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Intravenous Drug Preparation PDF
Intravenous Drug Preparation PDF
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IV DRUGS PREPARATION AND ADMINISTRATION
COMMITTEE
Acknowledgements
Dr Ahmad Suhailan Bin Mohamed, Editor of Intravenous Drugs Preparation and Administration Hospital Serdang
Emergency Department 2016.
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TABLE OF CONTENTS
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INFUSION FORMULA
Percentage Concentration
X% of drug equivalence with X GRAM of drug in 100ml diluent
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IV DRUGS PREPARATION AND ADMINISTRATION
1. Rules of 6 (from Paediatric Advanced Life Support (PALS) for Doctor 2005)
6 x Body weight (Kg) = drug in miligram and add total volume 100ml
simplified in 50ml syringe ie x 1/2:
3 x Body weight (Kg) = drug in miligram and add total volume 50ml
So, if we run
1 ml/h equivalence with 1.0mcg/kg/min.
2. Rules of 3 (from Manual of Drugs in Anaesthesia and Intensive Care, Department of Anaesthesia and Intensive Care Hospital Kuala
Lumpur 1998)
3 mg of any drug and add to total volume of 50 ml
So X ml/h equivalence to X mcg/min
*Not according to body weight
Example
a. Salbutamol infusion for asthma with dosage range 5-20mcg/min
b. Adrenalin infusion for anaphylaxis in adult (Tintinalli 8th edition)- start with 1 mcg/min and titrate
dose as needed
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3. Rules of 1/2 body weight (from ICU book Tan Tock Seng Hospital, Singapore)
1/2 BW in 50 mls
1 ml/h equivalence 10mcg/kg/h
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ADRENALINE INFUSION
Preparation: 1 ampoule 1ml (1:1000 = 1mg / ml)
Dilute 3.0 mg (3mls) of Adrenaline with 47 mls of Normal Saline in 50 mls syringe.
Rate: 1ml/hr = 1mcg/min (Document rate on Syringe Pump & in Patient’s Notes)
Dose: 1 – 10 mcg/min (starting infusion rate 0.1 mcg/kg/min)
Titrate accordingly to desired BP - (Infusion range 0.1-2.0mcg/kg/min ie for 50kg patient start with 5ml/h)
Calculations:
• Dilute 3mg adrenaline in 50mls NS (Preferable to use single strength in ED)
• 50mls —> 3mg —> 3000mcg
• 1ml —> 3000/50 = 60mcg
• 1ml/hr —> 60mcg/hr —> 60mcg/60min —> 1mcg/min
• 1ml/hr = 1mcg/min
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IV DRUGS PREPARATION AND ADMINISTRATION
Anaphylaxis
a) IV Adrenaline 1:10 000
-Dilute 1mg (1ml) to 10 cc N/S
-Dose: Give titrating bolus 1 ml up to 0.1ml/kg
b) or if IV line not available,
give deep IM Adrenaline 1:1000
-Dose: 0.01mg/kg (i.e: Body wt 50kg= 0.5mg = 0.5ml) Max 0.5mg
c) IV Infusion if patient not response with boluses.
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Take 1 ml from the 0.1mg/ml and dilute further to another 10ml syringe of normal saline = 0.01mg/ml
(10mcg/ml)
Starting dose Titration/ Incremental dose
5-20mcg (0.5-2.0 Repeat dose per direction of Emergency Physician (EP) every 1-5 minutes as needed. Increase dose per
ml) slow IV push direction of EP to 10-20mcg based on response
Important • Syringe provides dose to be given incrementally (eg 0.5-1ml (5-10mcg) with additional doses, or dose
Information increase based on response every 1-5 minutes
• MUST BE GIVEN BY EP OR MAY BE GIVEN BY STAFF NURSE PER DIRECTION OF EP
PRESENT AT BEDSIDE
• Extravasation risk- use CVL or large vein when available
• Use as temporising measure for hypotension
• Adrenaline has both alpha and beta- adrenergic activity- may cause tachycardia in addition
vasoconstriction. Consider phenylephrine in significant tachycardia or any tachyarrhytmias.
Minimum • ED use only
monitoring • Monitor HR and BP at least every 5 minutes while administering/ titrating, and if appropriate, q5min x
3 after administration.
( Holden et al, Safety Consideration and Guideline-Based Safe Use Recommendation for “Bolus Dose” Vasopressor in Emergency Department,
Annals of Emergency Medicine 2017.)
