Procedures For Administering Injectable Drugs: Version No 2

This procedure is adopted for PCH staff from:
Plymouth Community Healthcare CIC
Procedures for Administering Injectable

Drugs
Version No 2
Notice to staff using a paper copy of this guidance
The policies and procedures page of Intranet holds the most

recent version of this guidance. Staff must ensure they are
using the most recent guidance.
Author: Advanced Specialist Clinical Pharmacist

Adults and Older People
Asset Number: 385
Page 1 of 201
Procedures for Administering Injectable Drugs
Date Version
December 2013 Issue 9
Purpose
The purpose of this document is to inform Trust staff of the correct and safe methods of preparation
and administration of injectable drugs. It includes information on the use of infusion devices.
Who should read this document?
All staff working for or on behalf of Plymouth Hospitals NHS Trust who prepare and administer fluids
and drugs by injection or infusion.
Key messages
Staff working for or on behalf of Plymouth Hospitals NHS Trust who prepare and administer fluids and
drugs by injection or infusion must do so in accordance with these procedures.
Accountabilities
Production Peter Gray, Pharmacist
Review and approval Medicines Governance Committee
Ratification Medicines Governance Committee
Dissemination Peter Gray, Pharmacist
Compliance Medicines Governance Committee
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Links to other policies and procedures
Pharmacy documents available on PHNT StaffNet
• PHNT Medicines Management Policy
• SOPs for preparing and administering intravenous medicines and fluids.
• SOPs for the management of phlebitis, infiltraton, air embolism, speedshock and extravasation.
• SOPs for the safe handling and administration of injectable cytotoxic drugs.
• SOP for setting up and maintaining variable rate intravenous insulin infusions.
PHNT Vascular Access Documents:
• Administration of Medication through a Central Venous Catheter (CVC)
• Removal of a Central Line
• PHNT Central Vascular Access Guidelines
PHNT Infection Control Documents:

• Guidelines for the Management of Peripheral Intravenous Devices
• Guidelines for the Management of Central Intravenous Catheters
• Hand Hygeine Guidelines
• Guidelines for Aseptic Technique
• Safe Disposal of Sharps Policy
Other Documents:
• Royal College Nursing Standards for Infusion Therapy, 2010
• Department of Health High Impact Intervention Care Bundles for-
• Central venous catheter care
• Peripheral intravenous cannula care
• Renal haemodialysis
• Cleaning and decontamination
• Blood Cultures
• The Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and
related guidance (published 14 Dec 2010),
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Version History
Issue 6 November 2010
Issue 7 December 2011
• Appendix 1: protocol added for non-medical staff to assess a patient and administer IM
adrenaline without a prescription to an adult or child with anaphylaxisis.
• Alteplase monograph(for acute myocardial infarction):Concurrent use of IV heparin clarified.
• Enoxaparin no longer needs monitoring of platelet count at Day 4-7 & Day 10-14.
• Botulinum toxin: vial sharing in clinincs/day-case has been risk-assessed and sanctioned by
the Medicines Governance Committee. Stipulations in the monograph must be followed.
• Ergocalciferol Injection: New monograph providing advice on using green B.Braun syringe.
• DigiFab® replaces Digibind® which is now discontinued. Do not give DigiFab® via a filter.
• Ferinject®: Added to the Formulary. New monograph inserted.
• Filgrastim (Zarzio®): Added to the Formulary. New monograph inserted.
• Folinic acid monograph re-inserted.
• Instructions for preparing and giving 3g IV ceftazidime and 1g vials of Fosfocina®
(Fosfomycin) added to the respective monographs.
• Glucose 10% with Actrapid to treat hyperkalaemia: Need to use 29 gauge Magellan 12.7mm
Insulin Safety Syringe to penetrate the rubber port on the bag of glucose.
• Insuman® and Apidra® insulin monographs inserted.
• Intravenous Iron preparations: All monographs amended to include instruction to observe
closely for signs of hypersensitivity during and for at least 30 minutes after each injection or
infusion.
• Venofer® (Iron Sorbitol): Test dose no longer recommended.
• Ketamine for post-op analgesia: Rate reduced to 1-2ml/hour (100-200mcg/kg/hr).
• Metoclopramide IV bolus is now recommended over at least 3 minutes.
• Ondansetron: Due to the risk of QT-interval lengthening and subsequent Torsade-de-
Pointes, 8mg dose must be infused over 15 minutes in patients aged 65 and older, and 16
mg dose (by infusion only) is only allowed for patients younger than 75.
• Piperacillin/Tazobactam: Slow IV bolus is no longer recommended or licensed. Infuse this
over 30 minutes to achieve optimal MICs.
• Epoprostenol: Monograph now makes reference to the ICU protocol.
• Additional route (subcutaneous injection) added for alemtuzumab post kidney
transplantation.
• CSM Black Triangle status has been removed from a number of injectable medications.
Last Approval Due for Review
December 2013 December 2014
• PHNT is committed to creating a fully inclusive and accessible service.

• Making equality and diversity an integral part of the business will enable us to enhance the services we
deliver and better meet the needs of patients and staff.
• We will treat people with dignity and respect, actively promote equality and diversity, and eliminate all
forms of discrimination regardless of (but not limited to) age, disability, gender reassignment, race,
religion or belief, sex, sexual orientation, marriage/civil partnership and pregnancy/ maternity. Larger text,
Braille and Audio versions can be made available upon request.
An electronic version of this document is available on PHNT StaffNet > Departments > Clinical
support Services > Pharmacy > Injectable Medicines > “Procedures for Administration of Injectable
Drugs”
Alternatively copy the link into your internet browser:
http://StaffNet.plymouth.nhs.uk/Portals/1/Documents/Department%20Documents/Surgery/Critical%
20Care/Monographs%20for%20IV%20Drug%20Administration%20Version%208%202012%20Jun
e%202013.pdf
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Contents
Section Page
1.1 Injectable Drug Monographs 7
Chart of Injectable Drug Compatibilities 184
PHNT Analgesic ladder 185
PHNT Protocol for administering IV morphine to adults in Acute Care Areas 186
PHNT Protocol for administering IV morphine to adults in the Emergency Dept. 187
1.2 Management of Anaphylaxis 188
Appendix 1 Protocol for administering intramuscular adrenaline 1:1000 (1mg/ml) for treating
anaphylaxis, when there is no prescription available
A1.1 Legislation 189
A1.2 Persons who can be treated under this protocol 189
A1.3 Anaphylaxis 190
A1.4 Assessing the patient 190
A1.5 Explanation of treatment to the patient 191
A1.6 Patient consent 191
A1.7 Exclusions from treatment under this protocol 191
A1.8 Contra-indications to administration of adrenaline to treat anaphylaxis 191
A1.9 Immediate treatment 191
A1.10 Source of adrenaline 191
A1.11 Dosage of adrenaline 192
A1.12 Adverse Effects 192
A1.13 Follow up 192
A1.14 Documentation 192
A1.15 References 192
A1.16 Anaphylaxis algorithm 193
Appendix 2 Choice of Infusion device
A2.1 Introduction 194
A2.2 Choice of Infusion device 194
A2.3 Additional Information 196
A2.4 References 196
Appendix 3 Copy of PHNT Policy for maintenance of patency, flushing and locking of
intravascular lines catheters or devices
A3.1 Introduction 197
A3.2 Policy 197
Appendix 4 Document accountability, responsibility and dissemination
A4.1 Accountability 199
A4.2 Overall Responsibility for These Policies and Guidelines 199
A4.3 Dissemination and Implementation 199
1.1 Injectable Drug Monographs
All monographs contained in this section are the current versions as of the time of going to print and are
listed in alphabetical order according to generic name.
Detailed guidance for the administration of cytotoxic drugs is not given in the monographs, but should
be obtained from the appropriate ward or unit protocol.
Unlicensed use of medications
Where in the monographs the use of a drug is noted to be unlicensed, this either refers to the drug
formulation itself not having a UK product licence or where the indication, dosage, dilution or rate of
administration fall outside of the UK product licence.
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When an unlicensed medication is administered to a patient or a licensed medication is administered in
an unlicensed manner the prescribing doctor takes full responsibility for any adverse consequences.
Important notes
• Intravenous fluids and drug solutions prepared in clinical areas must be changed every
24 hours unless otherwise specified in the drug monograph. This includes infusions such
as Patient Controlled Analgesia (PCA) and sliding-scale insulin.
• Unless described in the drug monograph as “Multidose” all injectable products, including
bags of sodium chloride 0.9% and 5% glucose must be treated as single use only and
disposed of immediately after use.
• Any infusion containing drug(s) or potassium or any other additive must be administered
using an infusion pump.
• Dosiflows or other gravity-fed administration sets must only be used for administering
crystalloid infusions (eg. Sodium chloride infusion or glucose infusion) containing no
potassium or other additives.
• For patients on a sliding-scale insulin infusion and glucose infusion, the glucose must
be infused using a volumetric pump.
• Always read the label on the ampoule, syringe or box. Do not rely on familiar colours or shapes
of packaging to correctly identify medication.
• Always label an IV container or syringe containing drug or added electrolytes for infusion with a
completed “IV Additive Label”.
• All syringes containing drawn-up medication or flushing solution must be labelled with name of
medicine or flushing solution and the dose/strength, unless the risk of doing so (eg
contaminating a sterile field) is perceived by the individual practitioner to outweigh the risk of
mis-identifying un-labelled syringe(s). The individual practitioner is then responsible for ensuring
that any un-labelled syringes are not mis-identified. Labels for this purpose (Code QC31) can
be ordered from Pharmacy.
• Drug solutions that have been drawn up or prepared in clinical areas must be administered
immediately after preparation or drawing up.
• All the intravenous medications listed in the Section 4 monographs may be given via a
peripheral cannula or a central venous cannula, unless the monograph specifically says that a
particular drug or drug concentration must only be given via a central venous cannula.
• If you require information on intravenous compatibilities; contact Pharmacy Drug Information on

Ext. 39976.
• ♠ Groups of staff allowed to administer injectable medications which are referred to in the
monographs:
Group 1
o Registered and Provisionally Registered Medical Practitioners. It is recommended that IV

drugs are checked by a second person either another medical practitioner or a registered
healthcare professional before administration.
Group 2
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o Registered Nurses, Midwives and Operating Department Practitioners (ODP’s) who have
undertaken the Plymouth Hospitals NHS Trust IV drug administration training (or satisfy the
criteria for new employees from outside the Trust), and have been assessed as competent.
Group 2 can administer to adult patients only. Another Registered healthcare professional
should check all aspects of the administration with this Nurse or Midwife. Cytotoxic IV
drugs are NOT to be administered by this group.
o Exceptions are methotrexate are cyclophosphamide, which can be administered by this
group if the practitioner has previous experience of administering parenteral cytotoxics.
Group 3
o Nurses who qualify for Group 2, working in identified specialist areas, and have undertaken
additional training and assessment to administer cytotoxic IV drugs.
Group 4
o A Registered Sick Children's Nurse (RSCN) or Registered Nurse (Part 15 - Child Branch)
working in the paediatric field who qualifies for inclusion in Group 2.
o The exception is for staff who work regularly in the Emergency Department, Intensive Care
Unit, Theatres, Maternity and Neonatal Intensive Care Unit, who can administer Group 2
drugs to paediatric patients, providing they are familiar with the drug and the calculation (if
any) required.
Group 5
o Nurses who qualify for Group 4 and have undertaken additional training and assessment to
administer cytotoxic drugs.
Group 6
o Named Individual Radiographers/Sonographers who have completed and passed an

accredited training programme in the administration of IV drugs may administer named
contrast media, Hyoscine Butylbromide, Sodium Chloride 0.9% and Glucagon via the IV
route according to the department’s authorised and signed patient group direction.
Group 7
o Named and authorised technical, scientific and delegated medical staff of the department of
Nuclear Medicine who have the appropriate training required by IR(ME)R 2000 to
administer radiopharmaceuticals and who have completed an accredited course in IV drug
administration or equivalent. Such individuals may administer named drugs and
radiopharmaceuticals by IV route according to the department’s authorised and signed
patient group direction (PGD).
o All Registered healthcare professionals must be assessed as competent in the methods

required for administration as advised in section 4 monographs. If they have not been
assessed as competent with the administration method, e.g. using a central line, or aseptic
non-touch technique they must not proceed.
o All training and assessment of competency to administer intravenous medication should

include training and assessment of aseptic non-touch technique and administration via
central vascular access devices. For more information or training please contact the
Learning and Development Facilitator.
Abbreviations used in the drug monographs
(C) Continuous
(I) Intermittent
IV Intravenous
IM Intramuscular
SC Subcutaneous
N/S Sodium Chloride 0.9%
G Glucose 5%
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G/S Glucose 4% and sodium chloride 0.18%. Other combinations of glucose and sodium
chloride may not be compatible with the drugs listed in Section 4 – contact Pharmacy for
advice on ext.39976.
H Compound sodium lactate (Hartmann’s)
Hep/S Heparin 10 units in 1ml sodium chloride - heparinised sodium chloride (e.g. Hepsal)
W Water for Injection (preservative free)
Page 8 of 201
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE SUITABLE DILUENT
Abatacept (I) IV infusion via a ♠ Groups Infuse all doses over 30 Reconstitute each 250mg vial with Monitor blood pressure (increase in
(Orencia®) pump. 1 and 2 minutes 10ml W using the silicone-free syringe BP is common), pulse and
provided. Direct the stream of W down temperature. Monitor for allergic
Infuse via a non- the inside wall of the glass vial. reactions (rare) and rash (common).
pyrogenic low Minimise foam formation by rotating the Check LFTs (ALT and AST
protein binding vial slowly with gentle swirling to commonly raised).
filter (0.2-1.2 dissolve the powder. Do not shake. If any serious allergic or
microns) After dissolution, vent the vial with a anaphylactic reaction occurs
needle to dissipate any foam that may discontinue the infusion immediately
be present. Remove a volume of N/S and initiate appropriate therapy.
from a 100ml bag N/S equal to the Do not mix with any other drug
volume of reconstituted vials. Slowly solutions.
add the reconstituted solution from 0.375mmol sodium per 250mg vial
each vial to the infusion bag using the Flush with N/S.
same silcone-free syringe. Gently mix.
Abciximab Initial IV bolus ♠ Groups 1 minute Inject 5ml of air into the vial before For stabilisation of unstable angina,
1 and 2 withdrawing the solution. Use the 20ml bolus dose followed by the infusion
syringe to draw up sufficient volume for is started up to 24 hours prior to PCI
both the bolus and 12-hour infusion. and concluded 12 hours after PCI.
Connect the 0.2 or 0.22 micron filter For other patients bolus is given 10-
and connector provided. Draw the 60 minutes prior to PCI followed by
volumes necessary for the bolus dose the infusion for 12 hours.
and infusion into two separate syringes Do not shake unused vials.
through the connector. Flush: N/S or G.
(C) IV infusion via ♠ Groups 4ml/hour for 12 hours See Filter Pack for nomogram. Either Do not infuse with any other drugs.
pump immediately 1 and 2 (50ml syringe driver) or dilute the volume drawn up for infusion
following initial IV 19ml/hour for 12 hours with N/S or G to make 50ml or add the
bolus. (250ml infusion bag) drawn up volume to 250ml of N/S or G.
Acetazolamide IV bolus ♠ Groups Suggested maximum Reconstitute each 500mg with at least Flush with N/S or G.
1 and 2 100-500mg/minute 5ml W. Extravasation may cause tissue
damage.
• Intravenous fluids and drug solutions must be changed every 24 hours unless otherwise specified in the drug monograph. 9
• Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
• For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines http://nww.swretrieval.nhs.uk/DI_ALL.htm - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children (www.bnfc.org) or the Neonatal Formulary.
• For more detailed information refer to the current BNF (www.bnf.org ). For full details of the licensed indications, dosage, contraindications and side effects refer to
www.medicines.org.uk
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 9, December 2013
Acetylcysteine (C) IV infusion ♠ Groups 1 Treatment of paracetamol overdosage: A change in colour of solutions of
Infusion pump and 2 three consecutive infusions as detailed in acetylcysteine to light purple is
is required. the table below (For treating children insignificant.
<40kg follow the instructions on the next Flush with G or N/S.
2 pages). Sodium content 12.78mmol/10ml
(C) IV infusion ♠ Groups 1 On ICU or HDU acetylcysteine may be .
via central line and 2 infused in smaller volumes of G or
Infusion pump undiluted if necessary (unlicensed - see
is required. page 1) via a central IV line. However the
hourly infusion rate (ml/hour) will be
different to the figure in the table below.
Adult Dosage Table for Treating Paracetamol Overdose

Regimen First Infusion Second Infusion Third Infusion
Infusion Fluid 200ml G (or 200ml N/S if G is unsuitable) 500ml G (or 500ml N/S if G is unsuitable) 1000ml G (or 1000ml N/S if G is unsuitable)
Duration of 1 hour 4 hours 16 hours
Infusion
Drug Dose 150mg/kg 50mg/kg 100mg/kg
Patient’s weight Grams of Volume (ml)2 of Infusion rate Grams of Volume (ml)2 of Infusion Grams of Volume (ml)2 of Infusion
(kg)1 acetylcysteine acetylcysteine to (ml/hour) acetylcysteine to acetylcysteine to rate acetylcysteine acetylcysteine to rate
to prescribe add to 200ml fluid prescribe add to 500ml fluid (ml/hour) to prescribe add to 1000ml fluid (ml/hour)
40 - 49 6.8 34 234 2.4 12 128 4.6 23 64
50 - 59 8.4 42 242 2.8 14 129 5.6 28 64
60 - 69 9.8 49 249 3.4 17 129 6.6 33 65
70 – 79 11.4 57 257 3.8 19 130 7.6 38 65
80 – 89 12.8 64 264 4.4 22 131 8.6 43 65
90 – 99 14.4 72 272 4.8 24 131 9.6 48 66
100 – 109 15.8 79 279 5.4 27 132 10.6 53 66
≥ 110 16.6 83 283 5.6 28 132 11 55 66
1
Dose calculations are based on the weight in the middle of each band. If the patient weighs less than 40kg use the paediatric dosage table.
2
Ampoule volume has been rounded up to the nearest whole number.
Acetylcysteine for treating paracetamol overdose in Children
Children are treated with the same doses and regimen as adults. However, the quantity of intravenous fluid used has been modified to take into account age and weight,
as fluid overload is a potential danger. Doses should be administered sequentially using an appropriate infusion pump.
Preparation and administration of paediatric infusions

• Weigh the child to determine the correct weight band.
• Read off the table (on the next page) the total infusion volume required for each dose according to the weight of the child and make up the solutions according to the
directions below.
First Infusion
• Prepare the appropriate volume for the weight of the child.
• Prepare a 50 mg/mL solution by diluting acetylcysteine (200 mg/mL) with glucose 5% (preferred) or sodium chloride 0.9% as follows:
Weight 1-14kg add 10mls of acetylcysteine to 30ml of diluent
• The dose is infused over 1 hour at the infusion rate stated in the table (equiv to 3ml/kg/hour).
Second Infusion
• Prepare the appropriate volume for the weight of the child.
• Prepare a 6.25 mg/mL solution by diluting acetylcysteine (200 mg/mL) with glucose 5% (preferred) or sodium chloride 0.9% as follows:
Weight 1-9kg add 8mls of acetylcysteine 200mg/ml to a 250ml bag
• The dose is infused over 4 hours at the infusion rate stated in the table (equiv to 2ml/kg/hour).
Third Infusion
• Use the solution prepared under second infusion above.
• The dose is infused over 16 hours at the infusion rate stated in the table (equiv to 1ml/kg/hour).
For example for a child weighing 12 kg, the first infusion would be 38 mL infused at 38 mL/h over 1 hour,the second infusion would be 100 mL infused at 25 mL/h over 4
hours and the third infusion is 208 mL infused at 13 mL/h over 16 hours.
• Weigh the child and prepare the infusion as instructed on the previous page.
Paediatric Dosage Table for Treating Paracetamol Overdose
Regimen First Infusion Second Infusion Third Infusion
Infusion 50mg/ml for 1 hour 6.25mg/ml for 4 hours 6.25mg/ml for 16 hours
Infusion rate 3ml/kg/hour 2ml/kg/hour 1ml/kg/hour
Patient’s weight1 Dose of Total infusion Infusion rate Dose of Total infusion Infusion rate Dose of Total infusion Infusion rate
(kg) acetylcysteine volume (ml/hour) acetylcysteine volume (ml/hour) acetylcysteine volume (ml/hour)
to prescribe (ml) to prescribe (ml) to prescribe (ml)
1 150mg 3 3 50mg 8 2 100mg 16 1
2 300mg 6 6 100mg 16 4 200mg 32 2
3 450mg 9 9 150mg 24 6 300mg 48 3
4 600mg 12 12 200mg 32 8 400mg 64 4
5 750mg 15 15 250mg 40 10 500mg 80 5
6 900mg 18 18 300mg 48 12 600mg 96 6
7 1.05g 21 21 350mg 56 14 700mg 112 7
8 1.2g 24 24 400mg 64 16 800mg 128 8
9 1.35g 27 27 450mg 72 18 900mg 144 9
10-14 1.9g 38 38 625mg 100 25 1.3g 208 13
15-19 2.65g 53 53 875mg 140 35 1.8g 288 18
20-24 3.4g 68 68 1.125g 180 45 2.3g 368 23
25-29 4.15g 83 83 1.375g 220 55 2.8g 448 28
30-34 4.9g 98 98 1.625g 260 65 3.3g 528 33
35-39 5.65g 113 113 1.875g 300 75 3.8g 608 38
1
Dose calculations based on the weight in the middle of each band. If the patient weighs more than 40kg use the adult dosage table. Figures have been rounded up to
the nearest whole number.
Aciclovir (I) IV infusion ♠ Groups 1 hour Dilute each 250-500mg in a 100ml bag Flush with N/S, G/S or H.
(Ready-diluted Infusion pump 1,2,3,4 and 5 N/S, G/S or H. For doses between Sodium content approx
brands) is required. 500mg and 1000mg use two 100ml bags 1mmol/250mg.
or one 250ml bag. The concentration Discard infusion if any visible
should not exceed 5mg/ml. Shake the turbidity or crystallisation appears.
prepared infusion well before use. Extravasation may cause tissue
Aciclovir (I) IV infusion ♠ Groups 1 hour Reconstitute each 250mg with 10ml of W damage. Patient should be
or N/S to produce a solution containing adequately hydrated.
(Powder for Infusion pump 1,2,3,4 and 5
reconstitution) is required. 25mg/ml. Dilute further with N/S, G/S or
H to a concentration not exceeding
5mg/ml. For fluid restricted patients the
reconstituted solution may be infused
without further dilution via a central IV
line.
Actrapid® See Insulin Section page
Adenosine IV bolus ♠ Group 1 2 seconds Can be diluted with N/S if necessary. If given into an IV line, inject as
proximally as possible and follow
with a rapid N/S flush. Cardiac
monitoring and resuscitation
equipment should be available for
immediate use. Sodium content
0.154mmol/3mg.
(I) IV infusion ♠ Group 1 6 minutes Administer in accordance with the
for cardiac and Group 7 Nuclear Medicine Department
stress testing protocol.
Infusion pump
is required.
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Adrenaline (I) IV infusion ♠ Groups 1 Adjust rate according Usual local practice is to use Protect infusion from light.
(Epinephrine) Infusion pump is and 2 to response. 1:10,000 adrenaline in a 50ml If G used as diluent pH must be below
required. syringe (5mg in 50ml). 5.5 (pH of G stocked in this Trust is
. Adrenaline may be diluted with between 4-4.2). Infuse through a large
N/S, G, G10%, G/S or H. vein if possible. (I) IV infusion requires
continuous blood pressure monitoring.
Replace giving set - do not flush.
Extravasation may cause tissue
damage.
Note that 1mg ampoules are only
licensed for IM or SC use. However,
they are suitable for preparing an IV
infusion.
Emergency use in ♠ Group 1 1 - 2 seconds Use 1:10,000 (1mg in 10ml)
CPR: IV bolus prefilled syringe.
Emergency use in ♠ Groups 1 Refer to the Marsden Manual for Refer to the algorithm for the
anaphylaxis and 2 guidance on IM injection. management of suspected life-
IM Injection using threatening anaphylaxis on page 193.
1:1,000 injection IM is the usual route.
Emergency use in ♠ Group 1 Specialist use only: Use 1:10,000 injection or dilute
anaphylaxis – Adults: 0.5ml of dilute 0.5ml of 1:1,000 adrenaline to If a patient is suffering an anaphylactic
Only
IV route is only 1:10,000 adrenaline IV 5ml with N/S or G to make a reaction, there is no prescription for
anaesthetists
used in an acute over 1 minute with 1:10,000 solution. adrenaline and there is no doctor
and senior
hospital setting by continuous ECG immediately available to prescribe
clinicians
an experienced monitoring, pulse adrenaline, IM adrenaline can be given
working in
practitioner for a oximety and frequent by a non-medical member of staff who
intensive care,
patient with blood pressure has the skills to assess a patient and
theatre or the
immediately life- measurements. give IM injections. They should do this
Emergency
threatening Repeat dose as in accordance with the protocol in
Department.
profound shock. necessary according Appendix 1 (page 189)
to response
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Ajmaline Slow IV ♠ Group 1: No greater Undiluted For detailed instructions it is essential to
(Unlicensed- bolus junior doctors than read the Ajmaline Protocol (Copies on
see page 4) trained in the 5mg/minute. Torcross and Bickleigh wards)
For diagnosis technique Maximum dose Patient to be nil-by-mouth for at least 4 hours
of Brugada and with UK is 1mg/kg before the test.
Syndrome ALS Continuous 12-lead ECG monitoring required
accreditation, during administration. Cardiac rhythm
or a monitoring required for 4 hours following
consultant administration.
cardiologist
Check the blood pressure at 5 minute
intervals during administration and for 10
minutes afterwards.
Alcohol See Ethanol monograph
Alemtuzumab SC Injection ♠ Groups 1 1-2 minutes Alemtuzumab is prepared only by Give the following pre-medication 30-60
in to the and 2 Pharmacy. Contact the Renal minutes prior to giving alemtuzumab:
Post kidney deltoid or Pharmacist on Bleep 0728 or the Methylprednisolone 500mg IV prior to first
transplantation anterior Pharmacy Screening Room on dose, 250mg IV prior to second dose.
(unlicensed abdominal ext.32278 (send prescription Chlorphenamine 10mg IV and paracetamol
product – see wall. chart to Pharmacy). Out of office 1g PO prior to first and second dose.
page 4) hours, bleep the on-call
(I) IV infusion ♠ Groups 1 2 hours pharmacist through Switchboard. Additional information relating to IV
via an and 2 infusion of alemtuzumab:
infusion Protect IV infusion from light: Cover with
pump For SC injection, Pharmacy will
infusion bag with the plastic bag supplied
supply a 30mg in 1ml pre-filled
from Pharmacy. No need to cover the line.
syringe.
During and after administration monitor for
For IV infusion, Pharmacy will urticaria, rash, hypotension, nausea, rigors
supply 30mg in 100ml N/S. and fever. Serious but rare reactions include:
respiratory distress, bronchospasm,
syncope, MI and cardiac arrest.
Alemtuzumab (I) IV ♠ Groups See Alemtuzumab is prepared only by Premedication: see administration schedule below.
infusion via 1 and 2 administration Pharmacy (Tel. 31083). Protect the infusion from light: Cover with infusion bag with the
for treating MS an infusion schedule Dilution supplied is 12mg in plastic bag supplied from Pharmacy. No need to cover the line.
(unlicensed pump below. 100ml N/S During the infusion monitor for urticaria, rash, hypotension,
product – see nausea, rigors and fever. Serious but rare reactions include:
page 4) respiratory distress, bronchospasm, syncope, MI and cardiac
arrest. Refer to the full Alemtuzumab Prescribing
Guidelines held on the Planned Investigation Unit (PIU).
The guidelines are also available on Plymouth Healthnet
under Clinical Guidelines.
Premedication prior to alemtuzumab for treating Multiple Sclerosis Administration Schedule for premedication (treating Multiple Sclerosis)
(Allow 30 minutes for oral paracetamol to take effect). Day 1 – 3:
• Paracetamol 1gram PO Administer 1g methylprednisolone IV over 1 hour
• Chlorphenamine 10mg IV Administer chlorphenamine 10mg IV and paracetamol 1gram PO
• Methylprednisolone 1gram IV daily for the first 3 days immediately prior to Administer alemtuzumab 12mg in 100ml N/S over 4 hours
administartion of alemtuzumab Day 4 (1st course only):
Administer chlorphenamine 10mg IV and paracetamol 1gram PO
1st Course of alemtuzumab: Administer alemtuzumab 12mg in 100ml N/S over 3 hours
Alemtuzumab 12mg IV daily for 5 consecutive days Day 5 (1st course only):
2nd Course of alemtuzumab (Given 12 and 24 months after the 1st course) Administer chlorphenamine 10mg IV and paracetamol 1gram PO
Alemtuzumab 12mg IV daily for 3 consecutive days Administer alemtuzumab 12mg in 100ml N/S over 2 hours
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE OVER SUITABLE DILUENT
Alfacalcidol IV bolus ♠ Groups 1 Approximately
Shake the ampoule for a minimum of 5 For patients undergoing haemodialysis
and 2 30 seconds seconds before use. Give undiluted. the injection should be given into the
return line from the haemodialysis
machine at the end of dialysis.
Monitor serum calcium regularly during
treatment.
Alfentanil Staff prescribing, administering and/or screening prescriptions for opioid medications should be familiar with the PHNT Policy for
Reducing Errors with Opioid Medicines in Adults (Network Drive :Groups (G) > Trust Documents > Documents > Medicines Management
folder). The PHNT Analgesic Ladder and equivalent dosages of different opioids can be found on page 185.
IV bolus ♠ Groups 1 Approximately Can be diluted with N/S, G or H. Flush : N/S, G or H
using the and 2 30 seconds in Anaesthesia : Adequate plasma levels
500 microgram/ml spontaneously will only be achieved rapidly if the
injection breathing infusion (0.5-1 micrograms/kg/minute) is
patients. preceded by a loading dose of 50-100
Ampoules of Alfentanil 5mg/ml are 5000 micrograms/ml and must be diluted as below micrograms/kg given as a bolus or fast
before administration by infusion. infusion over 10 minutes.
(C) or (I) IV infusion ♠ Groups 1 Dilute with N/S, G or H to a usual

with assisted and 2 concentration of 0.5mg/ml.
ventilation. Infusion Occasionally concentrations of 1mg/ml
pump is required. or more have been used.
SC injection ♠ Groups Refer to the Marsden Manual for Follow the PHNT Care of the Dying
1,2,3,4 and 5 guidance on SC injection. Pathway in Advance Kidney Disease and
the PHNT Syringe Driver Policy.
(C) SC infusion via ♠ Groups Dilute with W when 2 or more drugs are
For combinations of 2 or 3 drugs in the
syringe driver for 1,2,3,4 and 5 being mixed in the same syringe.
same syringe refer to the compatibility
use in palliative care W or N/S may be used when the charts in the pump kit or contact
syringe only contains this drug. Pharmacy on ext. 39976 for advice.
Alfentanil is unlicensed by the SC route
and for use in palliative care (See page
4).
Alglucosidase (I) IV infusion ♠ Groups Initial rate of Remove the required number of vials Suitable filters include PALL 0.22 micron,
alfa Infusion 1,2 and 3 1mg/kg/hour. from the fridge and allow them to reach Braun Sterifix 0.2 micron, Technopharm
(Mycozyme®) pump is Gradually increased room temperature (may take about 30 codan 0.2 micron filters. These filters
required. by 2mg/kg/hour every minutes). Reconstitute each 50mg vial should be ordered through ORACLE.
30 minutes if there are with 10.3ml W. Add the W by slow drop-
no reactions to the wise addition down the side of the vial Instructions for dosing and administration
infusion, until a and not directly in to the powder. Tilt of alglucosidase alfa will usually be
maximum rate of and roll each vial gently. Do not invert, included in the patient’s treatment plan
7mg/kg/hour is swirl or shake the vials. The (Recommended dosage for Pompe
reached. reconstituted volume is 10.5ml Disease is 20mg/kg once every 2 weeks)
containing 5mg of enzyme/ml, and
appears as a clear colourless to pale During the infusion monitor for allergic
yellow solution which may contain reactions, monitor blood pressure, pulse,
particles in the form of thin white temperature, respiratory rate and for
strands or translucent fibres. If on difficulty in breathing.
immediate inspection foreign particles
other than those described above are
observed, or if the solution is
discoloured, do not use.
Dilute the drawn up dose of
alglucosidase alfa with N/S to a final
alglucosidase alfa concentration of
0.5mg/ml to 4mg/ml (Remove the same
volume of N/S from the bag first).
Remove airspace from within the bag.
Mix with gentle massage on inversion of
the bag. Do not shake or agitate the
bag. Infuse the solution via a 0.2micron
low protein-binding in-line filter.
Alprostadil (C) IV infusion ♠ Groups Initial rate: Dilute 150micrograms/kg weight of If using a burette avoid direct
(Prostin VR®) 1 and 2 5 nanograms/kg/minute baby to a final volume of 50ml with G, contact of the undiluted injection
= 0.1ml/hour of the N/S or G10%. with the wall of the plastic
Infusion pump is
prepared dilution. (Note that after dilution with G10% the burette. If this happens the
required.
product is unlicensed. See page 1) appearance of the burette chamber
may change and a hazy solution
may develop requiring the solution
to be discarded and the burette to
be changed.
Monitor arterial blood pressure,
heart rate, SaO2 pO2 pH and
respiratory rate
Alprostadil Intracavernosal ♠ Group 1 Fit the 22 gauge needle to the syringe. Using a half inch, 27 to 30 gauge
(Caverject®) injection Inject the 1ml of diluent into the vial, needle is generally recommended.
(See comments) and shake to dissolve the powder The intracavernosal injection must
entirely. Withdraw slightly more than be done with aseptic technique.
the required dose of Caverject solution, The site of injection is usually along
remove the 22 gauge needle, and fit the dorsolateral aspect of the
the 30 gauge needle. Adjust volume to proximal third of the penis. Visible
the required dose for injection. veins should be avoided. Both the
side of the penis that is injected
and the site of injection must be
alternated. Prior to the injection, the
injection site must be cleansed with
an alcohol swab.
Alteplase (TPA) If a special pre-programmed alteplase pump is unavailable then refer to the guidance on pages 19 and 20.
to treat: Initial IV bolus ♠ Groups Accelerated Reconstitute two 50mg vials each with ECG and haemodynamic
dose then (I) IV 1 and 2 regimen initiated the 50ml of W provided using the transfer monitoring required. Sodium
infusion within 6 hours of needles supplied. Agitate gently until the content nil.
Acute myocardial
using the symptom onset contents of the vials have dissolved. Do Flush with N/S.
infarction (AMI)
special pre- administer over: not shake. When treating AMI, alteplase is
programmed 90 minutes When using the special pre-programmed given together with IV heparin. The
alteplase pump Initiated between 6 alteplase pump, draw up the contents of IV heparin regimen is 5,000unit
(Available in the and 12 hours after both vials (100ml) into a 100ml syringe. bolus followed by a continuous IV
Emergency symptom onset infusion for at least 48 hours, using
Dept. and on administer over: the standard PHNT IV heparin
Torcross ward). prescription form.
3 hours
Alteplase and heparin infusions are
not compatible. They should be
infused through separate IV
catheters. If IV access is a problem,
the infusion of heparin can be
commenced once the alteplase
infusion has finished.
Alteplase (TPA) Initial IV bolus ♠ Group 1 1 – 2 minutes Reconstitute two 50mg vials each with ECG and haemodynamic
to treat: dose the 50ml of W provided using the transfer monitoring required. Sodium
Followed by (I) IV ♠ Groups 2 hours needles supplied. Agitate gently until the content nil.
Pulmonary infusion 1 and 2 contents of the vials have dissolved. Do Flush with N/S.
embolism using the not shake. Alteplase and heparin infusions are
special pre- Draw up the 10mg (10ml) bolus in a 10ml not compatible. They should be
programmed syringe for the doctor to inject over 1-2 infused through separate IV
alteplase pump minutes. catheters.
(Available in the When using the special pre-programmed
Emergency alteplase pump, draw up the remainder
Dept. and on of the total dose into a 100ml syringe.
Torcross ward)
Alteplase to treat Acute Myocardial Infarction within 6 hours of symptom onset (Accelerated Regimen)
Suggested method when a pre-programmed alteplase pump is not available: Reconstitute two 50mg vials each with 25ml of the W provided using the
transfer needles provided to make a 2mg/ml solution. Draw up the 50ml (100mg) of solution into a 50ml syringe. Then using a syringe pump set the
infusion rate as follows:
Bolus of 15mg over 2 minutes for patients of all weights (Set the pump at 225ml/hour for 2 minutes) then:
Patient Further doses and infusion rates

weight
≥ 65kg 50mg over 30 minutes. Set the pump at 50ml/hour for 30 minutes then 35mg over 60 minutes. Set the pump at 17.5ml/hour for 60 minutes
64kg 48mg over 30 minutes. Set the pump at 48ml/hour for 30 minutes then 32mg over 60 minutes. Set the pump at 16ml/hour for 60 minutes
62kg 46.5mg over 30 minutes. Set the pump at 46.5ml/hour for 30 minutes then 31mg over 60 minutes. Set the pump at 15.5ml/hour for 60 minutes
Alteplase to treat Acute Myocardial Infarction between 6 and 12 hours after onset of symptoms
transfer needles provided to make a 2mg/ml solution. Draw up the 50ml (100mg) of solution into a 50ml syringe. Then using a syringe pump set the
infusion rate as follows:
Bolus of 10mg over 2 minutes for patients of all weights.: set the pump at 150ml/hour for 2 minutes, then:
50mg over 1 hour for patients ≥ 40kg: set the pump at 25ml/hour for 1 hour, then:
Patient weight Dose and infusion rate

≥ 65kg 40mg over 2 hours. Set the pump at 10ml/hour for 2 hours
60 - 64kg 30mg over 2 hours. Set the pump at 7.5ml/hour for 2 hours
53.4 -63.9kg 20mg over 2 hours. Set the pump at 5ml/hour for 2 hours
46.7 – 53.3kg 10mg over 2 hours. Set the pump at 2.5ml/hour for 2 hours
40 – 46.6kg No additional alteplase
Alteplase to treat Pulmonary Embolism
transfer needles provided to make a 2mg/ml solution.
Draw up the Bolus of 10mg (5ml) in a 5 ml or 10ml syringe for the doctor to inject over 1 -2 minutes
Then draw up the remainder of the total dose in a 50ml syringe. Then using a syringe pump set the infusion rate as follows:
Patient weight Dose and infusion rate
≥ 65kg 90mg over 2 hours. Set the pump at 22.5ml/hour for 2 hours
< 65kg For patients less than 65kg the total prescribed dose (including bolus dose) should not exceed 1.5mg/kg.
Following the bolus dose of 10mg, the infusion rate = Total prescribed dose (mg) – Bolus dose (10mg) ml/hour for 2 hours
4
Alteplase Total dose is 900 micrograms/kg (Maximum dose 90mg). 10% of this dose (90micrograms/kg) given as a bolus over 2 minutes
to treat IV bolus ♠ Group 1 1 – 2 minutes Reconstitute one or two 50mg vials It is essential to follow the detailed
each with 50ml of the W provided to instructions in the PHNT Acute Ischaemic
Acute Ischaemic make 1mg/ml solution. For the bolus Stroke Protocol (Copy in the Emergency
Stroke dose, draw up 10% of the total dose Department).
(see table below) and inject using a Unless the patient or companion knows their
10ml syringe. recent weight, estimate to the nearest 5kg. Take
(I) IV infusion ♠ Groups 1 hour From the solution above, draw up the 2 initial blood pressure readings at 15 minute
1 and 2 remainder of total dose (see table intervals. Record in both arms initially to exclude
below) into one or two 50ml syringes. aortic dissection.
Weight(Kg) Weight (Imperial) Total dose Bolus dose (ml) Infusion dose
900micrograms/kg Inject over 1 -2 infused over 1 hour
(Maximum 90mg) minutes
45 7st 1lb 40 4 36
Use 1 x 50mg vial 50 7st 12lb 45 4.5 40.5
55 8st 9lb 49 4.9 44.1
60 9st 6lb 54 5.4 48.6
65 10st 3lb 58 5.8 52.2
70 11st 0lb 63 6.3 56.7
75 11st 11lb 67 6.7 60.3
Use 2 x 50mg vials
80 12st 8lb 72 7.2 64.8
85 13st 5lb 76 7.6 68.4
90 14st 2lb 81 8.1 72.9
95 14st 13lb 85 8.5 76.5
≥100 15st 10lb 90 9 81
Alteplase (Low-Dose) (C) IV Infusion ♠ Groups 2.5ml/hour Reconstitute 1 x 10mg alteplase with The minimum stable concentration
to treat acute venous 1,2,3,4 and 5 the 10ml of W provided. is 0.2mg/ml. Each prepared
thrombosis (subclavian or Further dilute the 10mg of infusion is stable upto 8 hours at
This will deliver
ilio-femoral deep vein reconstituted alteplase to 50ml with room temperature. Prepare a fresh
0.5mg alteplase
thrombosis) N/S. syringe and change the infusion
per hour
promptly, every 8 hours. After 8
This indication for alteplase hours, 30ml of solution will remain
is unlicensed – see page 4 in the used syringe which must be
discarded.
Follow the Low-Dose Alteplase

