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PHARMACEUTICAL ASPECTS OF

IV MEDICATIONS

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AIMS AND OBJECTIVES

• Rationale for IV use• Advantages and disadvantages of IV therapy• Roles and Responsibilities• Considerations for IV therapy

» Prescribing» Preparing» Administering» Monitoring

• National and Local Policies• Calculations

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THE FIVE RIGHTS OF MEDICINE ADMINISTRATION

1. Right patient2. Right medicine3. Right route4. Right dose5. Right time

……every time!

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WHY IV?

Oral or other route of administration not suitable or availablee.g. vomiting, diarrhoea, malabsorption, resting gastro-intestinal tract, low muscle mass

Where rapid effect or high/predictable concentrations essential

Medicine not effective via other routes e.g. gentamicin, benzylpenicillin

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ADVANTAGES

Medicine gets into the circulation quickly

Rapid effect achieved

Predictable concentrations achieved i.e. 100% reaches systemic circulation

Some medicines cannot be given by another route e.g. gentamicin and meropenem

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DISADVANTAGES

Risk of Infection

Severity of side effects

Multiple steps in preparation

Increased cost and nursing time

Increased complications e.g. extravasation, emboli, anaphylaxis reactions

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IV THERAPY INCIDENTS/REPORTS

Published in The Times 18th May 2010 Hospital is fined £100,000 over death of mother in drugs mix-up Patient died hours after her son was born when a nurse at the

Great Western Hospital in Swindon, Wiltshire, wrongly attached an epidural anaesthetic Bupivacaine to her intravenous drip instead of a saline solution.

NRLS incident reports 2005 -2006 24% of total medication incidents reported related to IV

medications. 93% of IV medication incidents reported to the NPSA were

prescribing, administration or preparation errors. 25 incidents of death reported to NPSA from IV medication

incidents between Jan 2005 – June 2006.

NPSA Patient Safety Alert 20 – Promoting Safer use of injectable medicines

Highlights actions to be taken by healthcare providers to ensure safe and effective IV medication use.

All healthcare providers have to comply with guidance.

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PROFESSIONAL RESPONSIBILITY

Prescription is clear, unambiguous and legal Medicine is essential and appropriate Dose, route and rate is appropriate Medicine is compatible with infusion fluid Patient is not allergic to prescribed medication Appropriate monitoring requirements are in

place e.g. ECG machine for potassium infusions

Prescriber and Administrator

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PROFESSIONAL RESPONSIBILITY

Must have completed IV Medicines Training, be certified competent and be aware of own limitations

Must not administer a drug if doubtful about any aspect of IV medicine prescription / calculation / preparation / compatibility / administration / monitoring

Must ensure that appropriate and current information sources are used

Nurse

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PROFESSIONAL RESPONSIBILITY Legal responsibility

Specialist knowledge

Access to specialist and up to date information

Can advise and provide support on any aspect of IV medicine use i.e. dose, calculations, method and rate of administration, diluents, stability and incompatibilities

Can provide advice via ward pharmacist or on-call pharmacist

Pharmacist

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CONSIDERATIONS FOR IV THERAPY DOSE, ROUTE AND RATE

Is the dose appropriate for the IV route

Is the route suitable for the medicine and required rate?

Is the expected duration of treatment specified and/or appropriate?

Properties of the medicine? e.g. osmolarity, pH, irritant, short half life

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CONSIDERATIONS FOR IV THERAPY CONCENTRATION, DILUENT AND VEHICLE

Concentration Check that the concentration of the drug is within the

recommended range for safety and efficacy and method of administration.e.g. erythromycin must be between 1-5mg/ml

Diluent and Vehicle Not always the same! !ALWAYS CHECK!

e.g. clarithromycin must be reconstituted with water but diluted in sodium chloride 0.9%

Often used interchangeably by most staff i.e. most refer to both as diluent.

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CONSIDERATIONS FOR IV THERAPYCOMPATIBILITY

Incompatibility occurs after mixing parental drugs if one or all of them become less effective. Changes that occur include:

Physical incompatibility e.g. precipitation, crystallisation, cracking e.g. TPN

Largely determined by pH and formulation

Chemical incompatibility e.g. degradation, inactivation or a new compound formed Chemical reaction between drugs

Never add medicines to fluid unless compatibility assured

Never mix medicines together unless compatibility assured

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CONSIDERATIONS FOR IV THERAPYCOMPATIBILITY

Caspofungin is incompatible with diluents containing glucose

Erythromycin must be diluted to 5mg/ml for peripheral use

Phenytoin is given as undiluted bolus into a large vein or as an infusion diluted in NaCl 0.9%, can easily participate thus in- line filter is necessary

Vitamin K flush with glucose

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Factor Effect Action Example

Light rate of degradation Ensure appropriate storage

TPN, Pabrinex®

Temperature rate of degradation / microbial growth

Ensure appropriate storage

Aciclovir, TPN

pH rate of degradation Add buffer Phenytoin (in glucose 5%)

