/5ml)
Indication:
In the setting of ventricular arrhythmia.
Dose (Adults)
Loading Dose: 50 – 100 mg (1 mg/kg) at a rate of 25 – 50 mg/minute.
Second Dose: 5 minutes later if desired clinical response not produced.
Maintenance Dose: 1-4 mg/min.1,2
Final concentration : 4 mg/ml
Infusion Rate (ml/hour)
Dose
(mg/min) 1mg/min 2 mg/min 3 mg/min 4 mg/min
Infusion Rate
(ml/hour) 15 ml/hr 30 ml/hr 45 ml/hr 60 ml/hr
Precautions:
Not more than 200- 300mg of Lignocaine should be administered during an hour period.1
IV infusion should be administered under ECG monitoring to avoid potential overdosage and toxicity.1
Stability:
The stability data for diluted solution is not available.
References:
1. Product information. ( Lignocaine Injection, Pfizer)
2. Micromedex 2013.
DILUTION:
2gm into total volume of 500ml with compatible diluents.2
Number of ampoules of Lignocaine Volume of diluents to be
added Total Volume
Lignocaine 1% ( 50 mg/5ml)
40 ampoules ( 2gm ) - 200ml 300 ml
500ml
Lignocaine 2% ( 100 mg/5ml)
20 ampoules ( 2gm ) - 100ml
400 ml
Compatible Diluents:
Sodium Chloride 0.9% ( Normal Saline)
Dextrose 5%
29
Streptokinase 1,500,000 IU per vial
Indication:
Pulmonary Embolism
Dose:
250,000 IU over 30 min,
Then 100,000 IU /hr for 24 hr
(72 hr if concurrent DVT is suspected)
Reconstitution:
1,500,000 IU with 5ml of NS OR D5% OR WFI
Dilutions:
1,500,000 IU (5ml) In total volume of 90ml with NS OR D5%
Infusions:
Dose Infusion Rate ( ml/hr)
250,000 IU over 30 min 15 ml over 30 min
Then , 100,000 IU /hr 6ml /hr
Precautions:
Reconstituted streptokinase vial should not be shaken or agitated to avoid foaming.
Infusion should ne slow if blood pressure lowered by 25mmHg or if asthmatic symptoms appear.
Stability:
Stability after reconstitution: 24 hour at 2-8 °C
References:
Product information Streptase®.
Micromedex Healthcare series 2009.
Lexi-comp’s Drug Information Handbook, 13th Edition, Charles F,Lacy, et al 2005.
30
Heparin
Indication Initial Bolus Initial Rate
Acute Coronary
Syndrome or in place of
warfarin maintenance
60 units/kg
(with fibrinolytic: max 4000
units.
Without fibrinolytic: max
5000 units)
12 units/kg/hour
(max: 1000 units per
hour)
Neuro/
Vascular Surgery
70 units/kg
(max: 5000 units)
15 units/kg/hr
(max: 1000 units/ hr)
Pulmonary Emboli (PE)
& Deep Veen
Thrombosis (DVT)
80 units/kg
(max: 8000 units)
18 units/kg/hr
(max: 1500 units/ hr)
* Loading dose to be infused over 10 min
Recommendation for monitoring and dosage adjustment
For in place of Warfarin maintenance/ Neuro/ Vascular surgery
aPTT Bolus
(units/kg)
Hold
(minutes)
Rate Change
(unit/kg/hr)
Example:
Body weight: 60kg
<50 60 0 +3 Bolus: 3600 units
Add 200units/hr from the
current dose
50-64 0 0 +2 Add 100 units/hr from the
current dose
65-90 0 0 Target
-no change No change
91-100 0 0 -1 Reduce 50 units/hr from
current dose
101-110 0 30 -2 Reduce 100 units/hr from
current dose
>110 0 60 -3 Reduce 200 units/hr from
current dose
For PE / DVT
aPTT Bolus
(units/kg)
Hold
(minutes)
Rate Change
(unit/kg/hr)
Example:
Body weight: 60kg
<50 80 0 +4 Bolus: 4800 units
Add 250units/hr from the
current dose
50-64 40 0 +2 Bolus: 2400 units
Add100units/hr from current
dose
65-100 0 0 Target
-no change No change
101-110 0 0 -2 Reduce 100 units/hour from
current dose
>110 0 60 -3 Reduce 200 units/hour from
current dose
31
Quick Guide To Heparin Monitoring (For Adult) Inj. Heparin 5000 units/ml (25000 units/5ml)
Dilution:
5000 units (1mL) diluted to 50ml 0.9% NaCI
(Concentration: 1ml = 100 units Heparin)
,'
Dose (Units/hour) Infusion Rate (ml/hour)
500 5
550 5.5
600 6
650 6.5
700 7
750 7.5
800 8
850 8.5
900 9
950 9.5
1000 10
1050 10.5
1100 11
1150 11.5
1200 12
1250 12.5
1300 13
1350 13.5
1400 14
1450 14.5
1500 15
1550 15.5
1600 16
1650 16.5
1700 17
1750 17.5
1800 18
1850 18.5
1900 19
1950 19.5
2000 20 Precautions:
Store between 15°-30°c. Protect from light. Do not refrigerate.