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E.g. 10 kg patient
10 x 0.15mg =1.5mg (Add 1.5mg adrenaline in D5% to make 50mls)
1 ml/hr = 0.05 mcg/kg/min
0.05 -0.5 mcg/kg/min (1-10 ml/hr)
*In smaller patients, dose can be concentrated to 0.3 mg/kg in 50ml D5%
Run at 0.5-5 ml/hr (0.05-0.5 mcg/kg/min)
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Dilute 50 mg vial of powder Alteplase with 50ml of provided water for injection
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AMIODARONE INFUSION
Preparation: 150mg / 3mls
Loading Dose:
5mg/kg bodyweight infused over 20-120 mins
Dilute 2 ampoules of amiodarone (300mg / 6mls)
In 100 mls of Dextrose 5% (Incompatible with Normal Saline)
Use microchamber or infusion pump
(Dilute 150 mg in 50 ml D5%, Run @100ml/Hour (Do in 2 syringes)
Run 300mg over 1 hour
Maintenance Dose:
Alternative dose:
Preparation from ICU Sungai Buloh
600mg in 50ml D5% (12mg/ml)
Run at 12.5ml/h (150mg) for 2 hours then
3ml/h (36mg/ml)
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AMINOPHYLINE INFUSION
Preparation: 250mg / 10 mls
Loading dose:
5mg/kg in 100mls NS over 1/2 Hour
Eg: 250-500 mg in 100mls Normal Saline (or 5mg/kg)
Run over 20 - 30 minutes
(Do not give bolus to patients already on oral theophylline/NEULIN)
Maintenance Dose:
Dose:
Non-smoker: 0.5mg/kg/hr
(i.e: BW= 50kg; run @ 5ml/Hr)
Smoker: 0.8mg/kg/hr
Elderly: 0.3mg/kg/hr
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ATROPINE INFUSION
Organophosphate poisoning
a) IV Bolus
IV Bolus 0.6 - 3 mg every 5 mins and doubling the last dosage for the next dose till atropinasation achieved
(SBP > 80 mmHg, HR> 80 bpm, clear lung, dry axillae)
b) IV Infusion
Signs of atropinasation (DR Mercedes Benz Hitam)
10-20% of total dose required to achieve atropinisation infused hourly in 0.9% Dry as bone
saline chloride for at least 48 hours then tapering down over days. Red as beet
Mad as Hatter
If cholinergic toxicity recurs at any point, restart the bolus doses until the Blind as Bat
Hot as Hare
patient is atropinized again and increase the infusion rate by 20% per hour
(Ref: Eddleston M, Chowdhury F R, Pharmacological Treatment of organophosphate Insectiside Poisoning: The Old and The (possible) new.
British Journal of Clinical Pharmacology. 2015, Sept; 81: 462–470.)
Inject 10-30ml of a 10% Calcium gluconate solution IV over 10 minutes (slow bolus)
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Ref: Lawrence S, Weisberg. Management of Severe Hyperkalemia. Critical Care Med 2008
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DIGOXIN
Preparation: 0.5mg in 10ml N/S
Give slow bolus over 10-20 mins
Atrial fibrillation
Loading dose for the management of atrial fibrillation was 0.25 mg IV every 2 hours up to 1.5 mg.
The recommended daily maintenance dose was 0.125 to 0.375 mg IV or orally
(ACC/AHA/ESCO)
Rapid digitalization may be achieved with a loading dose of 8 to 12 mcg/kg IV. Administer half of the total recommended
loading dose as a first dose, then give one-fourth of the total dose every 6 to 8 hours for 2 doses
Example- for pt 50 kg and take 10mcg/kg will be 500mcg ie 0.5mg. Given half as first dose ie 0.25mg then one-fourth ie
0.125mg every 6 hours.
