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/ Pharmacie Globale (IJCP) 2010, 5 (01)
Available online at www.pharmacie-globale.info
PHARMACIE GLOBALE INTERNATIONAL JOURNAL OF COMPREHENSIVE PHARMACY
A GUIDE ON INTRAVENOUS DRUG COMPATIBILITIES BASED ON THEIR pH
Vilma Loubnan1 and Soumana C Nasser*2
2Pharmacy 1School of Pharmacy, Lebanese American University, Beirut, Lebanon. Practice department, School of Pharmacy, Lebanese American University, Beirut, Lebanon.
Received: 1 November 2010; Revised: 28 November 2010; Accepted: 10 December 2010; Available online: 12 December 2010
Hospital pharmacies in many countries include a mix of both European and FDA approved medications in their Formulary. Mixing incompatible medications is a major intravenous (IV) medication error especially when data on compatibility is not available in commonly used references. The pH of IV medications is very important to consider when tackling compatibility of solutions. Developing a guide reporting the pH of medications, in addition to compatible solutions and light sensitivity, can serve as a unique tool during the preparation of special admixture for a specific patient. Keywords: pH solution, compatibility, intravenous, light sensitivity.
Hospital pharmacies in many non European or U.S. countries have a mix of both European and FDA approved medications in their Formulary. Developing a guide on intravenous (IV) medications compatibility for the commonly used medications in these countries can provide the pharmacists and nurses with a quick information tool, especially when additional information (such as pH data on medications) are required during special admixture preparation. Medication errors are causing substantial global public health concern, as many result in harm to patients and increased costs to health-care providers.6 Studies have shown that the second most frequent type of medication errors was related to the medication administration.4 Medication errors include prescribing errors, dispensing errors, medication administration errors and patient compliance errors.2 The pharmacist has a major role in ensuring safe administration and appropriate utilization of medications in patients. One of the medication administration errors is incompatibility which is defined as the reaction of IV medications when mixed together resulting in solutions that are no longer optimal for the patient. The stability is altered by physico-chemical reactions leading to decreased effectiveness of the drug or an increased micro-particles load leading ultimately to therapeutic failure, catheter occlusion or embolism.8
critically ill patients usually have multiple central IV lines, several medications have to be infused simultaneously through the same lines. Investigations have shown that mixing an IV drug with the wrong diluents can occur in up to 80% of the cases. This is alarming especially in the ICU where 25% of the IV incompatibilities are highly significant and 26% are life-threatening.8 On the other hand, delivering continuous infusions are more complex and may be more prone to errors than intermittent dosing. This includes medications with higher likelihood of harmful effect such as vasoactive substances (e.g. dopamine or epinephrine), sedatives, and narcotics. 5 This high incidence led investigators to find ways in order to decrease IV incompatibilities & their associated complications. Nemc K 2008 showed that standardization of infusion solutions allowed compatibility testing with a number of medications combinations and served as a measure to reduce the high risk of ward-based IV medication preparation.8 The pH of solution was one of the compatibility measure used in the establishment of standard concentrations of medications commonly given by continuous infusion and prepared at the bedside.8 This also allowed grouping medications that can be infused simultaneously through the same IV line or through the same lumen of a multi-lumen central-venous catheter in case of severe critical illness in