Protocol.
Amikacin IM injection ♠ Groups Do not dilute. Refer to the Marsden For most infections the
1,2,3,4 and 5 Manual for guidance on IM injection. intramuscular route is preferred, but
Slow IV bolus Undiluted the IV route may be used for life
♠ Groups 2 – 3 minutes
threatening infection or when IM
(For large once 1,2,3,4 and 5 injection is not feasible.
daily doses see (I)
IV infusion below) Once diluted for infusion use
immediately.
(I) IV infusion ♠ Groups 30 – 60 minutes A common dilution for adults is with Patient should be well hydrated
For once daily 1,2,3,4 and 5 100ml of N/S or G. during amikacin therapy.
doses of 15mg/kg
or greater. Infusion
pump is required
Irrigation ♠ Groups Dilute the required dose with N/S to a Sterile irrigation of amikacin may be
1,2,3,4 and 5 concentration of 2.5mg/ml. used in abscess cavities, the
pleural space, peritoneum or in the
cerebral ventricles.
Aminophylline (I) IV infusion ♠ Groups 1, Minimum 20 minutes. Dilute further with 100ml N/S, G, G/S or Flush with N/S, G or G/S.
(initial loading 2 3 and 7 H. However, the loading dose can be Do not give loading dose if
dose) Infusion diluted to a smaller volume e.g. 50ml or patient previously taking
pump is given undiluted (25mg/ml) if necessary. theophylline.
required.
(I) or (C) IV ♠ Groups Usual starting rates:Remove 20ml from a 500ml bag of N/S, Do not infuse aminophylline down
infusion (after 1,2,3,4 and 5 G, G/S or H then add 500mg (20ml) the same central line lumen or
loading dose). 0.5-0.7mg/kg/hour for aminophylline to make a concentration of peripheral line as salbutamol.
Infusion pump adults and children aged 1mg/ml.
is required. 12 years and older. Take blood to check theophylline
Can be diluted to higher concentrations levels 4-6 hours after commencing
0.3mg/kg/hour for the
than 1mg/ml or given undiluted the aminophylline infusion.
elderly.
(25mg/ml) through a central line, but take
care with the calculation and prescription
1mg/kg/hour for children of the infusion rate.
aged under 12 years.
To avoid excessive
dosage in obese
patients, the dose
should be calculated
on ideal body weight.
Adjust the rate

according to plasma
theophylline levels.
Amiodarone (C) or (I) IV ♠ Groups 1,2 5mg/kg loading Recommended dilution: 5mg/kg loading Cardiac monitoring required.
infusion. and 3 dose (usually dose (Usually 300mg) diluted in 250ml Flush with G.
Infusion pump 300mg) over 20 G. Repeat infusion (usually 900mg over Repeated or continuous infusion
is required. minutes - 2 hours. next 23 hours) diluted in 500ml G. via peripheral veins may lead to
This may be Where a lower volume is needed the local discomfort and inflammation.
followed by repeat dose (e.g. 300mg, 900mg or 600mg) Infusion concentrations greater
infusion up to 1.2g may be diluted in 50, 100 or 250ml G. than 2mg amiodarone per ml must
per 24 hours. Stability is concentration dependent - do be infused via a central venous
Adjust rate not over dilute. Do NOT add 300mg to catheter.
according to more than 500ml G or 600mg to more When repeated or continuous
response than 1 litre G. infusion of any concentration is
anticipated, administration via a
IV bolus ♠ Group 1 During Advanced Dilute each 150-300mg with 10-20ml G. central venous catheter is
Emergency use Life Support for Pre-filled syringe contains 300mg ready recommended.
VF/VT give as a diluted in 10ml G. Sodium content nil.
fast bolus.
Otherwise give over
a minimum of 3 As soon as an adequate response
minutes. Do not has been obtained, oral therapy
repeat dose for at should be initiated concomitantly at
least 15 minutes. the usual loading dose (i.e. 200mg
three times a day). Intravenous
amiodarone should then be phased
out gradually.
Amoxicillin IV bolus ♠ Groups Inject doses up to 1g Reconstitute each 500mg with 10ml W. Flush with N/S.
(Usual method) 1,2,3,4 and 5 over 3 - 4 minutes. Displacement 0.4ml/500mg. Add 9.6ml W Use infusion within 90 minutes of
Inject 2g doses to 500mg to produce 50mg/ml. preparation.
slowly over 6 - 8
minutes or give by
infusion (see below).
(I) IV infusion. 30 - 60 minutes Reconstitute as above then dilute with N/S Sodium content: 1.65mmol/500mg
Infusion pump is or G to 100ml. Alternatively each 500mg
required. amoxicillin may first be reconstituted with
5ml of the diluent (N/S or G). (Avoid Intrathecal administration)
IM Injection ♠ Groups Reconstitute a 500mg vial with 2.5ml W For Amoxil® brand only : If pain is
1,2,3,4 and 5 and shake vigorously (Final volume is experienced on IM injection,
2.9ml). Reconstitute a 250mg vial with lidocaine 1% or procaine 0.5%
1.5ml W and shake vigorously (Final injection may be used instead of W
volume is 1.7ml). Refer to the Marsden to reconstitute the vial.
Manual for guidance on IM injection.
Amphotericin (I) IV infusion ♠ Groups 2-4 hours. Displacement is negligible. Add 10ml A test dose must be given at start
(Fungizone® ) Infusion pump is 1,2,3,4 and 5 Up to 6 hours if diluent for 50mg in 10ml. of each new course of treatment;
required. poorly tolerated. Reconstitute vial with 10ml W, then dilute Infuse the first 1mg of the first
dose required with 50 times as much G to infusion over 20-30 minutes and
produce a maximum concentration of observe for signs of anaphylactic
100micrograms/1ml. Add 1ml of buffer reaction for at least a further 30
solution supplied by Pharmacy to each minutes. If no reaction then give the
500ml G before adding amphotericin. remainder of the first infusion.
Flush with G before and after
Concentrations up to a maximum of administration.
For AMBISOME
see next page 500micrograms/1ml can be given using a Protect infusion from light.
central line (unlicensed use - see page 1). May cause thrombophlebitis;
change infusion site frequently.
Sodium content 0.25mmol/50mg.
Liposomal (I) IV infusion ♠ Groups 30-60 minutes Add 12ml W (2-8oC), shake Administration of a test dose is advisable before a
Amphotericin Infusion pump 1,2,3,4 and vigorously for at least 15 new course: Give 1mg of prepared infusion over
(AmBisome ®) is required. 5 seconds. Resulting amphotericin 10 minutes, stop infusion and observe patient for
concentration 4mg/1ml. 30 minutes.
Dilute dose required with Protect infusion from direct sunlight. Flush before
between 1 and 19 parts by and after administration with G.
For Fungizone®
volume G, using 5 micron filter Do not infuse with any other drugs or infusion
See previous page provided, to give a final fluids.
concentration of 200micrograms- Sodium content less than 0.5mmol/vial.
2mg/1ml.
Anti-thymocyte (I) IV infusion ♠ Groups 8-12 hours Infusion to be prepared by A test dose is usually given. Give an IV
immunoglobulin into a large 1,2,3,4 and Pharmacy. Telephone Ext. antihistamine 1 hour before.
rabbit (ATG rabbit) vein. Infusion 5 31083. Doctor to prescribe dose Flush with N/S.
pump is in 250 – 500ml N/S. Do not infuse with any other drugs.
required.
Anidulafungin (I) IV infusion ♠ Groups Infuse the Reconstitute each 100mg vial Do not infuse with any other drugs or infusion
Infusion pump 1,2,3,4 and 200mg dose with 30ml WFI. Reconstitution fluids.
▼ This product is is required. 5 over at least 3 can take up to 5 minutes. If the un-reconstituted vials are accidentally left
being intensively hours. For the 200mg dose, remove out of the fridge, as long as the period at room
monitored by the 50ml from a 250ml bag of N/S or temperature does not exceed 96 hours, they can
CHM and MHRA. Infuse the G, then add 60ml (2 x 100mg in be returned to the fridge and are ok to use.
Please report all 100mg dose 30ml) of reconstituted solution Flush with N/S.
suspected over at least (Final volume 260ml).
reactions (including 1½ hours. For the 100mg dose, add the
non-serious ones) 30ml of reconstituted solution to a
using a Yellow 100ml bag of N/S or G (final
Card from the BNF volume 130ml).
Aprotinin IV bolus (initial ♠ Group 1 Maximum rate Provided ready diluted. Flush with N/S.
loading dose) 10ml/minute Initial 1ml (10,000 KIU) should always be given at
This drug is least 10 minutes prior to treatment to test for
unlicensed – see (I) IV infusion ♠ Groups 20-50ml/hour possible allergic and anaphylactic reactions.
page 4 Infusion pump 1 and 2 Sodium content 7.7mmol/50ml.
is required. Do not infuse with any other drugs including
heparin.
Patient must be in the supine position during the
administration of aprotinin.
Argatroban (I) IV infusion ♠ Groups Initial infusion rate in patients Add the 250mg in 2.5ml from the Obtain a baseline APTT. The target
via infusion 1 and 2 without hepatic impairment is vial to a 250ml bag of N/S or G. APTT is 1.5-3.0 times the baseline
pump. 2micrograms/kg/minute. Mix the solution for 1 minute by value, but not more than 100 seconds.
repeated inversion of the Check the APTT 2 hours after starting
For critically ill or hepatically prepared infusion. There may be the infusion or after a change of rate,
impaired patients the initial infusion some brief haziness of the and at least once a day thereafter (For
rate is 0.5micrograms/kg/minute. solution that clears upon mixing. critically ill or hepatically impaired
See tables at foot of monograph patients, check the APTT 4 hours after
for setting the initial infusion rate starting infusion or changing the rate).
The maximum rate is

10micrograms/kg/minute
Standard dosing schedule Critically Ill/Hepatically impaired patients
Initial Infusion Rate 2 micrograms/kg/minute Initial infusion rate 0.5 micrograms/kg/minute
APTT (s) Infusion Rate change Next APTT Infusion Rate change Next APTT
< 1.5 times baseline Increase by 0.5 mcg/kg/min. 2 hours Increase by 0.1 mcg/kg/min. 4 hours
1.5-3.0 times baseline (not No change 2 hours; after 2 consecutive No change 4 hours; after 2 consecutive
exceeding 100 s) APTT's within target range, APTT's within target range,
Check at least once per day Check at least once per day
> 3.0 times baseline or > 100 s Stop infusion until the APTT 2 hours Stop infusion until the APTT is 4 hours
is 1.5-3.0 times baseline; 1.5-3.0 times baseline;
Resume at half of the Resume at half of the previous
previous infusion rate. infusion rate.
2micrograms/kg/min 0.5micrograms/kg/min 2micrograms/kg/min 0.5micrograms/kg/min

Body weight (kg) Infusion rate (ml/hour) Infusion rate (ml/hour) Body weight (kg) Infusion rate (ml/hour) Infusion rate (ml/hour)
50 6 1.5 100 12 3
60 7 1.8 110 13 3.3
70 8 2.1 120 14 3.6
80 10 2.4 130 16 3.9
90 11 2.7 140 17 4.2
DRUG METHOD WHO MAY GIVE ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
OVER AND SUITABLE DILUENT
Argipressin See vasopressin
Atenolol IV bolus ♠ Groups 1 and 2 Maximum rate Can be diluted with N/S or G to any Severe bradycardia and hypotension
1mg/minute convenient volume e.g.10ml. may occur; monitor heart rate and
(I) Infusion ♠ Groups 1 and 2 20 minutes Dilute with N/S or G to a suggested blood pressure. Can cause
Infusion pump is volume of 50ml or 100ml. conduction defects; monitor ECG.
required. Infusing quickly increases incidence of
side effects.
Flush with N/S or G.
Sodium content : approximately 1.3-
1.8mmol/5mg
Atosiban Step 1: IV bolus loading ♠ Groups 1 and 2 0.9ml (6.75mg) Total duration of treatment should not
dose using 7.5mg/ml over 1 minute exceed 48 hours. The total dose given
Solution For Injection immediately should preferably not exceed 330mg.
followed by Step 2
Step 2: 24ml (18mg)/hour Withdraw 10ml from a 100ml bag of The vials and infusions should be
(I) IV loading infusion. for 3 hours N/S or G. Replace it with 10ml of inspected visually for particulate
Infusion pump is followed by Step 3 Atosiban 7.5mg/ml Concentrate matter and discolouration prior to
required. Solution for Infusion from two 5ml administration.
Step 2: 8ml (6mg)/hour for vials to obtain a concentration of
(I) IV infusion Infusion up to 45 hours 75mg in 100ml Do not mix with any other drug
pump is required. solutions.
Atracurium IV bolus ♠ Group 1 – must only Can be diluted with H, G, G/S or A 0.5mg/ml dilution is stable for 4
be given by doctors N/S. hours in H, 8 hours in G or G/S and
proficient in advanced 24 hours in N/S. Flush with N/S.
airway management. If the patient is ventilated IV bolus can
Also see comments. be administered by Group 2 staff.
(C) IV infusion. Infusion ♠ Groups 300-600 Incompatibilities include: propofol.
pump is required. 1 and 2 micrograms/kg/
hour
Atropine IV bolus ♠ Groups 1 & 2 See comments If necessary atropine injection can Give rapidly since slow IV
be diluted with N/S. administration may cause paradoxical
SC injection ♠ Groups Refer to the Marsden Manual for slowing of the heart. ECG monitoring
1 and 2 guidance on SC injection. required. Flush with N/S.
IM Injection ♠ Groups Refer to the Marsden Manual for IV incompatibilities include bromides,
guidance on IM injection. iodides, noradrenaline, metaraminol
1 and 2
and sodium bicarbonate.
Premedication: IV immediately before
induction. IM or SC 30-60 minutes
before induction.
Control of muscarinic side effects of
neostimine: IV bolus.
Augmentin See Co-amoxiclav

Azathioprine (I) IV infusion ♠ Group 1 or 30-60 minutes Azathioprine injection is Flush the IV bolus with at least 50ml
(preferred Group 2 who reconstituted and diluted only by N/S, G or G/S since very irritant.
method have previous Pharmacy (Tel. 31083). Extravasation may cause tissue
wherever experience of Handle the prepared injection or damage.
possible). administering infusion as for cytotoxic drugs (See Sodium content 0.2mmol/vial.
Infusion pump intravenous Appendix 3). Do not infuse with any other drugs.
is required. cytotoxics. Or a
Group 3 nurse.
IV bolus ♠ Group 1 or Usually 3-5 minutes.
through tubing Group 2 who Minimum 1 minute.
of a fast flowing have previous
N/S or G drip. experience of
administering
intravenous
cytotoxics. Or a
Group 3 nurse.
Aztreonam IV bolus ♠ Groups 3-5 minutes Reconstitute vial contents with 6 - 10ml Development of slight pink colour on
1,2,3,4 and 5 W and shake well. standing does not affect potency.
Displacement 0.8ml/1g. Add 9.2ml to 1g Flush with N/S or G.
vial for 100mg/ml Sodium content nil.
(I) IV infusion ♠ Groups 20-60 minutes Reconstitute each 1 gram with at least
Infusion pump is 1,2,3,4 and 5 3ml W and shake well .Then dilute each
required. 1 gram with at least 50ml N/S, G or H.
IM injection ♠ Groups Reconstitute a 1gram vial with at least Give by deep injection into a large
1,2,3,4 and 5 3ml W or N/S and shake well. muscle mass such as the upper
Refer to the Marsden Manual for quadrant of the gluteus maximus or
guidance on IM injection. the lateral part of the thigh. For doses
higher than 1g, or for septicaemia,
meninigitis, localised parenchymal
abcess, peritonitis or other severe
systemic or life-threatening infections,
use the IV route as above.
Baclofen (C) Intrathecal ♠ Group 1 or Prepare and administer in accordance * Restricted to those persons who are
infusion or Group 2* with the Pain Management Centre trained and competent to administer
Intrathecal bolus procedures. medication via the intrathecal route.
For regular intravenous benzylpenicillin see next page
Benzathine Deep IM injection ♠ Groups Shake the vial to loosen the powder Do not inject this formulation
benzylpenicillin 1,2,3,4 and 5 inside. Reconstitute the vial contents with intravenously.
(Extencillin®) the 8ml of W provided in the unlabelled
2.4 megaunit vial ampoule.
(Unlicensed Refer to the Marsden Manual for

product – see guidance on IM injection.
page 4)
Benzylpenicillin IV bolus ♠ Groups 3-5 minutes. Reconstitute each 600mg with 3.6-10ml Administration faster than the
(Usual method) 1,2,3,4 and 5 Maximum rate for W or N/S. recommended rate may cause
(Regular doses exceeding Displacement 0.4ml/600mg. Add 3.6ml seizures and CNS toxicity.
benzylpenicillin 1.2g: of W or N/S for 600mg in 4ml. Incompatibilities include: gentamicin.
600mg and 300mg/minute.
1200mg vials)
(I) IV infusion. ♠ Groups 30-60 minutes Reconstitute each 600mg with 10ml N/S Flush with N/S or G.
Infusion pump is 1,2,3,4 and 5 or W .Can be further diluted if necessary Sodium content 1.68mmol/600mg.
required. with N/S or G (Suggested volume 1 mega unit = 600mg.
100ml).
IM Injection ♠ Groups Reconstitute each 600mg vial with 1.6ml Doses greater than 1.2g should be
1,2,3,4 and 5 to 2ml W. Refer to the Marsden Manual given by the IV route.
for guidance on IM injection.
Basiliximab Preferred method: ♠ Groups 20-30 minutes Reconstitute 10mg vial with 2.5ml of the Use immediately and complete
(I) IV infusion. 1,2,3,4 and 5 W supplied in the accompanying administration within 4 hours of
Infusion pump is ampoule. Reconstitute 20mg vial with reconstitution.
required. 5ml of the W supplied in the Do not mix or infuse with other drugs
accompanying ampoule. Then dilute in the same lumen or IV line.
each 10mg to a volume of 25ml or Anaphylactic reactions can occur
greater with N/S or G. To avoid foaming rarely
mix by gently inverting – do not shake.
IV bolus ♠ Groups Reconstitute 10mg vial with 2.5ml of the Flush with N/S or G.
1,2,3,4 and 5 W supplied in the accompanying
ampoule. Reconstitute 20mg vial with
5ml of the W supplied in the
accompanying ampoule.
Beriplex P/N® (I) IV ♠ Groups Each 500 IU in 20ml Follow the nine steps illustrated The Consultant Haematologist will advise on the
Infusion 1,2,3,4 and W over 10-15 below and continued on the next dosage to be given, and the monitoring to be
Only prescribe using an 5 minutes page for reconstituting the vials. performed.
after consultation infusion Using the transfer device provided, Do not administer down the same lumen or catheter
with a Consultant pump So set the infusion reconstitute each 250 IU vial with the as other drugs and fluids. May be flushed with N/S.
Haematologist pump rate at 10ml of W provided.
80-120ml/hour Using the transfer device provided, Take care that no blood enters the syringe filled
Available on reconstitute each 500 IU vial with the with product, as there is a risk that the blood could
request from the 20ml W provided. coagulate in the syringe and fibrin clots would
Blood Bank The concentration is 25 IU/ml. therefore be administered to the patient.
Do not further dilute the
reconstituted solution.
Store Beriplex P/N® in the fridge. Use reconstituted
Beriplex® within 8 hours
Instructions for reconstituting Beriplex P/N®
1. Open the Mix2Vial package by 3. Carefully remove the package from the Mix2Vial set. Make
peeling away the lid. sure that you only pull up the package and not the Mix2Vial
set.
1 3
2. Place the diluent vial on an even, 4. Place the product vial on an even and firm surface. Invert
clean surface and hold the vial tight. the diluent vial with the Mix2Vial set attached and push the
Take the Mix2Vial together with the transparent adapter straight down through the product vial
package and push the blue end straight stopper. The diluent will automatically flow into the product
down through the diluent stopper. vial.
2 4
Instructions continued on the next page
Instructions for reconstituting Beriplex P/N® continued
5. With one hand hold the product-side of the 8. While keeping the syringe plunger pressed, invert the
Mix2Vial set, hold the diluent-side with the other system upside down and draw the concentrate into the
hand and unscrew the set into two pieces. syringe by pulling the plunger back slowly.
Discard the diluent vial with the blue part attached
5 8
6. Gently swirl the product vial until the substance is 9. Now that the concentrate has been transferred into the
fully dissolved. Do not shake. syringe, firmly hold on to the barrel of the syringe (keeping
the syringe plunger facing down) and disconnect the
Mix2Vial set from the syringe.
6
9
7. Draw air into an empty, sterile syringe. While the
product vial is upright, connect the syringe to the
Mix2Vial's Luer Lock fitting. Inject air into the
product vial.
Bivalirudin Rapid Initial IV ♠ Groups Suggestion: Add 5 ml W to one vial of 250mg Incompatible with alteplase,
bolus Patients 1,2,3,4 and 2 seconds bivalirudin and swirl gently until amiodarone, amphotericin B,
undergoing PCI, 5 completely dissolved and the chlorpromazine, diazepam,
including primary solution is clear. Withdraw 5 ml prochlorperazine, reteplase,
PCI : 0.75 mg/kg from the vial, and further dilute to streptokinase and vancomycin.
50 ml with G or N/S to give a final
bivalirudin concentration of 5
Patients with
unstable mg/ml. Mix thoroughly. The Activated Clotting Time (ACT)
angina/non-ST reconstituted/diluted solution will be values 5 minutes after
segment elevated a clear to slightly opalescent, bivalirudin bolus average 365
myocardial colourless to slightly yellow +/- 100 seconds. If the 5-minute
infarction: 0.1 mg/kg solution. ACT is less than 225 seconds,
a second bolus dose of 0.3
mg/kg should be administered.
(C) IV infusion ♠ Groups Patients undergoing PCI, Once the ACT value is greater
immediately 1,2,3,4 and including primary PCI : than 225 seconds, no further
following the IV 5 1.75mg/kg/hour = 0.35ml/kg/hour monitoring is required provided
bolus of the 5mg/ml infusion during the the 1.75 mg/kg infusion dose is
procedure and for up to 4 hours properly administered.
post PCI if necessary. Then
0.25mg/kg/hour = 0.05ml/kg/hour
for 4- 12 hours if necessary.
Patients with unstable

angina/non-ST segment elevated
myocardial infarction:
0.25 mg/kg/hour = 0.05ml/kg/hour
of the 5mg/ml infusion for up to
72 hours.
Botulinum toxin IM injection into ♠ Group 1 Reconstitute the 500unit vial with 1ml of Sharing a vials of botulinum between
(Dysport®) specific muscles W to make a 500unit/ml solution. patients in a day-case/clinic setting
to treat spasticity (i.e. not in-patient on ward or in
theatre) has been risk assessed and
Reconstitute the 300unit vial with 0.6ml
sanctioned by the PHNT Medicines
of W to make a 500unit/ml solution.
Governance Committee so long as the
SC injection into ♠ Group 1 Reconstitute the 500unit vial with 2.5ml following practice is strictly adhered
specific facial of W to make a 200unit/ml solution. to:
sites to treat • Between patients the reconstituted
blepharospam Reconstitute the 300unit vial with 1.5ml vial is kept in the fridge.
and hemifacial of W to make a 200unit/ml solution. • A separate drawing-up needle is
spasm. used for each patient.
• Any reconstituted botulinum
remaining in the vial(s) at the end
of the session must be discarded.
• The maximum time the product
may be stored at 2-80C following
reconstitution is 8 hours.
Bumetanide IV bolus ♠ Groups 1 Suggestion: 1 Give undiluted. Flush with N/S.
and 2 minute Leave a gap of 20 minutes between
repeat bolus doses.
(I) IV infusion. ♠ Groups 1 30-60 minutes Dilute 2 – 5mg with 500ml of G, N/S or Protect infusion from light and discard
Infusion pump is and 2 G/S. Alternatively dilute to 1mg/10ml if cloudiness develops.
required. with G, N/S or G/S (unlicensed dilution- Sodium content 0.007mmol/1ml.
see page 1)
IM Injection ♠ Groups 1 Refer to the Marsden Manual for
and 2 guidance on IM injection.
Bupivacaine All epidural administration sets and epidural catheters must be labelled “Epidural” when in use (NPSA/2007/21)
(epidural) Epidural infusion via ♠ Groups Adult patients: Pre-made bags are supplied from *Staff administering and monitoring
Adults: a McKinley epidural 1and 2* Epidurals: Pharmacy. epidural infusions must have received
0.167% pump, using a yellow Protocol “A” PCEA training from the Acute Care Team
coloured line which or “B” CEA. Modified and demonstrated their competency at
(with or without must be labelled epidural protocols administering and monitoring epidural
Fentanyl) “Epidural” are very rarely infusions. Follow the PHNT Epidural
Paediatric: prescribed by Protocols.
0.125% Anaesthetists Additional clinician boluses may be
administered by Pain Nurses if
required as per epidural protocol.
Bupivacaine For specialist use: ♠ Groups Refer to Acute Care Pre-made bags are supplied from Refer to the PHNT protocol for
Infusion for local infiltration at 1and 2 Team Guidelines Pharmacy. Continuous Local Anaesthetic
local infiltration other sites i.e. near Infusions.
0.167% nerves, wound,
0.125% joint, body cavity
0.0625% (e.g. interpleural,
paravertebral) Via a
dedicated, grey
McKinley 595 pump,
using a grey coloured
line which must be
labelled with the
route.
Buprenorphine IV bolus ♠ Groups 1 3-5 minutes Can be diluted with N/S or G. Flush with N/S.
and 2 Sodium content nil.
IM Injection ♠ Groups 1 Refer to the Marsden Manual for
Caffeine and (I) IV infusion ♠ Groups 1 1-2 hours Dilute 500mg caffeine sodium Record a resting ECG before
sodium and 2 benzoate in 1 litre of N/S. administration. Monitor for possible
benzoate side effects: tachycardia, cardiac
For treating low arrythythmias, extra-systoles,
CSF pressure restlessness, agitation, nausea,
headache diuresis, hypoglycaemia, and
hyperglycaemia.
Note that caffeine and sodium
benzoate injection is unlicensed (See
page 1
Calcitonin SC injection ♠ Groups Refer to the Marsden Manual for Allow the ampoule or vial to reach
1,2,3,4 and 5 guidance on SC injection. room temperature before SC or IM
IM injection ♠ Groups Refer to the Marsden Manual for injection.
1,2,3,4 and 5 guidance on IM injection. When in use the 400unit in 2ml
multidose vial can be stored at room
temperature. Record date of first use.
Discard the remaining contents of the
400unit in 2ml multidose vial 1 month
after first use.
Ampoules of calcitonin are for single
use only.
For hypercalcaemia ♠ Groups Suggestion: 1-2 May be given by IV injection for
of malignancy 1,2,3,4 and 5 minutes hypercalcaemia of malignancy after
IV injection* previous rehydration.* Do not use the
calcitonin from the multiple dose
400unit in 2ml vial for bolus injection
(As it contains phenol).
(I) IV infusion for ♠ Groups At least 6 hours Dilute 10units/kg in 500ml N/S. Some adsorption of calcitonin to the
severe or emergency 1,2,3,4 and 5 plastic of the infusion set will occur so
cases of monitor the patient’s response to
hypercalcaemia of treatment.
malignancy only.
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND SUITABLE COMMENTS
GIVE OVER DILUENT
Calcium IV bolus ♠ Groups Maximum adult If 10% Calcium Chloride Minijets are not available then Very irritant; always administer
chloride Emergency use 1 and 2 rates: in cardiac arrest give 6.8ml of 14.7% calcium chloride slowly. Extravasation may
or for severe acute 1ml of 14.7%/minute undiluted which is 6.8mmol Ca2+ (equivalent to a 10% cause tissue irritation and
hypocalcaemia 1-1.5ml of Calcium Chloride Minijet) necrosis. Flush with N/S.
10%/minute Calcium chloride 10% contains
1ml of 13.4%/minute 6.8mmol calcium/10ml.
Calcium chloride 13.4%
(I) or (C) IV ♠ Groups Adults: Maximum May be diluted with N/S, G or G/S to any suitable
contains 9.12mmol
infusion. Infusion 1 and 2 rate 1mmol/minute. volume. However, concentrations greater than 10ml of
pump is required. 14.7% calcium chloride in each 100ml diluent will be calcium/10ml.
irritant to peripheral veins and should ideally be given Calcium chloride 14.7%
via a central IV line. contains 10mmol calcium/10ml.
Calcium See Folinic Acid
folinate
Calcium IV bolus ♠ Groups Adults: Each 10ml If 10% Calcium Chloride Minijets are not available then Flush with N/S.
gluconate Emergency use or 1 and 2 ampoule preferably in cardiac arrest give 30ml of 10% calcium gluconate Calcium gluconate 10%
for severe acute over 5 minutes, undiluted which is 6.6mmol Ca2+ (approximately contains 2.2mmol calcium in
hypocalcaemia minimum 3 minutes. equivalent to a 10% Calcium Chloride Minijet) 10ml.
Irritant; extravasation may
(I) or (C) infusion ♠ Groups Adults: Maximum May be diluted with N/S, G or G/S to any suitable
cause tissue irritation and
using plastic 1 and 2 rate by infusion volume e.g. 100ml, 250ml, 500ml or 1 litre. However,
ampoules of 200mg (0.44mmol concentrations greater than 10ml of 10% calcium necrosis.
calcium gluconate Calcium)/minute gluconate in each 100ml diluent will be irritant to
peripheral veins and should ideally be given via a
central IV line.
In severe acute hypocalcaemia or hypocalcaemic tetany, an initial slow intravenous injection of 10–20 ml of calcium gluconate injection 10% (use the plastic
ampoules) should be given, with plasma-calcium and ECG monitoring (risk of arrhythmias if given too rapidly), and either repeated as required or, if only
temporary improvement, followed by a continuous intravenous infusion to prevent recurrence. For infusion, dilute 100 ml of calcium gluconate 10%(Use the
plastic ampoules) in 1 litre of glucose 5% or sodium chloride 0.9% (remove 100ml from the bag first) and give at an initial rate of 50 ml/hour adjusted according
to response.
Calcium gluconate injection in glass ampoules or vials is now contra-indicated for use as repeated or prolonged treatment, including as an IV infusion, in
children younger than 18 years and in patients with renal impairment. This is to limit exposure of patients to aluminium which is leached from the glass by the
calcium gluconate solution. (MHRA Drug Safety Update, August 2010).
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND SUITABLE COMMENTS
GIVE OVER DILUENT
‘Campath’ See Alemtuzumab
Caspofungin (I) IV infusion. ♠ Groups 1 hour Allow the vial to warm to room temperature. If the patient is fluid restricted
Infusion pump is 1,2,3,4 and 5 Reconstitute each 50mg and 70mg vial with 10.5ml the 50mg and 35mg doses may
required. W. For the 50mg dose withdraw 10ml from the be diluted in 100ml N/S or H.
reconstituted 50mg vial. For the 70mg dose Flush with N/S.
withdraw 10ml from the reconstituted 70mg vial. For Do not infuse caspofungin with
reduced dose in moderate hepatic impairment any other drug solutions or
(35mg) withdraw 7ml from the reconstituted 50mg infusions containing glucose.
vial. Further dilute with 250ml N/S or H.
Phebitis is commonly reported.
Cefotaxime IV bolus preferred ♠ Groups 3-5 minutes Reconstitute 500mg with 2ml, 1g with 4ml and 2g Flush with N/S, G or G/S.
Only to be method. 1,2,3,4 and 5 with 10ml W. Sodium content 2.09mmol/1g.
prescribed when Displacement 0.2ml for 500mg vial. Add 1.8ml of W
ceftriaxone is for 500mg in 2ml.
contra-indicated Displacement 0.5ml for 1g vial. Add 3.5ml W for 1g
due to the risk of in 4ml.
precipitation with Displacement 1.2ml for 2g vial. Add 8.8ml W for 2g
calcium in 10ml.
containing fluids (I) IV infusion via♠ Groups 20-60 minutes Reconstitute as above then dilute 1-2g with 40-
and TPN. infusion pump 1,2,3,4 and 5 100ml N/S, G, G/S or H.
IM Injection ♠ Groups Reconstitute as for IV bolus. For paediatric doses Refer to the Marsden Manual
1,2,3,4 and 5 apply the same displacement values. for guidance on IM injection.
Cefoxitine IV bolus preferred ♠ Groups 3-5 minutes Reconstitute the 2g vial with 10ml or 20ml W, N/S, Incompatible with
method 1,2,3,4 and 5 G or G10%. Displacement is 1ml for the 2g vial. aminoglycosides eg.gentamicin,
Shake to dissolve and let stand until clear. tobramycin and amikacin.
(Unlicensed
product – see
IM Injection ♠ Groups Reconstitute the 2g vial with 4ml W. Displacement is Inject into a large muscle mass,
1,2,3,4 and 5 1ml for the 2g vial. Shake to dissolve and let stand eg. gluteus maximus.
page 4)
until clear.
(C) IV infusion via ♠ Groups Reconstitute each 2g vial with 10ml W. Shake to Diluted solutions for IV infusion
infusion pump 1,2,3,4 and 5 dissolve and let stand until clear. Further dilute with must be discarded 12 hours
a suitable volume (eg. 500ml or 250ml) of N/S, G, after preparation.
G10% or H.
Cefradine Cefradine injection is no longer commercially available.
Ceftazidime IV bolus ♠ Groups 3-5 minutes Reconstitute 500mg vial with 5ml, 1g Flush with N/S, G or G/S.
1,2,3,4 and 5 vials with 10ml and 2g vial with 10ml Sodium content 2.3mmol/1g.
A 3g dose (1x1g N/S or G. Carbon dioxide is released; Displacement values vary between brands,
+1x2g vials) may be see package insert. and are not consistent. Refer to the SPC or
given by slow IV package insert for the brand and vial size
bolus. being used.
(I) IV infusion. ♠ Groups Maximum 30 minutes Reconstitute 2g vial with 50ml of N/S
Infusion pump 1,2,3,4 and 5 or G.
is required. For 3g dose, also reconstitute a 1g
vial with10ml N/S. Dilute the
reconstituted 1g and 2g vials further
to 75ml with N/S.
IM Injection ♠ Groups Reconstitute 250mg with 1ml, 500mg Doses exceeding 1g should be given IV – see
1,2,3,4 and 5 with 1.5ml and 1g with 3ml N/S or W. above. When IM injection causes pain
carbon dioxide is released, see Lidocaine 1% injection may be used to
package insert. reconstitute the vial instead of N/S or W.
Ceftriaxone IV bolus ♠ Groups 2-4 minutes Reconstitute 250mg vial with 5ml W Do not give with TPN or fluids containing
1,2,3,4 and 5 and 1g vial with 10ml. Displacement calcium, even by different infusion lines
values vary between brands and are (Cefotaxime is a suitable alternative for
not consistent – refer to the package these patients).
insert or SPC for the particular brand Sodium content: 3.6mmol/1g
and vial size being used. Flush with N/S or G
(I) IV infusion ♠ Groups At least 30 minutes Reconstitute 2g vial with 40ml G, G For infants and children up to 12 years, doses
(doses of 2g 1,2,3,4 and 5 10%, or N/S. of 50mg/kg or over should be given by slow IV
and above) via infusion over at least 30 minutes. (For
infusion pump neonates the dose is given over 60 minutes).
IM Injection ♠ Groups Reconstitute 250mg with 1ml, 1g with Give by deep IM injection. Doses greater than
1,2,3,4 and 5 3.5ml and 2g with 7ml of 1% 1g should be divided and injected at more
lidocaine injection. Refer to the than one site.
Marsden Manual for guidance on IM
injection.
Cefuroxime IV bolus ♠ Groups 3-5 minutes Reconstitute 250mg with at least 2ml, Flush with N/S, G or G/S.
(Usual method) 1,2,3,4 and 5 750mg with at least 6ml and 1.5g with at Sodium content: 1.8mmol/750mg
least 15ml W. Shake gently to produce an Cefuroxime can be added to an infusion bag of
opaque suspension. metronidazole.
(I) IV infusion. ♠ Groups Maximum 30 Reconstitute as above then dilute to Displacement values vary between brands and are
Infusion pump 1,2,3,4 and 5 minutes 50 - 100ml with N/S or G. not consistent – refer to the package insert or SPC
is required. for the particular brand and vial size being used.
IM Injection ♠ Groups Reconstitute 250mg with 1ml W and 750mg
1,2,3,4 and 5 with 3ml W. Shake gently to produce an
opaque suspension. Refer to the Marsden
Manual for guidance on IM injection.
Cernevit and Decan (see page 47) are added daily, Monday to Friday, by Pharmacy to TPN. The TPN bags held as stock on Penrose Ward do not contain
vitamins or trace elements. If TPN is commenced for a Penrose patient when Pharmacy is closed, Penrose staff should confirm whether the duty ICU consultant
wants Cernevit and Decan given separately to the patient (Do not add Cernevit and Decan to the TPN bag on the ward).
Cernevit Slow IV bolus ♠ Groups At least 10 Reconstitute the vial with 5ml of W, N/S or Dosage for adults and children aged over 11
1,2,3,4 and 5 minutes G. years: 1 vial of 5ml per day.
(Water and Mix gently to dissolve the powder forming a Cernevit does not contain Vitamin K.
fat-soluble yellow-orange coloured solution.
vitamins) Either give undiluted or dilute further with a Cernevit may be administered via any type of
small volume of N/S or G. intravenous cannula (including peripheral).
Do not mix with any other drug solutions.

(I) IV infusion ♠ Groups At least 10 Reconstitute the vial with 5ml of W, N/S or
Infusion pump 1,2,3,4 and 5 minutes G.
is required. Mix gently to dissolve the powder forming a
yellow-orange coloured solution, then dilute
further with N/S or G (e.g. up to 50ml).
Chloramphenicol IV bolus ♠ Groups At least 1 minute Reconstitute with W, N/S or G. See Flush with N/S.
sodium succinate (Usual method) 1,2,3,4 and 5 package insert. Suggested maximum Sodium content 2.98/1g
concentration 100mg/1ml. In order to ensure rapid attainment of high
Displacement 0.8ml/1g vial. Add blood levels, chloramphenicol succinate is
9.2ml diluent to 1g vial for 1g in 10ml best administered by IV injection. Where this
(100mg in 1ml). is not possible, however, IM injection may be
used, although it should be borne in mind that
absorption may be slow and unpredictable.
(I) IV infusion. ♠ Groups Give slowly over 15 Reconstitute as above then dilute
Infusion pump 1,2,3,4 and 5 to 30 minutes with N/S or G (suggested volume
is required. 100ml).
Clomethiazole Discontinued product