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DOBUTAMINE
Preparation: 1 vial contains 250mg in 20mls
1) Method 1
(Dilution dose is Fixed, but rate is adjusted according to weight)
2) Method 2
(Dilution dose is adjusted according to patient’s weight. The rate is fixed)
Eg 70kg patient
3 x BW = 3 x 70 = 210mg
• 210 mg in 50mls NS
• 50mls —> 210mg
• 1ml —> 210/50 = 4.2mg
• 1 ml/hr —> 4.2mg/hr —> 4.2mg/60min —> 4200mcg/60min —> 70mcg/min
—>1mcg/kg/min
Rate: 1ml/hr = 1mcg/kg/min (Document Rate on Syringe Pump & in Patient’s Notes)
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DOPAMINE
Preparation: 1 vial contains 200mg in 5mls
1) Method 1
(Dilution dose is Fixed, but Rate is adjusted according to Weight)
2) Method 2
(Dilution dose is adjusted to patient’s weight. The Infusion rate is fixed)
E.g. Patients weight 70kg
3 x BW = 3 x 70 = 210mg
• 210 mg in 50mls NS
• 50mls —> 210mg
• 1ml —> 210/50 = 4.2mg
• 1 ml/hr —> 4.2mg/hr —> 4.2mg/60min —> 4200mcg/60min —> 70mcg/min
—>1mcg/kg/min
Rate: 1ml/hr = 1mcg/kg/min (Document rate on Syringe Pump & in Patient’s Notes)
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Dose: 5-20mcg/kg/min
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ESMOLOL INJECTION
Preparation: 100 mg/10 ml
Dose may be titrated upward every 50 mcg/kg/min (not more frequently than every 4 mins to a max of 200mcg/kg/min.
Max dose 200 mcg/kg/min for 24-48 hours
(Ref: Dilution Protocol, Bhg Perkhidmatan Farmasi, Jabatan Kesihatan Negeri Selangor 2017
https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0007/306367/liverpoolEsmolol.pdf)
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FENTANYL INFUSION
Preparation: 100mcg / 2mls
Dose Infusion:
Dose range 0.5-1.5 mcg/kg/h
If 60kg pt may start with 3ml/h (30mcg/H)
Titrate to desired effect and BP
(Ref: Introductory Anaesthesia Handbook, Department Anaesthesiology & ICU HSAJB 3rd Edition)
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FRUSEMIDE INFUSION
Preparation: 20mg/2ml ampoule
Infusion Dose:
200mg (10 amps undiluted) = 20 mls in 20mls syringe
1 ml/hr = 10mg/hr
Run at 10-40 mg/h (1- 4 ml/h)
Adult: maximum rate 4mg/min (exceeding this rate increase risk of ototoxicity).
Children: maximum rate of 0.5mg/kg/min (Ref: Lexicomp, Wolter Kluwer Clinical Drug Information)
*Required single dedicated line (preferably CVL) because risk for crystallisation is high when mix with other infusion.
ALTERNATIVE
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Method 1:
LOWEST CONCENTRATION DOSE: 100mcg/ml (PREFER)
Rate: 3mls/hour = 5 mcg/min (Document Rate on Syringe Pump & in Patient’s Notes)
5mg in 50 mls
50 ml —> 5mg —> 5000mcg
1 ml —> 5000 / 50 —> 100 mcg
1 ml /hr —> 100 mcg /hr —> 100 mcg / 60 min —> 1.66 mcg / min
3 ml /hr = 5 mcg /min
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Method 2:
HIGHEST CONCENTRATION: 400mcg/ml
Rate : 1ml/hr = 10mcg/min (Document Rate on Syringe Pump & in Patient’s Notes)
20mg in 50 mls NS
50 mls —> 20mg —> 20000mcg
1 ml —> 20000 / 50 —> 400mcg
1 ml /hr —> 400 mcg / hr —> 400mcg / 60min —> 6.67 mcg/min
1 ml /hr = 6.67 mcg/min
1.5 ml/hr = 10 mcg/min
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100 cc Human Albumin 20% dilute with 400 cc Normal Saline 0.9%
Infusion rate: 10-20 ml/kg over 1 hour
Ref: Malaysia CPG on Management of Dengue Infection in Adults (3rd Ed) 2015
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HYDRALAZINE
For Pre-eclampsia / Eclampsia
Preparation: 20mg/ml
Method 1:
Method 2:
Dilute 50 mg in 50cc NS
Dose : 1ml/hr = 1mg/hr (Document Rate on Syringe Pump & in Patient’s Notes)
Start infusion 5ml/hr. Increase 1ml/hr every 15-20 mins
Max infusion rate - 10mls/hr (10 mg/hr)
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IV DRUGS PREPARATION AND ADMINISTRATION
HYPERTONIC SALINE
* Hypertonic saline may be more effective than mannitol in lowering intracranial pressure but no difference was found in short-
term mortality (Brain Trauma Foundation 2016)
NACL 3%
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KETAMINE
Preparation: 200mg in 20ml vial
Analgesia: 0.2-0.3 mg/kg bolus or 0.3mg/kg in 100ml Ns over 15min less feeling unreality.