order to simplify the administration technique.8 The pH of an IV solution is very important to consider when tackling compatibility of solutions. It is critical that infusion of parenteral solutions does not alter the body’s pH, as well as to prevent stinging, burning, pain, irritation or tissue damage. Medications admixture into a solution could alter the pH to acidic or basic depending on the solution buffer capacity. Normal Saline (NS) and Dextrose 5% in water (D5W) solutions have low buffer capacity, so that the solution will turn acidic with the admixture of an acidic medication, and it will turn basic with the admixture Pharmacie Globale (IJCP), Vol. 01, Issue 05
MIXING INCOMPATIBLE MEDICATIONS AND IV MEDICATION ERROR
Mixing incompatible medications is a major IV medication error. Patients in the intensive care units (ICU) setting are more prone to medication errors as they typically receive a greater number of medications, which are being administered in a more pressured environment.5 Although
*Corresponding Author: Dr Soumana C Nasser, Pharm D Lebanese American University, School of Pharmacy, Pharmacy Practice department, P.O.BOX 36, Byblos, 5053, Beirut, Lebanon. Contact no: +961-3-489860, Email: Soumana.firstname.lastname@example.org
Issue 05 .2 (2% aqueous solution) 9. directly after reconstitution to a 1mg/ml concentration or dilution with an equal volume of diluent to a 0.9% NaCl NA D5W.9% NaCl Yes ∥ NA Yes* 4.9% NaCl D5W ∥ ∥ Yes Store in container ∥ ∥ airtight D5W 0.45% NaCl.9% NaCl. 01.5 mg/ml IM injection IV infusion IV infusion Slow direct IV injection IV infusion after dilution IM injection Direct IV injection Intermittent IV IV injection IV infusion Slow IV infusion over 2 hours Intra-arterial Intrathecal IV infusion over 30-120 min IM injection Direct IV injection IV infusion IV injection IM injection Light Sensitivity ∥ ∥ ∥ Yes* ∥ Yes Amikacin Aminophylline Amiodarone HCl D5W. D10W Asparaginase Atosiban acetate Atropine sulfate 7.9% NaCl Administration Direct IV injection Slow IV infusion IV infusion IV injection over 30 seconds Continuous IV infusion Intra-arterial in neonates IV infusion.4 (6. 0. 5 (01) of a basic medication. 0.2 .5 .5 (3.9% NaCl D5W.9% NaCl D5W.6. 0.5 . 9 INTRAVENOUS DRUG COMPATIBILITIES BASED ON THEIR pH10-18 Commonly used diluent D5W.5 .11.9% NaCl D5W.5.5 . the solution will either remain neutral or the Drug Acetazolamide sodium Acyclovir sodium Alentuzumab Alfacalcidiol Alprostadil pH 9.5 D5W.9% NaCl 0.6 11 (10. 0.08 8 – 10 Amoxicillin sodium Amoxicillin/clavulanic acid Amphotericin B Amphotericin B liposomal Ampicillin sodium 6. 0. 0.9% NaCl 0.5 Aztreonam Betamethasone sodium phosphate 8.6 Bleomycin sulfate † Botulinum toxin A (Dysport) 0.9% NaCl D5W.7 Ascorbic acid D5W. 0. D5W in 0.5 .9% NaCl ∥ ∥ NA Anti-D (rh) immunoglobulin 5. Lactated Ringer’s (LR) solution has a high buffer capacity.9% NaCl.5) 8.5 . 0. The freeze-dried preparation should be stored in an airtight container Yes ∥ ∥ Yes* Azathioprine 4.6 D5W. 0.3 Alteplase 4. 0.9% NaCl D5W. 0.8) † 4.7 (Amphotericin B in D5W) † 8 – 10 (10mg/ml Ampicillin sodium) † pH will drop to a lesser extent than that observed with NS or D5W solution. / Pharmacie Globale (IJCP) 2010. 0. so that when adding an acidic medication.9% NaCl ∥ No dilution needed ∥ 2 Pharmacie Globale (IJCP). Vol.9% NaCl SC injection IV injection But IM injection is preferred Note: For IV. 0. it should be diluted with a large volume and infused slowly IV injection IM injection IV bolus followed by IV infusion SC injection IM injection Direct rapid IV injection IV injection Intermittent infusion over 30-60 min IV bolus Deep IM injection IV infusion IV injection IM injection Intra-articular IM injection SC injection IV injection Intrapleural IM injection Intradermal depending on indication Note: Given as a complex usually with haemagglutinin by local injection The liquid and freezedried preparations should be stored. protected from light.Nasser S C et al.7.6 – 9 4.45% NaCl D5W.6) † † † 7.9% NaCl NA D5W.5 .9.5 5. 0.
