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Section II

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Medication Generic - (Brand) ABCIXimab (Reopro) Antiplatelet IIb/IIIa How Supplied 2mg/ml 5 ml vial IV Push SVP or LVP Standard Diluent Conc / Rate Max/Min Concentrations Recommended Infusion Time Yes Percutaneous Coronary Intervention: 2 mg/ml 0.25 mg/Kg bolus followed by 0.125 Give bolus over 1 mcg/Kg/min infusion (up to max minute 10mcg/min = 7.2 mg) x 12 hours System Standard Concentration: 7.2 mg/ 250 ml NS (28.8 mcg/ml) Yes IV Push Preferred 100 mg/ml at max rate of 250 mg/min. NO Acetaminophen overdose: (Prescott Trial Protocol) Loading dose: 150 mg/kg IV over 60 minutes Maintenance dose: 50 mg/kg IV over 4 hours x 1 then 100 mg/kg IV over 16 hours Traditional dosing protocol may be used to dose IV rescue Loading Dose: 140mg/kg IV over 60minutes; Maintenance dose: 70mg/kg IV Q4h x 17 doses. N-acetylcysteine should continue until liver function improves!! Pediatric patients: recommended conc is 40 mg/ml to avoid hyponatremia and seizures. NO Up to 350 mg in 50 ml NS or D5W 351-700 mg in 100ml NS or D5W Infuse doses over at least 60 min. Max conc: 7 mg/ml

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AcetaZOLAMIDE (Diamox) Diuretic Acetylcysteine, Nacetylcysteine (Acetadote)

500 mg Vial

200 mg/ml 30 ml vial

Antidote acetaminophen overdose

Acyclovir (Zovirax) Antiviral

5 mg/ml 10ml and 20 ml vials

Units with cardiac monitoring and nurses who have demonstrated competency to manage this Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

Parenteral Medication Administration Guidelines

G H I J K L M N O P Q R S T U V W X Y Z
Precautions / Comments Stability / Storage Limitations / Restrictions Do not shake solution or transport via tube system. Administer in separate IV line 0.22 micron filter must be used in preparation!! ** Verify dose to be given. Discard vial after drawing up correct dose. ** May cause thrombophlebitis Caution with use in patients with asthma and/or history of bronchospasm Common adverse effects: rash, urticaria and pruritus Urticaria and pruritus may be treated with antihistamine (i.e. diphenhydramine) with physician order. Reconstitute vial with sterile water only.

r LVP Standard Diluent

mmended Infusion Time aneous Coronary Intervention: g/Kg bolus followed by 0.125 g/min infusion (up to max /min = 7.2 mg) x 12 hours

Preprinted order set available Monitor Hgb/Hct, platelets, PT, PTT 6 hours after admin and 24 hrs after administration

m Standard Concentration: 7.2 0 ml NS (28.8 mcg/ml)

minophen overdose: (Prescott rotocol) Loading dose: 150

Administer in separate IV line Solution may turn pink/lavender in color still ok to use

nance dose: 50 mg/kg IV over 4 x 1 then 100 mg/kg IV over 16

onal dosing protocol may be o dose IV rescue Loading 140mg/kg IV over 60minutes; nance dose: 70mg/kg IV Q4h x

ylcysteine should continue until

ric patients: recommended conc mg/ml to avoid hyponatremia and Renal tubular damage with infusions <60min. Phlebitis if conc.>7mg/ml Dose reduction recommended for CrCl < 50 ml/min Do NOT refrigerate precipitate may form.

350 mg in 50 ml NS or D5W 0 mg in 100ml NS or D5W doses over at least 60 min.

have demonstrated competency to manage this medication. elines - Revised Final 07-2009

Limitations /

ster in separate IV line

icron filter must be used

ster in separate IV line

vender in color still ok

Section II
Medication Generic - (Brand) Adenosine (Adenocard) How Supplied 3 mg/ml 2 ml vial, 3 mg/ml 2 ml and 4 ml syringe IV Push Conc / Rate Yes, 6 mg rapidly over 2 seconds followed with saline flush. May then give 12mg 1-2 min later, followed by another 12 mg 1-2 min later if needed. NO

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time IV Push Preferred

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Anti-arrhythmic

Albumin, Human Serum Plasma Expander Allopurinol (Aloprim) Xanthine oxidase inhibitor

5% - 250ml 25% - 50ml bottles

500mg/30 ml Vial

NO

Dose and rate of administration based upon patient condition. Recommended max rate of infusion: 5% at 10 ml/min 25% at 3 ml/min Intermittent Infusion 200-400mg/M/day (Max of 600mg) diluted in 100ml NS/D5W Give over 30 minutes

Alprostadil (PGE1)

500 mcg/ml 1 ml vial

NO

Usual dose range for treatment of pulmonary hypertension: 1-150 nanograms/kg/min System Standard Concentration: 1000 mcg/100 ml NS (10 mcg/ml) System Concentrated Concentration: 2000 mcg/100 ml NS (20 mcg/ml) Max conc: 20 mcg/ml

Vasodilator/ Prostaglandin

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time Dyspnea, flushing and heart-block (asystole) not uncommon with rapid resolution as half-life is only 10 seconds Reflex tachycardia may occur if given too slowly

Follow rapid IV push dose withSee footnote * 20 ml NS flush Continuous ECG, If given into IV line, use BP monitoring closest port to insertion site and recommended follow with NS flush. Elevate during extremity administration

Administer with IV tubing provided by pharmacy. mmended max rate of infusion:

Do not mix with other solutions Limited Indication: Hyperuricemia associated with chemotherapy Dose reduction recommended for CrCl < 20 ml/min Very short half-life necessitating continuous infusion administration

If diluting 25% albumin, NS is preferred. D5W may be used for limited volumes. DO NOT dilute with sterile water! Stable only 10 hours after dilution at room temp Do NOT refrigerate Reconstitute vial with sterile water only! Further dilute with NS or D5W Stable x 24 hours at room * See footnote temperature

Common side effects in adults include: flushing, nausea, abd cramps, tachycardia, hypotension, and edema. m Concentrated Concentration: Monitor respiratory and cardiac status May cause thrombophlebitis recommend central line administration

strated competency to manage this medication.

Section II
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Medication Generic - (Brand) Alteplase (Activase, TPA, Cathflo) How Supplied IV Push Conc / Rate

Parenteral Medication Adminis


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time MI Greater than 67kg: 15 mg over 2 min, 50 mg over 30min, 35 mg over next 60min. MI - 67kg or Less: 15mg over 2min, followed by 0.75mg/kg over 30min, then 0.5mg/kg over 60min. Total dose not to exceed 100mg. Ischemic stroke: 0.9 mg/Kg up to max 90Kg - Give 10% as bolus over 1min, then remainder over 60min Pulmonary Embolism: 100 mg over 2 hours Peripheral Vascular Thrombolysis: Per Interventional Radiology/Interventional Cardiology. Preprinted order sets available. Catheter Clearing: Metro: Give 0.5 ml of 1 mg/ml alteplase and dwell x 60 min. If still occluded, aspirate alteplase, instill 1 ml of 1 mg/ml alteplase and dwell 60 min. If still occluded, aspirate alteplase, instill 2 ml of 1 mg/ml alteplase and dwell 60 min. When patency is restored, withdraw 5-10 ml and discard then flush with 10 ml NS. If catheter capacity is greater than volume of alteplase, then follow dose with NS to fill catheter volume. If patency is not restored after 2 ml dose, contact physician for further orders. (Metro Nursing Clinical Policy MN-11) * Use 2 mg dose initially for hemodialysis catheters and fistulas Dilute in 100 ml D5W or NS Max conc: 5mg/ml Infuse over 60 minutes

*HIGH ALERT MEDICATION* Do not confuse with other thrombolytic medicines Thrombolytic

100 mg/ Yes, 100 ml (1 Up to 15 mg over mg/ml) vial 2 min. (7.5 & mg/min) 2mg Cathflo vials

Amikacin (Amikin) Antibiotic/ Aminoglycoside

250 mg/ml 2 ml & 4 ml vials

NO

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

Parenteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time Thrombolytic medication: Monitor for bleeding.

Minimize potential risks for bleeding: Establish all IVs prior to therapy. (Minimum of 2 peripheral IVs recommended in addition to thrombolytic infusion site.) - Give 10% as bolus over 1min, Avoid unnecessary arterial/venous punctures, excessive blood sampling, or IM injections for at least 24 hr after d/cd (malnourished patients 48 hr). Apply pressure dressings to all puncture sites.

Give 0.5 ml of 1 mg/ml se and dwell x 60 min. If still ed, aspirate alteplase, instill 1 ml g/ml alteplase and dwell 60 min. ccluded, aspirate alteplase, ml of 1 mg/ml alteplase and 0 min. When patency is d, withdraw 5-10 ml and discard

Reconstitution must be with *See footnote for sterile water. cardiopulmonary indications (i.e.: Conc 0.01-1 mg/ml stable 24AMI, PE). hours (if diluent is NS after reconstitution) Monitoring is at physician Avoid shaking reconstituted discretion for solution. Do not transport via peripheral tube system. vascular indications. Administer via separate IV line. No restrictions for alteplase use for catheter clearance or administration of low doses per chest tube.

eter capacity is greater than e of alteplase, then follow dose S to fill catheter volume. If y is not restored after 2 ml dose, t physician for further orders. Nursing Clinical Policy MN-11) Use 2 mg dose initially for * Aminoglycoside dosing and monitoring service available from pharmacy upon physician order. Monitor renal function.

strated competency to manage this medication.

Section II
Medication How Generic - (Brand) Supplied Aminocaproic Acid 250 mg/ml (Amicar) 20 ml Vial Hemostatic / Antifibrinolytic NO IV Push Conc / Rate

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Intermittent infusion: Typically 1 Gm in 50 ml NS/D5W Infuse over 60 minutes. Continuous infusion: System Standard Concentration: 5 gm/250 ml NS (20 mg/ml) Usual dose range: 1 1.25 Gm/hr Cardiac Surgery: Loading dose: 10 gm/40 mL drawn up in a syringe & administered IV over 20 minutes. Maintenance Drip: 2 gm/hr (40mL/hr) during surgery. (10 gram/40 mL added to 150mL NS; total volume 200 mL).

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Aminophylline See

Theophylline
Amiodarone 50 mg/ml (Cordarone) 3 ml vial, ampule Anti-arrhythmic Yes, V. fib or Pulseless V-tach: Give 300 mg undiluted over 30 seconds. Follow with 20ml NS flush. May give 150 mg after 3 5 min if V.fib/pulseless Vtach persists Bolus: 150 mg / 100ml D5W (PVC) System Standard Conc: 450 mg / 250 ml D5W (Excel Bag) System Concentrated conc: 600 mg/88 ml D5W (total volume 100 ml) (Excel Bag) (6 mg/ml) only! Usual starting dose: Bolus 150 mg in 100ml D5W over 10 min. then 60 mg/hr x 6 hours then 30 mg/hr x 18 hours via infusion.

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage

r LVP Standard Diluent

mmended Infusion Time Hypotension, bradycardia, arrhythmia Expiration dating: 7 days with too rapid infusion refrigerated. Recommended max dose: 30 Gm/24 hr

lly 1 Gm in 50 ml NS/D5W

m Standard Concentration: 5

dose range: 1 1.25 Gm/hr

g dose: 10 gm/40 mL drawn up ringe & administered IV over 20

nance Drip: 2 gm/hr (40mL/hr)

am/40 mL added to 150mL NS;

150 mg / 100ml D5W (PVC)

Central Line Required if concentration exceeds 2 mg/ml

m Standard Conc: 450 mg / 250 (1.8 mg/ml) Monitoring: m Concentrated conc: 600 Continuous EKG Monitoring ml D5W (total volume 100 ml) BP - Monitor during loading Central line dose: Continuous q15min x or 3; then q4-6hr while stable on infusion 0 Decreasing rate or stopping infusion may alleviate hypotension and/or bradycardia Preprinted order set available for new onset A.Fib

Two-hour stability if mixed in Poly Vinyl Chloride (PVC) plastic container. Infusions running longer than 2 hrs require Excel or glass containers. Stable 24 hours after dilution with D5W in Excel or glass. Use of in-line 0.22 micron filter required for infusions. Check with pharmacist for compatibility information.

150 mg in 100ml D5W over 10 hen 60 mg/hr x 6 hours then 30 x 18 hours via infusion.

strated competency to manage this medication.

Limitations / Restrictions

* See footnote y Vinyl Chloride (PVC)

ns running longer than 2 Excel or glass ners. Stable 24 hours

equired for infusions.

Section II
Medication Generic - (Brand) Amphotericin B (Fungizone) How Supplied 50 mg and 100 mg vials IV Push Conc / Rate NO

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Optional Test dose: 0.1 mg/kg up to 1 mg in 50 ml min Doses < 25 mg/250 ml 26-50 mg/500 ml Infuse over 3 hours

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Anti-fungal

Amphotericin B Lipid Complex (Abelcet) Anti-fungal

100 mg vial

NO

3 - 5mg / Kg / Day typical dose Dilute with D5W concentration of 2 mg / ml. Infuse over 2 hours

Amphotericin B Liposomal (AmBisome) Anti-fungal

50 mg Vial

NO

3 5 mg/Kg/Day typical dose Dilute with D5W concentration of 1-2 mg/ml Infuse over 2 hours

Ampicillin Antibiotic/ Beta-lactam

0.5, 1 & 2 Gm Vial

NO

Up to 1 Gm 50ml NS 2Gm 100ml NS Infuse dose over 30 min

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage

r LVP Standard Diluent

mmended Infusion Time al Test dose: 0.1 mg/kg up to 1 D5W

Test Dose no longer considered . Infuse over 10-30 necessary & no longer recommended. Monitoring: VS q15 min x 1 hr then q 1 hr for at least 1 hr post-infusion. Administer any pre-medications 30 minutes prior to starting daily infusion Premeds must be per physician order. Recommended pre-medications: Acetaminophen 500-1000 mg PO or 650 mg PR ; Diphenhydramine 25-50 mg PO/IV ; Hydrocortisone 25-50 mg IV (use only in pt history of severe rigors) Sodium loading recommended to prevent nephrotoxicity. 500 ml NS before and after infusion. Lower volume (i.e. 250 ml) may be consider in pt with cardiac compromise or develop HTN during NS infusion. Monitor VS q15 min x 1 hr then q 1 hr for at least 1 hr post-infusion. Administer any pre-medications 30 minutes prior to starting daily infusion See Amphotericin B for recommended pre-meds. Monitor VS q15 min x 1 hr then q 1 hr for at least 1 hr post-infusion. Administer any pre-medications 30 minutes prior to starting daily infusion See Amphotericin B for recommended pre-meds. Penicillin derivative check allergies

Use Protect from light. Do NOT filter

D5W D5W

Amphotericin may cause renal wasting of K , Mg , HCO

and Na Daily monitoring recommended. Supplementation may be required.

g / Kg / Day typical dose to final

Use Gently agitate solution prior to beginning infusion and every 2 hours. Stable 6 hr at room temp Use Gently agitate solution prior to beginning infusion and every 2 hours. Stable 6 hrs after dilution at room temp

mg/Kg/Day typical dose to final

strated competency to manage this medication.

Stability / Storage

Limitations / Restrictions only

D5W Protect from light. Do NOT filter

Amphotericin may cause renal wasting of K , Mg , HCO + and Na Daily monitoring recommended. Supplementation may be

2 3-

D5W Gently agitate solution prior to beginning infusion and every 2

only

Stable 6 hr at room temp D5W Gently agitate solution prior to beginning infusion and every 2 Stable 6 hrs after dilution at only

Section II
Medication Generic - (Brand) Ampicillin / Sulbactam (Unasyn) Antibiotic/ Beta-lactam Anidulafungin (Eraxis) Antifungal How Supplied IV Push Conc / Rate

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time <1.5 Gm/50 ml NS 1.6 to 3 Gm/100 ml NS Infuse dose over 30 minutes

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1.5 & 3 Gm Not advised Vial (2/3 amp, 01/03/13 sulbactam) 50 mg vial Not advised

Intermittent infusion: 50 mg in 100 ml NS or D5W 100 mg in 250 ml NS or D5W 200 mg in 500 ml NS or D5W MAX infusion rate 1.1 mg/minute

Anticoagulant Citrate Dextrose A (ACD-A) *HIGH ALERT MEDICATION* Anticoagulant

500 ml bags

NO

Not for intravenous administration. Do NOT infuse directly into patient.


Continuous infusion with Continuous Renal Replacement Therapy (CRRT) and Plasmapheresis Used as anticoagulant for the machines not effective as anticoagulant for patient.

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time Penicillin derivative check allergies dose over 30 minutes

Dose reduction recommended for CrCl < 30 ml/min


Reconstitute vials with accompanying diluent only

Histamine-mediated symptoms (rash, urticaria, flushing, pruritus, dyspnea, and hypotension) possible infrequent when infusion rate < 1.1 mg/min nfusion rate 1.1 mg/minute May cause hypocalcemia

nistration. Do NOT infuse

uous infusion with Continuous Replacement Therapy (CRRT)

as anticoagulant for the machines ffective as anticoagulant for

strated competency to manage this medication.

Section II
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Medication Generic - (Brand) Anti-thymocyte globulinEquine (Atgam, Lymphocyte Immune Globulin) How Supplied 50mg/ml 5ml Vial IV Push Conc / Rate NO

Parenteral Medication Adminis


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Intermittent Infusion Prevention/treatment transplant rejection: 5-15 mg/kg daily for 7-14 days. Frequency and duration may be modified in response to peripheral CD3 targets. Treatment of aplastic anemia: 15 - 20mg/kg daily for 5-8 days Dilute into 250-1000ml NS and infuse over at least 4 hours (Use concentrations of 4mg/ml or less)

Immunosuppressant

Anti-thymocyte globulinRabbit (RATG, Lymphocyte Immune Globulin, Thymoglobulin)

5 mg/ml 5ml Vial

NO

Treatment acute rejection Dose: 0.75mg/kg - 1.5 mg/kg daily x 7-14 days Infuse initial infusion over 6 hours, subsequent infusions over 4-6 hr Dose will be rounded to the nearest vial size!

Immunosuppressant

Units with cardiac monitoring and nurses who have demonstrated competency to manage this Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

Parenteral Medication Administration Guidelines


SVP or LVP Standard Diluent Precautions / Comments Max/Min Concentrations Recommended Infusion Time Intermittent Infusion Metro: Preprinted order set use is Prevention/treatment transplant mandatory per P&T!! rejection: 5-15 mg/kg daily for 7-14 days. Frequency and duration may be recommended prior to first Test dose modified in response to peripheral of each cycle. dose CD3 Pre-medication with a corticosteroid, Treatment of aplastic anemia: antihistamine and acetaminophen is 15 - 20mg/kg daily for 5-8 days recommended See preprinted physician orders for Dilute into 250-1000ml NS and infuse parameters. monitoring over at least 4 hours Moderate fever and chills common (Use concentrations of 4mg/ml or less) during infusion Do not mix with other solutions Stability / Storage Limitations / Restrictions

Use NS Do NOT use D5W due to possible precipitate formation Do not shake or transport via tube system

Use 0.22 micron filter

Central line administration preferred.


Treatment acute rejection Monitor BP, HR, respiratory status Dose: 0.75mg/kg - 1.5 mg/kg daily x continuously. Stop infusion and call PHYSICIAN stat if SBP < 70, HR > Infuse initial infusion over 6 hours, dyspnea, bronchospasm, 150 or subsequent infusions over 4-6 hr cyanosis or febrile reaction occurs. Anaphylaxis may occur. Dose will be rounded to the nearest Diphenhydramine 50mg IV and epinephrine 1 mg (1 ml) required at bedside. Pre-medication with a corticosteroid, antihistamine and acetaminophen 1 hr prior to infusion is recommended Moderate fever and chills common during infusion decreasing rate may relieve *See footnote Do not shake or transport via tube system Do not mix with other solutions Central line administration preferred. Addition of hydrocortisone and heparin recommended if infusing peripherally. Use 0.22micron in-line filter Metro: preprinted order set available

have demonstrated competency to manage this medication.

Limitations /

*See footnote

Section II
Medication Generic - (Brand) Argatroban *HIGH ALERT MEDICATION* How Supplied 100 mg/ml 2.5 ml Vial IV Push Conc / Rate NO

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time System Standard Conc: 250mg/ 250ml NS (1mg/ml) Treatment of Heparin Induced Thrombocytopenia: Start at 0.5-2 mcg/kg/min and titrate to achieve PTT of 50-80 seconds Argatroban preprinted order set available.

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Anticoagulant

Aripiprazole

(Abilify) Anti-psychotic
Ascorbic Acid Antioxidant/ Nutritional supplement

7.5mg/mL vial

NO IM ONLY

NO

500 mg/ml 50ml Vial

Yes, admin slowly over 3-5 minutes

Daily dose may be added to 1000ml volume D5W or NS and administered slowly over a few hours

Atracurium (Tracrium)

10 mg/ml 5 and 10 ml vials

Also, may be given IM or SQ Yes, administer bolus doses rapidly

Initial bolus: 0.4-0.5 mg/Kg, Usual dose range: 2 20 mcg/kg/min

*HIGH ALERT MEDICATION*

System Standard Conc: 500 mg/50 ml NS (total vol=100 ml) (5 mg/ml)

Neuromuscular blocker

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time Monitor for signs of bleeding Check PTT 3 hrs after dose changes Argatroban increases INR measurement falsely. Dose reduction recommended for pt w/ hepatic insufficiency, azole antifungals, amiodarone or hypotension. Monitor platelets, Hgb/Hct daily Platelets < 150,000 notify physician Do not administer IV or SQ. For deep IM injection only. Do not mix with other medications/solutions. Check with pharmacist for compatibility information.

May cause dizziness/faintness w/ rapid injection

Stability of opened vial questionable after 24 hours due to oxidation Protect from light

Metro Nursing Clinical Policy Neuromuscular blockade (MN-13)

Metro: preprinted order set available for ICU neuromuscular blockade al vol=100 ml) (5 mg/ml)

Refrigerate vials Controlled airway Vials stable x 14 days at room ventilation and temp but then must be required; discarded Critical Care only: ED, ICU, Surgery May give undiluted if necessary Sedation

strated competency to manage this medication.

must be administered prior to and during paralytic use! 8

Section II
Medication Generic - (Brand) Atropine Anticholinergic (Antimuscarinic) How Supplied IV Push Conc / Rate

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time NO

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AzaTHIOprine (Imuran) Immunosuppressant Azithromycin (Zithromax) Antibiotic/ Macrolide Aztreonam (Azactam) Antibiotic/ Monobactam B1 Vitamin

0.1 mg/ ml Yes, 10 ml give rapidly IV for vial/syringe bradycardia 1 mg/ml 1 ml Slow IV injection vial/syringe may cause paroxysmal bradycardia 100 mg Yes, Vial 100 mg over 5 min (20 mg/min). 500 mg Vial 1 Gm Vial, Premix: 1 Gm/50 ml NO

Dilute in 50 - 100 ml NS Infuse over 30 min Infuse over 60 minutes (2mg/ml Max Conc) < 1Gm/50 ml D5W over 30 min > 1 Gm /100 ml D5W over 60 min

NO

See Thiamine
B6 - Vitamin

See Pyridoxine
BASILIXimab (Simulect) Immunosuppressant BeneFIX See Factor 9 Recombinant Betamethasone (Celestone) Corticosteroid 20mg Vial NO Intermittent Infusion Typical dosing: 40 mg in 100 ml NS given over 30 minutes pre-op 1 hr prior to incision. Then 20mg in 50ml NS infuse over 30 minutes given POD#4.