Do not administer IM due to pain, irritation and hematoma formation.
Heparin solutions are colorless to slightly yellow. Minor color variation do not affect therapeutic efficacy.
Stability:
Heparin stability after reconstitution: Not available.
References:
Product Information Heparinol.
Lexi-comp's Drug information Handbook, 13thEdition,Charles F, Lacy, et al. 2005.
32
AMPHOTERICIN B INJECTION (CONVENTIONAL) 50MG *NOT FOR LIPOSOMAL AMPHOTERICIN B
TO AVOID NEPHROTOXICITY:
Hydrate patient with 500ml NS before and after IV Amphotericin B.
If patient is unable to tolerate full fluid/sodium load: 250ml NS before and after IV
Amphotericin B.
If patient cannot tolerate fluid/sodium load: should not receive hydration.
TEST DOSE
1mg Amphotericin B in 20ml D5% over 30 mins
PRE-MEDICATION IS NOT REQUIRED
VITAL SIGNS SHOULD BE MONITORED every 30 mins for 2-4 hours
(BP, PR, RR, TºC)
Tolerance to the immediate reactions (fever +/- rigors) usually develops over time. Therefore, if
pre-medications are used early in the treatment course, their need should be re-evaluated and
withheld if the infusion-related adverse effects have resolved.
PRE-MEDICATION (when necessary)
(30 minutes before IV Amphotericin B)
1) IV Promethazine 12.5-25mg and/or 2) Tab. Paracetamol 1g and/or
3) IV Hydrocortisone 50mg
(* Hydrocortisone may potentiate Amphotericin B induced hypokalemia)
(**Hydrocortisone should not be prescribed to patients already receiving corticosteroids)
IV AMPHOTERICIN B
Dose: 0.5-1.5 mg/kg/day (adult) Infusion time: over 4-6 hours (rapid infusion is associated with hypotension, hypokalemia,
shock, arrhythmias)
Route of administration: < 0.1 mg/ml (peripheral infusion)
< 0.25 mg/ml (central line)
MONITORING PARAMETERS
Vital signs: blood pressure, pulse rate, respiratory rate, temperature
Serum electrolytes: K+, Mg2+ Others: Renal profile, liver function test, FBC, input/output
33
RECONSTITUTION
Dissolve 1 vial of Amphotericin B 50mg with 10ml Water For Injection
FURTHER DILUTION *For peripheral administration, concentration should not exceed 0.1mg/ml to
avoid phlebitis.
** Concentration ≥ 0.25mg/ml should be limited to patients requiring volume
contraction (central infusion only).
DILUTION TABLE
DOSE
(mg)
VOLUME OF RECONSTITUTED
AMPHOTERICIN B (ml)
FURTHER DILUTION WITH
DEXTROSE 5% UP TO TOTAL
VOLUME OF (ml)
1 (Test Dose) 0.2 20
5 1 250
10 2 250
15 3 250
20 4 250
25 5 500
30 6 500
35 7 500
40 8 500
45 9 500
50 10 500
NOTE: PRECIPITATION OF AMPHOTERICIN B WILL OCCUR IF
DILUTED WITH SALT SOLUTION (eg. NORMAL SALINE/HALF SALINE)
STABILITY AND STORAGE
Drug vial: 2-8ºC, protect from sunlight
Reconstituted vial: stable up to 7 days at 2-8ºC
Parenteral admixtures: Protect from light during administration, stable for 24 hours at RT,
2 days under refrigeration.