7.6 – 6 † 4.5 .6.5 (Frozen premixed solutions) 3-5 3.Nasser S C et al.5 .5 Cefotaxime Ceftazidime Ceftizoxime Ceftriaxone sodium 6.3 3.8.4 (Injection pH) 3–4 † Daclizumab Dantrolene sodium Daunorubicin HCl Deferoxamine † Desmopressin acetate 7 .5 7.5 . Intra-arterial.9% NaCl D5W. 0.8.9% NaCl 0.6.9% NaCl D5W. 5 (01) Buflomedil hydrochloride Caffeine citrate Carmustine Caspofungin Cefazolin sodium 5 .6 4.9% NaCl Yes Dacarbazine D5W. 0.5) (Reconstituted vials) 5 – 7.9% NaCl Yes§ ∥ No 4–6 Cytarabine (Reconstituted lyophilized powder) 7.9% NaCl D5W.9% NaCl Yes* No No ∥ Yes Yes Cefepime HCl Cefuroxime Chlorpromazine HCl Cisatracurium besylate Cisplatin Clarithromycin Clindamycin phosphate Clomipramine HCl Clonidine HCl Cyanocobalamin 0.9% NaCl D5W.5 (5% aqueous solution) 4.65 3. 0.7 (6 .45%NaCl D5W.10 5.9% NaCl. D5W.9% NaCl D5W.9% NaCl D5W. 0.8) (6 .9% NaCl Yes ∥ NA D5W.45% NaCl. 0.5 – 10 (Solution having a concentration of 100mg/L) 5–7 4.5 – 7 usually 6 . 0. 0.45%NaCl D10W.9% NaCl D5W.5 – 7 3–9 Cyclophosphamide D5W. Continuous or intermittent IV infusion 4 mg/ml by IM.9% NaCl IM injection IV infusion Slow IV injection Slow IV injection IV infusion Slow intravenous infusion over about 1 hour Deep IM injection Direct IV injection Intermittent IV infusion Continuous IV infusion Deep IM injection Intermittent IV infusion Deep IM injection Continuous IV infusion Intermittent IV infusion Deep IM injection Intermittent IV infusion Deep IM injection Intermittent IV infusion Continuous IV infusion Deep IM injection Intermittent IV infusion Deep IM injection Direct IV injection Continuous IV infusion Intermittent IV infusion Slow deep IM injection Direct IV injection IV bolus Continuous IV infusion IV infusion with hydration with mannitol IV infusion only IM injection Intermittent IV infusion diluted IM injection IV infusion Continuous epidural infusion IM injection Deep SC injection IM injection Intraperitoneal Intrapleural Direct IV injection Continuous IV infusion Intermittent IV infusion SC injection Intrathecal Direct IV injection Continuous IV Intermittent IV IM injection Direct IV injection IV infusion IV injection over 15 min Central IV infusion Peripheral IV infusion IV injection IV injection only IM injection Slow IV after dilution at a rate not exceeding 15mg/kg/hr.9% NaCl 0.6. 0.5 – 7 (Frozen premixed solution) 4–6 5 .9% NaCl 5 8 6–8 NA D5W D5W NA D5W. IV injection only ∥ Yes* ∥ Yes* D5W. 0. 0.5 † D5W.7 5. intrasynovial 10 mg/ml by IM injection. 0.4. 01.9% NaCl NA Yes ∥ No Yes No No 0. 0. 0. Issue 05 . 0. / Pharmacie Globale (IJCP) 2010. D5W in 0. 0. 0. 0. 0.9% NaCl D5W.9% NaCl Yes§ ∥ 3 Pharmacie Globale (IJCP). 0.3.5 . SC via a portable infusion control device Slow IV infusion over 15-30 min IM injection SC injection 24 mg/ml by direct injection slowly.9% NaCl Yes* Yes ∥ NA D5W. Vol.5 Dexamethasone sodium phosphate † 4.9% NaCl.25 .
