Reconstitution and Dilution

HANDBOOK OF DRUG RECONSTITUTION & DILUTION TAWAU HOSPITAL 2018
General Guide for Healthcare

Professionals
2018
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PHARMACY DEPARTMENT
PREFACE
Tawau Hospital Handbook of Drug Reconstitution & Dilution 2018 is a collection of
summarized information from package inserts and other published literatures on the
pharmaceutics (i.e. the science of preparing and dispensing) of parenteral medications available
in Hospital Tawau (excluding cytotoxics).This handbook is intended to serve as a handy
reference and not as a complete drug information resource on parenteral drug administration.
It is specifically designed to present the common aspects of parenteral drug
administration; such as reconstitution and dilution, stability of parenteral preparations,
route and rate of administration, as well as storage condition of the injectable drugs.
Reconstitution of parenteral products containing the same active ingredient, but from different
manufacturers may differ, especially in terms of type and volume of diluents as well stability.
Hence, the brand name and/or manufacturer of the drug in hand should always be
checked against that listed in this handbook, before following the instructions stated in
this handbook.
Due to the complex nature of drug information, it is advised to use this handbook in
conjunction with other necessary information in making decisions regarding the
preparation and administration of parenteral medications in uncommon cases. Examples
include drug administration in fluid restricted patients and drug compatibility issues.
For more complete information, please refer to the Drug Information Pharmacist at ext 399
during office hours, or the On-call Pharmacist after office hours. Please contact the
operator of Tawau Hospital for on-call pharmacy services. Hereby, I would thank and
congratulate Pharmacy Department of Tawau Hospital for their effort in making this
publication a success.
DR. NORLIMAH ARSAD

Hospital Director,
Tawau Hospital
MEDICAL & DENTAL ADVISORY COMMITTEE, TAWAU HOSPITAL

Prepared by DIANA MUHD RIZAL 12TH JULY 2018
Presented by TAN YUI PING 24TH JULY 2018
Approved by DR. KHASNIZAL ABD KARIM 20TH AUGUST 2018
Acknowledged by DR. NORLIMAH ARSAD 27TH AUGUST 2018
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EDITORIAL COMMITTEE
Advisor Halimah Lego Chief Pharmacist
Coordinator Diana Muhd Rizal Drug Information Services Pharmacist
Committee Ahmad Shauqey Adnin Hasnam Total Parenteral Nutrition Pharmacist

Members
Alina Mat Yusoff Clinical Pharmacist
(in alphabetical
order) Catherine Ong Kim Yok Chemotherapy Drug Reconstitution
Pharmacist
Cheah Meng Fei Clinical Pharmacist
Connie Vun Sie Yee Therapeutic Drug Monitoring Pharmacist
Goh Fong Ying Chemotherapy Drug Reconstitution
Pharmacist, Clinical Pharmacist
Kohila Krishnan Inpatient Pharmacist
Lee Tsu Yen Clinical Pharmacist
Mohamad Fauzanudin Baharudin Clinical Pharmacist
Nora Awang Jalil Inpatient Pharmacist
Nur Amirah Mohd Noor Azami Clinical Pharmacist, Chemotherapy Drug
Reconstitution Pharmacist
Nur Shahirul Saidin Inpatient Pharmacist
Nurashikin Mazlan Clinical Pharmacist
Pang Yih Fui Clinical Pharmacist
Siti Noor Aisyah Mat Jusoh Inpatient Pharmacist
Tan Yui Ping Inpatient Pharmacist
Wong Jing Ting Clinical Pharmacist
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EXTERNAL REVIEWERS
MEDICAL & DENTAL ADVISORY COMMITTEE
Advisor Dr. Norlimah Arshad Director of Hospital Tawau
Chairman Dr. Khasnizal Abd Karim Head of Surgical Department,
Specialist Surgeon
Committee Dato' Dr. Sudesan Raman Head of Obstetrics & Gynecology Department,
Members Specialist Obstetrician & Gynaecologist
(in alphabetical
order) Dr. Abd Adzim E. Arim Sasi Head of Emergency & Trauma Department,
Specialist Emergency Physician
Dr. Baskaran Subramaniam Head of Pathology Department,

Specialist Pathologist
Dr. Chung Yaw Yee Head of Medical Department,

Specilaist Physician
Dr. Hairudin Achmad Head of Radiology & Imaging Department,

Sankala Specialist Radiologist
Dr. Khairuddin Othman Head of Ophthalmology Department,

Specialist Ophtalmologist
Dr. Maria Elina Zaid Head of Paediatric Department, Paediatrician
Dr. Naveen Vijayasingham Head of Orthopedic Department,

Specialist Orthopedic Surgeon
Dr. Saridah Mahdah Head of Oral & Maxillofacial Department,

Specialist Oral & Maxillofacial Surgeon
Dr. Sein Win Head of Anaesthesia & Intensive Care

Department, Specialist Anaesthetist & Intensive
Care Physician
Dr. Siti Noor Fadhlina Head of Psychiatry Department,

Misron Specialist Psychiarist
Dr. Syed Zaifullah Syed Head of Otorhinolaryngology Department,

Hamzah Specialist Otolaryngologist
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ACKNOWLEDGEMENT
All Praise be to God, The All Almighty, The All Knowing.
I would like to thank Puan Halimah Lego,

Mr. Cheah Meng Fei and Miss Nur Amirah Mohd Azami
for their invaluable advice and support
throughout the process of preparing this handbook.
My appreciation and thank you

to all editorial committee members for their effort and time
on this collaboration in making this handbook possible.
Diana Muhd Rizal

Drug Information Services
Pharmacy Department
Tawau Hospital, Sabah
12th July 2018
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HOW TO USE THE BOOK

The book is arranged according to spelling of injectable drugs in alphabetical order.
The title in capital letters on each page corresponds to the generic name of the drug.
Note : There could be variation in reconstitution, dilution and storage requirements for
product with the same active ingredient but different manufacturers. Always check the trade
name and manufacturer of product that is given in this handbook.
Information located inside light purple shaded boxes refers to adult only, whereas Information
located inside light orange shaded boxes are applicable for paediatric only (as shown below).
Adult
Paediatric
Information outside these 2 color shaded boxes is non-specific for adult or paediatric, and
therefore are general information.
High Alert Medications are indicated next to the title page

HIGH ALERT
MEDICATION
HAM (generic drug name).
Abbreviations used throughout this book and its meaning are listed in the following page.
______________________________________________________________________
IMPORTANT POINTS
1. Check that both drug and diluent packaging are intact and within the expiration date.
2. To avoid contamination, the solutions should be used immediately after reconstitution or

dilution.
3. If the solution prepared is intended for later use, date and time of
reconstitution/dilution should be recorded on the container of the solution.
4. Injections should be discarded if they contain particulate, discolored or become turbid.
5. Whenever possible, one injection should not be mixed with another drug intended for
use. If unavoidable, always check the compatibility of the drugs before administering
together.
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ABBREVIATIONS LIST
< Less than

> More than
≤ Less than or equal
≥ Equal or more than
1/2NS Sodium Chloride 0.45%
1/2NSD2.5 Sodium chloride 0.45% + dextrose 2.5%
1/2NSD5 Sodium chloride 0.45% + dextrose 5%
1/4NS Sodium chloride 0.225%
1/5NS Sodium chloride 0.18%
1/5NSD5 Sodium chloride 0.18% + dextrose 5%
ADR Adverse drug reaction
BP British Pharmacopeia
CAPD Continuous Ambulatory Peritoneal Dialysis
CCPD Continuous Cycling Peritoneal Dialysis
CKD Chronic Kidney Disease
con’t continuation
D10 Dextrose 10% in water
D5 Dextrose 5% in water
ECG electrocardiogram
ESRF End Stage Renal Failure
g Gram
HCl hydrochloride
HD Haemodialysis
hr Hour
IM intramuscular
INJ injection
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IT intrathecal
IU International unit
IV Intravenous
IVI Intravenous infusion
kg kilogram
L Liter
LR Lactated Ringer’s Solution or Hartmann’s Solution or Combination of Sodium
Chloride, Sodium Lactate, Potassium Chloride and Calcium Chloride in water
max Maximum
mcg microgram
mg miligram
min minute
mL milliliter
MU Mega unit ( 1 Mega unit = 1,000,000 unit)
ng Nano gram
NS sodium chloride 0.9%
NSAID Non-steroidal anti-inflammatory drugs
NSD5 Sodium chloride 0.9% + dextrose 5%
PCA Patient controlled analgesia
PO Per oral
SC Subcutaneous
sec Second
U unit
w/v Weight over volume
WFI Water for injection
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TABLE OF CONTENTS
DRUG NAME PAGE NUMBER
ACETAZOLAMIDE 15
ACETYLCYSTEINE 16
ACYCLOVIR 19
ADALIMUMAB 20
ADENOSINE 21
ADRENALINE 23
ALFACALCIDOL 22
ALPROSTADIL 28
AMIKACIN 30
AMINOPHYLLINE 31
AMIODARONE 32
AMOXICILLIN + CLAVULANATE 34
AMPHOTERICIN B 35
AMPICILLIN + SULBACTAM 37
AMPICILLIN 39
ANTI RHD GAMMA GLOBULIN 41
ANTIVENENE SERUM SEA SNAKE 43
ANTIVENENE SERUM SNAKE POLYVALENT 44
ARTESUNATE 45
ATRACURIUM BESYLATE 46
ATROPINE 48
AZITHROMYCIN 49
BCG VACCINE FREEZE-DRIED 50
BENZATHINE PENICILLIN 51
BENZYLPENICILLIN 1 MU 52
BENZYLPENICILLIN 5 MU 54
BERACTANT 56
BOX JELLYFISH ANTIVENOM 57
BROMHEXINE 58
BUPIVACAINE (PLAIN) 59
BUPIVACAINE (HEAVY) 60
BUPIVACAINE 0.5% + ADRENALINE 61
CALCITONIN (SYNTHETIC SALMON) 62
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CALCIUM GLUCONATE 64
CARBETOCIN 66
CARBOPROST TROMETHAMINE 67
CEFAZOLIN 68
CEFEPIME 70
CEFOPERAZONE 71
CEFOPERAZONE + SULBACTAM 72
CEFOTAXIME 73
CEFTAZIDIME 75
CEFTRIAXONE 77
CEFUROXIME 79
CHLORPHENIRAMINE 80
CIPROFLOXACIN 81
CISATRACURIUM BESYLATE 82
CLINDAMYCIN 83
CLOSTRIDIUM BOTULINUM TOXIN TYPE A 85
CLOXACILLIN 87
COBRA ANTIVENOM 88
COLISTIMETHATE (POLYMYXIN E) 89
CYANOCOBALAMIN 90
DANTROLENE SODIUM 91
DENOSUMAB 92
DESFERRIOXAMINE 93
DESMOPRESSIN ACETATE 95
DEXAMETHASONE 97
DEXMEDETOMIDINE 99
DIAZEPAM 100
DICLOFENAC SODIUM 102
DIGOXIN 103
DIPHTHERIA ANTITOXIN 104
DOBUTAMINE 105
DOPAMINE 108
ENOXAPARIN 112
EPHEDRINE 113
EPOIETIN BETA 114
ERTAPENEM 115
ERYTHROMYCIN LACTOBIONATE 117
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ERYTHROPOIETIN ALFA 119

ESMOLOL 121
ESOMEPRAZOLE 123
ETOMIDATE 125
FACTOR VIII INHIBITOR BYPASSING FRACTION (FEIBA) 126
FACTOR VIII, VON WILLEBRAND FACTOR (ALPHANATE) 129
FACTOR IX, II, X COMBINATION (PROTHROMBINEX-VF) 132
FENTANYL 135
FILGRASTIM 136
FLUCONAZOLE 138
FLUMAZENIL 139
FLUPENTHIXOL DECANOATE 141
FLUPHENAZINE DECANOATE 142
FONDAPARINUX 143
FRUSEMIDE 145
GENTAMICIN 147
GLUCAGON (LYOPHILISED) 149
GLYCERYL TRINITRATE 151
GLYCOPYRROLATE 153
GOSERELIN 154
GRANISETRON 155
GREEN PIT VIPER ANTIVENOM 156
HAEMOPHILUS INFLUENZAE TYPE B CONJUGATE 157
HALOPERIDOL 158
HEPARIN 159
HEPATITIS B VACCINE 163
HEPATITIS B IMMUNOGLOBULIN 164
HUMAN ALBUMIN 20% 165
HUMAN CHORIONIC GONADOTROPHIN 167
HUMAN NORMAL IMMUNOGLOBULIN 168
HYDRALAZINE 169
HYDROCORTISONE 171
HYOSCINE BUTYLBROMIDE 172
IMIPENEM + CILASTATIN 174
INFLUENZAE VACCINE TYPE A 176
INSULIN ISOPHANE 177
INSULIN REGULAR 178
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INSULIN REGULAR + ISOPHANE 181

IRON DEXTRAN 182
IRON SUCROSE 184
ISOPRENALINE 186
KANAMYCIN 188
KETAMINE 189
LABETALOL 191
LEUPROLIDE ACETATE 193
LIGNOCAINE 2% (WITH PRESERVATIVE) 195
LIGNOCAINE 2% (PRESERVATIVE FREE) 196
LIGNOCAINE 10% 197
LINEZOLID 198
MAGNESIUM SULPHATE 199
MEDROXYPROGESTERONE 201
MENINGOCOCCAL VACCINE 202
MEROPENEM 203
METHYLENE BLUE 1% 205
METHYLPREDNISOLONE 206
METOCLOPRAMIDE 208
METRONIDAZOLE 210
MIDAZOLAM 211
MORPHINE SULPHATE 214
NALBUPHINE 217
NALOXONE 218
NEOSTIGMINE 220
NORADRENALINE 222
OCTREOTIDE 226
OMEPRAZOLE 228
ONDANSETRON 230
OXYTOCIN 232
OXYTOCIN + ERGOMETRINE 234
PALIPERIDONE 235
PALIVIZUMAB 236
PAMIDRONATE 237
PANTOPRAZOLE 239
PARACETAMOL 241
PARECOXIB 242
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PENTAMIDINE 243
PETHIDINE 244
PHENOBARBITONE 246
PHENYLEPHRINE 248
PHENYTOIN 250
PIPERACILLIN + TAZOBACTAM 252
PNEUMOCOCCAL VACCINE 253
POTASSIUM CHLORIDE 254
POTASSIUM DIHYDROGEN PHOSPHATE 256
PRALIDOXIME 258
PROCHLORPERAZINE MESYLATE 260
PROCYCLIDINE 262
PROMETHAZINE 263
PROPOFOL 264
PROPRANOLOL 266
PROTAMINE 267
QUADRIVALENT SEASONAL INFLUENZA VACCINE 268
RABIES HUMAN VACCINE 269
RANITIDINE 270
REMIFENTANIL 272
ROCURONIUM 274
ROPIVACAINE 275
SALBUTAMOL 277
SODIUM BICARBONATE 279
SODIUM GLYCEROPHOSPHATE 281
SODIUM VALPROATE 282
SOMATROPIN 283
STREPTOKINASE 287
STREPTOMYCIN 289
SUGAMMADEX 290
SUXAMETHONIUM 291
SYNTHETIC ACTH (TETRACOSACTRIN ACETATE) 293
TERLIPRESSIN 294
TESTOSTERONE ENANTHATE 295
TETANUS IMMUNOGLOBULIN HUMAN 296
TETANUS TOXOID 298
THIAMINE 300
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THIOPENTAL 301
TRAMADOL 302
TRANEXAMIC ACID 303
TRIAMCINOLONE ACETONIDE 304
TRIMETHOPRIM + SULPHAMETHOXAZOLE 306
TUBERCULIN PPD 308
UROKINASE 309
VANCOMYCIN 312
VERAPAMIL 314
VITAMIN K1 (PHYTOMENADIONE) 316
ZIDOVUDINE 318
ZOLEDRONIC ACID 320
ZUCLOPENTHIXOL DECANOATE 321
APPENDICES
 ABBREVIATIONS LIST FOR APPENDICES 323