Procedural Sedation Analgesia (PSA): 0.5-1.0 mg/kg and repeat 1/3 of the dose for 5-10 minutes
Or preferred: Ketamine and Propofol (Ketafol- 2 different syringes): 0.3mg/kg of Ketamine (analgesic dose) and propofol
(sedative dose) titrate 40mg + 20mg + 20mg
Ketofol (1:1 mixture of 5ml ketamine 10 mg/mL and 5ml propofol 10 mg/mL-) given aliquot 3 ml till effect
The median dose of medication administered was ketamine at 0.75 mg/kg and propofol at 0.75 mg/kg
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IV DRUGS PREPARATION AND ADMINISTRATION
IV Ketamine + Midazolam
(Keta-Mida)
*Option for sedation post intubation especially for hyperactive airway such as status asthmaticus (disadvantages of tachycardia
and increase salivation )
Loading dose
Give IV Bolus of 0.05mg/kg midazolam
e.g body weight 70 kg= 3.5 ml
Increase infusion rate 1ml/hr every 20 mins till target RASS (i.e -2 to +1) achieved
Ref: Medication Reconstitution and Dilution Reference, Pharmacy Dept HSAJB 2013
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LABETALOL
Preparation: 25mg/5ml
Bolus:
Non diluted:
Give 1ml= 5mg bolus titrate up every 5 minutes up to 25mg (1 ampule). Maximum dose 200mg
Aim SBP not to lower than 160mmhg.
* Do not give bolus 1 ampule (25mg) stat
Continuous infusion:
Or
For hypertension bleed aim MAP reduction 25% from initial highest BP within 3-12 H
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LABETALOL – Con’t
*Incompatible with sodium bicarbonate
*Patient should receive drug in supine or left lateral position. Avoid raising patient into upright position within 3 hours which
may cause excessive postural hypotension.
*Avoid severely elevated blood pressure to drop rapidly which may cause catastrophic reaction eg. cerebral infarction
Ref: Ministry of health Malaysia, Dilution Guide For High Alert Medications 2011
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LIGNOCAINE INFUSION
* Second option for stable Ventricular Tachycardia after Amiodarone
Preparation:
Lignocaine Injection 2% for IV (plastic ampule) not IM (glass ampule)
100mg in 5mls (20mg in 1 ml)
0.125 ml/kg (1mg/kg) (Max 3mg/kg) over 3 mins (for 50 kg will be 6.25 ml bolus for 3 min) followed by
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MAGNESIUM SULPHATE
Preparation: 2.47 gm / 5mls (1 amp)
Maintenance dose:
1gm (2ml) in 50ml N/S run @ 50ml/Hr (1gm/Hr). Continue maintenance @ 1gm/Hr till delivery
Check patellar reflex before & during infusion, RR > 16, Urine Output > 25mls/hr
Dosage:
Dilute 2 gm (4 mls) in 20cc NS
Give using syringe pump over 20 minutes (run 60ml/hr)
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Dosage:
Dosage:
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Dose:
1g / kg
Calculations:
Body weight 50 kg
Mannitol 20 % meaning 20g in 100ml
Total volume of Mannitol needed (1 gm/kg ) = 50g
= (100ml/20g) X 50g
=250 ml of Mannitol 20 % to run in 30 minutes
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Calculations:
Body weight 10 kg
Mannitol 20 % ie 20gm in 100ml
Total volume of Mannitol needed (2.5 ml/kg)
10 kg x 0.5gm = 5 gm
= (100ml/20gm) x 5gm
= 25 mls of Mannitol 20% to run over 30 minutes
Preferable to use Hypertonic Saline (Normal Saline 3%) in cerebral oedema not Mannitol
Dose: 3-5 ml/kg NS 3 % over 30- 60 minutes
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Rate:
1mls/hr = 1 mg/hr of Midazolam and Morphine
Dose:
Infusion starting dose: 3ml/hr (3 mg/hr)
To titrate to desired effect
Bolus dose may be required for faster effect (3-5mls), followed by infusion dose
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If patient is small, avoid giving too much fluid —> can be double concentration