5mL vial (6mg/mL)

IM
Do NOT administer IV

only

NO

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nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time Bradycardia: 0.5 mg - may repeat every 3-5 min up to max dose of 0.04 mg/kg PEA/asystole: 1 mg every 3-5 min up to max of 3 mg total Pre-procedure medication: Usual dose is 0.4 0.6 mg IV/IM/SC x 1, 30-60 min prior to procedure Avoid extravasation

Follow dose with 20 ml NS * See footnote flush elevate extremity x 1020 seconds Pre-procedure use does not require Extremely large doses may be cardiac needed for treatment of monitoring. organophosphate (nerve agent) poisoning. Protect from light

Dose reduction recommended for CrCl < 30 ml/min

Do not mix with other solutions Do not shake solution or transport via tube system 0mg in 50ml NS infuse over

Stable only 4 hours at room temp 0

Betamethasone 12 mg IM q24h x 2 doses recommended for all pregnancies 24-34 weeks at risk for pre-term delivery.

strated competency to manage this medication.

Section II
Medication Generic - (Brand) Bivalrudin (Angiomax) *HIGH ALERT MEDICATION* Anticoagulant How Supplied 250mg Vial IV Push Conc / Rate Yes, May bolus 0.75 1mg/kg depending on indication

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Continuous infusion, weight-based and indication specific. Dose Range for Therapeutic Anticoagulation: 0.1 0.25 mg/kg/hr and titrated to target PTT. Dose for PCI: Refer to orderset. Standard conc: 250 mg/50 ml NS (5 mg/ml) Doses may be diluted in 25-50 ml D5W/NS and infused at max rate of 0.5 mg/min Continuous infusion System Standard Conc: 10 mg/ 60 ml NS (total volume 100 ml) (0.1 mg/ml) IV Push or IM preferred

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Bumetanide (Bumex)

2, 4, & 10 ml Vial (0.25 mg / ml)

Yes, Give at max rate of 0.5 mg/min

Diuretic

Buprenorphine (Buprenex) Narcotic Analgesic

0.3 mg / ml Amp

Yes, Give 0.3 mg dose over 2 min.

Butorphanol (Stadol) Narcotic Analgesic Caffeine/Sodium Benzoate Stimulant/analgesic Calcitriol (Calcijex) Vitamin D Analog

1, 2 & 10 ml Vial (2 mg / ml)

Yes, Admin at 0.5 mg/min

IV Push or IM preferred

250 mg/ml 2 ml vial

NO

1 mcg/ml 1 ml ampule

Yes, 2-3 mcg/min

Postdural Puncture Headache: 500 mg x 1 2 doses (Common dilution: 500 mg/L. Given over 60-90 min) Not advised

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time Dose reduction recommended for CRCL < 30 ml/min Range for Therapeutic Bleeding risk PTT & ACT affected by bivalrudin Pre-printed order sets for Cath Lab PCI & Therapeutic Anticoagulation in Heparin Allergic Patients High doses have been associated with muscle stiffness and tenderness Monitor BP/ fluid status

m Standard Conc: 10 mg/ 60 ml al volume 100 ml) (0.1 mg/ml) Monitor for excess sedation, cardiovascular and respiratory status ** NOTE: Reversal may require higher doses of naloxone** **After naloxone administration monitor for risk of recurrent respiratory depression. ** May cause withdrawal in opioid / methadone dependent patients. Monitor for excess sedation, cardiovascular and respiratory status

May cause withdrawal in opioid / methadone dependent patients. Monitor BP/HR may cause hypertension/tachycardia mon dilution: 500 mg/L. Given Used in the treatment of hypocalcemia/secondary hyperparathyroidism in chronic renal failure patients.

Do NOT refrigerate

* See footnote

Discard ampule after use. Stable 8 hr in syringe

strated competency to manage this medication.

10

Section II
Medication Generic - (Brand) Calcium Chloride *HIGH ALERT MEDICATION* How Supplied 100 mg/ml (10%) 10 ml vial/syringe IV Push Conc / Rate Yes, Admin at 50mg/min (0.5 ml/min) in emergency only For treatment of severe hyperkalemia, may give 5-10 ml over 2-5 min. If on digoxin do NOT give calcium IV push! Yes, Administer into large vein at max rate of 1.5 ml/min Infusion preferred! Electrolyte If on digoxin do NOT give calcium IV push!

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Intermittent infusion: 1 Gm in 25 ml D5W infuse over 30min 0 2 Gm in 50 ml D5W infuse over 60min

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Electrolyte

Calcium Gluconate *HIGH ALERT MEDICATION*

100 mg/ml (10%) 10 ml Vial

Intermittent infusion: 1 Gm in 25 ml D5W infuse over 15 min 2 Gm in 50 ml D5W infuse over 30 min

Caspofungin (Cancidas) Antifungal

50 mg, 70 mg vials

NO

CeFAZolin (Kefzol/Ancef) Antibiotic/ Cephalosporin

1 & 2 Gm Vials 1 Gm/ 50 ml D5W premix

May be given IV push over 3-5 min (i.e. hemodialysis patients) Routine use of IV push is not recommended May be given IM

Indicated for treatment of invasive candidiasis & aspergillosis Intermittent Infusion: Infuse over 60 min 50 mg/250 ml NS or 70 mg/250 ml NS Up to 1 Gm /50 ml D5W -- Infuse over 15 min > 1 Gm/100 ml D5W -- Infuse over 30 min

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

r LVP Standard Diluent

mmended Infusion Time IV push should be used ONLY in emergency situations! Avoid extravasation- See PPO 5046 for general guidelines / management. Never give IM or SQ-Irritant and may cause tissue necrosis Adverse reactions that may occur with too rapid administration: bradycardia, sense of oppression, burning sensation at IV site Avoid extravasation Incompatible with phosphate* See footnote solutions

n 25 ml D5W infuse over

n 50 ml D5W infuse over

Central line administration preferred


1 ml = 27.3 mg = 1.36 mEq elemental calcium Calcium chloride is 3 times as potent as calcium gluconate.

n 25 ml D5W infuse over 15

Central line administration preferred.


SQ/IM administration not recommended Avoid Extravasation see PPO 5046 for general guidelines / management Adverse reactions: same as calcium chloride Phlebitis common.

Incompatible with phosphate solutions 1 ml = 9.3 mg = 0.46 mEq elemental calcium

n 50 ml D5W infuse over 30

ed for treatment of invasive

NS only!!
Do not mix with any other medications/solutions! Contraindicated in patients with prior hypersensitivity to cephalosporins Check allergies

1 Gm /50 ml D5W -- Infuse over

m/100 ml D5W -- Infuse over 30

Dose reduction recommended with CrCl < 30 ml/min.

strated competency to manage this medication.

11

Limitations /

* See footnote

Section II
Medication Generic - (Brand) Cefepime (Maxipime) Antibiotic/ Cephalosporin Cefotaxime (Claforan) Antibiotic/ Cephalosporin 1 & 2 Gm Vials May be given IV push over 3-5 min (i.e. hemodialysis patients) Routine use of IV push is not recommended May be given IV push over 3-5 min (i.e. hemodialysis patients) Max rate: 1 gm/3 min Routine use of IV push is not recommended May be given IV push over 3-5 min (i.e. hemodialysis patients) Routine use of IV push is not recommended NO How Supplied 0.5, 1 & 2 Gm Vials IV Push Conc / Rate Not advised

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Infuse doses over 30 minutes

This section can be copied and kept for reference at bedside.

Up to 1 Gm/50 ml NS Infuse over 15 minutes > 1 Gm/100ml NS Infuse over 30 minutes

Cefoxitin (Mefoxin) Antibiotic/ Cephalosporin

1g & 2 g vials, Premix: 1g /50 ml

Infuse over 15-30 minutes

Ceftazidime (Fortaz)

1 g & 2g vials

Infuse over 30 minutes

Antibiotic/ Cephalosporin CefTRIAXone (Rocephin) Antibiotic/ Cephalosporin Cefuroxime (Zinacef) Antibiotic/ Cephalosporin 250 mg, 500 mg, 1 & 2 g vials. Premix: 1g/50 ml 0.75 & 1.5 Gm Vials, Premix: 1.5 g/50 ml

Infuse over 30 minutes

May be given IV push over 3-5 min (i.e. hemodialysis patients) Max rate: 750 mg/3 min Routine use of IV push is not recommended

Infuse over 15 to30 minutes

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time Contraindicated in patients with prior hypersensitivity to cephalosporins Check allergies Dose reduction recommended with CrCl < 60 ml/min Contraindicated in patients with prior hypersensitivity to cephalosporins Check allergies

Dose reduction recommended with CrCl < 50ml/min.


Contraindicated in patients with prior hypersensitivity to cephalosporins Check allergies

Dose reduction recommended with CrCl < 50 ml/min.

Contraindicated in patients with prior hypersensitivity to cephalosporins Check allergies

Dose reduction recommended with CrCl < 50 ml/min.


Contraindicated in patients with prior hypersensitivity to cephalosporins Check allergies

Do NOT co-administer with IV calcium products.


Contraindicated in patients with prior hypersensitivity to cephalosporins Check allergies

Dose reduction recommended with CrCl < 20 ml/min.

strated competency to manage this medication.

12

Section II
Medication Generic - (Brand) Chloramphenicol Antibiotic How Supplied 1 g vial IV Push Conc / Rate Yes over at least 1min (100mg/mL)

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Usual dose is 50 mg/kg/day divided Q 6 hr - infuse over 15-30 min Maximum concentration for infusion: <20mg/mL May be diluted with D5W or NS and given as infusion over 10 min

This section can be copied and kept for reference at bedside.

Chlorothiazide (Diuril)

500 mg vial

Thiazide Diuretic

Yes, Slowly give 500mg over 10 minutes (50mg/min) Usual dose: 0.25 1 gm daily to twice daily Yes, Dilute with NS to conc of 1 mg/ml (Dilute 1 ml with 24 ml NS) Max rate of admin is 1 mg/min May be given IM

ChlorproMAZINE (Thorazine)

25mg/ml vial (1 & 2mLs)

Up to 50 mg/25 ml D5W infused slowly over at a rate of 0.5-1mg/min

Antipsychotic

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions Do NOT administer IM.

mmended Infusion Time May cause idiosyncratic aplastic anemia. May cause dose related bone marrow suppression. Monitor CBC. May cause hypokalemia, hyponatremia, and hypochloremic alkalosis monitor electrolytes Monitor BP, fluid status

Stable in NS and D5W

Do NOT give SC/IM avoid extravasation!! Reconstitute each 500mg vial with 18 ml sterile water use immediately

Slow rate of administration if extrapyramidal symptoms develop (dystonia, motor restlessness, Parkinson-like symptoms) may be treated with diphenhydramine 50mg IV per physician order May cause hypotension (esp. in elderly or given IV) BP, HR monitoring recommended w/ IV administration

Avoid mixing with alkaline solutions

SQ administration not recommended.

strated competency to manage this medication.

13

Section II
Medication Generic - (Brand) Cidofovir (Vistide) Antiviral How Supplied 375 mg Vial (75 mg/ml) IV Push Conc / Rate NO

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time 5 mg/Kg dose in 100ml NS. Infuse over 60 minutes Administered every 1-2 weeks. Maximum recommended concentration is 5 mg/ml

This section can be copied and kept for reference at bedside.

To minimize potential nephrotoxicity, probenecid and IV saline pre-hydration must be ordered with each infusion

Ciprofloxacin (Cipro)

Antibiotic/ Fluoroquinolone

CISatracurium (Nimbex)
*HIGH ALERT MEDICATION*

Premix: 400 mg/200 ml D5W (2 mg/ml) 20ml Vial (10 mg/ml) 2 mg/ml 5, 10 ml vials 10 mg/ml 20 ml vial

NO

400mg/200ml in D5W premixed Infuse over 60 minutes Max conc: 2 mg/ml

Yes, Admin bolus doses rapidly 0.2 mg/Kg

Continuous infusion: Usual dose range: 0.5 10 mcg/kg/min System Standard Conc: 200 mg/ 80 ml NS (total volume 100 ml) (2 mg/ml)

Neuromuscularblocker

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time Give 2gm probenecid 3 hours prior to to prepare dose using Pharmacy cidofovir dose and 1gm at 2 and 8 chemotherapy precautions hours after infusion Administer and discard using Infuse 1 L NS over 1-2 hourschemotherapy immediately before each cidofovir precautions. dose. Patients who can tolerate additional fluid should receive a second liter either at the start of the cidofovir infusion or immediately afterwards and infused over a 1-3 hour period Monitor renal function.

Contraindicated with CrCl<55mL/min or SrCr>1.5 Dose reduction recommended with CrCl < 50 ml/min.

Metro Nursing Clinical Policy on Refrigerate vials Neuromuscular Blockade (MN-13) Vials stable x 21 days at room temp but then must be discarded. m Standard Conc: 200 mg/ 80 ml al volume 100 ml) (2 mg/ml) May give undiluted if necessary

Controlled airway and ventilation required; Critical Care only: ED, ICU, Surgery

strated competency to manage this medication.

Sedation must be administered prior to and during paralytic use! 14

Section II
Medication Generic - (Brand) Clindamycin (Cleocin) Antibiotic How Supplied 6 ml Vials (150mg/ml) Premix: 300 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml 15 mg/ml, 30 mg/ml and 60 mg/ml syringes IV Push Conc / Rate NO

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Doses < 300 mg, infuse over 15 min Doses > 300 mg, infuse over 30 min

This section can be copied and kept for reference at bedside.

Max conc: 18mg/ml

Codeine

NO IM or SQ administration preferred

NO

Narcotic Analgesic

Colistimethate/colistin (Coly-Mycin M) Antibiotic

150 mg vial Yes, Slowly over 3-5 min

Intermittent infusion preferred: Dilute in 50 ml NS and infuse over 30 minutes

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time Contraindicated for patients with allergy to lincomycin (Lincocin)

IV administration may lead to severe hypotension. Do not give IV.

Monitor respiratory status may cause respiratory depression or distress Reverse effects with naloxone (Narcan) Monitor renal function may cause/exacerbate acute renal failure Dose reductions recommended with decrease renal function Monitor neuro status may cause neurotoxicity.

strated competency to manage this medication.

15

Section II
Medication Generic - (Brand) Conivaptan (Vaprisol) How Supplied 20 mg/ 4 ml ampule IV Push Conc / Rate NO

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Loading dose: 20 mg in 100 ml D5W infused over 30 minutes Continuous infusion over 24hours: 10mg/250mL D5W or 20 mg in 250 ml D5W 40 mg in 250 ml D5W Total duration of therapy not to exceed 4 days.

This section can be copied and kept for reference at bedside.

Vasopressin antagonist

Cosyntropin (Cortrosyn) Diagnostic Adrenal function

250 mcg Vial

Yes, 250 mcg/ml in NS over 2 min. (125 mcg/min)

Intermittent infusion: 250mcg/250 ml NS or D5W Infuse over 6 hours

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

r LVP Standard Diluent

mmended Infusion Time Indicated for the treatment of euvolemic symptomatic hyponatremia Dilute with D5W only! Overly rapid correction of sodium via separate line. Infuse (>8-12 mEq/L/24 hrs) may result in serious sequelae. Protect ampule from light. VASCULAR IRRITANT! Peripheral infusion site must be rotated every 24 hours infuse via large vein only! Serial serum sodium levels (recommended every 6 hours) required with physician call back parameters (minimum: Call physician if increase in serum sodium > 8 mEq in 24 hours >0.5mEq/L/hr). If or levels and call back parameters not included in original order, physician must be contacted for order per Metro P&T 250 mcg = 25mg corticotropin (ACTH) Infusion stable 12 hr

g dose: 20 mg in 100 ml D5W

uous infusion over 24hours: or

uration of therapy not to exceed

ttent infusion: 250mcg/250 ml

strated competency to manage this medication.

16

Section II
This section can be copied and kept for reference at bedside.
Medication Generic - (Brand) CycloSPORINE (Sandimmune) How Supplied 50 mg Amp (10 mg/ ml) IV Push Conc / Rate NO

Parenteral Medication Adminis


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Intermittent Infusion typically q 12 hr For doses < 12.5 mg, give over 60 min For doses > 12.5 mg, Infuse over minimum of 2 hours. Concentration must be 0.4 2 mg/ml

Immunosuppressant Cytomegalovirus (CMV) Immune Globulin (CytoGam)

1 Gm and 2.5 Gm Vials

NO

Continuous infusion Change bag daily at 1800 System Standard Conc: 250 mg/250 ml NS System Concentrated Conc: 250 mg/ 100 ml NS Usual Dose: 50-150mg/kg doses up to 400mg/kg for severe CMV infection Initial Dose: 15 mg/kg/hr - May increase to 30 mg/kg/hr if no adverse reactions after 30 min. - May increase to max rate of 60 mg/kg/hr if no adverse reactions after a subsequent 30 min. Do NOT exceed 60 mg/Kg/hr!! Max volume = 75 ml/hr Subsequent Doses: 15 mg/kg/hr for 15 min, then 30 mg/kg/hr for 15 min, then 60 mg/kg/hr if no adverse reactions Do NOT exceed 60 mg/kg/hr!! Max volume = 75 ml/hr.

CMVIG/ IgG antibody to CMV Daclizumab (Zenapax) 5mg/ml 5ml vial NO

Intermittent Infusion 1mg/Kg diluted into 50ml NS. Infuse over 15 minutes via peripheral or central line.

Immunosuppressant

Units with cardiac monitoring and nurses who have demonstrated competency to manage this Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

Parenteral Medication Administration Guidelines


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Intermittent Infusion typically q 12 For doses < 12.5 mg, give over 60 min For doses > 12.5 mg, Infuse over minimum of 2 hours. Concentration must be 0.4 2 mg/ml Precautions / Comments Stability / Storage

Due to the risk of anaphylaxis, patients receiving cyclosporine IV should be under continuous observation for admin set provided by Use at least the first 30 minutes following pharmacy (Non PVC tubing) start of the infusion and at frequent intervals during. Epinephrine should ampule from light Protect st be available (UBC) during 1 30 minutes IV dose = 0.33 x PO dose

Continuous infusion Change bag System Standard Conc: 250 mg/250 ml (Excel) (1 mg/ml) System Concentrated Conc: 250 mg/ (Excel) Usual Dose: 50-150mg/kg doses up to 400mg/kg for severe CMV infection Initial Dose: 15 mg/kg/hr - May increase to 30 mg/kg/hr if no adverse reactions after 30 min. - May increase to max rate of 60 mg/kg/hr if no adverse reactions after a subsequent 30 min. Do NOT exceed 60 mg/Kg/hr!! Max volume = 75 ml/hr Subsequent Doses: 15 mg/kg/hr for 15 min, then 30 mg/kg/hr for 15 min, then 60 mg/kg/hr if no adverse reactions Do NOT exceed 60 mg/kg/hr!! Max volume = 75 ml/hr.

(2.5 mg/ml)

Monitor cyclosporine trough concentrations. Monitor vital signs before, midwayinfusion within 6 hr of Start through, after infusion and before anyvial. Complete entering change in rate. infusion within 12 hr of entering vial. Potential adverse reactions: flushing, chills, muscle cramps, back pain, Administer through IV line fever, nausea, vomiting, wheezing, and 15micron filter. with in-line decreased blood pressure. Administer using a separate IV If patient develops minor side effects be \"piggybacked\" line. May (nausea, back pain, flushing), slow the into pre-existing line of NS or IV rate or temporarily interrupt the however CMV-IG should D5W, infusion. not be diluted more than 50%. If anaphylaxis or hypotension occurs, discontinue the infusion and contact the physician. 5 doses define standard course of 24 hours after dilution Stable therapy. First dose before transplant refrigerated and subsequent doses 14 days apart hr at room temp Stable 4 Do not mix with other solutions Do not shake solution or transport via tube system

Intermittent Infusion 1mg/Kg diluted into 50ml NS. Infuse over 15 minutes via peripheral or central line.

have demonstrated competency to manage this medication. elines - Revised Final 07-2009

Limitations / Restrictions

acy (Non PVC tubing)

ster using a separate IV May be \"piggybacked\" e-existing line of NS or however CMV-IG should diluted more than 50%.

24 hours after dilution

mix with other solutions

17

Section II
Medication Generic - (Brand) Dalfopristin / Quinupristin (Synercid) How Supplied 500mg Vial

Parenteral Medication Administration G


IV Push SVP or LVP Standard Diluent Conc / Rate Max/Min Concentrations Recommended Infusion Time NO Usual dose: 7.5mg/Kg (in 250 ml D5W) q 8-12 hr Infuse over 60 minutes

This section can be copied and kept for reference at bedside.

Antibiotic Dalteparin (Fragmin) Anticoagulant/ Low molecular weight heparin Pre-filled syringes, multi-dose vial NO

Concentrated solution in 100ml D5W pain, burning, itch further dilute central line administration only

Not advised.

Dantrolene (Dantrium)
Malignant Hyperthermia Hotline (for contact with MH expert) 1-800-MH-HYPER (1-800-644-9737)

20 mg Vial

SC administration only! Do NOT give IM Yes,

Malignant Hyperthermia (MH):

Rapid admin Prevention : 2.5 mg/Kg infused over advised for 60 minutes 1.25 hours prior to treatment of anesthesia. Malignant Hyperthermia Treatment (MH) given rapidly. Repeat dose every 5
min until symptoms subside or 10mg/Kg (recommended upper limit) has been reached (subsequent doses may be given as needed!) Then continue 1 mg/kg every 4-8 hr for 24 48 hrs.

Muscle relaxant DAPTOmycin (Cubicin)

250 mg, 500 mg vial

NO

Dilute in 100 ml NS Infuse over 30 min Usual dose: 4-6 mg/kg IV q24h Max concentration: 20mg/mL

Antibiotic

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

r LVP Standard Diluent

Kg (in 250 ml D5W) q 8-12 hr

Flush IV lines before and after admin with D5W only, avoid NS

Do not shake

Infusion site reactions common n in 100ml D5W pain, burning, itch further dilute doses (500-750mL) if these occur Arthralgia & myalgia common SC administration only! Do NOT give IM

See syringe for manufacturer expiration date

nant Hyperthermia (MH):


: 2.5 mg/Kg infused over

Staff in areas where stored to periodically check expiration date on vials to insure use of in date medication when needed.

: 2.5 mg/Kg infusion Avoid extravasation central line administration preferred. Do not withhold care if no central access available!! Monitor urine output

Dilute with STERILE WATER only 60 ml per 20 mg = 0.33 mg/ml. Prepare immediately before administration. Six-hour stability at room temp.

** Powder in vials may take several minutes to dissolve **

ontinue 1 mg/kg every 4-8 hr

Call Code 4 and/or pharmacy for assistance if treating MH


Dose reduction recommended for CrCl < 30: q48 hr May cause elevated CPK levels monitor for myopathy ** Not compatible in dextrose !! Stable 12 hr at room temp/48 hrs refrigerated Check with pharmacist for compatibilities

dose: 4-6 mg/kg IV q24h

oncentration: 20mg/mL

strated competency to manage this medication.

18

Section II
Medication Generic - (Brand) Darbepoetin alfa (Arenesp) Red cell stimulating hormone How Supplied Vials: 25 mcg/ml 40 mcg/ml 60 mcg/ml 100 mcg/ml 200 mcg/ml IV Push Conc / Rate Yes, SQ or IV bolus

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Not necessary

This section can be copied and kept for reference at bedside.

Deferoxamine (Desferal)

500 mg, 2000 mg Vials

NO IM administration preferred May be given SC

Dose varies with indication. Acute Iron Overload: IM route preferred unless pt in shock. Recommended dose is 1000 mg then 500 mg Q 4 hr x 2 doses. Subsequent doses may follow. Max dose = 6 Gm/24 hr. If given via IV infusion: Max rate = 15 mg/kg/hr for first 1000 mg then max rate of 125 mg/hr for subsequent doses.