Concentration Less stable at changes in

concentration

Check volume Amiodarone, Amphotericin

Adsorption Drug loss into plastic/glass

Avoid or minimise contact

Insulin, Nitrates e.g. GTN

Preparation: Factors Affecting Stability

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DISPLACEMENT VOLUMES AND PH

Displacement volume Volume of fluid displaced by a powder when reconstituted Important when part-vials are used Mainly only relevant to paediatrics

pH Most medicines are stable at a specific pH Rate of degradation often pH dependent

e.g. amphotericin requires glucose pH>4.2

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LABELLING

When drugs are added to burettes, syringes or IV bags, the container must be clearly labelled with following:

Drug added Dose added Date and time of addition Signature of practitioner

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RATE OF ADMINISTRATION

Most IV bolus injections over at least 3-5 minutes 95% of IV bolus injections given too fast!!!!!!! Ensure device is capable of accurate delivery and

desired infusion rate

Systemic damage Furosemide ototoxicity Phenytoin arrhythmias Ranitidine bradycardia Vancomycin red man syndrome

Local damage Pain Extravasation Phlebitis

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MONITORING

• Extravasation

• Phlebitis more likely with• Irritants • Hypertonic solutions • Highly acidic solutions• Alkaline solution

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SOURCES OF INFORMATION

IV Drug Monographs/ Medusa website (http://www.injguide.nhs.uk/logon.asp)available on grapevine with log in details

BNF/BNFC Product Information Leaflet Medicines Information Pharmacist On-call Pharmacist University College London Hospitals Injectable Medicine

Administration Guide

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REMEMBER

If in doubt, don’t administer!

Most important consideration is the PATIENT They have to suffer the consequences

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CALCULATIONS

• 1gram (g) = 1000 milligrams (mg)

• 1milligram(mg) = 1000micrograms(mcg)

• 1microgram(mcg) =1000nanograms(ng)

• E.g. Digoxin 250mcg = 0.25mg

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CALCULATIONS

• 1:1000 means 1g in 1000ml

• How much adrenaline is there in 0.5ml if the strength you have is 1:1000

1:1000 = 1g in 1000ml» 1000mg in 1000ml» 1mg in 1ml» 0.5mg in 0.5ml

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CALCULATIONS

• A 6 year old boy (20kg) must receive a morphine infusion at a dose of 10mcg per kg per hour. The syringe is labelled 25mg in 50mls. What rate should infusion pump be set at?

--------------------------------------------------------------------------------------------------------------------------------- 1. We need: 10mcg/kg/hour

We have: 25mg in 50mls--------------------------------------------------------------------------------------------------------------------------------- 2. The boy weighs 20kg we need to calculate the total dose for his weight : 10 mcg x 20 kg/hour=200mcg/hour--------------------------------------------------------------------------------------------------------------------------------- 3. We need to give 200mcg/hour and the syringe is labelled in milligrams:

1000mcg=1mg 200mcg/hour= 0.2mg/hour --------------------------------------------------------------------------------------------------------------------------------- 4. We have got syringe with 25mg in 50ml, we need to calculate in what volume is 0.2mg. 25mg…………..50ml 0.2mg …………..Xml 0.2 X= ---------- x 50 =0.4ml 25--------------------------------------------------------------------------------------------------------------------------------- 5.The infusion pump should be set in 0.4ml/hour.

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CALCULATIONSDobutamine 250mg amp is diluted to a total of 50ml normal saline. A patient weighing 60kg

must receive 5mcg/kg/min. How many mls per hour would you give the patient?-----------------------------------------------------------------------------------------------------------------------------------------1. We need: X mls/hour We have: 250mg in 50ml-----------------------------------------------------------------------------------------------------------------------------------------2. The patient is 60kg, we need to calculate the total dose for his weight: 5mcg x 60 / min = 300mcg/min-----------------------------------------------------------------------------------------------------------------------------------------3. Our result needs to be per hour and the dose is per minute: 300mcg / min x 60 = 18 000 mcg/hour-----------------------------------------------------------------------------------------------------------------------------------------4. Dobutamine is available in mg and our dose is in mcg: 1000mcg = 1mg 18000mcg/hour = 18mg/hour---------------------------------------------------------------------------------------------------------------------------------------5. Ampoules available are 50ml, we have to calculate the dose per 1ml 250mg in 50ml 250 ? in 1ml ------------ = 5mg 50 ----------------------------------------------------------------------------------------------------------------------------------------6. We have solution with 5mg in 1ml and need to give 18mg /hour. How many mls per hour do we give? 5ml …………1ml 18 18mg………….Xml X = -------- = 3.6ml /hour 5----------------------------------------------------------------------------------------------------------------------------------------7.We need to give to patient 3.6ml/per hour of our Dobutamine.

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QUESTIONS?