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Dose:
a) Children: 20-80mcg/kg/hr (1 ml/hr = 20mcg/kg/hr)
Run at 1-4 ml/hr
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MIDAZOLAM-FENTANYL SEDATION
*Sedation of choice post intubation especially for hyperactive airway such as status asthmaticus (advantages of less tachycardia
and no increase in salivation)
Preparation:
300mcg (3 ampoules) of Fentanyl + Midazolam 30 mg
Dilute with NS to become 30mls in 50mls syringe
Rate:
1mls/hr = 1 mg/hr of Midazolam AND 10 mcg/hr of Fentanyl
Dose:
Infusion starting dose: 3ml/hr
To titrate to desired effect
Bolus dose may be required for faster effect (3-5 mls), followed by infusion dose
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Preparation:
2 gm / 10 mls (1ml = 200mg)
Dosage:
• 150mg/kg (Maximum 15g) in 200 mls of Dextrose 5% over 15 – 60 mins
• Then 50mg/kg (Maximum 5g) in 500 mls of D5% over 4 hour
• Then 100 mg/kg (Maximum 10g) in 1 litre of D5% over 16 hours
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Preparation:
2 gm / 10 mls (1ml = 200mg)
Dosage:
• 150mg/kg in 200ml over 1 hour
• 50mg/kg in 50ml over 4 hours
• 50mg/kg in 50ml over 8 hours x 6 cycles (48 hours)
Dosage:
• 3ml NAC (600mg) + heparin 5000 IU (1ml of heparin blue label) every 4 hourly for 7 days.
• Total of 4 ml, to give as nebulizer.
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Dose:
I/V 0.4 mg – 2.0 mg
Repeated dose with interval of 2 – 3 mins
Max: 6 mg
Naloxone infusion:
0.3mg/kg in 30ml at 1ml/H (0.01mg/kg/h)
Ref: Lexicomp, Wolter Kluwer Clinical Drug Information and Drug Doses Frank Shann 17th edition 2017
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NORADRENALINE INFUSION
Preparation: 4mg/4mls (1 amp)
Calculations:
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OMEPRAZOLE/ PANTOPRAZOLE
Preparation: 40mg per vial
Dose for severe Upper Gastrointestinal Tract (UGIT) Bleeding: 80mg bolus then 8mg/ hour for 72 hours
a) IV Bolus:
Omeprazole: 80mg (2 vial) + 20ml solvent and give over 5 min (max rate 4ml/min)
Pantoprazole: 80mg (2 vial) + 20ml NS and give over 2-15 min
b) IV Infusion:
40mg (1 vial) + NS = 50ml
Run 8mg/hour (10ml/ hour)
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Loading Dose:
20 mg/kg (maximum loading dose 1 gm) over 30 minutes, additional 5-10mg/kg doses every 15-20 minutes as needed for
refractory seizures up to total of 40mg/kg
Not more than 30mg/min in children, 60mg/min in adult (Ref: Lexicomp, Wolter Kluwer Clinical Drug Information)
Rapid IV administration may cause respiratory depression, apnoea, laryngospasm or hypotension.
Maintenance dose:
IV or PO 3-5mg/kg/day every 12 hours, starts 12-24 hours after loading dose
Dilution:
Dilute to 10 times its volume with diluent:
eg. Dose 200mg for BW 10kg: Dilute 1ml Phenobarbitone in 9ml NS to make 20mg/ml for IV Infusion
Administration:
Loading dose: slow IV run over 30 minutes.
Maintenance dose (after 12 hour of loading dose): slow IV bolus over 5 mins
Maximum rate do not exceed 1mg/kg/min.
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Flush the line with normal saline before and after infusion to avoid local venous irritation due to alkalinity of solution
Do not dilute in D5%- cause crystallization
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Loading Dose
Adult : IV 1-2 gm (in 100mls 0.9% NS) given over 15-30 mins
Children : 20-40 mg/kg over 30-60mins (Maximum 2g/dose)
Loading dose should not be given rapid - vomiting (risking aspiration), tachycardia & diastolic hypertension
May repeat after 1 hour if muscle weakness persists, additional doses every 10-12 hours as needed for persistent muscle
weakness. Maximum dose 12g in 24hours.