Iron Chelating agent Desmopressin (DDAVP) Hormone Vasopressin analog

1 ml Vial (4 mcg/ml)

Dexamethasone (Decadron) Corticosteroid

4 mg/ml 1, 5, 25 and 30 ml vials 24 mg/ml 5 ml vial

Yes, Usual Dose: 0.3 mcg/kg in 50 ml NS for treatment of given over 15-30 min diabetes insipidus To stabilize hemostasis before surgery may give 2-4 administer 30min prior to procedure. mcg/d Give at max Children < 10 kg, -dilute in 10 ml NS rate of 4 mcg/min May be given subcutaneously Yes, IV Push preferred. IV Push preferred all doses over 2 Doses may be diluted in NS or D5W min. IM injection used in OB 6 mg IM q12h x 4 doses recommended as alternative to betamethasone for all pregnancies 24-34 weeks at risk for pre-term delivery.

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time Monitor for injection site pain, headache, arthralgias, and myalgias. Hemoglobin <10 in chemotherapyinduced anemia. Hemoglobin < 12 mg/dl in chronic kidney disease / other indications.

Do not shake product or transport via tube system

Flushing, hypotension and shock have been reported with IV administration slow infusion rate if this occurs. Chronic Iron Overload: 500 1000 mg daily IM 2000 mg IV with each unit of transfused blood administered separately. Max rate = 15 mg/kg/hr. Max dose = 6 Gm/24 hr no matter amount of blood transfused. Dilute in 500 ml or 1000 ml NS Monitor HR and BP during infusion and for 60 minutes after. bilize hemostasis before surgery When used to manage diabetes insipidus, monitoring of urine output every 8 hr recommended May cause hyponatremia monitor Na+ Doses > 10 mg may be ordered as intermittent IV infusion Pt may complain about perianal itching/tingling with doses > 10 mg 4 doses recommended as tive to betamethasone for all ncies 24-34 weeks at risk for

Restricted to Outpatient administration Refrigerate only. Check hemoglobin prior to administration. Notify physician prn for dose reduction or interruption based on most recent hemoglobin. Reconstitute with STERILE WATER then dilute with NS

Protect from light Do NOT Refrigerate

Refrigerate vial Stable 12 hr after diluted refrigerated

strated competency to manage this medication.

19

Section II
Medication Generic - (Brand) Dexmedetomidine (Precedex) Sedative How Supplied 200mcg/2m l vial IV Push Conc / Rate

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time After bolus, start at 0.4 mcg/kg/ Increase 0.1 mcg/kg/hr q 10 minutes up to maximum of 0.7 mcg/kg/ hr Usual dose range: 0.2 0.7 mcg/kg/ System Standard Conc: 200 mcg/50 ml NS (4 mcg/ml) Usual duration of infusion < 24 hr

This section can be copied and kept for reference at bedside.

Loading dose of 1mcg/kg given over 10 min

Dextran-40 Solution Plasma volume expander

10% in NS or D5W 500ml

Not advised

For plasma volume expansion Total dose during first 24 hours should not exceed 20ml/Kg (2 Gm/kg) Therapy should not exceed 5 days Reversal of severe hypoglycemia when oral intervention is not possible.

Dextrose 50% Solution

Hypertonic glucose

25 Gm / 50ml (500mg/ml) vial/syringe

Yes, Administer at rate not > 5Gm/min or 10ml/min

DIAZepam (Valium) Sedative/ Benzodiazepine

5 mg/ml 1 & 2 ml syringes, Vials

Yes, Admin at rate not > 5mg/min IM absorption erratic.

Do not dilute precipitation

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions Critical Care only

r LVP Standard Diluent

mmended Infusion Time hr se 0.1 mcg/kg/hr q 10 minutes up

hr

m Standard Conc: 200 mcg/50 ml

Hypotension in 30% of patients; Bradycardia may occur Monitor cardiovascular and respiratory status Potentiates effects of opioids & benzodiazepines. Anticipate dose reductions / titrate to effect. Agent lacks amnestic properties. Preprinted order set available Observe for signs of allergic reaction. Do not administered unless solution is clear Check bag for expiration Highly osmotic solution! Irritating to peripheral veins - via central give line whenever possible Avoid Extravasation see PPO 5046 for general guidelines / management Preprinted inpatient hypoglycemic order set available. Avoid extravasation. Thrombophlebitis is common give preferably into Y-site of running IV. Monitor cardiovascular and respiratory status. May cause respiratory depression. Reverse with flumazenil (Romazicon)

duration of infusion < 24 hr

sma volume expansion ose during first 24 hours should ceed 20ml/Kg (2 Gm/kg)

py should not exceed 5 days sal of severe hypoglycemia oral intervention is not possible.

Incompatible with many medications and solutions contact pharmacist

strated competency to manage this medication.

20

Limitations /

Critical Care only

Section II
Medication Generic - (Brand) Diazoxide (Hyperstat) Diuretic Digoxin (Lanoxin) Cardiovascular/ Positive inotrope 0.25mg/ml 2ml Amp Yes, undiluted & give slowly over at least 3-5min or diluted to 10ml NS & give slowly over at least 3-5 min Yes, 10mg/ml -ONLY if Cardiac Arrest is imminent. Give over 5 min. How Supplied 300mg/20m l (15mg/ml) IV Push Conc / Rate Yes, Give rapidly over 30 seconds

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Dilution not advised If infused give 15-30 mg/min

This section can be copied and kept for reference at bedside.

Slow IV Push recommended

Digoxin Immune FAB (Digibind, Digifab) Digoxin antidote

38 mg Vial (Digibind) 40 mg vial (Digifab)

Diluted in 50ml NS. Infuse over 30 min. Metro: ** Dose rounded to nearest vial per P&T ** Preprinted order set available

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time Avoid extravasation Use Central Line if available. ed give 15-30 mg/min Do not administer IM/SQ Check apical pulse prior administration. If heart rate is less than 50 BPM or otherwise specified HOLD dose & call physician to

Do not mix with other IV * See footnote medications. Protect from light. Darkened solutions should not be used.

Monitor vital signs & ECG Monitor for hypokalemia obtain serial potassium levels especially during the hours after administration Digoxin serum level assay not accurate after digibind. Pharmacy will notify lab pt has received digoxin immune FAB

*See footnote Use reconstituted product immediately. Use administration set provided by pharmacy which includes 0.22 micron filter

strated competency to manage this medication.

21

Limitations /

* See footnote

*See footnote

Section II
Medication Generic - (Brand) Dihydroergotamine (DHE) Antimigraine/ Ergot alkaloid How Supplied 1mg/ml 1ml amp IV Push Conc / Rate Yes, Give at max rate of 1mg/min May be given IM

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Continuous infusion may be used in status migranosis

This section can be copied and kept for reference at bedside.

Contact physician immediately stop infusion if continuous infus if chest pain develops. Contac physician immediately if numbness/tingling of extremeti nausea/vomiting unrelieved by antiemetics, leg cramping, or coldness of skin develops. Contraindicated in patients with hypersensitivity to ergot alkaloi ergotamine. Contraindicated if ergotamine o triptan used within past 24 hour Contraindicated with multiple d classes (i.e. MAO-Inhibitors, po inhibitors of 3A4).

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time Total IV dose should not exceed 2 mg/day (3mg/day if continuous infusion). Total weekly dose should not exceed 6 mg (20mg over 7 days if continuous infusion). Monitor HR and BP. Contact physician immediately (and stop infusion if continuous infusion) if chest pain develops. Contact physician immediately if numbness/tingling of extremeties, nausea/vomiting unrelieved by antiemetics, leg cramping, or coldness of skin develops. Contraindicated in patients with hypersensitivity to ergot alkaloids ergotamine. Contraindicated if ergotamine or triptan used within past 24 hours Contraindicated with multiple drug classes (i.e. MAO-Inhibitors, potent inhibitors of 3A4). Contraindicated in patients with ischemic heart disease.

Protect ampule from light

strated competency to manage this medication.

22

Section II
Medication Generic - (Brand) How Supplied 5mg/ml 5 & 10 ml Vial, 5 ml syringe IV Push Conc / Rate Yes, Initial dose: 0.25 mg/kg over 2 min Second dose: 0.35 mg/kg over 2 min, give after 20 minutes if response to first dose is poor Or 15-20mg IV push over 5-10min; may repeat in 30min x 1 Administration through running IV line preferred

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time System Standard Conc: 125 mg/100 ml NS (total vol=125 ml) (1 mg/ml) System Concentrated Conc: 125 mg/25 ml NS (total volume 50 ml) (2.5 mg/ml) Usual dose range: 5 15 mg/hr Onset: 2-5 min Half-life: 3-9 hr

This section can be copied and kept for reference at bedside.

Diltiazem (Cardizem)

Cardiovascular/ Calcium Channel Blocker

DiphenhydrAMINE (Benadryl) Antihistamine

DOBUTamine (Dobutrex)

50mg/ml 1 & 10 ml Vial 1 ml Syringe 500mg in 250ml D5W Premix Bag

Yes, Max rate of 25 mg/min May be given IM NO

Usual dose: 25-50mg IV Push Preferred

System Standard Conc: 500 mg/250 ml D5W Premix (2 mg/ml) System Concentrated conc: 500 mg/60 ml NS (total volume 100 ml) (5 mg/ml)

Cardiovascular/ Positive inotrope 12.5 mg/ml 20ml Vial

Usual dose range: 2 20 mcg/Kg/min Onset: 2 min Half-life: 2 min

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time Increase infusion rate by 5 mg/hr every 60 min if HR remains > 100 beats per minute. Maximum Dose: 20mg/hr ml NS (total volume 50 ml) D/C infusion if HR < 60 BPM, 2 or 3 degree AV block, junctional rd rhythm or asystole.

Solution (vial) should be stored * See footnote in refrigerator.

nd

Check with pharmacist regarding compatibility information.

Monitoring: Continuous EKG Monitoring BP - Following initiation or dose titration: Continuous BP q15min x 3, then q4h x or 4 then q4-6hrs while stable.
Pre-printed order set available for new onset A.Fib Max single dose: 100 mg Max dose/day: 400 mg

Dilute to concentration of 25 mg/ml with NS or D5W

Continuous EKG Monitoring Monitoring: Following initiation or dose titration - Continuous BP q15min x 3, then q4-6hrs while stable. Monitor for ectopy, increase in heart rate Irritant to tissues administer via large vein. Central line preferred. Avoid Extravasation see PPO 5046 for general guidelines / management. May have slight pink coloration which is normal or

* See footnote if titrating dose. Not necessary for maintenance infusion for CHF

strated competency to manage this medication.

23

Limitations /

* See footnote

* See footnote if titrating dose. Not necessary for

infusion for CHF

Section II
This section can be copied and kept for reference at bedside.
Medication Generic - (Brand) Dolansetron (Anzemet) Antiemetic/ 5HT3 receptor antagonist How Supplied 20 mg/ml 0.625 ml ampule, 20mg/ml 5 & 25ml vials 400 mg/250 ml D5W Premix Bag 40 mg/ml5 & 10 ml Vial 80 mg/ml 5 ml vial IV Push Conc / Rate Yes, Give 12.5 25 mg over 30 seconds

Parenteral Medication Adminis


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Dose may be diluted in 50 ml D5W/NS. Infuse over 15 min

DOPamine (Inotrope)
Vasopressor

NO

System Standard Conc: 400 mg/250 ml D5W Premix (1.6 mg/ml) System Concentrated Conc: 800 mg/250 ml NS (3.2 mg/ml) Usual dose range is 2 20 mcg/kg/min Onset: 5 min Duration of action: 10 min Half-life: 2 min

Doxercalcifero (Hectorol) Vitamin D Analog Doxycycline (Vibramycin) Antibiotic/ Tetracycline

2 mcg/ml 1 ml and 2 ml ampules 100 & 200 mg Vial

Yes, 2-4 mcg/min

Not advised

NO

Max conc = 1 mg/ml Infuse over minimum of 60 min

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

Parenteral Medication Administration Guidelines


SVP or LVP Standard Diluent Precautions / Comments Stability / Storage Max/Min Concentrations Recommended Infusion Time Dose may be diluted in 50 ml May cause QT prolongation Do not mix with other D5W/NS. Infuse over 15 min medications. Limitations / Restrictions Non-formulary. Autosubstitution to ondansetron

System Standard Conc: 400Monitoring - Following initiation mg/250 ml D5W Premix (1.6 mg/ml) or dose titration: Continuous BP pharmacist for Consult System Concentrated Conc: 800 or q15min x 3, then q4x 4 then compatibility information. mg/250 ml NS (3.2 mg/ml) q4-6h while stable. Avoid infiltration Phentolamine (Regitine) Usual dose range is 2 20 mcg/kg/min intradermally Dopaminergic effects: /subcutaneously < 5 mcg/kg/min recommended for Beta effects (Improved Cardiac management Output): 2-10 mcg/Kg/min Alpha > Beta Effects Avoid Extravasation see (Vasoconstriction): PPO 5046 for general > 10-15 mcg/Kg/min guidelines / management

* See footnote Central Line Administration Required unless order obtained from physician for peripheral administration!! Midline access is not = to a central line.

Duration of action: 10 min Half-life: 2 min

Central Line Administration Required unless order obtained from physician for peripheral administration!! Check IV site every 30 minutes while dopamine is administered peripherally.
Used in the treatment of secondary from light Protect hyperparathyroidism in chronic renal failure patients. Discard ampule after use. Max conc = 1 mg/ml Avoid extravasation -Irritant to Stable 12 hr at room temp or tissues 72 hr refrigerated Infuse over minimum of 60 min Protect from light

Check IV site every 30 minutes while dopamine is administered peripherally.

strated competency to manage this medication.

24

Limitations /

Non-formulary. Autosubstitution to ondansetron

* See footnote

Administration Required unless order obtained from physician for peripheral administration!! Midline access is

Check IV site minutes while dopamine is administered peripherally.

Section II
Medication Generic - (Brand) Droperidol (Inapsine) Antiemetic May be given IM How Supplied 2.5mg/ml 2, 5ml vials IV Push Conc / Rate Yes, Give at max rate of 2.5 mg/min

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time May dilute dose to 50 ml in D5W or NS - administer over 15 min

This section can be copied and kept for reference at bedside.

Drotrecogin alfa (recombinant activated Protein C, Xigris)

5mg & 20mg vials

NO

Adjunctive treatment for severe sepsis

Weight based dose rounding 24mcg/kg/ hr Standard Bags: (100mcg/ml) 5mg/50ml NS 10mg/100 ml NS 15mg/150 ml NS 20mg/200 ml NS 25mg/250 ml NS

Edetate CALCIUM Disodium (CaEDTA) (Calcium Disodium Versentate) *HIGH ALERT MEDICATION* Heavy metal chelator

200mg/mL 5 ml vial

NO

Dose varies with indication. Usual Dose: 500-1000 mg/m /day in 500 ml D5W/NS Infuse over at least 4 hrs 8-12 hrs recommended

IM route preferred for patients with cerebral edema or lead encephalopathy

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

r LVP Standard Diluent

mmended Infusion Time lute dose to 50 ml in D5W or dminister over 15 min

Use with caution if cardiovascular disease is present. May cause QT prolongation. Avoid in patients with prolonged baseline QT. Normalization of potassium and magnesium levels recommended. Monitor for hypotension & tachycardia monitor BP and HR. Monitor for extrapyramidal effects Contraindicated in Parkinsons patients. Significant risk of bleeding Stable for 12 hr only. Mandatory pre-printed physician order set to review indications, warnings and contraindications! Patient must meet criteria to be eligible to receive drug! Hold infusion x 2 hr prior to invasive procedure (procedure with inherent risk of bleeding). Restart infusion immediately for uncomplicated less invasive procedure. Hold for at least 12 hr after major invasive procedure/surgery. If given IM, add lidocaine 1% 1 ml 2 for each 1 ml of CaEDTA Establish urine flow with adequate IV fluids prior to administration Dose reduction recommended for SCr > 2 mg/dl ***Caution: Do not confuse with Edetate Disodium (Endrate) verify product & indication. Confusion of products has resulted in fatalities.***

t based dose rounding X 96 hours ard Bags: (100mcg/ml)

Critical Care

Telemetry monitoring advised

Dose: 500-1000 mg/m /day in

over at least 4 hrs 8-12 hrs

strated competency to manage this medication.

25

Section II
Medication Generic - (Brand) Enalaprilat (Vasotec IV) Antihypertensive/ ACE inhibitor Enoxaparin (Lovenox) Anticoagulant/ Low molecular weight heparin How Supplied 1.25 mg/ml 1 & 2 ml vial IV Push Conc / Rate Yes, Max rate: 1.25 mg/ml over 5 min

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time May dilute in 50 ml NS give over 10 min

This section can be copied and kept for reference at bedside.

Pre-filled syringes and multidose vial

Yes, 30 mg for cardiac indications over 1 minute x 1 only Usually given SQ

NO

EPHEDrine Vasopressor

50 mg/ml, 1 ml amp.

Yes, Slowly at max rate of 25 mg/min

NO Usual Intermittent IV dose: 5-25mg repeated q5-10min as needed May be given IM/SQ System Standard Conc: 4 mg/250 ml NS (16 mcg/ml) System Concentration Conc: 8 mg/100 ml NS (80 mcg/ml) Usual dose range: 1 10 mcg/min

EPINEPHrine
Vasopressor

1 mg/ml, 1 ml amp & 30 ml vial

Yes, Usual dose is 1 mg Give rapidly & follow with NS flush May be given IM/SQ in treatment of hypersensitivity reactions/ anaphylaxis/asthm a

Dose may be given via ET tube if no IV access at 2 to 2 x IV dose, diluted in 10 ml NS

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time Peak Blood Pressure reduction may be anticipated within 15 minutes of administration Monitor BP

Contraindicated in patients receiving heparin (increased bleeding risk) and heparin-induced thrombocytopenia. Preprinted order set available for DVT/PE Treatment Doses rounded to nearest 10mg

See syringe for manufacturer expiration date. Do not expel air bubble in syringe before administering dose. Dose reduction recommended for patients with CrCl < 30 ml/min Critical Care

Monitor HR, BP every15 min and urine output every 1-2 h ed q5-10min as needed Consider continuous ECG Recommended max of 150 mg/24 hr Monitor BP, HR and rhythm every 15 min. Preferred measurement of BP per arterial line if possible. m Concentration Conc: 8 Monitor urine output every 1-2 hr Avoid Extravasation see PPO 5046 for general guidelines / management Phentolamine intradermally /subcutaneously recommended for management Central line administration advised!

Critical Care Do not use discolored solutions Protect from light

Incompatible with many meds and solutions contact pharmacist

**Check label as not all epinephrine can be given IV **

strated competency to manage this medication.

26

Section II
Medication Generic - (Brand) Epoprostenol (Flolan) Vasodilator/ Prostaglandin How Supplied 0.5 and 1.5 mg vials for reconstituti on IV Push Conc / Rate NO

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Continuous infusion required. Upon admission, patients are converted from home infusion device to hospital IV infusion pump. Usual starting dose is 2 nanogram/ Kg/min. Titrate per physician orders. **Metro: preprinted order set available use advised! **

This section can be copied and kept for reference at bedside.

Eptifibatide (Integrelin) Antiplatelet IIb/IIIa

Ertapenem (INVanz) Antibiotic/ Carbapenem Erythromycin Antibiotic/ Macrolide

2mg/ml 10ml Vial for loading doses & 0.75mg/ml 100ml Vial for maintenanc e infusions 1 Gm vial

Yes, 180mcg/Kg bolus over 1-2 minutes. ACS x 1 PTCA - Repeat bolus in 10 min

Continuous Infusion Acute Coronary Syndrome/PTCA: 0.5 - 2 mcg/Kg/min (max 15 mg/hr) System Standard Conc: 75 mg/ 100 ml Premix (0.75 mg/ml)

NO May be given IM

1 Gm/50 ml NS Infuse over 30 min

500 & 1000mg vials

NO

Up to 500 mg in 100ml NS 501 - 1000 mg in 250ml NS (Max Concentration = 500mg/100ml NS) Infuse all doses over 60 min.

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions * See footnote

mmended Infusion Time Avoid interruptions of infusion ( half-life = 6 min) loss of disease control could lead to death pital IV infusion pump. Monitor for hypotension, flushing, headache, N/V, anxiety & chest pain. . Titrate per physician orders. A Flolan Dosing Weight is established and used throughout the patients therapy. The Flolan Dosing Weight should be used when calculating infusion rate. Pre-printed order set available for ACS/PTCA mcg/Kg/min (max 15 mg/hr) Monitor for bleeding. Recommended to decrease infusion rate to 1 mcg/kg/min for pt with SrCr 2 4 mg/dl

Dilute only with manufacturer-supplied diluent!

Protect from light ** Metro: Bag must be changed every 8 hr even if bag not empty **

Compatible with heparin Use vented set to administer undiluted eptifibatide

Caution with PCN allergy check allergies

Stable 6 hr at room temp or 24 Restricted hr refrigerated use within 4indications per hr after removal from refrigerator P&T Stable in NS only! Stable 24 hours refrigerated, 8 hours at room temp after dilution

Dose reduction recommended for CrCl < 30 ml/min Slow infusion rate if vein irritation occurs Concentration = 500mg/100ml Avoid Extravasation see PPO 5046 for general guidelines / management

strated competency to manage this medication.

27

Section II
Medication Generic - (Brand) Erythropoietin, epoetin alfa (Epogen, Procrit) How Supplied 2,3,4,10, 20 & 40 thousand units/ml vials 20000 unit/2 ml Multi-dose vial IV Push Conc / Rate Yes Give SQ or IV Push over 30-60 seconds

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Dilution not advised Chronic Renal Failure: Recommended initial dose: 50 100 units/kg SQ or IV 3 times per week. SQ may be administered weekly

This section can be copied and kept for reference at bedside.

Red cell stimulating hormone

Esmolol (Brevibloc)
Cardiovascular/ BetaBlocker

10mg/ml 10 ml Vial Premix: 2.5 Gm/250 ml

Yes, IV push loading doses (500 mcg/Kg) over 60 seconds

System Standard Conc: 2.5 gm/250 ml NS Premix (10mg/ml) System Concentrated Conc: 2000mg/100 ml NS (20 mg/ml) Central Line Only Dose range: 50 200 mcg/Kg/min (Titrate in 50 mcg/Kg/min increments every 5 min to desired response) Onset: immediate Peak response: 5 min Duration: 10-30 min Half-life: 9 min System Standard Concentration: 80 mg/ 250 ml NS (0.32 mg/ml) Usual dose for GI bleeds: 80 mg (in 100ml NS) bolus over 30 minutes then 8 mg/hr continuous infusion

Esomeprazole (Nexium IV)

20 mg, 40 mg vials

Yes, 5 ml over 3 minutes Reconstitute vial with 5 ml NS

Proton Pump Inhibitor

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions Check hemoglobin prior to administration. See EMAR for Hold parameters. Notify physician prn for dose reduction or interruption based on most recent hemoglobin. Telemetry / Critical Care Advised * See footnote

mmended Infusion Time Monitor for hypertension, fever, headache, arthralgias & nausea c Renal Failure: Recommended Goal: Hemoglobin <10 in chemotherapyinduced anemia. Hemoglobin < 12 mg/dl in chronic kidney disease / other indications.