3 Furosemide Ganciclovir sodium Gemcitabine Gentamicin sulfate 11 2.2 .5 . 01. 0.9% NaCl (precipitate) & D5W (cloudiness & precipitate) D5W.5 . Vol.9% NaCl NA 0.5 4.6.2 4 9.3 (2.5 . Issue 05 .5 .8.5 (Premixed Gentamicin in 0.5 .9% NaCl.9% NaCl NA D5W. 0.9% NaCl Bacteriostatic 0.5.7.45% NaCl D5W.9% NaCl D5W.9% NaCl D5W. 0.9. 0.9% NaCl D5W.5. 0.9% NaCl 0.4) 2-3 6.7.5 Folinate de calcium 8 .8 .7 Incompatible with 0.6. 0.5 3-5 3. 0. 0.9 Diazepam Digoxin Dipyridamole Dobutamine Docetaxel Dopamine HCl Drotrecogin alpha (activated) Enoxaparin sodium Ephedrine sulfate 2.7.5 (In D5W diluents) 7.9% NaCl 0.9% NaCl D5W. 5 (01) 6. 0. 0. 0.9% NaCl NA D5W.7 .9% NaCl Direct IV injection Yes Direct IV injection diluted or undiluted IV injection in stress testing IV infusion after dilution IV infusion IV infusion IV infusion Deep SC injection SC injection IM injection Slow IV injection SC injection IM injection IV injection Intra-cardiac IV infusion Note: Not given IM. / Pharmacie Globale (IJCP) 2010.6 .7.5 .3 3 .5 (Ready-to-use) 9 – 10 4.4.5 4 .5) † 5.9% NaCl D5W.9% NaCl) † † 2-3 Glycopyrrolate 4.6 . SC IV injection SC injection IV infusion at a concentration of 10 mg/ml IV injection (≥3 min) IV infusion (10-30 min) IM injection IV injection IV injection over 30-60 seconds Slow IV injection Continuous IV infusion IV bolus over 2-5 min IV injection Intermittent IV Note: Do not administer direct IV injection IV infusion diluted Rapid IV injection Continuous IV infusion IV through a running IV infusion line into a large vein IV injection IM injection only IM injection IV injection IV infusion IM injection Direct IV injection IV infusion IV infusion IV infusion IM injection Intermittent IV IV injection IM injection SC injection Transdermal IV infusion IV injection IM injection without dilution or via a running IV infusion IV injection undiluted IV infusion after dilution Yes Yes* No Yes Yes ∥ ∥ Yes Yes ∥ Yes Esmolol Esomeprazole Etamsylate Etomidate Etoposide Factor VII a or Eptacog alpha (activated) Factor VIII Fluconazole D5W.7 . 0.6.9.9% NaCl 6.5 .2 .5 Epinephrine Epirubicin HCl Epoetin alpha 3 6.2 (Single-use vials) 5. 0.2 (8. 0.9% NaCl NA NA NA (IV bag shielding light) Yes must be against ∥ Yes* ∥ No ∥ Yes No D5W.5.6 (10% aqueous solution) † 3-4 † † 4–8 (In NaCl diluents) 3.9% NaCl NA No dilution needed D5W.9% NaCl D5W.4 (Multiple-dose vials) 3.8 .9% NaCl No ∥ Yes ∥ ∥ Yes No ∥ No Fludarabine phosphate Flumazenil Fluorouracil Flupenthixol NA NA D5W.2 .9% NaCl Yes Yes No ∥ Glucagon hydrochloride Glyceryl trinitrate Granisetron HCl 4 Pharmacie Globale (IJCP).5.3.5 (Concentrate) 4.3 (Single-use vials) 4–6 (Multiple-dose vials) D5W. 0.5.9% NaCl D5W.5 . 0. 0.8.2 † 2.5 . 0.9% NaCl D5W. 0.Nasser S C et al.9% NaCl D5W.
9%NaCl.5 .9% NaCl 0. 0.5 D5W.9 3-4 6. 0.9 . 0.8 (Neutral) Insulin regular Interferon alpha-2a 6.3.9% NaCl Yes‡ Yes‡ ∥ ∥ Yes ∥ Yes No Yes No Yes for Privigen® Immune Globulin IV Infliximab No Yes Yes* ∥ Interferon alpha-2b NA ∥ Irinotecan HCl Iron sucrose Isoproterenol HCl 3 .7 Iohexol 0.3. 0.9 .9% NaCl No Yes‡ Yes Isosorbide dinitrate Ketamine HCl Ketoprofen Ketorolac tromethamine Labetalol HCl † 3. 0.4 .4.8 . 0.4 .5 6. 0.7.4.7.5 (Reconstituted powder for injection) 6.Nasser S C et al.9% NaCl Gamimune N® diluted in D5W Sandoglobulin® diluted in D5W.5 (Heparin lock flush solution) † † † Hexoprenaline sulfate 3. 0. 5 (01) Haloperidol lactate 3 . products containing preservatives should not be given IV or Yes No Heparin Hepatitis B surface antigen (HBsAg) Hepatitis B virus surface antigen recombinant NA NA D5W.8 5–8 (Heparin sodium injection) 5 .9% NaCl 5-7 8 – 10 (2% aqueous solution) † 3 .5 6.9% NaCl.8 10.9% NaCl NA D5W.9% NaCl D5W. 0. / Pharmacie Globale (IJCP) 2010.5 11 2.6.5 (5-7) (Injection pH) 3–7 (Premixed infusion solutions in D5W) D5W.9% NaCl for IV infusion admixtures NA D5W.7. 