(Ref: Micromedex & Product Leaflet)
Infusion:
250-500 mg/hr, titrating to symptoms (Children 10-20 mg/kg/hr)
WHO:
Loading dose 30mg/kg, then infusion 8mg/kg/hr
Response seen after 10-40 mins of administration
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Active ingredient: Human coagulation factor II, VII, IX, X, Protein C, Protein S
Dose:
Method of administration:
Inject the solution intravenously at a slow speed: Initially 1 mL per minute, not faster than 2 - 3 mL per minute
The patients pulse rate should be measured before and during the infusion. If a marked increase in the pulse rate occurs, the
infusion speed must be reduced or the administration must be interrupted.
No blood must flow into the syringe due to the risk of formation of fibrin clots.
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2. Remove the caps from the powder vial and the water vial and clean the rubber stoppers with an alcohol swab.
3. Peel away the lid of the outer package of the Mix2Vial™.Place the solvent vial on an even
surface and hold it firmly. Place the blue part of the Mix2Vial™ on top of the solvent vial and
press firmly down until it snaps (Fig. 1). While holding onto the solvent vial, carefully remove
the outer package from the Mix2Vial™, being careful to leave the Mix2Vial™ attached firmly
to the solvent vial (Fig. 2).
4. Place the powder vial on an even surface and hold it firmly. Take the solvent vial with the
attached Mix2Vial™ and turn it upside down. Place the transparent part on top of the powder
vial and press firmly down until it snaps (Fig. 3). The solvent flows automatically into the
powder vial.
5. With both vials still attached, gently swirl the powder vial until the product is dissolved.
Octaplex dissolves quickly at room temperature to a colourless to slightly blue solution. Unscrew
the Mix2Vial™ into two parts (Fig. 4). Dispose the empty solvent vial with the blue part of the
Mix2Vial™.
6. Attach a 20 mL syringe to the transparent part of the Mix2Vial™. Turn the vial upside down
and draw the solution into the syringe. Once the solution has been transferred, firmly hold the
plunger of the syringe (keeping it facing down) and remove the syringe from the Mix2Vial™.
Dispose the Mix2Vial™ and the empty vial.
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Active ingredient: Human coagulation factor II, IX, X, Human plasma proteins (including low levels of factors V and VII),
Antithrombin III, Heparin sodium (porcine origin)
Method of administration:
Give the dose slowly approximately 3 mL per minute or as tolerated by the patient
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2. Remove the caps from the top of the Prothrombinex®-VF and Water for Injections vials.
3. Apply a suitable antiseptic to the exposed part of the rubber stoppers of both Prothrombinex®-VF and Water for Injections and allow to dry.
4. Open the outer package of the Mix2Vial™ filter transfer set by peeling away the lid. Place the Water for Injections on a level surface and hold the
vial firmly. Take the Mix2Vial™ together with its outer package and invert it. Push the blue plastic cannula of the Mix2Vial™ firmly through the
rubber stopper of the Water for Injections.
5. While holding onto the vial of Water for Injections, carefully remove the outer package from the Mix2Vial™, being careful to leave the
Mix2Vial™ attached firmly to the Water for Injections vial. Ensure that only the package and not the Mix2Vial™ is removed.
6. With the Prothrombinex®-VF vial held firmly on a level surface, invert the Water for Injections with the Mix2Vial™ attached and push the
transparent plastic cannula end of the Mix2Vial™ firmly through the Prothrombinex®-VF stopper. The water will be drawn into the vial by the
vacuum within.
7. With the Water for Injections and Prothrombinex®-VF vial still attached, gently swirl the product vial to ensure the product is fully dissolved.
Avoid excessive frothing. A clear or slightly opalescent solution is usually obtained in 10 minutes or less.
8. Once the contents of the Prothrombinex®-VF vial are completely dissolved, firmly hold both the transparent and blue parts of the Mix2Vial™.
Unscrew the Mix2Vial™ into two separate pieces, and discard the empty Water for Injections vial and the blue part of the Mix2Vial™ in an
appropriate waste container.
9. With the Prothrombinex®-VF vial upright, attach a plastic disposable syringe to the Mix2Vial™ (transparent plastic part). Invert the system and
draw the reconstituted Prothrombinex®-VF into the syringe by pulling the plunger back slowly. One large syringe may be used to pool several
vials of reconstituted Prothrombinex®-VF.