Do not shake product or transport via tube system Refrigerate vials

Monitor BP and Heart Rate/Rhythm every 5-15 min during dose initiation and titration. m Concentrated Conc: g/100 ml NS (20 mg/ml) Doses > 200 mcg/kg/min do not have increased benefits e in 50 mcg/Kg/min increments nd Contraindications: 2 /3 degree AV block, sinus bradycardia, cardiogenic shock

rd

Continuous infusion duration should not exceed 72 hr

Reconstitute vial with 5 ml NS. Use within 1 hour of reconstitution. Diluted solution stable for 12 hours (NS) Do not administer with other medications/fluids check with pharmacist for compatibility information

dose for GI bleeds: 80 mg (in NS) bolus over 30 minutes then r continuous infusion

strated competency to manage this medication.

28

Limitations /

hemoglobin prior to administration. See EMAR for Hold parameters. Notify physician

interruption based on most recent hemoglobin.

* See footnote

Section II
Medication Generic - (Brand) Estrogens, Conjugated (Premarin IV) Hormone - Estrogen How Supplied 25 mg vial IV Push Conc / Rate Yes, 5mg/min at 5 mg/ml conc.

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Not advised Usual intermittent dose -slow IV push Abnormal uterine bleeding: 25mg Uremic bleeding: 0.6mg/kg/day

This section can be copied and kept for reference at bedside.

Ethacrynic acid (Edecrin) Diuretic Etidronate Disodium (Didronel IV) Inhibitor of bone metabolism

50 mg Vial

Yes, Give over > 3 min Max of 100 mg per single dose NO

Slow IV push recommended

50mg/ml 6ml Amp (300mg)

Usual dose for treatment of hypercalcemia: 7.5 mg/Kg/day x 3 days Diluted in 250ml NS infuse over minimum of 2 hours (3 mg/ml max concentration)

Etomidate **HIGH ALERT MEDICATION**

2 mg/ml 10 ml vial, 20 ml vial/syringe

Yes 0.3 mg/Kg over 15-60 seconds

NO

Sedative

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time Slow rate of administration if body/facial flushing occurs ntermittent dose -slow IV push Used for treatment of abnormal uterine bleeding. Also used for uremic bleeding. ** Verify dose to be given. Discard vial after drawing up correct dose. ** Slow rate of administration if vein irritation occurs and/or consider different IV site No IM/SC administration! Temporary taste loss not uncommon following IV etididronate Adequate hydration recommended prior to administration Too rapid administration may lead to renal insufficiency Dose decrease recommended in pt with SrCr 2.5 4.9 mg/dl. Not recommended in pt with SrCr > 5 mg/dl Monitor BP, HR and RR Pain at injection site common Transient myoclonic movement/seizure-like activity may occur. Nausea/vomiting common Etomidate has no analgesic properties.

Refrigerate before and following reconstitution. Do not use darkened solution. Do not shake vial!! Do not mix with other solutions/medications

Critical Care

strated competency to manage this medication.

29

Section II
This section can be copied and kept for reference at bedside.
Medication Generic - (Brand) Exenatide (Byetta) **HIGH ALERT MEDICATION** Incretin mimetic/adjunctive therapy for diabetes Factor VIIa Recombinant (Novoseven) Blood factor How Supplied Pre-filled syringes IV Push Conc / Rate No SC administration ONLY

Parenteral Medication Adminis


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time NO

1mg, 2mg & 5 mg vials

Yes, min

give over 2-5 Usual single dose: 15 - 100 mcg/kg Continuous infusion may be done do NOT further dilute Factor VIIa or run into running IV line

Reconstitute with diluent provided to final concentration of 1mg/mL

Factor 8 Human ( Humate-P

Vials size varies based on pooled plasma source

Yes Slow IV push at rate not to exceed 4mL/min

VonWillebrand Disease (VWD) Usual Dose: 40-80 IU/kg** initial dose; for major bleeds or invasive procedures, continue with repeated doses of 25-30 IU/kg Q8- 12h Infusions: Use diluent & filter provided with product. No additional (inline) filtration or dilution recommended. Hemophilia A Usual Dose: 50 IU/kg initial dose; for major bleeds or invasive procedures, continue with 25 IU/kg repeated Q12h

Factor 8 Recombinant (Helixate)

250, 500, 1000,2000 units/vial

Yes - Slow IV push over 5-10min

Factor 9 Recombinant (BeneFIX)

250, 500, 1000,2000 units/vial

Yes - Slow IV push over 5min

Hemophilia B Usual Dose: 95 IU/kg to achieve a target Factor 9 level of 70-80%; Repeat doses at 12-24hr intervals at a dose of 40 IU/kg

Units with cardiac monitoring and nurses who have demonstrated competency to manage this

Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

Parenteral Medication Administration Guidelines


SVP or LVP Standard Diluent Precautions / Comments Max/Min Concentrations Recommended Infusion Time Not for use in Type 1 diabetics or for the treatment of diabetic ketoacidosis Common side effect: nausea Stability / Storage Limitations / Restrictions

Non-formulary. Refrigerate Patient may use Do NOT mix with insulin!! own supply if deemed necessary & appropriate by prescriber.

Usual single dose: 15 - 100 mcg/kg Coagulation profile, PTT/PT Vial stable at room temperature Monitor Hgb/Hct, platelets for 2 years prior to Continuous infusion may be done do reconstitution. NOT further dilute Factor VIIa or run May increase risk of thrombotic into running IV line events Once reconstituted administer within 3 hours. Non-emergent indications: Confirm final coagulation results and Factor VIIa order with prescriber prior to administration. VonWillebrand Disease (VWD) ***Caution: Product is labeled in Use diluent provided Factor 8 units and von Willebrand Usual Dose: 40-80 IU/kg** initial factor:Ristocetin Cofactor (VWF:RCo) Stability: 24hrs room temp or dose; for major bleeds or invasive procedures, continue with repeatedIn VWD disease dose is based on refrigerated units. VWF:RCo content. *** doses of 25-30 IU/kg Q8- 12h Product is NOT typically used for Infusions: Use diluent & filterHemophilia A provided with product. No additional (inline) filtration or dilution **Use higher dose for patients with type 2 and 3 VWD recommended. Hemophilia A Usual Dose: Multiple50 products in Hemophilia A Use diluent provided IU/kg initial dose; for major bleeds or this may be used as a available Stability: 3hrs invasive procedures, continue with 25 product for urgent universal Stability may be extended on a IU/kg repeated Q12h reconstitution. Life-threatening case-by-case basis bleeds/ Major surgery: Target Factor concentrations / dilutions must 8 levels of 80-100%. be considered. Hemophilia B Usual Dose: Decreased Factor 9 recovery requires 95 Use diluent provided IU/kg to achieve a target Factor 9 level higher relative dose to achieve target Stability: 3hrs of 70-80%; Repeat doses atFactor 9 levels. 12-24hr Stability may be extended on a intervals at a dose of 40 IU/kg Dose = Target level x Pt wt x 1.3 case-by-case basis. concentrations / dilutions must be considered.

have demonstrated competency to manage this medication.

30

elines - Revised Final 07-2009

Limitations /

Non-formulary. Patient may use deemed necessary & appropriate by

Section II
Medication Generic - (Brand) How Supplied Vial sizes vary based on pooled plasma source IV Push Conc / Rate Yes 5-10mL/min Do not exceed 10mL/min rates in excess of this may result in vasomotor reactions. Yes, 10mg/ml give over 1 min Dilute with 5-10 ml NS or D5W

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Warfarin reversal in life threatening bleeds Usual dose: 50 units/kg or 4,000 units Doses may be repeated based on INR response (total dose range 25100units/kg) IV Push preferred Intermittent infusion: 20mg/50 ml NS infuse over 15 min

This section can be copied and kept for reference at bedside.

Factor 9 Complex Human (Profilnine SD)

Famotidine
(Pepcid) H2 Receptor Antagonist

10mg/ml 2 & 4 ml Vial

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time Product FDA approved for Hemophilia B. Contains Factors II, VII, IX, X In life-threatening bleeds: coadministration with vitamin K & additional source of factor 7 (FFP or NovoSeven) is recommended. Dose reduction recommended for pt with CrCl < 50 ml/min 50 ml NS infuse over 15 min

Use diluent provided (SW)

strated competency to manage this medication.

31

Section II
Medication Generic - (Brand) How Supplied IV Push Conc / Rate

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time

This section can be copied and kept for reference at bedside.

Fat Emulsion (Intralipid, Liposyn) Local anesthetic toxicity

500 ml bag

20.% Yes 1.5 mL/kg IV bolus over 1 minute (for suspected local anesthetic toxicity); consider repeating bolus up to two more times q 3-5 minutes if adequate circulation not restored

Start continuous intravenous drip at 0.25 mL/kg/min upon initiation of first IV bolus.

Increase infusion to 0.5 mL/kg/min throughout fat emu if adequate circulation not restored/BP declines after second bolus. Continue lipid infusion until hemodynamic stability restored recovery may take longer than an hour. A total cumulative dose of 8 mL/kg has been recommended.
Continuous infusion recommended; Begin at 0.05 mcg/Kg/min and titrate up by 0.05mcg/Kg/min every 15 minutes to desired effect Usual dose range: 0.05 1.6 mcg/Kg/min System Standard Conc: 10 mg/ 250 ml NS (40 mcg/ml) System Concentrated Conc: 10 mg/100 ml NS (100 mcg/ml)

Fenoldopam (Corlopam)
Antihypertensive

10 mg/ml 5ml Amp

NO

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time

Do not use propofol as lipid source.

Stored at room temperature. None Recommended storage in L&D, OR, and other areas with high volume use of local anesthetics.

ACLS must be continued se infusion to 0.5 mL/kg/min throughout fat emulsion administration! ed/BP declines after second Achieving continuous infusion rate > 1200 ml/hr (0.25 mL/kg/hr for a 80 kg patient) may require infusion via multiple lines. ery may take longer than an ** No standard dosing has been established contact Poison Control and/or see www.lipidrescue.org for further information **

Monitor BP (preferably via arterial line if possible), HR q 15 min during dose initiation and titration. Half-life = 5 min. Effects quickly dose range: 0.05 1.6 reversed with D/C of drip Doses > 1.5 mcg/kg/min rarely required Tachycardia may occur if drug started at rate > 0.1 mcg/kg/min or if titrated too quickly

Critical Care Incompatible with many medications/solutions contact pharmacist

strated competency to manage this medication.

32

Section II
This section can be copied and kept for reference at bedside.
Medication Generic - (Brand) FentaNYL (Sublimaze) **HIGH ALERT MEDICATION** Narcotic analgesic How Supplied 50 mcg/ml various sized amps/vials IV Push Conc / Rate Yes, Slowly over 3 5 minutes

Parenteral Medication Adminis


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Continuous infusion or PCA recommended Bolus dose range: 1030 mcg Continuous IV dose range: 20 60 mcg System Standard Conc for continuous infusion: 1250 mcg/250 ml NS Premix (5 mcg/ml) System Concentrated Conc: 1000 mcg/ 100 ml NS (10 mcg/ml) Intermittent infusion: 62.5 mg 125 mg/100 ml NS Infuse over 30 - 60 min Doses greater than 125 mg require dilution Max dose per Metro P&T = 250 mg

Ferrous Gluconate Complex (Ferrlecit) Iron Supplement

Amps 62.5mg/5 ml

Yes, Max 12.5mg/min Give 62.5 mg over 5 min Give 125 mg over 10 min IV push not recommended for doses > 125 mg

Filgrastim (Neupogen) White cell stimulating hormone Fluconazole (Diflucan) Antifungal

300mcg/ 1 ml 480mcg/1.6 ml Vials Premix 200mg/200 ml & 400mg/400 ml

SQ preferred

Intermittent infusion: 300mcg/18ml D5W 480mcg/25ml D5W Infuse over 30 min Intermittent administration recommended Infuse at max rate of 200 mg/hour

NO

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

Parenteral Medication Administration Guidelines


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Continuous infusion or PCA recommended Bolus dose range: 1030 mcg Continuous IV dose range: 20 60 /hr System Standard Conc for continuous infusion: 1250 mcg/250 ml NS Premix System Concentrated Conc: 1000 mcg/ 100 ml NS (10 mcg/ml) Intermittent infusion: 62.5 mg 125 mg/100 ml NS Infuse over 30 - 60 min Doses greater than 125 mg require Metro: For Outpatient Admin Doses < 250 mg monitor patient for 1 hour post-infusion per P&T Doses of 250 mg monitor patient for 2 hours post- infusion per P&T May cause hypotension or hypertension, chest, back or groin pain. Symptoms typically resolve 1-2 hours after infusion completed. Intermittent infusion: 300mcg/18ml D5W 480mcg/25ml D5W Infuse over 30 min Intermittent administration recommended Infuse at max rate of 200 mg/hour Refrigerate Do not shake product or transport via tube system Dilute in D5W only!! Dose reduction recommended for CrCl < 50 ml/min Precautions / Comments Stability / Storage

Monitor BP, RR

Too rapid administration may cause respiratory depression/distress


Reverse effect with naloxone

(Narcan)
Optimal dose determined by patient response

Test dose not necessary Monitor vital signs (BP) including orthostatic BP Unopened ampules good until expiration dating from manufacturer

Max dose per Metro P&T = 250 mg

strated competency to manage this medication.

Limitations / Restrictions

Metro: If PCA ordered, mandatory order set must be used

ned ampules good until Metro: max dose per infusion is 250 mg per P&T

33

Section II
Medication Generic - (Brand) How Supplied 5 & 10 ml vial 0.1 mg/ml IV Push Conc / Rate Yes, Give rapidly over 15-30 seconds preferably into large vein with running IV

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time

This section can be copied and kept for reference at bedside.

Flumazenil (Romazicon)
**HIGH ALERT MEDICATION** **Reversal Agent**

To reverse benzodiazepine (BZD) effects intermittent


administration recommended: 0.2 mg IV repeated every 60 seconds to a total of 3mg/hr. Titrate to response using small IV doses. Most patients respond to total doses between 1 & 3 mg

Benzodiazepine (BZD) antagonist


Folic Acid Vitamin/Nutritional supplement 5mg/ml 10 ml vial Yes, Give over 1-2 min May be given SQ, IM 1Gm/ml 1.5 ml vials NO

Common component in banana bag. May dilute with NS or D5W and administered continuously via peripheral or central line Intermittent Infusion 15mg/Kg load then 10mg/Kg every 12h x 4 then 15mg/Kg every 12h until serum ethylene glycol <20mg/dL and / or resolution of acidosis Dilute with 100ml NS and infuse over 30 minutes

Fomepizole (Antizol) Ethylene glycol and Methanol Antidote

Fondaparinux (Arixtra) Anticoagulant

Pre-filled syringes

NO Administer SC only! Do NOT give IM!

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time Irritant, avoid infiltration intermittent Elim half-life = 60 min much less Monitor BP, HR, RR than typical BZDs and re-sedation following initial response is possible & not unusual May unmask BZD controlled seizures or precipitate BZD withdrawal in chronic BZD users. Dilution recommended for > 5 mg

Protect from light

Methanol Poisoning: Cofactor in elimination - Higher dose folic acid (50-75mg) administered q4h x 24h or until resolution of acidosis. Solution may solidify at temps < 77F, run under warm water or hold in hands to liquify ethylene glycol <20mg/dL and / Monitor for signs of allergic reaction shortness of breath, rash, hives, and pruritus. Do not wait for results of methanol/ethylene glycol blood levels to initiate therapy. Administer SC only! Do NOT give IM! Contraindicated per manufacturer in patients w/ CrCl < 30 ml/min or body weight < 50 kg

Monitor ethylene glycol or methanol serum Dialyzable dosing interval concentrations should be increased to every 4 hr during hemodialysis

See syringe for manufacturer expiration date. Do not expel air bubble in syringe before administering dose.

strated competency to manage this medication.

34

Section II
Medication Generic - (Brand) Foscarnet (Foscavir) Antiviral How Supplied 24 mg/ml in 250 and 500ml bottles

Parenteral Medication Administration Guidelines


IV Push SVP or LVP Standard Diluent Conc / Rate Max/Min Concentrations Recommended Infusion Time NO Peripheral Line: Must be diluted to 12 mg/ml with NS or D5W Central line: May be given undiluted. Induction Dose: rate not to exceed 1 mg/kg/min (minimum of 1 hour) every 8 hours. Maintenance Dose: 90-120 mg/kg/day given over 2 hours Yes May dilute to 50 or 100ml with NS. Dilute to total of Infuse not rate not faster than 10mL (or max 150mg/min concentration of 25mg/mL) andRate reduction to 75 mg/min administer at max recommended in elderly and pt with rate of 150mg coronary heart disease. /min May be given IM undiluted

This section can be copied and kept for reference at bedside.

Fosphenytoin (Cerebyx) Anticonvulsant

50 mg/ml 2 & 10 ml vial

Furosemide (Lasix) Diuretic

10mg/ml vial and pre-filled syringes

Yes, Dilute doses 100-200 mg with Doses < 100 mg NS/D5W and administered no faster may be giventhan 10 mg/min. Doses > 200 mg must IV push at max rate be diluted and given no faster than 4 of mg/min. 10 mg/min Continuous infusion usual dose range 1 20 mg/hr. Higher doses may be been used in kidney failure. System Standard Conc: 250mg/250ml NS (1 mg/ml) System Concentrated Conc: 250 mg/100ml NS (total volume 125 ml) (2 mg/ml)

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

dication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

Adequate hydration is recommended prior to and during treatment to minimize renal toxicity Dose reduction recommended in pt with decrease CrCl May cause thrombophlebitis Prodrug of phenytoin - preferred product for IV/ IM administration. Automatically substituted for phenytoin. Monitor BP/HR/RR during infusion and 30-60 min after. Flushed feeling with IV admin. not uncommon - pruritus commonly near groin area Do not use furosemide solutions that are yellow in color IV furosemide = 50% PO dose Monitor urine output/fluid status, BP

May administer Do NOT refrigerate undilutedundiluted through solution central line only! Incompatible with many medications and solutions, check with pharmacist

Refrigerate vials

Do NOT refrigerate - may crystallize with refrigeration

strated competency to manage this medication.

35

Section II
Medication Generic - (Brand) Ganciclovir (Cytovene) Antiviral How Supplied 500mg vial Reconstitut e with 10ml NS to 50mg/ml 10mg/ml and 40mg/ml in 2 & 20ml vials & premixed minibags in various doses 1 mg Vial

Parenteral Medication Administration Guidelines


IV Push SVP or LVP Standard Diluent Precautions / Comments Conc / Rate Max/Min Concentrations Recommended Infusion Time NO Dilute dose to Irritant D5W. 100ml - monitor for phlebitis and Infuse over 60infusion site pain minutes Final concentrationsreduction recommended for Cr Dose greater than 10mg/ml not recommended for peripheral administration Cl < 70 ml/min NO Dilute all doses in 50 -100ml NS or and Aminoglycoside dosing D5w monitoring service available from ** May be given Infuse over 30-60 minutes pharmacy upon physician order. undiluted intrathecally Extended interval (7mg/kg) dosing Monitor renal function. using preservative over 60min infuse free product **

This section can be copied and kept for reference at bedside.

Gentamicin Antibiotic/ Aminoglycoside

Glucagon Hormone, Antihypoglycemic Agent Granisetron (Kytril) Antiemetic/ 5HT3 receptor antagonist Haloperidol (Haldol) Antipsychotic/ Anxiolytic

1mg/ml Vial

Yes, Continuous infusions precipitate when mixed with Forms may be used in 1mg/ml over 60 treatment of calcium channel blocker or chloride solutions, NO seconds beta-blocker overdoses. Usual dose with sterile water or D5W May also be given range: 1 5 mg/hr hypoglycemia: usually awakens Tx of IM or SQ pt within 15 min Yes, IV Push preferred. dose 30 minutes prior to Give Undiluted overIntermittent infusion: Dilute into prevent 30 chemotherapy 25 to 50 seconds ml NS or D5Wnausea/vomiting. - Infuse over 5 minutes Yes, Prefer intermittent IV Push Use with caution if cardiovascular Give at max rate disease is present. of 5mg/min Titrate dose to desired effect Use only the May cause QT prolongation. lactate salt of Normalization of potassium and haloperidol for IV magnesium levels recommended. Push NOT Monitor for hypotension and/or Decanoate salt symptoms of angina. Also, monitor for extrapyramidal effects May be given IM Will NOT cause respiratory depression. Contraindicated in Parkinsons patients

5mg/ml Vial and syringe

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

dication Administration Guidelines


Stability / Storage Limitations / Restrictions

- monitor for phlebitis and Use chemotherapy precautions for preparation, administration & disposal

eduction recommended for Cr

glycoside dosing and ring service available from acy upon physician order.

precipitate when mixed with NS Dilute

Use immediately after reconstitution.

ypoglycemia: usually awakens

ose 30 minutes prior to

th caution if cardiovascular

Recommended to flush line with at least 2 ml NS before and after med admin

ause QT prolongation. lization of potassium and sium levels recommended. r for hypotension and/or oms of angina. Also, monitor for

indicated in Parkinsons patients

strated competency to manage this medication.

36

Section II
Medication Generic - (Brand) How Supplied IV Push Conc / Rate

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time

This section can be copied and kept for reference at bedside.

Helixate
See Factor 8 Recombinant

Heparin
**HIGH ALERT MEDICATION**

Various concentrations vials and syringes

Yes, All doses administered over 10-20 seconds, undiluted

Continuous infusion Standard conc: 25000 units/500 ml D5W premix (50 units/ml)

Recheck concentration of vial/bag before administering dose!

Premix bag: 50 units/ml 500 ml 6% solution in 500ml NS Do NOT give IM!!

See specific weight-based dosing protocols (PPOs) for Cardiac Indications and for Treatment of DVT/PE Intravenous infusion preferred. Not to exceed 1500ml/24 hours

Anticoagulant
Hetastarch (Hespan) Plasma expander NO

Humate-P

See Factor 8 - Human


HydrALAZINE (Apresoline) Antihypertensive 20mg/ml Vials Yes, Give undiluted at a max rate of 5mg/min Intermittent or continuous infusion NOT recommended Exception OB uses continuous infusions 50 mg/500 ml D5W or fluid per physician

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time

Monitor platelets may cause thrombocytopenia with any dose (even catheter flushing!) Monitor for signs of bleeding

Per manufacturer on vials and Recheck syringes concentration Multi-dose vials expire 28 days vial/bag of

before
from initial opening.

Monitor PTT 6 hours after any dose change or per orders ols (PPOs) for Cardiac ions and for Treatment of

administering dose!

Rare allergic reactions to hetastarch have been reported. Monitor for hypersensitivity reactions. Monitor for plasma volume overload (dyspnea, fluid in lungs, rapid increase in blood pressure) Dose reduction recommended for severe renal insufficiency

Monitor for reflex tachycardia after each dose. Monitor BP every 5 min until stabile. Maximal reduction in blood pressure seen 15-80 min after doses given Metro: See MWH-19-MAT: Womens Health Policy & Procedures Hydralazine: Continuous Infusion

Incompatible with many medications and solutions, check with pharmacist

strated competency to manage this medication.

37

Section II
Medication Generic - (Brand) Hydrocortisone Corticosteroid How Supplied Various vial sizes 100mg/2ml 250mg/2ml 500mg/4ml 1000mg/8m l 2, 4, or 10mg/ml Vials and syringes IV Push Conc / Rate Yes, Give undiluted doses over 30 60 seconds

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time IV Push preferred. May dilute dose to 50ml in NS or D5W and give over several minutes.

This section can be copied and kept for reference at bedside.

