jabatan farmasi hospital raja permaisuri bainun ipoh

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:


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)


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.


If higher concentration is used, > 500mg dobutamine in 50ml diluents of infusion, it should protect

from light and administer through central line.


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


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





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


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





References:



5

(Medical)

NORADRENALINE (4mg/4ml)

Dose:

0.01 - 2mcg/kg/min

Dilution:

4mg In 50ml Dextrose 5%

SINGLE STRENGTH


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).


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:


SINGLE STRENGTH


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).



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:


Precautions: Dopamine should be diluted before administration.


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)



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:


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)



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)



Stability:


References:


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


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



Stability:


References:


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


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



Stability:


References:


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:


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



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)


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


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.


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


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.



ISOPRENALINE Indication:

HEART BLOCK

Dose:

2 - 10mcg /min

Dilution:


DOUBLE STRENGTH

16


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


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:


Frusemide


added (ml)

Total Volume

(ml)

5 ampoules (100mg)

-10ml 40ml 50ml



(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.


4. Lexi-Comp’s Drug Information Handbook 12th edition, Charles F. Lacy.et.al, 2004.

18


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:


Labetalol


added (ml)

Total Volume

(ml)

4 ampoules ( 100mg) - 20ml 30ml 50ml

8 ampoules (200mg) - 40ml 60ml 100ml


Dextrose 5%,

Dextrose 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


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.


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:


Salbutamol


added (ml)

Total Volume

(ml)

3 ml ( 3mg) 47ml 50ml


Dextrose 5%,

Dextrose 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:


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%.


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.


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




50 13 ml 9 ml/hour 7 ml 4.5 ml/hour

55 15 ml 9.9 ml/hour 8 ml 5 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



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



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


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


mg/mL)


9mL sodium chloride 0.9% solution resulting in a




of 10mg/mL (total volume 4ml)

6. Ceftazidime 5mg/ml +


Stability:

No data

iv) Reconstitute Ceftazidime 2000 mg vial with 10 mL


mg/mL)

v) Withdraw 1 mL of 200mg/mL concentration & add



vi) Withdraw 2ml of 10mg/ml Solution A & add 2 mL of



7. Ceftazidime 2.5mg/ml +


Stability:

No data

i) Reconstitute Ceftazidime 2000 mg vial with 10 mL


mg/mL)

ii) Withdraw 0.5 mL of 200mg/mL concentration & add

19.5mL sodium chloride 0.9% solution resulting in a





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)




38

The solution remained

clear for up to 72 hours

of incubation at 37oC 4




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


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





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

40

jabatan farmasi hospital raja permaisuri bainun ipoh

Documents