References:
1. AMPHOTRET leaflet, manufactured by Bharat Serums and Vaccines LTD, Lexi-Comp
34
Iron Injection
A.IRON DEFICIENCY ANEMIA Use Ganzoni Formula with Iron store
B. Iron replacement for blood lost:
If the volume of blood lost is known:
Iron to be replace (mg) = number of blood units lost* x 200
* 1 unit blood = 400ml with content of Hb 15g/dl (Product information leaflet)
If the volume of blood lost is unknown and Hb reduced:-
Use Ganzoni formula without iron store
Cosmofer(Iron (III)-hydroxide dextran complex) – 100mg/2ml
Method administration:-
** Children <14kg should not use. There is no documentation for efficacy and safety
Diluent: 0.9% NS or D5%
Low Dose (100-200mg)
1 IV Drip infusion 100-200mg dilute in 100ml by infusion over 30mins
2 IV Injection 100-200mg dilute in 10-20ml by slow IV injection (0.2mg/min)
3 Injection into
dialyzer
During HD, administered directly into the venous limb of the
dialyzer under the same procedures as outlined for 1&2
High Dose (more than 200mg)
4 Total Dose
Infusion
(Dose from calculation) dilute in 500ml by infusion over 4-6hours.
**If Total Dose more than 20mg/kg, the administration need to
be split into multiple weekly administration
Dose iron(mg)=[Bodyweight (kg)x(target Hb– actual Hb)(g/dL) x 2.4 ]+ iron store(mg)**
Type of patient Target (g/dL)
(Product Information leaflet)
Iron store(mg)**
<35kg 13 15mg/kg
>35kg 15 500mg
>90kg (Use Ideal
Body weight)
15 500mg
Ideal Body weight for men: 50kg + 2.3kg x (Height in Inch -60)
Ideal Body weight for women: 45.5kg + 2.3kg x (Height in Inch -60)
Should not be used during pregnancy unless clearly necessary
Ganzoni formula
TEST DOSE: 25mg infuse 15minutes or inject 1-2 minutes, then wait for 15 minutes
and give the remaining dose if no adverse reaction*.
35
Others
5 IM Total dose administration as a series of undiluted injections up to
100mg iron.
It should be inject ONLY into muscle mass of the upper outer
quadrant of buttock.
Moderately active patient = daily into alternate buttocks ;
Inactive or bedridden patient = once or twice weekly
using a 20-21 gauge needle at least 50mm for normal & 80-
100mm for obese; Small adults use 23 gauge x 32mm
Wait a few seconds before withdrawing needle and not encourage
to rub
*Caution: Patients should monitored for sign & symptoms of anaphylaxis, mild allergic reaction,
hypotension and extravasation during the infusion and for 30 mins after each administration
Venofer(IRON SUCROSE)- 100mg/5ml Method administration:-
Drip Infusion (preferred)
Dilution:-
1 amp in 100ml 0.9% NS infuse over 15 minutes
2 amp in 200ml 0.9% NS infuse over 30 minutes
3 amp in 300ml 0.9% NS infuse over 1.5 hours
4 amp in 400ml 0.9% NS infuse over 2.5 hours
5 amp in 500ml 0.9% NS infuse over 3.5 hours
Maximum tolerate dose
For patient >70kg is 500mg per week
For patient <70kg is 7mg/kg per week
If total required dosage exceeds maximum daily dose permitted, venofer must be administered
over multiple visits.
Undiluted Slow IV Injection
Slow IV injection <20mg iron per minute (maximum 200mg per injection)
*Venofer may be administered during a HD session directly into the venous limb of the dialyser
Maximum tolerate dose
up to a maximum three times per week
TEST DOSE:
Adult and children >14kg : 20mg infuse over 15minute or inject over 1-2minutes
Children <14kg : 1.5mg/kg infuse over 15minute or inject over 1-
2minutes
If no adverse reactions occur, give remaining portion as recommended speed
36
Antibiotic Lock Solutions: Lock Solution
Final Concentration
Preparation Instructions
1. Vancomycin 5mg/ml +
Heparin 2500units/ml 2, 3
Stability:
Physically compatible;
>90% of vancomycin
concentration retained
over 72hrs with
incubation at 37oC 9