HYDROmorphone (Dilaudid) *HIGH ALERT MEDICATION* Narcotic analgesic

Yes, Give dose slowly over 2-3 min or max rate of 0.5 mg/min

Continuous infusion: System Standard Conc: 50 mg/250 ml NS (0.2 mg/ml) System Concentrated Conc: 50 mg/ 100 ml NS (0.5 mg/ml)

Hydroxocobalamin (Cyanokit)

1 kit = 2 x 2.5 gm vials

NO

2.5 gm reconstituted with 100 ml NS infuse over 7.5 minutes repeat x 1 for total of 5 gm

Antidote cyanide poisoning

HydrOXYzine (Vistaril) Antihistamine

25 & 50mg/ml Vials & Syringes

NO IM preferred

2nd 5 gm dose may be given over 15 minutes to 2 hours depending on severity/clinical response for total dose of 10 gm Intermittent Infusion Not advised; IM Preferred!

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time Local infusion related adverse effects are rare.

Check vial/syringe for expiration date.

Intrathecal administration: use preservative-free ONLY!! Reverse effects with naloxone (Narcan) Monitor RR, HR, BP Give lower doses to elderly, debilitated or patients on additional CNS depressants Hydromorphone 1.5 mg IV = Morphine 10 mg IV Urine and skin will turn red May cause hypertension Very Potent opioid analgesic. High doses (IV >1mg or IM > 2mg) in opioid nave patientsMetro: If PCA must be verified with ordered, prescriber. mandatory PCA order set must be IV dose = 1/3 to 1/5 PO dose. used

Stable 6 hours

Allergic reactions including anaphylaxis, pruritus, rash may occur s to 2 hours depending on y/clinical response for total dose May interfere with various lab tests Hypotension, phlebitis and hemolysis reported following IV administration Intra-arterial administration has resulted in endarteritis, thrombosis and gangrene. Do NOT give IV-push

strated competency to manage this medication.

38

Section II
Medication Generic - (Brand) Ibutilide (Corvert) Anti-arrhythmic How Supplied 1mg/10ml IV Push Conc / Rate NO

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time 1 mg/50 ml NS Infused over 10 min Stop infusion when afib/aflutter terminated If < 60kg dose @ 0.01mg/Kg May repeat same dose 10 minutes after completion of initial dose if rhythm not converted Preprinted order set available

This section can be copied and kept for reference at bedside.

Imipenem/Cilastatin (Primaxin) Antibiotic/ Carbapenem

500mg Vial

NO

< 500mg/100ml NS Infuse over 0 30 minutes


> 500 mg/250ml NS. Infuse over 60 minutes

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions * See footnote bedside monitor & defibrillator recommended

mmended Infusion Time Continuous cardiac monitoring recommended for at least 4 hours after completion of infusion. Monitor for increased QT interval prolongation and ventricular arrhythmia potential Check potassium and magnesium levels: should be within normal limits at time of infusion Reduce rate of infusion if nausea/vomiting occur Caution with penicillin allergy Check allergies Dose reduction recommended for CrCl < 70 ml/min

strated competency to manage this medication.

39

Section II
Medication Generic - (Brand) Immune Globulin Intravenous (IVIG) How Supplied Various strengths & brands IV Push Conc / Rate Not advised

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Standard IVIG (Carimune) contains sucrose Initial Dose -Carimune: 3% solution recommended for previously untreated patients. First dose dispensed as partial dose ( 3% solution usually 6g dose). If tolerated after first bag remainder of dose is provided as 6% solution. Solution may be further concentrated to 12% as needed. Initial Rate -Carimune 3% Solution: Initiate at 30-60mL/hr x 15-30min. If tolerated may increase rate every 15-

This section can be copied and kept for reference at bedside.

Immune modulator

30minutes to a maximum of 150mL/hr. - Monitor patient f Subsequent Doses (Carimune 6% and 12% Solutions): After 1st dose of 3% solution, subsequent infusions (6% or 12%) may be administered at a higher concentration and higher rate (i.e. increasing q15-30 min). Infuse at a maximum rate of 2 mg/kg/min Sucrose-free IVIG 10% Solutions

Initial Dose-Gammagard & Privigen Initiate at 15-30mL/hr and increase as tolerated every 30min to maximum of 5mL/kg/hr (Gammagard) and 2.4mL/kg/hr (Privigen), respectively. Subsequent Doses: Higher rates may be possible for Privigen based on indication & tolerability (check with pharmacist).

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions Unless clinically indicated (i.e. IgA deficiency) -

mmended Infusion Time Monitoring - Monitor BP every 15 minutes for first Filter not required for: hour of every infusion, then every 30Carimune, Privigen or 60 min. for duration of the initial Gammagard. infusion. Monitor Blood Pressure

every 30-60 min. during subsequent infusions if the patient has a history of intolerance to IVIG. Decrease rate or stop infusion if patient experiences adverse reactions. Consider premedication with acetaminophen +/- diphenhydramine Refer to IVIG PPO ed may increase rate every 15symptoms of anaphylaxis and have epinephrine available to treat.

requests for specific brands Gammagard S/D requires filter cannot be use provided administration set that includes 15 micron accommodated. filter. If administration set notIndication provided, contact pharmacy for required with all filter! orders. Pharmacists will Reconstitute Carimune vials provide ordered with sterile water dose as 3%, 6% or 12% solution (Carimune) or a 10% solution (Gammagard, Privigen). Pharmacist will round dose down to nearest vial (3, 5, 6 or 10g) depending on availability within 90% of calculated dose.

- Monitor renal function st dose of 3% solution, Adverse reactions include hypotension, headache, fatigue, change in pulse, flushing, tightness in chest, chills, fever, dizziness, nausea/vomiting, backache, leg cramps, uticaria, and diaphoresis Standard (Sucrose-containing) IVIG is appropriate for most patients; however, IVIG has been associated with renal dysfunction, ARF, osmotic nephrosis, and death. Patients predisposed to ARF include patients with: 1) any degree of pre-existing renal insufficiency, 2) diabetes mellitus, 3) age > 65, 4) volume depletion, 5) sepsis, 6) paraproteinemia, 7) pts receiving known nephrotoxic drugs In these patients, IVIG should be administered at the minimum concentration and the minimum infusion rate that is practical.

Sucrose-free IVIG may also be considered.

40

Section II
Medication Generic - (Brand) How Supplied 20 ml amp (5 mg/ml) IV Push Conc / Rate Yes May give undiluted via central line or running IV. Give over 2-3 min.

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Loading dose 0.75 mg/Kg Usual dose range: 5-10 mcg/Kg/min Standard conc: 400 mg/250 ml NS (total vol=330 ml) (1.2 mg/ml) Concentrated conc: 500 mg/100 ml NS (total vol=200 ml) (2.5 mg/ml) Maximum Concentration = undiluted (5 mg/ml) Not advised

This section can be copied and kept for reference at bedside.

Inamrinone
(Inocor) formerly amrinone

Cardiovascular/ Positive inotrope

Indomethacin (Indocin) Anti-inflammatory/ NSAID

1mg Vial

Yes, Give 0.1 0.25 mg/Kg dose over 5-10 seconds

InFLIXimab (Remicade) Monoclonal antibody

100 mg Vial

NO

Infuse slowly over 2 hours Recommended Doses: Crohns: 5 mg/Kg Rheumatoid Arthritis: 3 mg/Kg Concentration should be 0.4 - 4mg/ml

Insulin- Human Regular


Also see Section III *HIGH ALERT MEDICATION* Recheck insulin name and dose before administering!

100 Regular Insulin units/ml 10 used for IV route. ml vial Give all doses over 15-30 seconds

System Standard Concentration: 150 Units/150ml NS (1 unit/ml)

Also administered SQ see section IV of guidelines

Antidiabetic Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions * See footnote

mmended Infusion Time Dose-related thrombocytopenia occurs in 2-3% within 48-72 hr after initiation. Reverses within one week upon d/c of med. Monitor BP, HR every 15 min

Dilute with NS only

Incompatible with many medications/solutions check with pharmacist

entrated conc: 500 mg/100 ml Total cumulative dose should not exceed 10 mg/kg um Concentration = undiluted For closure of Patent Ductus Arteriosis in premature infants between 500 & 1750 Gram Weight. See labeling for age specific dosing Course of therapy involves 3 doses 1224 hours apart Monitor for allergic symptoms shortness of breath, rash, hives, and pruritus. Prepare solution just prior to Neonatal administration Intensive Care Do not dilute with agents containing benzyl alcohol. Use preservative-free sterile water or NS only! Administer within 3 hrs of preparation Do NOT shake or transport solution through pneumatic tube system Use administration set provided by pharmacy (contains 1.2 micron filter)

Premedication with acetaminophen and diphenhydramine recommended ntration should be 0.4 - 4mg/ml Preprinted order sets available

Waste 10-20 ml of diluted solution through the administration set to saturate binding sites in IV tubing before connection to infusion pump. Preprinted order sets available for insulin infusions in ICU patients, Adult Surgical/Medical Patients, and DKA/Hyperosmolar Nonketotic Coma Patients Monitor blood glucose

Recheck
Vials are stable x 28 days after insulin name first use refrigerated or at room dose and temp before

administering!

strated competency to manage this medication.

41

Section II
Medication Generic - (Brand) Iron Dextran How Supplied 50 mg/ml2ml Vial IV Push Conc / Rate

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Yes, Dose > 200mg = Total Dose Infusion Doses up to 200mg (TDI) - dilute into 250-500 ml NS Max at max rate of 50 conc = 50 mg/ml mg/min Infuse over 2-6 hours

This section can be copied and kept for reference at bedside.

(INFed)
Iron supplement

May be given IM IV infusion preferred over IM due to local complications and unpredictable absorption with IM admin

Iron Sucrose Complex (Venofer )

20mg/ml 5ml vial

Yes, Undiluted up to 200mg at max rate of 20mg/min

Iron supplement

50 mg IV in 50 ml NS over 15 min 100 mg IV in 50 ml NS over 30 min 200 mg IV in 50 ml NS over 60 min 300 mg IV in 100 ml over 2 hours

Maximum Dose per P&T: 300 mg no more frequently than once weekly

Isoniazid (Nydrazid) Antimicrobial

100 mg / ml Vial 10ml

Yes, Administer undiluted & slowly over 5 minutes

Dilution not advised.

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

r LVP Standard Diluent

mmended Infusion Time > 200mg = Total Dose Infusion nto 250-500 ml NS Max

25 mg test dose IV-Push over 30 seconds to 5 min recommended before each total dose infusion Observe and monitor BP and HR every 15 min for 60 minutes after test dose before implementing infusion Have the following readily available during infusion: diphenhydramine 50 mg IV, epinephrine 1:1000 (1 mg/ml) and hydrocortisone 100mg/2ml Anaphylactoid/Hypotensive reactions possible. Hypotensive reactions may be possible Test dose not necessary. Monitor vital signs (BP) including orthostatic BP Metro: For Outpatients Doses < 100 mg monitor patient for 1 hour post-infusion per P&T Doses 200-300 mg monitor patient for 2 hours post- infusion per P&T May cause hypotension or hypertension, chest, back or groin pain. Symptoms typically resolve 1-2 hours after infusion completed. Solution may cause local irritation Slow rate if tingling sensation reported in extremities Oral administration preferred. May be given IM via ventrogluteal site due to volume per dose.

Use NS D5W has increased incidence of phlebitis/pain at injection site Lean body weight (or ideal body weight) not actual body weight should be used in calculating dose Incompatible with many medications/solutions, check with pharmacist

e given IM IV infusion ed over IM due to local cations and unpredictable

IV in 50 ml NS over 15 min g IV in 50 ml NS over 30 min g IV in 50 ml NS over 60 min g IV in 100 ml over 2 hours

um Dose per P&T: 300 mg no requently than once weekly

Solution may crystallize at low room temperature. Warm slowly to re-dissolve

strated competency to manage this medication.

42

Section II
Medication Generic - (Brand) How Supplied 0.2 mg / ml 5 ml amp IV Push Conc / Rate NO

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time System Standard Conc: 1 mg/250 ml NS (4 mcg/ml) System Concentrated Conc: 2 mg/250 ml NS (8 mcg/ml) Usual dose range: 1-10mcg/min Decrease/temporarily stop infusion if HR > 110. Doses sufficient to increase HR > 130, may induce ventricular arrhythmias or angina.

This section can be copied and kept for reference at bedside.

Isoproterenol (Isuprel )
Cardiovascular/ Chronotrope

K Vitamin K

See 10 mg/ml 20 ml vial; 50 mg/ml 10 ml vial; Yes, Slowly over 2-3 min (conc max 50mg/ml) Usual dose for sedation: 0.2 1 mg/kg IV Continuous infusions may be used during surgery as general anesthetic. Infusion may be used as sedative / analgesic for refractory pain syndromes Infusion: Dilute dose in D5W or NS to final concentration of 1-2mg/mL (max: 2 mg/mL)

Phytonadione
Ketamine

Analgesicsedative/anesthetic

May also be given IM

** Oxygen via nasal cannula at minimum w/continuous pulse oximetry/ECG monitoring recommended while sedated

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time Monitor ECG continuously; BP and HR every 15 min Monitor urine output every 1-2 hr May cause PVCs Cardiac transplant patients have little or no response to Atropine. Isoproterenol is considered first line drug for treatment of severe bradycardia in heart transplant patients

Incompatible with many * See footnote meds/solutions check with pharmacist

Monitor RR, BP, HR and mental Protect from light status. May cause * respiratory depression with high doses or too rapid injection * cardiovascular stimulation (HTN, tachycardia) * hypersalivation / excessive secretions - may be managed with atropine/glycopyrolate. *Emergence phenomenon (vivid dreams, hallucinations, delirium, confusion) gen via nasal cannula at Benzodiazepines (eg. midazolam) may decrease/alleviate CV stimulation and emergence phenomenon

Critical Care & prescriber experienced w/administratio n

strated competency to manage this medication.

43

Section II
Medication Generic - (Brand) Ketorolac (Toradol) Analgesic/ Antiinflammatory/ NSAID How Supplied 15 mg & 30 mg per ml syringe & vial IV Push Conc / Rate Yes, Give over 15-30 seconds

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Give IV - push

This section can be copied and kept for reference at bedside.

Labetalol (Trandate, Normodyne) Antihypertensive

5 mg/ml 4 ml syringe, 20 ml vial

Yes, Give minutes

Continuous infusion: Initial rate: 0.5 10 mg over 2 2 mg/min titrate to desired effect System Standard Conc: 250 mg/150 ml NS (total vol 200 ml) (1.25 mg/ml) System Concentrated Conc: 300 mg/40 ml NS (total vol 100ml) (3mg/ml) Undiluted 5mg/ml = max conc Dilute all doses in 100mL NS and administer over 30min

Lacosamide

(Vimpat) Anti-seizure
Lansoprazole (Prevacid) Proton Pump Inhibitor

10mg/mL single dose 20mL vial 30 mg vial

NO

NO

30 mg in 50 ml NS Infuse over 30 min

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time Pain with injection common-slow infusion if this occurs NSAID check allergies Recommended max dose is 120 mg/day Recommended max dose for CrCl < 50 ml/min or age > 65 y.o. is 60 mg/day Max recommended length of therapy is 5 days * Continuous infusion - see NOT compatible with alkaline footnote solutions such as furosemide (Lasix) check with Intermittent doses pharmacist for compatibilities monitor VS. May cause hypotension and bradycardia IV doses mixed in 0.9% NaCl are stable for 24 hours at room temperature. Vial must be reconstituted with Sterile Water and further diluted within 1 hr In-line filter must be used! Do not administer with other medications/fluids check with pharmacist for compatibility information

Maximum anti-hypertensive effect apparent approximately 5 min after each dose g/150 ml NS (total vol 200 ml) Titrate to desired BP parameters

May cause orthostatic hypotension. Administer to pt while in supine position if possible. ed 5mg/ml = max conc IV dose = PO dose

IV dose = PO dose

strated competency to manage this medication.

44

Section II
Medication Generic - (Brand) How Supplied 5 mg/ml 10 ml vial IV Push Conc / Rate Yes, Loading dose (0.4 mg/kg max 44 mg)*: IV Push over 30 seconds

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Maintenance infusion: 0.1 mg/Kg/Hr, titrate to target aPTT System Standard Conc: 50mg/ 100 ml NS (0.5 mg/ml) Preprinted order set available

This section can be copied and kept for reference at bedside.

Lepirudin
(Refludan) *HIGH ALERT MEDICATION* Anticoagulant

Levetiracetam (Keppra) Anticonvulsant

500 mg/5 ml vial

NO

Dilute in 100 ml NS and infuse over 15 minutes

Levofloxacin (Levaquin) Antibiotic/ Fluoroquinolone Levocarnitine (Carnitor) Nutritional supplement/Amino acid Levothyroxine (Levothroid, Synthroid) Hormone - thyroid

25mg/ml Vial. Premix: 500mg/100 ml 200 mg/ml 2.5 ml ampule

NO

Infuse 250 and 500 mg doses over 60 min Infuse 750 mg dose over 90 min

Yes, Give over 2-3 min

May be given as intermittent infusion diluted to conc of 0.5 to 8 mg/ml in NS or LR

200 mcg/5 ml vial

Yes, Give over 2 min

Slow IV push recommended

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time Anticoagulant for use in patients with heparin associated thrombocytopenia Monitor for signs of bleeding! Monitor therapy with aPTT (1.5-2.5 x baseline) 4 hours after beginning drip or change in the rate of a continuous infusion *Adjust dose if CrCl < 60 ml/min, SrCr > 1.5, or if pt has received thrombolytic Double check drug name Store at room temperature IV Dose = PO Dose Dose reduction for patients with CrCl Compatible with NS, D5W, < 50 ml/min recommended. LR, lorazepam, diazepam and valproate Dose reduction for patients with CrCl < 50 ml/min recommended

750 mg dose over 90 min

May cause HTN monitor VS Discard ampule immediately ed to conc of 0.5 to 8 mg/ml in after use May cause N/V slow rate of infusion Use NS or LR NOT D5W May cause hypercalcemia ** Verify dose to be given. Discard Use immediately after vial after drawing up correct dose. ** reconstitution Use NS only to reconstitute IV dose = 50% of PO dose Do not combine with other solutions

strated competency to manage this medication.

45

Section II
Medication Generic - (Brand) How Supplied 100mg Syringes, 2Gm/500ml Premix IV Push Conc / Rate Yes, 50-100mg over 2 minutes at max rate of 50mg/min

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Continuous infusion required to maintain anti-arrhythmic effect Usual dose range: 1 4 mg / min System Standard Conc: 2000 mg/ 500 ml D5W Premix (4 mg/ml) System Concentrated Conc: 2000 mg/ 100 ml NS (total volume 200ml) (10 mg/ml) Can be given via ET tube: 2 2 x IV dose

This section can be copied and kept for reference at bedside.

Lidocaine
Anti-arrhythmic

** Do not use in WPW syndrome **

Linezolid (Zyvox) Antimicrobial

Premix: 400mg/ 200ml NS, 600mg/ 300ml NS Premix bags 2&4 mg/ml syringe / Vial

NO

Max conc: 2 mg/ml Administer dose over 60 minutes

LORazepam (Ativan) Sedative/ Benzodiazepine

Yes, Dilute with equal volume NS-Give at max rate of 2 mg/min

Continuous infusion System Standard Conc: 100 mg/ 50 ml D5W Excel or glass bottle (total volume 100 ml) (1 mg/ml)

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions * See footnote Continuous ECG monitoring. Therapeutic serum lidocaine levels: 1.5 to 5 Toxic levels: > 5

mmended Infusion Time Continuous EKG Monitoring in anti-arrhythmic effect Do NOT exceed 300 mg/hour or 4 mg/min Cardiac signs of toxicity: Widening of QRS, bradycardia, increasing PVCs, hypotension, heart block Non-cardiac signs of toxicity: 0 ml NS (total volume 200ml) numbness of lips, tongue and face; tremors; paresthesias; diploplia; mental status changes, nausea/vomiting; confusion; slurred speech Weak MAO inhibitor verify patient on low tyramine diet (in addition to ordered diet) Low tyramine diet to continue x 3 days after d/c of medication. Avoid co-administration with meds that may increase risk of serotonin syndrome (i.e. SSRIs, SNRIs, TCAs) Monitor respiratory and cardiovascular status May cause respiratory depression

Compatible with NS, D5W and tyramine Low LR restriction (in addition to Incompatible with ceftriaxone ordered diet) Normally may exhibit a yellow color Critical Care for Vials stable 60 days at room continuous temp infusion Observe for crystals (may use 5 Continuous micron in-line filter). infusion may be given unmonitored if used for comfort care/hospice pt

Reverse with flumazenil (Romazicon)

strated competency to manage this medication.

46

Section II
Medication Generic - (Brand) How Supplied Vials: 4 mEq/ml multiple vial sizes Premix bags: 1 Gm/100 ml, 2 Gm/50 ml, 4Gm/100 ml, 6 Gm/ 50 ml & 20 gm/50 ml Premix Vial 25%(12.5Gm/5 0ml) Premix: 20% (100 Gm/500 ml) 10% (50 Gm/ 500 ml) 25,50,75 & 100 mg/ml syringe, 50 mg/ml vial IV Push Conc / Rate Yes, Bolus dose only for Torsades de Pointes Dilute with 10 ml NS/D5W for 1 gm dose; 20 ml NS/D5W for 2 gm dose. Give at max rate of 1Gm/min

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Intermittent infusion: Magnesium supplementation - 1 2 Gm over 30 min Pre-eclampsia/eclampsia: Usual bolus dose is 4 grams given over 20-30 minutes Pre-term labor: Usual bolus dose is 6 grams given over 20-30 minutes Continuous Infusion: 1- 4 Gm/hr System Standard Conc: 20 grams/ 500 ml Sterile Water Premix (40 mg/ml) Intermittent Infusion: Infuse over 30-60 min

This section can be copied and kept for reference at bedside.

Magnesium
*HIGH ALERT MEDICATION*

Electrolyte

Mannitol (Osmitrol) Osmotic diuretic

Yes, 12.5 Gm/50 ml over 5 min or 1g/kg over no less than 10 min

12.5 gm = 62.5 ml of 20%, 50 ml 25% 25 gm = 125 ml of 20%, 100 ml 25% 50 gm = 250 ml 20%, 200 ml 25% Metro: Infusion bags from pharmacy contain extra volume for priming of tubing and filter. Continuous infusion NOT advised PCA administration recommended

Meperidine (Demerol) *HIGH ALERT MEDICATION*

Yes, Dilute dose to 10ml with NS and give at max rate of 10 mg per minute

Narcotic analgesic

System Standard Conc: 250 mg/ 250 ml NS (1 mg/ml) System Concentrated Conc: 250 mg/ 100 ml NS (2.5 mg/ml)

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions **Metro OB: Mandatory use of order set for IV infusion

r LVP Standard Diluent

mmended Infusion Time ttent infusion: Magnesium mentation - 1 2 Gm over 30

1 Gm = 8.12 mEq Mg. Metro OB: Assess DTR, respirations, signs and symptoms of Mg toxicity (muscle weakness, ECG changes, hypotension, sedation, confusion), I&Os. Obtain Mg levels as order by physician May cause respiratory/cardiovascular collapse Antidote for Mg toxicity: calcium gluconate Use 0.22 micron in-line filter Do not refrigerate!!

lampsia/eclampsia: Usual bolus s 4 grams given over 20-30

m labor: Usual bolus dose is 6 given over 20-30 minutes

uous Infusion: 1- 4 Gm/hr

m Standard Conc: 20 grams/ 500 rile Water Premix (40 mg/ml)

Inspect vials/bags for crystals prior to administration


Hypertonic solutions monitor venous site for irritation. Avoid Extravasation see PPO 5046 for general guidelines / management Common hold parameters: Na+ > 145 or Serum Osmolarity > 310 Not recommended for patients 65 years or older nor patients with poor renal function Monitor for delirium, or other CNS toxicity Monitor respiratory status may cause respiratory depression or distress Reverse respiratory depression with naloxone (Narcan)

m = 62.5 ml of 20%, 50 ml 25% = 125 ml of 20%, 100 ml 25% = 250 ml 20%, 200 ml 25%

Infusion bags from pharmacy n extra volume for priming of

uous infusion NOT advised

PCA: Check syringe for expiration date 0

dministration recommended

Metro: If PCA ordered, mandatory set must be used

m Standard Conc: 250 mg/ 250

m Concentrated Conc: 250

strated competency to manage this medication.