01.9% NaCl D5W.4 Hydralazine Hydrocortisone Hydroxocobalamin Hydroxyprogesterone caproate Hyoscine butylbromide 3.5 .9% NaCl D5W.8 (Sandoglobulin®) † 7 .9% NaCl D5W D5W. Vol.9% NaCl 0.5 Note: Not recommended to add to infusion solutions NA NA NA D5W. Issue 05 .9% NaCl IM injection Deep SC injection Intermittent IV undiluted diluted Continuous IV infusion IM injection IM injection SC injection IV infusion preceded by slow IV injection in the management of premature labor IM injection Rapid IV injection IV injection IM injection IM injection IM injection SC injection Slow IV injection IM injection SC injection Slow IV injection Slow IV infusion Continuous IV infusion Slow IV infusion initially then the rate is gradually increased according to patient tolerance IV infusion over at least 2 hours SC injection IM injection IV infusion IM injection SC injection IV infusion for reconstituted dry powder products IM injection or SC injection for the solution products IV injection Intra-arterial Intrathecal (except for Omnipac® 350mg) Intra-articular IV infusion IV infusion IV infusion Direct IV injection IM injection SC injection IV infusion Intracoronary bolus during PTCA IM injection Slow IV injection IV injection IM injection Slow deep IM injection IV injection Direct IV injection Continuous IV infusion Direct IV injection Continuous IV infusion Note: Products containing 40. 0.5 Idarubicin HCl Ifosfamide 6 4 .7. 0. 100 or 200 mg/ml should not be given by direct IV without prior dilution.9% NaCl D5W. 0.6.5 (Gamimune N®) 6.4.7. or sterile water for injection NA 0.5.45% NaCl Yes§ ∥ Yes§ Yes Yes No Lidocaine 5 Pharmacie Globale (IJCP). 0.
Vol. 5 (01) Lincomycin Mesna 3 .9% NaCl 0.5 5.02% aqueous solution) 2.5 7-8 NA ∥ 0. Because of the very low pH of the reconstituted solution.5 (7.45% NaCl D5W.5 Neostigmine methylsulfate Nicardipine HCl 3.5% solution) 4. D5W in 0.4 .2 (0.3. 0. 0. 0. 0. 0.8. 0. 01.2 .6.9% NaCl NA ∥ ∥ Yes ∥ ∥ Yes Metronidazole 0.9% NaCl Yes Yes* Yes injection ∥ Diluted before slow continuous IV infusion 6 Pharmacie Globale (IJCP).7 .9% NaCl 0.5 Metoclopramide 2.5-7.5 . 0.5. 0.5 . 0.5 Metoclopramide hydrochloride D5W.9% NaCl NA D5W.7 Methylprednisolone acetate 7-8 Methylprednisolone sodium succinate Methylthioninium chloride 2.9% NaCl NA D5W.5 7.9 . / Pharmacie Globale (IJCP) 2010.6.6. 0.4 3 . 0.Nasser S C et al.5 D5W.5. 0.5. 0.9% NaCl ∥ No Methylprednisolone 3.5 Metoclopramide HCl 3 .5 – 2 (After reconstitution) 6–7 (On further dilution and subsequent neutralization) D5W.6.9% NaCl ∥ Yes 3.9% NaCl.5 8.9% NaCl Yes Micafungin sodium Midazolam Milrinone Mitoxantrone HCl Molsidomine † 2.6. Issue 05 . 0.45% NaCl D5W.5 D5W.9% NaCl D5W.5 (1% solution in water) 2.5 .9% NaCl Deep IM injection Slow IV infusion IV injection IV infusion IM injection Intra-arterial Intrathecal Direct IV injection Intermittent IV infusion Continuous IV infusion IM injection Slow IV over at least 1 min in case of emergency IM injection Slow IV injection IM injection Direct IV injection Intermittent IV Continuous IV infusion IM injection Intra-articular Intrasynovial without dilution Note: Must not be administered IV Deep IM injection Direct IV injection Continuous IV infusion Intermittent IV infusion IV over several minutes Dye in diagnostic procedures IM injection Direct IV injection undiluted slowly Intermittent IV infusion IM injection Direct IV injection undiluted Intermittent IV infusion diluted IM injection Direct IV injection undiluted slowly over 1-2 min for 10 mg dose Intermittent IV infusion over 15 min diluted for larger doses Continuous IV Intermittent IV infusion over 1 h Note: MTZ must be diluted to 8mg/ml or less and neutralized prior to administration.5 .4 .9% NaCl D5W.9% NaCl D5W ∥ No ∥ Yes Morphine sulfate 3-4 Naloxone HCl † Nandrolone decanoate 5 .9% NaCl D5W.3.5 .9) Methotrexate sodium D5W.4. it cannot be given by direct IV injection IV infusion IM injection Slow IV injection IV infusion diluted IV continuous infusion Slow IV infusion after dilution Continuous IV IV single dose IV infusion at a rate of 3mg/hr SC injection IM injection Slow IV injection Slow continuous SC or IV infusion SC injection IM injection Continuous IV infusion Oily IM injection IM injection SC Slow IV injection No No Yes Methylergometrine maleate Methylergonovine Maleate 4.2 (0.5 .9% NaCl D5W.7 NA D5W.