Chloroquine (C) IV infusion. ♠ Group 1 Initially 10mg/kg of Dilute with N/S to a suitable volume Oral therapy is started as soon as possible to
Infusion pump is Chloroquine base e.g. 50ml. complete the course.
required. over 8 hours then Flush with N/S.
5mg of base/kg for 3
more 8-hour
infusions
Chlorphenamine IV bolus ♠ Groups Minimum 1 minute May be diluted with N/S to a Flush with N/S (IV)
1,2,3,4 and 5 convenient volume e.g. 10ml. Extra care should be taken when preparing the
injection for children under 1 year due to the
IM injection ♠ Groups Refer to the Marsden Manual for
guidance on IM injection. small volumes that are required. Dilution of
(Use the IV route 1,2,3,4 and 5
chlorphenamine injection with N/S should
if a rapid effect is
facilitate preparation. For example, diluting
required)
0.2ml chlorphenamine injection to 2ml with
SC injection ♠ Groups Refer to the Marsden Manual for N/S produces a solution containing
(Use the IV route 1,2,3,4 and 5 guidance on SC injection. chlorphenamine 1mg/ml. The diluted product
if a rapid effect is should be used immediately.
required)
Chlorpromazine Deep IM ♠ Groups Refer to the Marsden Manual for IM injection can be repeated at 6 to 8 hour
injection 1,2,3,4 and 5 guidance on IM injection. intervals if required. Substitute with oral
(I) IV infusion via ♠ Groups Slowly Dilute 25-50mg with 500ml-1 litre chlorpromazine as soon as possible.
an infusion pump 1,2,3,4 and 5 (Suggestion: 12 N/S. Very irritant; avoid IV administration if
to treat hiccups hours) possible. Do not administer via the SC
when IM route.
injection fails.
IV bolus ♠ Groups Adults: Maximum Dilute to a maximum concentration of
1mg/minute. 1mg/1ml with N/S. Flush with N/S (IV).
1,2,3,4 and 5
(This method is Sodium content 0.2mmol/2ml.
unlicensed – see Hypotension can occur, especially with rapid
page 1). administration: Keep the patient supine and
monitor the blood pressure during and for 30
minutes after IM or IV administration.
Ciclosporin (I) IV infusion. ♠ Groups 2-6 hours Dilute to a concentration of each Use infusion within 6 hours of
Infusion pump is 1,2,3,4 and 5 50mg in 20-100ml of N/S or G. preparation because the solution
required. contains polyethoxylated castor oil
which causes phthalate leaching from
PVC containers and tubing.
Observe patient continuously for the
first 30 minutes and at frequent
intervals thereafter (Risk of
anaphylactic reactions, acute
respiratory distress, blood pressure
changes).
Flush with N/S.
Ciprofloxacin (I) IV infusion. ♠ Groups Adults: 200mg over Provided suitably diluted. Flush with N/S.
Not for general Infusion pump is 1,2,3,4 and 5 30 minutes, 400mg Sodium content 15.4mmol/100ml.
use. Refer to Trust required. over 60 minutes.
Policy for Control Infusion into a For children, infuse
of Infection. large vein will the dose over 60
reduce venous minutes.
irritation (low pH)
Clarithromycin (I) IV infusion via a ♠ Groups 60 minutes Reconstitute 500mg vial with 10ml W Do not give by IV bolus (can cause
large peripheral vein (or 1,2,3,4 and 5 and shake to dissolve the contents. cardiac arrythmias). Do not give by IM
central vein). Infusion Further dilute to a concentration of injection.
pump is required. 2mg/ml with N/S, G or H (Adult dose The reconstituted vial contains 500mg
of 500mg = 10ml of reconstituted in 10ml (although the final volume in
solution in 250ml N/S, G or H). the vial will be 10.4ml).
Use infusion within 6 hours of
preparation.
Flush with N/S or G. Sodium content:
Less than 0.5mmol/500mg
For fluid restricted patients 500mg Incompatible with aminophylline,
clarithromycin, reconstituted as cefuroxime, furosemide, heparin,
above, may be diluted in 100ml of phenytoin, flucloxacillin and
N/S and infused over 60 minutes via ceftazidime.
a central IV line (This dilution is Monitor infusion site for signs of
unlicensed). inflammation, tenderness, phlebitis and
pain.
Clindamycin (I) IV infusion ♠ groups 300mg over at least Dilute to a maximum concentration of Flush with N/S.
Maximum 1.2g. Infusion 1,2,3,4 and 5 10 minutes, 600mg 18mg/ml with N/S or G. Sodium content: Nil.
pump is required. over at least 20 Typically:
minutes, 900mg over For doses of 300mg, 600mg or
at least 30 minutes, 900mg, dilute in 50ml or 100ml N/S
1.2g over at least 40 or G.
minutes. Dilute 1200mg in 100ml N/S or G.
(C) IV infusion ♠ Groups Rate not to exceed Dilute to a maximum concentration of Continuous intravenous infusion may
Doses above 1.2g 1,2,3,4 and 5 30mg/minute. 18mg/ml with N/S or G. begin with a single rapid infusion of the
Infusion pump is first dose (generally over 30minutes),
required. followed by a continuous infusion of
0.75 to 1.25mg/minute.
IM injection ♠ Groups Refer to the Marsden Manual for Single IM injections of greater than
1,2,3,4 and 5 guidance on IM injection. 600mg are not recommended.
Clonazepam IV bolus ♠ Groups Adults: Maximum rate Immediately before use dilute Resuscitation equipment must be readily
0.25 - 0.5mg/minute
In to a large vein 1,2,3,4 and each 1mg in 1ml with 1ml W available.
in the antecubital 5 Infants & children: (diluent supplied), to produce a EEG, respiratory function and blood pressure
fossa. 50microgram/kg 1mg in 2ml solution. should be monitored.
Emergency use (maximum 1mg) over at Flush with N/S, G or G10%.
least 2 minutes Sodium content: Nil
(I) IV infusion. ♠ Groups Adjust rate according to Dilute up to 3mg in 250ml of N/S, If using a PVC bag and/or a PVC line begin
Infusion pump is 1,2,3,4 and response. G, G10% or G/S(2.5%/0.45%). the infusion immediately and infuse over a
required. 5 Neonates and children 1 On Neonatal ICU dilute to a period no longer than 2 hours.
month to 18 years: maximum concentration of Alternatively dilute to 12 micrograms/ml with
300micrograms in 25ml or N/S in a 50ml Terumo or BD syringe using a
10 – 60
600micrograms in 50ml (12 PVC-free extension set. The following are
micrograms/Kg/hour =
micrograms/ml) with G10%. In available to be ordered from NHS Supplies:
0.83 – 5ml/kg/hour of
fluid restricted infants Codan PVC-free extension set 71.4001, order
the 12microgram/ml
concentrations up to code FKA064
dilution.
100micrograms/ml have been Alaris G30302M line, order code FKA058
used. Using this method the solution will be stable
for 12 hours.
Clonidine IV bolus ♠ Groups Give slowly preferably Can be diluted with N/S or G to Flush with N/S.
1 and 2 over 10-15 minutes to any suitable volume. Sodium content 0.15mmol/1ml.
avoid transient pressor (C) IV infusion is unlicensed (See page 4).
effect. Monitor for bradycardia and hypotension.
(C) IV infusion ♠ Groups Usual rate: 0.5 - 1 Dilute 750 micrograms to 50ml Withdraw gradually to avoid rebound
for sedation/ 1 and 2 micrograms/kg/hour. with N/S or G. tachycardia, hypertension, agitation and
withdrawal from Rates up to 2 sweating.
sedation in microgram/kg/hour have Very little compatibility data – infuse through a
critical care been used. dedicated lumen or line. May be infused via a
areas only. peripheral or central IV line.
Infusion pump is
required.
(C) Intrathecal ♠ Group 1 Prepare and administer in * Restricted to those persons who are trained
infusion or or Group 2* accordance with the Pain and competent to administer medication via
Intrathecal bolus Management Centre procedures the intrathecal route.
Co-amoxiclav IV bolus ♠ Groups 3-4 minutes Reconstitute 1.2g vial with 20ml Flush with N/S.
Usual method. 1,2,3,4 and 5 W and 600mg vial with 10ml W. Complete infusion within 4 hours of
For doses requiring part of a vialreconstitution.
Displacement values: Sodium content 2.7mmol/1.2g.
Bowmed/Actavis brand: Potassium content 1mmol/1.2g.
0.4ml for the 600mg vial and For bolus injection use within 20 minutes of
0.7ml for the 1.2g vial. reconstitution.
Augmentin® and Wockhardt Do not dilute Co-amoxiclav with G.
brands: Not suitable for IM injection.
0.5ml for the 600mg vial and Example: How to give 900mg
0.9ml for the 1.2g vial. Using a 20ml syringe, reconstitute a 1.2g vial
(I) IV infusion. ♠ Groups 30-40 minutes Reconstitute as above then dilute with 15ml WFI. Draw up the entire vial
Infusion pump is 1,2,3,4 and 5 1.2g with 100ml N/S or 600mg contents into the syringe then draw up more
required. with 50ml N/S. W to the 20ml mark. Mix the syringe contents.
Then administer 15ml (contains 900mg) and
discard 5ml.
Colistimethate (I) IV infusion. ♠ Groups 30 minutes Reconstitute all vial strengths Flush with N/S.
(Colistin) Infusion pump is 1,2,3,4 and 5 with 10ml W or N/S. Roll vial in Do not infuse with any other drugs.
(Colomycin ®) required. hand to dissolve. Do not shake to Sodium content: less than 0.5mmol per
avoid foam formation, then dilute 500,000 unit and 1,000,000 unit vials
further with N/S to 50ml.
Patients with a ♠ Groups Via TIVAD only: Reconstitute all vial strengths The powder for injection is also licensed for
Totally Implantable 1,2,3,4 and 5 Minimum 5 with 10ml W or N/S. Roll vial in use via a nebuliser. To nebulise dissolve
Venous Access minutes hand to dissolve. Do not shake to dose in 2-4ml of W or N/S. The output from
Device (TIVAD) avoid foam formation. the nebuliser may be vented to the open air
may tolerate a or a filter may be fitted. Nebulisation should
slow IV bolus of up take place in a well ventilated room.
to 2 million units
Collagenase 0.58mg per ♠ Group 1 Remove the vial from the fridge Each vial is for single use only.
Clostridium injection into a and allow to stand at room When injecting a cord affecting a
histolyticum palpable temperature for at least 15 proximal interphalangeal joint of the fifth
▼ This product is Dupuytren's cord minutes and no longer than 60 finger, the needle insertion must not be
being intensively minutes. Reconstitute the vial more than 2 to 3 mm in depth and not
monitored by the CHM with the solvent supplied more than 4 mm distal to the palmar
and MHRA. Please according to the table below. Use digital crease.
report all suspected only the supplied solvent as it
reactions (including contains calcium required to Sodium injected per joint:
non-serious ones) activate the medication. Inject the Metacarpophalangeal joints: 0.9mg
using a Yellow Card appropriate volume (see below) Proximal interphalangeal joints: 0.7mg
from the BNF of the solvent slowly into the
sides of the vial. Do not invert or
shake the solution. Slowly swirl to
ensure dissolution. The final
solution must be clear and
colourless.
Volumes needed for reconstitution and administration of Collagenase Clostridium histolyticum
Joint to be treated Solvent required for reconstitution Injection volume to deliver 0.58 mg dose*
Metacarpophalangeal joints 0.39ml 0.25ml
Proximal interphalangeal joints 0.31ml 0.20ml
* Note that injection volume for delivery of a 0.58 mg dose is less than the total volume of solvent used for reconstitution.
Co-trimoxazole (I) IV infusion. ♠ Groups The dilution of Septrin For patients with Pneumocystis Do not infuse with any other drugs.
Infusion pump 1,2,3,4 and brand for PJP jirovecii (formerly known as Flush with N/S.
is required. 5 (Formerly known as Pneumocystis carinii) Monitor all infusions carefully for turbidity and
PCP) – each 5ml with pneumonitis crystallization.
75ml G – should be Commence the infusion within half an hour of
Septrin brand: Dilute each 5ml
given over no longer preparation.
with at least 75ml G.
than 1 hour. High doses have been given undiluted via a
Other infections dilute each central line and syringe pump over 1.5 - 2
Other dilutions should hours; not recommended by manufacturer.
480mg (5ml) with 125ml,
be given over no Sodium content 1.64mmol/480mg.
960mg (10ml) with 250ml,
longer than 90 Extravasation : may cause tissue damage.
1440mg (15ml) with 500ml or an
minutes, but this
equivalent dilution with N/S, G or
should be balanced
G/S.
against the patient’s
These infusions must be
fluid requirements
administered within 6 hours
Cyclizine IV bolus ♠ Groups 3-5 minutes Can be diluted with N/S or G if Flush with 5 ml of N/S or G.
1,2,3,4 and necessary to a convenient Sodium content nil.
5 volume e.g. 5ml. If diluted with
N/S, visually check the dilution.
Discard if there is any
crystallization, precipitation or
haziness. Otherwise use
immediately.
IM Injection ♠ Groups Refer to the Marsden Manual for
1,2,3,4 and guidance on IM injection.
5
(C) SC ♠ Groups Continuous over 24 Dilute with W. Follow the PHNT Care of The Dying Pathways
infusion via 1,2,3,4 and hours and the PHNT Syringe Driver Policy.
syringe driver 5 Cyclizine may precipitate if the concentration
in palliative in W exceeds 10mg/ml.
care Precipitation occurs if mixed with N/S.
For combinations of 2 or 3 drugs in the same
(C) SC ♠ Groups Refer to the Marsden Manual for
injection for guidance on SC injection. syringe, refer to the Syringe Driver Drug
1,2,3,4 and
use in Compatibility chart provided in the pump kit.
5
palliative care Contact Pharmacy on ext. 39976 for further
compatibility advice if necessary.
Cyclizine is not licensed via the SC route (See
page 124).
Cyclophosphamide When cyclophosphamide is prescribed to treat conditions including multiple sclerosis, glomerular kidney disease or rheumatoid
arthritis, it may be administered by Group 2 ♠ practitioners who have previous experience of administering parenteral cytotoxics.
Read Appendix 3 for guidance on the handling of cytotoxic drugs. On the Planned Investigation Unit, refer to the Unit protocol.
Danaparoid IV loading dose ♠ Groups See comments Dilute with N/S, G or G/S. The Seek advice of Consultant Haematologist as
injected over 30 1,2,3,4 and 5 volume of diluent is not critical and the Consultant Haematologists have different
seconds followed by (C) can be adjusted to the fluid needs of regimens for different indications.
IV infusion to treat the patient.
thrombo-embolism in One suggested dilution: Draw up the
patients with contents of six 750 unit ampoules
Heparin- Induced (6x750 units = 4500 units) into a
Thrombocytopenia 50ml syringe and dilute to 45ml with
(HIT). Infusion pump is N/S or G to make a 100unit/ml
required. dilution.
However, if the maintenance
infusion rate is less than 187
units/hour the above dilution will
waste danaparoid (expensive). In
this case draw up the contents of
three 750 unit ampoules (3x750units
= 2250 units) into a 50ml syringe
and dilute to 45ml with N/S or G to
make a 50unit/ml dilution.
Dantrolene IV bolus ♠ Group 1 Give rapidly Reconstitute 20mg with 60ml W. Due to high pH (9.5) avoid extravasation.
Shake the vial until the solution is Sodium content 2mmol/20mg vial.
clear. Each 20mg vial also contains 3g mannitol.
Protect from light.
Incompatible: do not give with any other
drugs or infusion fluids including G and N/S.
Daptomycin IV bolus ♠ Groups 2 minutes Reconstitute the 500mg vial with 10ml Contains negligible sodium (<0.05mmol/vial).
May only be 1,2,3,4 and 5 N/S or the 350mg vial with 7ml N/S Do Treatment should be discontinued if the CPK
initiated on the not use W to reconstitute. Gently level reaches greater than 5 times upper limit
advice of a rotate the vial to ensure complete of normal in the presence of unexplained
consultant wetting of the product and then allow to muscle symptoms.
microbiologist stand for 10 minutes. The vial should Store vial in a refrigerator at 2-8oC.
then be gently rotated/swirled for a few If clotting profiles are required during
minutes as needed to obtain a clear treatment, samples should be taken pre-dose.
reconstituted solution. Vigorous Compatible with: Aztreonam, ceftazidime,
shaking/agitation should be avoided to ceftriaxone, dopamine, fluconazole,
prevent foaming of the product. The gentamicin, heparin, levofloxacin, lidocaine.
concentration of the reconstituted Incompatible with Glucose solutions.
solution is 50mg/ml (No displacement)
Flush with N/S.
(I) IV infusion ♠ Groups 30 minutes Reconstitute and dissolve as above.
1,2,3,4 and 5 Further dilute to 50ml or 100ml N/S.
Cernevit (See page 35) and Decan are added daily, Monday to Friday, by Pharmacy to TPN. The TPN bags held as stock on Penrose Ward do not contain
vitamins or trace elements. If TPN is commenced for a Penrose patient when Pharmacy is closed, Penrose staff should confirm whether the duty ICU
consultant wants Cernevit and Decan given separately to the patient (Do not add Cernevit and Decan to the TPN bag on the ward).
Decan (I) IV infusion ♠ Groups Suggestion: 1 Via a peripheral IV cannula, 40ml Dosage for adults: 1 vial of 40ml per day.
Infusion 1,2,3,4 and 5 hour Decan must be diluted to at least 250ml Contra-indicated in children, patients
(Trace pump is with N/S, or to at least 500ml with G. weighing less than 40kg and in patients with
elements) required. Via a CVC or PICC line, 40ml Decan pronounced cholestasis (serum bilirubin >
may be diluted in a smaller volume of 140micromol/l).
N/S or G or given undiluted if
necessary. Do not mix with any other drug solutions.
Desferrioxamine (I) or (C) IV ♠ Groups Treatment of acute Reconstitute each 500mg with 5ml W Discard infusion if opalescent.
infusion. 1,2,3,4 and 5 iron poisoning: and each 2g vial with 20ml W then Flush with N/S.
Infusion 15mg/kg/hour, dilute with N/S, G or G/S. to any May be infused into the blood line through
pump is reduced as soon as suitable volume (e.g. 500ml, 1000ml a “Y” adaptor located near to the venous
required. the situation permits or 250ml). site of injection.
(usually after 4-6 Example for treating acute iron For use in children with chronic iron
hours). Total IV dose poisoning: Reconstitute 5 x 2g vials overload follow the protocol on CYPOD
not to exceed each with 20ml W, remove 100ml (Childrens’ and Young Persons Outpatient
80mg/kg in any 24 from a 500ml bag of N/S and add the Department).
hour period contents from the 5 x 2g vials to the
Chronic iron bag then to produce 10g
overload: desferrioxamine in 500ml(=20mg/ml). Desferrioxamine is incompatible with
The initial rate for will be heparin solutions.
20 – 60mg/kg/day
0.75ml/kg/hour (= 15mg/kg/hour).
Displacements: 0.4ml/500mg
Desferal® vial, 0.3ml/500mg Hospira
vial and 1.5ml/2g vial (both brands).
SC infusion ♠ Groups Chronic iron Suggestion: Reconstitute as above
If giving by SC infusion, monitor for
using a 1,2,3,4 and 5 overload: then either dilute with N/S or give
irritation or discomfort at the site of
portable 20 – 60mg/kg/day. without further dilution.
administration.
ambulatory Infuse the dose over
pump 8 to 24 hours
Desmopressin SC injection ♠ Groups Refer to the Marsden Manual for Flush after IV bolus with N/S.
4micrograms in 1,2,3,4 and 5 guidance on SC injection. After repeated doses monitor for fluid
1ml overload; restrict fluid intake and check body
weight regularly
1,2,3,4 and 5 guidance on IM injection.
IV bolus ♠ Groups Suggestion: 1 minute Undiluted
1,2,3,4 and 5
(I) IV infusion ♠ Groups 20 minutes Dilute the dose to 50ml with N/S Tachycardia, hypotension and facial flushing
(Haemophilia 1,2,3,4 and 5 but see comments. may occur during infusion; monitor blood
and Von pressure continuously during infusion.
Willibrands). For (I) IV infusion 100ml N/S can be used
Infusion (unlicensed) if necessary but the 20 minute
pump is infusion time should be adhered to.
required. Do not mix with other fluids or drugs
Desmopressin SC injection ♠ Groups Refer to the Marsden Manual for
15micrograms 1and 2 guidance on SC injection.
in 1ml
(I) IV infusion ♠ Groups 1 20 minutes Dilute the dose to 50ml with N/S Tachycardia, hypotension and facial flushing
(OCTIM Brand) but see comments. may occur during infusion; monitor blood
Infusion and 2
For specialist pump is pressure continuously during infusion.
use in Birch required. Do not mix with other fluids or drugs.
Outpatients or
Restrict fluid intake and check body weight
Haematology
regularly.
Outpatients
Continued monitoring of Factor VIII levels is
recommended.
Dexamethasone IV bolus or ♠ Groups Organon brand: May be diluted with N/S, G or H to Organon brand contains a quantity of
sodium (I) IV infusion. 1,2,3,4 and Give 4mg over 1 any convenient volume. dexamethasone phosphate equivalent to
phosphate Infusion pump is 5 minute. 4mg/ml dexamethasone.
required. Give large doses
over several Hospira brand contains a 8mg in 2ml of
minutes. dexamethasone phosphate equivalent to
6.6mg dexamethasone in 2ml (3.3mg/ml).
Hospira brand:
Flush IV doses with N/S.
For a 4mg Anaphylactic reactions can occur.
dexamethasone
dose give 1.2ml (For treatment of anaphylaxis see page 38).
over 1 minute. The IV and IM routes of administration of
Give large doses dexamethasone should only be used where
over several acute illness or life-threatening situations
minutes. exist. Oral therapy should be substituted as
soon as possible.
Note that absorption will be slower after IM
1,2,3,4, 5 guidance on IM injection.
injection.
Intra-articular ♠ Group 1 Prior to intra-articular injection, the joint fluid
should be examined to exclude a septic
process. Administer under strictly aseptic
conditions.
Soft tissue ♠ Group 1 Licensed sites include: bursae, tendon
infiltration sheaths and ganglia.
(Intralesional)
Intrathecal ♠ Group 1 Administer in accordance with the *Restricted to those persons who are trained
(Use Hospira or Group 2* Pain Management Centre and competent to administer medication via
brand vials) procedures or current anaesthetic the intrathecal route.
(Unlicensed practice. Use Hospira brand dexamethasone as it does
route) not contain glycerol or disodium edetate.
Dexrazoxane (I) IV infusion ♠ Groups 15 minutes Infusion to be prepared by Administer about 30 minutes before
(Cardioxane®) 1,3 and 5 Pharmacy. Telephone Ext. 31083. anthracycline (e.g. doxorubicin or epirubicin)
administration.
Handle as for cytotoxics. Wear gloves and
safety glasses when handling – See
Appendix 3. Avoid handling drug if pregnant.
Store the prepared infusion in the fridge and
use within 6 hours of pharmacy preparation.
Dexrazoxane (I) IV infusion ♠ Groups 1 – 2 hours Infusion to be prepared by The first infusion should be initiated as soon
(Savene®) into a large vein 1,3 and 5 Pharmacy. Telephone Ext. 31083. as possible and within the first six hours after
in extremity/area the accident. Cooling procedures such as ice
other than the packs should have been removed from the
one affected by area at least 15 min before the Savene
the extravasation administration in order to allow sufficient
blood flow. Treatment Day 2 and Day 3
should start at the same hour (+/- 3 hours) as
on the first day.
Refer to the Guidelines for the administration
of Savene(dexrazoxzane) for the treatment of
extravasations caused by anthracyclines.
Diamorphine Staff prescribing, administering and/or screening prescriptions for opioid medications should be familiar with the PHNT Policy for
Reducing Errors with Opioid Medicines in Adults (Network Drive :Groups (G) > Trust Documents > Documents > Medicines Management
folder). The PHNT Analgesic Ladder and equivalent dosages of different opioids can be found on page 185.
IV bolus ♠ Groups Maximum rate Usually reconstitute 5mg, 10mg , Observe respiratory rate (especially with IV
1,2,3,4 and 1mg/minute 30mg and 100mg ampoules with bolus doses). Naloxone and resuscitation
5 1ml W. Use a minimum of 2ml W to equipment should be available.
reconstitute 500mg ampoule. For acute pain the IV dose will be a quarter to
Can be diluted with N/S or G. half of the corresponding IM dose. For elderly
and frail patients reduce the usual dose by
half. Flush with N/S or G. Sodium content nil.
IM injection ♠ Groups Reconstitute as above. Refer to the
1,2,3,4 and Marsden Manual for guidance on IM
5 injection.
SC injection ♠ Groups Reconstitute as above. Refer to the For use in palliative care follow the PHNT Care
1,2,3,4 and Marsden Manual for guidance on of The Dying Pathways
5 SC injection.
(C) SC infusion ♠ Groups Continuous over 24 Reconstitute as above. Dilute further Follow the PHNT Care of The Dying Pathways
via syringe 1,2,3,4 and hours with W when 2 or more drugs are and the PHNT Syringe Driver Policy.
driver in 5 being mixed in the same syringe. For combinations of 2 or 3 drugs in the same
palliative care W or N/S may be used where the syringe, refer to the Syringe Driver Drug
syringe only contains diamorphine. Compatibility chart provided in the pump kit.
Contact Pharmacy on ext. 39976 for further
In chronic pain, the total daily dosage of IM or
SC diamorphine is about one third of the
equivalent total daily dosage of oral
morphine.
Epidural or ♠ Group 1 Administer in accordance with All syringes containing solution for epidural
spinal injection standard anaesthetic practice. administration should be labelled “For Epidural
Use Only” (NPSA/2007/21)
Diamorphine 50 All epidural administration sets and epidural catheters must be labelled “Epidural” when in use (NPSA/2007/21)
micrograms/ml Epidural ♠ Groups Background rate of Pre-made bags supplied by *Staff administering and monitoring epidural
with infusion via 1and 2* 0 -10 ml/hour with Pharmacy. infusions must have received training from
bupivacaine McKinley additional Patient- the Acute Care Team and demonstrated their
0.167% epidural pump Controlled Epidural When these are not available the competency at administering and monitoring
infusion for Analgesia (PCEA) of anaesthetist may prepare the epidural infusions. Follow the Acute Care
adults 5ml boluses with a infusion in theatre, with the bag Team Protocols. Additional clinician boluses
lock-out time of 30 labelled “For Epidural Use Only”. may be administered by Pain Nurses if
minutes, if prescribed. required as per epidural protocol.
Diazepam IV bolus ♠ Groups Maximum rate: 5mg Do not dilute. Flush with G (do not use N/S).
emulsion 1,2,3,4 and 5 (1ml) per minute.
(Diazemuls) (I) IV infusion. ♠ groups Titrate dose to Dilute 2-8ml with 100ml G or Use infusion within 6 hours. Diazepam is
(This is the Infusion response. G10%, to produce a adsorbed by plastic infusion equipment.
1,2,3,4 and 5
preferred pump is concentration between 100- It can be injected into the infusion tubing
diazepam required. . 400micrograms/1ml. during an ongoing infusion of N/S, G or
formulation for G10%.
IV injection)
Diazepam IV bolus ♠ Groups Suggestion for adults: Undiluted Elderly or debilitated patients should be given
1,2,3,4 and 5 Maximum rate 5mg not more than half of the usual dose.
(1ml) per minute Flush with N/S or G. Give IV injections into a
(C) or (I) IV ♠ Groups Titrate dose to Dilute with N/S or G to a large vein to reduce local reactions
infusion. 1,2,3,4 and 5 response. concentration not exceeding (thrombophlebitis and thrombosis).
Infusion 40mg in 500ml. It is recommended that patients should
pump is remain under medical supervision and in a
required. supine position for at least one hour after
administration. Resuscitation equipment
should be available. Use infusion within 6
hours. Diazepam is adsorbed by plastic
infusion equipment.
IM injection ♠ Groups Refer to the Marsden Manual for The IM route should only be used when IV or
1,2,3,4 and 5 guidance on IM injection. oral administration is not possible.
Diclofenac (C) or (I) ♠ Groups 1 Treatment of post-op First add 0.5ml of 8.4%, or 1ml of Only use if solution is clear. Once prepared,
Infusion. and 2 pain: 4.2% sodium bicarbonate solution use infusion immediately.
Do NOT give 75mg over to 100-500ml N/S or G with then Maximum daily dosage is 150mg.
as IV bolus. 30 minutes - 2hours. add the contents of one ampoule Parenteral administration should not exceed 2
Infusion Prevention of post-op (75mg diclofenac in 3ml). days.
pump is pain: Flush with N/S or G.
required. 25-50mg over Sodium content: negligible.
15 minutes - 1 hour Do not infuse with any other drugs.
then (C) IV infusion at
5mg/hour.
IM injection ♠ Groups 1 Give undiluted. By deep intragluteal injection into the outer
and 2 Refer to the Marsden Manual for quadrant. If a second IM injection of
guidance on IM injection. diclofenac is needed, it is advised that the
other buttock is used.
Dicobalt edetate IV bolus. ♠ Group 1 Adults: Each 300mg Give undiluted. Each dose may be followed immediately with
dose over 1 minute, 50ml G 50%.
or in less severe 100% oxygen should be administered
poisoning over 5 concurrently with Dicobalt Edetate.
minutes. When the patient is fully conscious, it is
unlikely that the extent of poisoning warrants
the use of Dicobalt Edetate Injection.
DigiFab ® (I) IV infusion. ♠ Groups 30 minutes Reconstitute each vial with 4 ml Can rarely cause anaphylaxis, allergic or
(Digoxin Infusion 1,2,3,4 and 5 W. Mix gently. The reconstituted febrile reactions.
Immune Fab) pump is solution may be further diluted to Resuscitation equipment should be available.
required. any convenient volume with N/S. Monitor blood pressure & body temperature.
Bolus only if ♠ Group 1 Reconstitute as above. Monitor ECG continuously during and for at
cardiac arrest least 24 hours after Digibind.
seems Hypokalaemia can develop- sometimes
imminent rapidly. Monitor serum potassium level
carefully during and after DigiFab.
Digoxin (I) IV infusion. ♠ Groups Emergency Loading Adults: Dilute loading and ECG monitoring required. Flush with N/S.
Infusion 1,2,3,4 and 5 Dose of maintenance doses to 50-100ml Emergency Loading Dose depends on age,
pump is 500micrograms to with N/S. lean body weight and renal function. Consider
required. 1mg infused over at giving a reduced dose if digoxin has been
least 2 hours (see taken within the last 2 weeks.
comments) Note that 500micrograms of IV digoxin is
Maintenance dose equivalent to 750micrograms of digoxin in
(when patient unable tablet form.
to take by mouth or For plasma monitoring, take blood at least 6
enteral feeding tube) hours after a dose.
infused over 1 hour.
Dihydro- For the use of IV dihydroergotamine to treat migraine or cluster headache, follow a copy of the protocol from the Planned Investigation
ergotamine Unit (PIU). The protocol may also be found on Plymouth Healthnet > Depts > Pharmacy. Note that dihydroergotamine injection is an
unlicensed product (see page 4).
Disopyramide Slow IV ♠ Groups Adults: 2mg/kg Either give undiluted or dilute ECG monitoring is necessary. Monitor for ventricular
Regimen 1 bolus 1 and 2 (maximum 150mg) further with any suitable volume of arrythmias, widening of QRS complex and lengthening
over at least 5 N/S or G. of QT interval, hypotension, hypoglycaemia, myocardial
minutes depression, AV block and antimuscarinic side effects.
Stop administration of disopyramide if width of QRS-
complex or QT-interval increase by more than 25%, or
hypogylaemia occurs.
If cardioversion occurs during the injection, stop

injecting the remainder of the dose.
If cardioversion is achieved (usually within 10-15

minutes after the first injection) but the arrhythmia
recurs, a second dose of 2mg/kg (maximum 150mg)
may be given by slow IV injection over at least 5
minutes (maximum of 300mg in the first hour,
maximum of 800mg disopyramide by any route in 24
hours).
Flush slowly with N/S.
Disopyramide Slow IV ♠ Groups Adults: 2mg/kg Either give undiluted or dilute ECG monitoring is necessary. Monitor for ventricular
Regimen 2 loading 1 and 2 (maximum 150mg) further with any suitable volume of arrythmias, widening of QRS complex and lengthening
This regimen dose over at least 5 N/S or G. of QT interval, hypotension, hypoglycaemia, myocardial
should be used for minutes depression, AV block and antimuscarinic side effects.
patients who are Stop administration of disopyramide if width of QRS-
unable to take complex or QT-interval increase by more than 25%, or
disopyramide by (C) IV ♠ Groups Adults: Suggested dilution: hypogylaemia occurs.
mouth or who maintenance 1 and 2 0.4mg/kg/hour Remove 50ml from a 500ml bag of
have serious infusion Maximum N/S or G. Then add 500mg = 50ml
arrhythmias being 30mg/hour. of disopyramide injection into the
treated in critical or Maximum total bag to make a 1mg/ml dilution.
coronary care 800mg in 24
areas. hours.
Dobutamine (C) IV infusion ♠ Groups 1 Adjust rate Dilute 250mg to at least 50ml with N/S or Do not flush - replace giving set.
Infusion pump is and 2 according to G (If no central IV access available see Infusion may turn a harmless pink colour.
required. response. below*) Haemodynamic monitoring required.
Sodium content: 0.046mmol/vial.
Administration via Concentrations of up to 10mg/1ml have
a central IV line is been used via a central IV line but this is An alternative dilution: For administration
recommended* outside the manufacturer's via a central IV line draw up milligrams of
as solutions of recommendations. dobutamine equal to six times the patient’s
dobutamine have body weight in kilograms, and dilute to
a low pH. *In circumstances where a central 100ml with N/S or G (or milligrams of
venous catheter is not available and the dobutamine equal to three times the
infusion is going to be run for more than patient’s body weight in kg in 50ml). The
a couple of hours, use a solution of 1mg infusion rate set in ml/hour will equal
in 1mL (250mg in 250ml N/S) and micrograms/kg/minute.
administer via a large peripheral vein.
Pump rate (ml/hour) = Prescribed rate (mcg/kg/min) x weight(kg) x 60(minutes in an hour)

1000 x concentration(mg/ml)
Rate (mcg/kg/min) = Pump rate(ml/hour) x concentration(mg/ml) x 1000

60 x weight(kg)
(I) IV infusion ♠ Group 1 or See comments Calculate the required amount of Infuse at 10mcg/kg/min for 4 minutes, then
using infusion Group 7 dobutamine and dilute to 50ml with N/S. 20mcg/kg/min for 4 minutes, then
pump for cardiac 30mcg/kg/min for 4 minutes, then
stress testing. 40mcg/kg/min.
Infusion pump is
required.
Dopamine (C) IV infusion. ♠ Groups 1 For administration via a central IV ECG monitoring usually required. Do not
Rate dependent on
Infusion pump is and 2 indication and line draw up milligrams of flush - replace giving set.
required. response. dopamine equal to six times the For peripheral administration use a dilute
patient’s body weight in kilograms, solution and a large vein. Use a central
Administration and dilute to 100ml with N/S, G, venous line for concentrations over
via a central IV G10%, G/S or H (or milligrams of 1.6mg/ml.
line is preferred dopamine equal to three times the Extravasation causes local vasoconstriction;
as solutions of patient’s body weight in kg in 50ml). irrigate affected area with 5-10mg
dobutamine The infusion rate set in ml/hour will phentolamine in 10-15ml N/S.
have a low pH. equal micrograms/kg/minute. Sodium content 0.52mmol/200mg.
Alternatively for administration via
If no central IV a central IV line dilute 200mg
access is dopamine to 50ml with N/S, G,
available the G10%, G/S or H and infuse at the
maximum calculated rate.
concentration for For administration via a peripheral
infusion through IV line add 400mg dopamine to
a peripheral vein 250ml N/S and infuse at calculated
is 1.6mg/ml. rate.
Pump rate (ml/hour) = Prescribed rate (mcg/kg/min) x weight(kg) x 60(minutes in an hour)
1000 x concentration(mg/ml)
Rate (mcg/kg/min) = Pump rate(ml/hour) x concentration(mg/ml) x 1000

60 x weight(kg)
Dopexamine (C) IV infusion. ♠ Groups 1 Adjust rate according Dilute with N/S, G, G/S or H to a Infuse via a central vein or a large peripheral
Infusion pump is and 2 to response. maximum concentration of 4mg/ml vein.
required. via a central IV line or a maximum Monitor BP, heart rate, ECG, urine flow and
concentration of 1mg/ml via a large where possible cardiac output.
peripheral vein. Infusion may turn a harmless pink colour.
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR COMMENTS
GIVE DILUTION AND SUITABLE
DILUENT
Doxapram IV bolus ♠ Group 1 Minimum 30 seconds Ampoule can be diluted with Flush with N/S or G.
N/S, G or G10%. IV bolus dose may be repeated at one hour
(C) IV ♠ Groups Adults: 1.5 – 4mg/minute Adults: Dilute 1g doxapram in intervals if necessary.
infusion. 1,2,3,4 and 5 = 45 – 120ml/hour using 500ml G. Monitoring of blood pressure, heart rate and
Infusion pump the 1g in 500ml infusion, deep tendon reflexes is recommended to
is required. increasing the rate prevent overdosage.
gradually. Check arterial blood gases (ABGs)
frequently (every 30 minutes suggested)
after starting infusion. If no improvement
increase infusion rate in suggested
increments of up to 1 mg/min (to a maximum
of 4 mg/min)
Eculizumab (I) IV infusion. ♠ Groups 1 25 – 45 minutes Infusion to be prepared by Patients should be monitored for one hour
▼ This product is Infusion pump and 2 Pharmacy. Telephone Ext. following infusion. If an adverse event occurs
being intensively is required. For example, to give 31083. during the administration of eculizumab, the
monitored by the 900mg in 180ml N/S over infusion may be slowed or stopped at the
CHM and MHRA. 30 minutes, set the Doctor to prescribe each dose medical team’s discretion. If the infusion is
Please report all infusion pump at as an infusion in N/S at a slowed, the total infusion time must not
suspected 360ml/hour. concentration of 5mg/ml, eg. exceed two hours in adults and adolescents
reactions To give 1200mg in 240ml prescribe 900mg eculizumab (aged 12 years to under18 years) and four
(including non- over 30 minutes, set the in 180ml N/S hours in children aged less than 12 years.
serious ones) pump at 480ml/hour. Prescribe 1200mg eculizumab Flush with N/S.
using a Yellow in 240ml N/S. Sodium content: 5mmol/300mg eculizumab.
Card from the BNF
Edrophonium IV bolus ♠ Group 1 Can be diluted with W, but Have atropine available to counteract
maintenance of stability possible severe cholinergic reactions. In
cannot be guaranteed. case of cholinergic crisis resuscitation
equipment should be available.
Enoxaparin SC injection ♠ Groups Refer to the Marsden Manual for Do not press the plunger before injecting to
Pre-filled For dose banding 1,2,3,4 and 5 guidance on SC injection. expel the air bubble. Hold the syringe so
syringes and guidance on that the needle is pointing downwards
choice of syringe (vertically at a 900 angle). Insert the full
strength(s) and length of the needle into the skin fold.
volumes to inject To avoid bruising, do not rub the
see the table below injection site after giving the injection.
Enoxaparin VTE Dosing Guidance