 DEXTROSE PREPARATIONS CALCULATION 325
 DEXTROSE PREPARATIONS TABLE 327
 SALINE & DEXTROSE PREPARATIONS CALCULATION 328
 SALINE & DEXTROSE PREPARATIONS TABLE 331
QUICK REFERENCE 335
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HANDBOOK OF DRUG RECONSTITUTION & DILUTION TAWAU HOSPITAL 2018 A
ACETAZOLAMIDE
Brand Name & Strength
o Acetazolamide 500 mg (Diamox®)
Reconstitution
Reconstitute 500 mg with provided 5 mL WFI (Concentration: 100 mg/mL) [1,2]
Further Dilution
Not Required. [1]
Diluent
[1]
WFI
Administration & Infusion Rate
IV Slow bolus : ≤ 500 mg over 3 min [2]
Storage & Stability

Conditions Room Temperature (<25 ⁰C) Fridge ( 2 – 8 ⁰C)
After reconstitution - 24 hours [1]
After dilution - -
Remarks
 Protect from light [1]
 Single use only[1]
References
1. Mercury Pharmaceuticals Ltd, Acetazolamide (Diamox®) Product Leaflet. Revised date: February
2015
2. MimsGateaway. Mims 2018. Available at
https://online1.mimsgateway.com.my/Malaysia/home/index?redir=%2F%2Fdrug%2Finfo%2Facetaz
olamide%2F%3Fq%3Dacetazolamide%26type%3Dbrief%26mtype%3Dgeneric%26portal%3Dy
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ACETYLCYSTEINE
o DBL™ Acetylcysteine Injection Concentrate 2 g/10 mL
Reconstitution
Not required [1]
Further Dilution
General Paracetamol Poisoning : Refer to Administration & Infusion Rate table
Adult Non-Paracetamol Liver Injury : Refer to Administration & Infusion Rate table
Prevention of Contrast Induced Nephropathy : 600 - 1200 mg in 100 mL D5 [4-6]

Paediatric Non- Paracetamol Liver Injury : Refer to Administration & Infusion Rate table
Diluent
NS, D5 [1]

General Paracetamol Poisoning[1,2,3] :
- Patient < 20 kg
150 mg/kg (max. 15 g) in 3 mL/kg diluent, infused over 60 minutes
50 mg/kg (max. 5 g) in 7 mL/kg diluent, infused over 4 hours
100 mg/kg (max. 10 g) in 14 mL/kg diluent, infused over 16 hours
- Patient 20 kg to 50 kg
150 mg/kg (max. 15 g) in 100 mL diluent, infused over 60 minutes
50 mg/kg (max. 5 g) in 250 mL diluent, infused over 4 hours
100 mg/kg (max. 10 g) in 500 mL diluent, infused over the next 16 hours
- Patient > 50 kg
150 mg/kg (max. 15 g) in 200 mL diluent, infused over 60 minutes
50 mg/kg (max. 5 g) in 500 mL diluent, infused over 4 hours
100 mg/kg (max. 10 g) in 1,000 mL diluent, infused over 16 hours
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ACETYLCYSTEINE
Adult Non-Paracetamol Liver Injury [1,7] :
150 mg/kg/hr in 200 mL NS/D5, infuse over 1 hour, followed by
12.5 mg/kg/hr in 500 mL NS/D5, infuse over 4 hours, followed by
6.25 mg/kg/hr in 300 mL NS/D5 ,infuse over 19 hours, followed by
6.25 mg/kg/hr in 300 mL NS/D5, infuse over 24 hours, followed by
6.25 mg/kg/hr in 400 mL NS/D5, infuse over 24 hours.
Prevention of Contrast Induced Nephropathy [4-6]

- IV Slow bolus : over 15 mins (12 hour & 24 hour pre & post contrast)
Paediatric Non- Paracetamol Liver Injury : 10 mg/kg/hr for at least 48 - 72 hours [8]
Storage & Stability

After reconstitution - -
After dilution 24 hours [1] -
Remarks
 This product does not contains antimicrobial preservative, thus use in one patient on one
occasion only and discard the residue [1]
 No specific dilution was recommended for IV Acetylcysteine for non-paracetamol liver
injury. However, the dilution of IV Acetylcysteine used for Paracetamol poisoning can be
applied for this indication (as recommended by product leaflet) [1]
References
1. Hospira. Acetylcysteine (DBL™ Acetylcysteine Injection Concentrate) Product leaflet. Revised date :
1 December 2012
2. Clinical Pharmacokinetics Pharmacy Handbook, PSD MOH 2015
3. Lexi-Comp, Inc. (Lexi-Drugs®) 2018 Version 4.1.1
4. Consensus Guidelines for the Prevention of Contrast Induced Nephropathy. Canadian Association of
Radiologist (Approved: June 17,2011)
5. N-Acetylcysteine in the prevention of contrast induced nephropathy. Clinical Journal American
Society of Nephrology2008, 3:281-287
6. Drug Information Handbook, 20th Edition, page 32-34
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ACETYLCYSTEINE
References (continued)
7. Lee WM et.al. Intravenous N-Acetylcysteine Improves Transplant-Free Survival in Early Stage Non-
Acetaminophen Acute Liver Failure.Gastroenterology 2009;137:856 – 864
8. Paediatric Protocols for Malaysian Hospitals, 3rd Edition
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ACYCLOVIR
o Zovirax 250 mg
o Vaxcel Acyclovir 250 mg
Reconstitution
Reconstitute powder with 10 mL WFI or NS. Concentration: 25 mg/mL [1,2]
Further Dilution
Adult IV Infusion : Dilute 250 – 500 mg with 100 mL diluent [1]
(Concentration : 2.5 - 5 mg/mL)
Paediatric IV Infusion : Dilute to a concentration ≤ 5 mg/mL [1,2]
Diluent
NS, D5, 1/2NS, LR solution [1,2]

Adult IV Infusion : over 1 hour [1,2]
Paediatric IV Infusion : over 1 hour [1,2]
Storage & Stability

After Zovirax 12 hours [1] -
reconstitution Vaxcel 48 hours [2] -
After Zovirax 12 hours [1] -
dilution Vaxcel 48 hours [2]
Remarks
 Reconstituted or Diluted solution should NOT be refrigerated as they may precipitate [1]
 Infusion concentration ≤ 7 mg/mL is recommended. Concentration greater 10 mg/mL
increase the risk of phlebitis [3]
References
1. GlaxoSmithKline. Acyclovir ( Zovirax®) Product leaflet. Revised date : 26 October 2015
2. KotraPharma. Acyclovir (Vaxcel Acyclovir) Product leaflet
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ADALIMUMAB
o Humira 40 mg Injection [1,2]
Reconstitution
Not required [1]
Further Dilution
Not required [1]
Diluent
Not required

SC (PFSy) [2]
Storage & Stability

-
After dilution -
Remarks
 Store between 2 – 8 ⁰C, and protect from light [1,2]
References
1. Vetter Pharma-Fertigung GmbH & Co.KG. Adalimumab (Humira Solution for Injection) Product
leaflet. Revised date : 7 February 2017
2. MimsGateaway. Mims 2018. Available at https://online1.mimsgateway.com.my
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HIGH ALERT
ADENOSINE MEDICATION

o Adenosine 6 mg/2 mL (Adenocor®)
Reconstitution
[1]
Not required
Further Dilution
Undiluted [1]
OR
May be diluted with NS if required [2]
Diluent
NS [3]

Adult IV Rapid bolus : Administer over 2 sec at a peripheral IV site as proximal as
possible to trunk (not in lower arm, hand, lower leg, or foot);
follow each bolus with a rapid 20 mL NS flush [1]
OR
Give over 2 seconds into central or large peripheral vein
followed by rapid NS flush [2]
Storage & Stability

After dilution Use immediately [1] -
Remarks
 Safety and efficacy in paediatric population (children age 0-18 years old) have not been
established [1]
 Do NOT refrigerate as crystallisation may occur. If crystals form, dissolve them by warming
to room temperature [1]
References
1. Sanofi Winthrop Industrie. Adenosine (Adenocor® Injection) Product leaflet. Revised date : July 2013
2. British National Formulary (BNF 74) 2017-2018
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HIGH ALERT
ADRENALINE MEDICATION

o CCM Adrenaline Injection 1 mg/mL
Reconstitution
Not required [1]
Further Dilution
Adult IM : Use undiluted [1]
IV infusion : Dilute 3 mg in 50 mL diluent (Concentration : 60 mcg/mL) [2]
Paediatric IM : Use undiluted [1]
IV infusion : Dilute 3 mg/kg in 50 mL diluent [3]
Diluent
NS, D5 [1]
Calculation
Example: Doctor ordered IV Adrenaline 0.5mcg/kg/min. Patient’s body weight is 65 kg. What is
the infusion rate ?
a. Determine dose (mg/hr) = Dose (mcg/kg/min) x BW (kg) x 60 min/hr

1000 mcg/mg
= 0.5 x 65 x 60
1000
= 1.95 mg/hr
b. Determine concentration = 0.06 mg/mL (if dilute 3 mg in 50 mL diluent)
c. Calculate infusion rate (mL/hr) = Dose (mg/hr) ______

Concentration (mg/mL)
= 1.95
0.06
= 32.5 mL/hr
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HIGH ALERT

Adult IM : 500 mcg, repeat every 5 min as required [1]
IV Slow bolus : 1 mg in 10 mL NS (Concentration: 100 mcg/mL) [4]

500 mcg, given at a slow rate of 100 mcg/min, stop when
response is achieved [1]
IV infusion : 0.05 – 2 mcg/kg/min [4] (Refer Infusion Rate Guide page 25)
Paediatric IM : 10mcg/kg, repeat every 5 min as required [1]
IV Slow bolus : 1 mg in 10 mL NS (Concentration: 100 mcg/mL) [4]

10mcg/kg, given at a slow rate of 100 mcg/min, stop when
response is achieved [1]
IV Infusion : Up to 1.5 mcg/kg/min via central venous catheter [3]

(Refer Infusion Rate Guide page 26)
Storage & Stability

After dilution - -
Remarks
 Rapid IV administration may cause death from cerebrovascular hemorrhage or cardiac
arrhythmias. However, rapid IV administration during pulseless arrest is necessary [4]
 For cardiopulmonary resuscitation with intravenous use in adults, administration through a

central line results in a faster response than peripheral administration, however placement
of a central line must not interfere with chest compressions; drugs administered
peripherally must be followed by a flush of at least 20 mL NS injection to aid entry into the
central circulation [6]
 For hypersensitivity reactions, preferred IM injection site is anterolateral aspect of the thigh
[4]
 For continuous infusion, central line administration is preferred, and required infusion
pump [4]
 Adrenaline is sensitive to light and air. Solutions should not be used if they are discolored or
contain a precipitate [ 4]
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HIGH ALERT
References
1. CCM Duopharma. Adrenaline (CCM AdrenalineInjection) Product leaflet. Revised date : July 2011
2. Dilution Guide for High Alert Medication Pharmacy Service Division 2011
3. British National Formulary Children 2014-2015
5. Shann F. Drug Doses. 17th ed. Victoria: 2017
6. British National Formulary 2017-2018
24 | P a g e
HIGH ALERT
Infusion Rate Guide
ADULT : Adrenaline 3 mg in 50 mL NS/D5 (60 mcg/mL; through central line) [5]
40 kg 45 kg 50 kg 55 kg 60 kg 65 kg 70 kg 75 kg 80 kg 85 kg 90 kg 95 kg
mcg/kg/min mL/hr
0.1 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5 9 9.5
0.2 8 9 10 11 12 13 14 15 16 17 18 19
0.3 12 13.5 15 16.5 18 19.5 21 22.5 24 25.5 27 28.5
0.4 16 18 20 22 24 26 28 30 32 34 36 38
0.5 20 22.5 25 27.5 30 32.5 35 37.5 40 42.5 45 47.5
0.6 24 27 30 33 36 39 42 45 48 51 54 57
0.7 28 31.5 35 38.5 42 45.5 49 52.5 56 59.5 63 66.5
0.8 32 36 40 44 48 52 56 60 64 68 72 76
0.9 36 40.5 45 49.5 54 58.5 63 67.5 72 76.5 81 85.5
1 40 45 50 55 60 65 70 75 80 85 90 95
Reference : Shanmugam S. ICU Management Protocol No.5: Inotropic and Vasopressor Support. Program Anestesiologi &
Cawangan Kualiti Penjagaan Kesihatan BPP, KKM; 2006 Aug
25 | P a g e
[6]
HIGH ALERT
MEDICATION
Reference : Shann F. Drug Doses. 17th ed. Victoria: 2017

26 | P a g e
ALFACALCIDOL
o One-Alpha 2 mcg /mL
Reconstitution
Not required [1]
Further dilution
Not required [1]
Diluent
Not required [1]

Injection must be shaken before use [1,2]
IV bolus [1,2]
Storage & Stability

-
After dilution -
Remarks
 Injection solution must be stored between 2-8 ⁰C, and protected from light [1,2]
 Use with caution in small premature infants; it contains small amounts of ethanol (alcohol)
as an excipient, less than 100 mg per 1 mL dose [1]
References
1. LEO Pharma. Alfacalcidol ( One-Alpha®) Product leaflet. Revised date : July 2014
27 | P a g e
ALPROSTADIL
o Prostin VR Pediatric® 500 mcg/mL
Reconstitution
Not required [1]
Further dilution
See Administration & Infusion Rate section
Diluent
[1]
NS, D5

IV Continuous infusion only (Max. concentration : 20 mcg/mL)
Max. rate : 0.4 mcg/kg/min [1]
Add 1 ampoule (500 mcg) Approximate concentration of Infusion rate

Alprostadil to: resulting solution (mcg/mL) (mL/min/kg)
250 mL 2 0.05
100 mL 5 0.02
50 mL 10 0.01
25 mL 20 0.005
Storage & Stability