47

Limitations /

Mandatory use of order set for IV

Metro: If PCA order set must be used

Section II
Medication Generic - (Brand) Meropenem (Merrem) Antibiotic/ Carbapenem How Supplied 500 mg & 1 Gm vials IV Push Conc / Rate May be given IV push over 3-5 min (i.e. hemodialysis patients) Routine use of IV push is not recommended

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Intermittent Infusion Usual Dose: 500mg/50mL 1g/100mL NS IV over 30min Extended infusions over 3 hours may be used for treatment of resistant pathogens.

This section can be copied and kept for reference at bedside.

Methyldopate (Aldomet IV) Antihypertensive Methylene Blue

50mg/ml 5 & 10ml Vial

NO

1.% Solution (10mg/mL) 1 ml amp/vial 10 ml amp/vial

Yes, 1-2 mg/kg SLOWLY over 35 min

Intermittent Infusion Up to 250mg in 50ml D5W over 30min 251-500mg in 100ml D5W over 60min Continuous infusion: Methemoglobinemia: (converts methemoglobin to hemoglobin) 0.1 0.15 mg/kg/hr Metro: Preprinted order set available for treatment of septic shock/refractory hypotension Loading dose 2mg/kg in 50mL NS over 30min followed by infusion of 0.5-2mg/kg/hr System Standard Conc: 500 mg/ 50 ml NS (total volume 100 ml) (5 mg/ml)

Thiazone dye

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time Monitor for allergic reaction-rash, hives, and shortness of breath, pruritus. Caution with penicillin allergy

Stable 24 hr after dilution with NS refrigerated Stable only 4 hr after dilution with D5W refrigerated

Check allergies! Dose reduction recommended in pts w/ CrCl < 50 ml/min


Monitor BP / Orthostasis Uncommon anecdotal reports of paradoxical pressor response with IV methyldopate-blood pressure may increase Urine and feces may turn blue-green. Skin discoloration may also occur. Avoid extravasation may cause necrotic abscesses

Incompatible with many * See footnote medications/solutions contact pharmacist Use only NS for dilution

Preprinted order set Total doses > 7 mg/kg may cause dyspnea, cyanosis, dysrhythmias, hypotension, CNS depression 0min followed by infusion of Use with caution in pts w/ severe renal insufficiency or G-6-PD deficiency m Standard Conc: 500 mg/ 50 ml Administer via Central Line only! Pulse Ox reading may be artificially low during IV administration

strated competency to manage this medication.

48

Section II
Medication Generic - (Brand) Methylergonovine (Methergine) Uterine Stimulant How Supplied 0.2 mg/ml 1 ml amp IV Push Conc / Rate NO Give IM only 0.2 mg over 1 min

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Usual dose: 0.2 mg IM q4 hr

This section can be copied and kept for reference at bedside.

Methylnatrexone (Relistor) Opioid Antagonist MethylPREDNISolone (Solu-Medrol)

12mg / 0.6ml vial

NO

Not recommended. Intermittent SQ administration ONLY.

SQ administration ONLY
40, 125 & 500mg Vial, 1&2 Gm Vial Yes at mg/min

Corticosteroid

MetoCLOPramide (Reglan) Prokinetic/antiemetic

5mg/ml in 2,10, 20 & 30 ml Vial

Yes, Give at

IV Push preferred method of max rate of 50 administration Intermittent Infusion 100-250mg in 50ml NS give over 15 min > 250mg in at least 50ml NS give over 60 min Intermittent Infusion 5 mg/min Doses > 10mg, dilute in 50 ml. Infuse over 15 min

MetoPROLOL (Lopressor) Cardiovascular/Beta Blocker

1mg/ml 5ml Syringe & Amp

Yes, Give at max rate of 5mg/min

IV-push preferred Acute myocardial infarction: 5 mg IVP every 5 minutes x 3

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

r LVP Standard Diluent

mmended Infusion Time dose: 0.2 mg IM q4 hr

Monitor BP do not administer if BP > 140/90

Discard discolored solutions

ttent SQ administration ONLY.

h preferred method of

0mg in 50ml NS give over 15

Do NOT give via IV administration due to increased risk of HTN and CVA. Intravenous administration in severe, life-threatening situations ONLY. Usual dose q48h SQ in upper arm, Store at room temperature. abdomen or thigh only. Once drawn up in a syringe Frequency not to exceed Q24h dose is stable at room temperature for 24hours Acute Spinal Cord Injury : Critical Care Continuous Infusion -- Usual dose: Reconstitute vials with sterilerecommended for 30 mg/kg bolus over 15 min then 5.4 water only. May further dilutecontinuous mg/kg/hr x 23 (or 48) hours with NS. infusion ** Depo-Medrol must be given IM not IV ** Slow rate if extra-pyramidal symptoms (dystonia, motor restlessness, parkinson-like symptoms) occur Reverse EPS with diphenhydramine (Benadryl) 50mg IV per physician order Contraindicated in Parkinsons patients. Monitor HR and BP

mg in at least 50ml NS give

> 10mg, dilute in 50 ml. Infuse

Contraindicated in patients with Parkinsons disease.

Administer undiluted

* See footnote

myocardial infarction: VP every 5 minutes x 3

strated competency to manage this medication.

49

Limitations /

recommended for

Contraindicated in patients with

* See footnote

Section II
This section can be copied and kept for reference at bedside.
Medication Generic - (Brand) MetroNIDAZOLE (Flagyl) How Supplied 500 mg Vial, Premix: 500 mg/100 ml IV Push Conc / Rate NO

Parenteral Medication Adminis


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Infuse over 60min

Antibiotic

Micafungin (Mycamine)

50 mg, 100 mg vials

NO

For treatment of candidemia, invasive candidiasis, aspergillus infections Intermittent infusion: 50-150 mg in 100 ml NS or D5W infused over 60 minutes Continuous infusion: Usual dose range: 0.5 10 mg/hr System Standard Conc: 50 mg/ 100 ml NS (0.5 mg/ml)

Antifungal MIDAZolam (Versed) 1&5 mg/ml Vial & Syringes Yes, 1 2.5 mg doses over 2 3 minutes. Titrate SLOWLY

Sedative/ Benzodiazepine

Milrinone (Primacor)

Cardiovascular/ Positive inotrope

200 mcg/ml100ml Premix, 10 & 20 ml vial 1 mg/ml

Yes, Loading dose of mcg/Kg over 10 minutes

Continuous Infusion: 50 Usual dose range: 0.25 1 mcg/kg/min titrate to response System Standard Conc: 20mg/100 ml D5W Premix (200 mcg/ml) System Concentrated Conc: 20 mg/30 ml NS (total volume 50 ml) (400 mcg/ml) Half-life: 1-3 hr

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

Parenteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

r LVP Standard Diluent

mmended Infusion Time Incompatible with many meds and solutions check with pharmacist May form crystals if refrigerated, warm to room temperature to re-dissolve

atment of candidemia, invasive iasis, aspergillus infections

Avoid ETOH use during treatment and 72 hours post due to possible disulfiram like reaction No dose adjustments required in renal/hepatic dysfunction

Dilute vials prior to reconstitution with NS (without bacteriostatic agent)

ttent infusion: 50-150 mg in NS or D5W infused over 60 Titrate doses slowly elderly Monitor respiratory and cardiovascular status especially in the *See footnote Critical Care for continuous infusion

dose range: 0.5 10 mg/hr

m Standard Conc: 50 mg/ 100 ml

Rapid and/or frequent administration may cause respiratory depression


Reverse effects with flumazenil (Romazecon) Dose reduction recommended for decreased renal function

dose range: 0.25 1 g/min titrate to response

* See footnote Incompatible with many meds check with pharmacist

Monitoring: Continuous EKG Monitoring

m Standard Conc: 20mg/100 ml

Following initiation or dose m Concentrated Conc: 20 titration: Continuous BP or ml NS (total volume 50 ml) q15min x 3, then q1h x 4 then q4h x 2 then q4-6 hours while stable. strated competency to manage this medication.

50

Limitations /

*See footnote Critical Care for

* See footnote

Section II
Medication Generic - (Brand) Morphine *HIGH ALERT MEDICATION* How Supplied Various concentrations, vials & syringes. IV Push Conc / Rate Yes, at mg/min

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Continuous Infusion max rate of 1 System Standard Conc: 50mg/250ml NS (0.2 mg/ml) System Concentrated conc: 50mg/100ml NS (0.5 mg/ml)

This section can be copied and kept for reference at bedside.

Narcotic analgesic

Chronic pain management- maximum dose is effective dose

Moxifloxacin (Avelox) Antibiotic/ Fluoroquinolone Multivitamin Vitamin/ Nutritional supplement Muromonab CD3 (Orthoclone OKT3)

400 mg/250 ml Premix

NO

Infuse over 60 min

MVI-12 (adult) 10 ml vial

NO

Common component of banana bag. Manufacturer recommends minimum volume for infusions of 500 ml. NO

1 mg/ml 5 ml Amp

Yes, 5 mg over 60 seconds

Immunosuppressant

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage

mmended Infusion Time Hierarchy of effects ? sedation ? m Standard Conc: 50mg/250ml Monitor respiratory and cardiovascular status may cause respiratory depression/distress Titrate to dose that relieves pain without excessive sedation avoid abrupt dose changes Lower doses advised in elderly, debilitated or in patients receiving other CNS depressants Reverse effects with naloxone (Narcan)

? respiratory depression

analgesia

PCA: Check syringe for expiration date

on component of banana bag.

Common component of TPN. um volume for infusions of Pre-dose corticosteroid, antihistamine and acetaminophen recommended Be aware of potential for cytokine release syndrome (CRS) & acute hypersensitivity (allergy) reactions with initial doses Dose is 5 mg IV daily x 10-14 days in adults Do not mix with other solutions/medications

strated competency to manage this medication.

Stability / Storage

Limitations / Restrictions

PCA: Check syringe for expiration date Metro: If PCA ordered, mandatory order set must be used

* See footnote Do not mix with other solutions/medications

51

Section II
Medication Generic - (Brand) Mycophenolate mofetil (CellCept) Immunosuppressant How Supplied 500mg Vial IV Push Conc / Rate NO

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Infuse over 2 hours

This section can be copied and kept for reference at bedside.

Nafcillin (Nafcil)

1 & 2 Gm Vials 2 Gm/100 ml Premix

NO

Intermittent Infusion < 2 Gm give over 30min > 2 Gm give over 60min

Antibiotic/ Penicillin

Nalbuphine (Nubain)

10mg/ml 10ml Vial 20mg/ml 10ml Vial

Yes, at mg/min

Not Advised Give IV Push max rate of 1

Narcotic Analgesic

NaLOXone (Narcan) REVERSAL AGENT Narcotic Antagonist/

0.4 & 1 mg/ml, various size syringes & vials

Yes, 0.1 0.4 mg 1 minute May repeat IV doses at 2-3 min intervals or per order

Reversal agent for Narcotics Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

Not advised Give IV Push over Continuous infusion for epidural associated pruritis System Standard Conc: 1 mg/250ml NS (4mcg/mL) System Concentrated Conc: 2 mg/100 ml NS (20mcg/mL)

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

r LVP Standard Diluent

mmended Infusion Time Each 500mg vial reconstituted with 14ml D5W Final concentration of solution should be 6 mg/ml Avoid direct contact with solution. If this occurs, thoroughly wash exposed area with soap and water teratogen. Penicillin derivative check allergies Avoid Extravasation see PPO 5046 for general guidelines / management Tissue damage reported with infiltration prefer central line administration if available Slow rate or further dilute if phlebitis occurs 10 mg Nalbuphine = 10 mg IV Morphine Do not mix with other solutions/medications

vised Give IV Push

Monitor respiratory status may cause respiratory depression


Reverse with naloxone (Narcan) May cause withdrawal in opioid dependent patients. Used for reversal of narcotic agents Onset of action within 2 min If no response after 10 mg given, question narcotic overdose Reversal of opiod depression may cause nausea/vomiting, sweating, tremulous, tachycardia, and HTN.

vised Give IV Push

uous infusion for epidural

m Standard Conc: 1 mg/250ml

m Concentrated Conc: 2 0 ml NS (20mcg/mL)

strated competency to manage this medication.

52

Section II
Medication Generic - (Brand) NATALizumab (Tysabri) How Supplied 300mg/15 ml vial IV Push Conc / Rate NO

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Intermittent infusion: 300 mg in 100 ml NS. Infuse over 1 hour.

This section can be copied and kept for reference at bedside.

Monoclonal antibody for Multiple Sclerosis & Crohns Disease

Neostigmine (Prostigmin)

Anticholinesterase

1 mg/ml = 1:1000 10 ml vial 0.5 mg/ml = 1:2000 1 ml amp/vial 0.25 mg/ml = 1:4000 1 ml amp

Yes, 0.5 2 mg. Give SLOWLY May give IM

NO

Usual max/total dose is 5 mg

Nesiritide (Natrecor)

1.5 mg vial

Cardiovascular/ Vasodilator

Bolus dose: 2 mcg/kg IV push over 1 minute. Bolus not always given.

Continuous infusion: Usual dose = 0.01 mcg/kg/min. Drip may be increased by 0.01 mcg/kg/min q3h if needed to maximum dose of 0.03 mcg/kg/min. System Standard Conc: 1.5mg/250ml NS (6 mcg/ml)

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time Restrictions in administration apply patient, physician, in fusion center and pharmacy must be registered with FDA. Preprinted order set available for administration in ASLMC CND and ASLMC ATC. May cause infusion-related/ hypersensitivity reactions. Monitor patient during and x 1 hour postinfusion. Emergency preprinted order set available. Antidote for non-depolarizing neuromuscular blockade

Vials: Refrigerate and protect Must be only from light administered in FDA registered USE NS ONLY! outpatient infusion areas Stable 8 hours after dilution check with site refrigerated. Warm to room (i.e. ASLMC temp prior to infusion. CND/ATC only; no inpatient Do NOT shake. Do NOT areas) transport via tube system.

*See footnote (see Precautions/ Comments)

Metro: For Acute Colonic PseudoObstruction (Ogilvies Syndrome): Per P&T --Bedside telemetry/RN presence required during administration. Give over 10 min. Patients must remain in monitored bed 4-6 hours after administration. Use with caution in renal dysfunction. Decrease dose for CrCl < 50mL/min Monitoring parameters and IV incompatibilities available on preprinted order set d to maximum dose of 0.03 For initiation or dose titration, monitor BP every 15 min x 4, every 30 min x 2, every 1hr x 2 hr then every 4 hr. Hold for BP < 90.

Flush tubing with approx. 25 * See footnote ml prior to connecting to patient and prior to bolus if ordered. Incompatible with heparin, insulin, furosemide, bumetanide, enalaprilat, and hydralazine. Consult pharmacist for compatibility information.

strated competency to manage this medication.

53

Section II
Medication Generic - (Brand) NiCARdipine (Cardene) Cardiovascular/ Calcium Channel Blocker How Supplied 2.5mg/ml 10ml Amp IV Push Conc / Rate NO

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Continuous Infusion System Standard Conc: 25 mg/250 ml NS (0.1mg/ml) System Concentrated conc: 50 mg/80 ml NS (total vol 100 ml) (0.5 mg/ml)

This section can be copied and kept for reference at bedside.

NitroGLYcerin (Tridil)
Cardiovascular/ Vasodilator

Vial 50mg/10ml Premix 50mg/500m l& 50mg/250m l

NO

Usual dose range: 2.5 15 mg/hr Recommended titration: Initiate at 2.55mg/hr & increase infusion by 2.5 mg/hr Q15min until at BP goal (max of 15 mg/hr). Once desired effect reached, reduce to maintenance of 3 mg/hr. Continuous Infusion Initial dose: 10 mcg/min then titrate by 10mcg increments q5min to desired BP goal Usual dose: 10-200 mcg/min System Standard Conc: 50 mg/250 ml D5W Premix (glass bottle) (200 mcg/ml) System Concentrated conc: 100 mg/250 ml NS (glass bottle) (400 mcg/ml)

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time Rate >3mg/hr: Continuous BP & EKG Monitoring

Critical Care See footnote* Central line access advised!

Rate 1-3mg/hr: Continuous BP & HR vitals q15min x 3, q30 x 2 then or ml NS (total vol 100 ml) (0.5 q4-6h while stable.

Manufacturer recommends changing IV site every 12 hours if run peripherally

Normally solution light yellow in color mmended titration: Initiate at 2.5Incompatible with Lactated Ringers or bicarbonate solutions contact pharmacist for compatibility information Monitoring - For initiation or dose titration: Continuous BP &HR or q5min x 3, then q15min x 3, then Q46hr while stable. Side effects include: hypotension, HA (common), tachycardia ** If IV tubing changes are needed, monitor pt every 15 min x 1 hr for possible NTG-retitration. IV tubing sets must be changed every 72 hr. ** Glass container only Use vented set Check with pharmacist regarding compatibility information. * See footnote

strated competency to manage this medication.

54

Section II
Medication Generic - (Brand) How Supplied 50mg/2 ml vial IV Push Conc / Rate NO

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Continuous Infusion: Usual dose range: 0.5 10 mcg/Kg/min System Standard = 50 mg/250 ml NS (200mcg/ml) System Concentrated conc: 50 mg/100 ml NS (500mcg/ml) Onset: 30-60 sec Peak effect: 1-2 min Duration: 1-10 min Half-life: 3-4 min

This section can be copied and kept for reference at bedside.

NitroPRUSSide (Nipride)
Cardiovascular/ Vasodilator

Tachyphylaxis has been reported particularly with doses > 10 mcg/kg/min d/c drug immediately if occurs!!

Norepinephrine (Levophed)
Vasopressor

1 mg/ml4 ml amp

NO

Continuous Infusion: Usual dose range: 2 12 mcg/min System Standard Conc: 4 mg/250 ml NS (16 mcg/ml) System Concentrated Conc: 8 mg/250 ml NS (32 mcg/ml) Onset: immediate Duration: 1-2 min Intermittent Infusion Dilute with 50ml NS Infuse over 15 minutes Continuous IV/Subcutaneous Infusion System Standard Conc: 500 mcg/250 ml NS (2 mcg/ml) System Concentrated Conc: 1000 mcg/100 ml NS (10 mcg/ml)

Octreotide (SandoSTATIN)

Hormone - Somatostatin

0.05 mg/ml 1 ml, 0.1 mg/ml 1 ml, 0.5 mg/ml 1 ml ampules; 0.2 mg/ml 5 ml, 1 mg/ml 5 ml vials

Yes, Give dose over 3 minutes May be given SQ

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time Monitor BP (via arterial line if possible) and HR every 15 min Monitor urine output every 1-2 hr Excessive infusion may produce cyanide toxicity. Monitor for signs and symptoms of cyanide toxicity: mental status changes, dyspnea, HA, N/V, ataxia, absent reflexes, distant heart sounds, widely dilated pupils, shallow breathing, and coma. Increased risk of cyanide toxicity in pt with renal dysfunction or hepatic insufficiency. May need to check thiocyanate (renally cleared metabolite) levels. S/sx thiocyanate toxicity: fatigue, muscle weakness, tinnitus, confusion, psychosis, hallucinations, nystagmus, coma

Protect from light Critical Care Sodium thiosulfate 500mg may be added to each nitroprusside infusion bag to decrease cyanide formation. Addition is recommended when nitroprusside dose is > 2 mcg/kg/min for more than one hour or for infusion duration > 72 hr

** Do not run infusion at 10 mcg/kg/min for longer than 510 min if this high of dose needed, call physician for alternative**

Central Line Advised!


Check with pharmacist regarding compatibility information ( PPO 5046) Monitor BP, HR every 5-15 min Monitor urine output every 1-2 hr

Critical Care

dose range: 2 12 mcg/min Avoid infiltration Phentolamine (Regitine) SQ recommended for management of infiltration

Refrigerate undiluted product Multi-dose vial stable 14 days refrigerated after initial use

with 50ml NS Infuse over 15

uous IV/Subcutaneous Infusion m Standard Conc: 500 mcg/250

m Concentrated Conc: 1000 00 ml NS (10 mcg/ml)

strated competency to manage this medication.

55

Section II
This section can be copied and kept for reference at bedside.
Medication Generic - (Brand) Ondansetron (Zofran) Antiemetic/ 5HT3 receptor antagonist Oxytocin (Pitocin) 10 units/ml 1 ml syringe/vial How Supplied 2mg/ml 2 & 20ml Vials IV Push Conc / Rate Yes, 4 mg over 1-2 min for post-op nausea/vomiting

NO

*HIGH ALERT MEDICATION* Hormone Uterine stimulant

Pamidronate (Aredia)

30 mg/10 ml and 90 mg/10 ml vials

NO

Bisphosphonate

Pancuronium (Pavulon)
*HIGH ALERT MEDICATION*

1 mg/ml 10 ml vial, 2 mg/ml 2 ml and 5 ml vials/ syringes

Yes, 0.1 mg/Kg bolus given rapidly

Neuromuscular blocker

Units with cardiac monitoring and nurses who have demonstrated competency to Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

Parenteral Medication Administration Guidelines


SVP or LVP Standard Diluent Precautions / Stability / Storage Comments Max/Min Concentrations Recommended Infusion Time Intermittent Infusion Chemotherapy Recommended max dose is 32 8, 12, 16, 20 or 24 mg in 50ml NS mg/day Infuse over 15 minutes Flat dose response from 1-4mg. Continuous infusion: Max of 32mg/day Continuous Infusion Metro: See MWH-11-MAT: Induction of labor: 1-2 milli-units/min, Health Policy and Womens increase by 1-2 milli-units every 15-30 Maternal for Oxytocin: Procedures minutes as needed Induction and Augmentation of Labor System Standard Conc: 20 units/1000 Metro: Pre-printed order set available ml NS (0.02 units/ml) for Labor Induction/Stimulation System Concentrated Conc: 40 site specific administration policy See units/ 1000 ml NS (0.04 units/ml) Monitor VS may cause Postpartum Hemorrhage: Infusion hypotension, hypertension, titrated to absence of hemorrhage. bradycardia Infuse over 3 to 24 hr Renal function should be assessed prior to each dose Dose should not exceed 90 mg May cause HTN and bone pain Infusion site reactions possible slow infusion rate if occurs Continuous Infusion Refer to Clinical Nursing Policies (vial) Store undiluted product System Standard Conc: 100mg/50 ml on Neuromuscular refrigeration under Blockade NS (total volume 100 ml) (1(i.e MN13) mg/ml) Refer to Preprinted order sets available for ICU neuromuscular blockade

d nurses who have demonstrated competency to manage this medication. Admin. Guidelines - Revised Final 07-2009

Limitations / Restrictions

Controlled airway and ventilation required; Critical Care only Sedation must be administered prior to and during paralytic use!

56

Section II
Medication Generic - (Brand) Pantoprazole (Protonix) How Supplied 40mg /10ml vials IV Push Conc / Rate Yes, 4080mg over 2min

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Continuous infusion: System Standard Conc: 80 mg/ 500 ml NS (0.16 mg/ml) System Concentrated Conc: 80 mg/ 100 ml NS (0.8 mg/ml)

This section can be copied and kept for reference at bedside.