Treatment Dose
Weight Continue for at least 5 days AND until two consecuive INRs >2.0 Prophylactic Dose
(kg) Separate protocol applies to pregnant women
GFR > 30ml/minute (≈1.5mg/kg) GFR < 30ml/minute (≈1mg/kg) GFR > 30ml/minute GFR < 30ml/minute
40 – 49 60mg Daily 40mg Daily 20mg Daily
50 – 59 80mg Daily
60 – 74 100mg Daily 60mg Daily 40mg Daily 20mg Daily
75 – 89 120mg Daily 80mg Daily
90 – 99
100 – 109 150mg Daily 100mg Daily
110 – 120 180mg Daily 120mg Daily 40mg TWICE Daily 40mg Daily
121 – 150 Contact Consultant Haematologist
• For patients over 150kg or complex cases, advice may be obtained from a Consultant Haematologist.
• For patients requiring treatment doses who are morbidly obese (BMI> 35mg/m2), pregnant, or have significant renal impairment (eGFR <30ml/minute)
monitor anti-Xa levels. Take the first anti-Xa level 3 hours after the 3rd dose and state time dose was administered and time of level take on blood form.
Thereafter, repeat level if patient’s condition changes or advised by Haematology.
• For ACS patients, use fondaparinux unless patient’s eGFR < 30ml/minute, then use enoxaparin ≈1mg/kg daily as above.
Enoximone (C) or (I) ♠ Groups Initial rate: 90 micrograms/ Dilute with an equal volume of W or Flush with N/S.
IV 1 and 2 kg/minute for 10-30 minutes until the N/S (i.e. dilute to a concentration of Extravasation will cause tissue
infusion required haemodynamic response is 2.5mg/ml). damage.
via a achieved (This is 2.16ml/kg/hour Do not administer unless diluted
pump. using an infusion of 2.5mg/ml) then product is a clear yellow solution.
Maintenance rate: Monitor blood pressure, heart rate,
5-20 micrograms/kg/minute. ECG and CVP.
(This is 0.12ml/kg/hour to Incompatible: do not infuse with any
0.48ml/kg/hour using an infusion of other drugs including G and
2.5mg/ml) furosemide.
Ephedrine IV bolus ♠ Group 1 3-5 minutes Must be diluted prior to Flush with N/S.
administration with N/S (suggested
dilution: 3mg in 1ml).
Epoprostenol (C) IV ♠ Groups See package insert. Withdraw about 10ml of the diluent Cardiac and blood pressure
infusion 1,2,3,4 and For use during CVVH on ICU, refer to provided, inject into the vial of monitoring required until dose is
via a 5 the critical care protocol for epoprostenol and shake gently to titrated.
pump. epoprostenol. dissolve the powder. Then draw up Do not stop infusion for more than a
the reconstituted epoprostenol and few minutes. Replace giving set; do
re-inject via the filter into the not flush.
remainder of the diluent Mix well. On the Derriford Hospital Critical Care
This is the “Concentrated solution” Unit the prepared solution is used for
(10micrograms/ml). up to 24 hours. This is unlicensed but
For use during CVVH on ICU, patient cost-saving. A drop in blood pressure
is initially acclimatized with systemic is possible when renewing an infusion
IV infusion of 2microgram/ml that’s been made up longer than 12
epoprostenol for 2 hours (10ml of hours.
“Concentrated solution” diluted Sodium content 2.5mmol/reconstituted
further to 50ml with N/S). vial.
Incompatible: do not infuse with any
other drugs including G and G/S.
Ergocalciferol IM Injection ♠ Groups The product packaging states “Only glass syringes
300,000unit 1,2,3,4 and should be used”, as the solution is very difficult to
injection 5 expel from ordinary plastic syringes. However, glass
syringes are not available. The injection is easier to
expel from green B.Braun 3ml syringes which are
available from Pharmacy. One of these syringes
should be supplied with each dispensed ampoule.
Within Pharmacy, further supplies are available in
T/Services.
Ertapenem (I) IV infusion ♠ Groups 30 minutes Reconstitute the contents of the 1g Use the infusion within 6 hours of preparation.
via pump 1,2,3,4 and vial with 10ml W or N/S to give a The product information suggests using a 50ml bottle
May only be 5 solution of approximately 100mg/ml. or bag of N/S but these are not stocked in this Trust.
initiated on the Shake well to dissolve. Dilute further Sodium content: 6mmol/1g
advice of a with N/S to a final concentration of
consultant 20mg/ml or less (e.g.1g in 100ml
microbiologist N/S).
Erythromycin (I) IV infusion ♠ Groups 20-60 minutes Reconstitute each 1g with 20ml W to Extravasation is hazardous.
via pump 1,2,3,4 and produce 50mg/1ml then further dilute IV infusion may cause thrombophlebitis, particularly
5 to a maximum concentration of concentrations exceeding 5mg/1ml.
5mg/ml with N/S, G or G/S. Flush with N/S. Sodium content nil.
If G or G/S are used add 5ml sodium 125mg erythromycin used as prokinetic for GI tract
bicarbonate 8.4%/litre as a buffer. (Unlicensed use - see page 1) should be diluted in
Displacement is allowed for. Addition 25ml N/S and given over 5 minutes.
of 20ml W to 1g vial gives 1g in 20ml Prepare a fresh infusion every 8 hours.
(50mg in 1ml).
(C) IV ♠ Groups Reconstitute as above then dilute as
infusion via 1,2,3,4 and above to a concentration of 1mg/ml
pump 5 to 5mg/ml (1mg/ml is recommended).
(I) IV infusion ♠ Groups Minimum 60 Reconstitute as above then dilute 1g In addition to the above points, this is an unlicensed
via a central 1,2,3,4and minutes to 100ml with N/S. use for use in fluid restricted patients. Cardiac
line using a 5 monitoring necessary.
pump
Esmolol (I) IV infusion via an ♠ Groups Follow the Vials containing 100mg esmolol
Treatment of supraventricular tachycardia: After
infusion pump. Preferably 1 and 2 dosage titration in 10ml (10mg/ml) are used
achieving adequate control of heart rate introduce
administer via a central flow chart in without further dilution.
alternative oral agent and gradually reduce esmolol
line to avoid potential the package infusion rate - see package insert for instructions.
venous irritation as the insert. Monitor the blood pressure frequently. Caution: Flushing
preparation has a low pH. the line will administer a bolus dose. However 5ml N/S
If this is not possible, use has been used as a flush following loading doses, given
a large peripheral vein at the same slow rate as the loading dose.
10mg/ml IV infusion of esmolol for supraventricular tachycardia or post-operative tachycardia and/or hypertension
Elapsed Time Loading dose given before each titration step to produce rapid Maintenance Infusion
(Minutes) onset of action, infused over 1 minute (pump setting) (pump setting)
0–1 500micrograms/kg (=3ml/kg/hour)
1–5 50micrograms/kg/minute (=0.3ml/kg/hour)
5–6 500micrograms/kg (=3ml/kg/hour)
6 – 10 100micrograms/kg/minute (=0.6ml/kg/hour)
10 – 11 *500micrograms/kg (=3ml/kg/hour)
11 – 15 *150micrograms/kg/minute (=0.9ml/kg/hour
16 – 20 *200micrograms/kg/minute (=1.2ml/kg/hour)
20 - 21 *500micrograms/kg (=3ml/kg/hour)
21 – 25 *250micrograms/kg/minute (=1.5ml/kg/hour)
26 - 30 *300micrograms/kg/minute (=1.8ml/kg/hour)
*As the desired heart rate or endpoint (eg. Lowered blood pressure) is approached, omit the loading dose and reduce the incremental increases in infusion rate to
25micrograms/kg/minute (0.075ml/kg/hour to 0.15ml/kg/hour). The interval between titration steps may be increased from 5 to 10 minutes.
Once the desired clinical endpoint is reached continue the maintenance infusion at that rate.
10mg/ml IV infusion of esmolol for intra-operative immediate control of tachycardia and/or hypertension
80 mg (approximately 1 mg/kg) bolus dose over 15 to 30 seconds followed by a 150 mcg/kg/min infusion (0.9ml/kg/hour), if necessary. Adjust the infusion rate as
required up to 300 mcg/kg/min (1.8ml/kg/hour) to maintain desired heart rate and/or blood pressure.
Esomeprazole IV bolus ♠ Groups At least 3 minutes Reconstitute 40mg vial with 5ml
The reconstituted solution is clear and
1,2,3,4 and N/S. colourless to very slightly yellow.
5 Revert to omeprazole capsules orally as soon
(I) IV infusion ♠ Groups 10 – 30 minutes Reconstitute as above then further as possible. Alternatively revert to dispersible
via infusion dilute up to 100ml with N/S. lansoprazole Fastabs via PEG/NG/NJ as soon
1,2,3,4 and
pump as possible.
5
Use infusion in N/S within 12 hours.
Do not infuse with any other drugs.
Esomeprazole IV Loading ♠ Groups 80mg in 100ml N/S over For each 40mg vial, withdraw 5ml of Use infusion in N/S within 12 hours.
For the specialist dose of 1,2,3,4 and 30 minutes N/S from a 100ml bag and use to Do not infuse with any other drugs.
treatment of 80mg 5 reconstitute the vial. Then inject the
endoscopically reconstituted esomeprazole into the * The Gastroenterologists have agreed to a 70-
controlled bleeding bag. Do not add more than 80mg hour treatment (rather than 72 hours). A pre-
peptic ulceration. esomeprazole to 100ml of diluent. printed prescription is available.
(C) IV ♠ Groups After loading dose, infuse Reconstitute and dilute each 40mg
infusion via 1,2,3,4 and at 8mg/hour for 70 hours* vial as above.
infusion 5 (This is 10ml//hour with
pump each 80mg in 100ml N/S)
Ethanol (Alcohol) (C) IV ♠ Groups For ethylene glycol or Dilute to 5 or 10% with G. Flush with N/S or G.
infusion via 1,2,3,4 and methanol overdose: 10% solutions of ethanol are hyperosmolar and
(Unlicensed infusion 5 For a 5% solution: irritant to veins and are best given by central
product- see page pump Refer to the Toxbase Remove 56ml from a litre bag of 5% venous catheter.
4) . Website for details of the glucose. Then add 56ml of 90% Some references recommend discontinuing
infusion rates. ethanol injection into the bag. gradually over 24-48 hours to avoid a possible
major secondary withdrawal reaction.
For a 10% solution: For ethylene glycol overdose adjust infusion
Remove 111ml from a litre bag of rate to achieve blood ethanol conc. of 1- 1.5g/L.
5% glucose. Then add 111ml of Monitor blood glucose level.
90% ethanol injection into the bag. Always refer to the Toxbase website for more
detailed instructions in the case of ethylene
glycol or methanol overdose.
Etomidate IV bolus ♠ Group 1 30 – 60 seconds May be diluted with N/S or G. Pain can occur after injection into veins of the
dorsum of the hand. Use of larger veins
reduces pain on injection. Incompatible with
Hartmann’s. Flush with N/S or G.
Can reduce serum cortisol levels during
induction so no longer kept in Main Theatres
Fentanyl Staff prescribing, administering and/or screening prescriptions for opioid medications should be familiar with the PHNT Policy for
Reducing Errors with Opioid Medicines in Adults (Network Drive :Groups (G) > Trust Documents > Documents > Medicines
Management folder). The PHNT Analgesic Ladder and equivalent dosages of different opioids can be found on page 185.
IV bolus ♠ Groups 1 Follow the algorithm Dilute 200 micrograms fentanyl to Monitor the patient in accordance with the
(Theatre and 2 from Recovery 2 10ml with N/S algorithm from Recovery 2.
Recovery)
IV bolus ♠ Groups 1 Can be diluted with N/S, G, G/S or For sedation in conscious adult patients follow
and 2 H. the Sedation Guidelines on Plymouth Healthnet
(under Clinical Guidelines).
All healthcare practitioners involved directly or
participating in sedation techniques must have
the necessary knowledge, skills and
competences required.
Flush with N/S.
Patient ♠ Groups 1000 micrograms fentanyl (20ml of PCA: 20 microgram (1ml) bolus, 5 minute lock-
Controlled 1,2,3,4 and 5 injection) diluted to 50ml with N/S. out period. Follow the Acute Pain/Care Service
Analgesia Protocols.
(PCA)
(I) or (C) IV ♠ Groups 1 Sodium content 0.3mmol/1ml.
infusion. and 2
Infusion
pump is
required.
Fentanyl All epidural administration sets must be labelled “Epidural” when in use (not just the epidural catheter) NPSA/2007/21
2micrograms/ml Epidural ♠ Groups Background rate of Pre-made bags supplied by *Staff administering and monitoring epidural
with bupivacaine infusion via 1and 2* 7 – 15ml/hour with Pharmacy. infusions must have received training from the
0.1% epidural McKinley pump additional Patient- Acute Care Team and demonstrated their
infusion Controlled Epidural competency at administering and monitoring
Analgesia (PCEA) of epidural infusions. Follow the Acute Care Team
5ml boluses with a Protocols. Additional clinician boluses may be
lock-out time of 30 administered by Pain Nurses if required as per
minutes. epidural protocol.
Ferric For doses of ♠ Groups Suggestion: 2 Either give undiluted or dilute with a Inspect vials visually for sediment and damage
carboxymaltose 100-200mg: 1 and 2 minutes small volume N/S eg.10ml N/S before use. Use only those that are sediment-
(Ferinject®) IV bolus (No more than 50ml of N/S). free.
The patient should be monitored closely for
▼ This product is signs of hypersensitivity during administration
being intensively For doses of ♠ Groups 5 minutes For slow IV bolus, either give and for 30 miutes after every dose of Ferinject®
monitored by the 201-500mg: 1 and 2 undiluted or dilute with a small given.
CHM and MHRA. Either slow IV volume N/S eg.10ml. A single dose of Ferinject® should not exceed
Please report all bolus or (I) IV 1000mg. Do not administer 1000mg more than
suspected infusion via For IV infusion, dilute with no more once a week. If the total dose is greater than
reactions pump than 100ml N/S. 1000mg then it should be divided and given
(including non- For doses of ♠ Groups 15 minutes Either give undiluted or dilute with over 2 weeks.
serious ones) 501-1000mg: 1 and 2 N/S (No more than 250ml of N/S). Dilutions less than 2mg/ml are unstable.
using a Yellow (I) IV infusion Do not mix with any other infusion or drug
Card from the BNF via pump solutions, including glucose.
Flush with N/S.
Each 50mg in 1ml of Ferinject® contains
0.24mmol sodium.
Ferumoxytol IV Bolus ♠ Groups Maximum rate Do not dilute further. Follow the administration with a slow flush of
1,2,3,4 and 1ml/second N/S to clear the line.
▼ This product is 5 (i.e. the Monitor the patient for signs of hypotension
being intensively contents of and hypersensitivity reactions for at least 30
monitored by the each 17ml vial minutes after giving the injection.
CHM and MHRA. over at least 17 The maximum dose for a course of
Please report all seconds). treatment is 2 vials, but these must not be
suspected reactions given at the same time (The second
(including non- injection should be given 2 to 8 days after
serious ones) using the first injection).
a Yellow Card from
the BNF
Filgrastim SC injection ♠ Groups Do not dilute further. Within its shelf-life and for the purpose of
(Zarzio®) Post chemotherapy, 1,2,3,4 and Refer to the Marsden Manual for guidance ambulatory use, the patient may remove the
Chronic neutopenia, 5 on SC injection. product from the refrigerator and store it at
or HIV room temperature (not above 25°C) for one
Short IV infusion ♠ Groups 30 minutes Dilute the required dose in 20ml G to produce single period of up to 72 hours. At the end of
Post chemotherapy 1,2,3,4 and a final concentration of at least 1.5MU/mL this period, the product should not be put
or for mobilisation of 5 (15micrograms/mL; 300micrograms in 20ml). back in the refrigerator and should be
PBPCs after bone disposed of.
marrow transplant Do not dilute to a concentration of less than
Continuous SC or ♠ Groups Over 24 hours 0.2MU/ml (2micrograms/ml). Flush with G.
IV infusion for If a concentration of less than 1.5MU/ml
1,2,3,4 and (15micrograms/ml; equivalent to less than
mobilisation of 5 Zarzio® is not compatible with saline
300micrograms in 20ml) is prepared in glucose
PBPCs after bone solutions.
5%, add human serum albumin to a final
marrow transplant
concentration of 2mg/ml (e.g. in a final volume
of 20mL add 0.2ml 20% human serum
albumin). This is to reduce the amount of
filgrastim adsorbed on to the surface of the
administration set.
Do not shake the syringe before removing the
required dose.
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR COMMENTS
GIVE DILUTION AND SUITABLE
DILUENT
Flebogamma® See Immunoglobulin Human Normal
Flecainide IV bolus ♠ Groups In an emergency or for Can be diluted with G and given Flush with G.
Adults: 1 and 2 rapid effect, give over at as a mini-infusion (e.g. 50ml or Continuous ECG monitoring required for bolus
2mg/kg least 10 minutes. Minimum 100ml of G). doses.
Maximum 30 minutes for patients with It is recommended that the maximum duration
150mg cardiac failure or ventricular by infusion is 24 hours.
tachycardia. The maximum cumulative dose in the first 24
(I) IV ♠ Groups Adults: Loading dose over Suggested dilution for hours should not exceed 600mg.
infusion. 1 and 2 30 minutes as above maintenance infusion: Dilute Switch to oral treatment as soon as possible.
Infusion followed by IV infusion at 300mg to 50ml with G. If infusion in N/S or H is necessary 150mg
pump is 1.5 mg/kg/hour for the first flecainide must be diluted in at least 500ml.
required. hour then 0.1-0.25
mg/kg/hour thereafter.
Using a 300mg in 50ml
dilution, this is
0.25ml/kg/hour for the first
hour then 0.017 –
0.042ml/kg/hour thereafter.
Flucloxacillin IV bolus ♠ Groups Inject doses up to 1g Reconstitute 250-500mg with 5- Flush with N/S.
Usual method 1,2,3,4 and 5 over 3-4 minutes 10ml and 1g with 15-20ml W. Can Sodium content 0.57mmol/250mg.
be diluted with N/S or G.
Inject 2g doses Displacement volumes:
slowly over 6-8 Bowmed/Actavis brand: 0.15mL for For IV administration: The following drugs are
minutes or give by 250mg, 0.3mL for 500mg, 0.6mL incompatible with flucloxacillin: amiodarone,
infusion (see below). for 1g. atropine sulphate, buprenorphine, calcium
Wockhardt brand: 0.2mL for gluconate, chlorpromazine hydrochloride,
250mg, 0.4mL for 500mg, 0.7mL ciprofloxacin, diazepam, dobutamine
for 1g. hydrochloride, erythromycin lactobionate,
(I) IV infusion. ♠ Groups 30-60 minutes Reconstitute as above then dilute gentamicin sulphate, metoclopramide
Infusion pump 1,2,3,4 and 5 with N/S or G to 100ml. hydrochloride, morphine sulphate, netilmicin
is required. sulphate, ofloxacin, papaveretum, pethidine
IM Injection ♠ Groups Add 1.5ml of water for injections to hydrochloride, prochlorperazine edisylate,
1,2,3,4 and 5 250mg vial contents or 2ml of water promethazine hydrochloride, tobramycin and
for injections to 500mg vial verapamil hydrochloride.
contents. Refer to the Marsden
Manual for guidance on IM
injection.
Intrapleural ♠ Group 1 Dissolve 250mg in 5 to 10ml of
water for injections.
Intra-articular ♠ Group 1 Dissolve 250 to 500mg in up to 5ml
of water for injections or 0.5%
lidocaine hydrochloride solution for
injection.
Fluconazole (I) IV infusion. ♠ Groups 10-20mg/minute. Provided ready diluted (2mg/ml). Flush with N/S.
Infusion pump 1,2,3,4 and 5 Set the pump at Fluconazole is well absorbed from the gut so
is required. 300 – 600ml/hour consider an early switch to oral/NG/PEG
treatment.
Sodium content 15mmol/200mg (100ml bottle).
Flucytosine (I) IV infusion. ♠ Groups 20-40 minutes Provided ready diluted. Flush with N/S. Must be stored at 18oC to 25oC.
Infusion pump 1,2,3,4 and 5 Can be administered concurrently Sodium content 34.5mmol/250ml.
is required. with N/S, G or G/S. Infusion must not be used as a multidose
container. Incompatible: do not infuse with any
other drugs except N/S, G, or G/S.
Flumazenil IV bolus ♠ Group 1 Minimum 15 Can be diluted with N/S or G to any Flush with N/S.
seconds suitable volume. Give (I) IV infusion if drowsiness recurs after
initial IV bolus.
(I) IV infusion. ♠ Groups 100-400 Flumazenil infusion should be used within 3
Infusion pump 1,2,3,4 and 5 micrograms/ hour hours of preparation.
is required. Incompatible: do not infuse with any other
drugs.
Fluorescein IV bolus ♠ Group 1 or F Test dose in 5ml N/S then 3-5ml of Follow the REI Fluorescein Angiograhy
grade Group 2 10%-20% fluorescein injection Guidelines
with ENB346 or followed by N/S flush.
relevant
ophthalmic
qualification
Folic acid IV bolus ♠ Groups Suggestion: 1 Can be diluted with N/S Flush with N/S. Flush with N/S.
1,2,3,4 and 5 minute
Folinic acid IV bolus ♠ Groups Minimum 3-5 Can be diluted with N/S. Folinic acid (calcium folinate) 350mg contains
(calcium folinate) 1,2,3,4 and minutes 0.7mmol of calcium therefore administer
5 slowly.
(I) infusion ♠ Groups Maximum Dilute with N/S or G. Intravenous incompatibilities include:
1,2,3,4 and rate of droperidol, methotrexate, 5-fluorouracil and
5 160 mg/minute foscarnet.
Fondaparinux Deep SC injection. ♠ Groups To avoid the loss of fondaparinux 2.5mg once daily initiated as soon as possible
Alternate sites 1,2,3,4 and solution, do not expel the air bubble following diagnosis and continued for up to 8
For the treatment between the left & 5 from the pre-filled syringe before days. The medical team can stop the
of Acute right anterolateral injection. treatment once the patient has had no chest
Coronary and left & right pain for 48 hours.
Syndrome posterolateral For patients with ACS and an eGFR less than
abdominal wall. 30ml/minute, prescribe 1mg/kg enoxaparin
Insert the whole once daily instead.
length of the needle
at right angles into Refer to the Marsden Manual for guidance on
the skin. SC injection.
Foscarnet (I) IV infusion. ♠ Groups Rate Infusion to be prepared by Pharmacy. Can be infused undiluted via a central line.
sodium Initial loading dose. 1,2,3,4 and determined by Telephone Ext 31083. Flush with N/S or G.
Infusion pump is 5 renal function, Sodium content 15.6mmol/1g.
required. see data sheet. Incompatible: do not infuse with any other
(C) IV infusion ♠ Groups Minimum drugs.
Maintenance 1,2,3,4 and infusion time of Peripheral administration may lead to local
therapy. 5 1 hour. irritation and thrombophlebitis.
Infusion pump is DO NOT administer by rapid intravenous
required. injection.
Wear gloves, gown and safety glasses when
handling. Avoid handling drug if pregnant.
Fosfomycin (I) IV infusion. ♠ Groups Infuse all doses over 1 Reconstitute the 4g vial with 20ml of W. Sodium content 14.35mmol/1g fosfomycin
(Fosfocina®) Infusion pump 1,2,3,4 and 5 hour Reconstitute each 1g vial with 10ml W Incompatible with the following drug
is required. (ampoule provided). Upon dissolving, the solutions: erythromycin, gentamicin and
N.B. This vial will become slightly warm. To give a 4g rifampicin.
brand is dose, remove 50ml G from a 250ml bag of Flush with N/S.
unlicensed G. Then add 4g of reconstituted
fosfomycin into the bag containing 200ml
G. To give a 2g dose, add 2g reconstituted
fosfomycin to 100ml G.
Fosfomycin (I) IV infusion. ♠ Groups Sodium content 14.5mmol/1g fosfomycin
Infuse all doses over Reconstitute the 2g bottle with 40ml to
(Infectofos®) Infusion pump 1,2,3,4 and 5 30 minutes Monitor serum electrolytes, in particular
60ml W and begin infusion immediately.
is required. serum sodium, potassium and creatinine.
Reconstitute the 3g and 5g bottles with
Monitor patient for phlebitis at the infusion
100ml W. Reconstitute the 8g vial with
site. Flush with N/S.
200ml W. Begin the infusion immediately
Safe to be given to patients with allergies to
after reconstitution. During reconstitution
the solution may get warm. any other commonly used antibiotics
If necessary G or G10% may be used including penicillins, cephalosporins,
levofloxacin, tetracyclines, trimethoprim and
instead of W to reconstitute the bottles
erythromycin.
(volumes as for W). Do not further dilute.
On storage the bottles should be protected
from light (Keep in original box)
Furosemide IV bolus ♠ Groups Adults: The rate Either dilute with N/S (a common dilution is Flush with N/S.
1,2,3,4,5 and should not usually 1mg/ml) or give undiluted. Sodium content 0.14mmol/1ml for 20mg/2ml
(C) or (I) IV 7 exceed 4mg/minute, and 50mg/5ml; 0.04mmol/1ml for
infusion. however single doses 250mg/25ml. Rapid administration may
Infusion pump of up to 80mg may be damage the hearing. Furosemide
is required. given more quickly. precipitates in glucose solutions.
Fusidic Acid See Sodium Fusidate
Gallamine IV bolus ♠ Group 1 Flush with N/S.
Gammanorm® See Immunoglobulin Human Normal
Gammapex® See Immunoglobulin Human Normal
Ganciclovir (I) IV infusion. ♠ Group 1 or Minimum 60 Infusion to be prepared by To facilitate accurate measurement of the
Infusion pump is Group 2 minutes Pharmacy. Telephone Ext. 31083. dose, the prescribed dose in milligrams
required. Doctor to prescribe dose (see (rounded up or down if necessary) divided
comments) in 100ml N/S or G. by 50 should have no more than one
decimal figure.
Wear gloves, gown and safety glasses when
handling. Avoid handling drug if pregnant.
Preferably infuse through a large vein. Flush
with N/S or G.
Gentamicin IV bolus ♠ Groups 3-5 minutes Either give undiluted or dilute with Administration by (I) IV infusion once a day
1,2,3,4 and 5 (minimum 3 N/S or G (usually 10-20ml). is current Trust policy, although this use is
Refer to the minutes) outside of the manufacturer’s
Plymouth (I) IV infusion for ♠ Groups 30 minutes Dilute with 50ml or 100ml N/S or G. recommendations. Flush with N/S.
Healthnet Clinical once-daily dosing 1,2,3,4 and 5 Sodium content negligible
Guidelines/ (>200mg). Infusion Incompatibilies include benzylpenicillin and
Infection Control pump is required. teicoplanin.
for the use and Intraperitoneal ♠ Groups 1 and Follow the Renal Services Directorate
current dosage of 2 Peritoneal Dialysis Peritonitis Protocol
gentamicin,
teicoplanin and IM injection ♠ Groups Refer to the Marsden Manual for guidance
vancomycin. Discuss further with a 1,2,3,4 and 5 on IM injection.
Consultant
Microbiologist if
unable to give
gentamicin via the IV
route
Glargine insulin See Insulin Section page
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND SUITABLE COMMENTS
GIVE DILUENT
Glucagon SC Injection ♠ Groups Reconstitute with diluent provided (1ml W) and Intravenous glucose must be given
1,2,3,4,5 and 6 shake gently until the glucagon has dissolved and if the patient fails to respond to
the solution is clear. The resulting solution is Glucagon within 10 minutes.
1mg/ml. Do not further dilute. Refer to the Marsden
Manual for guidance on SC injection.
IM Injection ♠ Groups Reconstitute as above. Refer to the Marsden Intravenous glucose must be given
1,2,3,4,5 and 6 Manual for guidance on IM injection. if the patient fails to respond to
Glucagon within 10 minutes.
IV bolus ♠ Groups Reconstitute as above. However, for doses > 2mg Flush with N/S.
(For diagnostic 1,2,3,4,5 and 6 reconstitute each vial with 1ml G instead of the
testing) diluent provided, to avoid administration of large
amounts of preservative.
Treatment of cardiogenic shock caused by beta-blocker poisoning
IV bolus ♠ Groups Loading dose of 2 -10mg For loading doses > 2mg reconstitute each vial with (I) IV infusion is an unlicensed use
(Loading 1,2,3,4 and 5 (Child: 50 – 150 1ml G instead of the diluent provided, to avoid (See page 1) to treat cardiogenic
dose) microgram/kg, max. administration of large amounts of preservative. shock from beta blocker poisoning.
followed by (I) 10mg) by slow IV bolus Suggestion for the infusion for an adult:
IV infusion. over 3 – 5 minutes Reconstitute 10 x 1mg vials, each with 1ml G (Do
Infusion pump followed by IV infusion not use the diluent provided as the patient will get a
is required. of 50 micrograms/kg/hour: large dose of preservative).
Using syringe pump
Using 1mg/ml glucagon Draw up the reconstituted glucagon into a 50ml
for infusion: syringe and either infuse undiluted (1mg/ml) or
50micrograms/kg/hour dilute further with G.
= 0.05ml/kg/hour
Using a volumetric pump
Using a dilution of 10mg Draw up the reconstituted glucagon and dilute
in 100ml for infusion: further with G. (suggestion for an adult: 10mg
glucagon diluted to a volume of 100ml with G. 10ml
50micrograms/kg/hour
G from the bag can be used to reconstitute the 10
= 0.5ml/kg/hour vials of glucagon).
Glucose 5-10% IV bolus ♠ Groups Glucose infusions can be diluted G5% is iso-osmotic with blood and can be infused
N.B All bags of 1,2,3,4 and 5 with W if the concentration required through a peripheral line.
glucose are for is unavailable.
single use only. (C) or (I) IV ♠ Groups If G10% is administered peripherally use a large vein
infusion via 1,2,3,4 and 5 and preferably alter the injection site daily.
infusin
pump
Glucose 20-50% (C) or (I) IV ♠ Groups Concentrations greater than 20% should be infused
infusion 1,2,3,4 and 5 through a central line to prevent venous irritation and
thrombophlebitis.
Glucose 5% to treat Fast IV ♠ Groups Fast IV infusion (PHNT Hypoglycaemia Guideline 2011)
severe infusion 1,2,3,4 and 5 200ml of 5%
hypoglycaemia glucose
or Glucose 10% to Fast IV ♠ Groups Fast IV infusion
treat severe infusion via 1,2,3,4 and 5 100ml of 10%
hypoglycaemia a large vein glucose
Glucose 50% to IV bolus via ♠ Groups 20ml of 50% 20ml of 50% glucose over 1-2 minutes is very irritant
treat severe a central 1,2,3,4 and 5 glucose over 1-2 and potentially damaging to peripheral veins.
hypoglycaemia vein. minutes
Glucose 10% to (I) IV ♠ Groups 500ml of 10% Add 10 units of Actrapid insulin into Monitor U&E’s every 2 hours until the serum
treat hyperkalaemia infusion via 1,2,3,4 and 5 glucose over 30 the 500ml of 10% glucose using a potassium is stable and less than 6mmol/L. Monitor
a large vein minutes 29 gauge Magellan 12.7mm blood glucose every 30 minutes during the infusion of
(1.3cm) Insulin Safety Syringe glucose with Actrapid, and for 2 hours after the
available from Thrushel, Tavy or infusion
ED (NHS order code: FTR1276)
For patients at risk (I) IV ♠ Groups 50ml of 50% Add 10 units of Actrapid insulin into Monitor U&E’s every 2 hours until the serum
from heart failure or infusion via 1,2,3,4 and 5 glucose over 15 the 50ml of 50% glucose. potassium is stable and less than 6mmol/L. Monitor
fluid overload : a large vein minutes blood glucose every 30 minutes during the infusion of
Glucose 50% to glucose with Actrapid, and for 2 hours after the
treat hyperkalaemia infusion
Glucose 5% (C) SC ♠ Groups Usual rate is Maximum concentration of glucose Maximum of 2 litres of glucose 5% in 24 hours. The
infusion 1,2,3,4 and 5 500ml over 8 for SC infusion is 5% needle and giving set should preferably be changed
Only use hours (21 drops every 72 hours. However, infusion sets can be left in
gravity-feed per minute). place for up to 5-7 days if there are no complications.
administratio Maximum rate is Refer to potassium chloride monograph for SC
n sets. 500ml over 4 potassium.
Never use hours (40 drops Due to the acidic pH of glucose 5%, monitor the
an infusion per minute) infusion site regularly for early signs of inflammation
pump for and irritation.
SC
infusions.
Glyceryl trinitrate (C) or (I) IV ♠ Groups 1 0.6 - 12 mg/hour Use the 50mg in 50ml ready-made Give via a syringe driver and either a polyethylene-
infusion via and 2 vials. If these are not available lined PVC extension set or a PVC-free extension.
pump Up to a maximum dilute with G to 1mg/ml. The following extension sets are suitable and are
of 24 mg/hour available to order from NHS Supplies:
depending on Can be diluted with N/S instead. Codan PVC-free extension set 71.4001, order code
indication. FKA064.
Alaris G30302M line, order code FKA058
Vygon PE-lined extension set 6222.151, order code
FSB147.
BMS PE-lined extension set 30-7200, order code
FSB646.
Other suitable sets include the Vygon 71100.15 PE
extension set and the Vygon 0832.211R PE-lined
extension set.
Do not flush - replacing giving set.
Monitor blood pressure and pulse during infusion.
Intra- ♠ Group 1 Follow Cardiac Catheter Laboratory procedures.
coronary in
Cardiac
Catheter
Labs.
Glycopyrronium IV bolus ♠ Groups 1 Rapid IV bolus May be diluted with N/S or G if Flush with N/S or G.
(Glycopyrrolate) and 2 needed.
IM injection ♠ Groups 1 Refer to the Marsden Manual for
SC injection to ♠ Groups Refer to the Marsden Manual for Follow the PHNT Care of The Dying Pathways and the
reduce 1,2,3,4 and guidance on SC injection. PHNT Syringe Driver Policy.
secretions in 5 For combinations of 2 or 3 drugs in the same syringe,
palliative care refer to the Syringe Driver Drug Compatibility chart
(C) SC infusion ♠ Groups Continuous over Dilute with W when 2 or more provided in the pump kit. Contact Pharmacy on ext.
via syringe 24 hours drugs are being mixed in the 39976 for further compatibility advice if necessary.
1,2,3,4 and Glycopyrronium is not licensed via the SC route (See
driver to reduce 5 same syringe.
secretions in W or N/S may be used where the page 124).
palliative care syringe only contains
glycopyrromium.
Glypressin See Terlipressin.
Gonadorelin IV bolus or SC ♠ Group 1 Reconstitute HRF brand Refer to the Marsden Manual for guidance on SC
Injection (for 100micrograms with 1ml diluent injection.
pituitary provided.
function test)
Granisetron IV bolus ♠ Groups Minimum 30 seconds Dilute each 1mg with 5ml with N/S. Flush with N/S.
1,2,3,4 and 5
(I) IV infusion 5 minutes Dilute each 3mg with 20-50ml N/S, Sodium content 1.17mmol/3mg vial,
(Adults). H, G or G/S. 0.15mmol/1mg vial.
Infusion pump
is required.
Haloperidol IM injection ♠ Groups Oral treatment should succeed IM administration
1,2,3,4 and 5 as soon as practicable. Oral bioavailability is
about 60% of that from the IM route so
adjustment of the dosage may be necessary.
IV bolus ♠ Groups 1-2 minutes, longer if Do not dilute to give by IV route. Flush with N/S.
1,2,3,4 and 5 possible. Maximum Note that haloperidol injection is no longer
5mg/minute. licensed by the IV route in the UK. This is not due
to any new safety concerns about IV haloperidol.
The manufacturer has only taken this action to
standardise the license across all global markets.
SC injection for ♠ Groups Refer to the Marsden Manual for Follow the PHNT Care of The Dying Pathways and
use in palliative 1,2,3,4 and 5 guidance on SC injection. the PHNT Syringe Driver Policy.
care For combinations of 2 or 3 drugs in the same
(C) SC infusion ♠ Groups Continuous over 24 Dilute with W when 2 or more drugs syringe, refer to the Syringe Driver Drug
via syringe 1,2,3,4 and 5 hours are being mixed in the same Compatibility chart provided in the pump kit.
driver in syringe. Contact Pharmacy on ext. 39976 for further
palliative care W or N/S may be used where the compatibility advice if necessary.
syringe only contains haloperidol. Haloperidol is not licensed by the SC route (See
page 4).
Heparin IV bolus ♠ Groups 3 – 5 minutes 5,000 units = 5ml of 1,000 unit/ml
loading dose 1,2,3,4 and 5 solution with no further dilution.
followed by (C) (Or 10,000 units = 10ml of 1,000
below. unit/ml solution with no further
dilution for severe pulmonary
embolism – see prescription).
(C) IV infusion ♠ Groups Initial infusion rate 15 Take a 20ml ampoule containing Use of a PVC-free or PE-lined extension set will
Immediately 1,2,3,4 and 5 units/kg/hour = 20,000 units of heparin. Draw up avoid adsorption of heparin to the line. The
following the 0.015ml/kg/hour of the 20ml into a 50ml syringe. following extension sets are suitable and are
loading dose. 1,000 unit/ml infusion. available to order from NHS Supplies:
Infusion pump Do not dilute this any further
is required. Alter rate according to Codan PVC-free extension set 71.4001, order
APTTR (Check before code FKA064.
commencing heparin Alaris G30302M line, order code FKA058
therapy, then 4-6 hours Vygon PE-lined extension set 6222.151, order
after commencing the code FSB147.
infusion, 4-6 hours after BMS PE-lined extension set 30-7200, order
every infusion rate code FSB646.
change, and at least Other suitable sets include the Vygon 71100.15
once daily thereafter. PE extension set and the Vygon 0832.211R
PE-lined extension set.
Prepare a fresh infusion every 24 hours.
SC injection ♠ Groups Refer to the Marsden Manual for
1,2,3,4 and 5 guidance on SC injection.
Intraperitoneal ♠ Groups 1 1,000 units per litre of dialysis fluid Follow the PHNT Renal Services Directorate
and 2 Procedures
Heparin may only be used for locking or flushing IV lines, cannulae or devices in accordance with PHNT policy – see Appendix 5, page 215
Hizentra® See Immunoglobulin Human Normal
Humalog® See Insulin Section
Humalog Mix®
Humulin®
Hyaluronidase With S/C infusion of fluid ♠ Groups Reconstitute 1,500iu of 1,500iu hyaluronidase is sufficient for the
(Hypodermoclysis) 1,2,3,4 and 5 hyaluronidase with 1ml of N/S administration of 500-1000ml of most fluids.
Either give 1,500iu by S/C or W.
injection into the site before Compatible fluids include: N/S, G,
the infusion is set up, or G/S(4%/0.18%), G/S(2.5%/0.45%).
iniect 1,500iu into the tubing
of the infusion set about
2cm back from the needle
at the start of the infusion.
With S/C and I/M ♠ Groups 1,500iu to be dissolved directly Compatible when mixed with: morphine,
injections 1,2,3,4 and 5 in the solution to be injected. diamorphine, hydrmorphone, chlorpromazine,
metoclopramide, dexamethasone and very low
concentrations of adrenaline.
Incompatible with: heparin, moderate to high

concentrations of adrenaline, furosemide,
phenytoin and benzodiazepines.
With local anaesthetics ♠ Group 1 1,500iu mixed with the quantity
(Other of local anaesthetic solution to
Groups be used.
only in In ophthalmology 15iu
accordance hyaluronidase per ml is the
with specific recommended concentration.
PGDs)
Extravastion where ♠ Groups Reconstitute 1,500 iu of Follow the PHNT protocol for managing
dispersal rather than 1,2,3,4 and 5 hyaluronidase with 1ml of N/S extravasation – See Section 2.8.6
localisation is indicated. or W.
Administer by S/C infiltration
Haematoma ♠ Groups Reconstitute 1,500 iu of
By S/C infiltration 1,2,3,4 and 5 hyaluronidase with 1ml of N/S
or W.
Hydralazine Slow IV ♠ Groups Over at least 5 minutes to avoid over-rapid Reconstitute with 1ml W then dilute Flush with N/S.
bolus 1,2,3,4 and 5 reduction in blood pressure. with 10ml with N/S. If necessary, a repeat
injection can be given after
an interval of 20-30
minutes.
Sodium content nil.
(C) IV ♠ Groups Adults: Reconstitute as above then dilute Monitor heart rate and
infusion via 1,2,3,4 and 5 Initial rate of 200-300micrograms/minute 20mg with 500ml of N/S to give 40 blood pressure.
an infusion micrograms/ml. Incompatible with glucose
pump Usual maintenance rate of solutions.
50-150micrograms/minute However, for fluid restricted patients
60mg hydralazine may be diluted to
Adjust rate according to patient's blood 60ml with N/S to make a
pressure response and tolerance. 1000microgram/ml solution, and
infused via a central IV line. (This
dilution is unlicensed).
Pump rate (ml/hour) =Prescribed rate(micrograms/minute) x 60(minutes in an hour)

Concentration of the infusion(micrograms/ml)
Hydrocortisone IV bolus ♠ Groups Manufacturer recommends injection over Reconstitute each 100mg with not Flush with N/S or G.
sodium (Usual 1,2,3,4 and 5 1 - 10 minutes more than 2ml W and shake before Sodium content
succinate method) drawing up. 0.5mmol/100mg.
(C) or (I) IV ♠ Groups Reconstitute as above then dilute to
infusion via 1,2,3,4 and 5 100-1000ml with N/S or G (maximum
an infusion concentration of 1mg/1ml).
pump
IM injection ♠ Groups Reconstitute as for IV bolus. Refer to The preferred method for
1,2,3,4 and 5 the Marsden Manual for guidance on initial emergency use is IV
IM injection. injection.
Hyoscine Slow IV bolus ♠ Groups 3-5 minutes Can be diluted with G or N/S. Flush with N/S or G.
butylbromide 1,2,3,4,5 and Give “slowly” as in rare cases it has caused a marked
(Buscopan®) 6 drop in blood pressure or even shock.
1,2,3,4,5 and guidance on IM injection.
6
(C) SC infusion ♠ Groups Continuous Dilute with W when 2 or more drugs Follow the PHNT Care of The Dying Pathways and the
via syringe driver 1,2,3,4 and 5 over 24 hours are being mixed in the same syringe. PHNT Syringe Driver Policy.
in palliative care W or N/S may be used when the For combinations of 2 or 3 drugs in the same syringe,
syringe only contains this drug. refer to the Syringe Driver Drug Compatibility chart
provided in the pump kit. Contact Pharmacy on ext.
39976 for further compatibility advice if necessary.
Hyoscine butylbromide is not licensed via the SC route
(See page 124).
Hyoscine IM injection as ♠ Groups Refer to the Marsden Manual for
hydrobromide premedication 1,2,3,4 and 5 guidance on IM injection.
SC injection as ♠ Groups Refer to the Marsden Manual for
premedication 1,2,3,4 and 5 guidance on SC injection.
IV bolus as ♠ Groups 3-5 minutes
premedication 1,2,3,4 and 5
(For acute use)
SC injection for ♠ Groups Refer to the Marsden Manual for Follow the PHNT Care of The Dying Pathways and the
use in palliative 1,2,3,4 and 5 guidance on SC injection. PHNT Syringe Driver Policy.
care For combinations of 2 or 3 drugs in the same syringe,
(C) SC infusion ♠ Groups Continuous Dilute with W when 2 or more drugs refer to the Syringe Driver Drug Compatibility chart
via syringe driver 1,2,3,4 and 5 over 24 hours are being mixed in the same syringe. provided in the pump kit. Contact Pharmacy on ext.
in palliative care W or N/S may be used when the 39976 for further compatibility advice if necessary.
syringe only contains this drug. Hyoscine hydrobromide is not licensed for use in
palliative care (See page 124).
Ibandronic acid For prevention of skeletal events in patients with breast cancer and bone metastases: Do not mix with calcium containing
(Ibandronate) solutions.
(I) IV infusion ♠ Groups 1 At least 15 minutes. Add the dose to 100ml N/S or G.
Infusion pump and 2 If GFR<50ml/minute Extravasation can lead to tissue damage.
is required. then infuse dose over If GFR<50ml/minute then add the
1 hour. reduced dose to 500ml N/S or G.
Treatment of tumour-induced hypercalcaemia:
(I) IV infusion ♠ Groups 1 2 hours Add the dose to 500ml N/S (or G).
Infusion pump and 2 Patient should be adequately rehydrated
is required. with N/S prior to treatment for tumour-
induced hypercalcaemia.
Treatment of post-menopausal osteoporosis:
IV bolus using ♠ Groups 1 15-30 seconds The contents of the prefilled syringes may
the prefilled and 2 be injected into an existing IV line through
syringes which N/S or G is running.
Ibuprofen (I) IV infusion ♠ Groups 1 15 minutes Preferably do not dilute further. If A course of therapy is defined as three
(Pedea®) Infusion pump and 2 necessary, the injection volume may be intravenous injections of Pedea given at 24-
is required. adjusted with either N/S or G. hour intervals. The first injection should be
given after the first 6 hours of life.
1st injection:10 mg/kg, 2nd and 3rd injections:
5 mg/kg.
If anuria or manifest oliguria occurs after the
first or second dose, the next dose should
be withheld until urine output returns to
normal levels.
If the ductus arteriosus does not close 48
hours after the last injection or if it re-opens,
a second course of 3 doses may be given.
Iloprost (I) IV infusion ♠ Groups 1 6 hour infusion Dilute 50 micrograms(0.5ml) to 25ml Obtain written administration instructions
via a syringe and 2 (once each day). with N/S or G. For patients who require from Pharmacy or from Braunton Ward.
pump. more than 50 micrograms during the 6 Iloprost injection is not licensed in the UK
Preferred hour infusion dilute 100 (See page 124).
method. micrograms(1ml) to 50ml with N/S or
Infusion pump G.
is required.
(I) IV infusion. Dilute 50 micrograms(0.5ml) to 250ml
Infusion pump with N/S or G. For patients who require
is required. more than 50 micrograms during the 6
hour infusion dilute 100
micrograms(1ml) to 500ml with N/S or
G.
Immunoglobulin (I) IV infusion. ♠ Groups Initially 0.6 – Provided ready diluted. If side effects occur reduce rate or interrupt
human normal Infusion pump 1,2,3,4 and 5 1.2ml/kg/hour for 30 infusion until symptoms subside then
(Flebogamma®DIF) is required. minutes. If well restart at lower tolerated infusion rate.
50mg/ml = 5% tolerated, the rate Have adrenaline available in case of
may be gradually anaphylactoid reactions.
Supplied by Pharmacy increased to a Monitor vital signs and observe patient
maximum of during infusion and for 20 minutes
6ml/kg/hour afterwards (for 1 hour after the first
infusion, or after the first infusion after a
long interval in treatment eg. Several
weeks).
Do not infuse with other drugs or fluids.
Immunoglobulin (I) IV infusion. ♠ Groups Initially 0.6ml/kg/hour for Provided ready diluted. If side effects occur reduce rate or interrupt
human normal Infusion 1,2,3,4 and 5 30 minutes. If tolerated, infusion until symptoms subside then
(Flebogamma®DIF) pump is advance to 1.2ml/kg/hour restart at lower tolerated infusion rate.
100mg/ml = 10% required. for the second 30 minutes. Have adrenaline available in case of
Again, if tolerated, anaphylactoid reactions.
Supplied by Pharmacy advance to 2.4ml/kg/hour Monitor vital signs and observe patient
for the third 30 minutes. It during infusion and for 20 minutes
the patient tolerates the afterwards (for 1 hour after the first
infusion well, additional infusion, or after the first infusion after a
increments of long interval in treatment eg. Several
1.2ml/kg/hour may be weeks).
made at 30 minute Do not infuse with other drugs or fluids.
intervals up to a maximum
of 4.8ml/kg/hour.
Immunoglobulin Subcutaneous ♠ Groups Initial infusion rate: Provided ready diluted Instruct the patient in the use of a syringe
Human Normal infusion via 1,2,3,4 and 5 10ml/hour per syringe driver, infusion techniques, the keeping of
(Gammanorm®) syringe driver for Also driver. The infusion a treatment diary and measures to be
16.5%=165mg/ml home treatment. administered rate may be gradually taken in case of severe adverse events.
by patient or increased by 1ml/hour When large doses are given, it is
Supplied by Pharmacy If Gammanorm is patient’s per syringe driver advisable to administer them in divided
accidentally guardian. every three to four doses at different sites.
administered into a weeks. The maximum Monitor vital signs and observe patient
blood vessel, the dose administered has during infusion and for 20 minutes
patient could been 40 ml/hour using afterwards.
develop shock. two syringe drivers Sodium content: 100mg/40ml
simultaneously.
IM Injection-Only ♠ Groups Provided ready diluted
in exceptional 1,2,3,4 and 5
cases where
subcutaneous
administration is
not possible
Immunoglobulin (I) IV infusion. ♠ Groups Infuse at an initial rate Provided ready diluted. If side effects occur reduce rate or interrupt
human normal Infusion pump is 1,2,3,4 and 5 of 0.6 - 1.2 ml/kg/hour infusion until symptoms subside then
(Gammaplex®) required. for 15 minutes. If well restart at lower tolerated infusion rate.
50mg/ml = 5% tolerated, the rate of Have adrenaline available in case of
administration may be anaphylactoid reactions.
Supplied by Pharmacy increased to Monitor vital signs and observe patient
2.4ml/kg/hour for 15 during infusion and for 20 minutes
▼ This product is minutes, then to afterwards (for 1 hour after the first
being intensively 3.6ml/kg/hour for 15 infusion, or after the first infusion after a
monitored by the CHM minutes, followed by a long interval in treatment eg. Several
and MHRA. Please maximum of weeks).
report all suspected 4.8ml/kg/hour for the Do not infuse with other drugs or fluids.
reactions (including remainder of the
non-serious ones) infusion.
using a Yellow Card
from the BNF
DRUG METHOD WHO MAY ADMINISTER OVER
INSTRUCTION FOR DILUTION COMMENTS
Immunoglobulin Subcutaneous ♠ Groups The recommended Provided ready diluted Instruct the patient or carer in the use of a
human normal infusion via syringe 1,2,3,4 and 5 initial infusion rate syringe driver, infusion techniques, the
(Hizentra®) driver for home Also depends on individual keeping of a treatment diary and
200mg/ml = 20% treatment. Suitable administered needs of the patient measures to be taken in case of severe
sites of by patient or and should not exceed adverse events.
Supplied by Pharmacy administration patient’s 15 ml/hour/site. If well-
include the carer. tolerated, the infusion If side effects occur reduce rate or interrupt
▼ This product is abdomen, thigh, rate can then infusion until symptoms subside then
being intensively upper arm and gradually be increased restart at lower tolerated infusion rate.
monitored by the CHM lateral hip. to 25 ml/hour/site. Have adrenaline available in case of
and MHRA. Please anaphylactoid reactions.
report all suspected If Hizentra is Up to 4 infusion sites Monitor vital signs and observe patient
reactions (including accidentally can be used during infusion and for 20 minutes
non-serious ones) administered into a simultaneously, afterwards (for 1 hour after the first
using a Yellow Card blood vessel, provided that the infusion, or after the first infusion after a
from the BNF patients could maximum infusion rate long interval in treatment eg. several
develop shock. for all sites combined weeks).
does not exceed 50 Do not infuse with other drugs or fluids.
ml/hour. Injection sites
should be at least 5cm Hizentra® is essentially sodium-free.
apart.
Immunoglobulin (I) IV infusion via ♠ Groups Initially 0.5ml/kg/hour Provided ready diluted. If side effects occur reduce rate or interrupt
human normal pump. 1,2,3,4 and 5 for 30 minutes. If well infusion until symptoms subside then
(Kiovig®) tolerated, the rate may restart at lower tolerated infusion rate.
10%=100mg/ml be gradually increased Have adrenaline available in case of
to a maximum of anaphylactoid reactions.
Supplied by Pharmacy 6ml/kg/hour Monitor vital signs and observe patient
during infusion and for 20 minutes
afterwards (for 1 hour after the first
infusion, or after the first infusion after a
long interval in treatment eg. several
weeks).
Immunoglobulin (I) IV ♠ Groups Initially 1ml/kg/hour for Provided ready diluted. If side effects occur reduce rate or interrupt
human normal infusion via 1,2,3,4 and 5 30 minutes, If well infusion until symptoms subside then restart at
(Octagam®) pump. tolerated, the rate of lower tolerated infusion rate.
5%=50mg/ml administration may Have adrenaline available in case of
gradually be increased anaphylactoid reactions.
Supplied by Pharmacy to a maximum of 5 Monitor vital signs and observe patient during
ml/kg/hour. infusion and for 20 minutes afterwards (for 1 hour
after the first infusion, or after the first infusion
after a long interval in treatment eg. several
weeks).
(I) IV ♠ Groups Initially 0.6ml/kg/hour Provided ready diluted. If side effects occur reduce rate or interrupt
infusion via 1,2,3,4 and 5 for 30 minutes. If well infusion until symptoms subside then restart at
pump. tolerated, the rate of lower tolerated infusion rate.
administration may Have adrenaline available in case of
gradually be increased anaphylactoid reactions.
to a maximum of Monitor vital signs and observe patient during
7.2ml/kg/hour. infusion and for 20 minutes afterwards (for 1 hour
after the first infusion, or after the first infusion
after a long interval in treatment eg. several
weeks).
Immunoglobulin (I) IV ♠ Groups Initially 0.3ml/kg/hour. Provided ready diluted. Have adrenaline available in case of
human normal infusion. 1,2,3,4 and 5 If well tolerated, the anaphylactoid reactions.
(Privigen®) Infusion rate may be gradually However, if dilution prior to Monitor vital signs and observe patient during
10%=100mg/ml pump is increased to infusion is required Privagen® infusion and for 20 minutes afterwards (for 1 hour
required. 4.8ml/kg/hour. 100mg/ml may be diluted with after the first infusion, or after the first infusion
Supplied by Pharmacy In patients with an equal volume of G to make a after a long interval in treatment eg. Several
Primary 50mg/ml solution. weeks).
Immunodeficiency who In all patients, IV immunoglobulin administration
have tolerated requires:
4.8ml/kg/hour well, the • adequate hydration prior to the initiation of the
rate may be further infusion of IV immunoglobulin.
increased gradually to • monitoring of urine output
7.2ml/kg/hour • monitoring of serum creatinine levels
• avoidance of concomitant use of loop
diuretics.
In case of adverse reaction, either the rate of
administration must be reduced or the infusion
stopped.
Privigen® is essentially sodium-free.
Immunoglobulin Subcutaneous ♠ Groups The recommended Provided ready diluted Instruct the patient in the use of a syringe driver,
Human Normal infusion via 1,2,3,4 and 5 initial rate is 10 infusion techniques, the keeping of a treatment
(Subcuvia®) syringe driver for Also ml/hour per syringe diary and measures to be taken in case of severe
16%=160mg/ml home treatment, administered driver. adverse events.
preferentially by patient or The infusion speed The infusion site should be changed every
Supplied by administered into patient’s can be increased by 1 5-15ml.
Pharmacy the abdominal guardian. ml/hour per syringe Monitor vital signs and observe patient during
wall, thigh and/or driver every infusion and for 20 minutes afterwards (for 1 hour
buttocks. subsequent infusion. after the first infusion, or after the first infusion
The recommended after a long interval in treatment eg. several
If Subcuvia is maximum speed is 20 weeks).
accidentally ml/hour.
administered into a More than one pump
blood vessel, can be used
patients could simultaneously.
develop
anaphylactic shock
or thromboembolic
events.
IM Injection- ♠ Groups Provided ready diluted In exceptional cases where IM administration is