[1]
After dilution 24 hours -
28 | P a g e
ALPROSTADIL
Remarks
 Store unopened PROSTIN VR Sterile solution in fridge at temperature between 2 - 8 ⁰C [1]
 Prepare fresh infusion solutions every 24 hours. Discard any solution more than 24 hours
[1]
old
 Undiluted solution may interact with sidewalls of volumetric infusion chambers causing
changes in appearance of the chamber and creating a hazy solution. Should this occur, the
[1]
solution and the volumetric infusion chamber should be replaced
 Avoid direct contact of undiluted solution the walls of volumetric infusion chamber by
[1]
adding it into the intravenous infusion solution
 Preferred route is continuous intravenous infusion into a large vein or through an umbilical
[1]
artery catheter placed at ductal opening
References
1. Pfizer. Alprostadil (Prostin VR Pediatric®) Product leaflet. Revised October 2008.
29 | P a g e
AMIKACIN
o Apalin 250 mg/2 mL
Reconstitution
Not required [1]
Further Dilution
IM : Undiluted [1]
IV Infusion : Dilute 500 mg to 200 mL of diluent (Concentration : 2.5 - 5 mg/mL) [1]
Diluent
NS, D5, Ringer’s Solution [1]

Adult IM : Administer into large muscle mass [2]
IV Infusion : Administer over 30 - 60 min [1,2]

Pediatric IM : Administer into large muscle mass [2]
IV Infusion : Adminster over 30 - 60 min [1,2]

– Newborn infants : Administer over 1 - 2 hours [1,2]
Storage & Stability

After dilution 24 hours [1] 60 days [1]
Remarks
 Slow infusion may help to avoid neuromuscular blockade [1]
 Discard dark-coloured solutions [1]
 Pediatric patients may require a proportionately smaller volume of diluent [1]
References
1. Duopharma (M) SDN BHD. Amikacin (Apalin) Product leaflet. Revised 16 January 2012
30 | P a g e
AMINOPHYLLINE
o Aminophylline 250 mg/10 mL [1]
o DBL Aminophylline Injection 250 mg/10 mL [2]
Further Dilution
IV Slow bolus : Undiluted [1,3]
IV Infusion : Dilute 250 or 500 mg in 500 mL diluent [3]
Diluent
NS [1-3], D5 [2,3], Dextrose saline [1]

IV Slow bolus : 5 - 10 min, [1] for dose 250 mg over 20 min [3]
IV Infusion : Administer at a rate of 0.5 mg/kg/hr. Dose must be individualised based on

patient characteristics, clinical response, and steady state theophylline
concentration [2,3]. Rate of administration not to exceed 20 – 25 mg/min [2]
Storage & Stability

References
1. Atlantic Laboratories Corporation Ltd Product leaflet.
2. Hameln Pharmaceuticals. Aminophylline (DBL Aminophylline Injection) Product Leaflet.
3. Sarawak Handbook of Medical Emergencies, 3rd edition 2011
31 | P a g e
HIGH ALERT
AMIODARONE MEDICATION

o BioindustriaL.I.M. Amiodarone Hydrochloride 150 mg/3 mL
Reconstitution
Not required [1]
Further Dilution
Adult IV Slow bolus : Dilute in 10 - 20 mL diluent [1]
[1]
IV infusion : Dilute 5 mg/kg in 250 mL diluent
Paediatric IV Slow bolus : 10 - 20 mL diluent [1]
IV infusion : Dilute to a concentration of ≥ 600 mcg/mL with diluent [2]
Diluent
D5 only [1,2]

Adult Administer via a large peripheral or central vein whenever possible with ECG
monitoring. If large peripheral line needs to be used, concentration should not
exceed 2 mg/mL [3]
IV Slow bolus : Adminster over ≥ 3 min

(Should not be repeated for at least 15 min) [1]
IV Infusion : 20 min – 2 hours [1]
Paediatric IV administration via central venous catheter recommended if repeated or
continuous infusion required, as infusion via peripheral veins may cause pain
and inflammation [2]
IV Slow bolus : 5 mg/kg (max. 300 mg) over at least 3 min [2]
IV Infusion
– Neonates : Initially 5 mg/kg over 30 min then 5 mg/kg over
30 min every 12 – 24 hours [2]
– Children (1 month-18 years) : Initially 5 – 10 mg/kg over 20 min – 2 hours then
by continuous infusion 300 mcg/kg/hr, adjusted
according to response, increased if necessary up to
1.5 mg/kg/hr; Max 1.2 g in 24 hours [2]
32 | P a g e
HIGH ALERT
AMIODARONE MEDICATION
Storage & Stability

After dilution Discard immediately [1] -
Remarks
 Incompatible with sodium chloride solution [1,2]
 Should only be used in a special care unit under continuous monitoring (ECG and blood
pressure) [1]
 IV Infusion is prefered to bolus due to the haemodynamic effects sometimes associated
with rapid injection such as circulatory collapse [1]
 When repeated or continuous infusion is anticipated, administration by a central venous
catheter is recommended. [1]
 Dilution of less than 0.6 mg/mL is unstable. Solutions containing less than 2 ampoules
Amiodarone Injection in 500 mL D5 are unstable and should not be used [1]
 Reconstituted or Diluted solution should NOT be refrigerated or kept under 15⁰C as they
may precipitate[1]
References
1. Bioindustris Laboratoria Italiano Medicinali. Amiodarone Injection Product leaflet. Revised date :
July 2014
2. British National Formulary Children 2017-2018\
3. Dilution Guide for High Alert Medications Pharmacy Services Department 2011
33 | P a g e
AMOXICILLIN + CLAVULANIC ACID
o Clavam 1.2 g (Amoxicillin 1 g and Clavulanic Acid 200 mg)
Reconstitution
Reconstitute powder with 20 mL WFI. Final volume: 20.9 mL [1]
Further Dilution
IV Slow bolus : Not required [1]
IV Infusion : Dilute to 100 mL diluent [1]
Diluent
NS, LR Solution, Ringer’s Solution [1]

[1]
IV Slow bolus : Over 3 - 4 min
[1]
IV Infusion : Over 30 - 40 min (completes within the time stated)
Storage & Stability

Conditions Room Temperature (<25 ⁰C) Fridge ( 5 ⁰C)
[1]
After reconstitution 20 minutes -
After NS, WFI 4 hours 8 hours
[1]
dilution LR Solution, 3 hours -
Ringer’s Solution
Remarks
[1]
 Not suitable for IM
[1]
 For single use only. Not suitable for multi-dose use
[1]
 Less stable in infusion containing glucose, dextrose or bicarbonate
 For storage at 5 ⁰C, the reconstituted solution should be added to pre-refrigerated infusion
bags which may be stored for up to 8 hours. Thereafter, the infusion should be
[1]
administered immediately after reaching room temperature
References
1. Alkem Laboratories Limited. Amoxicillin 1 g and Clavulanic Acid 200 mg (Clavam®) Product
leaflet. Revised date: 04/2016
34 | P a g e
AMPHOTERICIN B
o Amphotret 50 mg freeze dried preparation for IV injection
Reconstitution
AMPHOTRET is a yellow coloured cake, on reconstitution gives a clear yellow solution.
Reconstitute 1 vial with 10 mL of Sterile WFI, shaking the content until a visibly clear solution
obtained [1]
Further Dilution
Adult IV Infusion : Dilute reconstituted solution with a diluent to a final concentration
of 0.1 mg/mL (50 mg vial in 500 mL D5) [1]
Final concentration should not exceed 0.1 mg /mL (peripheral
infusion) or 0.25 mg/mL (central infusion) [2]
Diluent
D5 [1]

Adult IV Infusion : Infuse over 2 - 6 hours [1,2]
Storage & Stability

After reconstitution - 7 days [1]
After dilution - -
Remarks
 Store AMPHOTRET at temperature not exceeding 8 ⁰C in a refridgerator.
 Test dose: 1 mg in 20 mL of D5 administered 20 - 30 minutes may be preferred. Patient’s
temperature, pulse, respiration and blood pressure should be monitored every 30 minutes
for 2 - 4 hours [1]
 Solution should be protected from light during administration [1], short-term exposure (<24
hours) to light during infusion does not appreciably affect potency. [2]
 In-line microbial membrane filter with pore size 1 micron or more can be used.[1]
 Discard the solution on reconstitution if the solution not visibly clear or contains foreign
particles [1]
35 | P a g e
AMPHOTERICIN B
Remarks (continued)
 Premedicate 30 - 60 minutes prior infusion with NSAID and/or diphenhydramine OR
acetaminophen/paracetamol with diphenhydramine OR hydrocortisone for patients who
experience infusion-related immediate reactions. [2]
 Safety and effectiveness in pediatric patients have not established through adequate and
well-controlled studies [1]
References
1. Bharat Serums and Vaccines Limited. Amphotericin B for Injection U.S.P (Amphotret) Product
Leaflet. Revised date : -
36 | P a g e
AMPICILLIN+SULBACTAM
o Ampicillin & Sulbactam Powder for Injection 1.5 g (Ampicillin sodium 1000 mg &
Sulbactam sodium 500 mg)
Reconstitution
IM : Reconstitute with 3.2 mL of Sterile WFI or 0.5% Lignocaine HCl or 2% Lignocaine HCl
(Final concentration : 375 mg/mL which equal to 250 mg ampicillin/125 mg sulbactam
per mL) [1, 2]
IV : Reconstitute with 3.2 mL of sterile WFI [1]
Further Dilution
Adult IV Infusion : Dilute reconstituted solution in 50 – 100 mL of compatible diluent [3]
or 3 g of ampicillin/sulbactam dilute in 70 mL NS or D5 [4]
Paediatric IV Infusion : Dilute with compatible dilution (Final concentration ≤ 45 mg/mL
Unasyn; 30 mg/mL Ampicillin and 15 mg/mL Sulbactam) [2]
Diluent
D5, NS, LR Solution [3]

Adult IM : Deep IM injection into large muscle mass [2]
IV Slow Bolus : Administer over 3 min [1]
IV Infusion : Administer over 15 – 30 min [1] or extended over 4 hours [4]
Paediatric IV Slow Bolus : Administer over 10 – 15 min [2]

IV Infusion : Administer over 15 – 30 min [2]
Storage & Stability

After NS - 72 hours
[2]
dilution D5 - 4 hours
37 | P a g e
AMPICILLIN+SULBACTAM
Remarks
 If patient also being administered with aminoglycosides concurrently, both medication
should be administered at separate site at least 1 hour apart.[1]
 Safety and efficacy of intramuscular administration of ampicillin/sulbactam not established
in pediatric. [5]
References
1. Karnataka Antibiotics & Pharmaceuticals Limited. Ampicillin & Sulbactam Powder for Injection 1.5g
Product Leaflet. Revised Date : 9 August 2016
3. McGraw Hill’s IV Drug Handbook App Version 8.0.249
4. Guide to Antimicrobial Therapy in the Adult ICU 2017. Malaysian Society of Intensive Care
5. Truven Health Analytics. (Micromedex®) 2018 Version 1.17
38 | P a g e
AMPICILLIN
o Ampicillin Sodium for Injection BP 500 mg
Reconstitution
IM : Reconstitute 1 vial (500 mg) with 1.5 mL of Sterile WFI [1]
IV : Reconstitute 1 vial (500 mg) in 10 mL of Sterile WFI [1]
Further Dilution
Adult IV Infusion : Dilute reconstituted solution with 50 – 100 mL NS [3]
Paediatric IV Infusion : Dilute reconstituted solution with compatible diluent to a

concentration of 50 – 100 mg/mL [4]
Diluent
NS [3]

Adult IM : Deep IM into a large muscle mass
IV Slow Bolus : Dose 125 - 500 mg, administer over 3 - 5 min [1]
Dose 1 – 2 g, administer over 10 – 15 min [2,3]
Paediatric IV Infusion : Administer over 30 min if dose more than 50 mg/kg to avoid
convulsions [4]
Storage & Stability

After dilution at 30 mg/mL - 24 hours
different ≤ 30 mg/mL 8 hours -
[2]
concentration ≤ 20 mg/mL - 48 hours
39 | P a g e
AMPICILLIN
Remarks
 If patient also being administered with aminoglycosides concurrently, both medications
should be administered at separate site at least 1 hour apart [1]
 Rapid infusion may cause seizures [2]
References
1. Karnataka Antibiotics & Pharmaceuticals Limited. Ampicillin Sodium for Injection BP 500mg Product
Leaflet. Revised Date : 9 August 2016
4. BNF for Children September 2017-2018
40 | P a g e
ANTI RhD GAMMA GLOBULIN
o Rhophylac® 300 (300 mcg/2 mL)
Reconstitution
Not required [1]
Further Dilution
Not required [1]
Diluent
Not required [1]

Adult IM : Inject into deltoid muscle of the upper arm or anterolateral aspect
of the upper thigh. [2]
IV Slow bolus : In case of hemorrhagic disorders where intramuscular injections

is contraindicated,[1] infuse at 2 mL per 15 – 60 seconds [2]
Storage & Stability

After dilution - -
Remarks
 Store in a refrigerator between 2 – 8 ⁰C. Do not freeze [1]
 Should be brought to room or body temperature before use [1]
 Do not use solutions which are cloudy or have deposits [1]
 Must not be mixed with other medicinal products [1]
 Use only once. Any unused product or waste material should be disposed of in accordance
with local requirements [1]
 Avoid injecting at the gluteal region due to risk of sciatic nerve injury [2]
 Do not administer subcutaneously into the fatty tissue [2]
 If large doses ( > 5 mL) are required and intramuscular injection is chosen, administer in
divided doses at different sites [1, 2]
41 | P a g e
ANTI RhD GAMMA GLOBULIN
References
1. CSL Behring AG. Human Anti-D Immunoglobulin (Rhophylac®) Product Leaflet. Revised date :
October 2014
42 | P a g e
ANTIVENIN SERUM
HIGH ALERT
SEA SNAKE MEDICATION

o Sea Snake Antivenom 1000 U
Reconstitution
Not required [1]
Further Dilution
Adult IV Infusion : Dilute with 250 – 500 mL NS or D5 [2]
Paediatric IV Infusion : Dilute with 5 – 10 mL NS or D5 per kg body weight [2]
Diluent
NS, D5, LR Solution [1,2]

IV Infusion : Start slow, 1 – 2 mL/min over 10 – 15min [2]
If there is no reaction, increase to higher rate 5 – 10 mL/min to complete within
less than 1 hour [2]
Storage & Stability