Proton Pump Inhibitor Dilute 40 mg vial with 10 ml NS

Parenteral Nutrition (PN)

-----------

No

Paricalcitrol (Zemplar) Vitamin D Analog

2 mcg/ml 1 ml, 5 mcg/ml 1 ml vials

Yes 5 mcg/min

IV push preferred

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time Continuous infusion duration should not exceed 72 hr m Standard Conc: 80 mg/ 500 ml Run separately!! Do not infuse with any other medications !! m Concentrated Conc: 80 mg/ Check with pharmacist for possible compatible medications.

Vial: stable at room temperature or refrigeration 24 hrs after reconstitution. Intermittent / Continuous Infusion (40mg-80mg/100mL): Stable for 24hrs room temp. Infusion (80mg/500mL NS): Stable for 12hrs at room temp. Filtration not required during preparation or administration.

Route of administration:

Central line

Do not administer any If no central line access , confirm with medications/solutions/blood pharmacist that osmolality (< 900 products etc. with PN. If millimoles) is appropriate for alternative IV access is a peripheral administration. problem, contact the pharmacist for compatibility PN which includes lipids: change information. tubing every 24 hours. Use 1.2 micron filter for PN with lipids. PN with no lipids: change tubing every 96 hours. Use 0.22 micron filter for PN without lipids. Avoid Extravasation see PPO 5046 for general guidelines / management Used in the prevention and treatment Discard vial after use. of secondary hyperparathyroidism in chronic renal failure patients.

strated competency to manage this medication.

57

Section II
Medication Generic - (Brand) Pegfilgrastim (Neulasta) White cell stimulating hormone Penicillin G (sodium or potassium salt) How Supplied 6mg/0.6ml syringe

Parenteral Medication Administration Guidelines


IV Push SVP or LVP Standard Diluent Conc / Rate Max/Min Concentrations Recommended Infusion Time NO Give only SQ!! Give 6 mg SQ as a 1 time dose only

This section can be copied and kept for reference at bedside.

Antibiotic/ Penicillin

1,5,10 & 20 Million Unit Vials Premix: 3 Million Unit/50ml container

NO

Intermittent Infusion Up to 3 Million Units/50 ml NS. Infuse over 30 minutes 3.1 - 5 Million Units/100 ml NS. Infuse over 60 minutes

Pentamidine (Pentam)

300mg vial

NO

Intermittent Infusion 4 mg/Kg diluted into 250ml D5W over 60 minutes

Antiprotozoal Nebulized product also available.

Pentazocine (Talwin)

Narcotic Analgesic

30 mg/ml 1 ml syringe and amp, 30 mg/ml 10 ml vial

Yes, Not recommended Max rate of 5 mg/min

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

dication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

Long acting filgrastim May cause bone pain

Refrigerate Do not shake product or transport via tube system

Penicillin allergy precautions Check allergies Avoid rapid infusions seizures may result Dose reduction recommended for CrCl < 50 ml/min Watch K+ -- 1 million units PCN G contains 1.7 mEq K+ Monitor BP every 15 min during 60 min infusion Administer in supine position Monitor blood glucose daily during therapy-hypoglycemia common Daily BUN/SCr, and LFTs recommended Metallic taste noted to be common Recommended max dose is 360 mg/24 hr Monitor respiratory status may cause respiratory depression Reverse with naloxone (Narcan) Do NOT refrigerate crystallization may occur

Pentazocine 30 mg = Morphine 10 mg IV

strated competency to manage this medication.

58

Section II
Medication Generic - (Brand) PENTobarbital (Nembutal) How Supplied 50mg/ml 1 ml syringe, 20 & 50 ml Vials IV Push Conc / Rate Yes, Give slowly at max rate of 50 mg/min

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time System Standard Conc: 2000 mg/210 ml NS (total volume 250 ml) (8 mg/ml) Metro: Preprinted order set available for Barbiturate Coma for elevated ICP. Refer to ICP protocol (PPO 02974) Loading /Bolus Doses: 2.5-10mg/kg over 15-60min, respectively. Continuous Infusion: Initiate at 1.5mg/kg/hr. 5 mg/ml 1 ml amp Yes but only use IV if absolutely necessary Dilute 5 mg w/ 9 ml NS and give 0.5 mg/min IM administration recommended Yes, Give slowly at max rate of 60 mg/min

This section can be copied and kept for reference at bedside.

*HIGH ALERT MEDICATION* Sedative/ Barbiturate

Perphenazine (Trilafon)

Antipsychotic Agent

PHENObarbital (Luminal)

60 mg/ml 1 ml, 130 mg/ml 1 ml syringes

Intermittent Infusion: Loading dose: 15mg/kg in 100 ml NS Infuse over 15-30 minutes Maintenance doses: 1-3mg/kg/day (divided doses) may be given slow IV push

Anticonvulsant/ Sedative/ Barbiturate

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time Undiluted solution is alkaline avoid infiltration. Central line administration preferred. With IV administration monitor respiration & cardiac function continuously Monitor pentobarbital levels. Goal levels: Hyponotic/sedation: 15 mcg/ml Coma: 10-50 mcg/ml Usual dose is 1 mg every 2-3 min Recommended max dose is 5 mg May cause contact dermatitis; Extrapyramidal symptoms (ie. Dystonia rxn) possible Postural hypotension may occur monitor BP Undiluted solution is very alkaline avoid infiltration Monitor BP, HR, RR With continuous IV administration monitor respiration & cardiac function continuously Too rapid administration may cause respiratory distress and hypotension

Incompatible with most Controlled medications/solutions check airway and with pharmacist ventilation required Use 0.22 micron filter with infusion Critical care only!

*See footnote Incompatible with most Critical Care for medications/solutions check continuous with pharmacist infusions

strated competency to manage this medication.

59

Section II
Medication Generic - (Brand) Phentolamine (Regitine) How Supplied 5mg/ml 1ml Vial IV Push Conc / Rate Yes, 5mg/10ml NS Give over 30 seconds SQ administration preferred

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time SQ administration preferred Administer within 12 hr of extravasation

This section can be copied and kept for reference at bedside.

Vasodilator

Phenylephrine (Neosynephrine) Vasopressor

10 mg/ml 1 & 5ml Vial

Yes, rarely. 0.1-0.5 mg given over at least 1 min Prep: add 1 ml of phenylephrine 10 mg/ml to 100 ml NS final conc 0.1 mg/ml Yes, M mg/min

Continuous Infusion System Standard Conc: 50 mg/250 ml NS (200 mcg/ml) System Concentrated Conc: 50 mg/ 100 ml NS (0.5 mg/ml) Usual dose range: 40-60 mcg/min is usually adequate

PhenyTOIN (Dilantin)

Anticonvulsant

50 mg / ml 2ml Syringe & 2 or 5ml vial

Dilute with only ax rate of 50 between 2 & 10 mg/ml.

Rate of 25 mg/min recommended in elderly or presence of coronary artery disease.

Recommended loading dose: 15-20 mg/kg Recommended maintenance dose: 5 mg/kg/day

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

r LVP Standard Diluent

mmended Infusion Time ministration preferred

Antidote for peripheral ischemia due to dopamine, dobutamine, norepinephrine, metaraminol, epinephrine , phenylephrine. See PPO 5046 SQ admin: dilute to 0.5-1 mg/ml and inject 0.5 ml in multiple sites to cover extravasation area (doses up to 50 mg have been used) Avoid infiltration Phentolamine (Regitine) SQ recommended for management of infiltration -see PPO 5046 for general extravasation guidelines / management Monitor BP, HR every 15 min Monitor urine output every 1-2 hr

Use reconstituted solution immediately

Critical Care

m Standard Conc: 50 mg/250 ml

m Concentrated Conc: 50 mg/

dose range: 40-60 mcg/min is

Central line advised! NS to a concentration BP Monitor Central line administration required for doses > 300mg. Fosphenytoin may be given peripherally. Watch for crystal formation. Alkaline solution local burning upon administration is common slow infusion if occurs Avoid Extravasation see PPO 5046 for general guidelines / management Fosphenytoin is preferred refer to fosphenytoin entry.

Administer immediately after dilution. Stable only 4 hr. Use in-line filter (0.22 micron) Flush IV line with 10 ml NS before and after dose administered

mmended loading dose: 15-20

mmended maintenance dose: 5

strated competency to manage this medication.

60

Section II
Medication Generic - (Brand) Phosphate Potassium or Sodium Salts *HIGH ALERT MEDICATION* Electrolyte Physostigmine (Antilirium) Cholinergic How Supplied IV Push Conc / Rate

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Infuse slowly as dilute solutions Recommended infusion rates: 5 mMol Phos/100 ml D5W over 1 hr 10 mMol Phos/150 ml D5W over 2 hr 15 mMol Phos/250 ml D5W over 3 hr 20 mMol Phos/250 ml D5W over 4 hr 30 mMol Phos/250 ml D5W over 6 hr NO max rate of

This section can be copied and kept for reference at bedside.

5 & 10 ml NO Vial 3 mMol (Millimoles ) Phosphate & 4.4 mEq K or 4 mEq Na per ml 1mg/ml Yes, 2ml Amp at 1mg/min

Phytonadione (Vitamin K Aquamephyton) Vitamin/ Reversal of Anticoagulation

1 mg/0.5 ml amp/ syringe 10 mg/ml amp 50mg/5 ml vial

NO

Intermittent infusion- Usual Dose: 5-10mg/50 ml NS over 30-60minutes, respectively. May be administered over 15min in emergency reversal (ICH).

Piperacillin (Pipracil) Antibiotic/Penicillin

2, 3, and 4 gm vials

NO IM administration recommended

Dilute in 100 ml NS/D5W and infuse over minimum of 30 minutes

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

r LVP Standard Diluent

mmended Infusion Time slowly as dilute solutions mmended infusion rates: l Phos/100 ml D5W over 1 hr ol Phos/150 ml D5W over 2 hr ol Phos/250 ml D5W over 3 hr ol Phos/250 ml D5W over 4 hr ol Phos/250 ml D5W over 6 hr

Lower dose recommended with concomitant hyper-calcemia Recommended dose range is 0.08 0.24 mMol/Kg Sodium Phosphate or Potassium Phosphate should always be ordered in millimoles (mMol) For reversal of anti-cholinergic toxicity Recommended max dose is 4 mg in 30 min

Not compatible with calcium solutions

Too rapid administration *See footnote may cause bradycardia and not confuse Do respiratory distress with pyridostigmine. Atropine readily available (UBC) Use immediately after dilution. route IV restricted to Protect from light. Critical Care, OR & ED administration. Outside of these areas: physician administration only.

ttent infusion- Usual Dose: g/50 ml NS over 30-60minutes,

e administered over 15min in ency reversal (ICH).

Severe anaphylactoid reactions have occurred usually during / immediate following infusions. Fatal reactions have been reported. Monitor closely for signs of flushing, weakness, tachycardia, SOB, abdominal pain, and hypotension; discontinue infusion. Consider fluids, diphenhydramine, epinephrine, corticosteroids & supportive therapy. Penicillin derivative Check allergies Slow infusion rate if vein irritation occurs Dose reduction recommended for CrCl < 40 ml/min

n 100 ml NS/D5W and infuse inimum of 30 minutes

strated competency to manage this medication.

61

Limitations /

*See footnote Do not confuse pyridostigmine. Atropine readily available (UBC)

Critical Care, administration. Outside of these areas: physician administration

Section II
This section can be copied and kept for reference at bedside.
Medication Generic - (Brand) Piperacillin/Tazobactam (Zosyn) How Supplied 2/0.25, 3/0.375 & 4/0.5 Gm Vial and Premix 2/0.25 in 50 ml, 3/0.375 in 50 ml, 4/0.5 in 100 ml IV Push Conc / Rate NO SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Infuse over minimum of 30 min

Antibiotic/ Penicillin

Potassium Chloride
*HIGH ALERT MEDICATION*

Electrolyte

Vials 2mEq/ml Premix bags: 10mEq/ 50 & 100ml, 20mEq /50 & 100ml

NEVER GIVE IV PUSH!!

Maximum concentration:


Administration rate:

Pramlintide (Symlin)
*HIGH ALERT MEDICATION*

No,

Not advised

SC administration only!

Synthetic analog of amylin/ adjunct treatment of diabetes

Units with cardiac monitoring and nurses who have demonstrated competency to manage this Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

Parenteral Medication Administration Guidelines


SVP or LVP Standard Diluent Precautions / Comments Max/Min Concentrations Recommended Infusion Time Infuse over minimum of 30 min Penicillin derivative Check allergies Stability / Storage

Slow infusion rate if vein irritation occurs Dose reduction recommended for CrCl < 40 ml/min Extended infusions over 3 -4 hours may be used for treatment of resistant pathogens. Maximum concentration: Avoid extravasation see PPO 5046 Intermittent infusion, peripheral for general guidelines / management. line: 20 mEq/100 ml Intermittent infusion, central line: 20 mEq/50 ml LVP/IV fluids: 80 mEq/L Administration rate: Usual: 10 mEq/hr (20 mEq/hr for 20 mEq/50 ml) Max admin rate without telemetry: 20 mEq/hr Max. admin rate with telemetry: 40 mEq/hr (exceeding 40mEq/hr for severe, life-threatening, symptomatic hypokalemia requires cardiac monitoring & physician presence) Used as adjunct to mealtime insulin in Type I & Type 2 DM. Can cause severe hypoglycemia used with insulin monitor for s/sx of hypoglycemia Caution: Product labeled in mg/mL. Dosed in mcg . Administered using insulin syringes labeled in units. when

Slowing potassium infusion rate, increasing maintenance fluid rate, or increasing SVP volume may reduce stinging if encountered with peripheral administration. If these measures fail, lidocaine 10-50 mg may be added for peripheral administration upon MD order. Greater than 100 mg/day not recommended.

Do NOT mix with insulin!! Unopened vials: refrigerate/protect from light. See vial for expiration date. Opened vials: Discard after 28 days

have demonstrated competency to manage this medication. elines - Revised Final 07-2009

Stability / Storage

Limitations / Restrictions

Slowing potassium infusion rate, footnote if * See increasing maintenance fluidrate of infusion rate, or increasing SVP volume exceeds may reduce stinging if 20mEq/Hr encountered with peripheral administration. If these measures fail, lidocaine 10-50 mg may be added for peripheral administration upon MD order. Greater than 100 mg/day not recommended.

Metro: Do NOT mix with insulin!! Pramlintide will NOT be Unopened vials: dispensed for refrigerate/protect from light. inpatients per See vial for expiration date. P&T. See Metro Pharmaceutical Opened vials: Discard after 28 Services P&P 3.55 (06/06)

62

Section II
Medication Generic - (Brand) How Supplied 100 mg/ml 10 ml vials 500 mg/ml 2 ml vials for IM injections 5mg/ml, syringes and Vials IV Push Conc / Rate

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Continuous Infusion: Usual dose range: 2 6 mg/min

This section can be copied and kept for reference at bedside.

Procainamide (Pronestyl)

Cardiovascular/ Antiarrhythmic

Yes, Diluted to 20mg/ml and give at 20-50 mg/minSystem Standard Conc: 1 Gm/250 ml Up to total dose of NS (4mg/ml) 1 Gm System Concentrated Conc: 1 Gm/100 ml NS (10 mg/ml) Intermittent Infusion 10mg in 50ml NS over 15min

Prochlorperazine (Compazine)

Yes, 5 mg per minute maximum rate

Antiemetic

Profilnine SD See Factor 9 Complex Human Promethazine (Phenergan) Antihistamine/ antiemetic

25 & 50mg/ml Vials

Yes, max of 25 mg/min For IV admin: Dilute to 10-20 ml with NS and admin via running IV line IM Preferred

Not advised IM Preferred

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions * See footnote Check with pharmacist regarding compatibility information.

mmended Infusion Time Monitor BP every 2-3 min during loading dose then every 15 min until stable during initial infusion. m Standard Conc: 1 Gm/250 ml Continuous ECG monitoring. Elimination half-life extended in renal

failure. Do not exceed 40 mg in 24 hours n 50ml NS over 15min Slow rate if extra-pyramidal symptoms (dystonia, motor restlessness, parkinson-like symptoms) occur Monitor for hypotension recommend patient lay down or sit for 30 min after dose

Protect diluted solutions from Contraindicated light in patients with Parkinsons disease

Monitor for hypotension, tachycardia. Avoid extravasation --Apply warm compresses for 20-30 minutes 4-6 times a day for 1-2 days. Extravasation see PPO 5046 for general guidelines / management

Metro: Promethazine injection is not available due to safety concerns including extravasation.

strated competency to manage this medication.

63

Section II
Medication Generic - (Brand) Propofol (Diprivan) *HIGH ALERT MEDICATION* Sedative How Supplied 10mg/ml 20ml Amp, 50 & 100ml bottles fat emulsion IV Push Conc / Rate Yes, Give slowly over 3-5 min.

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Continuous Infusion ICU sedation 5mcg/kg/min with additional 5-10 mcg/kg/min increments every 5 minutes to sedation level desired. Usual dose range: 5-50 mcg/kg/min System Standard Conc: 1000 mg/100 ml Premix (10 mg/ml)

This section can be copied and kept for reference at bedside.

Propranolol (Inderal)

1mg/ml vial

Cardiovascular/ BetaBlocker

Yes, 0.5mg then 1mg/min every 510 min to max of 0.1mg/Kg Max rate: 1 mg/min Yes, 10mg/ml given over 1-3 minutes. Max dose: 50mg in any 10 minute period Yes Max rate of 5 mg/min

NO

Protamine Heparin antagonist

10mg/ml 5 and 25ml Vials

NO

Pyridostigmine (Mestinon) Cholinergic

5 mg/ml 2 ml amp, 5 mg/ml 5 ml vial

NO

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time Do not mix with other solutions or infuse if emulsion appears separated g/min increments every 5 Propofol contains 1.1 Kcal/ ml Monitor closely for hypotension, bradycardia, and respiratory depression

For infusions > 72 hours, recommend checking triglycerides


Avoid Extravasation see PPO 5046 for general guidelines / management BP every 5 min during titration, then q 15min until stable Monitor Heart Rate-bedside monitor + defibrillator IV maintenance dose may be given every 4 hrs Monitor for hypotension & bradycardia 1 mg protamine for approx 100 units USP Heparin Used in pt with myasthenia gravis May be used to reverse effects of nondepolarizing neuromuscular blockers. Other agents preferred.

Discard unused solutions after Critical Care for 12 hours continuous infusion; Change tubing every 12 IV push mode hours limited to areas that can provide Do not filter respiratory monitoring and prompt intubation

May dilute w/ 10 ml D5W or * See footnote give undiluted

Incompatible with many Monitored bed medications/solutions check recommended. with pharmacist Do not confuse with physostigmine.

strated competency to manage this medication.

64

Section II
This section can be copied and kept for reference at bedside.
Medication Generic - (Brand) Pyridoxine (Vitamin B-6) Vitamin/ Nutritional Supplement How Supplied 100mg/ml in 10 & 30ml vials IV Push Conc / Rate Yes, 50 100 mg/min

Parenteral Medication Adminis


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Intermittent Infusion 5 Gm in 50ml NS over 30min 50-100mg in 50mL NS over 30min

Ranitidine (Zantac) H Receptor 2 Antagonist Remifentanil

25mg/ml vial and syringe

(Ultiva)
*HIGH ALERT MEDICATION*

Powder for Injection: 1mg,2mg, 5mg vials

Yes, Dilute 50mg dose up to 5ml with NS and give over 2-3 minutes Yes, over 30-60 seconds by Anesthesia or with continuous airway support

Slow IV-Push preferred Continuous Infusion: System Standard Conc: 150mg/250ml NS (0.6 mg/ml) Slow IV push or via continuous infusion Continuous Infusion: System Standard Conc: 2mg/100mL (20mcg/mL). Dose range 0.0252mcg/kg/min May be used for treatment of Peripheral Arterial Occlusion (PAO)

Narcotic Analgesic
Reteplase (r-PA, Retevase) 1 unit/ml 10 ml vial Yes, For AMI: 10 units over 2 min . Repeat 10 units after 30 min Flush with minimum of 30-50 ml NS or D5W

*HIGH ALERT MEDICATION* Do not confuse with other thrombolytic medicines.

Thrombolytic

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

Parenteral Medication Administration Guidelines


SVP or LVP Standard Diluent Precautions / Comments Max/Min Concentrations Recommended Infusion Time Intermittent Infusion Antidote: Isoniazid poisoning or 5 Gm in 50ml NS over 30minoverdose - Give equivalent amounts of 50-100mg in 50mL NS over 30min pyridoxine as ingested Isoniazid. Antidote: Ethylene glycol toxicity administer 50-100mg q6h until ethylene glycol levels undetectable / resolution of acidosis Slow IV-Push preferred Continuous Infusion: System Standard Conc: 150mg/250ml NS (0.6 mg/ml) Slow IV push or via continuous of apnea / respiratory depression. Risk Stability / Storage Limitations / Restrictions

Anesthesia / Anesthesia Consult Only

Continuous Infusion: System Standard Conc: 2mg/100mL (20mcg/mL). Dose range 0.0252mcg/kg/min May be used for treatment ofThrombolytic medication: Monitor Peripheral Arterial Occlusionfor bleeding. (PAO) Minimize potential risks for bleeding: Establish all IVs prior to therapy. (Minimum of 2 peripheral IVs recommended in addition to thrombolytic infusion site.) Avoid unnecessary arterial/venous punctures, excessive blood sampling, and IM injections for at least 24 hr after d/cd (malnourished patients 48 hr). Apply pressure dressings to all puncture sites.

Do not shake or transport via*See footnote for tube system. cardiopulmonary indications (ie: Incompatible with heparin!! AMI, PE). Check compatibilities with pharmacist Monitoring is at physician Do not mix with any discretion for meds/solutions. peripheral vascular indications.

strated competency to manage this medication.

65

Limitations /

Consult Only

*See footnote for cardiopulmonary indications (ie:

Monitoring is at

Section II
Medication Generic - (Brand) RifAMPIN (Rifamycin) How Supplied 600mg Vial for Injection IV Push Conc / Rate NO

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Intermittent Infusion Up to 600mg diluted into 100ml D5W or NS over 30 minutes

This section can be copied and kept for reference at bedside.

Antibiotic

Rocuronium (Zemuron)
*HIGH ALERT MEDICATION*

10mg/ml 5ml Vial

Yes, intubation dose 0.6 mg/Kg rapidly

Continuous Infusion: Usual dose range: 5-20 mcg/Kg/min

Neuromuscular blocker

Sargramostim (GM-CSF Leukine) Colony Stimulating Factor Sodium Bicarbonate

500mcg/ml vial

NO

Intermittent infusion: 25 ml NS Infuse over 2 hours

Electrolyte

8.4% solution 1mEq/ml & syringe Neonatal: 4.2% solution 0.5 mEq/ml 10 ml syringe

Yes, 50 mEq (50 ml) over 1-2 minutes Neonates: avoid admin of 10 ml/min or greater

Sodium bicarbonate may be added to IV fluids check with pharmacist for compatibility/stability information

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time May cause a reddish-orange discoloration of urine, saliva, tears, sweat and stool Permanent discoloration of soft contact lenses may occur. Avoid infiltration = local irritation and inflammation. If this occurs, the infusion should be discontinued and started at another site. Refer to Nursing Clinical Policies on Neuromuscular Blockade (i.e. MN-13)

Protect from light Expires 4 hours after preparation.

Refrigerate vials. Unopened Controlled airway vial stable at room temp x 60and ventilation days but then must be required; discarded. Critical Care only: ED, ICU, Surgery Sedation must be administered prior to and during paralytic use!

Do not filter solution Use only NS to dilute

Monitor BP syncope may occur especially after 1 dose st

Concentrations less than 10mcg/mL require albumin 0.1% added to solution to prevent adsorption.