Only in exceptional 1,2,3,4 and 5 necessary, cumulative monthly dose should be
cases where divided up into weekly or bi-weekly applications,
subcutaneous in order to keep the injected volume low. To
administration is further minimize the discomfort for the patient,
not possible. each single dosage may need to be injected at
different anatomic sites.
DRUG METHOD WHO MAY ADMINISTER OVER
INSTRUCTION FOR DILUTION COMMENTS
Immunoglobulin Subcutaneous ♠ Groups Initially the infusion Provided ready diluted Instruct the patient in the use of a syringe driver,
Human Normal infusion via 1,2,3,4 and 5 rate should be no infusion techniques, the keeping of a treatment
(Subgam®) syringe driver for Also more than 10ml/hour diary and measures to be taken in case of severe
16%=160mg/ml home treatment. administered for each syringe adverse events.
by patient or driver. If well tolerated Monitor vital signs and observe patient during
Supplied by If Subgam is patient’s it can be increased at infusion and for 20 minutes afterwards (for 1 hour
Pharmacy accidentally guardian. weekly intervals by after the first infusion).
administered into a 2ml/hour per syringe
blood vessel, driver to a maximum
patients could of 20ml/hour. The
develop shock. administration can be
performed at two or
more different sites
simultaneously to
reduce infusion time.
IM Injection- ♠ Groups Provided ready diluted In exceptional cases where IM administration is
Only in exceptional 1,2,3,4 and 5 necessary, cumulative monthly dose should be
cases where divided up into weekly or bi-weekly applications,
subcutaneous in order to keep the injected volume low. To
administration is further minimize the discomfort for the patient,
not possible. each single dosage may need to be injected at
different anatomic sites.
Immunoglobulin (I) IV infusion via ♠ Groups Initially: Provided ready diluted. If side effects occur, reduce rate or interrupt infusion.
Human Normal pump. 1,2,3,4 and 0.6 – 1.2ml/kg/hour Have adrenaline available in case of anaphylactoid
(Vigam®) 5 for 30 minutes. reactions.
5%=50mg/ml Infuse via an IV Increase gradually Monitor vital signs and observe patient during infusion
infusion set fitted up to 2.4ml/kg/hour and for 20 minutes afterwards (for 1 hour after the first
Supplied by with a 15 micron (Maximum of infusion, or after the first infusion after a long interval
Pharmacy filter 180ml/hour). in treatment eg. several weeks).
Careful consideration needed before giving to diabetic
patients (contains sucrose). Flush with G or N/S.
Indometacin (I) IV infusion ♠ Groups 1 20 – 30 minutes Either reconstitute the 1mg of Do not reconstitute with glucose solutions.
(Indocid PDA®) and 2 powder with 1ml of N/S or W to If anuria or marked oliguria (urinary output
produce a concentration of <0.6ml/kg/hour) is evident at the time of the scheduled
Single use vials 100micrograms in 0.1ml, or second or third dose, further doses must not be given
reconstitute the 1mg of powder until laboratory studies indicate that renal function has
with 2ml N/S or W to produce a returned to normal.
concentration of 50micrograms If the ductus reopens, a second course of treatment
in 0.1ml. Do not further dilute. may be given.
Infliximab (I) IV infusion. ♠ Groups Not less than 2 Reconstitute each 100mg vial Observe patients for at least 1-2 hours after the
Infusion pump is 1,2,3,4 and hours. with 10ml W to make a 10mg/ml infusion for anaphylactic reactions.
required. 5 (Infusion rate not solution. Direct the stream of W Equipment and medication to treat anaphylaxis must
more than to the glass wall of the vial and be immediately available.
2ml/minute for 250ml gently swirl the solution. Avoid Use an infusion set with an in-line sterile non-
infusion). vigorous agitation and do not pyrogenic, low protein-binding filter (pore size 1.2
In carefully selected shake as foaming is common. micrometre or less). PIU (Planned Investigation Unit)
patients who have Allow the reconstituted solution use these filters routinely to administer infliximab and
tolerated three 2- to stand for 5 minutes. First will know where to obtain them.
hour infusions, remove from a 250ml bag of N/S The displacement value is insignificant.
subsequent infusions a volume equal to the volume of
may be given over infliximab being added then add
not less than 1 hour. in the required dose of
infliximab. Mix gently.
Insulin Section
Important notes for all insulins
• When prescribing and administering insulin refer to the patient’s Insulin Passport to confirm the brand of insulin and type of injection device.
• Only use Insulin syringes to draw up insulin. Do not use intravenous syringes to draw up or measure insulin (Even for IV sliding scale infusion).
• Subcutaneous administration should be in the upper arms, thighs, buttocks, or abdomen.
• When administered subcutaneously, care should be taken when injecting to ensure that a blood vessel has not been entered (inject into a lifted skin-fold).
Keep the needle under the skin for at least 6 seconds to ensure that the entire dose is injected. After injection, the site of injection should not be massaged.
• Patients must be educated to use the proper injection techniques.
• Before first use store all insulin products in the refrigerator (2 – 80C). Do not freeze.
• If the package insert is missing, refer to the SPC on www.medicines.org.uk for instructions on how to use the various devices.
• Patients’ own insulin pens containing insulin do not need to be kept in a fridge when they are in current use.
Insulin neutral (C) IV infusion ♠ Groups In accordance with Inspect product before use: Actrapid Follow the appropriate PHNT protocols/pre-printed
(e.g. Human Infusion pump 1,2,3,4 and 5 the sliding-scale and Humulin S injection should be prescriptions for the control of blood glucose:
Actrapid®, is required. instructions. clear and colourless. • Peri-operative/Fasting/Unstable Adults
Humulin S®) • Adult patients with an acute MI
Multidose Vial Dilute with N/S to 1unit/1ml. • Hyperglycaemic Emergencies in diabetic
adults
See the guidelines for setting up • Critical Care Unit insulin protocol
and maintaining I.V Sliding Scale Loss of drug into bag, plastic syringe or giving set
Insulin Infusion in Section 8. may occur. If an infusion bag is used ensure
insulin is not injected into dead space of injection
port.
Compatible with IV glucose infusion/injection and
N/S or G containing potassium chloride for
infusion.
SC Injection ♠ Groups Inspect product before use: Actrapid Refer to the Marsden Manual for guidance on SC
1,2,3,4 and 5 and Humulin S injection should be injection.
clear and colourless. Actrapid: Discard vial 6 weeks after first use
Humulin S: Discard vial 4 weeks after first use
Record the date of first use on the vial.
DRUG METHOD ADMINISTRATION COMMENTS
Humalog® (Insulin SC Injection Refer to the Marsden Manual for Give Humalog very close to mealtimes.
Lispro) by ♠ Groups guidance on SC injection. Give Humalog Mix (25 or 50) shortly before meals. When necessary, Humalog Mix®
Humalog Mix 25 1,2,3,4 and 5 (25 or 50) can be given soon after meals.
Humalog Mix 50 Humalog should not be mixed with insulin produced by other manufacturers or with
animal insulin preparations.
Expiry after cartridge insertion, or after first use (vial and prefilled pen): 28 days.
After cartridge insertion or first use (pre-filled pen) store below 30°C. Do not
refrigerate. The pen with the inserted cartridge and the pre-filled pen should not be
stored with the needle attached.
Humulin I® SC Injection Refer to the Marsden Manual for Vials containing Humulin I or the Humulin M3 formulations should be rotated several
(Isophane) by ♠ Groups guidance on SC injection. times in the palms of the hands before use to completely resuspend the insulin, until
Humulin M3® 1,2,3,4 and 5 it appears uniformly cloudy or milky. Cartridges and pre-filled pens containing
Humulin I and Humulin M3 formulations should be rolled in the palms of the hands
ten times and inverted 180° ten times immediately before use to resuspend the
insulin until it appears uniformly cloudy or milky. If not, repeat the above procedure
until contents are mixed. Cartridges contain a small glass bead to assist mixing. Do
not shake vigorously
Expiry after insertion of the cartridge in the pen or first use of a vial: 28 days.
Do not use beyond this period. When in use, the cartridges and vials should be
stored below 30°C.
Insuman Basal® SC Injection Refer to the Marsden Manual for The cartridge or pen in-use or carried as a spare may be stored for a maximum of 4
Insuman Comb 15® by ♠ Groups guidance on SC injection. weeks not above 25°C and away from direct heat or direct light.
Insuman Comb 25® 1,2,3,4 and 5 The pen containing a cartridge in-use or the solostar pen in-use must not be stored
Insuman Rapid® in the refrigerator.
The pen cap must be put back on the pen after each injection in order to protect from
light. Before use, keep a new cartridge (in the pen) or the new solostar pen at room
temperature for 1 to 2 hours.
Apidra® SC Injection Refer to the Marsden Manual for As for Insuman preparations above.
(Insuline glulisine) by ♠ Groups guidance on SC injection.
1,2,3,4 and 5
DRUG METHOD ADMINISTRATION COMMENTS
Lantus® SC Injection Inspect the cartridge, pen or vial If the Lantus has been in the refrigerator, it should ideally be taken out 1 to 2 hours
(Insulin Glargine) by ♠ Groups before use. It must only be used if the before injection to allow it to warm up as cold insulin is more painful to inject.
1,2,3,4 and 5 solution is clear, colourless, with no After first use, Lantus may be kept for a maximum of 4 weeks at a temperature
solid particles visible, and if it is of below 25°C. Record the date of first use on the vial.
water-like consistency
Levemir® SC Injection Inspect the Levemir injection: it must Shelf life after first opening: A maximum of 6 weeks when stored below 30°C.
(Insulin Detemir) by ♠ Groups not be used if it does not appear clear Each Penfill cartridge, Flexpen or Innolet must only be used for a single patient.
1,2,3,4 and 5 and colourless.
Refer to the Marsden Manual for
guidance on SC injection.
NovoMix 30® SC Injection Refer to the Marsden Manual for Allow the NovoMix30 to warm up to room temperature (Makes mixing easier).
by ♠ Groups guidance on SC injection. Alternate rolling the pen 10 times horizontally in your palm with tilting to get the glass
1,2,3,4 and 5 ball to roll from one end to the other several times until the suspension of insulin
appears uniformly white and cloudy.
When stored at room temperature (less than 300C) the expiry date of a vial, Penfill or
Flexpen is 4 weeks from the date of first use.
Each Penfill cartridge or Flexpen must only be used for a single patient
Novorapid® Inspect product before use: Novorapid NovoRapid should generally be given immediately before a meal. When necessary
(Insulin Aspart) injection should be clear and NovoRapid can be given soon after a meal.
colourless. When stored at room temperature (less than 300C) the expiry date of a vial, Penfill or
Refer to the Marsden Manual for Flexpen is 4 weeks form the date of first use.
guidance on SC injection. Each Penfill cartridge or Flexpen must only be used for a single patient.
Intralipid® 20% IV bolus and IV ♠ Group 1 Follow the Association of Anaesthetists of GB and Ireland guidelines. The • Continue CPR throughout
infusion Intralipid is located on the crash trolleys in Theatre, along with a laminated treatment with Intralipid®.
For the copy of the guideline. • Recovery from local
treatment of anaesthetic induced cardiac
cardiac arrest 1. Give IV bolus of 1.5ml/kg over 1 minute and start IV infusion at arrest may take more than 1
due to toxic 15ml/kg/hour. hour.
intravenous 2. After 5 minutes give a maximum of two repeat IV boluses of 1.5ml/kg if: • Propofol is not a suitable
concentrations • adequate circulation has not been restored or substitute for Intralipid®.
of local • an adequate circulation deteriorates. • Lidocaine should not be used
anaesthetic Leave 5 minutes between boluses. as an anti-arrythmic therapy.
A maximum of three boluses can be given (including the initial bolus).
3. Continue the infusion at the same rate, but double the rate to
30ml/kg/hour at any time after 5 minutes if:
• cardiovascular stability has not been restored or
• an adequate circulation deteriorates.
4. Continue the infusion until stable and adequate circulation restored or the
maximum cumulative dose of Intralipid has been given.
Do not exceed a maximum cumulative dose of Intralipid of 12ml/kg
Iron dextran First test dose ♠ Groups Test dose (25mg = 0.5ml) over 1- Consult the Haematology Cosmofer
(Cosmofer®) before 1,2,3,4 and 2 minutes. Monitor the patient protocol.
administration of 5 closely. If no adverse reactions Monitor patient closely in case of
Each ml Cosmofer® to all occur after 60 minutes give the anaphylaxis.
contains new patients remainder of the very first dose as Resuscitation equipment should be
50mg Iron(III) below. available.
Slow IV bolus
Stop the infusion or injection immediately if
Preferred method: ♠ Groups Infuse the first 25mg over 15 Dilute 100-200mg iron (2 – 4ml) any signs of hypersensitivity or intolerance
1,2,3,4 and minutes before each subsequent in 100ml of N/S or G. occur.
(I) IV infusion.
infusion. If no adverse effects Observe the patient closely for signs of
Infusion pump is 5
during this time infuse the hypersensitivity during Cosmofer
required.
remaining solution at maximum administration and for at least 1 hour after IV
rate of 100ml/30 minutes. administration (Especially after Total Dose
Hospital Use ♠ Groups Infuse the first 25mg of the For Total Dose Infusion add the Infusion to monitor for delayed
Only:Total Dose 1,2,3,4 and infusion over 15 minutes. If no required dose (determined by hypersensitivity-like reactions).
IV Infusion. 5 adverse effects during this time the dosage table or calculation Do not infuse with any other drugs or fluids.
Infusion pump is infuse the remaining solution over in the product leaflet) to 500ml Flush with N/S.
required. 4 – 6 hours. The rate of infusion N/S or G.
may be increased progressively Cosmofer® may alternatively be given by
to 135-180ml/hour. deep IM injection – refer to the SPC for
IV bolus ♠ Groups Administer the first 25mg over 1-2 Dose of 100-200mg iron (2-4ml) further instructions (www.medicines.org.uk)
(or injection into 1,2,3,4 and minutes before each subsequent preferably diluted in 10-20ml Do not give Cosmofer® to patients with a
the venous limb 5 slow bolus. Wait 15 minutes and N/S or G. history of asthma, allergic eczema or other
of the dialyser monitor for adverse effects. If no atopic allergy by the IV route (For these
during adverse effects give remainder of patients IM is the preferred route for
haemodialysis) each dose at 10mg/minute Cosmofer®).
(0.2ml/minute) For use on the Planned Investigation
Unit, follow the PIU Cosmofer® Pathway.
Iron sucrose IV bolus ♠ Groups 1ml/minute (5ml Undiluted Do not give Venofer by IM injection.
(Venofer®) (or injection into 1,2,3,4 and ampoule over 5 The patient should be monitored closely for
the venous limb 5 minutes). signs of hypersensitivity during administration
Each ml of the dialyser and for 30 minutes after every dose of Venofer
contains 20mg during Maximum 10ml (200mg) given. If hypersensitivity reactions or signs of
Iron haemodialysis ) per injection. intolerance occur during administration, the
treatment must be stopped immediately
(I) IV infusion. ♠ Groups 100mg over at least 15 Dilute each 5ml ampoule to a Resuscitation equipment should be available.
Infusion pump 1,2,3,4 and minutes maximum of 100ml with N/S. Do not infuse with any other drugs or fluids.
is required. 5 Extravasation may cause tissue damage.
200mg over at least 30 Two 5ml ampoules should not be
minutes diluted to more than 200ml with
N/S
Isoniazid IV bolus ♠ Groups Give slowly. Suggestion: Recommended to administer
1,2,3,4 and 3-5 minutes undiluted but can be further diluted
5 with W if needed.
Isophane Isophane insulin should be prescribed by brand. See Insulin Section page
insulin
Isoprenaline (C) or (I) IV ♠ Groups For severe Via a central IV line (or large ECG monitoring required.
infusion. 1,2,3,4 and 5 bradycardia: Dose peripheral vein if central access is
Infusion pump range 0.5 – 10 not available) dilute 2mg or
is required. micrograms/minute 2.25mg isoprenaline sulphate
Preferably Adjust rate according (depending on the brand of
administer via a to response ampoule available) in 500ml G.
central venous In fluid restricted patients 2mg or
catheter to 2.25mg isoprenaline sulphate
avoid potential (depending on the brand of
venous irritation ampoule available) may be diluted
as the to 50ml with G and given via a
preparation has central line.
a low pH
Pump rate (ml/hour) =Prescribed rate(micrograms/minute) x 60(minutes in an hour)

Infusion using 2mg isoprenaline sulphate in 500ml G: 0.5 – 10micrograms/minute = 7.5 – 150ml/hour
Infusion using 2.25mg isoprenaline sulphate in 500ml G: 0.5 – 10micrograms/minute = 6.7 – 133ml/hour
If patient is fluid restricted then via a central line:
Infusion using 2mg isoprenaline sulphate in 50ml G: 0.5 – 10micrograms/minute = 0.75 – 15ml/hour
Infusion using 2.25mg isoprenaline sulphate in 50ml G: 0.5 – 10micrograms/minute = 0.67 – 13.3ml/hour
IV bolus ♠ Group 1 Using the 100microgram in 2ml
ampoule, dilute 2ml
(100micrograms) to 5ml with N/S
or G.
Isosorbide (C) or (I) IV ♠ Groups 1 Usually 2-12mg/hour. Up Provided ready-diluted 25mg of Use a plastic syringe with a PVC-free or PE-lined
dinitrate infusion via and 2 to 20mg/hour if needed. isosorbide dinitrate in 50ml. extension set. The following extension sets are suitable
(Isoket®) pump This equates to 4 -24 and are available to order from NHS Supplies:
ml/hour (Max 40ml/hour) of
0.05% (25mg in 50ml) Codan PVC-free extension set 71.4001, order code
solution. FKA064.
Alaris G30302M line, order code FKA058
Vygon PE-lined extension set 6222.151, order code
FSB147.
BMS PE-lined extension set 30-7200, order code
FSB646.
Other suitable sets include the Vygon 71100.15 PE
extension set and the Vygon 0832.211R PE-lined
extension set.
Flush with N/S or G. Monitor blood pressure and pulse
during infusion.
Intra- ♠ Group 1 1mg bolus given prior to Manufacturer recommends Further doses may be given, not exceeding 5mg within a
coronary balloon inflation dilution to 0.5mg/ml with N/S or G. 30 minute period.
Itraconazole (I) IV ♠ Groups Administer 60 ml (200mg) Following the package insert To avoid incompatibility problems, after infusing the
infusion. 1,2,3,4 and over 1 hour instructions remove the outer itraconazole flush the extension line with 15-20ml N/S at
Infusion 5 Stop the infusion when wrap from the 50ml bag of N/S the two-way stop cock, just before the 0.2 micron in-line
pump is 60ml (200mg) has been provided. Inject 250mg filter as directed in the package insert instructions.
required. administered itraconazole (25ml) into the bag in Do not infuse any other drug solutions together with
(About 15ml will remain in a slow single action (up to 60 itraconazole down the same line/lumen.
the bag and infusion set to seconds) and agitate gently.(The Protect prepared infusion from direct sunlight.
be discarded) bag now contains 250mg in Do not administer if the solution is a milky white colour that
75ml). Close the infusion set does not disappear after gentle mixing.
clamp then push the pin of an
infusion set into the flexible port of
the infusion bag. Then prime the
infusion set in the usual manner.
Connect the infusion set to the
two-way stop cock of the
extension line and open the
clamp to allow all the air to be
expelled from the infusion set and
extension line.
DRUG METHOD WHO MAY GIVE ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
AND SUITABLE DILUENT
Ketamine Induction & ♠ Group 1 Minimum 60 seconds 50mg/ml is the recommended Flush IV bolus with N/S or G.
maintenance of maximum concentration.
anaesthesia
IV bolus
Low dose as ♠ Groups 1 and 2 3-5 minutes 50mg/ml is the recommended
premedication prior maximum concentration.
to invasive or
painful procedures
IV bolus
(C) IV infusion. ♠ Group 1 Can be diluted to 1mg/1ml with G Resuscitation equipment should be
Infusion pump is Can be given by or N/S or infused as 10mg/ml or available.
required. Group 2 staff to a 50mg/ml (undiluted product). Monitor cardiac and respiratory functions.
ventilated patient in Ketamine is chemically incompatible with
level 3 critical care. barbiturates and diazepam because of
Induction & ♠ Group 1 Refer to the Marsden Manual for precipitate formation. Therefore, these
maintenance of guidance on IM injection. should not be mixed in the same syringe
anaesthesia or infusion fluid.
IM Injection
Post-operative Only to be 1 – 2ml/hour via anti- Draw up 0.1ml/kg of ketamine Monitor the patient in accordance with the
(C) IV Infusion. prescribed by an siphon/reflux line. 50mg/ml injection. Dilute this to PHNT Acute Pain protocols.
Use a locked anaesthetist or the Titrate to response. 50ml with N/S.
infusion pump Acute Care Team.
designated for Group 2 staff can
ketamine. administer.
Kidney Kidney perfusion via ♠ Group 1 or Chill to 4oC then Do not further dilute. Not for Intravenous Infusion
perfusion kidney transplant Group 2 trained in rapidly perfuse kidney
solution catheter the use of the with 8 litres, followed Follow the operating instructions for the
(Soltran) LifePort system by slower perfusion of LifePort system.
75-100ml/minute
Kiovig® See Immunoglobulin Human Normal
Labetalol IV bolus ♠ Groups 1 50mg bolus over at IV bolus can be repeated every 5
and 2 least 1 minute. minutes to a maximum dose of 200mg.
Lower doses are used ECG and blood pressure monitoring
during anaesthesia. required.
(C) or (I) IV ♠ Groups Usual maximum rate Dilute to 1mg/1ml with G or G/S. The patient should remain supine for at
infusion. 1,2,3,4 and 5 120mg/hour Suggested volume 200ml. least 3 hours after administration.
Infusion pump Flush with G.
is required. For patients in critical care areas who
are fluid restricted undiluted labetolol
injection (5mg/ml) may be given by IV
infusion via a central IV line -this method
is unlicensed (See page 4)
Lantus ® See Insulin Section page
Lenograstim (I) IV infusion. ♠ Groups 30 minutes Using the 19G needle provided, Flush with N/S.
Infusion pump 1,2,3,4 and 5 reconstitute with the 1.05ml W provided
is required. and agitate gently to ensure complete
dissolution (do not shake vigorously).
Dilute with N/S or G up to 50ml/vial for
Granocyte-13 or up to 100ml/vial for
Granocyte-34.
SC Injection ♠ Groups Reconstitute as above using the 19G Refer to the Marsden Manual for
1,2,3,4 and 5 needle. Keep the19G needle and the guidance on SC injection.
syringe attached to the vial and
withdraw the required volume of
reconstituted solution from the vial.
Replace the needle used for
reconstitution and fit the syringe with the
26G needle provided for subcutaneous
injection.
Leucovorin See Folinic Acid
calcium
Levemir® See Insulin Section page
Levetiracetam (I) IV infusion. ♠ Groups Give all doses over 15 Dilute all doses with 100ml N/S or IV and oral dosage (dose and frequency) are
Infusion pump 1,2,3,4 and 5 minutes G. the same. No adjustment is needed when
is required. switching between these routes.
Sodium content: 1.5g dose contains 25mmol
sodium.
The SPC states that there is no experience with
administration of IV levetiracetam for longer
than 4 days.
Levobupivacaine Epidural ♠ Group 1 Administer in accordance with All syringes containing solution for epidural
injection standard anaesthetic practice administration should be labelled “For Epidural
Local Infiltration Use Only” (NPSA/2007/21)
Intrathecal
injection
Peripheral
nerve block
Peribulbar
block
Levofloxacin (I) IV infusion. ♠ Groups 250mg over at least 30 Provided ready diluted. Flush with N/S or G.
Infusion pump 1,2,3,4 and 5 minutes. 500mg over Sodium content : 15.4mmol/100ml bottle.
is required. at least 60 minutes. Rarely, profound hypotension may occur during
infusion. If this happens halt the infusion
immediately.
Levofloxacin is well absorbed from the GI tract
so consider an early switch to the oral route.
The bag should only be removed from the
outer covering at the time of infusion as the
shelf life reduces to 7 days once this outer
covering is removed.
Levomepromazine IV bolus ♠ Groups 1 3-5 minutes Dilute with at least an equal Protect infusion from light. Discard injection if
and 2 volume of N/S before pink or yellow colouration occurs.
administration. Flush with N/S.
Postural hypotension can occur, particularly in
patients over 50; monitor blood pressure.
Sodium content: 0.037mmol/1ml
SC injection for use ♠ Groups Refer to the Marsden Manual for Follow the PHNT Care of The Dying Pathways.
in palliative care 1,2,3,4 and guidance on SC injection.
5
(C) SC infusion via ♠ Groups Continuous over 24 Dilute with W when 2 or more Follow the PHNT Care of The Dying Pathways
syringe driver in 1,2,3,4 and hours drugs are being mixed in the and the PHNT Syringe Driver Policy.
palliative care 5 same syringe. For combinations of 2 or 3 drugs in the same
W or N/S may be used when the syringe, refer to the Syringe Driver Drug
syringe only contains this drug. Compatibility chart provided in the pump kit.
Contact Pharmacy on ext. 39976 for further
Lidocaine Slow IV bolus ♠ Groups 1 and 2 – 3 minutes ECG monitoring required.
(Lignocaine) 2 Flush with N/S.
Loading Dose ♠ Groups 1 and Infusion for adults: Dilute with N/S or G. Usual 50mg bolus dose for patients who have
(Slow IV bolus 2 4mg/minute for 30 concentration of 1mg/ml or gross circulatory impairment or low body
as above) minutes then 2mg/ml but concentrations up to weight.
followed by (C) 2mg/minute for 2 8mg/ml have been used in fluid Use reduced dosage for patients with CCF,
or (I) IV hours than restricted patients. hepatic failure and cardiac surgery.
infusion. 1mg/minute. If an IV infusion is not immediately
Infusion pump commenced, the slow bolus may be
is required. repeated once or twice at intervals of at
least 10 minutes.
1gram Lidocaine in 500ml G (2mg/ml)
ready-made infusion available from
Pharmacy.
Anaesthesia: ♠ Group 1 Administer in accordance with
Infiltration (Other Groups standard anaesthetic practice
Regional IV only in
Nerve blocks accordance with
specific PGDs)
Linezolid (I) IV infusion. ♠ Groups 1 and 30 to 120 minutes Provided ready diluted Flush with N/S or G.
Infusion pump 2 Linezolid is a reversible non-selective
is required. With the new FreeFlex bag inhibitor of Monoamine Oxidase (MAOI)
containing linezolid, the spike of and may theoretically enhance increases
the giving set should be pushed in blood pressure produced by
into the blue port, after twisting off sympathomimetics (e.g. dopamine,
the cap marked with a down-ward noradrenaline, adrenaline). Theoretically it
pointing arrow. The white port is may cause serotonin syndrome with
not intended to be used. serotonin re-uptake inhibitors e.g. SSRI’s
(fluoxetine etc).
Sodium content 5mmol/600mg.
Liothyronine Slow IV bolus ♠ Groups 3-5 minutes Reconstitute the 20microgram vial with 1 to Flush with N/S.
20micrograms 1,2,3,4 and 5 2ml W and shake gently until the powder has Sodium content 1.49mmol/1g.
dissolved.
Displacement 0.2ml/20micrograms.
(For example, to give 10micrograms,
reconstitute with 1ml W which expands to
1.2ml. Then withdraw 0.6ml = 10micrograms)
Lorazepam IV bolus ♠ Groups Usual Can be diluted 1:1 with N/S or W.
(Preferred route) 1,2,3,4 and 5 maximum rate
2mg/minute
except in
control of status
epilepticus
where rapid
injection is
required.
IM injection ♠ Groups For IM administration the injection must be Absorption from an IM injection is too slow
(Give IV to treat 1,2,3,4 and 5 diluted 1:1 with N/S or W. Refer to the for a rapid effect, and no more rapid than
status Marsden Manual for guidance on IM injection. oral administration.
epilepticus)
(DL)-Lysine acetyl IV bolus ♠ Groups Suggestion: 2 –
Immediately before use, reconstitute the Do not mix with other injectable products in
salicylate 1,2,3,4 and 5 3 minutes contents of each 500mg vial with the 5ml of the same line.
(Aspegic®) W provided to make a 100mg/5ml solution.
(I) infusion ♠ Groups Suggestion: 30 Reconstitute as above then dilute the dose Minimum interval between doses is 4 hours.
(product – see 1,2,3,4 and 5 minutes (500mg or 1g) with N/S or G – suggested
page 4) volume 100ml.
Deep IM ♠ Groups Reconstitute as above. Refer to the Marsden
injection 1,2,3,4 and 5 Manual for guidance on IM injection.
MabCampath® See Alemtuzumab
Magnesium sulphate (I) IV ♠ Groups Arrythmias: 2g (8mmol
2+
10% (1g in 10ml) magnesium Flush with N/S.
infusion. 1,2,3,4 and Mg ) over 10-15 minutes sulphate injection may be given Monitor blood pressure and pulse. Also monitor
2g (8mmol Mg2+) Infusion 5 repeated once if necessary. undiluted. for signs of Mg overdose which include
magnesium sulphate= pump is Dilute 50% (5g in 10ml) weakness, nausea, drowsiness & slurred
20ml of 10%(1g in 10ml) required. Treatment of magnesium sulphate injection to speech.
injection or hypomagnesaemia: a maximum concentration of
4ml of 50%(5g in 10ml) 2g (8mmol Mg2+) over a 200mg/1ml with N/S or G (e.g. 2g
injection. minimum of 30 minutes or (4ml of 50% injection) diluted to
5g (20mmol Mg2+) over a at least 10ml).
4g (16mmol Mg2+) minimum of 1 hour
magnesium sulphate= For patients requiring rehydration
40ml of 10%(1g in 10ml) Prevention of Re-Feeding or larger volumes of fluid, the
injection or Syndrome: magnesium replacement dose
8ml of 50%(5g in 10ml) 0.2mmol/kg (0.05g/kg) over may be diluted with 500ml or 1L
injection. a minimum of 1 hour of N/S or G.
Treatment of seizures and Loading dose: Draw up 4g (8ml Continue the infusion for at least 24 hours after
5g (20mmol Mg2+) and prevention of of 50% magnesium sulphate the seizure or delivery, whichever is later. If
magnesium sulphate= recurrence in Eclampsia: injection). Dilute to 20ml in a seizure recurs, increase the infusion rate to 1.5-
50ml of 10%(1g in 10ml) 4g loading dose over 5-15 50ml syringe with N/S. Mix well. 2g/hour or give an additional IV bolus of 2g over
injection or minutes. 5 minutes (Dilute 4ml of 50% magnesium
10ml of 50%(5g in 10ml) sulphate injection to 10ml with N/S).
injection. Maintenance infusion:
1g/hour. Using 5g in 50ml Maintenance infusion: Draw up Monitor the patellar reflex and oxygen saturation
dilution set pump at 5g (10ml of 50% magnesium levels hourly during administration of
10ml/hour. sulphate injection). Dilute to 50ml magnesium sulphate (including overnight) to
in a 50ml syringe with N/S. Mix exclude signs of toxicity.
well.
Magnesium IM Injection, ♠ Groups For adults, administer the dose using IM injection of magnesium sulphate is painful.
sulphate only if IV 1,2,3,4 and 50% (1g in 2ml) injection undiluted, or Refer to the Marsden Manual for guidance
(Continued access is not 5 dilute to 25% (1g in 4ml) with N/S. on IM injection.
from previous possible or For children a maximum
page) impractical recommended concentration for IM
injection is 20% (200mg/ml) eg. For a
500mg dose, dilute 1ml of 50%
magnesium sulphate injection to 2.5ml
with N/S.
SC infusion, ♠ Groups Keep the concentration as low as There is little published data to support
only if no other 1,2,3,4 and possible, preferably not greatly administration of magnesium sulphate by the
route is 5 exceeding the isotonic concentration of S/C route. There are isolated case reports of
possible or 6.3% w/v in Water For Injections (6.3g between 2 and 4mmol magnesium sulphate
practical =25.2mmol in 100ml Water For added to 500ml - 1 litre of N/S being tolerated
Injections). Discuss and check by S/C infusion. Administration via the S/C
dose/concentration/route with a route is not licensed in the UK (See page
Pharmacist. 124).
Mannitol (I) IV infusion. ♠ Groups Reduction of intracranial 500ml of ready-to-use 10% (50g in Flush with N/S
Infusion pump 1,2,3,4 and pressure: 500ml) mannitol is routinely stocked. Infusion may crystallise at low temperatures;
is required. 5 0.25g -0.5g/kg over 30-60 redissolve by warming.
minutes. (If using 20% mannitol, infuse through Extravasation causes inflammation and
Can be repeated as necessary. an administration set incorporating a thrombophlebitis.
filter*). 20% mannitol should preferably be
Urgent reduction of intra-ocular administered via a central IV line or at least
pressure before eye surgery: through a large peripheral vein due to its high
Up to 500ml of 20% mannitol osmolarity.
given by slow IV infusion until the *Suitable filters to administer mannitol are
intra-ocular pressure has been PALL 0.22 micron,
satisfactorily reduced. Braun Sterifix 0.2 micron, Technopharm
codan 0.2 micron filters. These filters should
be ordered via ORACLE.
Meropenem IV bolus for doses ♠ Groups 5 minutes Reconstitute each 250mg Flush with N/S or G.
up to 1g 1,2,3,4 and meropenem with 5ml W. This Sodium content: 4mmol/gram.
5 provides an approximate
concentration of 50mg/ml.
(I) IV infusion. ♠ Groups 15-30 minutes Reconstitute and dilute to 50- The preferred method for administering doses
Infusion via pump 1,2,3,4, 5 200ml using N/S or G. greater than 1g is intermittent IV infusion.
Mesna (I) IV infusion when ♠ Groups 15-30 minutes Dilute the required dose of mesna When protection against urothelial toxicity is
ifosfamide or 1,2,3,4 and (Usually 20% of the dose of required, three doses of mesna are typically given
cyclophosphamide 5 cyclophosphamide or ifosfamide) with each dose of cyclophospamide or ifosfamide.
are given as an (I) to 50ml or 100ml with N/S. The first dose of mesna is usually IV and given just
infusion over 1-2 prior to the dose/infusion of cyclophosphamide or
hours or as IV ifosfamide. Intravenous second and third doses are
bolus, or given at 4 hours and 8 hours (after the end of an
cyclophosphamide infusion). Alternatively, the second and third doses
has been given of mesna can be given orally, in which case each
orally oral dose is 40% of the dose of cyclophosphamide
or ifosfamide given, given at 2 hours and 6 hours
(after the end of an infusion), using mesna injection
by the oral route.
(C) IV infusion ♠ Groups Typically, for the duration of Dilute with N/S or G to any On occasions Pharmacy Technical Services add the
1,2,3,4 and a (C) infusion of ifosfamide, convenient volume required dose of Mesna into the bag containing
5 and then for a further 12 ifosfamide.
hours afterwards.
Example shown for 2 hour infusion of cyclophosphamide:
IV mesna over IV mesna over IV mesna over IV mesna over Oral mesna Oral mesna
15-30 minutes 15-30 minutes 15-30 minutes 15-30 minutes (40% of the cyclophos. dose) (40% of the cyclophos. dose)
2 hr OR 2 hr
Cyclophos Cyclophos
infusion infusion
0 2 4 6 8 10 0 2 4 6 8 10
Hours Hours
Metaraminol IV bolus ♠ Groups 1 Undiluted. Bolus dose: 0.5 – 5mg (0.05 – 0.5ml)
Emergency use and 2 Flush with N/S or G.
only. Sodium content : 0.087mmol/ml.
IV bolus ♠ Groups 1 0.5 – 1ml over a few Dilute 10mg in 1ml with 19ml of Follow each bolus dose with a 20ml flush of
and 2 seconds via a large N/S to make 10mg in 20ml. N/S. The bolus dose of 0.5 – 1ml of the
peripheral vein or a central prepared dilution may be repeated every 1 – 5
vein. minutes as indicated by the mean arterial
pressure (MAP) and patient response.
(C) IV infusion. ♠ Groups 1 Adjust rate according to
Dilute 15-100mg in 500ml N/S or Metaraminol injection from Torbay
Infusion pump is and 2 response. G. Manufacturing Unit is unlicensed (See page
required. The volume may be varied 4).
depending on the rate of
administration and the patient's
fluid needs.
Methotrexate When methotrexate is prescribed to treat conditions including multiple sclerosis, glomerular kidney disease, severe psoriasis or rheumatoid
arthritis, it may be administered by Group 1 or 2 practitioners who have previous experience of administering parenteral cytotoxics. Read
For use in Appendix 3 for guidance on the handling of cytotoxic drugs. Explicitly inform the patient of the once a week dosing schedule for ongoing therapy
haematology and and determine a fixed weekday as the day of injection. This should be stated on the prescription.
oncology refer to IV bolus Group 1 or 2 Consider folic acid supplementation.
chemotherapy injection (Not for Refer to the SPC for Metoject® on
protocols children or www.medicines.org.uk for details of the
adolescents) recommended monitoring to detect signs of
SC bolus Group 1 or 2 Refer to the Marsden Manual for toxicity (Mouth and throat examinations, full
injection guidance on SC injection. blood counts, liver function tests, renal
IM injection Group 1 or 2 Refer to the Marsden Manual for function etc). Refer to specific protocols as
guidance on IM injection. appropriate:
IM methotrexate for ectopic pregnancy (EPU
and Monkswell).
Methylene Blue (I) IV infusion. ♠ Groups 15 – 60 minutes Dilute to a suggested Dose to treat hypotension in septic shock
Infusion pump is 1 and 2 concentration of 1mg/ml with G.
refractory to fluids and vasopressors is
To treat hypotension required. . 1-2mg/kg over 15-60 minutes. May be repeated
refractory to fluids (C) IV infusion. ♠ Groups 0.25-2 mg/kg/hour Dilute to a suggested as required, alternatively after 2 hours set up a
and vasopressors in Infusion pump is 1 and 2 concentration of 1mg/ml with G. continuous infusion.
septic shock required. Do not infuse down the same lumen/line as any
other drugs.
Do not dilute with N/S.
Extravasation can cause tissue damage.
The use of methylene blue to treat hypotension
in septic shock is unlicensed (See page 4)
Methyl-prednisolone IV bolus (doses ♠ Groups Give slowly minimum Reconstitute with diluent provided. Flush with N/S, G or G/S.
sodium succinate up to 250mg) 1,2,3,4 and 5 5 minutes. Sodium content: 2mmol/g.
(I) IV infusion ♠ Groups Minimum 30 minutes Reconstitute as above then dilute For Acute Spinal Cord Injury refer to protocol
(Solu-Medrone) (doses over with G, N/S or G/S to any suitable on Pencarrow.
1,2,3,4 and 5
250mg) via pump volume (e.g. 50-250ml).
IM injection ♠ Groups Reconstitute with diluent provided.
1,2,3,4 and 5 Refer to the Marsden Manual for
guidance on IM injection.
Methyl-prednisolone IM injection ♠ Groups Inject deeply into the gluteal Refer to the Marsden Manual for guidance on
acetate 1,2,3,4 and 5 muscle. IM injection.
Intra-articular ♠ Group 1 Prior to intra-articular injection the joint fluid
(Depo-Medrone) Peri-articular should be examined to exclude a septic
Intrabursal process. Administer under strictly aseptic
Intralesional conditions.
Into tendon Do not give via the intrathecal route
sheaths (potentially neurotoxic) or the IV route.
Metoclopramide Slow IV bolus ♠ Groups At least 3 minutes Give undiluted. Flush with N/S or G.
10mg in 2ml 1,2,3,4 and 5 Sodium content 10mg/2ml = 0.26mmol.