12. 0.9% NaCl NA D5W. 0.5 6 .5. 5 (01) † Nimodipine D5W. 0. 0.10.5 Octreotide acetate Olanzapine Omeprazole Ondansetron HCl Oxacillin Oxytocin Paclitaxel Pamidronate Pancuronium bromide Papaverine HCl Pemetrexed Penicillin G potassium 5 .8 4.Nasser S C et al.3 (1% aqueous solution) 3.4.9% NaCl 0. It's drawn into a syringe and connected to a 3-way stopcock and polyethylene tube IV infusion after dilution Yes Nitroglycerine 3 .2 ≥3 4. 0.9% NaCl ∥ Yes ∥ No Yes No No Yes ∥ Phenobarbital sodium Phenylephrine HCl Phenytoin sodium Phloroglucinol/ trimethylphloroglucinol Phytonadione Piperacillin/Tazobactam Piracetam Pneumococcal vaccine (23valent) Pralidoxime methyl sulfate 9.9% NaCl.9% NaCl D5W. 0. 0.5 † 11 3.3 .8.9% NaCl D5W. 0.9% NaCl infusion NA D5W.7.5 D5W.6. LR IV infusion Intracisternal Note: Should not be added to an infusion bag or bottle. 0.9% NaCl No Noradrenaline tartrate 3. 0. 0.4.5 (Concentrate for injection) 4 (3 .9% because of lack of oxidative protection D5W.2 3 . Issue 05 .45%NaCl D5W.9% NaCl D5W.5 – 7 5–7 (Phytonadione Merck) 4. 0. 0.5 .5 D5W.4 6 .9 .5. 0.5 Penicillin G sodium Pentoxifylline † 3. 0.3 4–6 (1% aqueous solution) 3.4 .5 Note: Not administer Noradrenaline in NaCl 0.6 Pethidine 3-5 4.4 3.9% NaCl D5W.9% NaCl D5W. 0.6.5 .9% NaCl.4 Injected into a running 0.5 .9% NaCl Yes 7 Pharmacie Globale (IJCP).6 8.9% NaCl IV infusion diluted in base & D5W with or without NaCl SC injection IV injection IV infusion IM injection Deep IM injection IV infusion IV injection IV infusion Deep IM injection Direct IV injection Continuous IV infusion Intermittent IV infusion IV infusion IM injection IV infusion Intermittent IV IV infusion IV injection IM injection Slow IV injection IV injection IM injection Continuous IV infusion Intermittent IV infusion IM injection Continuous IV infusion Intermittent IV infusion Slow IV injection IV infusion after dilution Intermittent SC IM injection Direct IV injection Intermittent IV IV infusion Note: IM for repeated doses and SC for occasional use IM injection Slow IV injection SC injection IM injection Direct slow IV IV infusion Direct IV in a running infusion IV injection IM injection SC injection IM injection preferred Direct IV injection IV infusion IV infusion after dilution Infusion via infusion pumps IM injection Slow IV infusion.8 .9% NaCl Preservative-free 0.9% NaCl D5W.6.9% NaCl NA NA NA No ∥ Yes‡ ∥ Promethazine HCl 4 .4. Vol.5) (Baxter premixed infusion solution) 3 .9% NaCl D5W.2 .8. 01. 0.9% NaCl D5W.9% NaCl No Yes* 10 .9% NaCl ONLY D5W.7. 0.9% NaCl Yes for extended capsules Yes Yes D5W.5 D5W.4. / Pharmacie Globale (IJCP) 2010. 0. 0. as a drop IV IM injection SC injection Slow IV injection over 5 to 10 minutes IV infusion over 15 to 30 minutes SC injection IM injection Deep IM injection IV injection Yes ∥ Yes ∥ ∥ No D5W.5 .