After reconstitution Use immediately [1] -
After dilution - -
Remarks
 SEA SNAKE ANTIVENOM should be protected from light and stored between 2 – 8 ⁰C. Do
not freeze [1]
 Use once only and discard any residue [1]
References
1. CSL Limited. Sea Snake Antivenom Product Leaflet. Revised date: 13 January 2014
2. Snakebite Management Guide for Healthcare Providers in Malaysia. Ahmad Khaldun Ismail.
Updated: August 2015
43 | P a g e
A N T I V E N I N S E R U M
HIGH ALERT
S N A K E P O L Y V A L E N T MEDICATION

o Polyvalent Snake Antivenin
Reconstitution
 Reconstitute 1 vial with 10 mL of Sterile WFI. Swirl well (Do not shake) to dissolve the
contents until the serum became clear and colourless or pale yellow liquid before
administration [1]
Further Dilution
Adult IV Infusion : Dilute with 250 – 500 mL NS or D5 [2]
Paediatric IV Infusion : Dilute with 5 – 10 mL NS or D5 per kg body weight [2]
Diluent
NS, D5 [2]

IV Infusion : Start slow, 1 – 2 mL/min over 10 – 15 min [2]
If there is no reaction, increase to higher rate 5 – 10 mL/min to complete within
less than 1 hour [2]
Storage & Stability

After dilution - -
Remarks
 Initial dose at least 20 mL of reconstituted serum should be given by slow IV infusion (not
more than 1 mL/min) [1]
References
1. Queen Saovabha Memorial Institute. The Thai Red Cross Society. Polyvalent Snake Antivenin
Product Leaflet.
2. Snakebite Management Guide for Healthcare Providers in Malaysia. Ahmad Khaldun Ismail.
Updated: August 2015
44 | P a g e
ARTESUNATE
o Artesun® 60 mg
Reconstitution
Reconstitute with provided solvent (5% Sodium Bicarbonate solution) [1]
Further Dilution
Route
IM IV
Diluent
D5 2 mL 5 mL
NS 2 mL 5 mL
Final volume after dilution 3 mL 6 mL
Final concentration after dilution 20 mg/mL 10 mg /mL
Diluent
D5, NS [1]

IM : Inject into the anterior thigh [1,2]
IV Slow bolus : Administer at the rate of 3 – 4 mL/min [1]
Storage & Stability

Remarks
 Do not use in intravenous drip. [1]
 Discard if solution is not clear [1]
References
1. Guilin Pharmaceutical Co. Ltd. Artesunate Powder For Injection 60mg (Artesun®) Product Leaflet.
3. Paediatric Protocols For Malaysian Hospitals 3rd Edition
45 | P a g e
HIGH ALERT
ATRACURIUM MEDICATION

o Atralex 10 mg/mL
Reconstitution
Not required [1]
Further Dilution
Adult IV Slow bolus : Undiluted
IV Continuous infusion : Dilute to obtain concentration of ≥ 0.5 mg/mL [1]
Paediatric IV Continuous infusion : Dilute in diluent to a concentration of 0.5 – 5 mg/mL [3]
– Neonatal intensive care : Dilute 60 mg/kg body weight to a final volume of
50 mL (min. concentration: 500 mcg/mL, max.
concentration: 5 mg/mL) [3]
Diluent
NS, D5, 1/5NS, Ringer’s Solution, LR Solution [1]

Adult IV Slow bolus : Administered at rate of 0.3 – 0.6 mg/kg/hr [1,2]
IV Continuous infusion : Administered at rate of 0.3 – 0.6 mg/kg/hr [1]

Paediatric IV Continuous infusion : Administered at rate of 0.3 – 0.6 mg/kg/hr [3]
– Neonatal intensive care : Infuse at rate of 0.1 mL/hr, which provides a dose
of 120 mcg/ kg/ hr [3]
Storage & Stability

After NS 24 hours -
dilution [1] D5
1/5NS 8 hours -
Ringer’s Solution
LR Solution 4 hours -
46 | P a g e
HIGH ALERT
ATRACURIUM MEDICATION
Remarks
 Store ampoule in fridge between 2 – 8 ⁰C. Protect from light. Do not freeze [1]
 Atracurium besylate is hypotonic and must not be administered into the infusion line of
blood transfusion [1]
 Atracurium besylate injection has acid pH, should not be mixed with alkaline solutions (eg:
barbiturates solution) [1]
 When injecting into small vein, the IV line should be flushed with Normal Saline before and
after injection [1]
 Do not give as IM [1]
 Dose for pediatrics should be calculated using ideal body weight [3]
References
1. Duopharma (M) Sdn.Bhd. Atralex Injection Product Leaflet.
47 | P a g e
ATROPINE
o Acipan Injection 1 mg/mL
Reconstitution
Not required [1]
Further Dilution
Not required [1]
Diluent
Not required [1]

Adult SC [1]
IM [1] : Administer to the outer thigh [2]
IV Slow bolus : Undiluted, rapid IV injection [2]
Paediatric SC [3]
IM [3]
IV Bolus [3]
Storage & Stability

After dilution - -
Remarks
 Should not be added to any intravenous infusion solutions for administration. [1,3]
 Slow IV infusion or adult dosages below 0.5 mg may slow the heart rate further. [3]
References
1. Duopharma (M) Sdn.Bhd. Acipan Injection Product Leaflet
48 | P a g e
AZITHROMYCIN
o Azomax 500 mg
Reconstitution
Reconstitute 1 vial (500 mg) with 4.8 mL of Sterilized WFI (Final concentration : 100 mg/mL) [1]
Further Dilution
Dilute 5 mL of reconstituted solution with 250 mL diluent (Final concentration : 2 mg/mL) or
500 mL diluent (Final concentration : 1 mg/mL) [1,2,3]
Diluent
NS, D5, 1/2NS, LR solution [1,3]

IV Infusion : Administer at a final concentration of 1 mg/mL over 3 hours; for concentration
2 mg/mL, administer over 1 hour [2]
Storage & Stability

After reconstitution ≤ 24 hours [1] -
After dilution ≤ 24 hours [1] ≤ 7 days [1]
Remarks
 Do not administer as bolus or intramuscular injection [1,2,3]
 Discard the reconstituted solutions if there is evidence of foreign materials [1,2,3]
References
1. M/s. Gland Pharma Limited. Azomax (Azithromycin for injection Lyophilized) Product Leaflet.
Revised date : September 2013
49 | P a g e
HANDBOOK OF DRUG RECONSTITUTION & DILUTION TAWAU HOSPITAL 2018 B
BCG VACCINE FREEZE DRIED
o Freeze-Dried Glutamate BCG Vaccine (Japan) for Intradermal Use
Reconstitution
Reconstitute with provided diluent [1]
Further Dilution
Not required [1]
Diluent
Not required [1]

IM : Half way down the outer aspect of the upper arm [1]
Storage & Stability

After dilution - -
Remarks
 BCG Vaccine and provided diluent should be stored and transported between 2 – 8 ⁰C [1]
 The skin should not be cleaned with antiseptic [1]
 The vaccine and diluent should be transported together. Only provided diluent should be
use to reconstitute the vaccine. Do not diluent from other types of vaccines or from other
manufacturers [1]
 Water for injection should not be used to reconstitute the vaccine and incorrect diluent
may damage the vaccine [1]
 Do not vaccinate at the shoulder or revaccinate at a previously vaccinated site [1]
References
1. Japan BCG Laboratory. Freeze-Dried Glutamate BCG Vaccine (Japan) for Intradermal Product Leaflet.
Revised date : December 2013
50 | P a g e
BENZANTHINE PENICILLIN
o Sterile Penicillin G Benzathine USP 2.4 MU
Reconstitution
Reconstitute 1 vial in 8 mL or more of Sterile WFI [1]
Further Dilution
Not required [1]
Diluent
Not required [1]

Adult IM : Administer by deep IM injection in the upper outer quadrant of the
buttock [2]
Paediatric IM : Children ≤ 2 years old, IM injections into the midlateral muscle of the thigh,
not the gluteal region [2]
Storage & Stability

After dilution - -
Remarks
 Do not administer as intravenously, intra-arterially or subcutaneously. [2]
 If patient also being administered with aminoglycosides concurrently, both medication
should be administered at separate site at least 1 hour apart [1]
 Do not inject near artery or a nerve, may cause permanent neurological damage or
gangrene. [2]
References
1. Karnataka Antibiotics & Pharmaceuticals Limited. Sterile Penicillin G Benzathine USP 2.4MU Product
Leaflet. Revised date : 13 July 2009
51 | P a g e
BENZYLPENICILLIN 1 MU
o Bepen Injection 1 MU (600mg)
Reconstitution
Reconstitute in 2 mL or more of Sterile WFI immediately before use [1]
Further Dilution
Adult IV Continuous Infusion : Dilute reconstituted solution in 1 – 2 L diluent [2]
IV Intermittent infusion : Dilute reconstituted solution in 50 or 100 mL diluent [3]
Paediatric IV Infusion : Dilute with compatible diluent [4]
Diluent
NS, D5 [3]

Adult IM : Administer IM by deep injection on the upper outer
quadrant of the buttock. [2]
IV Continuous Infusion : Administer over 24 hours [3]
IV Intermittent Infusion : Administer over 15 – 30 minutes [2]
Paediatric IV Infusion : Administered over 15 – 30 minutes. Longer
administration time if use doses ≥ 50 mg/kg to avoid
CNS toxicity. [4]
Storage & Stability

After reconstitution 2 days [1] 6 days [1]
After dilution - -
Remarks
 Alternate sites should be used for repeated injections [1]
52 | P a g e
References
1. Karnataka Antibiotics & Pharmaceuticals Limited. Bepen Injection (Benzylpenicillin Sodium) Product
Leaflet. Revised date : 14 February 2017
53 | P a g e
o Benzyl Penicillin Injection 5 MU (3 g)
Reconstitution
Reconstitute powder with 10 mL WFI(Concentration: 300 mg/mL equivalent to 500,000 U/mL)[1]
Further Dilution
Adult IM : Further dilute in 5 mL of diluent
(Final concentration : 100,000 U/mL) [2]
IV Infusion : Further dilute in 3.5 - 10 mL of diluent
(Final concentration : 50,000 - 145,000 U/mL) [2]
Paediatric IM : Further dilute in at least 5 mL of diluent
(Final concentration ≤ 100,000 U/mL) [2]
IV Infusion : Further dilute in 5 - 10mL of diluent
(Final concentration : 50,000 - 100,000 U/mL) [2]
Diluent
NS, D5[2,3,4]

IM [1,2,3]
IV Infusion : Administer over 15 – 30 min [2,4] Rate ≤ 300 mg/min or 500,000 U/min [1]
Storage & Stability

After reconstitution 2 days [1] 6 days [1]
After dilution - -
Remarks
 IV route recommended in neonates and infants [4]
 High dose of Benzylpenicillin Sodium may result in hypernatremia and hypokalemia [1]
 Longer administration time is recommended when high dose of Benzylpenicillin is used
[1,2,3,4]
54 | P a g e
References
1. Karnataka Antibiotics. Benzylpenicillin Product Leaflet. Revised date: 9 August 2016
3. MIMS. (MIMSGateway®) 2018 Version 17.4.1
4. MedHand (BNF Children®) 2014
55 | P a g e
BERACTANT
o Survanta 200 mg Phospholipids/8 mL suspended in NS solution. The color is off white to
light brown.
Reconstitution
Not applicable
Further Dilution
Paediatrics Not applicable
Diluent
Not applicable

Paediatric Intratracheal [1,2]
Storage & Stability

After dilution - -
Remarks
 Store unopened vials at refrigeration temperature 2 – 8 ⁰C. Protect form light [1]
 If settling occurs, swirl the vial gently and do not shake.[1]
 Before administration, Survanta® should be warmed by standing in room temperature for
atleast 20 minutes or warmed in the hand for at least 8 minutes.[1]
 Drug should not be warmed and returned to refrigerator more than once.[1]
 Vial is for single use only. [1]
References
1. Abbvie. Beractant (Survanta®) Product Leaflet. Revised date : November 2012
56 | P a g e
BOX JELLYFISH
HIGH ALERT
ANTIVENOM MEDICATION

o Box Jellyfish Antivenom 20,000 U
Reconstitution
Not applicable
Further Dilution
Adult IM : Undiluted [1]
IV infusion : Dilute 1:10 with diluent [1]
Paediatric IM : Undiluted [1]
IV infusion : Dilute 1:5 with diluent [1]
Diluent
NS [2]

IM : Administer at 3 different sites [1]
IV infusion [1] : Complete within 20 minutes if no adverse reaction[2]
Storage & Stability

After dilution - -
Remarks
 Store between 2 – 8 ⁰C and protect from light. Do not freeze [1]
 Allergic reaction or anaphylactic reaction may occur, thus, a syringe loaded with 1:1,000
(adult) or 1:10,000 (children up to age 12) adrenaline must be available prior to
administration [1,2]
References
1. BioCSL. Box Jellyfish Antivenom Product Leaflet. Revised date: 14 December 2009
2. Guidelines for The Treatment Of Box Jellyfish Envenomation In Malaysia. Malaysian Society on
Toxinology. 2017
57 | P a g e
BROMHEXINE
o Mucolex® 4 mg/2 mL
Reconstitution
Not required
Further Dilution
May further dilute with compatible diluent (optional) [1]
Diluent
D5, Ringer’s Solution [1]
IM [1]
IV Slow bolus : Administer over 2 - 3 minutes [1]
IV Infusion [1]
Storage & Stability

After dilution - -
Remarks
 Should not be mixed with alkaline solution as it may cause cloudiness or flocculation [1]
References
1. Duopharma. Bromhexine (Mucolex®) Product leaflet. Revised date: 17 January 2007
58 | P a g e
HIGH ALERT
BUPIVACAINE (PLAIN) MEDICATION

o Pivakan 0.5% w/v (100 mg/20 mL)
Reconstitution
Not required
Further Dilution
Adult Not required
Paediatric May further dilute with preservative-free NS [1,2]
Diluent
NS [2]

Intrathecal [1]
Storage & Stability

After dilution - -
Remarks
 Solution should be used immediately after opening and discard any remaining portion [1]
References
1. Duopharma. Bupivacain plain (Pivakan®) Produvt Leaflet. Revised date g: 28 July 2005
59 | P a g e
HIGH ALERT
BUPIVACAINE (HEAVY) MEDICATION

o Bupican® Heavy 20 mg/4 mL
Reconstitution
Not required
Further Dilution
Not required
Diluent
Not required

Intrathecal [1]
Storage & Stability

After dilution - -
Remarks
References
1. Claris Injectible Limited. Bupivacaine Heavy (Bupican®) Product Leaflet. Revised date : 7 December
2015
60 | P a g e
BUPIVACAINE 0.5%
HIGH ALERT
+ ADRENALINE MEDICATION

o Marcain 0.5% Adrenaline
Reconstitution
Not required
Further Dilution
Adult Not required
Diluent
Not required