SC injection for ♠ Groups Refer to the Marsden Manual for Follow the PHNT Care of The Dying
use in palliative 1,2,3,4 and 5 guidance on SC injection. Pathways.
care
(C) SC infusion ♠ Groups Continuous over 24 Dilute with W when 2 or more Follow the PHNT Care of The Dying
for us in 1,2,3,4 and 5 hours drugs are being mixed in the Pathways and the PHNT Syringe Driver
palliative care same syringe. Policy. For combinations of 2 or 3 drugs in
W or N/S may be used when the the same syringe refer to the compatibility
syringe only contains this drug. charts in the pump kit or contact Pharmacy
on ext. 39976 for advice.
If an infusion containing metoclopramide
becomes discoloured it should be discarded.
Metoprolol IV bolus ♠ Groups Cardiac arrhythmias: Give undiluted Early intervention post MI:
1,2,3,4 and 5 1-2 mg/minute 5mg every 2 minutes up to a maximum of
During anaesthesia: 15mg total as determined by blood pressure
2-4mg injected “slowly” and heart rate.
Further injections of 2mg
up to a maximum overall Monitor blood pressure, heart rate and ECG.
dose of 10mg may be
given Flush with N/S or G.
Metronidazole (I) IV infusion. ♠ Groups Adults: Provided ready diluted. Flush with N/S, G or G/S. Cefuroxime can be
Infusion pump 1,2,3,4 and 5 300ml/hour (5ml/minute) mixed into an infusion of metronidazole.
is required. will deliver the 100ml Sodium content: 13.5mmol/500mg infusion.
infusion over 20 minutes.
Midazolam IV bolus for sedation ♠ Groups Administer over at least 30 seconds an Dilution not recommended. For sedation in conscious adult
in conscious adult 1,2,3,4 and initial dose of midazolam guided by: patients follow the Sedation
(Monograph patients 5 • Age Policy on Plymouth Healthnet
continues on • Weight (under Clinical Guidelines).
the next • Other medications All healthcare practitioners
page) involved directly or participating
• Medical history and co-existing in sedation techniques must
disease
have the necessary knowledge,
• Planned procedure skills and competences required
Assess the level of sedation after 2-5 Flush with N/S.
minutes and repeat as necessary Respiratory depression and
(minimum of 2 minutes between arrest have occurred when doses
subsequent doses). were given too rapidly.
During the procedure, additional doses Naloxone, Flumazenil and
may be given. resuscitation equipment must be
IV bolus for induction ♠ Groups Induction of anaesthesia and loading Dilution not recommended. immediately available.
of anaesthesia 1,2,3,4 and dose for ICU sedation for adults: Each
5 increment over 20-30 seconds allowing
2 minutes between successive
increments.
(I) or (C) IV infusion ♠ Groups 1 Dilute with N/S, G or G/S.
following initial and 2 Usual dilution is 50mg in 50ml.
loading dose via (Pharmacy stocks 50mg in 50ml
infusion pump vials).
Midazolam Slow IV bolus for ♠ Groups 1 2.5 – 5mg over 1-2 minutes repeated at Use the 5mg in 5ml pre-filled For the Management of Carotid
(Continued) Carotid Artery and 2 2 minute intervals if sedation is not syringe prepared by Pharmacy and Artery Rupture (Carotid Blow
Rupture adequate. kept in the patient’s bedside locker. Out) follow the specific additional
If a pre-filled syringe is not available guideline on Lynher ward.
use a 5mg in 5ml ampoule.
SC injection for ♠ Groups Refer to the Marsden Manual for Follow the PHNT Care of The
terminal restlessness 1,2,3,4 and guidance on SC injection. Dying Pathways and the PHNT
and agitation 5 Syringe Driver Policy. For
(C) SC infusion via ♠ Groups Continuous over 24 hours Dilute with W when 2 or more drugs combinations of 2 or 3 drugs in
syringe driver for 1,2,3,4 and are being mixed in the same the same syringe, refer to the
terminal restlessness 5 syringe. Syringe Driver Drug
and agitation W or N/S may be used when the Compatibility chart provided in
syringe only contains this drug. the pump kit. Contact Pharmacy
on ext. 39976 for further
DRUG METHOD WHO MAY GIVE ADMINISTER OVER INSTRUCTION FOR COMMENTS
DILUTION AND SUITABLE
DILUENT
Milrinone (I) or (C) IV ♠ Groups 1 and 2 Loading dose (50microgram/Kg) Dilute to 200 microgram/ml Monitor blood pressure, heart rate, ECG,
infusion. over 10 minutes followed by with N/S or G (e.g. 10mg fluid balance and renal function.
Infusion pump infusion at 0.375-0.75 ampoule diluted to 50ml). Do not mix with other drugs.
is required. microgram/kg/minute according Flush with N/S or G.
to haemodynamic response (For However solutions of different Using a 200microgram/ml dilution the
help setting the infusion pump concentrations may be used recommended maintenance infusion rate
rate see table below). according to the patient’s fluid is 0.11-0.22ml/kg/hour.
requirements.
Milrinone 10mg in 50ml G dilution For patients with renal impairment (eGFR < 50ml/minute) using Milrinone 10mg in 50ml G dilution
eGFR >50ml/minute
Maintenance infusion rate: Infusion pump rate eGFR Initial maintenance infusion rate Initial Infusion pump rate
Titrate from 0.375 to 0.750 ml/kg/hour ml/minute/1.73m2 micrograms/kg/minute (titrate ml/kg/hour (titrate according to
micrograms/kg/minute according to haemodynamic response). haemodynamic response).
0.375 0.11 5 0.20 0.06
0.400 0.12 10 0.23 0.07
0.500 0.15 20 0.28 0.08
0.600 0.18 30 0.33 0.10
0.700 0.21 40 0.38 0.11
0.750 0.22 50 0.43 0.13
Mivacurium IV bolus ♠ Group 1 – must Doses up to 150micrograms/kg Can be administered undiluted Give IV bolus over 60 seconds to patients
only be given by over 5-15 seconds. or diluted to 500 micrograms with cardiovascular disease, those with
doctors proficient in Higher doses over 30 seconds. in 1ml with N/S, G, G/S or H. increased sensitivity to histamine (eg.
advanced airway See comments asthmatics) and those who may be
management unusually sensitive to falls in arterial blood
(C) IV infusion. ♠ Groups 1 and 2 8-10 micrograms/kg/ pressure (eg. those with cardiovascular
Infusion pump minute disease).
is required. Monitor blood pressure.
Flush with N/S.
Morphine Staff prescribing, administering and/or screening prescriptions for opioid medications should be familiar with the PHNT Policy for Reducing
Errors with Opioid Medicines in Adults (Network Drive :Groups (G) > Trust Documents > Documents > Medicines Management folder). The
PHNT Analgesic Ladder and equivalent dosages of different opioids can be found on page 185.
IV bolus ♠ Groups 1 Follow the algorithm from Dilute 10mg morphine to 10ml Flush with N/S, G or G/S.
(Theatre Recovery) and 2 Recovery 2 with N/S Sodium content negligible.
IV bolus ♠ Groups 1 Follow the IV Morphine Dilute 10mg morphine to 10ml
(Acute Care Areas) and 2 Protocol for Adults in with N/S
Acute Areas (Copy on
page 186)
IV bolus ♠ Groups 1 Follow the IV Morphine For monitoring required when IV morphine is
(Emergency and 2 Protocol for Adults in the given in the Emergency Department, see the
Department) Emergency Department protocol on page 187.
(Copy on page 187)
(C) or (I) IV infusion ♠ Groups 1 Vials of ready-diluted morphine Monitor blood pressure, heart rate,
in Critical Care areas and 2 50mg in 50ml N/S are available respiratory rate. Have naloxone and
via infusion pump. from Pharmacy). resuscitation equipment available.
Patient Controlled ♠ Groups See comments Vials of ready-diluted morphine Adult PCA: Usual bolus dose 1mg. Usual
Analgesia (PCA) 1,2,3,4 and 5 50mg in 50ml N/S are available lock-out period is 5 minutes. Refer to Acute
from Pharmacy). Pain/Care Service Protocols. Background
morphine infusion may only be prescribed by
a member of the Acute Pain/Care Team.
Nurse-led Controlled Analgesia via the PCA
pump is available – seek advice from the
Acute Pain/care Team.
SC injection ♠ Groups Refer to the Marsden Manual for SC injection not suitable for oedematous
1,2,3,4 and 5 guidance on SC injection. patients
Morphine 40mg (C) Intrathecal ♠ Group 1 or Prepare and administer in accordance with * Restricted to those persons who are
in 1ml infusion or Group 2* the Pain Management Centre protocols. trained and competent to administer
preservative-free Intrathecal bolus medication via the intrathecal route.
(Unlicensed)
Mycophenolate (I) IV infusion ♠ Groups 2 hours. Infusion to be prepared by Pharmacy. Avoid direct contact of the drug solution
1,2,3,4 and 5 Telephone Ext. 31083. Doctor to prescribe with skin or mucous membranes. If such
dose in 100ml G. contact occurs, wash thoroughly with
soap and water.
Commence the infusion immediately after
preparation.
Mycozyme® See Alglucosidase alfa
Naloxone IV bolus for: ♠ Groups Adults: Bolus dose of 100 micrograms may be Dilute to a concentration of Use infusions within 12 hours.
Reversal of opiate 1,2,3,4 and repeated at intervals of not less than 2 minutes 100micrograms/ml with N/S. If Monitor for possible
induced respiratory 5 to achieve desired response. repeated bolus doses are hypotension, hypertension,
depression in adults insufficient a continuous infusion ventricular tachycardia and
prescribed opiates as may be required using an infusion fibrillation and withdrawal
part of their pump – Dilute 2mg naloxone with syndrome.
palliative, chronic 500ml N/S or G (Resulting Flush with N/S or G.
pain or peri-operative concentration 4micrograms/ml). Note that 4mg in 20ml is an
care Starting rate is 60% of the initial IV unlicensed dilution (see page
bolus infused over 1 hour then 1).
titrate to response. When using a continuous
IV bolus followed by ♠ Groups 40microgram IV bolus (=0.1ml of 400mg/ml For the infusion, dilute infusion to treat opiate induced
(C) infusion to treat 1,2,3,4 and injection) followed by 200micrograms infused 200micrograms in 1 litre N/S respiratory depression in
PCA or epidural 5 over 6 – 8 hours. infused over 6 – 8 hours. adults prescribed opiates as
opiate-induced part of their palliative, chronic
pruritis pain or peri-operative care do
IV boluses to treat ♠ Groups 1 400 micrograms – 2000 micrograms (2mg) not suddenly stop the infusion.
Acute opiate and 2 over 2-3 minutes. If no response then repeat Once the patient is stabilised
overdose/poisoning every 2-3 minutes to a maximum of 10mg and it is deemed appropriate,
(then review the diagnosis).Further doses may the naloxone infusion should
be required if respiratory function deteriorates. be titrated down rather than
IV infusion to treat ♠ Groups 1 Initially the rate may be set at 60% of initial Dilute 10mg in 50ml N/S or G. just turned off. Close
Acute opiate and 2 resuscitive IV bolus infused over 1 hour, then monitoring is essential at this
overdose/poisoning adjusted according to respiratory rate and stage for the possibility of
level of consciousness. opioid toxicity recurring again
IM Injection only if IV ♠ Groups Refer to the Marsden Manual for guidance on especially when it is due to
administration is not 1,2,3,4 and IM injection. long acting opioids.
possible 5
SC injection only if IV ♠ Groups Refer to the Marsden Manual for guidance on
administration is not 1,2,3,4 and SC injection.
possible 5
Natalizumab (I) IV infusion. ♠ Groups Approximately 1 Observe the patient during the infusion and
Check that the solution is clear and free of
(Tysabri®) Infusion 1,2,3,4 and 5 hour for 1 hour after the completion of the infusion
particles. Draw up 15 ml from the vial and
▼ This product is being pump is for signs and symptoms of hypersensitivity
add to 100ml N/S. Gently invert the bag to
intensively monitored required. mix completely. Do not shake. Visuallyreactions.
by the CHM and Do not administer as a bolus injection.
inspect the diluted product for particles or
MHRA. Please report Equipment and medication to treat
discolouration prior to administration.
all suspected reactions anaphylaxis must be immediately available.
Flush the line with N/S when the infusion
(including non-serious has finished. Discontinue administration of natalizumab
ones) using a Yellow Do not mix with any other drugs or and initiate appropriate therapy at the first
Card from the BNF diluents. symptoms or signs of hypersensitivity.
Neostigmine IV bolus ♠ Groups Minimum 3-5 Give undiluted. Flush with N/S. Protect from light.
1 and 2 minutes. Have atropine or glycopyrollate available to
However, for counteract possible cholinergic reactions.
reversal of For use in Critical Care for acute colonic
neuromuscular pseudo-obstruction, follow the Critical Care
block, administer Bowel Management Protocol (Use for this
over 1 minute. indication is unlicensed -see page 1).
(I) or (C) IV ♠ Groups Start at 0.4mg/hour Dilute 5mg neostigmine to 50ml with N/S to Use atropine or glycopyrronium if necessary
infusion to 1 and 2 (4ml/hour). If no make a concentration of 0.1mg/ml. to treat bradycardia, and for patients with
treat severe response after 8 spinal cord lesions.
constipation hours increase to Follow the Critical Care Bowel Management
in Critical 0.8mg/hour Protocol (Use for this indication is unlicensed
Care (8ml/hour) - see page 1). The only confirmed Y-Site
compatibilities are with heparin,
hydrocortisone and potassium chloride.
SC Injection ♠ Groups Refer to the When treating Myaesthenia Gravis,
1 and 2 Marsden Manual 500micrograms of neostigmine metilsulfate
IM injection for guidance on IM by intravenous injection is equivalent in
♠ Groups effect to about 1 to 1.5mg of neostigmine
or SC injection.
1 and 2 metilsulfate by intramuscular or
subcutaneous injection, and to about 60mg
of oral pyridostigmine
Nimodipine (I) IV infusion ♠ Groups 500micrograms Provided ready diluted (10mg in 50ml). Draw up solution into 50ml syringe and
via a central 1 and 2 -2mg/ hour use the polyethylene line provided in the
IV line. =2.5 – box. Administer via a central catheter
Infusion 10ml/hour through a Y-piece connector into an
pump is infusion of N/S, G, H, Dextran 40, human
required. albumin 5% or mannitol 10% running at
40ml/hour.
Protect infusion from direct sunlight.
Incompatible with PVC
Nitroprusside See Sodium Nitroprusside
Noradrenaline (C) or (I) IV ♠ Groups Adjust rate “Single Strength” Infuse via a central venous catheter. Loss
(Norepinephrine) base infusion via a 1 and 2 according to 4ml (4mg noradrenaline base) diluted to of potency occurs if diluent is N/S. Discard
1mg/1ml central IV response. 50ml with G (or G/S) = 80micrograms/ml. infusion if brown colour develops.
line. Infusion “Double strength” Flush with G or N/S.
(=Noradrenaline pump is 8ml (8mg noradrenaline base) diluted to Protect infusion from direct sunlight.
tartrate 2mg/ml) required. 50ml with G (or G/S) = 160micrograms/ml. Haemodynamic monitoring required.
“Quadruple Strength”
16ml (16mg noradrenaline base) diluted to
50ml with G (or G/S)= 320micrograms/ml.
Rate (micrograms/kg/minute) = Pump rate (ml/hour) x concentration (micrograms/ml)

Patient’s weight (kg) x 60
Pump rate (ml/hour) =Prescribed rate(micrograms/kg/minute) x 60(minutes in an hour) x Patient’s weight (kg)
Novomix 30® Insulin See Insulin Section, page 103

Novorapid® Insulin
Octagam® See Immunoglobulin Human Normal
Octreotide SC injection ♠ Groups 1 Refer to the Marsden Manual for
Subcutaneous injection is preferred method of
and 2 guidance on SC injection.
administration.
IV bolus ♠ Groups 1 3-5 minutes Dilute each 1ml octreotide injection ECG monitoring necessary with IV injection (Not
with a minimum of 1ml and a with SC injection). Flush after IV injection with N/S.
and 2
maximum of 9ml of N/S. It is not recommended to use G to dilute octreotide
(except for treatment of variceal bleeding below).
The rubber caps of the Multidose vials should
not be punctured more than 10 times.
(C) SC infusion via ♠ Groups Continuous over Dilute with W when 2 or more drugs Follow the PHNT Care of The Dying Pathways and
syringe driver in 1,2,3,4 and 5 24 hours are being mixed in the same the PHNT Syringe Driver Policy.
palliative care. syringe. For combinations of 2 or 3 drugs in the same
(Unlicensed – see W or N/S may be used when the syringe refer to the compatibility charts in the pump
page 1) syringe only contains this drug. kit or contact Pharmacy on ext. 39976 for advice.
Octreotide Instructions for IM injection of Sandostatin LAR for deep intragluteal injection only
Depot 1. Remove the cap from vial containing Sandostatin LAR. Ensure that the powder is settled at the bottom of the vial by lightly tapping the vial.
(Sandostatin Remove the cap from the vehicle syringe. Attach one of the supplied needles to the vehicle syringe.
LAR®) 2. Insert needle through centre of rubber stopper of the Sandostatin LAR vial.
IM injection by 3. Without disturbing the Sandostatin LAR powder, gently inject the vehicle into the vial by running the vehicle down the inside wall of the
♠ Groups 1 vial. Do not inject the vehicle directly into the powder. Withdraw any excess air present in the vial.
and 2 4. Do not disturb the vial until the vehicle has wetted the Sandostatin LAR powder for suspension. Once complete wetting (approximately 2-5
minutes) has occurred, the vial should be moderately swirled until a uniform suspension is achieved. Do not vigorously shake the vial.
5. Immediately draw 2ml of air into the syringe and re-insert the needle through the rubber stopper. Inject the 2ml of air into the vial and then,
with the bevel down and the vial tipped at approximately 45 degree angle, slowly draw the entire contents of the vial containing the
suspension into the syringe. Immediately change the needle (supplied).
6. Gently invert the syringe as needed to maintain a uniform suspension. Eliminate air from syringe and disinfect the injection site. Insert
needle into right or left gluteus and draw back to ensure that no blood vessel has been penetrated. Immediately inject IM by deep
intragluteal injection.
7. Sandostatin LAR must be given only by intragluteal injection, never IV If a blood vessel has been penetrated, select another injection site.
Omalizumab SC injection in the ♠ Groups 1 Available in pre-filled syringes.
deltoid region of the and 2
arm. Alternatively, the
injections can be
administered in the
thigh if there is any
reason precluding
administration in the
deltoid region.
Omeprazole (I) IV infusion. Infusion ♠ Group 20-30 minutesReconstitute each 40mg with Flush with N/S.
pump is required. 1,2 and 3 approximately 5ml N/S or G. Dilute each Sodium content 0.1mmol/40mg vial.
40mg to 100ml with N/S or G. Revert to omeprazole capsules orally or
omeprazole dispersible tablets via
PEG/NG/NJ as soon as possible.
Use infusion in N/S within 12 hours, 3
hours if in G. Incompatible: do not infuse
with any other drugs.
Omeprazole IV Loading dose of ♠ Groups 80mg in 100ml For each 40mg vial, withdraw 5ml of Use infusion in N/S within 12 hours.
For the specialist 80mg 1,2,3,4 and N/S over 30 N/S from a 100ml bag and use to Omeprazole infusion must not be infused
treatment of 5 minutes reconstitute the vial. Then inject the through the same venflon or line lumen as
endoscopically reconstituted omeprazole into the bag. any other drug solution.
controlled bleeding Do not add more than 80mg Each bag is for single use only and must
peptic ulceration omeprazole to 100ml of diluent. be used immediately after preparation.
(C) IV infusion. ♠ Groups After loading Reconstitute and dilute each 40mg vial
Infusion pump is 1,2,3,4 and dose, infuse at as above.
required. 5 8mg/hour for * The Gastroenterologists have agreed to
70 hours* a 70-hour treatment (rather than 72
(This is hours). A pre-printed prescription is
10ml//hour with available.
each 80mg in
100ml N/S)
Ondansetron IV bolus only for: ♠ Groups 3-5 minutes Either give undiluted or dilute to any Flush with N/S.
• 4mg dose in 1,2,3,4 and 5 convenient volume of N/S or G. Sodium content 0.16mmol/1ml.
any adult As recommended in MHRA Drug Safety
patient. Update July 2013 to prevent lengthening of
• 8mg dose in the QT-interval and possible Torsade De
patients Pointes.
younger than • 8mg doses for patients aged 65 or older
65 years. should be given by IV infusion over 15
(I) IV infusion via ♠ Groups 15 minutes Dilute with 50ml to 100ml N/S or G minutes.
infusion pump is 1,2,3,4 and 5 • 8mg is the maximum dose for patients
required for: aged 75 or older.
• 8mg doses in • All 16mg doses should be given by IV
patients aged infusion over 15 minures.
65 and older. • Repeat doses should be given at least 4
• 16mg doses hours apart.
(only allowed • Ondansetron should be avoided in
for patients patients with congenital long QT
younger than syndrome.
75 years). • Caution must be used if administering
(C) IV infusion. ♠ Groups 1mg/hour ondansetron to patients with risk factors
Infusion pump is 1,2,3,4 and 5 for QT interval prolongation or cardiac
required. arrhythmias. These include: electrolyte
IM injection ♠ Groups Refer to the Marsden Manual for abnormalities; use of other medicines that
1,2,3,4 and 5 guidance on IM injection. prolong QT interval (including cytotoxic
drugs) or that may lead to electrolyte
abnormalities; congestive heart failure;
bradyarrhythmias; or use of medicines
that lower heart rate .
• Hypokalaemia and hypomagnesaemia
should be corrected before ondansetron
administration.
Oxytocin (C) infusion. ♠ Groups 1 Increase the rate Dilute 3 units of oxytocin (3 units = For detailed instructions it is essential
Infusion pump is and 2 every 30 minutes 0.6ml of the 5 units/ml injection) to to read the PHNT Guidelines for
required. until contractions are 50ml with N/S. Augmentation of Labour
satisfactory (4 – 5/10)
Using the 3 unit in 50ml dilution:
Continuous electronic fetal monitoring
Time from start of infusion Infusion rate Infusion rate during administration is required.
(Minutes) (milliunits/minute) (ml/hour
0 1 1
30 2 2 Stop the infusion during a prolonged
60 4 4 deceleration or definite fetal distress (if
90 8 8 CTG is abnormal perform FBS first).
120 12 12
150 16 16 Do not infuse through the same line as
180 20 20 blood or plasma.
Only increase the rate beyond this point following review and at the discretion of the specialist
registrar or consultant.
210 24 24
240 28 28
270 32 32
Optiray 300® ♠ Group 1 or 50ml from prefilled Do not dilute. Monitor for possible anaphylaxis or other
Group 6 syringe allergic reactions. Resuscitation
equipment must be immediately available.
Flush catheter frequently
Orencia® See Abatacept
Oxycodone Staff prescribing, administering and/or screening prescriptions for opioid medications should be familiar with the PHNT Policy for
SC bolus ♠ Groups Refer to the Marsden Manual for Follow the PHNT Care of the Dying
1,2,3,4 and 5 guidance on SC injection. Pathway in Advance Kidney Disease and
(C) SC infusion ♠ Groups 24 hours Dilute with W when 2 or more drugs the PHNT Syringe Driver Policy.
via syringe driver 1,2,3,4 and 5 are being mixed in the same syringe. For combinations of 2 or 3 drugs in the
for use in W or N/S may be used when the same syringe refer to the compatibility
palliative care. syringe only contains this drug. charts in the pump kit or contact
Pharmacy on ext. 39976 for advice.
Pabrinex ® IV high (I) IV infusion ♠ Groups 1 30 minutes The contents of the pair(s) of Flush with N/S or G.
potency injection (Preferred and 2 ampoules should be diluted with 50 to Mild allergic reactions are warning signs
method). 100ml N/S or G. (Up to 3 pairs of 5ml that further doses may cause anaphylactic
Infusion pump is ampoules can be diluted with 50- shock
required. 100ml N/S or G).
IV bolus ♠ Groups 1 10 minutes Mix contents of one 5ml Ampoule Facilities for treating anaphylaxis must be
and 2 No.1 and one 5ml Ampoule No.2 available.
(Maximum volume 10ml) in a single
syringe immediately before use.
Pabrinex ® IM high IM injection ♠ Groups 1 The contents of one ampoule number Do not give the IM formulation via the IV
potency injection and 2 1 and one ampoule number 2 of route.
Pabrinex Intramuscular High Potency Refer to the Marsden Manual for
(total 7ml) are drawn up into a guidance on IM injection.
syringe to mix them just before use, Mild allergic reactions are warning signs
then injected slowly high into the that further doses may cause anaphylactic
gluteal muscle, 5cm below the iliac shock.
crest. Facilities for treating anaphylaxis must be
available.
Pamidronate (I) IV infusion. ♠ Groups Maximum 1mg/minute. For some brands the vials contain solution Flush with N/S. Sodium content
Infusion pump is 1,2,3,4 and 5 that requires further dilution. 0.11mmol/15mg.
required. A dose of 90 mg should Monitor serum electrolytes, calcium and
normally be For vials that contain powder needing phosphate.
administered as a 2- reconstitution before further dilution: Aredia® and Medac® brands state that
hour infusion. reconstitute each 15mg vial with 5ml W. they should not be given if eGFR<30
Reconstitute each 30mg and 90mg vial unless the hypercalcaemia is life-
In renally impaired with 10ml W. threatening and the benefit outweighs the
patients the maximum risk.
recommended rate is Further dilution is necessary: In order to minimise local reactions at the
20mg/hour. Dilute 30mg to at least 125ml with N/S infusion site, the cannula should be
Dilute 60mg to at least 250ml with N/S inserted carefully into a relatively large
Dilute 90mg to at least 375ml with N/S vein.
Pancuronium IV bolus ♠ Groups 1 . Flush with N/S or G.

preferably via a and 2
central IV line or
through tubing of
flowing N/S or G
drip.
Pantoprazole Pantoprazole is non-formulary and should only be used if both intravenous omeprazole & esomeprazole are unavailable
IV bolus ♠ Groups 2 minutes Reconstitute 40mg vial with 10ml The reconstituted solution is clear and
1,2,3,4 and 5 N/S. yellowish.
(I) IV infusion. ♠ Groups 15 minutes Reconstitute as above then further Revert to omeprazole capsules orally as
Infusion pump 1,2,3,4 and 5 dilute with 100ml with N/S or G. soon as possible. Alternatively revert to
is required. dispersible lansoprazole Fastabs via
PEG/NG/NJ as soon as possible.
(C) infusion is Use infusion in N/S within 12 hours.
unlicensed (See page Incompatible: do not infuse with any other
4) and is for specialist drugs.
use after endoscopic (C) IV infusion. ♠ Groups After loading dose*, Reconstitute each 40mg vial with *The loading dose is 2 x 40mg doses, each
treatment of bleeding Infusion pump 1,2,3,4 and 5 infuse at 8mg/hour 10ml N/S and dilute up to 100ml diluted in a 100ml bag of N/S and infused
peptic ulceration. is required. for 72 hours with N/S or G. over 15 minutes each, one after the other.
(This is 20ml//hour
with each 40mg in (Do not add the contents of more
100ml) than one vial to larger bags of
N/S)
Paracetamol Intravenous paracetamol must only be used when a patient cannot take any medicines by mouth and paracetamol cannot be given via an
enteral feeding tube. Peri-operative patients able to take sips of water can take paracetamol orally with a little water.
(I) IV infusion. ♠ Groups 15 minutes Provided ready-diluted Can be flushed with N/S.
Infusion pump 1,2,3,4 and 5 Each bottle is for single use only.
is required.
Parecoxib IV bolus ♠ Groups Rapid bolus directly Reconstitute 40mg vial with 2ml Do not administer parecoxib together with
1,2,3,4 and 5 into a vein or into an N/S (can be reconstituted with 2ml opioids in the same syringe.
existing line through G instead of N/S if necessary). Do not reconstitute with Hartmann’s as this
which N/S, G or H is Dissolve the powder with a gentle will cause precipitation.
running. swirling motion.
Deep IM ♠ Groups Reconstitute as above. Refer to
injection 1,2,3,4 and 5 the Marsden Manual for guidance
on IM injection.
Parenteral nutrition (C) IV infusion. Infusion ♠ Groups Adults: Each bag Do not infuse with any other drugs.
(TPN) pump is required. 1,2,3,4 and 5 should run over no See back of Pharmacy TPN order
longer than 24 form for required monitoring of
hours electrolytes, and LFT’s etc.
1. TPN must be ordered by 12 noon on the day it is required. Ensure that biochemistry results are available before the TPN is
prescribed. It is advised to “Red Spot” the samples to speed the results.
2. All patients (except those on Penrose or Pencarrow) should be referred to the Nutrition Support Team (NST). If you wish to contact
or refer a patient to the NST contact Dr Stephen Lewis Consultant Gastroenterologist on bleep 89756, Dr Andrew Latchford
Consultant Gastroenterologist on bleep 89149, Nutrition Nurse Specialist bleep 89755 or 89760, Dietitian on Ext 52266 or
Pharmacy Technical Services on Ext 53429.
3. For patients on ICU please follow the ICU TPN protocol.
4. The protocol for connecting TPN bags and monitoring should be followed with meticulous attention.
5. TPN should not be commenced out-of-hours on weekdays (Between 5pm and 9am). On a Saturday, Sunday or Bank Holiday TPN
is only available after discussion with the on-call Gastroenterologist. Once the on-call Gastroenterologist has agreed on the
commencement of TPN, then he will contact the on-call pharmacist for a supply. This applies to all wards other than Penrose and
Pencarrow (TPN bags are no longer available from the Pharmacy Night Cupboard).
Pentamidine (I) IV infusion with patient ♠ Groups Minimum 1 hour Pharmacy must prepare this. Flush with N/S or G. Sodium content
(Pentamidine supine, via an infusion 1,2,3,4 and 5 Contact Ext. 31083 nil.
isethionate) pump, Blood pressure must be closely
for the treatment of monitored. To reduce the risk of
Pneumocystis jirovecii severe, sudden hypotension, patient
(formerly known as should be supine. Do not infuse with
Pneumocystis carinii) any other drugs.
pneumonia, or
Trypanosomiasis
IM injection for the ♠ Groups 1 Refer to the Marsden Manual for

treatment of and 2 guidance on IM injection.
Leishmaniasis or
Trypanosomiasis
Pethidine IM injection ♠ Groups Refer to the Marsden Manual for Flush after IV bolus with N/S or G
1,2,3,4 and 5 guidance on IM injection. Monitor blood pressure, heart rate
Slow IV bolus ♠ Groups 2 - 5 minutes Can be diluted with N/S or G. and respiratory rate. Have naloxone
1,2,3,4 and 5 and resuscitation equipment
available.
SC injection ♠ Groups Refer to the Marsden Manual for
Sodium content nil.
Phenobarbitone IV bolus ♠ Groups For status epilepticus Dilute to 10 times its own volume Flush with N/S.
1,2,3,4 and 5 in adults: 10mg/kg at with W. Sodium content 0.79mmol/200mg.
a rate of no more The injection is highly alkaline and
than 100mg/minute. may produce local tissue damage.
Maximum dose 1g. Extravasation may cause tissue
damage. Monitor sedation score,
respiratory rate, heart rate and blood
pressure.
Phentolamine IV bolus ♠ Group 1 May be diluted with N/S if Flush with N/S or G.
mesylate To treat hypertensive required. Monitor blood pressure and ECG.
episodes due to Protect from light.
phaeochromocytoma Use with care in asthmatics: monitor
for hypersensitivity reactions.
Rapid IV bolus or IM ♠ Group 1 Refer to the Marsden Manual for Refer to the translation of the
injection for guidance on IM injection. package insert for details of how to
perform the test and the monitoring
Diagnosis of required.
phaeochromocytoma -
Rogitine blocking test
(C) IV infusion ♠ Group 1 0.2-2mg per minute Dilute with a suitable volume of Note that IV infusion of phentolamine
titrating the dose to N/S or G. is unlicensed.
the desired blood
pressure response
Phenylephrine IV bolus ♠ Group 1 100-500micrograms slowly Dilute to 1mg in 1ml with N/S. Flush IV bolus with N/S or G.
over 3-5 minutes, repeated Extravasation may cause tissue damage.
if necessary after at least Monitor blood pressure and heart rate.
15 minutes. When an IV infusion is discontinued,
(I) IV infusion. ♠ Groups 1 Adults: Maximum initial Add 10mg to 500ml of N/S or G. slow the infusion rate gradually; do not
Infusion pump is and 2 rate 180micrograms/ stop it abruptly
required. minute reduced according
to response to 30 – 60
micrograms/minute
IM injection ♠ Groups 1 Refer to the Marsden Manual for
SC injection ♠ Groups 1 Refer to the Marsden Manual for
and 2 guidance on SC injection.
Phenytoin Slow IV bolus or ♠ Groups Adults: Maximum Give undiluted. ECG and blood pressure monitoring
sodium (I) IV infusion into 1,2,3,4 and 5 50mg/minute. essential. Monitor for possible respiratory
a large vein. A depression. Flush with N/S before and
pump is required after administration of each injection or
for infusion. infusion to avoid venous irritation.
(I) IV infusion ♠ Groups Adults: Maximum An in-line 0.22-0.5 micron filter Sodium content 0.91mmol/250mg.
through a large 1,2,3,4 and 5 50mg/minute. should be used to administer Incompatible: Do not infuse with any other
vein. Infusion Children: up to phenytoin injection diluted in N/S. If drugs.
pump is 1mg/kg/minute. Maximum a suitable in-line filter is not Resuscitation equipment should be
required. 50mg/minute. available then give as undiluted available.
injection via a syringe driver as Suitable filters to administer phenytoin
After dilution: Use above. If a suitable filter is available diluted in N/S include PALL 0.22 micron,
immediately, complete dilute in 50-100ml N/S to a final
Braun Sterifix 0.2 micron, Technopharm
infusion within 1 hour. concentration not exceeding
codan 0.2 micron filters. These filters
10mg/1ml. Do not use if solution is
should be ordered through ORACLE.
hazy or contains precipitate.
Phosphate (I)infusion via ♠ Groups Infuse over 6 – 12 Provided ready-diluted. Do not Dosage: Serum phosphate 0.5-0.7mmol/L
Polyfusor peripheral or 1,2,3,4 and 5 hours. further dilute. infuse 1 - 2ml/kg. Serum phosphate <0.5mmol/L
central IV line. Maximum rate: infuse 2 – 5ml/kg. Maximum dose 500ml per
Infusion pump is 150ml/hour infusion. Infusion can be repeated if necessary.
required. To treat Re-feeding Syndrome, 500ml (50mmol
phosphate) is typically infused over 12 hours.
Incompatible with
This dose may be repeated depending on serum
other solutions
phosphate levels.
containing calcium
or magnesium, Consider reduced dosage in the elderly or
Hartmann’s patients with impaired renal function. Monitor
solution, Ringer’s serum electrolytes including phosphate and
solution, calcium (frequently in renal impairment). Monitor
ciprofloxacin, renal function, ECG and fluid balance.
dobutamine and Pain and phlebitis may occur at the infusion site.
TPN Sodium content 162mmol/L
Potassium content 19mmol/L
Phosphate content 100mmol/L
Flush with N/S.
Phytomenadione IV bolus ♠ Groups Over at least 30 May be given undiluted. Product has been reformulated without
(Konakion MM® 1,2,3,4 and 5 seconds, usually 3-5 Alternatively, draw up the required polyethoxylated castor oil, however there is still a
vitamin K) minutes per 10mg. dose from the ampoule then dilute risk of anaphylaxis with rapid IV administration.
10mg in 1ml further with a small volume (eg. Protect infusion and giving set from light.
10-20ml) of G. Flush with G.
Do not dilute the 10mg in 1ml with The contents of the 10mg in 1ml ampoules can
G and take the fraction of the be given by mouth, but this use is unlicensed
diluted injection corresponding to (See page 4)
the required dose, as the MM Do not administer via the IM route.
formulation does not distribute
evenly in the diluent.
Phytomenadione IV bolus. ♠ Groups Do not further dilute. Product has been reformulated without
(Konakion MM® The dose may be 1,2 and 4 polyethoxylated castor oil, however there is
Paediatric injected into the still a risk of anaphylaxis with rapid IV
vitamin K) lower part of an administration.
2mg in 0.2ml infusion set
containing 5% Flush with G.
dextrose or 0.9% The contents of the 2mg in 0.2ml ampoules
sodium chloride are also licensed to be given by mouth.
running at
0.7ml/minute
IM injection ♠ Groups For neonatal use following the protocols Further neonatal information can be found
1,2 and 4 on NICU in the Neonatal Formulary 6th Edition.
Konakion MM Paediatric must be
administered by IV injection when used as
an antidote to anticoagulant drugs such as
warfarin & phenindione, as IM injections
may result in significant bleeding in these
patients.
Piperacillin/ (I) IV infusion. ♠ Groups 30 minutes Reconstitute each 2.25g with 10ml and Flush with N/S.
Tazobactam Infusion pump is 1,2,3,4 and 5 each 4.5g with 20ml of W, or N/S. Sodium content: 4.7 - 5.58mmol/2.25g vial
required. Swirl until dissolved. When swirled and 9.4 – 11.2mmol/4.5g vial.
constantly reconstitution should occur Incompatible with all aminoglycosides.
within 10 minutes. Do not mix with or give through the same
Displacement ranges 1.5 – 1.7ml per line at the same time as gentamicin,
2.25g. amikacin, tobramycin etc. If only one line
Slow IV bolus of available separate the doses and flush well
this medication Dilute further to at least 50ml with N/S
or G (adding to a 100ml bag is ok). with N/S before and after each dose.
is no longer
recommended Do not give through the same line as
or licensed. In paediatrics, the maximum Hartmann’s
concentration for infusion is 90mg/ml.
Pitressin ® See vasopressin
Potassium chloride (C) IV infusion. ♠ Groups Adults: Maximum If a concentration of potassium other Pain or phlebitis may occur during
ready prepared Infusion pump is 1,2,3,4 and 5 rate 20mmol than 20, 40 or 80mmol/litre is peripheral administration of solutions
infusion bags required. potassium/hour. prescribed contact the ICU pharmacist containing 30mmol or more
containing or the on-call pharmacist. potassium/litre. Solutions containing more
20mmol/L than 40mmol/litre potassium should ideally
or 40mmol/L be given via a central line. However, in
potassium in N/S, G cases of serious hypokalaemia with no
or G/S. central access up to 80mmol/litre
Can be kept as stock potassium may be tolerated peripherally if
by all wards and given via a large vein (e.g. femoral vein).
departments. Extravasation will cause tissue damage.
Ready-made bags ECG monitoring essential and
containing resuscitation equipment must be available
80mmol/litre are also when administering more than 20mmol
available potassium/hour to adults.
Administration of IV potassium at a rate
Potassium chloride (I) IV infusion. ♠ Groups 1 Adults: Usual Critical care areas only may give exceeding 40mmol/hour poses a serious
15% injection Infusion pump is and 2 maximum rate undiluted 2mmol/ml potassium risk of asystole.
May only be stocked required. 20mmol injection via a central line with ECG Flush with N/S.
by Critical Care potassium/hour. monitoring, or dilute to the required For instructions on the use of potassium
areas concentration with N/S, G , G/S or H chloride injection during cardiopulmonary
Children: with thorough mixing. bypass refer to the Blood Cardioplegia
Usual maximum Management section of the Clinical
rate Perfusion policy.
0.2mmol/kg/hour
Potassium chloride (C) SC infusion ♠ Groups Adults: maximum Use the ready-made infusion bags There is anecdotal evidence that up to
ready prepared Only use gravity- 1,2,3,4 and 5 rate 20mmol containing 20mmol/L potassium 40mmol/L potassium can be given by SC
infusion bags feed potassium/hour. chloride available from Pharmacy. infusion. However, SC potassium infusion
containing administration can cause ulceration and the risk is greater
20mmol/L sets. Never use at 40mmol/L than at 20mmol/L.
potassium in N/S, G an infusion Monitor the infusion site regularly for early
or G/S. pump for SC signs of irritation and inflammation.
infusions.
Potassium chloride Intra-cardiac for ♠ Group 1 To be administered in accordance with A single ampoule may be ordered as a
15% injection feticide procedures for feticide on the Early Controlled Drug by these Units. Records of
Pregnancy Unit or the Emergency receipt and administration are as for
Gynaecology Unit. Controlled Drugs.
Potassium (I) infusion. ♠ Groups 1 Adult patients on a Critical care areas only may give Flush with N/S
phosphate Infusion pump is and 2 critical care unit: undiluted potassium phosphate Up to 0.3 – 0.6mmol/kg/day of phosphate
(Dipotassium required. Usual maximum injection via a central line with ECG may be required during the treatment of
hydrogen rate 20mmol monitoring. For administration via a Refeeding Syndrome.
phosphate) potassium/hour peripheral line dilute with N/S, G or G/S Dipotassium phosphate 17.42 % injection
injection (30mmol phosphate to a usual maximum concentration of contains 1mmol phosphate/ml and 2 mmol
over 3 hours) 40mmol potassium/litre. potassium/ml.
*May only be
stocked by Critical It is suggested that
Care areas. general wards ask
the doctor to
prescribe a dose of
Phosphate
Polyfusor instead
(See page 182)
Privigen® See Immunglobulin Human Normal
Prochlorperazine Deep IM injection ♠ Groups 1 Refer to the Marsden Manual for Flush IV bolus with N/S.
and 2 guidance on IM injection. Prochlorperazine is unlicensed (See page
IV bolus ♠ Groups 1 Maximum rate Dilute 1 part with 5 parts N/S before 4) by the IV route.
and 2 6.25mg/minute administration. IV administration can cause hypotension
and venous irritation.
Procyclidine IV bolus ♠ Groups 1 Suggestion: over 3 Dilution is not recommended.
and 2 minutes
Propofol IV bolus ♠ Groups 1 Do not dilute. Can be administered Monitor ECG and blood pressure. Also
and 2* through tubing (close to the injection monitor for airway obstruction and oxygen
site) of infusions of N/S, G or G/S. saturation. Resuscitation equipment should
be available.
*Boluses of propofol may only be given by
Group 2 nurses to ventilated patients in
level 3 critical care.
(C) IV infusion. ♠ Groups 1 Dependent on Infuse undiluted or dilute with G to a Administer immediately after preparation of
and 2 indication. concentration of not less than 2mg/1ml. the syringe or infusion.
Anaesthetics Directorate policy: Administer
B.Braun Propfol-Lipuro can be diluted propofol within 30 minutes of drawing up
with G, N/S or G/S to a concentration into syringe.
of not less than 2mg/1ml. Use propofol diluted with G, N/S or G/S
within 6 hours of preparation.
When using B.Braun (Propofol –Lipuro),
Generics UK and Fresenius kabi brands of
propofol in bottles for infusion, the bottle
and line should be changed at least every
If diluted in a PVC bag withdraw a 12 hours.
volume of infusion fluid and replace it To reduce pain on injection 20ml 1%
with an equal volume of propofol 1%. propofol may be mixed with up to 1ml of 1%
lignocaine immediately before use.
Flush with N/S.
Propranolol IV bolus ♠ Group 1 Adults: 1mg over 1 Can be diluted with N/S or G. ECG monitoring required.
Emergency minute. May be Flush with N/S. Sodium content nil.
use. repeated at 2-minute If IV used as temporary substitute for oral
intervals until desired propranolol 1mg IV = 10mg orally.
response observed or *Maximum dose of 10mg in conscious
until maximum dose* patients or 5mg in patients under
anaesthesia.
DRUG METHOD WHO MAYADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
Protamine Reversal of IV heparin ♠ Groups Slow injection over Can be diluted with N/S. Flush with N/S.
sulphate infusion 1,2,3,4 and 5 10 minutes. Monitor APTT coagulation tests.
IV bolus Maximum rate
5mg/minute
Reversal of SC heparin: ♠ Groups Slow IV injection Dilute to a suitable volume with Too rapid administration of
Dose: 1mg protamine per 1,2,3,4 and 5 (maximum rate N/S or G. protamine sulphate may cause
100 units heparin. Give 5mg/minute) severe hypotension and
25-50mg of this dose by followed by infusion anaphylactoid reactions. Facilities
slow IV bolus followed by of the remainder of for resuscitation and treatment of
(C) IV infusion of the the calculated shock should be available.
remainder of the protamine dose over
calculated protamine 8-16 hours
dose via an Infusion
pump.
Partial (60% maximum) ♠ Groups Maximum rate Can be diluted with N/S. Decisions regarding the necessity
reversal of enoxaparin 1,2,3,4 and 5 5mg/minute and dose of subsequent protamine
Within the first 8 hours injections should be based on
after enoxaparin clinical response rather than
administration: 1mg measurement of anti Xa or anti XIIa
protamine per 1mg results. The physician should also
enoxaparin (maximum consider that the amount of
dose 50mg protamine) by enoxaparin in the body drops to
slow IV bolus 50% after 8 hours and 33% or less
after 12 hours. The dose of
protamine should be adjusted
depending on the length of time
since enoxaparin was administered.
Protirelin IV bolus ♠ Group 1 Suggestion: Over 30-60 Do not dilute. Diagnostic test.
seconds
Quinine (I) IV infusion. ♠ Groups 4 hours Flush with N/S
Dilute required dose in 250ml or
dihydrochloride Infusion pump 500ml N/S or G. Quinine may cause hypoglycaemia.
1 and 2
is required. Therapy should be changed to oral
However, in fluid restricted
See comments for
as soon as possible.
patients a maximum dilution of
alternative possible
Sodium content: negligible.
30mg/ml may be infused via a
administration of loading
central IV line, Usual loading dose is 20mg/kg (upto
dose on ICU.
a maximum of 1.4g) quinine
dihydrochloride over 4 hours. On ICU
the loading dose can alternatively be
given as 7mg/kg quinine
dihydrochloride infused over 30
minutes followed immediately by
10mg/kg over 4 hours.
Ranitidine IV bolus ♠ Groups Adults: at least 2 minutes* May be diluted further with G or Flush with N/S, G or G/S.
1,2,3,4 and 5 Children: at least 3 minutes* N/S (20ml for example) Sodium content 0.12mmol/2ml.
*A slower bolus over 5 minutes is
(I) IV infusion. ♠ Groups 2 hours at 25mg/hour Add 50mg ranitidine to 100ml N/S
recommended by some references
Infusion pump 1,2,3,4 and 5 or G.
because of the risk of causing
is required.
bradycardia on administration.
(C) IV infusion ♠ Groups 125-250 micrograms/ Dilute 150mg ranitidine to 250ml
following initial 1,2,3,4 and 5 kg/hour with N/S or G.
IV bolus.
Infusion pump
is required.
Radio- ♠ Group 1 Refer to Group Protocols/PGD’s within
Pharmaceuticals and Group 7 the Department of Nuclear Medicine.
Rasburicase (I) IV infusion ♠ Group 1 30 minutes Rasburicase infusion is prepared Infuse through a different line to that used
and Group 2 in Pharmacy. Tel. ext. 31083. for chemotherapy agents. If this is not
The prescribed dose will be diluted possible, flush between the chemotherapy
to 50ml with N/S. agents and rasburicase with N/S.
Rasburicase is not cytotoxic.
Rasburicase is not compatible with
glucose solutions.
Remifentanil IV bolus infusion ♠ Groups 1 If not using pre- Reconstitute to a concentration of IV bolus infusion not necessary if
at induction of and 2 programmed syringe 1mg/ml with N/S, G, W or 0.45% intubation is to occur more than 8-10
anaesthesia. pump see table on the saline. Further dilute to a minutes after commencing remifentanil
(C) IV infusion next page concentration of 20-250 infusion.
during micrograms/ml with N/S, G or IV bolus infusion is not recommended for
maintenance of 0.45% saline. induction in cardiac anaesthesia .Instead
anaesthesia or (20 -25 micrograms/ml is intubate at least 5 minutes after start of
for sedation of recommended for paediatric infusion. Bolus infusions are not
ventilated patients aged 1 year and over). recommended when infusing remifentanil
patients in For TCI (Target Controlled for ICU sedation.
intensive care. Infusion) the recommended dilution Monitor cardiovascular and respiratory
is 20-50 micrograms/ml. However, functions.
Infusion pump is
100 microgram/ml (eg 5mg in Resuscitation equipment must be
required.
50ml) is often used for TCI and for available.
sedation of ventilated ICU patients. Do not flush line. Sodium content: Nil.
REMIFENTANIL INFUSION RATES
Anaesthesia in adults Anaesthesia in children Sedation in Intensive Care
including cardiac anaesthesia 1 – 12 years of age
Bolus infusion Continuous Bolus infusion Continuous Starting rate 0.1 – 0.15 micrograms/kg/minute
0.5 – 1 microgram/kg infusion 0.025 – 2 1 microgram/kg infusion 0.05 – 1.3 adjusting by 0.025 micrograms/kg/minute at
over at least 30 microgram/kg/minute over at least 30 microgram/kg/minute intervals of at least 5 minutes
seconds. (rate dependent on seconds. (rate dependent on
choice of general choice of general
anaesthetic(s)) anaesthetic(s))
Concentration: Set pump at:: Set pump at: Set pump at: Set pump at: Set pump at:
100 micrograms/ml 0.6 – 1.2 ml/kg/hour 0.015 – 1.2 1.2 ml/kg/hour for 0.03 – 0.78 0.06 – 0.09 ml/kg/hour. Adjust by 0.015 ml/kg/hour
(eg. 5mg in 50ml) for 30 seconds ml/kg/hour 30 seconds ml/kg/hour
60 micrograms/ml 1 – 2 ml/kg/hour for 0.025 – 2 ml/kg/hour 2 ml/kg/hour for 0.05 – 1.3 ml/kg/hour 0.1 – 0.15 ml/kg/hour. Adjust by 0.025 ml/kg/hour
(eg. 3mg in 50ml) 30 seconds 30 seconds
50 micrograms/ml 1.2 – 2.4 ml/kg/hour 0.03 – 2.4 ml/kg/hour 2.4 ml/kg/hour for 0.06 – 0.12 – 0.18 ml/kg/hour. Adjust by 0.03 ml/kg/hour
for 30 seconds 30 seconds 1.56ml/kg/hour
40 micrograms/ml 1.5 – 3 ml/kg/hour for 0.0375 – 3 3 ml/kg/hour for 0.075 – 1.95 0.15 – 0.225 ml/kg/hour. Adjust by 0.0375
30 minutes ml/kg/hour 30 minutes ml/kg/hour ml/kg/hour
25 micrograms/ml 2.4 – 4.8 ml/kg hour 0.06 – 4.8 ml/kg/hour 4.8 ml/kg hour for 0.12 – 3.12 0.24 – 0.36 ml/kg/hour. Adjust by 0.06 ml/kg/hour
for 30 seconds 30 seconds ml/kg/hour
20 micrograms/ml 3 – 6 ml/kg/hour for 0.075 – 6 ml/kg/hour 6 ml/kg/hour for 0.15 – 3.9 0.3 – 0.45 ml/kg/hour. Adjust by 0.075ml/kg/hour
30 seconds 30 seconds ml/kg/hour
DRUG METHOD WHO MAY GIVE ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
SUITABLE DILUENT
Rifampicin (I) IV infusion. ♠ Groups 1,2,3,4 2-3 hours Reconstitute with diluent provided (10ml) and Flush with N/S.
Infusion and 5 shake vigorously for 30 seconds. Then dilute to Discard remaining infusion after 6
pump is a concentration of 600mg in 500ml N/S, G or hours. Sodium content less than
required. G10%. 0.5mmol/600mg.
If patient is fluid restricted 600mg may be Displacement volume for a
diluted in 100ml G and given over 30 minutes. 600mg vial is 0.48ml.
Do not infuse with any other
drugs.
Rituximab The monograph for rituximab is on the next page.
Rocuronium Rapid IV ♠ Group 1- must No specific recommendations. Dilute to Flush with N/S or G.
bolus only be given by appropriate volume with N/S, H or G. Compatible with G/S and H.
doctors proficient in Sodium content 0.72mmol/50mg.
advanced airway If the patient is ventilated IV
management. Also bolus can be administered by
see comments Group 2 staff.
(C) IV ♠ Groups 1 and 2 300-600
infusion. micrograms/kg/hour
Infusion
pump is
required.
Rituximab Read and print off the full guideline from the Royal College of Nursing:
For treating http://www.rcn.org.uk/__data/assets/pdf_file/0008/262385/Rituximab_protocol.pdf
severe active (I) IV ♠ Groups 1 (Premedication is required – see comments) Although rituximab may be diluted Premdication:
Rheumatoid infusion via and 2 First infusion on Day 1: with N/S to a concentration between Dose of oral paracetamol 60
Arthritis in an infusion 1mg/ml and 4mg/ml, the usual minutes before each rituximab
50mg/hour (25ml/hour of 1g in 500ml dilution)
adults after pump concentration is 2mg/ml. infusion (not if paracetamol
for the first 30 minutes then
failure of already given in the last 4 hours).
100mg/hour (50ml/hour of 1g in 500ml dilution) So the usual dilution of a 1g dose is Chlorphenamine 10mg IV 60
treatment with
for the second 30 minutes, 1g in 500ml N/S. minutes before each rituximab
a TNF inhibitor
then the rate can be increased by 50mg/hour infusion. Methylprednisolone
(25ml/hour of 1g in 500ml dilution) every 30 Rituximab infusion should be 100mg in 100nl N/S infused over
minutes to a maximum rate of 400mg/hour prepared by Pharmacy. Telephone 30 minutes to be commenced 60
(200ml/hour of 1g in 500ml dilution) providing Ext. 31083. minutes before each rituximab
no adverse reactions occur. infusion.
Full resuscitation facilities must
(Premedication is required – see comments) be immediately available.
Monitoring:
Second infusion on Day 15: 1st hour – blood pressure, pulse,
100mg/hour (50ml/hour of 1g in 500ml dilution) temperature and O2 sats every 15
for the first 30 minutes then minutes. Thereafter, every 30
200mg/hour (100ml/hour of 1g in 500ml minutes after increasing the
dilution) for the second 30 minutes, infusion rate, and throughout the
then the rate can be increased by 100mg/hour course of the infusion once
(50ml/hour of 1g in 500ml dilution) every 30 maximum rate is reached.
minutes to a maximum rate of 400mg/hour Possible reactions:
(200ml/hour of 1g in 500ml dilution) providing Low grade fever, BP drop of
no adverse reactions occur. <30mmHg from baseline: halve
the infusion rate.
Fever >38.50C, chills, mucosal
swelling, dyspnoea, BP drop of >
30mmHg from baseline: stop the
infusion and contact the doctor.
DRUG METHOD
Romiplostim 1. Remove the plastic cap from 5. Holding the pre-filled syringe of
Romiplostim powder vial and clean water for injections with one hand,
(Nplate®)
rubber stopper using the provided bend the tip of the white plastic cover
SC Injection by alcohol swab. downward with your other hand. This
♠ Groups 1 and 2 will break the seal of the white plastic
cover. Once the seal is broken, pull
cover off to separate the grey rubber
Each vial is for cap from the clear plastic syringe tip.
single use only.
2. Attach vial adapter to Romiplostim 6. Keeping the vial on the bench,
Do not mix with
vial by peeling off paper backing attach the pre-filled syringe of water
N/S or any drug from vial adapter, keeping the vial for injections to vial adapter: hold the
solutions adapter in its packaging. Keeping outer edge of the vial adapter with
the vial on the bench, push the vial one hand and twist the syringe tip
Refer to the adapter down onto the centre of the clockwise onto the adapter with the
Marsden Manual vial until it is firmly in place. other hand until you feel a slight
for guidance on resistance.
SC injection.
3. Remove and discard vial adapter 7. Very slowly and gently expel all
packaging. water (0.72ml) into the 250
microgram powder vial. Water should
flow slowly onto powder. GENTLY
swirl the vial until all of the powder
has dissolved and the fluid in the vial
is clear and colourless. Do not shake
or agitate vial
4. Attach plunger rod to the pre- 8. Visually inspect the reconstituted solution for particulate matter and/or
filled syringe of water for discoloration. The reconstituted solution should be clear and colourless and
injections by twisting the plunger rod should not be administered if particulate matter and/or discolouration are
clockwise onto the syringe plunger, observed. Make sure solution is fully dissolved before removing syringe.
until you feel a slight resistance. Instructions continued on next page…
DRUG METHOD (Continued from previous page)
Romiplostim 9. Remove the empty pre-filled 13. Twist off administration