5 . 0.4. / Pharmacie Globale (IJCP) 2010.8 (1% aqueous solution) 6.6.6. 01.9% NaCl) 2.9 (Vancomycin in 0. 0.5% aqueous solution) † Teichoplanin Tenecteplase Tenoxicam Tetanus Immunoglobulins Tetracosactide acetate Thiopental sodium Tirofiban TMP-SMX Tramadol HCl Tranexamic acid Triamcinolone acetonide Triptorelin acetate Tropisetron HCl Urapidil HCl 7.9% NaCl D5W.11.Nasser S C et al. 0.9% NaCl NA D5W.5 .5 . 0.5 . 5 (01) Propofol Propranolol HCl Protamine sulfate Quinine hydrochloride 4. 0. 0.6 Sufentanil citrate Suxamethonium chloride 4–5 (0. 0.8 .6 Valproate sodium 3. 0.5 Sodium Bicarbonate pH of the reconstituted solution is dependent on the diluent used 5-8 3.5%) IV injection Intra-arterial Intracoronary infusion after dilution Deep IM injection Slow IV injection IV infusion IM injection IV injection IV infusion IM injection IM injection after reconstitution Direct IV bolus IV infusion after dilution of the reconstituted solution IV bolus IM injection IV bolus IM injection IV infusion IV injection IM injection Slow IV infusion only IV infusion IV injection only after dilution IM injection Direct IV injection slowly IV infusion after dilution IV infusion IM injection Intra-articular Daily SC injection IM or SC depot preparation Slow IV injection IV infusion IV injection IV infusion over 60 min at a rate that does not exceed 20mg/min diluted in at least 50 ml of a compatible infusion solution Intermittent IV infusion Continuous IV infusion No Yes No ∥ Yes§ Ranitidine HCl 6. 0.9% NaCl NA NA D5W.9% NaCl D5W.9% NaCl Risperidone ∥ Yes ∥ Yes No ∥ Streptokinase Streptomycin sulfate Yes Yes ∥ ∥ ∥ ∥ Yes Yes No No Yes Yes ∥ ∥ ∥ ∥ Yes (Wrapped in aluminum) No No Vancomycin HCl 8 Pharmacie Globale (IJCP). Vol.6.7.5 Rituximab 4 Rocuronium bromide 3.9% NaCl Undiluted or diluted IV injection/infusion IV injection Slow IV undiluted as 10 mg/ml IV infusion after dilution IM injection IV infusion IM undiluted Slow IV after dilution Intermittent IV infusion Continuous IV infusion Direct IV injection IM injection IV infusion Note: Do not give direct IV injection Rapid IV injection IV infusion when admixed in IV infusion solution SC injection IM injection Direct IV injection after dilution IV injection undiluted or diluted SC injection if diluted to isotonicity (1. 0.7 .9% NaCl D5W. 0.9% NaCl 6.9% NaCl NA D5W.8. 0. 0.2 5.9% NaCl but 0.5 10 † † † NA Addition to infusion solutions is not recommended NA NA D5W.5 .5 .9% NaCl 0.8 † † 5 † D5W.9% NaCl NA D5W.5 (Vancomycin in D5W) 3–5 (Premixed Vancomycin) D5W.6. 0.9% NaCl D5W.9% NaCl D5W. 0.2 . 0.9% NaCl NA † † 10.9% NaCl D5W.9% NaCl D5W.9% NaCl is the preferred diluent D5W. Issue 05 .6 2. 0.5 Scopolamine hydrobromide 7 .4 6-7 6 .3 D5W D5W.9% NaCl D5W D5W.