Adult Epidural [1]
Storage & Stability

After dilution - -
Remarks
References
61 | P a g e
HANDBOOK OF DRUG RECONSTITUTION & DILUTION TAWAU HOSPITAL 2018 C
CALCITONIN
(SYNTHETIC SALMON)
o Miacalcic 100 IU
Reconstitution
Not required
Further Dilution
Adult Paget Disease SC, IM : Undiluted [1,2,3]
SC, IM : Undiluted[1,2,3];
Hypercalcemia
IV infusion : 10 U/kg dilute with 500 mL diluent [2]
Postmenopausal SC,IM : Undiluted [1,2,3]
Osteoporosis
Diluent
NS [1]
Adult SC [1,2,3]
Paget Disease
IM [1,2,3]
SC [1,2,3]
Hypercalcemia
IM [1,2,3]
IV infusion : Administer over at least 6 hours [2]
Postmenopausal SC [1,2,3]
Osteoporosis
IM [1,2,3]
Storage & Stability

After dilution - -
62 | P a g e
CALCITONIN
(SYNTHETIC SALMON)
Remarks
 Store between 2 – 8 ⁰C and protect from light. Do not freeze [1]
 If volume to be injected exceeds 2 mL, intramuscular injection is preferable and multiple
sites of injection should be used [1]
 Safety and effectiveness not established in children [3]
References
3. Truven Health Analytics. (Micromedex®) 2018 Version 2.1.1
63 | P a g e
CALCIUM GLUCONATE
o B Braun Calcium Gluconate 10%
Reconstitution
Not applicable
Further Dilution
Adult IV Slow bolus : Undiluted, [2,3] OR
Dilute to final concentration of 10 – 50 mg/mL [2,3]
IV Infusion : Dilute to final concentration of 5.8 – 10 mg/mL [2]
Paediatric IV Slow bolus, IV Infusion : Dilute 1:10 with diluent[1] or 1:1 [2,6]
(Concentration ≤ 50 mg/mL) [2,6]
Diluent
NS, D5 [1,2]

Adult Hyperkalemia IV Slow bolus : 10 mL over 2 - 10 min [3,5]
Symptomatic IV Slow bolus : 10 – 20 mL over 10 min [5] (Max. rate at
Hypocalcemia ≤ 200 mg/min [2] or approx. 1.5 mL/min [7])
followed by
IV infusion : 1 - 2 mg/kg/hr every 6 – 12 hour [5]
Paediatric Hyperkalemia IV Slow bolus : By using 1:1 dilution, give over 5 – 15 min [2,6]
Symptomatic IV infusion : 0.5 mL/kg (50mg/kg, max. dose 20mL) infused
Hypocalcemia over 10 - 20 min [6]
(Max. rate at ≤ 100 mg/min [2])
Alternatively,
IV Slow bolus : 100 – 200 mg/kg/dose over 5 - 10 min
followed by
IV Continuous infusion : 500 – 800 mg/kg/day[2]
64 | P a g e
CALCIUM GLUCONATE
Storage & Stability
After dilution 48 hours [1] 24 hours [1]
Remarks
 Peadiatric dose is 0.5mL/kg with maximum 20 ml of 10% calcium gluconate solution [3,4,6]
 Do not administered via IM as it may cause severe necrosis and sloughing in peadiatrics [1,2]
 Any unused solution should be discarded immediately after initial use [1]
 Care should be taken to administer the IM injection sufficiently deep IM, preferably into the
gluteal region [1]
References
1. B. Braun: Calcium Gluconate 10% Product leaflet. Revision date: November 2005
4. Frank Shann Drug Doses. 2017
5. Critical Care Pharmacy Handbook. Pharmaceutical Service Division MOH 2013
6. Peadiatric Protocol. Ministry of Health 2012
65 | P a g e
CARBETOCIN
o Duratocin 100 mcg
Reconstitution
Not applicable
Further Dilution
Adult Not applicable
Diluent
Not applicable

Adult IV Slow bolus : Over 1 min [1,2,3]
Storage & Stability

After dilution - -
Remarks
 DURATOCIN must be stored at refrigerator temperature 2 – 8 ⁰C [1]
 Should not be frozen [1]
 Only administered when delivery of the infant has been completed [1]
 Use immediately once the ampoule has been opened [1]
References
1. Ferring. Carbetocin (Duratocin®) Product leaflet. Revised date :November 2013
66 | P a g e
CARBOPROST TROMETHAMINE
o Hemabate 250 mcg
Reconstitution
Not applicable
Further Dilution
Adult Not applicable
Diluent
Not applicable

Adult Deep IM [1,2,3]
Storage & Stability

After dilution - -
Remarks
 HEMABATE must be refrigerated at 2 – 8 ⁰C [1]
 Should only be administered deep IM, do not inject IV [2]
 Total dose administered should not exceed 12mg and 2mg (8doses) for abortion and post-
partum bleeding respectively [1]
References
1. Pfizer.Carboprost (Hemabate®) Product leaflet. Revised date :N/A
67 | P a g e
CEFAZOLIN
o Cefazolin Sandoz 1000 mg
Reconstitution
Reconstitute powder with 2.5 mL WFI. Concentration : 330 mg/mL [1,2,3]
Further Dilution
Adult IV Slow bolus : Further dilute with 5 mL WFI [2]
IV infusion : Dilute with 50 - 100 mL diluent [1,2]
Paediatrics IV Slow bolus : Further dilute with 5 mL WFI [2]
IV Infusion : Dilute with 50 - 100 mL diluent(Concentration : 5 – 20 mg/mL) [1,2]
Diluent
NS, D5 [1,2]

Adult IM [1,2,3]
IV Slow bolus : Over 3 – 5 min [1,2,3]
IV Infusion : Over 30 – 60 min [1,2,3]
Paediatric IM [1,2,3]
IV Slow bolus : Over 3 – 5 min [1,2,3]
IV Infusion : Over 10 – 60 min [1,2,3]
Storage & Stability

After reconstitution 24 hours [2] 10 days [2]
Remarks
-
68 | P a g e
CEFAZOLIN
References
2. IBM Cooperation (IBM Micromedex®) 2018 Version 2.0
69 | P a g e
CEFEPIME
o Cefmex 1000 mg
Reconstitution
IM : Reconstitute powder with 3 mL WFI, D5 or NS.
Approx. Concentration : 230 mg/mL [1]
IV Slow bolus, IV Infusion : Reconstitute powder with 10 mL WFI, D5 or NS.
Approx. Concentration : 90 mg/mL [1]
Further Dilution
IV Infusion : Dilute 500 - 1000 mg with 50 - 100 mL diluent [1]
(Concentration : 1 - 40 mg/mL)
Diluent
NS, D5 [1]

IM [1,2]
IV Slow bolus : Over 3 - 5 min [1,2]
IV Infusion : Over 30 min [1,2,3]
Storage & Stability

-
After reconstitution 48 hours [1]
After dilution 24 hours [1,3] 48 hours [1]
Remarks
 The colour of Cefepime powder and solution may darken on storage, however, product
potency is not adversely affected [1]
 Final concentration of diluted solution should NOT exceed 40 mg/mL [2]
References
1. Duopharma. Cefepime (Cefmex®) Product leaflet. Revised date : 14 October 2014
3. IBM Cooperation (IBM Micromedex®] 2018 Version 2.0
70 | P a g e
CEFOPERAZONE
o Bicafar 1 g
Reconstitution
IM : Add 2.6 mL of Sterile WFI or Bacteriostatic WFI into the 1-gram vial and agitate
until the powder is completely dissolved. Subsequently, add 0.9 mL of 2%
lignocaine solution and mix. This produces a final concentration of 250 mg/mL [1]
IV Slow bolus : Reconstitute with 5 mL of NS, D5, D10, NSD5, or Sterile WFI [1]
IV infusion : Reconstitute with 5 mL of NS, D5, D10, NSD5, or Sterile WFI [1]
Further Dilution
IM : Not required
IV Slow bolus : Dilute to a final concentration of 100 mg/mL [1]
IV Infusion : Dilute with 20 – 100 mL of diluent [1]
Diluent
NS, D5, D10, NSD5, LR Solution [1]

IM : Inject into the large muscle mass of gluteus maximus or anterior thigh [1]
IV Slow bolus : Administer over 3 – 5 minutes [1]
IV Infusion : Administer over 15 minutes – 1 hour [1]
Storage & Stability

Conditions Room Temperature (<25 ⁰C) Fridge (2 – 8 ⁰C)
After reconstitution 24 hours [1] 5 days [1]
After dilution - -
Remarks
 Incompatibility or loss of activity has been reported between cefoperazone and
aminoglycosides, perphenazine or pethidine hydrochloride [1]
Reference
1. Duopharma. Cefoperazone ( Bicafar®) Product leaflet. Revised date: 14 August 2012
71 | P a g e
CEFOPERAZONE+SULBACTAM
o Vaxcel Cefobactam 1 g
Reconstitution
IM : Reconstitute with 3.4 mL of Sterile WFI. Subsequently, add 2% lignocaine
solution to yield solutions containing up to 125 mg cefoperazone and 125 mg
sulbactam/mL in approximately a 0.5% lignocaine solution. [1]
IV Slow bolus, IV infusion : Reconstitute with 3.4 mL of NS, D5 or Sterile WFI (Concentration
125 mg/mL cefoperazone and 125 mg/mL sulbactam) [1]
Further Dilution
IV infusion: Dilute to 20 mL of diluent [1]
Diluent
NS, D5, Sterile WFI, LR Solution [1]

IM [1]
IV Slow bolus : Administer over a minimum of 3 min [1]
IV Infusion : Administer over 15 min – 1 hr [1]
Storage & Stability

After reconstitution 1 day [1] -
After dilution - -
Remarks
 Incompatible with aminoglycosides. [1]
 Initial reconstitution with Hartmann’s solution or 2% lignocaine solution should be avoided
due to incompatibility of the mixture. However, a 2-step dilution process involving initial
reconstitution in WFI will result in a compatible mixture when further diluted with
Hartmann’s solution or 2% lignocaine solution. [1]
References
1. Kotra Pharma. Cefoperazone/Sulbactam ( Vaxcel®) Product leaflet. Revised date: Not available
72 | P a g e
CEFOTAXIME
o Rekaxime 1 g
Reconstitution
Reconstitute 1 vial (1 g) with 4 mL of WFI [1]
Further Dilution
Adult IV Short infusion : 2 vials to be diluted in 40 mL of diluent [1]
IV Continuous drip : 2 vials to be diluted in 100 mL of diluent [1]
Paediatric IV Slow bolus : Dilute to a concentration of 50 mg/mL [2]
IV Infusion : Dilute to a concentration 10 – 50 mg/mL [2]
Diluent
IV Short infusion : WFI, D10 [1]
IV Continuous drip : NS, D5 [1]

Adult IM : Inject deep into the gluteus muscle (not to inject > 4 mL into
either side) [1]
IV Slow bolus : Over 3 – 5 min [1]
IV Short infusion : Over approximately 20 min [1]
IV Continuous drip : Over 50 – 60 min [1]
Paediatric IM : Inject deep into the gluteus muscle (not to inject > 4 mL into
either side) [1]
IV Slow bolus : Over 3 – 5 min [1,2]
IV infusion : Over 15 – 60 min [1,2]
Storage & Stability

After reconstitution 24 hours [1] -
After dilution - -
73 | P a g e
CEFOTAXIME
Remarks
 Cefotaxime is incompatible with hetastarch sodium chloride and alkaline solutions such as
sodium bicarbonate [1]
 If daily dose exceeds 2 g of cefotaxime, IV injection is to be preferred [1]
References
1. Duopharma. Cefotaxime ( Rekaxime®) Product leaflet. Revised date: 19 November 2013
2. Truven Health Analytics. (Micromedex®) 2018 Version 1.17.0b783
74 | P a g e
CEFTAZIDIME
o Cefatum 1 g
Reconstitution
IM : Reconstitute with 3 mL of WFI or 0.5% lignocaine solution (Approximate concentration
260 mg/mL) [1]
IV : Reconstitute with 10 mL of WFI (approximate concentration 90 mg/mL) [1]
Further Dilution
Adult IV Intermittent infusion : Dilute to a concentration of 1 – 40 mg/mL [1]
IV Extended or Continuous infusion : 1 – 2 g dilute in 50 mL of diluent [2]
Paediatric IV Infusion : Dilute to a concentration ≤ 40 mg/mL [3]
Diluent
NS, D5, D10, 1/2NSD5, 1/4NSD5, LR Solution [1-5]

Adult IM : Inject deep into a large muscle mass such as the upper quadrant of
the gluteus maximus or lateral part of the thigh [1,3-5]
IV Intermittent infusion : Over up to 30 min [5]
IV Extended or Continuous infusion : Over 4 hours or interval prescribed [2]
Paediatric IM : Inject deep into a large muscle mass such as the upper quadrant of
the gluteus maximus or lateral part of the thigh [1,3-5]
IV infusion : Over 20 – 30 min [3]
Storage & Stability

After WFI 12 hours 7 days
reconstitution [1] 0.5% Lignocaine 6 hours 4 days
After dilution [1] 12 hours 7 days
75 | P a g e
CEFTAZIDIME
Remarks
 Sodium bicarbonate is not recommended as diluent. [1]
 For severe or life-threatening infections or if the daily dose exceeds 1 g of ceftazidime, the
IV route is to be preferred. [1,4]
References
1. Duopharma. Ceftazidime ( Cefatum®) Product leaflet. Revised date: 21 June 2014
2. Guide to Antimicrobial Therapy in the Adult ICU. Malaysian Society of Intensive Care (MSIC) 2017.
3. British National Formulary for Children 2017-2018
76 | P a g e
CEFTRIAXONE
o Unocef 1000 mg
Reconstitution
IM : Reconstitute with 3.6 mL of solution (concentration 250 mg/mL) [1]
IV : Reconstitute with 9.6 mL of solution (concentration 100 mg/mL) [1]
Appropriate solutions : Sterile WFI, NS, D5, Bacteriostatic Water + 0.9% Benzyl Alcohol or 1%
Lignocaine solution (without adrenaline) [1]
Further Dilution
IV infusion : Dilute to 25 mL to 100 mL of diluent (concentration: 10 – 40 mg/mL) [1]
Diluent
NS, D5, D10, NSD5, 1/2NSD5 [1]