10. Once the Prothrombinex®-VF has been transferred into the syringe, firmly hold the barrel of the syringe (keeping the syringe plunger facing down)
and detach the Mix2Vial™ from the syringe. Discard the Mix2Vial™ (transparent plastic part) and empty Prothrombinex®-VF vial in an
appropriate waste container. Fit the syringe to a suitable injection needle to administer the reconstituted Prothrombinex®-VF. Do not use the
Mix2Vial™ for injection.
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IV DRUGS PREPARATION AND ADMINISTRATION
Loading dose:
250mcg over 10 mins
(0.25ml dilute in 10ml N/S run @ 60ml/Hr)
Slow IV:
Dilute 1ml in 10ml NS (Final concentration: 50mcg/ml)
Maintenance:
3mg + N/S = 50ml
* ml/hr = * mcg/min
Dose: 5-20 mcg/min (5ml/Hr-20 ml/Hr) (increments at 15-30 mins, if necessary) (Product Leaflet)
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IV DRUGS PREPARATION AND ADMINISTRATION
Choice of antivenom must be selected by a physician trained and familiar with management of snakebite in
Malaysia. All antivenom is administered intravenously.
Adrenaline should be prepared in readiness to treat possible anaphylaxis, that may occur in response to antivenom.
This must be prepared before the administration of antivenom (0.5 mg for adults and 0.01mg/kg body weight for
children (0.1% solutions, 1 in 1,000 dilution,1mg/ml)
Patient must be monitored during and for at least one hour AFTER completion of
intravenous infusion. Serially chart vital signs and clinical progression.
(For Dosage of AV kindly refer to Guideline Management of Snakebite Ministry Of Health Malaysia, 2017)
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IV DRUGS PREPARATION AND ADMINISTRATION
Dosage depend on Base Excess/ HCO3 level dan body water of patient
Calculation:
(24 - pt’s HCO3) or BE X BW X 0.6 X 1/3= Z ml
And only give 1/2 from Z
IV Infusion:
Dilute with D5 to a maximum concentration of 0.05mEq/ml, run over 2 hours.
Maximum rate is 1mEq/kg/hr
ETD HSAJB 64 of 81
IV DRUGS PREPARATION AND ADMINISTRATION
75 ml of IV Sodium Bicarbonate 8.4% + 425ml of Dextrose 5% (becomes NaHCO3 1.26%) and run accordingly to 1.5 to 2 times
patient maintenance.
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IV DRUGS PREPARATION AND ADMINISTRATION
STREPTOKINASE INFUSION
For STEMI
(Product Leaflet)
Observe
• BP every 15 mins (every 5 mins at the start of infusion)
• Hypotension, Gum bleeding, Epistaxis, Allergy
• If complication occurs kindly inform Emergency Physician.
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IV DRUGS PREPARATION AND ADMINISTRATION
Dosage:
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IV DRUGS PREPARATION AND ADMINISTRATION
TENECTAPLASE (METALYSE)
(For STEMI)
Metalyse should be reconstituted by adding the complete volume of solvent provided in the pre-filled syringe to the vial of
Metalyse powder for solution for injection solvent via the connector provided (see picture below)
ETD HSAJB 68 of 81
IV DRUGS PREPARATION AND ADMINISTRATION
Dose and volume to be withdrawn and administered to patient are according to body weight as in table below:
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IV DRUGS PREPARATION AND ADMINISTRATION
TRANEXAMIC ACID
Bolus: 1gm over 10 mins
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IV DRUGS PREPARATION AND ADMINISTRATION
VITAMIN K
For Bleeding in over warfarinization (not for pt with any heart valve replacement)
(CPG on Venous Thromboembolism (VTE), KKM 2013)
IV Vitamin K 5 mg
Dilute dose in minimum of 50ml NS (Ref: Lexicomp, Wolter Kluwer Clinical Drug Information & Micromedex)
run over 30 mins (@ 50ml/Hr ) ( rate: 0.16mg/min)
IV Vitamin K 1-3 mg
Dilute dose in minimum of 50ml NS
run over 30 mins ( @ 50 ml/Hr) (rate:0.03-0.1mg/min)
IV route should be used in major bleeding patient. IM route should be avoided due to risk of hematoma formation.