9% NaCl D5W. Hawkins B. Snow EK.5 † Zoledronic acid † * D5W. Brown D. Lance L L. The authors have no conflicts of interest to disclose. Sweetman SS. 1974. Intensive Care Med 1998. and light sensitivity. 2004. AHFS Drug Information. 5. Handbook on injectable drugs. 6. Its uniqueness resides in the combination of commonly used FDA and European approved medications. 9. 35th ed. 0. and Stability Considerations for Technicians. Lebanon National Drug Index 2008 and databases as Micromedex. Hudson (OH): Lexi-Comp Inc. 10. we decided to formulate the following table on parenteral medications. European Pharmacopeia. Lacy CF. to serve as a guide for hospital practitioners. European Pharmacopeia. Martindale.5 (target 4.5 – 5 (Reconstituted lyophilized) 3. Anaesthesia 2005. Observational study of potential risk factors of medication administration errors. Ministry of Public Health of Lebanon. compatible diluents. 50:305-314. Buffer Capacity. Vol. USP28/NF23.5. 2006. Graystake (IL): Royal Pharmaceutical Society. ‡: do not freeze. Wheeler S J. 5 (01) Vecuronium bromide Verapamil Vinblastine sulfate Vincristine sulfate Vinorelbine tartrate 4 4 . Apkon M. London (UK). 7. 13.9) 3. Trissel’s tables of physical compatibility. 1998. 9 Pharmacie Globale (IJCP). Qual Saf Health Care 2004. Lake Forest (IL): Multimatrix. Limat S et al. Cornette C. Drug information handbook with trade names index. editors. 0. Rockville: Board of Trustees. Kopelent-Frank H. 18. Am J Health-Syst Pharm. 65:1648-54. Trissel L A .9% NaCl D5W. Medication errors at the administration stage in an intensive care unit. McEnvoy GK. Bethesda: Board of ASHP American Hospital Formulary. 14. editor. 2009. Pannatier A. 2nd ed. Pharm World Sci 2003. Martindale W. This table will serve as a unique tool in helping decrease hospital related IV incompatibilities and stability errors. 2.5 . 5th ed. Evaluation of nurses’ errors associated in the preparation and administration of medication in a pediatric intensive care unit.9% NaCl Note: not to be mixed with LR or solutions containing divalent cations NA Rapid IV injection IV infusion Slow IV injection Direct IV injection IV infusion IV injection only Continuous IV infusion Intermittent IV infusion IV injection after dilution only IV infusion over not less than 15 min Yes Yes Yes Yes Yes ∥ Zuclopenthixol acetate Deep IM injection Yes †: no data on pH. USP28/NF23. Incidence and severity of intravenous drug errors in a German hospital. Guidelines on preventing medication errors in hospitals. Tissot E. Eur J Clin Pharmacol 2003. Greif R.9 11. Design of a safer approach to intravenous drug infusions: failure mode effects analysis. Pharm World Sci. American Pharmacists Association. ASHP. 12. Tissot E. Taxis K. §: tablets are light sensitive. especially when PH levels of medications to be mixed together in dextrose in water or normal saline solutions are needed during special admixture preparation. 52th ed. REFERENCES 1. Tertiary references used include Drug Information Handbook. Demoly P et al. Barber N. Armstrong L L. AHFS Drug Information. Standardization of infusion solutions to reduce the risk of incompatibility. Wheeler D W.9% NaCl D5W. Micromedex. 20(4): 178-182. editor. Martindale: the complete drug reference. Council of Europe. 59: 815–817. Strasbourg Cedex (France): European Directorate for the Quality of Medicines of the Council of Europe. et al. 1997. Leonard J. 01.. Handbook on Injectable Drugs. 13: 265271. JPSW 2009. American Society of Health-System Pharmacists.6. Trissel L A.Nasser S C et al. NA: not available CONCLUSION Given the importance of compatibility of IV medications admixture. 0. Nemec K. Am J Hosp Pharm 1993. 2008.. ∥: no data on light sensitivity. ACKNOWLEDGMENT The authors would like to thank the Lebanese American University for the financial support in conducting this report.9% NaCl 0. 8. Issue 05 . Healthcare series. Schneider M P. 4. 15. Italian cooperation-basic health services 2008. 0.9% NaCl D5W. Leissing N C. Inc. / Pharmacie Globale (IJCP) 2010. 60: 257273. 25: 353-359. Committee of revision. editors. 200. 16. 2004. 25(6): 264-268. Probst L. Thomson Reuters. : store in airtight container. Lebanon National Drug Index. 17. Tonicity. Trissel’s Tables of Physical Compatibility. their pH. 12th ed. their administration techniques. United States Pharmacopeial Convention. Goldman M P. 17th ed. Cornette C.5 3. pH. Medication errors in anesthesia and critical care. 2009. Cotting J. Bethesda (WI): American Society of Health-System Pharmacists. 0. 3.
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