syringe from the vial adapter. syringe from vial adapter.
(Nplate®)
10. Remove 1 ml administration Attach safety needle to the filled
SC Injection by syringe from package. Attach the administration syringe by twisting
♠ Groups 1 and 2 1 ml syringe to vial adapter of needle clockwise into syringe Luer
reconstituted solution by twisting the lock tip.
(Continued) syringe tip onto the vial adapter until
you feel a slight resistance.
11. Turn assembled syringe-vial 14. Prepare injection site with a new
unit upside down, so the vial of alcohol swab. Pull back on the
reconstituted product is above the pink safety cover toward the
syringe. Withdraw all of the syringe and away from the needle.
medicinal product solution into the Remove clear needle shield from
administration syringe. prepared needle by holding syringe
in one hand and carefully pulling
shield straight off with the other
hand.
12. Ensure the correct amount of 15. Administer subcutaneous injection following local protocols and
solution for the patient dose is in good aseptic technique.
the administration syringe by
16. After injecting, activate the
expelling any excess solution back
pink safety cover by pushing the
into the vial.
cover forward using the same hand
until you hear and/or feel it
0.5ml of reconstituted solution
click/lock.
contains 250micrograms
17. Immediately discard syringe and needle into an approved Sharps

Container
Salbutamol IV bolus ♠ Groups 3-5 minutes Dilute 500micrograms in 1ml Flush with N/S or G.
1and 2 salbutamol injection with 9ml W, ECG monitoring recommended.
N/S or G to give a concentration of Sodium content 0.15 mmol/ml.
50micrograms in 1ml. If necessary in adult or paediatric
SC injection ♠ Groups 1 Refer to the Marsden Manual for intensive care salbutamol 5mg/5ml IV
and 2 guidance on SC injection. solution for infusion may be given
(C) IV infusion. ♠ Groups Asthma: Asthma: Dilute 5ml (5mg) of undiluted via a central IV line (this method
Infusion pump 1,2,3,4 and 3-20 micrograms/minute Ventolin Solution for Infusion to is unlicensed -see page 1) 3 – 20
is required. micrograms/minute = 0.18 – 1.2ml/hour
5 = 18 -120ml/hour of the 5mg in 500ml with G or N/S to make a
concentration of 10micrograms/ml using this dilution.
500ml dilution
(I) IV infusion ♠ Groups 1 Premature Labour: Premature labour: Dilute 10ml
using syringe and 2 10 micrograms/minute (10mg) of Ventolin Solution for
pump. increasing the rate at 10 minute Infusion to 50ml with G or N/S to
intervals to maximum rate of 45 make a concentration of 200
micrograms/minute. Once micrograms/ml
(I) IV infusion. ♠ Groups 1 uterine contractions have Premature Labour: Dilute 10ml
Using and 2 ceased the infusion rate should (10mg) of Ventolin Solution for
volumetric be maintained at the same level Infusion to 500ml with G or N/S to
pump. for one hour and then reduced make a concentration of
by 50% decrements at six 20 micrograms/ml
hourly intervals
10 – 45micrograms/minute =
3 -13.5ml/hour of the 10mg in
50ml dilution.
10 – 45micrograms/minute =
30 – 135ml/hour of the 10mg in
500ml dilution.
Secretin IV bolus ♠ Groups 1 For exocrine Reconstitute each vial with the Can be given as infusion using a syringe
pentahydrochloride and 2 pancreatic function test 10ml N/S provided making a pump depending on how the test is run.
(Secrelux®) inject over 1 – 2 concentration of 10 Clinical
minutes Units/ml. Draw up the prescribed 1 Clinical Unit/kg dose = 0.1ml/kg of
(Secrelux® is an dose. reconstituted secretin
unlicensed product- (I) IV infusion. ♠ Groups 1 1 hour Reconstitute each vial with the
see page 4) Infusion pump is and 2 10ml N/S provided making a 2 Clinical Unit/kg dose = 0.2ml/kg of
required. concentration of 10 Clinical reconstituted secretin.
Units/ml. Draw up the prescribed
dose and infuse over 1 hour. Administer immediately after preparation.
Sodium benzoate Loading dose ♠ Groups 1 90 minutes Draw up 250mg/kg = 1.25ml/kg Follow the BRHC guidelines for the
2g in 10ml (I) IV infusion and 2 of injection and dilute in 5ml/kg of management of hyperammonaemia –
10%G. http://nww.swretrieval.nhs.uk/DI_ALL.htm
(Unlicensed product- Maintenance ♠ Groups 1 24 hours Draw up 250mg/kg = 1.25ml/kg Click on “Clinical Guidelines” then
see page 4) (C) IV infusion and 2 of injection and dilute in 5ml/kg of “Hyperammonaemia”
10%G.
Sodium bicarbonate (C) IV infusion. ♠ Groups Ready prepared infusions are Flush with N/S or G.
Infusion pump is 1,2,3,4 and 5 available from pharmacy. Concentrations for IV infusion greater
required. Can be diluted with N/S or G. than 1.4% should be given via a central IV
line
IV bolus ♠ Group 1
Sodium chloride (C) or (I) IV ♠ Groups Ready prepared infusions are Concentrations over 1.8% should be
infusion. 1,2,3,4 and 5 available from pharmacy. given via a central line. Sodium content of
N.B. All bags of 0.9% injection is 150mmol/1 litre.
sodium chloride are IV bolus ♠ Groups Can be diluted with G, G/S or H.
for single use only. 1,2,3,4,5,6
and 7
(C) SC infusion ♠ Groups Usual rate is 500ml Maximum concentration of sodium
Only use gravity- 1,2,3,4 and 5 over 8 hours (21 drops chloride by subcutaneous infusion is
feed per minute). Maximum 0.9%.
administration rate is 500ml over 1 Usual maximum of 2 litres in 24 hours.
sets. Never use hour (167 drops per However, 3 litres may be given if
an infusion minute) necessary over 24 hours using two SC
pump for SC sites. The needle and giving set should
infusions. preferably be changed every 72 hours.
However, infusion sets can be left in place
for up to 5-7 days if there are no
complications. Refer to potassium
chloride monograph for SC potassium.
Sodium fusidate/ (I) IV infusion into ♠ Groups 2 hours Displacement is negligible. Add
Fusidic acid a central venous 1,2,3,4 and 5 10ml buffered diluent for 500mg in G can be used as diluent but opalescence
line (preferred 10ml (50mg in 1ml). may occur with more acidic samples
method). Infusion Reconstitute with 10ml buffered (infusion must be discarded).
pump is required diluent provided then dilute with Flush with N/S.
500ml N/S or G. When reconstituted with 10ml buffer,
6 - 8 hours For fluid restricted patients preparation contains 3.1mmol sodium and
reconstitute as above then dilute 1.1mmol phosphate.
with 100ml N/S (unlicensed dilution Sodium fusidate is well absorbed from the
- see page 1) GI tract so consider an early switch to
(I) IV infusion into ♠ Groups 6 -8 hours Reconstitute and dilute with 500ml tablets or mixture.
wide bore 1,2,3,4 and 5 as above. Alternatively for fluid
peripheral vein. restricted patients dilute with 250ml
Infusion pump is N/S or G (unlicensed dilution - see
required. page 1).
Sodium (C) IV infusion. ♠ Groups Increase rate slowly until Reconstitute 50mg with 2-3ml G (or Intra-arterial blood pressure monitoring
nitroprusside Infusion pump is 1 and 2 desired effect occurs. necessary.
the 5ml G provided in the case of
required. The maximum rate is Protect infusion and administration set
the unlicensed Spanish
(N.B Nitroprussiat 8micrograms/kg/minute from light: Use the tin foil provided to wrap
Nitroprussiat fides brand) then
fides brand is in order to avoid the bag and administration set, or the line.
further dilute with 500ml or 1000ml
unlicensed – see excessive levels of of G. Use an amber syringe if giving by syringe
page 4) cyanide and thiocyanate pump.
Intensive care areas or Theatres
and to lessen the Discontinue infusion gradually over 15-30
only may use a dilution of 1mg/ml minutes.
possibility of a sudden
50mg in 50ml) in G via a central IV Discard infusion solution if it is highly
drop in blood pressure.
line. coloured.
When using the Nitroprussiat fides
brand the prepared infusion should be
discarded after 4 hours.
Do not flush - replace giving set.
Sodium content 0.34mmol/50mg.
Using the 50mg in 50ml dilution for Intensive Care areas or Theatres:
Hypertensive crisis 0.5 – 8micrograms/kg/minute = 0.03 – 0.48ml/kg/hour
Maintenance of blood pressure at 30-40% lower than pre- 20 – 400micrograms/minute =1.2 – 24ml/hour
treatment diastolic (Lower doses if treated with other
antihypertensives)
Controlled hypotension in surgery Up to a maximum of =Up to a maximum of 0.09ml/kg/hour
1.5micrograms/kg/minute
Heart failure 10 – 200micrograms/minute =0.6 – 12ml/hour
Sodium Loading dose ♠ Groups 1 About 90 minutes Draw up 250mg/kg = 1.25ml/kg of Follow the BRHC guidelines for the
phenylbutyrate (I) IV infusion and 2 injection and dilute in 5ml/kg of management of hyperammonaemia –
2g in 10ml 10%G. http://nww.swretrieval.nhs.uk/DI_ALL.htm
Maintenance ♠ Groups 1 24 hours Draw up 250mg/kg = 1.25ml/kg of Click on “Clinical Guidelines”, then “ALL”
(Unlicensed (C) IV infusion and 2 injection and dilute in 5ml/kg of then “Hyperammonaemia”
product- see page 10%G.
4)
For a ready-made phosphate infusion that can be given via a peripheral or central vein, see the monograph for Phosphate Polyfusor
Sodium (I) or (C) IV ♠ Groups Adult patients on a Via a peripheral vein dilute dose Flush with N/S.
Phosphate infusion. Infusion 1,2,3,4 and 5 critical care unit: with a suggested volume of 500ml
(Disodium pump is required Suggested maximum N/S or G. Up to 0.3 – 0.6mmol/kg/day of phosphate
Hydrogen infusion rate of may be required during the treatment of
Phosphate) 10mmol phosphate per Undiluted sodium phosphate Refeeding Syndrome.
hour (30mmol injection may be infused via a
phosphate in 50ml central IV line using a syringe Disodium hydrogen phosphate 21.49%
over 3 hours). pump. injection contains 6mmol phosphate in
It is suggested that 10ml
general wards infuse (30mmol phosphate in 50ml).
the dose of phosphate
over 12 hours or ask
the doctor to prescribe
a dose of Phosphate
Polyfusor instead (See
page 182)
Sodium valproate IV bolus ♠ Groups 3 - 5 minutes. Reconstitute with 4ml diluent Flush with N/S, G or G/S.
Usual method 1,2,3,4 and 5 provided. Sodium content 2.41mmol/400mg vial.
Due to the product displacement Usually continue the patient’s current oral
this produces a solution of dosage as repeated slow bolus injections.
95mg/ml. Alternatively continue total usual oral daily
(C) IV infusion. ♠ Groups Divide total infusion Reconstitute as above then dosage as a continuous IV infusion over
Infusion pump 1,2,3,4 and 5 volume by 24 to set the dilute with N/S, G or G/S to any24 hours.
is required. hourly rate on the pump suitable volume of at least 50mlFor patient’s not previously treated with
(I) IV infusion. ♠ Groups 1 hour Reconstitute as above then sodium valproate a slow bolus of 400 –
Infusion pump 1,2,3,4 and 5 dilute with N/S, G or G/S to any800mg depending on patient’s weight (up
is required. suitable volume of at least 50mlto 10mg/kg) is given followed by
continuous infusion (Max. 2500mg per
day).
Streptokinase (C) or (I) IV ♠ Groups 1,2 Myocardial Infarction: Streptase brand reconstitute all ECG and blood pressure monitoring
infusion. and 3 1.5 MU over 60 sizes with 5ml N/S. Further required.
Infusion pump minutes. dilute 1.5 MU dose in 50- 1 MU= 1,500,000 units
is required. Embolism/thrombosis 200mlN/S, G or H. Flush with N/S.
250,000 units over 30 Dilute other doses in any Duration of infusion: 72 hours for DVT or
minutes followed by suitable volume of N/S or G e.g. 24 hours for PE or 24-72 hours for arterial
100,000units/hour. 50-250ml. thrombosis or 12 hours for central retinal
thrombosis.
Streptomycin Deep IM ♠ Groups 1 Refer to the Marsden A 1g dose is usually dissolved in In the treatment of tuberculosis the usual
injection and 2 Manual for guidance on 2 -3ml W. dose for adults, and children 1month to
(Unlicensed product IM injection. 18 years is 15mg/kg up to a maximum of
– see page 4) Change the The displacement volume is 1000mg, given daily or three times a
injection site approximately 0.75ml week. For the elderly and adults over 40
each time. years of age or less than 50kg body
So if you dissolve the powder weight give 500mg-750mg once daily or
with 3.25ml W the solution 750mg three times a week.
produced will be 250mg/ml
Monitor serum levels, particularly in
patients with renal impairment, and
adjust dosage accordingly.
One hour (peak) levels should be 15 –

40mg/litre and pre-dose (trough) levels
should be less than 5mg/litre (less than
1mg/litre in renal impairment or in those
over 50 years).
Subcuvia® See Immunoglobulin Human Normal
Subgam® See Immunoglobulin Human Normal
Sugammadex Rapid IV bolus ♠ Group 1 Rapid injection within Adult dose for immediate If sugammadex is administered via the
10 seconds reversal of rocuronium block is same infusion line that is also used for
Approved use in this 16mg/kg of undiluted 500mg in other medicinal products, flush before
Trust: Immediate 5ml injection. and after sugammadex administration
reversal of with N/S.
neuromuscular block 16mg/kg = 0.16ml/kg of the
by rocurronium when 500mg in 5ml injection However, sugammadex can be injected
intubation and into the intravenous line of a running
ventilation have failed. infusion with the following intravenous
solutions: N/S, G, H, and sodium chloride
It will also be effective 0.45% and glucose 2.5%.
in a similar emergency
situation to reverse
vecuronium.
Sulphadiazine (I) IV infusion. ♠ Groups 1,2,3,4 and Minimum 30-60 Dilute dose with N/S to a Flush with N/S.
Infusion pump 5 minutes maximum concentration of Sodium content approximately 4mmol/1g.
is required. 50mg/1ml. Preferably dilute To reduce the risk of crystallisation in the
required dose to 500ml to 1 litre urine a high fluid intake (2.5-3.5 litres in
to reduce risk of crystallisation in 24 hours) should be maintained with
the urine. urinary output of not less than half that
amount. In addition the urine should be
rendered alkaline.
Suxamethonium IV bolus ♠ Group - must only Ready diluted Flush with N/S or G.
be given by doctors
proficient in advanced
airway management.
(C) IV infusion. ♠ Groups 1 and 2 2.5 - 4mg/minute Infuse as a 1mg/ml to 2mg/ml Infusion not usually recommended due to
Infusion pump solution diluted in N/S or G. development of phase II neuromuscular
is required. block and likelihood of exceeding
maximum dose.
Synacthen® See Tetracosactide.
Tacrolimus (C) IV ♠ Groups Infuse daily Draw up the correct dose in a 1ml Tacrolimus is adsorbed to PVC and must be infused though a
infusion. 1,2,3,4 and dose in 48ml syringe (See table below). PVC-free or PE-lined extension set
Give by mouth Infusion 5 over 24 hours Transfer and dilute to 48ml with The following extension sets are suitable and are available to
or enteral pump is (Pump set at N/S or G in a 50ml Terumo or BD order from NHS Supplies:
feeding tube required. 2ml/hour) syringe. The final concentration
routes if at all should be between 4 and 100 Codan PVC-free extension set 71.4001, order code FKA064.
possible. micrograms/ml. Infuse through a Alaris G30302M line, order code FKA058
PVC-free extension set (Codan Vygon PE-lined extension set 6222.151, order code FSB147.
PVC-free extension set 71.4001 BMS PE-lined extension set 30-7200, order code FSB646.
available via ORACLE, order Other suitable sets include the Vygon 71100.15 PE extension set
code FKA064 or Alaris G30302M and the Vygon 0832.211R PE-lined extension set.
line via ORACLE order code Where the need is immediate and a PVC-free extension set has
FKA058) not been provided with the supply of IV tacrolimus a PVC-free
extension set can be obtained from Neonatal ICU.
Wear gloves when preparing the infusion
Not Y-site compatible with ganciclovir or aciclovir.
Oral to IV tacrolimus conversion chart Oral to IV tacrolimus conversion chart (continued)
Total oral dose of Approximately Volume of tacrolimus Total oral dose of Approximately Volume of tacrolimus
tacrolimus in 24 hours equivalent IV dose injection (5mg in 1ml) to tacrolimus in 24 hours equivalent IV dose injection (5mg in 1ml) to draw
over 24 hours draw up for further dilution over 24 hours up for further dilution
0.5mg 100micrograms 0.02ml 5.5mg 1.1mg 0.22ml
1mg 200micrograms 0.04ml 6mg 1.2mg 0.24ml
5mg 1mg 0.2ml 10mg 2mg 0.4ml
Tazocin® See Pipercillin/Tazobactam
Teicoplanin IV bolus ♠ Groups 3 – 5 minutes for Slowly reconstitute each 200mg or 400mg Flush with N/S.
Usual method 1,2,3,4 and 5 all doses. vial with the 3.2ml of W provided. Roll the Sodium content less than 0.5mmol/vial
Refer to the vial gently until the powder has (200mg and 400mg).
Plymouth Healthnet completely dissolved. Take care to avoid Incompatibile with aminoglycosides (eg.
Clinical formation of foam. If it does foam, leave gentamicin).
Guidelines/Infection the vial to settle for 15 minutes until the Teicoplanin solutions will precipitate when
Control for the use foam subsides. Reconstituted in this they come into contact with gentamicin –
and current dosage manner you will be able to extract 200mg flush the catheter well with N/S between
of gentamicin, in 3ml from the 200mg vial and 400mg in giving these two antibiotics.
teicoplanin and 3ml from the 400mg vial.
vancomycin.
(I) IV infusion. ♠ Groups 30 minutes Reconstitute as above then dilute the
Infusion pump is 1,2,3,4 and 5 required dose further with N/S, G, G/S or
required. H (e.g. 50ml or 100ml).
IM injection of ♠ Groups Reconstitute as above. Refer to the Marsden Manual for guidance
doses up to 400mg 1,2,3,4 and 5 on IM injection.
possible only when
IV access cannot
be established and
after discussion
with Microbiologist
Temocillin Slow IV bolus ♠ Groups 3 – 4minutes Reconstitute each 1g with 10ml W and Incompatible with aminoglycosides e.g.
1,2,3,4 and 5 shake vigorously. The final volume is gentamicin, tobramycin & amikacin – if
10.7ml (i.e. displacement volume is 0.7ml) administering down the same IV line, flush
with N/S between the temocillin and the
(I) IV infusion ♠ Groups 30-40minutes Reconstitute as above then add the dose
to 100ml N/S. aminoglycoside.
Infusion pump is 1,2,3,4 and 5
required.
IM injection ♠ Groups Reconstitute each 1g with 2ml W and Refer to the Marsden Manual for guidance
1,2,3,4 and 5 shake vigorously. The final volume is on IM injection.
2.7ml (i.e. displacement volume is 0.7ml).
If pain is experienced at the site of IM
injection each 1g can be reconstituted with
2ml of lidocaine 0.5% or 1% injection
instead of W.
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND SUITABLE DILUENT
GIVE OVER
Tenecteplase IV bolus ♠ Groups About 10 seconds 1) Remove the flip-off cap from the vial.
1and 2 2) Remove the tip-cap from the syringe. Then immediately screw the pre-filled
syringe onto the vial adapter and penetrate the vial stopper in the middle with the
Follow the protocol for
spike of the vial adapter.
the treatment of Acute
3) Add the water for injections into the vial by pushing the syringe plunger down
Myocardial Infarction
slowly to avoid foaming.
(See Plymouth
4) Reconstitute by swirling gently.
Healthnet Clinical
5) The reconstituted preparation results in a colourless to pale yellow, clear solution.
Guidelines)
Only clear solution without particles should be used.
6) Directly before the solution will be administered, invert the vial with the syringe still
attached, so that the syringe is below the vial.
7) Transfer the appropriate volume of reconstituted solution of Metalyse into the
syringe, based on the patient's weight.
8) Disconnect the syringe from the vial adapter.
9) Alternatively the reconstitution can be performed with the included needle.
Do not inject into a line containing glucose. Compatible with N/S

Patient Weight Vial size to Reconstitute with Dose Volume to give
pick the W provided
<60kg 40mg 8ml 30mg 6ml
>60kg to <70kg 40mg 8ml 35mg 7ml
>90kg 50mg 10ml 50mg 10ml
Terbutaline SC injection ♠ Groups Refer to the Marsden Manual for
Slow IV bolus ♠ Groups Suggestion: 3 – 5 SC and IM injection are usually preferable to slow IV
1,2,3,4 and 5 minutes bolus, but if slow IV bolus is necessary monitor the
patient’s pulse.
(C) IV infusion for ♠ Groups Adult dosage: Dilute 3 – 5ml (1.5 – 2.5mg) of
bronchodilation via 1,2,3,4 and 5 30 – 60ml/hour for 8 terbutaline injection in 500ml G, N/S
a volumetric pump – 10 hours or G/S.
(C) IV infusion for ♠ Groups Initially 3ml/hour Dilute 10ml (5mg) of terbutaline Titrate the hourly rate with reference to suppression
premature labour 1,2,3,4 and 5 (5microgram/minute) injection to 50ml with G. of contractions, increase in pulse rate and changes
via syringe pump. for 20 minutes. in blood pressure, which are limiting factors. These
(Recommended Titrate dosage in parameters should be carefully monitored during
method to avoid fluid increments of treatment. A maternal heart rate of more than 135
overload) 1.5ml/hour beats/min should be avoided. In order to minimise
(2.5microgram/minut the risk of hypotension associated with tocolytic
e) therapy, special care should be taken to avoid caval
compression by keeping the patient in the left or
(C) IV infusion for ♠ Groups Initially 30ml/hour Dilute 10ml (5mg) of terbutaline
premature labour right lateral positions throughout the infusion.
1,2,3,4 and 5 (5microgram/minute) injection to 500ml with G (remove
via volumetric pump. for 20 minutes. 10ml G from the bag first). Infusion via a syringe pump is preferable to keep
Titrate dosage in the volume of fluid administered to a minimum and
increments of to avoid maternal pulmonary oedema.
15ml/hour The recommended diluent in premature labour is G.
(2.5microgram/minut If it is necessary to use N/S monitor for maternal
e) pulmonary oedema.
SC infusion treating ♠ Groups Typical dose range: Can be infused undiluted or diluted SC infusion of terbutaline is unlicensed – see page 1
brittle asthma 1,2,3,4 and 5 5 – 15mg/24 hours with N/S to the required volume.
Terlipressin IV bolus ♠ Groups Suggestion: Each 1mg For Variquel® brand: Monitor blood pressure, serum sodium
1,2,3,4 and 5 over 1 minute Slowly add the entire contents of the and potassium and fluid balance. Flush
solvent ampoule (5ml) to the powder with N/S.
vial and roll the vial gently until the
powder is completely dissolved. The
powder should dissolve to form a
colourless solution within 10 seconds.
This may be further diluted to 10 ml
with N/S if required.
ForGlypressin® brand:
Ready diluted (1mg in 8.5ml)
Terlipressin to(C) infusion in ♠ Groups 1 1.3micrograms/kg/hour For Variquel® brand: This is an unlicensed regimen (see page
treat septic Critical Care and 2 =0.065ml/kg/hour of a Reconstitute one 1mg vial as above 1) to reduce noradrenaline requirements
shock in areas only via 1mg in 50ml G dilution. and dilute the contents further to 50ml in patients with septic shock based on
critical care central IV line. with G. the following reference:
areas only, (Preceded by an (Infusion rate may be
http://www.biomedcentral.com/content/pdf/cc799
when IV bolus of 0.5mg 0.pdf
titrated to effect at the ForGlypressin® brand:
vasopressin is or 1mg at the N/S is not a suitable diluent for
discretion of the Dilute the contents of a 1mg ampoule
unavailable discretion of the terlipressin infusion.
consultant intensivist) further to 50ml with G.
consultant The suggested expiry for terlipressin in G
intensivist) infusion is 12 hours after preparation.
Tetracosactide IV bolus ♠ Groups Suggestion: Give over Ready diluted. Flush with N/S.
(Synacthen®) 1,2,3,4 and 5 30 to 60 seconds Keep patient under observation for 30
minutes after the injection –
hypersensitivity reactions are possible.
The Planned Investigation Unit (PIU) have
copies of the “Short Synacthen test”
protocol.
IM injection ♠ Groups Inject deep into the Refer to the Marsden Manual for
1,2,3,4 and 5 deltoid muscle guidance on IM injection.
Thiopental IV bolus ♠ Group 1 Anaesthesia – Reconstitute 500mg vial with 20ml W Flush with N/S.
(Thiopentone) induction: to produce a 2.5% (25mg/ml) solution. Check for haze or precipitation before
100 –150mg over 10- administering.
15 seconds Longer in Extravasation causes local tissue necrosis
the elderly or and severe pain. This can be relieved by
debilitated) repeated application of an ice pack and local injection
after 1 minute if of hydrocortisone.
necessary.
Control of The reconstituted solution should be
convulsions: discarded after 7 hours.
75 –125mg over 3-5
minutes
Lowering raised
intracranial
pressure:
1.5 –3mg/kg over 3-5
minutes. Repeat as
necessary.
(C) infusion ♠ Groups 1 For the management Reconstitute three 500mg vials, each (C) IV infusion is not a licensed method of
via a central and 2* of refractory with 20ml W, making an infusion of administration of thiopentone (See page
IV line Pump intracranial 1500mg in 60ml (2.5% solution). 126)
is required. hypertension or Sodium content: 2.31mmol/500mg
Status Epilepticus, In intensive care areas or Theatres Use the prepared solution within 7 hours.
refer to the only, the 2.5% (25mg/ml) solution may For the management of refractory
appropriate critical be infused without further dilution intracranial hypertension or Status
care protocol. through a central line (local practice). Epilepticus, refer to the appropriate critical
care protocol.
*Group 2 nurses may only administer
prescribed additional boluses of thiopental to
ventilated patients in level 3 critical care.
Ticarcillin with See Timentin®
clavulanic acid
Tigecycline (I) IV infusion ♠ Groups 30 – 60 minutes Reconstitute the powder in the vial with Flush with N/S or G.
Infusion pump is 1,2,3,4 and 5 5.3ml N/S or G to make a 10mg/ml Tigecycline in N/S is compatible at a Y-
May only be initiated required. solution. Gently swirl to dissolve the Site with dobutamine, dopamine,
on the advice of a powder. Then withdraw 5ml (50mg) gentamicin, lidocaine,morphine,
consultant from the vial and add to a 100ml bag of potassium chloride, propofol, ranitidine
microbiologist N/S or G. For the 100mg dose and Hartmann’s
reconstitute two vials as above and add The solution should be inspected for the
▼ This product is 10ml to a 100ml bag of N/S or G. presence of particulate matter or green
being intensively or black discolouration before use.
monitored by the Tigecycline should be yellow/orange in
CHM and MHRA. colour once reconstituted, if it is not, it
Please report all should be discarded.
suspected reactions
(including non-
serious ones) using a
Yellow Card from the
BNF.
Timentin® (I) IV infusion ♠ Groups 30-40 minutes Reconstitute the 3.2g vial with 10ml W Incompatible with gentamicin and other
Infusion pump is 1,2,3,4 and 5 to form a pale straw-coloured solution. aminoglycosides.
required. Heat is released when the powder Each 3.2g of Timentin® contains
dissolves. Further dilute 3.2g with 100 - approximately 15.9mmol of sodium.
150ml G. Do not administer Timentin® by IV bolus
or IM injection.
Displacement value: 2.2ml for 3.2g of Flush with N/S.
Timentin® so reconstitute 3.2g vial with
7.8ml W to get 3.2g in 10ml.
Tinzaparin Injection into the ♠ Groups 1 No further dilution required. Follow the PHNT guidelines for the use
2,500units arterial limb of and 2 of tinzaparin (sodium) for preventing
3,500units the dialyser at clotting in the haemodialysis circuit.
4,500units the start of (Firstly, prime the circuit with 1 litre N/S).
Pre-filled syringes haemodialysis
Tinzaparin SC injection ♠ Groups Refer to the Marsden Manual for Tinzaparin must not be administered by
40,000units in 2ml 1,2,3,4 and 5 guidance on SC injection. intramuscular injection due to the risk of
Multidose vial haematoma. Do not administer
(Non-Formulary) intravenously.
Discard the vial 14 days after first use.

Record the date of first use on the vial.
Tirofiban Loading dose ♠ Groups See below for Withdraw 50ml from a 250ml bag of Intravenous infusion of unfractionated heparin (5,000unit IV
followed by 1,2,3,4 and indication- N/S or G and replace with 50ml of bolus followed by IV infusion at initial rate of 1,000units per
(C) IV infusion 5 specific infusion Tirofiban solution to make a hour: target APTTR approximately 2) should be
via Infusion rates. concentration of 50 micrograms/ml. administered concurrently with Tirofiban and may be
pump Mix well before use. infused through the same catheter/Venflon as the Tirofiban.
For patients diagnosed with NSTE-ACS and managed with an invasive For NSTE-ACS patients managed with an early invasive strategy and not
strategy undergoing angiography within 4 hours after the diagnosis, planned to undergo angiography for at least 4 hours and up to 48 hours after
tirofiban is given IV initially by 25 microgram/kg bolus dose given over 3 diagnosis, tirofiban is given IV at an initial infusion rate of 0.4 microgram/kg/min
minutes initiated at the start of PCI followed by a continuous infusion of 0.15 for 30 minutes. At the end of the initial infusion, tirofiban is continued at a
microgram/kg/min for 18-24 hours and up to 48 hours. maintenance infusion rate of 0.1 microgram/kg/min.
When administering the bolus dose, always pre-set the infusion pump with the When administering the loading infusion, always pre-set the infusion pump with the
total bolus volume to be administered total loading infusion volume to be administered.
Patient weight(kg) Bolus (ml) 3 minute bolus Maintenance infusion rate Patient weight(kg) 30 minute loading 30 minute loading infusion Maintenance infusion
infusion rate (ml/hour) (ml/hour) infusion (ml) rate (ml/hour) rate (ml/hour)
30 – 37 17 340 6 30 – 37 8 16 4
38 – 45 21 420 7 38 – 45 10 20 5
46 – 54 25 500 9 46 – 54 12 24 6
55 – 62 29 580 11 55 – 62 14 28 7
63 – 70 33 660 12 63 – 70 16 32 8
71 – 79 38 760 14 71 – 79 18 36 9
80 – 87 42 840 15 80 – 87 20 40 10
88 – 95 46 920 16 88 – 95 22 44 11
96 – 104 50 1000 18 96 – 104 24 48 12
105 – 112 54 1080 20 105 – 112 26 52 13
113 – 120 58 1160 21 113 – 120 28 56 14
121 – 128 62 1240 22 121 – 128 30 60 15
129 – 137 67 1340 24 129 – 137 32 64 16
138 – 145 71 1420 25 138 – 145 34 68 17
146 – 153 75 1500 27 146 – 153 36 72 18
In patients with an eGFR<30ml/min reduce the dosage by 50% In patients with an eGFR<30ml/min reduce the dosage by 50%
Tobramycin IV bolus ♠ Groups 3 – 5 minutes Flush with N/S.
1,2,3,4 and 5 N.B. Current recommended dose of
10mg/kg once daily in Cystic Fibrosis
(I) IV infusion ♠ Groups 30 minutes 10mg/kg dose in Cystic Fibrosis diluted
patients exceeds the dose stated in the
for once daily 1,2,3,4 and 5 to 50ml or 100ml with N/S or G.
package insert.
dosing in cystic
fibrosis Maximum once daily dose in Cystic
Infusion pump Fibrosis is 660mg with trough levels
is required. measured before the 2nd and 8th doses
(Target trough level <1mg/L. Modify dose
IM injection ♠ Groups Refer to the Marsden Manual for interval if trough level >2mg/L.
TPN See Parenteral Nutrition
Tramadol Staff prescribing, administering and/or screening prescriptions for opioid medications should be familiar with the PHNT Policy for
IV bolus ♠ Groups Slowly over 2 – 3 Undiluted Maximum total IV/IM dose in 24 hours is
1,2,3,4 and 5 minutes 600mg
IV infusion is incompatible with diazepam,
(I) IV infusion ♠ Groups 12 – 24mg/hour Dilute 200mg tramadol in 500ml N/S, G
diclofenac, indometacin, midazolam and
1,2,3,4 and 5 (=30 – 60ml/hour) or H
piroxicam.
Tranexamic acid IV bolus ♠ Groups 100mg/minute Can be diluted with any convenient Flush with N/S or G.
1,2,3,4 and 5 volume of N/S or G (e.g.. 20-50ml for a
bolus or more for an infusion) or given
(C) IV infusion. ♠ Groups 25-50mg/kg/24
undiluted.
Infusion pump 1,2,3,4 and 5 hours
is required.
Tri-iodothyronine See Liothyronine
Trimethoprim Trimethoprim injection is a discontinued product
Triptorelin IM injection ♠ Groups Draw up the mannitol diluent provided This is a single-use vial
(Decapeptyl®) 1,2,3,4 and 5 into the syringe provided using one of
the injection needles and inject in to
Refer to the Marsden Manual for
the vial containing the powder. Gently
guidance on IM injection.
swirl the vial until a uniform suspension
is formed, then draw the mixture back
into the syringe without inverting the
vial. The injection needle should then
be changed and the second needle
used to administer the injection. As the
product is a suspension, the injection
should be administered immediately
after reconstitution to prevent
sedimentation.
Tysabri® See natalizumab
Urokinase Lock for unblocking ♠ Groups Retain in the Reconstitute one 10,000unit vial of If the lumen is completely blocked do not force
midlines and PICC 1and 2 line for 1-2 urokinase with 3ml of N/S. Instil 1.5ml urokinase into the lumen.Refer to the full PHNT
lines (Adults) hours guidelines:
(5,000units) of the reconstituted solution into
(or longer) each lumen of the catheter. http://www.plymouthhospitals.nhs.uk/ourservices/clinic
aldepartments/Pages/VascularAccessTeam.aspx
Catheter lock for ♠ Groups • Reconstitute urokinase 25,000unit vial with N/S in a volume equal to the priming volume of both catheter lumen
unblocking 1and 2 plus an additional 0.2mls (e.g. ‘A’ lumen = 1.7, ‘V’ lumen = 1.9, therefore 1.7 + 1.9 + 0.2 = 3.8 ml of N/S).
haemodialysis • Draw up solution into two syringes: one equal to arterial lumen volume + 0.1ml and one equal to venous
CVC lumen + 0.1ml (e.g. ‘A’ lumen syringe = 1.7 + 0.1 = 0.8 ml; ‘V’ lumen syringe = 1.9 + 0.1 = 2ml)
(Adults) • All staff must be aware that any connection/disconnection to a haemodialysis CVC must be performed using
aseptic technique
o Flush each lumen with 10ml of N/S
o Inject 12,500unit urokinase into each lumen to the priming volume
o Positively lock the lumen and place the red obdurate, then wait for 30 minutes
o Aspirate 5mls from each lumen and flush with 10-20ml of N/S if flows have restored
• Commence dialysis treatment
Inter-dialysis ♠ Groups The decision to use an inter-dialysis infusion of urokinase must be agreed beforehand with one of the
infusion via the 1and 2 Trust consultant nephrologists each time it is used, and after assessment of any increased bleeding risk.
haemodialysis • Reconstitute two 100,000unit vials of urokinase each with 2ml N/S and add both vials to 100ml N/S
CVC (200,000unit urokinase in 100ml N/S).
(Adults) • Draw up the urokinase solution into two 50ml luer-lock syringes.
• Attach the 50ml syringes to the lumens of the dialysis CVC.
• Using a syringe driver, infuse a 50ml syringe containing the urokinase solution (100,000iu in 50ml N/S) down
each lumen over 90 minutes (34ml/hour).
• When the infusion is complete, flush each lumen with 10–20ml N/S to establish blood-flow.
• Commence haemodialysis.
Intraperitoneal ♠ Groups Retain in Dilute 12,500 international units with 5ml Follow the Renal Services Directorate Peritoneal
catheter lock for 1and 2 catheter for 2 N/S. Dialysis Protocols
unblocking the hours
catheter.
Vancomycin (I) IV infusion ♠ Groups Adults: 500mg over 1 Reconstitute 1g vial with 20ml W and Flush with N/S or G.
preferred 1,2,3,4 and hour. Doses over 500mg vial with 10ml W. In practice 1g in 100ml may be used in
Refer to the method. 5 500mg maximum rate Dilute 500mg with at least 100ml N/S or fluid restricted patients; but the use of
Plymouth Healthnet Infusion pump 10mg/minute. G. such high concentrations may increase
Clinical is required. Dilute 750mg with at least 150ml N/S or the risk of infusion related events when
Guidelines/Infection (C) IV infusion. ♠ Groups 24 hours G. administered via a peripheral vein. Note
Control for the use Infusion pump 1,2,3,4 and Dilute 1g with at least 200ml N/S or G. that the current recommended target
and current dosage is required. Dilute 1.5g with at least 300ml N/S or G. trough level is higher than that in the SPC
5
of gentamicin, Dilute 2g with at least 400ml N/S or G. and is therefore unlicensed (See page 4).
teicoplanin and
vancomycin.
Example IV Set pump rate at :
calculations 500mg vancomycin (in 10ml W) added to a 100ml bag N/S = 110ml over 1 hour 110ml/hour
750mg vancomycin (in 15ml W) added to a 250ml bag N/S = 265ml over 1½ hours 177ml/hour
1g vancomycin (in 20ml W) added to a 250ml bag N/S = 270ml over 2 hours 135ml/hour
1.5g vancomycin (in 30ml W) added to a 500ml bag N/S = 530ml over 2½ hours 212ml/hour
2g vancomycin (in 40ml W) added to a 500ml bag N/S = 540ml over 3⅓ hours (200 minutes) 162ml/hour
Intrathecal ♠ Group 1 Refer to the Neurosurgical Antibiotic
Injection Therapy Guidelines for Adults on
Plymouth Healthnet (Under Clinical
Guidelines)
Intraperitoneal ♠ Groups 1 Follow the Renal Services Directorate
and 2 Peritoneal Dialysis Peritonitis Protocol
Vasopressin (I) IV infusion. ♠ Groups 1 Dosage for use in Dilute 20 units to 50ml with G. Flush with G.
=Argipressin Infusion and 2 critical care for Note that Regent and Sandoz brand vials
pump is refractory septic shock: are only labelled for IM and SC use.
For use in Critical required. 0.6–2.4 units/hour However, they are also suitable for IV
Care to reduce Administer (= 1.5 -6ml/hour using use. Regent and Sandoz brands are
noradrenaline via a central 20 units/50ml dilution) unlicensed in the UK (see page 1).
requirements in IV line.
patients with Note that Sandoz brand vials are
refractory septic multidose 40units in 2ml. Part-used vials
shock. should be stored at room temperature
Regent and Sandoz and discarded 28 days after initial use.
brands must be kept
at room (Unlicensed indication- see page 1).
temperature
Pitressin ® - keep in
the fridge
DRUG METHOD WHO MAY GIVE ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
SUITABLE DILUENT
Vecuronium IV bolus ♠ Group 1– must See Data Sheet The 10mg vial can be reconstituted with Flush with N/S or G.
only be given by 5ml W to produce 2mg/ml solution. The reconstituted solution can be injected
doctors proficient in Alternatively reconstitute the 10mg vial or infused in to the line of a running
advanced airway with 10ml W, G, N/S or H to produce a infusion of Hartmann’s.
management. Also 1mg/ml solution. The reconstituted If the patient is ventilated IV bolus can be
see Comments. solution can be given undiluted or administered by Group 2 staff.
diluted further with N/S or G to a
(I) IV infusion. ♠ Groups 1 and 2 Bolus of 40-100
micrograms/kg maximum dilution of 4mg/100ml.
Infusion
pump is followed by 48 - 84
required. micrograms/kg/hour.
Using a 2mg/ml dilution e.g. 100mg in 50ml 48 – 84micrograms/kg/hour = 0.024 – 0.042ml/kg/hour