Do not mix with other medications Check with pharmacist m bicarbonate may be added to

Neonates: Flush w/ 10-20 ml NS before after administration

Avoid extravasation!! Central line administration advised when ever possible. (See PPO 5046) strated competency to manage this medication.

66

Section II
Medication Generic - (Brand) How Supplied 500 ml bag IV Push Conc / Rate Not advised

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Rate and infusion duration variable.

This section can be copied and kept for reference at bedside.

Sodium Chloride 3%
*HIGH ALERT MEDICATION*

Hypertonic solution

Sodium citrate, 4%

500 ml bags

NO

NOT to be infused directly intravenously.

Anticoagulant StreptoMYCIN

1g vial (powder)

NO

Antimicrobial

Intermittent IV Infusion - usual dose: 500-1000mg in 100mL NS over 3060min May administer via deep IM injection

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time Hypertonic (3%) saline is non- not mix with any Do physiologic and is only indicated in medications/solutions. Contact neurosurgical patients or patients + pharmacist for compatibility with severe (Na < 120) or information. symptomatic hyponatremia. Chronic Hyponatremia: Risk associated with rapid sodium line administration and Central correction (greater than Critical Care admission 0.5mEq/L/hr or 8 mEq/24 hr) advised. includes osmotic demyelination and permanent neurologic damage. Periodically hypertonic saline is used at low rates for short periods of times s/p urological surgeries, etc. the limitations/restrictions need not apply in such instances. May be used as an alternative to capping with heparin (ex. PICC lines, Mahukar lines, etc.) Dose adjustment in elderly / reduced renal function. Monitor hearing, renal function & serum concentrations as indicated.

Metro: Mandatory PPO with serial sodium levels (minimum q 4 hr) and mandatory call parameters (minimum order + to call if Na correction exceeds 8 mEq/24 hr) if not included in original order, physician must be contacted per P&T.

strated competency to manage this medication.

67

Limitations /

Mandatory PPO sodium levels (minimum q 4 mandatory call (minimum order

mEq/24 hr) if not included in original order, physician must be contacted per

Section II
Medication Generic - (Brand) How Supplied 20mg/ml 10ml Vial IV Push Conc / Rate Yes, prior to intubation 0.6mg/kg slowly over 30 seconds

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Other medications preferred as continuous infusions

This section can be copied and kept for reference at bedside.

Succinylcholine
*HIGH ALERT MEDICATION*

Neuromuscular blocker

Contraindicated in patients with personal or family history of malignant hyperthermia or history of skeletal muscle myopathy!!

Tacrolimus (Prograf)

5mg/ml 1ml Amp

NO

Continuous Infusion Usual dose: 0.05 0.1 mg/Kg/Day Standard conc: 5 mg/250 ml NS (Excel) (20 mcg/ml) Intermittent infusion (q12h) run over 4 hr Conc must be 0.004 0.02 mg/ml

Immunosuppressant

Tenecteplase (Tnkase)

50mg vial

*HIGH ALERT MEDICATION* Do not confuse with other thrombolytic medicines. Thrombolytic

Yes, Weight based bolus dosing (15 50mg depending on weight) Give dose over 5 seconds into running NS line

Acute Coronary Syndrome/Acute Myocardial Infarction: Preprinted order set available Peripheral Vascular Thrombolysis: Per Interventional Radiology. Preprinted order set available

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions Controlled airway and ventilation required; Critical Care only: ED, ICU, Surgery. Sedation must be administered prior to and during paralytic use!

mmended Infusion Time Refer to Nursing Clinical Policies Neuromuscular Blockade (i.e. MN-13) Too rapid administration may cause bradycardia May cause hyperkalemia increased risk with use in patients with burns, severe trauma, stroke, spinal cord injury, muscular dystrophy, multiple sclerosis, tetanus, Parkinsons disease. May cause rhabdomyolysis *NOTE: Sublingual administration preferred due to risk of allergic reaction with IV product*

Refrigerate

aindicated in patients with

Use admin set provided by pharmacy IV = PO Dose

Monitor for allergic reaction especially during initial 30 minutes of first infusion anaphylaxis must be 0.004 0.02 mg/ml Monitor for hyperkalemia, hyperglycemia and elevated BP

Monitor trough tacrolimus levels


Thrombolytic medication: Monitor for bleeding. Minimize potential risks for bleeding: Establish all IVs prior to therapy. (Minimum of 2 peripheral IVs recommended in addition to thrombolytic infusion site.) Avoid unnecessary arterial/venous punctures, excessive blood sampling, and IM injections for at least 24 hr after d/cd (malnourished patients 48 hr). Apply pressure dressings to all puncture sites. *See footnote for cardiopulmonary indications (ie: AMI, PE). Monitoring is at physician discretion for peripheral vascular indications.

May precipitate in IV lines with D5W. Flush line with NS before and after administering. Do not mix with other medications/solutions.

strated competency to manage this medication.

68

Limitations /

Controlled airway and ventilation

Sedation must be administered during paralytic

*See footnote for cardiopulmonary indications (ie:

Monitoring is at

Section II
Medication Generic - (Brand) Terbutaline (Brethine) Sympathomimetic How Supplied 1 mg/ml ampule IV Push Conc / Rate NO SQ administration preferred 0.25 mg SQ x 1, may repeat x 1 after 1530 min. Max dose of 0.5 mg in 4 hr recommended.

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Continuous infusion: Used to inhibit pre-term labor contractions (tocolysis). Titrate to contractions >/= 15 minutes or absence of contractions Uterine relaxation: 0.25 mg in 5 ml NS given IV push

This section can be copied and kept for reference at bedside.

Theophylline

Bronchodilator

Premix bags: 800mg/500 ml

NO

Intermittent Infusion 5mg/kg theophylline loading dose over 30 min Continuous Infusion 0.4mg/Kg/hr theophylline System Standard Conc: 800mg/500ml Premix (1.6 mg/ml)

Thiamine (Vitamin B-1)

100mg/ml 2ml vial

Vitamin/ Nutritional supplement Thiopental (Pentothal) Sedative/ Barbiturate 400 mg & 500 mg syringes

Yes, Administer via large vein over at least 3 min with running IV fluids. Also may be given IM Yes, Over 10-15 seconds

A common component in a banana bag 1000 ml bag. May also be given as intermittent infusion: 100 mg/50 ml D5W. Infuse over 15 30 min.

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions * See footnote Protect ampule from light

mmended Infusion Time Monitor for s/sx pulmonary edema in pt on continuous infusion Monitor HR (maternal and fetal), BP, ECG, I&Os See site specific administration policy

Metro: See MWH-17-MAT: Womens Health Policies & Procedures Terbutaline sulfate: Administration for Tocolysis Theophylline serum level monitoring is recommended periodically during IV infusion uous Infusion 0.4mg/Kg/hr Monitor HR, BP (Note: Aminophylline is 80% theophylline: 500mg aminophylline = 400mg theophylline) ** Verify dose to be given. Discard vial after drawing up correct dose. **

Pain at IV site noted at times. n: 100 mg/50 ml D5W. Infuse

Avoid infiltration may treat affected area with lidocaine 1% Central line administration preferred Monitor respiration & cardiac function continuously Contraindicated in patient with porphyria

Controlled airway and ventilation required Critical care only!

strated competency to manage this medication.

69

Section II
Medication Generic - (Brand) Tigecycline (Tygacil) Antibiotic How Supplied 50 mg/5 ml vial IV Push Conc / Rate NO

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Intermittent infusion: 100 mg in 100 ml D5W or NS then 50 mg in 100 ml D5W or NS. Infuse over 30-60 minutes Max conc = 1 mg/ml

This section can be copied and kept for reference at bedside.

Tirofiban (Aggrastat)

12.5 mg/ml 50 ml vial, 12.5mg/250 ml premix bag

Yes, 25 mcg/Kg over 3 minutes in PTCA

Continuous Infusion PTCA: 0.15mcg/Kg/min Unstable Angina: 0.4 mcg/Kg/min x 30min then 0.1 mcg/Kg/min Standard Conc: 12.5mg/250ml NS (50mcg/ml)

Antiplatelet IIb/IIIa

Tobramycin (Nebcin) Antibiotic/ Aminoglycoside Torsemide (Demadex) Loop Diuretic Tranexamic acid (Cyclokapron) Antifibrinolytic

10mg/ml & 40mg/ml Vial

NO

Intermittent Infusion All doses diluted into 50 - 100ml NS or D5W and infused over 30-60 minutes May be given as continuous infusion. System Standard Conc: 100 mg/100 ml NS (1 mg/ml) IV infusion during cardiac surgery. Refer to PPO as needed.

10mg/ml 2 & 5ml Amps 100mg/ml 10ml Amps

Yes, Max 5 mg/min

NO

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time Dose reduction needed for patients w/ hepatic impairment 100 ml D5W or NS. Infuse over

Diluted solution is yellow/orange in color Stable 6 hrs at room temp/ 24 hrs refrigerated after dilution Contact pharmacist for compatibility information

Pre-printed orders for unstable angina or PTCA applications are available ble Angina: 0.4 mcg/Kg/min x Monitor for signs of bleeding!! Monitor VS every 15 min ard Conc: 12.5mg/250ml NS Dose reduction to 0.05mcg/kg/min recommended for pt with CrCl < 30ml/min Monitor APTT, Hgb/Hct, PT/INR, and platelets daily while receiving tirofiban Aminoglycoside dosing and monitoring service available from pharmacy upon physician order.

Monitor renal function. Recommended max single dose is 200 mg m Standard Conc: 100 mg/100 ml Do not mix with penicillin

strated competency to manage this medication.

70

Section II
Medication Generic - (Brand) Treprostinil (Remodulin) How Supplied 1, 2.5, 5, and 10 mg/ml 20 ml vials IV Push Conc / Rate NO

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Subcutaneous or intravenous continuous infusion

This section can be copied and kept for reference at bedside.

Cardiovascular/ Vasodilator

*** Metro: Use of preprinted order set advised ***

Trimethoprim & Sulfamethoxazole (Cotrimoxazole) (Bactrim, Septra)

80mg TMP + 400mg SMX per 5ml vial

NO

Antibiotic/ Sulfonamide

Urokinase (Abbokinase)

*HIGH ALERT MEDICATION* Thrombolytic

250000 Varying doses unit vial depending on indication consult external reference or pharmacist. Give over 10 min

Intermittent Infusion PCP (Pneumocystis Carinii Pneumonia): 15-20mg/kg/day into 4 doses (q 6h) Each 80mg (5ml) TMP diluted into 100ml D5W Infuse dose over 90min Varying continuous infusions depending on indication consult external reference or pharmacist System Standard Conc: 1 million units/250 ml NS (4000 units/ml)

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions SC: Stable 28 * See after initial days footnote use if refrigerated; 14 days at room temp SC administration: Only use syringe pump provided by 0 home health care agency. IV: 1 mg in 100ml NS stable 48 hr at room temp.

mmended Infusion Time Avoid infusion interruptions loss of disease control could lead to death Monitor for hypotension, flushing, headache, N/V, anxiety & chest pain A Remodulin Dosing Weight is established and used throughout the patients therapy. The Remodulin Dosing Weight should be used when calculating infusion rate. Flush line before and after Cotrimoxazole with D5W Do not mix with any other medications/solutions contact pharmacist Thrombolytic medication: Monitor for signs of bleeding. Minimize potential risks for bleeding: Establish all IVs prior to therapy. (Minimum of 2 peripheral IVs recommended in addition to thrombolytic infusion site.) Avoid unnecessary arterial/venous punctures, excessive blood sampling, and IM injections for at least 24 hr after d/cd (malnourished patients 48 hr). Apply pressure dressings to all puncture sites. Thrombin time elevated

Sulfa 5 ml in 100 ml derivative D5W Stable 4 hourscheck


5 ml in 75 ml D5W allergies!! Stable 2 hours Critical Care for continuous infusion Monitoring is at physician discretion for peripheral vascular indications.

strated competency to manage this medication.

71

Section II
Medication Generic - (Brand) Valproate Sodium (Depacon) Anticonvulsant How Supplied 100mg/ml 5ml vial IV Push Conc / Rate NO

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Intermittent Infusion Loading dose: 15 mg/Kg in 50-100 ml NS or D5W over 10-15 minutes Maintenance dose: 2-5 mg/kg q6-8h in 50-100 ml NS or D5W Infusion rate may be up to 3 mg/kg/min (total dose </= 15 mg/kg) Intermittent Infusion <500mg in 100ml NS/D5W > 500 mg in 250ml NS/D5W Infuse doses < 500 over 60 minutes Infuse doses < 1 gm over 90 minutes Infuse doses > 1 gm over 120 minutes

This section can be copied and kept for reference at bedside.

Vancomycin Antibiotic/Glycopeptide

500mg & 1Gm vial, Premix bag: 500mg /100ml

NO

Vasopressin (Pitressin) Hormone

20 units/ml 1 & 10ml vial

Yes, Continuous Infusion For persistent Usual dose range: VF/pulseless VT 0.2-1.0 units/min (GI bleeds) or asystole/PEA 0.02- 0.1 units/min (Shock) 40 units IV push x 1 after flush w/System Standard Conc: 100 Units/ 100ml NS (1 unit/ml) 10 ml NS

Vecuronium (Norcuron)
*HIGH ALERT MEDICATION*

10 & 20 mg vials (powder)

Yes, intubation dose 0.1 mg/Kg rapidly

Continuous Infusion: Usual dose range: 1-2 mcg/Kg/min System Standard Conc: 50 mg/50 ml NS (total vol=100 ml) (0.5 mg/ml)

Neuromuscular blocker

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

r LVP Standard Diluent

mmended Infusion Time Dosing and monitoring service available from pharmacy per physician order.

g dose: 15 mg/Kg in 50-100 ml D5W over 10-15 minutes nance dose: 2-5 mg/kg q6-8h in

n rate may be up to 3 min (total dose </= 15 mg/kg) Slow rate of infusion if hypotension or flushing occur Avoid extravasation Refer to PPO 5046 Aminoglycoside dosing and monitoring service available from pharmacy upon physician order. Monitor renal function. Avoid extravasation/infiltration central line advised. Monitor BP, HR every 15 min Monitor urine output every 1-2 hr Monitor fluid and electrolyte status

mg in 250ml NS/D5W doses < 500 over 60 minutes

doses < 1 gm over 90 minutes doses > 1 gm over 120 minutes

Critical Care

units/min (GI bleeds)

m Standard Conc: 100 Units/

dose range: 1-2 mcg/Kg/min

Bradycardia and hypertension are early signs of toxicity Refer to Nursing Clinical Policies on Neuromuscular Blockade (i.e. MN-13) Preprinted order set available for ICU neuromuscular blockade

m Standard Conc: 50 mg/50 ml al vol=100 ml) (0.5 mg/ml)

Controlled airway and ventilation required; Critical Care only: ED, ICU, Surgery. Sedation must be administered prior to and during paralytic use!

strated competency to manage this medication.

72

Limitations /

Controlled airway and ventilation

Sedation must be administered during paralytic

Section II
Medication Generic - (Brand) Verapamil (Isoptin) Cardiovascular/ Calcium Channel Blocker How Supplied 2.5mg/ml 2 & 4ml vial IV Push Conc / Rate Yes, 5-10 mg over 2 minutes (max rate of 5 mg/min) Slower in elderly patients max rate of 2 mg/min

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Continuous Infusion: Usual dose range: 5-20 mg/hr Standard conc: 125 mg/150 ml NS (total vol=200 ml) (0.625 mg/ml) Concentrated conc: 125 mg/50 ml NS (total vol=100 ml) (1.25 mg/ml)

This section can be copied and kept for reference at bedside.

Vitamin K See

Phytonadione
Voriconazole (Vfend) Antifungal Dilute in 250 ml NS Infuse over 2 hr Refer to preprinted order set (PPO 2627) for dose, indications & contraindications Warfarin (Coumadin) Anticoagulant IM administration NOT advised! 5 mg vial Yes, Give dose over 12 minutes NO 10 mg/ml 20 ml vial NO Recommended dose: 6 mg/kg IV every 12 hr x 2 doses then 4 mg/kg IV every 12 hr

Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions * See footnote

mmended Infusion Time Not compatible with bicarbonate solutions ard conc: 125 mg/150 ml NS Avoid mixing with other medications/solutions check with pharmacist

IV formulation contraindicated in pt with CrCl < 50 ml/min. PO formulation not contraindicated in pt with renal insufficiency nor is any dose reduction recommended Dose reduction recommended in pt with hepatic insufficiency/drug-drug interactions for dose, indications & Transient visual disturbances may occur ** Verify dose to be given. Discard vial after drawing up correct dose. ** Monitor INR

Use only sterile water for reconstitution Once reconstituted, use within 4 hours Keep vial in carton until use Do NOT refrigerate

strated competency to manage this medication.

73

Section II
Medication Generic - (Brand) Ziconotide intrathecal infusion (Prialt) *HIGH ALERT MEDICATION* How Supplied 100 mcg/ml 1 & 5 ml vials, 25 mcg/ml 20 ml vial IV Push Conc / Rate

Parenteral Medication Administration G


SVP or LVP Standard Diluent Max/Min Concentrations Recommended Infusion Time Indicated for the management of severe chronic pain in patients whom intrathecal therapy is warranted, and who are intolerant of or refractory to other treatments.

This section can be copied and kept for reference at bedside.

Intrathecal administration only!!

due to intrathecal administration!!


Non-opioid analgesic

Zidovudine

10 mg/ml 20 ml vial

NO

Intermittent infusion: Infuse over 30-60 min L&D: 2mg/kg IV bolus over 1hour followed by 1mg/kg/hr IV infusion until cord clamped, then PO regimen for infant(s). Hypercalcemia / Bone Metastases: 4 mg/100ml NS or D5W over a minimum of 15 minutes X 1 dose Repeat prn usually every 3-4 weeks, but no more than once per week Pagets Disease / Osteoporosis: 5mg/100mL premixed solution over minimum of 15minutes once yearly. Doses given over < 15 minutes increase risk of renal toxicity!

Antiviral

Zoledronic Acid (Zometa / Reclast)

4 mg vial 5mg premixed solution

NO

Bisphosphonate

Reference: Aurora Health Care - Department of Pharmacy Services March 2009


Units with cardiac monitoring and nurses who have demonstrated competency to manage this medication. Formerly Metro Nursing Policy MN-18-B Med Admin. Guidelines - Revised Final 07-2009

nteral Medication Administration Guidelines


Precautions / Comments Stability / Storage Limitations / Restrictions

mmended Infusion Time Approved only for use in Medtronic SynchroMed EL, SynchroMed II Infusion Systems and Simms Deltec CADD Micro External Microinfusion Device and Catheter. Expiration once placed in infusion pump: Initial fill: 25 mcg/ml undiluted = 14 days Refill of pump: 25 mcg/ml & 100 mcg/ml undiluted = 60 days 100 mcg/ml diluted = 40 days May cause anemia or neutropenia

Refrigerate Dilute only with free NS preservative

Protect from light

Stable after dilution: 8 hr at room temp 24 hr refrigerated Vial: Protect from light Do not mix with other medications/solutions Restricted to outpatient use. Mandatory System-wide orders required for use.

100 mg PO zidovudine every 4 hr = 1 mg/kg IV every 4 hr ord clamped, then PO regimen

Assess baseline renal function, serum calcium and vitamin D levels prior to administration. Monitor renal function (I/O, SCr) more than once per week Dose reduction recommended for patients with CrCl < 60 ml/min. Not recommended if CrCl <30ml/min um of 15minutes once yearly. Hypotension in 10% of patients Bone pain common Mild fever and flu-like symptoms

rvices March 2009


74

strated competency to manage this medication.

Limitations /

outpatient use.

orders required

Insulin & Parenteral Antiglycemic Agents Aurora Hospitals


Rapid-Acting Insulin Apidra; Insulin Glulisine Onset: 5 minutes Duration: 2-4 hours May be mixed with Novolin N (NPH) only 1 unit Apidra 1 unit regular human insulin ? Give within 15 minutes before a meal or within 20 minutes after starting a meal In hospital: administer only when meal tray available Therapeutically equivalent to insulin aspart / lispro. Note: peak & duration extended in T2DM Rapid-Acting Insulin Novolog; Insulin Aspart * Onset: 5-15 minutes Duration: 3-5 hours May be mixed with Novolin N (NPH) Therapeutically equivalent to Lispro (Humalog) In hospital: administer only when meal tray available

Short-Acting Insulin Novolin R; Regular Insulin * Onset: 30-60 minutes Duration: 5-8 hours May be mixed with: Novolin N (NPH) Therapeutically equivalent to Humulin R

Intermediate-Acting Insulin Novolin N; NPH Insulin * Onset: 2-4 hours Duration: 14-18 hours May be mixed with Novolog and Novolin R Therapeutically equivalent to Humulin N

Long-Acting Insulin Lantus; Insulin Glargine* Onset: 1.5-2 hours Duration: Can not be mixed with any other insulins Administered once daily in most patients.

20-24 hours

Aurora Hospitals

Novolog; Insulin Aspart *

Long-Acting Insulin Levemir ; Insulin Detemir * Onset: 3-14 hours Duration: Can not be mixed with any other insulins Administered once or twice daily

Insulin Aspart Mix Novolog Mix 70/30 Onset: More rapid than regular insulin mixes administer with meals Peak effect: Duration: Administered once or twice daily. Do not mix with other insulin products. Shake prior to use must appear uniformly white & cloudy. Premixed 70/30 Insulin Novolin 70/30 * Onset: 30-60 minutes Duration: Premixed with 70% NPH and 30% Regular Cannot be mixed with any other insulin

Parenteral Antigylcemic Agents These are


Symlin ; Pramlintide Amylin Analog - augments effects of insulin and reduces prandial insulin requirements by 50% Should not be started in hospitalized patients due

Do not mix with insulin products. Byetta ; Exenatide Glucagon-like Peptide-1 Analog (GLP-1) used in Type 2 DM Peak response: 2 3 hours Duration: up to 5 hours Hold if NPO.

Insulin Product Ordered Insulin Glulisine (Apidra) Insulin Lispro (Humalog) Humulin 50/50 Humalog (Lispro Mix) 75/25 Humalog (Lispro Mix) 50/50 Novolin 70/30

Note: Formulary Substitutions as of April 2009. Contact your pharmacist with questions regarding substitutions as ne

6-24 hours

1-4hours up to 24hours

30-60 minutes 14-18 hours

not

Insulin Products

? to high risk of nausea, vomiting, & hypoglycemia.

Do likely to skip a meal/not eat enough, hypoglycemic, or has gastroparesis Give SQ immediately prior or within 15 min before meals.

only, -

as an alternative to insulin

Formulary Insulins & Antiglycemics are indicated with an asterix (*). AHC Formulary Substitution Equivalent number of units of Insulin Aspart (Novolog) Equivalent number of units of Insulin Aspart (Novolog) 50% of the ordered dose as NPH and 50% of ordered dose as Equivalent number of units of Insulin Aspart Mix 70/30 (Novolog Mix 70/30) 50% of the ordered dose as NPH and 50% of the ordered dose as Equivalent number of units of Insulin Aspart Mix 70/30 (Novolog Mix 70/30)

harmacist with questions regarding substitutions as necessary

Insulin Products

not use pramlintide if the patient is NPO, likely to skip a meal/not eat enough, hypoglycemic, or has gastroparesis Give SQ immediately prior or within 15 min each major meal, do not give after

Twice daily SQ injection, before breakfastand supper.


Dose anytime before1 hour meals. within

Insulin Aspart (Novolog) Insulin Aspart (Novolog) Insulin Aspart (Novolog) Insulin Aspart (Novolog)