i) Reconstitute Vancomycin 500 mg vial with 5 mL
sterile water for injection (standard concentration of 100
mg/mL)
ii) Withdraw 1 mL of 100mg/mL concentration & add
9mL of sodium chloride 0.9% solution resulting in a
concentration of 10mg/mL (as “Solution A”)
iii) Withdraw 2ml of Solution A & add 2 ml of Heparin
(5000units/ml) resulting in a final concentration of
5mg/ml (total volume 4ml)
Note:
*No issue on compatibility between Vancomycin & Heparin
*If a precipitate appears, continue agitating the solution for
about 10 seconds until the precipitation resolves
2. Vancomycin 2.5mg/ml +
Heparin 2500units/ml 4
Stability:
Solution remained clear
up to 72hours of
incubation 37oC 4
i) Reconstitute Vancomycin 500 mg vial with 10 mL
sterile water for injection (standard concentration of 50
mg/mL)
ii) Withdraw 1 mL of 50mg/mL concentration & add 9mL
sodium chloride 0.9% solution resulting in a
concentration of 5mg/mL (Label as “Solution A”)
iii) Withdraw 2ml of 5mg/ml Solution A & add 2 mL of
Heparin (5000units/ml) resulting in a final concentration
of 2.5mg/mL (total volume 4ml)
3. Gentamycin 5mg/ml +
Heparin 4375unit/ml
Stability:
No data
i) Withdraw 1mL of Gentamycin (80mg/2ml) & add 7mL
heparin (5000u/mL)
ii) Mix the solution well
Note: Protocol from HKL, used for all patients who are on
regular HD in HKL (include cuffed&non-cuffed catheters)
4. Gentamycin 1mg/ml +
Heparin 2500 unit/ml
Stability:
At lower concentration
(<4mg/mL), the solution
remained clear for up to
72hours of incubation at
37oC4
i) Withdraw 1mL of Gentamycin (80mg/2ml) & further
dilute with 19mL of NS for a final concentration of
2mg/ml. Label as “solution A”
ii) Withdraw 1.5mL of solution A (gentamicin 3mg)
iii) Add 1.5mL of heparin 5000units/mL to the 1.5mL of
solution A, for a total volume of 3mL
37
5. Ceftazidime 10 mg/ml +
Heparin 2500units/ml
Stability:
No data
i) Reconstitute Ceftazidime 2000 mg vial with 10 mL
sterile water for injection (standard concentration of 200
mg/mL)
ii) Withdraw 1 mL of 200mg/mL concentration & add
9mL sodium chloride 0.9% solution resulting in a
concentration of 20mg/mL (Label as “Solution A”)
iii) Withdraw 2ml of 10mg/ml Solution A & add 2 mL of
Heparin (5000units/ml) resulting in a final concentration
of 10mg/mL (total volume 4ml)
6. Ceftazidime 5mg/ml +
Heparin 2500units/ml
Stability:
No data
iv) Reconstitute Ceftazidime 2000 mg vial with 10 mL
sterile water for injection (standard concentration of 200
mg/mL)
v) Withdraw 1 mL of 200mg/mL concentration & add
19mL sodium chloride 0.9% solution resulting in a
concentration of 10mg/mL (Label as “Solution A”)
vi) Withdraw 2ml of 10mg/ml Solution A & add 2 mL of
Heparin (5000units/ml) resulting in a final concentration
of 5mg/mL (total volume 4ml)
7. Ceftazidime 2.5mg/ml +
Heparin 2500units/ml
Stability:
No data
i) Reconstitute Ceftazidime 2000 mg vial with 10 mL
sterile water for injection (standard concentration of 200
mg/mL)
ii) Withdraw 0.5 mL of 200mg/mL concentration & add
19.5mL sodium chloride 0.9% solution resulting in a
concentration of 5mg/mL (Label as “Solution A”)
iii) Withdraw 2ml of 5mg/ml Solution A & add 2 mL of
Heparin (5000units/ml) resulting in a final concentration
of 2.5mg/mL (total volume 4ml)
8. Ceftazidime 0.5mg/mL +
heparin 100units/mL 1,9
Stability:
Compatible and stable for
up to 7 days at 25 and 37oC,
confirmed via bioassay 1,9
i) Dilute 2000mg ceftazidime product with 20mL of NS,
for a concentration 100mg/mL – Label as “solution A”
ii) Remove 1mL of solurion A(Ceftazidime 100mg) and
further dilute with 19mL of NS to a solution 5mg/mL –
Label as “Solution B”
iii) Withdraw 1.5mL of solution B (ceftazidime 7.5mg) and
add 0.3mL of heparin 5000unit/mL.