Using a 1mg/ml dilution e.g. 100mg in 100ml 48 – 84micrograms/kg/hour = 0.048 – 0.084ml/kg/hour
Verapamil IV bolus ♠ Group 1 or 2 minutes Ready diluted. ECG and blood pressure monitoring
Emergency use. Group 2 (elderly patients necessary.
minimum 3 minutes) Flush with N/S.
Sodium content 0.15mmol/ml.
Vigam® See Immunoglobulin Human Normal
Vitamins B and C See Pabrinex
High Potency IV
injection
Vitamin K See phytomenadione
Voriconazole (I) IV infusion. ♠ groups Over 1-2 hours. Add 19ml W to each 200mg vial. Do not infuse concomitantly with other
Infusion pump is 1,2,3,4 and 5 Maximum rate Resulting concentration is 200mg drug solutions through the same
required. 3mg/kg/hour. in 20ml (Displacement 1ml/200mg lumen/Venflon.
vial). Dilute the required dose with
N/S, G, H or 0.45% saline to a final
concentration of 0.5 to 5mg/ml.
Xiapex® See Collagenase Clostridium histolyticum
X-ray Contrast IV bolus ♠ Groups According to X-ray Do not dilute. Monitor for possible anaphylaxis or other
Medium, 1 and 6 Department protocol. allergic reactions. Resuscitation
Non-ionic, equipment should be immediately
tri-iodinated available.
X-ray Contrast IV bolus ♠ Groups According to X-ray Do not dilute Monitor for possible anaphylaxis or other
Medium, 1and 6 Department protocol allergic reactions. Resuscitation
Gadolinium based. equipment should be immediately
available.
Zidovudine (I) IV infusion ♠ groups 1 hour Dilute the prescribed dose to Example: For a 63mg dose you would
1,2,3,4 and 5 2mg/ml or 4mg/ml with G – see draw up 6.3ml of zidovudine
comments for examples. injection(10mg/ml) and dilute to 31.5ml
with G in a 50ml syringe to make a final
concentration of 2mg/ml, and set the
pump rate at 31.5ml/hour.
Example for doses > 100mg:
For a 130mg dose, you would draw up
13ml zidovudine injection(10mg/ml) and
dilute to 32.5ml with G in a 50ml syringe
to make a final concentration of 4mg/ml,
and set the pump rate at 32.5ml/hour.
Do not give by IM injection.
Zoledronic acid (I) IV infusion ♠ groups Infuse all doses over at Ready diluted. Do not mix with magnesium or calcium
(Aclasta® 5mg in 1,2,3,4 and 5 least 15 minutes. containing solutions such as Hartmann’s.
100ml bags) Set the pump rate at a
maximum of
400ml/hour
Zoledronic acid (I) IV infusion ♠ groups Infuse all doses over at Draw up the prescribed dose Do not mix with magnesium or calcium
(Zometa® 4mg in 1,2,3,4 and 5 least 15 minutes. (dependent on renal function – see containing solutions such as Hartmann’s.
5ml vials) When diluted with below) and add to 100ml N/S or G. For the treatment of tumour-induced
100ml N/S set the hypercalcaemia ensure the patient is well
pump rate at a hydrated before and after administration
maximum of of zoledronic acid.
400ml/hour
Dosing according to renal function
GFR > 60 4mg dose Draw up 5ml from the vial
GFR 50 – 60 3.5mg dose Draw up 4.4ml from the vial
GFR 40 – 49 3.3mg dose Draw up 4.1ml from the vial
GFR 30 -39 3mg dose Draw up 3.8ml from the vial
186
Compatibilities of Injectable Drugs
Alteplase 100mg in 100ml Water
Aciclovir up to 5mg/ml in 5% glucose

Updated by Derriford Pharmacy December 2012
Aminophylline up to 25mg/ml in saline

Acetylcysteine in 5% glucose
Important warnings: The table below shows Y-site physical or visual (not chemical) compatibilities between drugs tested at specific concentrations
Amiodarone in 5% glucose (Central IV)
Co-trimoxazole (Septrin) 480mg/75ml 5% glucose

in specific diluents. The concentrations tested are often different to those used in practice on the ward which are shown in the table below.
Adrenaline 1:10,000 undiluted

This table gives information for two-drug combinations only. The information cannot be extrapolated to three-drug combinations. While the
Clindamycin up to 18mg/ml in 5% glucose

Argatroban 1mg/ml in 0.9% saline
indications of compatibility in the table are consistent with the best currently available advice, there is no absolute guarantee of compatibility
Ceftriaxone 2g in 40ml 0.9% saline
Dopamine 200mg in 50ml 5% glucose (Central IV)

Atracurium 10mg/ml (Undiluted)
where the concentrations in the literature differ significantly from those shown below. Pay careful attention to the diluent(s) quoted for particular
drugs in the table below.
Dobutamine 250mg in 50ml 5% glucose

Alteplase 100mg in 100ml Water C = Compatible but read the warnings above
Dopexamine 50mg in 50ml 5% glucose
Furosemide 10mg/ml (Undiluted) or 1mg/ml in 0.9% saline

Digoxin in 100ml 0.9% saline
Acetylcysteine in 5% glucose
Erythromycin 125ml in 25ml 0.9% saline

Aciclovir up to 5mg/ml in 5% glucose I = Incompatible
Adrenaline 1:10,000 undiluted (Central IV)
Esomeprazole 40mg in 100ml 0.9% saline

Doxapram 2mg/ml in 5% glucose
Aminophylline up to 25mg/ml in saline I or (empty box) = no data available therefore this combination cannot be recommended
Amiodarone in 5% glucose (Central IV) C I
Fentanyl 50micrograms/ml (Undiluted)

Esmolol 10mg/ml in 5% glucose
Gentamicin up to 5mg/kg dose in 100ml saline

Argatroban 1mg/ml in 0.9% saline I
Isoprenaline sulphate 2.25mg in 50ml or 500ml 5% glucose

Atracurium 10mg/ml (Undiluted) C I C
Fluconazole 2mg/ml (in 0.9% saline)

Ceftriaxone 2g in 40ml 0.9% saline C I
Glyceryl trinitrate 50mg in 50ml 5% glucose
Labetalol 1mg/ml in 5% glucose or 5mg/ml undiluted (Central IV)

Clindamycin up to 18mg/ml in 5% glucose C I C I Do not infuse the following drugs together
Co-trimoxazole (Septrin) 480mg/75ml 5% glucose C C with any other drug solutions down the same
Digoxin in 100ml 0.9% saline I central line lumen or venflon:
Insulin soluble 50 units in 50ml 0.9% saline

Dobutamine 250mg in 50ml 5% glucose I I C I C C C I
Isosorbide dinitrate 25mg in 50ml 5% glucose

Dopamine 200mg in 50ml 5% glucose (Central IV) I I C C C C C Enoximone, Ambisome
Ketamine 10mg/ml or 50mg/ml in 0.9% saline

Dopexamine 50mg in 50ml 5% glucose I C C C
I I I I C Epoprostenol (Flolan)
Heparin sodium 1,000 units/ml

Doxapram 2mg/ml in 5% glucose
Erythromycin 125mg in 25ml 0.9% saline C C C
Linezolid 600mg in 300ml glucose (Ready diluted)

Esmolol 10mg/ml in 5% glucose C C C C C C C C Flumazenil
Levofloxacin 500mg in 100ml 0.9% saline

Glucose 10%
Esomeprazole 40mg in 100ml 0.9% saline
Magnesium sulphate 5g in 100ml 0.9% saline

Fentanyl 50micrograms/ml (Undiluted) C C C C C C C C Rifampicin, salbutamol
Fluconazole 2mg/ml (in 0.9% saline) C C C I I I I C C
Hartmann's
Furosemide 10mg/ml (undiluted) or 1mg/ml in 0.9% saline I C I C I C I I I I I C I Sodium valproate
Lidocaine 2mg/ml in 5% glucose

Gentamicin up to 5mg/kg dose in 100ml saline C C I C C I I C I C C I
Pabrinex up to 3 pairs of ampoules in 50 or 100ml 5% glucose

Glucose 10% C C C C C C C C C I I C
Metronidazole 500mg in 100ml 0.9% saline

Glyceryl trinitrate 50mg in 50ml 5% glucose I I I C C C C C C C C I C I
Midazolam 1mg/ml or 2mg/ml in 0.9% saline
Phenytoin up to 10mg/ml in 0.9% saline using in-line filter

Hartmann's C C C C I I C C C C C I C C C C
Methyl prednisolone in 0.9% saline
Morphine sulphate 50mg in 50ml (0.9% saline)

Heparin sodium 1,000 units/ml I C C C I I C C I I I I C C C I I C I
Noradrenaline up to 16mg in 50ml 5% glucose

Insulin soluble 50 units in 50ml 0.9% saline I I I I C C C C C C
Metaraminol in 0.9% saline
Potassium chloride 2mmol/ml undiluted (Central IV)

Isoprenaline sulphate 2.25mg in 50ml or 500ml 5% glucose I C C C I C C
Milrinone 10mg in 50ml 5% glucose

Isosorbide dinitrate 25mg in 50ml 5% glucose I I I I I I I
Potassium phosphate 30mmol in 50m (Central IV)
Sodium nitroprusside up to 1mg/ml in 5% glucose (Central IV)

Ketamine 10mg/ml or 50mg/ml in 0.9% saline I C
Remifentanil upto 250micrograms/ml in 5% glucose

Mannitol 10%
Labetalol 1mg/ml in 5% glucose or 5mg/ml undiluted C C I C C C C C C I C C I I
Levofloxacin 500mg in 100ml 0.9% saline (Ready diluted) I C C C C C C I C I I I C
Sodium phosphate 30mmol in 50ml undiluted (Central IV)

Lidocaine 2mg/ml in 5% glucose C C C C C I C C C C C I C C C C C C C
Linezolid 600mg in 300ml 5% glucose (Ready diluted) C C I C I C C C I C C C C C C C C C C
Magnesium sulphate 5g in 100ml 0.9% saline C I I I C C C C C C C
Mannitol 10% C I C
Metaraminol in 0.9% saline C I I C
Sodium bicarbonate 8.4% (Central IV)

Methyl prednisolone in 0.9% saline C I I C I I C C I C I
Propofol 10ml/ml undiluted

Metronidazole 500mg in 100ml 0.9% saline C C C I C C C C I C C C C C
Sodium bicarbonate 1.26%

Midazolam 1mg/ml or 2mg/ml in 0.9% saline C I C C C I C I C C C C C I C C I C C I C C C
Tirofiban 50micrograms/ml in 5% glucose

Milrinone 10mg in 50ml 5% glucose C C C C C C C C C C C I C C C C C C C C C C C
Vancomycin up to 5mg/ml in 5% glucose

Morphine sulphate 50mg in 50ml (0.9% saline) I C I C C C C C C C C C C C C I C C C C I C C C C C C C C C C
Vasopressin 10 units in 50ml 5% glucose

Noradrenaline up to 16mg in 50ml 5% glucose C I C C C C C I C I C I C I C
Thiopentone 25mg/ml in water

Pabrinex up to 3 pairs of ampoules in 50 or 100ml 5% glucose I C
Phenytoin up to 10mg/ml in 0.9% saline using in-line filter I I I C I I I I I I I I I I
Potassium chloride 2mmol/ml undiluted (Central IV) C C C C C C C I C C C C C C C C C C C C C C I C I C C C I
Potassium phosphate 30mmol in 50ml (Central IV) I I C C I C I I
Vecuronium 2mg/ml in water

Propofol 10ml/ml undiluted C C I C I C C C C C C I C C C C C I C C I C C C I C C C C I
Remifentanil upto 250micrograms/ml in 5% glucose C C C C C C C C C C C C I C C C C C C C C C C C C C C C
Sodium bicarbonate 1.26% C I C I C I I I I I C I I C C I I I C I C I C I I C C C
Sodium bicarbonate 8.4% (Central IV) I I C I I I I I C I I C I I I C I I C I I C C
Sodium nitroprusside up to 1mg/ml in 5% glucose I C I I I C C I C C C C C C I C I C C C
Sodium phosphate 30mmol in 50ml undiluted (Central IV) I I
Thiopentone 25mg/ml in water I I I I I I I I I C C I C I I I I I I I I C I I C C I I
Tirofiban 50micrograms/ml in 5% glucose C C C C C C C C C C C
Vancomycin up to 5mg/ml in 5% glucose I C C I C C C C C I C C C C C C C C I C C
Vasopressin 20 units in 50ml 5% glucose C C I C C C C C I C
Vecuronium 2mg/ml in water C C C C C C C C C C I C C C C C I C C C C C C C C I C
187
Derriford Hospital Analgesic Ladder Notes

for non-malignant acute pain Severe pain
Surgical Patients
If pain unresolved: eGFR ≥30ml/min Oramorph dose PRN 2hrly
Identify type of pain and Age (years) Dose(mg)
consider adjuvant medication As for moderate pain 18-59 20-30mg
Alternative or parenteral Plus 60-69 10-20mg
opioid 70-89 5-10mg
Surgical Patients
Contact Team for review
ACT Nurse Specialist 0195
Moderate pain PRN Oramorph 20-30mg >89 2.5-5mg
2 hourly Oxynorm dose PRN 2hrly
Regular Paracetamol 1g qds
(adjust by age - see notes) Age (years) Dose(mg)
(maximum paracetamol
18-59 10-15mg
dosage 60mg/kg/day if weight
Mild pain < 50kg. See drug chart for
60-69 5-10mg
Regular Paracetamol 1g qds Medical Patients 70-89 2.5-5mg
further advice)
(maximum paracetamol Regular Oramorph 5mg 4 >89 2.5mg
Plus
dosage 60mg/kg/day if weight Regular NSAID hourly
< 50kg.See drug chart for unless contraindicated Increase to 10mg 4 hourly if This guideline is to be used in conjunction
further advice) e.g. eGFR < 30ml/min necessary with the BNF and PHNT joint formulary.
Caution if eGFR <60ml/min >75 years old reduce to 2.5mg Ensure a full pain history is taken from all
eGFR ≥ 30ml/min Plus 4 hourly patients and regular analgesics are
Consider PRN NSAID unless Plus PRN Oramorph of the prescribed.
PRN intermediate opioid
contraindicated (see drug chart same dose 4 hourly Be aware of the dose equivalence of
(eg:Codeine 30-60mg qds, opioids prescribed – particular care is
for further advice). Tramadol 50-100mg qds) needed with opioid patches.
Caution if eGFR < 60ml/min
Consider subcutaneous route rather than
repeated im injections.
eGFR < 30ml/min eGFR < 30ml/min eGFR < 30ml/min Be aware of the influence of renal
SurgicalPatients:
Patients impairment, age and opioid tolerance on
Surgical
PRN Oramorph
Oxynorm 10-15mg opioid prescribing. Refer to opioid
PRN 20-30mg prescribing guidelines if unsure.
Avoid non-steroidal drugs. 22 hourly
hourly (adjust
–observe
by for
ageopioid
- see
Avoid non-steroidal drugs. toxicity Opioid equivalence:
notes)
Caution with tramadol and (adjust by age - see notes) 10mg oral morphine
codeine – observe for opioid •5 mg Morphine SC/IM
toxicity •3mg Morphine iv
Medical Patients •5mg oral Oxycodone
Regular Oxynorm 2.5mg 4 •50mg oral Tramadol
•120mg oral Codeine
hourly – observe for opioid
•200mcg sublingual Buprenorphine
toxicity NB: Fentanyl patches are not to be used for
acute pain (consultant prescribing only)
Pain is the “Fifth Vital Sign” and must be assessed and recorded alongside other vital signs
All staff involved in the prescribing, dispensing and administration of controlled drugs must be familiar with the
characteristics of the drug
188
189
Emergency Department Adult Intravenous Morphine
Guideline
• This guideline is to be used in conjunction with BNF & PHNT joint

formulary & Trust acute pain analgesic ladder.
• No intravenous morphine to be given in minors.
• Always take into account age, weight and co-morbidities – use with extreme
caution in renal impairment. Give 1/2 or 1/3 of below doses in elderly and
frail.
• Consider non-pharmacological methods of analgesia – eg splintage, LA

blocks.
• Actively seek out times and doses of prior (including pre-hospital) analgesia.
• Patients with high pain scores should be asked if they require further pain
relief. Only prescribe if the patient says they do.
• Seek senior advice for non-responsive pain.
Severe Pain = 8-10

Moderate Pain = 4-7
Mild Pain = 1-3
No Pain = 0 Prescribe multi-modal analgesia (paracetamol
+/-NSAIDs) to be given simultaneously.
Assess with pain score & consider IV

morphine for moderate or severe pain.
Prescribe IV morphine on STAT section

of the drug chart 0.1mg/kg titrated to
effect over 2-3 minutes but see above
Reassess at 20 minutes with

observations including RR, conscious
level & pain score
Repeat up to above dose as required but no

sooner than 20 mins
If a second dose is given in ED apply monitoring –
minimum of pulse oximetry
Author: Dr Mark Rockett 2012

190
For more information please contact the Resuscitation Department on 52851
References
• The Electronic Medicines Compendium 2012 published by Datapharm Communications Ltd

(http://www.medicines.org.uk/emc/)
• The Injectable Medicines Guide produced by the network of UK hospital pharmacists,
published by the Pharmacy Dept. Charing Cross Hospital, London, and endorsed by the UK
Medicines Information service (http://medusa.wales.nhs.uk/)
• The British National Formulary No.64 (September 2012) (http://bnf.org/bnf/bnf/current/)
• The British National Formulary for Children (2012-2013) (http://bnfc.org/bnfc/bnfc/current/
• UK Resuscitation Council Anaphylaxis Algorithm
(http://www.resus.org.uk/pages/anaalgo.pdf)
191
Appendix 1
Protocol for administering intramuscular adrenaline 1:1000 (1mg/ml) for treating
anaphylaxis, when there is no prescription available
Date Version
September 2013 1
Purpose
To instruct staff on how to correctly identify when a person is suffering an anaphylactic reaction and to
treat the person correctly with intramuscular adrenaline, when there is no prescription for this medication
Scope of this document
Applies to all non-medical clinical staff working in any area with the skill and competence to assess a
patient’s condition and administer intramuscular medication.
Key Message
Non-medical clinical staff working for or on behalf of Plymouth Hospitals NHS Trust may legally
administer adrenaline injection to treat anaphylaxis without a prescription. They must do so in
accordance with this protocol.
Accountabilities
Production Peter Gray, Senior Pharmacist
Ratification Medicines Governance Committee
Dissemination Peter Gray, Senior Pharmacist
Links to other policies and procedures
Pharmacy Documents:
• PHNT Medicines Management Policy
• Procedures For Administering Injectable Medicines
Other Documents:
• Emergency Treatment of Anaphylactic Reactions- Guidelines For Healthcare Providers: Working Group of
the Resuscitation Council (UK) 2008
• Medicinal products for parenteral administration in an emergency. The Human Medicines Regulations
2012, Regulation 238, Schedule 19.
Version History
Version 1 October 2013
Last Approval Due for Review
Version 1 October 2015
1.1 Adrenaline (1:1000) can legally be administered without a prescription for

the purpose of treating anaphylaxis
Medicines legislation restricts the administration of Prescription-Only injectable medicines.
Unless self administered, they may only be administered by in accordance with a prescription.
However, in the case of 1:1000 adrenaline there is an exemption to this restriction which means
in an emergency, a suitably trained person (eg. nurse or ODP) is permitted to administer it by
(intramuscular) injection for the purpose of treating anaphylaxis without a prescription or
instruction from a doctor.
1.2 Persons who can be treated under this protocol

Individuals displaying the signs and symptoms described below who are:
• Hospital in-patients
• Hospital out-patients attending out-patient or diagnostic departments
• Visitors or members of staff
192
1.3 Anaphylaxis
Anaphylaxis is a severe, life-threatening, generalised or systemic hypersensitivity reaction. This

is characterised by rapidly developing life-threatening airway and/or breathing and/or circulation
problems usually associated with skin and mucosal changes.
Administration of intramuscular (IM) adrenaline should be considered for individuals who show
signs and symptoms of an anaphylactic reaction.
Anaphylaxis is likely when all of the following three criteria are met:
• Sudden onset and rapid progression of symptoms.

• Life-threatening airway and/or breathing and/or circulation problems.
• Skin and/or mucosal changes (flushing, urticaria, angioedema).
1.4 Assessing the patient
The ABCDE approach to assess and treat a patient should be followed, as patients can have an
Airway, Breathing or Circulation Problem or any combination which is life threatening.
Airway
• Airway swelling, e.g. throat and tongue
• Hoarse voice, unable to speak
• Stridor
Breathing
• Shortness of breath
• Wheeze
• Confusion caused by hypoxia
• Patient becoming tired
• Cyanosis – late sign
• Respiratory arrest
Circulation
• Signs of shock, pale, clammy
• Increased pulse rate
• Low blood pressure, feeling faint, collapse
• Decreased conscious level or loss of consciousness
• Cardiac arrest
The above Airway, Breathing and Circulation problems can all alter the patient’s neurological
status (Disability problems) because of decreased brain perfusion. There may be confusion,
agitation and loss of consciousness.
Patients can also have gastro-intestinal symptoms (abdominal pain, incontinence, vomiting)
Exposure
The patient must be exposed ensuring dignity to observe for skin and/or mucosal changes. This
is often the first feature present in over 80% of anaphylactic reactions.
• They can be subtle or dramatic.

• There may be just skin, just mucosal, or both skin and mucosa changes.
• There may be erythema – a patchy, or generalised, red rash.
• There may be urticaria which can appear anywhere on the body. The weals may be pale,
pink or red, and may look like nettle stings. They can be different shapes and sizes and
are often surrounded by a red flare. They are usually itchy.
• Angioedema is similar to urticaria but involves swelling of deeper tissues, most
commonly in the eyelids and lips, and sometimes in the mouth and throat.
193
1.5 Explanation of treatment to the patient
Prior to the administration of adrenaline the patient should receive an explanation that they are
having an allergic reaction and that IM adrenaline is going to be administered to relieve the
symptoms and help reverse the reaction.
1.6 Patient Consent
Prior to the administration of the drug, consent should be obtained either from the patient, parent,
guardian or person with parental responsibility. Verbal consent is acceptable in the emergency
scenario. This should be documented in the patient’s medical records once the patient’s
condition is stable.
If the patient, parent or guardian does not wish treatment to be given under this protocol they
should be advised of the potential risks.
If the patient is unable to give consent due to a life-threatening situation, or if parents or

guardians are not present, adrenaline should be administered where treatment is judged
to be in the best interests of the patient.
1.7 Exclusions from treatment under this protocol
None
1.8 Contra-indications to administration of adrenaline to treat anaphylaxis
There are no absolute contra-indications to the administration of adrenaline under this protocol.
1.9 Immediate Treatment – Also refer to treatment algorithm on page 193
• Reassure and explain the situation to the patient.

• Assess airway and breathing and identify signs and symptoms of anaphylaxis (see 2.1).
• Identify and discontinue trigger factors.
• Call for help, e.g. 999, a doctor, 2222 Clinical Emergency Team.
• Patients with airway or breathing problems may prefer to sit up as this will make
breathing easier.
• Assess circulation (see Section 2). Laying the patient flat with or without leg elevation
may be helpful for patients with hypotension. If the patient feels faint, do not sit or stand
them up as this may cause cardiac arrest. NB. A sudden change to a more upright
position may be dangerous due to the effect on blood flow to the heart.
• If the patient presents with signs of clinical shock and/or stridor, administer IM adrenaline
1:1000 as recommended, noting the time given and the response.
• Continue to observe the patient supporting and maintaining a clear airway, observing
breathing.
• Continuous assessment of the patient is important using the ABCDE approach.
• Patients who are breathing and unconscious should be placed in the recovery position.
• Pregnant patients should lie on their left side to prevent caval compression.
• If the patient is not breathing or has no pulse, commence cardio pulmonary resuscitation
(CPR) using current guidelines.
• Continue until:
o More qualified help arrives
o You become exhausted
o Patient shows signs of recovery
1.10 Source of Adrenaline
Use ampoules of adrenaline 1:1000 (1mg/1ml). If these are not available, use any pre-filled auto-
injector (eg. Epipen or Anapen) that the patient may be carrying.
194
1.11 Dosage of Adrenaline
Dose for Adults: 500micrograms (0.5mL) of adrenaline 1:1000 (1mg/mL).
Dose for Infants and Children:
Age Dose of Volume of 1:1000

Adrenaline (1mg/mL) solution
Under 6 years 150 micrograms IM 0.15mL
6 - 12 years 300 micrograms IM 0.3mL
Over 12 years 500 micrograms IM 0.5mL
(300 micrograms IM if the (0.3mL)
patient is small or pre-pubertal)
Frequency
The dose stated above can be repeated once, as necessary after 5 minutes if there is no
improvement in the patient’s condition or on assessment of the patient’s blood pressure, pulse and
respiratory function.
1.12 Adverse Effects
Adverse effects are extremely rare with correct doses injected intramuscularly
1.13 Follow-Up
Hospital in-patients require close observation on the ward (or Theatre/Recovery). They may need
to be transferred to HDU depending on the severity of reaction and medical decision. Any
affected hospital out-patients, staff or visitors, patients in the community or those attending
clinics/health centres/lectures/training need to be transferred to the Emergency Department.
1.14 Documentation of all events and actions once the patient is stable
For patients, document all events and actions in the medical notes. For affected members of
staff, visitors or other persons, all events and actions must be documented on admission to the
Emergency Department. Details recorded should include:
• Full details of the event

• Time course of the reaction
• Whether consent to treatment has been given
• All drugs and treatments administered, including details of dose(s) given
• Resuscitative measures
• Patient’s response to treatment
• Any previous adverse reactions
• Signature and printed name of person administering treatment under this protocol
• Date
• Statement that adrenaline was administered to treat suspected anaphylaxis without a
prescription in accordance with the hospital protocol.
• If the anaphylactic reaction is considered to be drug-induced, the medical practitioner should

consider completing a “Yellow Card” from the BNF and sending it to the MHRA or reporting
the reaction via the MHRA website at http://yellowcard.mhra.gov.uk
1.15 References
• Emergency Treatment of Anaphylactic Reactions- Guidelines For Healthcare Providers:

Working Group of the Resuscitation Council (UK) 2008
• Medicinal products for parenteral administration in an emergency. The Human Medicines
Regulations 2012, Regulation 238, Schedule 19.
195
1.16 Management of Anaphylaxis
196
Appendix 2
Choice of Infusion device
2.1 Introduction
All individuals that operate infusion devices within the remit of their role have a responsibility to
ensure that they are competent to operate the equipment in a safe and effective manner, seek
advice and training where necessary and complete relevant documentation with their assessor in
line with the Trusts Policy and Procedure document for the ‘Training of Plymouth Hospitals NHS
Staff in the Use of Medical Devices.’
It is the responsibility of the person administering the drug to select the appropriate infusion
pump for the therapy required. Alterations to the pump setting may only be made and recorded
by a person entitled to administer intravenous drugs. The volume of fluid administered must be
recorded on the fluid chart. All pumps must be checked 2 hourly throughout the infusion and
details of the infusion should be recorded on the relevant infusion chart.
Infusion Devices must always be operated and serviced in accordance with the Manufacturers
operating instructions and the MEMS Medical Equipment Users’ Guide. Every area should
maintain a library of user manuals for commonly used equipment, which may be kept in the Ward
Equipment File. Manuals for commonly used infusion devices can be found on the Medical
Devices Training webpage on TrustNet. The MEMS Medical Equipment Users Guide is available
on the Trust documents drive.
2.2 Choice of Infusion device
The choice of infusion device should be based upon the clinical application it is intended for, and
the safety features incorporated within the device. Infusion devices may be grouped into the
following categories:
a. Volumetric pumps
• Pump of choice for medium and high flow rates, and large volume infusions.
• Pressure sensitivity of pump: Some pumps have selectable occlusion pressure alarm levels.
Selecting low levels will help to prevent excessive delivery pressures and possible vein
damage.
• Some may allow for the addition of piggyback or secondary infusions.
• The majority of volumetric pumps will perform satisfactorily at rates down to 5 ml/hr.
Although the controls can set rates below 1ml/hr, these pumps are not considered
appropriate for delivering drugs at such low rates.
• Once the infusion has been connected to the patient, the vertical position of the device
should be altered as little as possible as an increase in height of the device above the
infusion site may result in a bolus of infusate being delivered to the patient.
• Blood transfusions may be given through a Baxter Colleague Volumetric Pump safely if given
with correct blood giving set.
• Most volumetric pumps also incorporate the following safety features:
o Automatic alarm and stopping of infusion following detection of air in line,
upstream/downstream occlusion, and reservoir/bag empty alert.
o Facility to pre-set volume to be infused (VTBI) and digital read out of total volume
infused.
o Automatic switch to ‘keep vein open’ (KVO) rate towards end of infusion.
o Automatic battery operations in the case of mains supply failure.
• PHNT has standardised on the Baxter Colleague pump as the volumetric pump of choice,
although others may still be in service in some areas.
197
b. Syringe pumps
• The preferred choice for lower volumes and low rate infusions.
• Capable of delivering very low flow rates of < 1ml/hr.
• Operated by driving a syringe plunger forward at a controlled rate to deliver the infusate to
the patient.
• The syringe is located and clamped within the device, with the plunger attached to a moving
carriage.
• Users should be aware that the flow delivered at the start of an infusion might be
considerably less than the rate set on the device. At low flow rates, the mechanical slack
must be taken up before the set rate is achieved. Mechanical slack can be eliminated by
operating the syringe pump to purge the line prior to connection to the patient.
• Some pumps have a selectable occlusion pressure alarm levels. Selecting low levels will
help to prevent excessive delivery pressures and possible vein damage.
• Additional features may include:
o In line pressure monitoring
o Syringe barrel clamp alarm
o Syringe plunger disengagement alarm
o ‘Volume to be infused’ (VTBI) display
o ‘Volume infused’ (VI) display
o Automatic ‘keep vein open’ (KVO) rate facility
o Patient history log
o Drug name library
PHNT has standardised in the Alaris GH syringe pump of choice. Other syringe pumps may still
be available in some areas.
c. Patient Controlled Analgesia pumps (IVPCA)
• Used specifically for the patient to administer a prescribed intravenous dose of opioid as
required, by activating a demand button, which has a pre-set lockout interval.
• PCA pumps (the Alaris IVAC PCAM) contains a memory log, to enable the clinician to
determine how frequently the patient has made a demand, and the total volume of drug
infused over a given time.
• Monitoring of patients with PCA devices may only be performed by those individuals who
have received formalised training from the Department of Pain Management or those that
have already been deemed competent in the use of PCA.
d. Ketamine Infusions
• Ketamine is an anaesthetic agent with analgesic properties. A low dose Ketamine infusion
can provide safe and effective analgesia. It is usually used with IVPCA to improve pain relief
and reduce opioid side effects.
• The Graseby 3300 pump must always be used for these infusions. This is a locked pump.
The responsibility of Ketamine infusions falls to the Acute Care Team / Anaesthetic team.
Ward areas should not be the key holder unless under specific instructions of the Pain Team.
In an emergency situation ward nurses should be aware of how to stop the infusion pump.
Specific guidelines / protocols are in place within the Trust on all Advanced Pain
Management Systems and must be followed. Please refer to the Acute Pain Resource
Manuals or on the Hospital Healthnet
198
e. Ambulatory pumps
• Allows for the mobility of the patient due to the small nature of the device.
• Preferred pump of choice for treatment in palliative care.
• Ambulatory pumps may be powered by electricity or by other means.
• The previously used Graseby MS26 has now been replaced, in this Trust, with the Mckinley
T34 ambulatory syringe pump. The T34 is calibrated in ml/hr in common with other types of
infusion device.
• The ‘Syringe Driver Infusion Chart’ should be used in conjunction with every infusion given
via an ambulatory syringe driver device.
f. Gravity feed
• Gravity feed involves the control of infusion rate by means of the height of the infusion
reservoir being sufficiently greater than the infusion site to allow a slow flow of the infusate.
Control is further refined by use of a clamp on the infusion line.
• Generally suited to the delivery of fluids containing no added drugs or drugs with no potential
for vaso-irritation or damage. This is due to the poor reliability of flow rate and pressure
sensing in the delivery system.
• Provides a cheap and readily available delivery system.
2.3 Additional Information
• Only luer-lock syringes should be used within syringe pumps/drivers, PCA pumps. This is a
standard instruction issued by all infusion device manufacturers, as there is a risk of the
pressure generated in the infusion line causing the line to come apart from the syringe.
Plymouth Hospital NHS Trust currently uses BD Plastipak syringes for this purpose.
• Anti-syphon lines must be used on all syringe pump infusions in all areas.
• Gravity lines may be used for administration of electrolytes and most antibiotics. If
considered necessary however, an infusion device may be used.
2.4 References
Medical Devices Agency (2000) Equipped to Care
CQC Essential Standards of Quality & Safety
Medicines and Healthcare products Regulatory Agency (2008) Devices in Practice

199
Appendix 3
Copy of the PHNT Policy for maintenance of patency, flushing and locking of
intravascular lines catheters or devices
3.1 Introduction
This appendix contains tables of instructions which have been copied from the PHNT Medicines
Management Policy. The full ratified copy of this policy can be found on Plymouth Healthnet
using the link:
http://nww.picts.nhs.uk/PHNetLive/Portals/57ad7180-c5e7-49f5-b282-
c6475cdb7ee7/prowsea_TRW.MMA.POL.265.6%20Medicines%20Management%20Policy.pdf
These tables were produced following review of current local practice and extensive local
consultation, and in response to the National Patient Safety Agency Rapid Response Alert No.2
(2008) “Risks with Intravenous Heparin Flush Solutions”.
3.2 Policy
• All flushes (Bolus and infusions) and line/catheter locks must be prescribed.
• Administration of all flushes and line/catheter locks must be recorded on the
prescription chart.
• Always attempt to aspirate the heparin lock before use of the line. If unable to aspirate the
heparin from the line, discuss with the duty consultant whether the heparin may be flushed
into the patient.
• Heparin must not be used in a patient with recognised or suspected HIT, or at risk of HIT
(Heparin-induced thrombocytopenia) without discussion with a Consultant Haematologist.
Type of intravascular line, Maintenance of Patency, Flushing and Locking

catheter or device
Short-term Peripheral Venous Flush with 5 -10ml 0.9% sodium chloride
Catheters
(Adults and children)
Cannula, venflon
Arterial Lines Maintain patency with an infusion of 0.9% sodium chloride.
(Adults and children)
Central Venous Lines Flush with 0.9% sodium chloride (at least 10ml for adult
(Inpatient Adults) patients) and lock with 0.9% sodium chloride (volume stated
Tunnelled lines eg. Hickman on the line) using a positive pressure clamp technique.
or Broviac lines
PICCs and Midlines
Short-term CVCs
Long Lines
Short-term Central Venous All lines without a continuous infusion running should be
Catheters flushed with 0.9% sodium chloride 6-hourly. To avoid blood
(Children) flashing back into the lumen, “positive pressure” is applied
at the end of the flush.
Above table continued on the next page

Table continued from the previous page
200
Type of intravascular line, Maintenance of Patency, Flushing and Locking

catheter or device
Long-term Central Venous Lines • Hickman, Cook & Broviac Lines: Flush with 0.9%
(Children) sodium chloride and lock with 3ml of 10 units/ml
heparin.
• Groshong Lines: Flush with 0.9% sodium chloride and
lock with 5ml sodium chloride 0.9%.
Long Lines (Children) Use 10 units/ml heparin to flush and lock Long Lines in
children
Long Lines (Neonates) Maintain patency with an infusion of 0.9% sodium chloride.
In the case of an extremely premature infant maintain
patency with an infusion of 0.45% sodium chloride.
Umbilical Arterial Catheters Maintain patency with an infusion of 1unit/ml heparin,
(Neonates) prepared by diluting 10 units/ml heparin, according to the
Neonatal ICU protocol.
Vascaths Lock the catheter with 1,000 units/ml heparin (volume as
(In General and Cardiothoracic stated on the catheter lumen). Before use, aspirate the
Intensive Care) heparin from the catheter and flush with 10ml of 0.9%
sodium chloride. If unable to aspirate the heparin, discuss
with the duty consultant whether the heparin may be flushed
into the patient.
Renal-type large bore lines Flush the line with at least 10ml 0.9% sodium chloride then
(On Adult Renal and lock the line/catheter with trisodium citrate 46.7% solution (If
Haemodialysis Units, and in Adult no allergy). The locking volume will be stated on the
Haematology patients) catheter. Before use, aspirate the trisodium citrate 46.7%
solution from the line/catheter. If this is not possible, the
Dialysis lines trisodium citrate 46.7% solution may be slowly flushed into
Vascaths the patient. Then flush with at least 10ml 0.9% sodium
chloride.
Ports When in use with the needle in, flush with at least 10ml
(Adults and children) 0.9% sodium chloride. Lock the device with the appropriate
Totally implantable venous volume of 10 units/ml heparin. Before the needle is
access devices eg. removed, flush with at least 10ml 0.9% sodium chloride then
Portacaths lock the device with the appropriate volume of
100 unit/ml heparin.
Central Lumen of Intra-aortic Use Heparin Sodium 2000 units/L in 0.9% Sodium Chloride
Balloon Pump Catheter IV Infusion, 500mL bags, REF Baxter B0953, as a
continuous flush of the central lumen of the Intra-Aortic
Balloon Catheter, as per protocol.
Central Venous Lines Flush the line with at least 10ml 0.9% sodium chloride then
(Outpatient or Day Case Adults) lock the line/catheter with trisodium citrate 46.7% solution (If
Tunnelled lines eg. Hickman no allergy). The locking volume will be stated on the
or Broviac lines catheter. Before use, aspirate the trisodium citrate 46.7%
solution from the line/catheter. If this is not possible, the
trisodium citrate 46.7% solution may be slowly flushed into
the patient. Then flush with at least 10ml 0.9% sodium
chloride.
Line lock in patients receiving Lock the line with the appropriate volume of Taurolock®
TPN who have had a previous (This contains taurolidine and sodium citrate).
line infection
201
Appendix 5
Document accountability, responsibility and dissemination
4.1 Accountability
Production Peter Gray, Pharmacist

Dissemination Peter Gray, Pharmacist
4.2 Overall responsibility for this document

The Director of Pharmacy has overall responsibility for the safe preparation and administration of
medicines in this Trust, and therefore has overall responsibility for this document.
4.3 Dissemination and Implementation

• Following approval and ratification by the Medicines Governance Committee this eighth
edition of the injectable drug monographs with appendices will be rolled out across the Trust.
• Publication of the eighth issue will be publicised in Vital signs and in the weekly staff news
brief. The new edition will be held in the Pharmacy Dept. Section of PHNT StaffNet.
• Paper copies will be printed by the hospital Print Room, and together with electronic copies
for selected recipients, will be distributed according to a distribution list held in Pharmacy.

Procedures For Administering Injectable Drugs: Version No 2

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This procedure is adopted for PCH staff from:

Plymouth Community Healthcare CIC

Procedures for Administering Injectable

Notice to staff using a paper copy of this guidance

The policies and procedures page of Intranet holds the most

Author: Advanced Specialist Clinical Pharmacist

Asset Number: 385

PHNT Infection Control Documents:

• PHNT is committed to creating a fully inclusive and accessible service.

1.1 Injectable Drug Monographs

Unlicensed use of medications

• If you require information on intravenous compatibilities; contact Pharmacy Drug Information on

o Registered and Provisionally Registered Medical Practitioners. It is recommended that IV

o Named Individual Radiographers/Sonographers who have completed and passed an

o All Registered healthcare professionals must be assessed as competent in the methods

o All training and assessment of competency to administer intravenous medication should

Adult Dosage Table for Treating Paracetamol Overdose

Preparation and administration of paediatric infusions

(C) or (I) IV infusion ♠ Groups 1 Dilute with N/S, G or H to a usual

Patient Further doses and infusion rates

Patient weight Dose and infusion rate

Alteplase to treat Pulmonary Embolism

Follow the Low-Dose Alteplase

Adjust the rate

The maximum rate is

2micrograms/kg/min 0.5micrograms/kg/min 2micrograms/kg/min 0.5micrograms/kg/min

Augmentin See Co-amoxiclav

(Unlicensed Refer to the Marsden Manual for

Discard the diluent vial with the blue part attached

Patients with unstable

Do not mix with any other drug solutions.

Clomethiazole Discontinued product

If cardioversion occurs during the injection, stop

If cardioversion is achieved (usually within 10-15

Pump rate (ml/hour) = Prescribed rate (mcg/kg/min) x weight(kg) x 60(minutes in an hour)

Rate (mcg/kg/min) = Pump rate(ml/hour) x concentration(mg/ml) x 1000

Rate (mcg/kg/min) = Pump rate(ml/hour) x concentration(mg/ml) x 1000

Enoxaparin VTE Dosing Guidance

Incompatible with: heparin, moderate to high

Pump rate (ml/hour) =Prescribed rate(micrograms/minute) x 60(minutes in an hour)

Privigen® is essentially sodium-free.

IM Injection- ♠ Groups Provided ready diluted In exceptional cases where IM administration is

Do not exceed a maximum cumulative dose of Intralipid of 12ml/kg

Pump rate (ml/hour) =Prescribed rate(micrograms/minute) x 60(minutes in an hour)

IM injection ♠ Groups Refer to the Marsden Manual for

Rate (micrograms/kg/minute) = Pump rate (ml/hour) x concentration (micrograms/ml)

Novomix 30® Insulin See Insulin Section, page 103

Pancuronium IV bolus ♠ Groups 1 . Flush with N/S or G.

IM injection for the ♠ Groups 1 Refer to the Marsden Manual for

Romiplostim 9. Remove the empty pre-filled 13. Twist off administration

17. Immediately discard syringe and needle into an approved Sharps

One hour (peak) levels should be 15 –

Do not inject into a line containing glucose. Compatible with N/S

Discard the vial 14 days after first use.

Tysabri® See natalizumab

Using a 2mg/ml dilution e.g. 100mg in 50ml 48 – 84micrograms/kg/hour = 0.024 – 0.042ml/kg/hour

Alteplase 100mg in 100ml Water

Aciclovir up to 5mg/ml in 5% glucose

Aminophylline up to 25mg/ml in saline

Amiodarone in 5% glucose (Central IV)

Co-trimoxazole (Septrin) 480mg/75ml 5% glucose

Adrenaline 1:10,000 undiluted

Clindamycin up to 18mg/ml in 5% glucose