Adult IM : Inject well within the body of a relatively large muscle [1]
Doses over 1 g must be divided between more than one site [2]
IV Slow bolus : Over 5 min [2]
IV infusion : Over at least 30 min [1,2]
Paediatric IM : Inject well within the body of a relatively large muscle [1] Doses over
1 g must be divided between more than one site. [3] May be mixed
with 1% lignocaine solution to reduce pain at the site of injection. [3]
IV infusion
– Neonates : Over 60 min [1,3]
– Infant & Children : Over at least 30 min [1,3]
77 | P a g e
CEFTRIAXONE
Storage & Stability
Conditions Concentration Room Temperature Fridge
(mg/mL) (<25 ⁰C) (4 ⁰C)
WFI, NS, D5 100 3 days 10 days
250 24 hours 3 days
After Bacteriostatic Water + 100 24 hours 10 days
reconstitution 0.9% benzyl alcohol or
[1]
1% lignocaine solution 250 24 hours 3 days
(without adrenaline)
-
After WFI, NS, D5, D10 3 days 10 days
dilution [1] NSD5, 1/2NSD5 -
3 days Incompatible
Remarks
 Do not use diluents containing calcium, such as Hartmann’s solution due to the particulate
formation. [1,2,3]
 The admixture of sterile ceftriaxone with other antibacterials is not recommended. [1]
 Doses greater than 2 g must be given via IV route. [2,3]
 Intravenous doses of 50 mg/kg or more in children under 12 years should be given by
infusion. [3]
References
1. Duopharma. Ceftriaxone ( Unocef®) Product leaflet. Revised date: 2 October 2013
78 | P a g e
CEFUROXIME
o Anikef 750 mg
o Pharmaniaga Cefuroxime Injection 1.5 g
Reconstitution
IM : Reconstitute 750 mg with 3 mL of WFI.
Shake gently to produce an opaque suspension [1]
IV : Reconstitute 750 mg with at least 6 mL of WFI [1] and 1.5 g with 16 mL WFI [2]
Further Dilution
IV infusion : Dilute 1.5 g in 50 mL of diluent [1]
Diluent
WFI [1], NS, D5, D10, NSD5, 1/2NSD5, 1/4NSD5, LR solution [2]

IM : Inject deep into a large muscle mass such as the gluteus or lateral part of the
thigh [2]
IV infusion : Over up to 30 min [1]
Storage & Stability

After reconstitution 5 hours [1] 48 hours [1]
Remarks
 May be incompatible with aminoglycosides. [1]
References
1. Duopharma. Cefuroxime ( Anikef®) Product leaflet. Revised date: 2 September 2013
2. Pharmaniaga. Cefuroxime (Pharmaniaga Cefuroxime Injection®) Product leaflet. Revised date: Not
available
79 | P a g e
CHLORPHENIRAMINE
o Pirimat Injection 10 mg/mL
Reconstitution
Not required
Further Dilution
Not required
Diluent
-

SC, IM, IV Slow bolus : Over one minute [1]
Storage & Stability

After dilution - -
Remarks
 IV route is recommended when a rapid effect is desired [1]
References
1. Duopharma (M) Sdn Bhd. Chlorpheniramine Maleate (Pirimat) Product leaflet. Revised date : 24
October 2011
80 | P a g e
CIPROFLOCAXIN
o Ciproxol 200 mg/100 mL
Reconstitution
Not required
Further Dilution
Dilute up to final concentration 1 mg/mL (optional) [3]
Diluent
NS, D5, LR Solution [3]

IV Infusion : Over a period of 60 min [1,2]
Storage & Stability

After dilution - -
Remarks
 Slow infusion into a large vein will minimize patient’s discomfort and reduce the risk of
venous irritation [1,2]
 Infusion solution can be infused either directly or after mixing with the other compatible
infusion solution [1]
 Product should not be administered with any other drug product [1]
References
1. Ain Medicare Sdn Bhd. Ciprofloxacin (Ciproxol) Product leaflet. Revised date : 21 May 2012
81 | P a g e
CISATRACURIUM
HIGH ALERT
BESYLATE MEDICATION

o Cisatracurium Besylate 2 mg/mL (5 mL)
Reconstitution
Not required
Further Dilution
Dilute up to 25 – 100 mL (Final concentration: 0.1 – 0.4 mg/mL) [1,2]
Diluent
NS, D5 [1,2]

Adult IV Slow bolus : Undiluted over 5 – 10 seconds [1,2]
IV Infusion : 3 mcg/kg/min (range : 0.5 – 10 mcg/kg/min) [1,2]
Paediatric IV Slow bolus : Undiluted over 5 – 10 seconds [1,2]
IV Infusion : 1 – 4 mcg/kg/min [1]
Storage & Stability [1,2]

-
After reconstitution -
After dilution depends on 24 hours 24 hours
concentration (0.1 – 0.2 mg/mL) [1,2] (0.1 mg/mL) [1]
Remarks
 Refrigarate intect vials at 2 – 8 ⁰C [1]
 Not for IM injection due to tissue irritation [1,2]
 Continuous administration requires the use of an infusion pump [1]
References
2. Cisatracurium. Intravenous Dilution Database. Global Rph. [cited 7 July 2018] Available at
http://www.globalrph.com/cisatracurium_dilution.htm
82 | P a g e
CLINDAMYCIN
o Dalacin C 300 mg/2 mL
Reconstitution
Not required
Further Dilution
IM : Undiluted
IV Infusion : Dilute to a final concentration ≤ 18 mg/mL [1, 2]

Dose Diluent
300 mg 50 mL
600 mg 50 mL
900 mg 50 – 100 mL
1200 mg 100 mL
Diluent
NS, D5 [2]

IM : Rotate sites [2] Do not exceed 600 mg in a single injection [1, 2]
IV Infusion : Administer over at least 10 – 60 minutes [1,2]

Infusion rates should not exceed 30 mg/min [1, 2]
Administration of more than 1200 mg in a single 1-hour infusion is not
recommended [1, 2]
Dose Time
300 mg 10 min
600 mg 20 min
900 mg 30 min
1200 mg 40 min
83 | P a g e
CLINDAMYCIN
Storage & Stability
After dilution 16 days [2] 32 days [2]
Remarks
 Store unopened DALACIN C in fridge at 2 – 8 ⁰C. Do not freeze [1]
 Should not be injected intravenously undiluted as a bolus [1, 2]
 Hypotension and cardiopulmonary arrest have been reported following rapid IV
administration [2]
 Contain benzyl alcohol and it has been associated with a fatal “Gasping Syndrome” in
premature infants [1]
References
1. Pfizer Manufacturing Belgium NV. Clindamycin (Dalacin C) Product leaflet. Revised date : April 2014
84 | P a g e
CLOSTRIDIUM BOTULINUM
TOXIN TYPE A
o Botox 100 U
Reconstitution
Reconstitute with sterile NS without a preservative [1,2]
Diluent Added Resulting Dose in U per 0.1 mL

0.5 mL 20 U
1 mL 10 U
2 mL 5U
4 mL 2.5 U
8 mL 1.25 U
10 mL 1U
Neurogenic Detrusor Over-activity: [1,2]

 Reconstitute two 100 U vials, each with 6 mL of preservative-free NS and mix gently
 Withdraw 4 mL from each vial into each of two 10mL syringes
 Withdraw remaining 2 mL from each vial into the third syringe, for a total of 4mL in each
of the three 10 mL syringes
 Add 6mL preservative-free NS into each of the three 10mL syringes and mix gently
 Each of the 10 mL syringes will contain 10mL (approximately 67U in each), for a total of
200 U
Further Dilution
Not required
Diluent
-
Administration & Infusion Rate [1]

SC : Blepharospasm
IM : Blepharospasm, Strabismus, Cervical Dystonia, Spasticity, Upper Facial Lines,

Chronic Migraines [1,2]
Intradermal : Primary Hyperhidrosis of Axillae
Intradetrusor : Bladder Dysfunction
85 | P a g e
CLOSTRIDIUM BOTULINUM
TOXIN TYPE A
Storage & Stability
After dilution - -
Remarks
[1]
 Unopened vials should be stored in refrigerator between 2 – 8 ⁰C
[1,2]
 Discard the vial if a vacuum does not pull the diluent into the vial
References
1. Allergan Pharmaceuticals Ireland. Botulinum Toxin Type A (Botox) Product leaflet. Revised date :
April 2015
86 | P a g e
CLOXACILLIN
o Cloxacillin Sodium 500 mg
Reconstitution
IM : Reconstitute with WFI to concentration of 125 – 250 mg/mL [2]
IV Slow bolus : Reconstitute with WFI to concentration of 50 - 100mg/mL [2]
IV Infusion : Reconstitute with WFI to concentration of 250mg/mL [2]
Further Dilution
IV Infusion : Dilute up to 250 – 500mL (Final concentration : 1 – 2 mg/mL) [2]
Diluent
NS, D5 [2]

IM
IV Slow bolus : Administer over 2- 4 min [2]
Storage & Stability

Remarks
 Administer in separate sites at least 1 hour apart with aminoglycoside [1]
 Balance solution should be discarded [1]
References
1. Karnataka Antibiotics & Pharmaceuticals Limited. Cloxacillin Sodium Product leaflet. Revised date :
9 August 2016
2. Lexi- Comp, Inc. (Lexi-Drugs®) 2018 Version 4.0.4
87 | P a g e
HIGH ALERT
COBRA ANTIVENOM MEDICATION

o Cobra Antivenin (Purified)
Reconstitution
Reconstitute with 10 mL WFI [1,2]
Gently swirl (never shake) to dissolve the freeze-dried antivenom [1,2]
Further Dilution
Adult Dilute with 250 – 500 mL of diluent [1,2]
Paediatric Dilute with 5 – 10 mL/kg of diluent [1,2]
Diluent
NS, D5 [1]

Administer at approximately 1 -2mL/min over 10 -15 minutes, then increased to a higher rate if
no reaction, to complete within one hour [2]
Storage & Stability

After dilution - -
Remarks
 Patient must be monitored during and for at least one hour AFTER completion of
intravenous infusion [2]
 Administer same dose of antivenin in adults and children [1]
References
1. Queen Saovabha Memorial Institute. Cobra Antivenom (Cobra Antivenin (Purified)) Product leaflet.
Revised date : April 2012
2. Guideline: Management of Snakebite. Ministry of Health. Malaysia. 2017
88 | P a g e
COLISTIMETHATE(POLYMYXIN E)
o Colomycin Injection 1 MIU
Reconstitution
Reconstitute with 5 mL NS or WFI
Further Dilution
IV Infusion : Dilute up to 50 mL of diluent [1]
Diluent
NS, WFI [1]

IV Slow bolus : Administer up to 2 MIU in 10 mL over 5 minutes (for patient with TIVAD) [1]
IV Infusion : Administer over 30 minutes [1]
Storage & Stability

After reconstitution Immediately [1,2] 24 hours [1,2]
After dilution - -
Remarks
 The solution is for single use [1]
References
1. Xellia Pharmaceuticals APS. Colistimethate Sodium (Colomycin) Product leaflet. Revised date : 10
September 2015
89 | P a g e
CYANOCOBALAMIN
o Cyanocobalamin 1000 mcg/mL
Reconstitution
Not required
Further Dilution
Not required
Diluent
-
IM [1]
SC [2]
Storage & Stability [1]

After dilution - -
Remarks
 IV administration is not recommended [2]
References
1. Pharmaniaga Lifescience Sdn Bhd. Cyanocobalamine Product leaflet. Revised date : 19 October
2015
90 | P a g e
HANDBOOK OF DRUG RECONSTITUTION & DILUTION TAWAU HOSPITAL 2018 D
DANTROLENE SODIUM
o Revonto 20 mg
Reconstitution
Reconstitute with 60 mL of sterile WFI (without a bacteriostatic agent) [1,2]
Shaken for approximately 20 seconds or until the solution is clear [1,2]
Further Dilution
Not required
Diluent
-
Administer by continuous rapid intravenous push [1,2]
Administer follow-up doses over at least 1 hour [2]
Storage & Stability

After dilution - -
Remarks [1]
 Reconstituted solution must be protected from direct light [1]
References
1. US WorldMeds. Dantrolene Sodium (Revonto) Product leaflet. Revised date : October 2016
91 | P a g e
DENOSUMAB
o Prolia 60 mg
o Denosumab 120 mg
Reconstitution
Not required
Further Dilution
Not required
Diluent
-
Adult SC [1,2] (in the upper arm, upper thigh or abdomen) [2]
Storage & Stability [1]

After dilution - -
Remarks
 Store PROLIA in refrigerator 2 – 8 ⁰C. Protect from light. Do not freeze. [1]
 Bring to room temperature prior to administration [2]
 Avoid vigorous shaking [2]
 Safety and efficacy in paediatric have not been established [1]
References
1. Amgen Manufacturing Limited (AML). Denosumab (Prolia) Product leaflet. Revised date : 28 March
2015
92 | P a g e
DESFERRIOXAMINE
o Desferal 500 mg
Reconstitution
IM : Reconstitute with 2 mL of sterile WFI [1]
Final concentration: 213 mg/mL [1]
SC Infusion & IV Infusion : Reconstitute with 5mL of sterile WFI [1]

Final concentration: 95 mg/mL [1]
Further Dilution
IV Infusion : Dilute with 150 mL of diluent [1]
Diluent
NS, D5, Ringer’s solution, LR solution, peritoneal dialysis solutions such as Dianeal 137 Glucose
2.27%, Dianel PD4 Glucose 2.27%, and CAPD/ DPCA 2 Glucose 1.5% [1]

SC Infusion : Administer using portable, light-weight infusion pump
Treatment of Chronic over 8 – 12 hours or 24 hours, 5 – 7 times a week
Iron Overload [1]
IV Infusion : Administer only if SC Infusion is not feasible
IM : Administer only if SC Infusion is not feasible
Treatment of Acute IV Continuous infusion : Administer 15mg/kg/hr, reduce as soon

Iron Poisoning [1] as circumstances permit, usually after
4 – 6 hours, maximum total IV
dose < 80 mg/kg/24hr
Treatment of Chronic Post-Deferrioxamine Test Serum Aluminium ≤ 300 ng/mL

Aluminium Overload - Slow IV Infusion : during last 60 minutes of dialysis session
[1]
in ESRF (HD)
Post- Deferrioxamine Test Serum Aluminium > 300 ng/mL
- Slow IV Infusion : 5 hours prior to dialysis session
Treatment of Chronic intraperitoneal, IM, Slow IV Infusion or SC, prior to final exchange
Aluminium Overload of the day
[1]
in ESRF (CAPD & CCPD)
93 | P a g e
DESFERRIOXAMINE
Storage & Stability
After reconstitution Immediately [1] -
After dilution - -
Remarks
 Intravenous bolus route may lead to circulatory collapse [1]
 Should not be given at concentrations > 95mg/mL when given SC as this increases the risk of
local reactions [1]
 One vial is for single use only [1]
 Rapid intravenous infusion may lead to hypotension and shock [1]
References
1. Norvatis. Desferrioxamine (Desfeal) Product leaflet. Revised date : January 2015
94 | P a g e
DESMOPRESSIN
HIGH ALERT
ACETATE MEDICATION

o Minirin Desmopressin Acetate 4 mcg/mL
Reconstitution
Not required
Further Dilution
Adult Central diabetes insipidus IV Slow bolus : Not required [2,3]
Renal concentrating capacity test SC, IM : Not required [2,3]
Haemophilia A, IV infusion : Dilute in 50 mL diluent [1,2,3]
von Willebrand disease Type 1
Paediatric Central diabetes insipidus IV Slow bolus : Not required [2,3]
Renal concentrating capacity test SC, IM : Not required [2,3]
Haemophilia A, IV infusion
von Willebrand disease Type 1 – Child weight < 10 kg : Dilute in 10 mL
diluent [2,3]
– Child weight ≥ 10 kg : Dilute in 50 mL
diluent [2,3]
Diluent
[1,2,3]
NS