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IV DRUGS PREPARATION AND ADMINISTRATION
1. Augmentin 1.2g
(Amoxicillin 1g +Clavulanate 200mg)
Dilute 1.2 g with 20 ml WFI (Must be used within 20mins after reconstitution)
2. Ampicillin 500mg
Dosage: IV Ampicillin 2g q6h
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IV DRUGS PREPARATION AND ADMINISTRATION
3. Unasyn 1.5g
(Ampicillin 1 g + Sulbactam 500 mg)
4. Azithromycin 500mg
Dosage: IV Azythromycin 500mg q24h
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IV DRUGS PREPARATION AND ADMINISTRATION
5. Benzylpenicillin (Penicilline G)
1 MIU or 5 MIU
(600 mg = 1 MIU)
IV
Dilute 1MIU with 10ml NS (60mg/ml or 100,000 IU/ml), syringe out required dose
Eg. BW: 10kg for dose 500,000 IU, syringe out 5ml to serve patient
IV bolus over 5mins
IM
Dilute 1MIU with 1.6ml WFI
6. Cefepime 1g
Dosage: IV Cefepime 2g q8h
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IV DRUGS PREPARATION AND ADMINISTRATION
7. Cefoperazone 1g
Dosage: IV Cefoperazone 2g q12h
IV bolus 3-5min
8. Cefotaxime 1g
Dosage: IV Cefotaxime 2g q8h
IV bolus 3-5min
9. Ceftazidime 1g
Dosage: IV Ceftazidime 2g q6h
IV bolus 3-5min
ETD HSAJB 75 of 81
IV DRUGS PREPARATION AND ADMINISTRATION
10. Ceftriaxone 1g
Dosage: IV Ceftriaxone 2g q12h
IV infusion over 30mins (Ref: Lexicomp, Wolter Kluwer Clinical Drug Information & Micromedex)
IV Bolus over 2-5mins may cause tachycardia, diaphoresis, restlessness and palpitations.
(Ref: Lexicomp, Wolter Kluwer Clinical Drug Information)
IV bolus 3-5min
IV bolus 3-5min
ELECTROLYTES CORRECTION IN ED
1-Hyponatremia
Rapid correction should not exceed more than 12 mmol/ 24 H or 0.5 mmol/H to avoid Osmotic Demyelinating Syndrome (ODS);
previously Central Pontine Myelinosis (CPM)
Calculation.
1-First, calculate the expected change in serum sodium from the infusion of a liter of saline solution.
2-Second, determine the portion of the liter required to raise the sodium the desired amount
3-Third determine duration for correction to avoid ODS
Examples.
Correction for 50 y/o male with weight 70kg having seizure secondary to Na 108mmol/l, using 3% Normal saline (consist of Na
513mmol/Liter) -if using NaCl 0.9% consist of 154mmol/L will lead to overload.
1- Total sodium deficit= Total Body Water (TBW) X (desired Na - current Na)
[0.6 X BW ] X (130 - current Na)
[0.6 X 70] X (130- 108) = 924 mmol/l
2- NACL 3%—> 513mmol per Liter
924 mmol =(1000ml/513) X 924
= 1800 ml of NACL 3%
3- Duration
0.5 mmol/H—> 22/0.5= 44 hours
Thus infusion rate of NACL 3% will be 41ml/H
(Document time of start till time of ending examples from 0800H 23.08.18 till 0400H 25.08.18)
However, the does of correction may change according to result of sodium preferably bd BUSE)
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IV DRUGS PREPARATION AND ADMINISTRATION
2-Hypernatremia
Calculation of total body water (TBW) deficit.
TBW deficit (L) = TBW X [ (measured Na/ Normal Na) - 1]
Example
Patient BW 60kg with Na 170mmol/l
Calculation of TBW deficit = (60kg X 0.6 ) X [ (170/150) -1]
= 4.8 liter
To avoid cerebral oedema correction should slower within 48H to 72 H
Thus to give Dextrose 5% 4800ml over 48H = 100ml/h
or if pt intubated with Ryle’s tube may give water through the RT in divided dose ie 2.4L/day ie 600ml of
water every 6 hly
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IV DRUGS PREPARATION AND ADMINISTRATION
3- Hypokalaemia
Do an ECG- if have changes ie u waves, need a fast correction or patient is symptomatic such as in Periodic Paralysis
If patient 50kg—> for 2 mmol/kg/day will be 100mmol—> 7.5g of KCL per day.
If patient in 2 liters of maintenance drip ie 4 pints of NS thus may put 2 g KCL in each pints.
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IV DRUGS PREPARATION AND ADMINISTRATION
4. Hyperkalaemia
-refer cocktail regime page 19
ETD HSAJB 81 of 81