iv) Further dilute with NS to final volume 15mL
9. Cefazolin 5mg/ml +
Heparin 2500units/ml 4,6
Stability:
i) Reconstitute Cefazolin 1000mg vial with 4mL sterile
water for injection (standard concentration of 200
mg/mL)
ii) Withdraw 1 mL of 200mg/mL concentration & add
19mL sodium chloride 0.9% solution resulting in a
concentration of 10mg/mL (Label as “Solution A”)
38
The solution remained
clear for up to 72 hours
of incubation at 37oC 4
iii) Withdraw 2ml of 10mg/ml Solution A & add 2 mL of
Heparin (5000units/ml) resulting in a final concentration
of 5mg/mL (total volume 4ml)
10. Ciprofloxacin
0.2mg/ml + Heparin
2500units/ml 7
Stability:
7 days at room temp 7
i) Withdraw 1mL of Ciprofloxacin Injection
(200mg/100mL) & add 4mL sodium chloride 0.9%
solution resulting in a concentration of 0.4mg/mL
(Label as “Solution A”)
ii) Withdraw 2ml of Solution A & add 2 mL of Heparin
(5000units/ml) resulting in a final ciprofloxacin solution
of 0.2mg/mL (total volume 4ml)
11. Ciprofloxacin
1mg/ml + Heparin
2500units/ml 9
Stability:
Compatible and stable
for up to 72hr at 37oC;
confirmed via bioassay 9
i) Withdraw 2mL of Ciprofloxacin Injection
(200mg/100mL) & add 2 mL of Heparin (5000units/ml)
resulting in a final ciprofloxacin solution of 1mg/mL
(total volume 4ml)
12. Ampicillin 10mg/ml
+ Heparin 2500units/ml 5
Stability:
Compatible at 4 and 37oC
for 14 days with heparin
sodium 10-5000
units/mL9
i) Reconstitute Ampicillin 500 mg vial with 10 mL sterile
water for injection (standard concentration of 50
mg/mL)
ii) Withdraw 2mL of 50mg/mL concentration & add 3mL
sodium chloride 0.9% solution resulting in a
concentration of 20mg/mL (Label as “Solution A”)
iii) Withdraw 2ml of 20mg/ml Solution A & add 2 mL of
Heparin (5000units/ml) resulting in a final concentration
of 10mg/mL (total volume 4ml)
Administration instructions:
1) Prior to installation of antibiotic, withdraw contents from catheter lumen
2) Flush catheter with normal saline
3) Instill antibiotic lock solution to fill catheter lumen
4) Label the catheter “DO NOT USE –antibiotic Lock’
5) Allow lock solution to dwell for a period of time specified by the physician order
6) After dwell time is complete, aspirate antibiotic lock solution from catheter lumen
7) Flush catheter with normal saline before using line to administer medication or perform dialysis.
39
References:
1. Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines for the diagnosis and management of
intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America. Clin
Infect Dis. Jul 1 2009;49(1):1-45.
2. Lee JY, Ko KS, Peck KR, Oh WS, Song JH. In vitro evaluation of the antibiotic lock technique (ALT)
for the treatment of catheter-related infections caused by staphylococci. J Antimicrob Chemother
2006;57:1110–5.
3. Vercaigne LM, Sitar DS, Penner SB, Bernstein K, Wang GQ, Burczynski FJ. Antibiotic-heparin lock: in
vitro antibiotic stability combined with heparin in a central venous catheter. Pharmacotherapy 2000;
20:394–9.
4. Krishnasami Z, Carlton D, Bimbo L, et al. Management of hemodialysis catheter-related bacteremia with
an adjunctive antibiotic lock solution. Kidney Int 2002;1:1136–42
5. Robinson JL, Tawfik G, Saxinger L, Stang L, Etches W, Lee B. Stability of heparin and physical
compatibility of heparin/antibiotic solutions in concentrations appropriate for antibiotic lock therapy. J
Antimicrob Chemother 2005; 56:951–3
6. Vercaigne LM, Sitar DS, Penner SB, Bernstein K, Wang GQ, Burczynski FJ. Antibiotic-heparin lock: in
vitro antibiotic stability combined with heparin in a central venous catheter. Pharmacotherapy 2000;
20:394–9.
7. Droste JC, Jeraj HA, MacDonald A, Farrington K. Stability and in vitro efficacy of antibiotic-heparin
lock solutions potentially useful for treatment of central venous catheter-related sepsis. J Antimicrob
Chemother 2003; 51:849–55 8. Jacobs J, Kletter D, Superstine E, Hill KR, Lynn B, Webb RA. Intravenous infusions of heparin and
penicillins. Journal of clinical pathology. Oct 1973;26(10):742-746.
9. Bookstaver P.B, Rokas K.E.E, Norris L.B,et al. Stability and compatibility of antimicrobial lock solutions.
Am J Health-Syst Pharm . Vol 70 Dec 15, 2013
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