Adult Central diabetes insipidus IV Slow bolus : Over 1 min [2,3]
Renal concentrating capacity test SC, IM [2,3]
Haemophilia A, IV infusion : Over 15 – 30 min [2,3]
95 | P a g e
DESMOPRESSIN
HIGH ALERT
ACETATE MEDICATION
Administration & Infusion Rate (continued)

Paediatric Central Diabetes Insipidus IV Slow bolus : Over 1 min [2,3]
Renal concentrating capacity test SC, IM [1]
– Infant & Child > 12 months
Haemophilia A, IV infusion : 15 – 30 min [2,3]
Storage & Stability

Remarks
 Store unopened MINIRIN ampoules refrigerated between 2 – 8 ⁰C [1]
References
1. Ferring. Desmopressin (Minirin) Product leaflet. Revised date : July 2006
3. McGraw-Hill. IV Drug Handbook 2009
96 | P a g e
DEXAMETHASONE
o Penatone 4 mg/mL in 2 mL (8 mg/2 mL)
Reconstitution
Not required [1]
Further Dilution
Adult Intra-articular, Intralesional, Soft-tissue injection : Undiluted [1,2,3]
IM, IV Slow bolus : Undiluted [1,2,3]
IV Infusion : Dilute with 50 mL diluent or dilute to a concentration of
0.5 mg/mL [3]
Paediatric IV Slow bolus : Undiluted [5]
IV Infusion : There is no specific guide on how much volume to dilute
Diluent
NS, D5 [1]

Adult Intra-articular [1,2,3]
Intralesional [1,2,3]
Soft-tissue injection [1,2,3]
IM [1,2,3]
IV Slow bolus : Administer over ≤ 1 min [1,2]
IV Infusion : Over 5 - 15 min [2]
Paediatric IV Slow bolus : Over 1 to several min [4]
IV Infusion : Over 15 - 20 min [5]
For high doses, over 15 - 30 min [2]
Storage & Stability

After dilution 24 hours [1,2] -
97 | P a g e
DEXAMETHASONE
Remarks
 For neonate (especially in premature infant), use preservative free solution for further
dilution [1,2]
 IV route must be used for shock [1,2]
 Rapid administration of IV route (especially in higher doses) may be associated with perineal
irritation [2,3]
References
1. Duopharma Sdn. Bhd. Dexamethasone (Penatone) Product leaflet. Revised date : 11 May 2005
2. Lexi-Comp, Inc. (Lexi-Drugs®), 2018 Version 4.1.1
3. Truven Health Analytics. (Micromedex®) 2018
4. ASHSP The Teddy Bear Book Pediatric Injectable Drugs 10th Edition 2013
98 | P a g e
HIGH ALERT
DEXMEDETOMIDINE MEDICATION

o Precedex 200 mcg/2 mL
Reconstitution
Not required [1]
Further Dilution
Adult Dilute 1 vial (2 mL) with 48 mL of diluent (Concentration : 4 mcg/mL) Shake gently
to mix well [1,2]
Diluent
NS [1,2]

Adult IV infusion :
Initiation 1 mcg/kg over 10 min [1,2]
-ICU Sedation
Maintenance 0.2 – 0.7 mcg/kg/hr titrate accordingly [1,2]
Initiation 0.5 – 1 mcg/kg over 10 min [1,2]
-Procedural Sedation
Maintenance 0.2 – 1 mcg/kg/hr titrate accordingly [1,2]
Storage & Stability

After dilution - -
Remarks
 Important : Maintenance dose of dexmedetomidine is expressed in mcg/kg/hr [2]
 Should not be co-administered through the same IV cathether with blood or plasma [1,2]
 Safety and efficacy of dexmedetomidine is not established in paediatric population [1,3]
References
1. Hospira Inc. Dexmedetomidine (Precedex®) Product leaflet. Revised date : 11 May 2005
99 | P a g e
HIGH ALERT
DIAZEPAM MEDICATION

o Zopam Diazepam 10 mg/2 mL
Reconstitution
Not required [1]
Further Dilution
Adult IM, IV Slow bolus : Undiluted [2]
Paediatric – Children > 2 years old [1]
IM, IV Slow bolus : Undiluted [2]
Diluent
NS, D5 [1]

Adult IM [1]
IV Slow bolus : Administer at a rate not exceeding 5 mg/min [2,3]
Paediatric – Children > 2 years old [1]
IM [1]
IV Slow bolus : Administer over 3 min period at a dosage not exceeding
0.25 mg/kg [1,3] or at a rate not exceeding 1 - 2 mg/min [2]
Storage & Stability

After dilution - -
Remarks
 Contraindicated in infant and children under 2 years of age [1]
 Zopam preparation contains benzyl alcohol, its use should be avoided in children under 2
years of age and not to be used in neonates [1]
 Rapid injection may cause respiratory depression or hypotension [2]
 IV route preferred over IM route due to slow or erratic IM absorption [3]
 Do not dilute or mix with other drugs or solutions [1,3]
 IV infusion is not recommended because of precipitation formation in IV fluids and drug
instability in plastic bags and IV tubing [1,2,3]
100 | P a g e
HIGH ALERT
DIAZEPAM MEDICATION
References
1. SM Pharmaceuticals Sdn Bhd. Diazepam (Zopam) Product leaflet. Revised date : 8 June 2017
101 | P a g e
DICLOFENAC
o Dicloran 75 mg/3 mL
Reconstitution
Not required
Further Dilution
Adult IM : Undiluted
Diluent
Not required

Adult IM : inject deep into gluteal muscle. If more than one injection needed, inject
into different sites with interval of a few hours [1]
Storage & Stability

After dilution - -
Remarks
 Not suitable for use in children [1]
References
1. Unique Pharmaceutical Laboratories. Diclofenac (Dicloran) Product leaflet. Revised date : February
2008
102 | P a g e
HIGH ALERT
DIGOXIN MEDICATION
Brand Name &Strength

o Lanoxin Injection 500 mcg/2 mL
Reconstitution
Not required [1]
Further Dilution
Adult IV infusion : Dilute 1 ampoule (0.5mg) in 50 mL diluent.
(Max. concentration : 62.5 mcg/mL) [4]
Paediatric IV infusion : Dilute with diluent to max. concentration of 62.5 mcg/mL [3]
Diluent
NS, D5 [1]

IV Slow bolus : ≥ 5 min [4,5]
IV infusion : infuse over 10 - 20 min [1,3,4]
Storage & Stability

Conditions Room Temperature (<25⁰ C) Fridge (2 - 8⁰ C)
After Reconstitution - -
After Dilution 48 hours [1] -
Remarks
 Minimum of 4 fold dilution needed to avoid precipitation (should be diluted into ≥ 8 mL for
each ampoule of 0.5 mg/2 mL)[1,2,4,5]
 Rapid IV infusion is not recommended (may cause systemic and coronary arteriolar
constriction)[1,4]
 IM route is not recommended (may cause local irritation & pain ) [1,2,4,5]
References
1. Aspen GlaxoSmithKline. Digoxin (Lanoxin 500mcg/2mL) Product Leaflet. Revised date : Nov 2011
3. British National Formulary For Children 2016 – 2017
5. Lexi - Comp, Inc. (Pediatric & Neonatal Lexi - Drugs®) 2018 Version 2.3.4
103 | P a g e
DIPHTHERIA ANTITOXIN
o Diphtheria Antitoxin 10,000 IU 10 mL Injection
Reconstitution
Not required[1]
Further Dilution
IM (for mild to moderately severe case) [1,2] : Undiluted [3]
IV Infusion (for severe case ) : Dilute with 250 - 500mL of diluent [1,2]
Diluent
NS [1]

IM (for mild to moderately severe case) [1,2]
IV infusion (for severe case ) : Administered over 2 - 4 hours [1,2]
Storage & Stability

-
After Dilution -
Remarks
 Store at temperature 2 - 8⁰C in a refrigerator. Do NOT freeze. [1]
References
1. Vins Bioproducts Limited. Diphtheria Antitoxin 10000 IU 10mL Product Leaflet. Revised date : 2
March 2016
2. Centers for Disease Control and Prevention (CDC). Expanded Access Investigational New Drug (IND)
Application Protocol: Use of Diphtheria Antitoxin (DAT) for Suspected Diphtheria Cases Version 7.
Revised : 21/9/16
3. Tiwari, T., and Clark, T. (2014). Use of Diphtheria Antitoxin (DAT) for Suspected Diphtheria Cases IRB
(Atlanta, GA).
104 | P a g e
HIGH ALERT
DOBUTAMINE MEDICATION

o Mobitil Injection 250 mg/ 20 mL
Reconstitution
Not required [1]
Further Dilution
Adult IV Continuous infusion : Dilute 250mg up to 50mL with diluent [5]
(Max. concentration : 5 mg/mL) [5]
Paediatric IV Continuous infusion : Dilute 15 mg/kg (<30kg) [4] or 6 mg/kg (>30kg) [4] to total
volume of 50 mL [4] diluent (Max. concentration :
5 mg/mL) [3]
Diluent
NS, D5 [1]
Calculation
Example: Doctor ordered IV Dobutamine 3mcg/kg/min. Patient’s body weight is 65kg. What is
the infusion rate ?
1000mcg/mg
= 3 x 65 x 60
1000
= 11.7 mg/hr
b.Determine concentration = 5mg/ml (if dilute 250mg in 50ml diluent)
c.Calculate infusion rate (ml/hr) = Dose (mg/hr) ______

= 11.7
5
= 2.34 mL/hr
105 | P a g e
HIGH ALERT

Adult IV Continuous infusion : 0.5 – 1 mcg/kg/min up to 2.5 – 20 mcg/kg/min
(Max : 40 mcg/kg/min) [1,5] (See remarks)
Refer Infusion Rate Guide on page 107
Paediatric IV Continuous infusion : 2 - 20 mcg/kg/min (Max : 20 mcg/kg/min) [3,6]
(See remarks)
Storage & Stability

After Dilution 24 hours [1,2,5] -
Remarks
 Infuse higher concentration through central venous catheter using syringe pump to avoid
extravasation and fluid overload [3]
 Prepared solution must be used immediately after dilution.[1]
 Incompatible with Sodium bicarbonate and other alkaline solutions. [2,5]
References
1. Duopharma (M) Sdn Bhd. Dobutamine (Mobitil Injection ) Product Leaflet. Revised date : 10 July
2012
2. Truven Health Analytics. (Micromedex ®) 2018 Version 2.1.1
4. Shann F, 2017, Drug Doses, 17th Edition
106 | P a g e
D
HIGH ALERT
Infusion Rate
ADULT : Dobutamine 250 mg in 50 mL NS or D5 (5 mg/mL)

mcg/kg/min mL/hr
3 1.4 1.6 1.8 2 2.2 2.3 2.5 2.7 2.9 3.1 3.2 3.4
4 1.9 2.2 2.4 2.6 2.9 3.1 3.4 3.6 3.8 4.1 4.3 4.6
5 2.4 2.7 3 3.3 3.6 3.9 4.2 4.5 4.8 5.1 5.4 5.7
6 2.9 3.2 3.6 4 4.3 4.7 5 5.4 5.8 6.1 6.5 6.8
7 3.4 3.8 4.2 4.6 5 5.5 5.9 6.3 6.7 7.1 7.6 8
8 3.8 4.3 4.8 5.3 5.8 6.2 6.7 7.2 7.7 8.2 8.6 9.1
9 4.3 4.9 5.4 5.9 6.5 7 7.6 8.1 8.6 9.2 9.7 10.3
10 4.8 5.4 6 6.6 7.2 7.8 8.4 9 9.6 10.2 10.8 11.4
11 5.3 5.9 6.6 7.3 7.9 8.6 9.2 9.9 10.6 11.2 11.9 12.5
12 5.8 6.5 7.2 7.9 8.6 9.4 10.1 10.8 11.5 12.2 13 13.7
13 6.2 7 7.8 8.6 9.4 10.1 10.9 11.7 12.5 13.3 14 14.8
14 6.7 7.6 8.4 9.2 10.1 10.9 11.8 12.6 13.4 14.3 15.1 16
15 7.2 8.1 9 9.9 10.8 11.7 12.6 13.5 14.4 15.3 16.2 17.1
16 7.7 8.6 9.6 10.6 11.5 12.5 13.4 14.4 15.4 16.3 17.3 18.2
17 8.2 9.2 10.2 11.2 12.2 13.3 14.3 15.3 16.3 17.3 18.4 19.4
18 8.6 9.7 10.8 11.9 13 14 15.1 16.2 17.3 18.4 19.4 20.5
19 9.1 10.3 11.4 12.5 13.7 14.8 16 17.1 18.2 19.4 20.5 21.7
20 9.6 10.8 12 13.2 14.4 15.6 16.8 18 19.2 20.4 21.6 22.8
107 | P a g e
HIGH ALERT
DOPAMINE MEDICATION

o Loxin 200 mg/5 mL Injection
Reconstitution
Not required[1]
Further Dilution
Adult IV Infusion
Single strength : Dilute 200 mg with 50 mL diluent (concentration : 4 mg/mL) [6]
Double strength : Dilute 400 mg with 50 mL diluent (concentration : 8 mg/mL) [6]
Fluid restriction : Dilute 200 mg with 50 mL diluent (concentration : 4 mg/mL) [5]
Paediatric IV Infusion : Dilute 15 mg/kg (<30kg) [4] or 6 mg/kg (>30 kg) [4] to total
volume of 50 mL [4] diluent (max. concentration : 3.2 mg/mL) [3]
Diluent
NS, D5 [1]
Calculation
Example: Doctor ordered IV Dopamine 4 mcg/kg/min. Patient’s body weight is 70kg. What is
the infusion rate ?
1000mcg/mg
= 4 x 70 x 60
1000
= 16.8 mg/hr
b. Determine concentration = 4 mg/mL (if single strength dilution is used)
c. Calculate infusion rate (ml/hr) = Dose (mg/hr) ______

= 16.8
4
= 4.2 mL/hr
108 | P a g e
HIGH ALERT
DOPAMINE MEDICATION

Adult IV Continuous infusion : 2 – 5 mcg/kg/min , then increase to 5 – 10 mcg/kg/min [5]
(Max : 20mcg/kg/min) [5,8] (See remarks)
Refer Infusion Rate Guide page 110 (Single Strength)
Refer Infusion Rate Guide page 111 (Double Strength)
Paediatric IV Continuous infusion : 1 – 4 mL/hr (5 – 20 mcg/kg/min) [4]
(Max : 20 mcg/kg/min) [3,7] (See remarks)
Storage & Stability

After Dilution 24 hours [1,2,5] -
Remarks
 Administer into large vein to prevent the possibility of extravasation (central line
administration); monitor continuously for free flow; use infusion device to control rate of
flow [7,8]
 Infuse higher concentration through central venous catheter using syringe pump to avoid
extravasation and fluid overload [3]
 Incompatible with sodium bicarbonate and other alkaline solutions. [2,5]
 Loading dose or bolus injection are NOT recommended.[5]
References
1. Duopharma (M) Sdn Bhd. Dopamine (Loxin Injection 200mg/5mL) Product Leaflet.
4. Frank Shann, 2017, Drug Doses, 17th Edition
6. UKCPA :Minimum Infusion Volumes for Fluid Restricted Critically ill Patients 4th Edition (v4.4)
December 2012
7. Lexi - Comp, Inc. (Pediatric & Neonatal Lexi - Drugs ®) 2018 Version 2.3.4
8. Lexi - Comp, Inc. (Lexi-Drugs®) 2018 Version 4.1.1
109 | P a g e
D
HIGH ALERT
DOPAMINE MEDICATION
Infusion Rate Guide
ADULT : Single strength Dopamine 200 mg in 50 mL NS or D5 (4 mg/mL)

mcg/kg/min mL/hr
3 1.8 2 2.2 2.4 2.8 3 3.2 3.4 3.6 3.8 4 4.2
4 2.4 2.8 3 3.4 3.6 4 4.2 4.6 4.8 5.2 5.4 5.8
5 3 3.4 3.8 4.2 4.6 4.8 5.2 5.6 6 6.4 6.8 7.2
6 3.6 4 4.6 5 5.4 5.8 6.4 6.8 7.2 7.6 8.2 8.6
7 4.2 4.8 5.2 5.8 6.4 6.8 7.4 7.8 8.4 9 9.4 10
8 4.8 5.4 6 6.6 7.2 7.8 8.4 9 9.6 10.2 10.8 11.4
9 5.4 6 6.8 7.4 8.2 8.8 9.4 10.2 10.8 11.4 12.2 12.8
10 6 6.8 7.6 8.2 9 9.8 10.6 11.2 12 12.8 13.6 14.2
11 6.6 7.4 8.2 9 10 10.8 11.6 12.4 13.2 14 14.8 15.6
12 7.2 8.2 9 10 10.8 11.8 12.6 13.6 14.4 15.4 16.2 17.2
13 7.8 8.8 9.8 10.8 11.8 12.6 13.6 14.6 15.6 16.6 17.6 18.6
14 8.4 9.4 10.6 11.6 12.6 13.6 14.8 15.8 16.8 17.8 19 20
15 9 10.2 11.2 12.4 13.6 14.6 15.8 16.8 18 19.2 20.2 21.4
16 9.6 10.8 12 13.2 14.4 15.6 16.8 18 19.2 20.4 21.6 22.8
17 10.2 11.4 12.8 14 15.4 16.6 17.8 19.2 20.4 21.6 23 24.2
18 10.8 12.2 13.6 14.8 16.2 17.6 19 20.2 21.6 23 24.4 25.6
19 11.4 12.8 14.2 15.6 17.2 18.6 20 21.4 22.8 24.2 25.6 27
20 12 13.6 15 16.6 18 19.6 21 22.6 24 25.6 27 28.6
110 | P a g e
D
HIGH ALERT
DOPAMINE MEDICATION
Infusion Rate
ADULT : Double strength Dopamine 400 mg in 50 mL NS or D5 (8 mg/mL)

mcg/kg/min mL/hr
3 0.9 1 1.1 1.2 1.4 1.5 1.6 1.7 1.8 1.9 2 2.1
4 1.2 1.4 1.5 1.7 1.8 2 2.1 2.3 2.4 2.6 2.7 2.9
5 1.5 1.7 1.9 2.1 2.3 2.4 2.6 2.8 3 3.2 3.4 3.6
6 1.8 2 2.3 2.5 2.7 2.9 3.2 3.4 3.6 3.8 4.1 4.3
7 2.1 2.4 2.6 2.9 3.2 3.4 3.7 3.9 4.2 4.5 4.7 5
8 2.4 2.7 3 3.3 3.6 3.9 4.2 4.5 4.8 5.1 5.4 5.7
9 2.7 3 3.4 3.7 4.1 4.4 4.7 5.1 5.4 5.7 6.1 6.4
10 3 3.4 3.8 4.1 4.5 4.9 5.3 5.6 6 6.4 6.8 7.1
11 3.3 3.7 4.1 4.5 5 5.4 5.8 6.2 6.6 7 7.4 7.8
12 3.6 4.1 4.5 5 5.4 5.9 6.3 6.8 7.2 7.7 8.1 8.6
13 3.9 4.4 4.9 5.4 5.9 6.3 6.8 7.3 7.8 8.3 8.8 9.3
14 4.2 4.7 5.3 5.8 6.3 6.8 7.4 7.9 8.4 8.9 9.5 10
15 4.5 5.1 5.6 6.2 6.8 7.3 7.9 8.4 9 9.6 10.1 10.7
16 4.8 5.4 6 6.6 7.2 7.8 8.4 9 9.6 10.2 10.8 11.4
17 5.1 5.7 6.4 7 7.7 8.3 8.9 9.6 10.2 10.8 11.5 12.1
18 5.4 6.1 6.8 7.4 8.1 8.8 9.5 10.1 10.8 11.5 12.2 12.8
19 5.7 6.4 7.1 7.8 8.6 9.3 10 10.7 11.4 12.1 12.8 13.5
20 6 6.8 7.5 8.3 9 9.8 10.5 11.3 12 12.8 13.5 14.3
111 | P a g e
HANDBOOK OF DRUG RECONSTITUTION & DILUTION TAWAU HOSPITAL 2018 E
HIGH ALERT
ENOXAPARIN MEDICATION

o Clexane 6,000 IU/0.6 mL prefilled syringe
Reconstitution
Not required[1]
Further Dilution
Not required[1]
Diluent
Not required [1]

SC [1,2,4,5]
Storage & Stability

After Dilution - -
Remarks
 Not intended for IM administration. [1,3]
References
1. Sanofi Aventis. Enoxaparin (Clexane) Product Leaflet. Revised date : Oct 2015
2. Lexi - Comp, Inc. (Lexi-Drugs) 2018 Version 4.1.1
3. Truven Health Analytics. (Micromedex) 2018 Version 2.1.1
5. Lexi - Comp, Inc. (Pediatric & Neonatal Lexi - Drugs) 2018 Version 2.3.4
112 | P a g e
HIGH ALERT
EPHEDRINE MEDICATION

o CCMD Ephedrine HCL Injection 30 mg/mL
Reconstitution
Not required[1]
Further Dilution
Adult IV Slow bolus : Dilute with diluent to 5 – 10 mg/mL [2]
Paediatric IV Slow bolus : Dilute with diluent to 1 – 2 mg/mL [3]
Diluent
NS, D5 [2,4]

Adult SC [1]
IM [1]
IV Slow bolus [1]
Paediatric IV Slow bolus [1,3,5]
Storage & Stability

After Dilution - -
Remarks
 Care should be taken to avoid extravasation (cause tissue necrosis & sloughing) [1]
References
1. Duopharma (M) Sdn Bhd. Ephedrine Hydrochloride (CCMD Ephedrine HCL) Product Leaflet. Revised
date : 19/6/2013
113 | P a g e
E
EPOIETIN BETA
o Recormon ® 2,000 IU/0.3 mL pre-filled syringes
Reconstitution
Not required[1]
Further Dilution
Not required[1]
Diluent
Not required[1]

SC (preferred for non-HD patients) [1,2,3]
IV Slow bolus : 2 min [1,2,3] via arteriovenous fistula at the end of dialysis [1]
Storage & Stability

After Dilution - -
Remarks
 Store at refrigerator (2 - 8⁰C) [1]
 For purpose of ambulatory use, the patient may remove product from refrigerator and
store it not above 25⁰C for one single period of up to 3 days.[1]
 Incompatibilities: Must not mixed with other medical product. [1]
References
1. F. Hoffmann-La Roche Ltd, Basel, Switzerland. Recormon R
○pre-filled syringe Product Leaflet
2. British National Formulary 74 September 2017 - March 2018
3. British National Formulary For Children 2016 - 2017
114 | P a g e
ERTAPENEM
o Invanz ® 1 g injection
Reconstitution
IM : Reconstitute 1 g vial with 3.2 mL of 1% or 2% Lidocaine HCL (without
epinephrine) [1,2,3]
IV Infusion : Reconstitute 1 g vial with 10 mL WFI, NS or Bacteriostatic WFI [1,2,3]
Further Dilution
Adult IV infusion : Dilute reconstituted vial with 50 mL of diluent [1,2,3]
Paediatric IV infusion : Dilute with diluent to final concentration of ≤ 20 mg/mL [1,2,3,4,5]
Diluent
NS [1,2,3,4,5]

IM : Deep IM into large muscle (gluteal muscle or lateral part of thigh)
IV infusion : Over 30 min [4,5]
Storage & Stability

Conditions Room Temperature (<25⁰ C) Fridge ( 5⁰ C)
After IV Use within 6 hours [1,3] 24 hours & use within 4 hours
reconstitution IM Use within 1 hour [1,3] after removal from fridge [1,2,3,4,5]
After IV 6 hours [1] 24 hours & use within 4 hours
dilution after removal from fridge [1]
Remarks
 Do not use diluent containing dextrose. [1,2,3,4,5]
 Do not mix or co-infuse Invanz with other medication [1]
 Invanz is not recommended in infants under 3 months of age as no data are available [1,4]
115 | P a g e
ERTAPENEM
References
1. Laboratories Merck Sharp & Dohme Chibret. Ertapenem (INVANZ) Product Leaflet. Revised date :
August 2015
2. Lexi - Comp, Inc. (Lexi-Drugs ®) 2018 Version 4.1.1
116 | P a g e
ERYTHROMYCIN LACTOBIONATE
o Eritrotex injection 500 mg
Reconstitution
Reconstitute with 10 mL WFI (concentration : 50 mg/mL] [1,2,3]
Further Dilution
Adult IV Intermittent infusion : Dilute with ≥ 100 mL diluent to concentration of
1 – 5 mg/mL [3]
– Fluid restriction : Concentration of ≤ 10 mg/mL (via central venous
catheter) [4]
IV Continuous infusion : Dilute to concentration of 1 mg/mL [3]
Paediatric IV Intermittent infusion : Dilute to concentration of 1 – 5 mg/mL [4]
– Fluid restriction : Concentration of ≤ 10 mg/mL (via central venous
catheter) [4]
Diluent
NS, D5 [1,3,4]

Adult IV Intermittent infusion : Over 20 – 60 min [1,2,3]
IV Continuous infusion : 6 – 24 hours [1,5]
Paediatric IV Intermittent infusion : 20 – 60 min [4]
Storage & Stability

After Reconstitution 24 hours [2] 14 days [2]
After Dilution 8 hours [2,3] -
Remarks
 Do not administer IV push or bolus. [1,2,3]
 Rapid infusion is more likely to be associated with arrhythmia or hypotension. [1]
 Erythromycin should not reconstituted with inorganic salt solution. [1]
 For dilution with D5, first buffer the D5 solution by adding 0.5 mL of 8.4% Sodium
bicarbonate to each 100 mL of D5 [1,3]
117 | P a g e
ERYTHROMYCIN LACTOBIONATE
References
1. Fisiopharma S.r.L: Erithromycin Lactobionate 500mg Product Leaflet. Revised date : 3 July 2017
5. Web MD, LLC. Medscape Drug Reference 2017 v 1020.0
118 | P a g e
ERYTHROPOIETIN ALFA
o Binocrit 2,000 IU/mL Injection in pre-filled syringe
Reconstitution
Not required [1]
Further Dilution
Not required [1]
Diluent
Not required [1]

Adult SC : Inject to thighs or anterior abdominal wall (≤ 1 mL per injection
site). In case of larger volumes, more than one injection site should
be chosen for injection [1,4]
IV Slow bolus : ≥ 1 – 5 min (depending on total dose). To be given during
hemodialysis via suitable venous port in dialysis line OR at
completion of hemodialysis session, via fistula needle tubing [1,4]
Paediatric IV Slow bolus : 1 – 5 min [2]
Storage & Stability

After Dilution - -
Remarks
 Store and transport in fridge at 2 - 8⁰ C. Do not freeze. Protect from light [1]
 For purpose of ambulatory use, the patient may remove Binocrit from refrigerator and store
it not above 25⁰C for one single period of up to 3 days [1]
 Binocrit must not be used if the solution is cloudy and solution has been accidentally frozen
[1]
 The pre-filled syringe should not be shaken [1]

 A slower injection is preferable in patients who react to treatment with"flu-like"symptom [1]
 IV slow bolus is the preferred route of administration in patients with CKD on hemodialysis.
[3]
119 | P a g e
ERYTHROPOIETIN ALFA
References
1. Sandoz. Binocrit® Epoetin alfa Product Leaflet. Revised date : 7 October 2015
4. British National Formulary 74 September 2017 - March 2018
120 | P a g e
HIGH ALERT
ESMOLOL MEDICATION

o Esocard Injection 100 mg/mL
Reconstitution
Not required [1]
Further Dilution
Dilute to final concentration of 10 mg/mL [1,3]
Diluent
NS, D5, NSD5, 1/2NS, 1/2NSD5, LR Solution

Adult Supraventricular IV Slow bolus : Administer loading dose
Tachycardia (500 mcg/kg/min) over 1 min
followed by
IV Infusion : 4 min maintenance dose
(50 mcg/kg/min) Max. dose is
200 mcg/kg/min for 24 - 48 hr) [1,2]
Intraoperative and IV Slow bolus : Administer 80mg (1mg/kg) over
Postoperative Tachycardia 30 sec , if needed
or hypertension IV Infusion : 150 mcg/kg/min to max. of
300 mcg/kg/min [1,2]
Paediatric Hypertensive Emergency IV Slow bolus : Administer loading dose
(500 mcg/kg/min) over 1 min
followed by
IV Infusion : 4 min maintenance dose
(50 mcg/kg/min) Max. dose is
200 mcg/kg/min [4,5]
Tetralogy of Fallot IV Slow bolus : Administer 0.5 mg/kg over 1 min
followed by
IV Infusion : 0.05 mg/kg/min for 4 min [6]
121 | P a g e
HIGH ALERT
ESMOLOL MEDICATION
Storage & Stability

After Dilution 24 hours [1,2,3] 24 hours [1,2,3]
Remarks
 Avoid infusion (concentration > 10 mg/mL) into small vein or use butterfly catheters (cause
thrombophlebitis) [2]
 Intended for short-term use, not longer than 48 hours [7]
 Incompatible : Sodium bicarbonate (5%) [1]
References
1. Samarth Life Sciences PVT LTD. Esmolol 10mg/mL Product Leaflet. Revised date : November 2010
6. Paediatric Protocols For Malaysian Hospitals 3rd Edition
7. Web MD, LLC. Medscape Drug Reference 2017 v1012.0
122 | P a g e
ESOMEPRAZOLE
o Nexium 40 mg
Reconstitution
Reconstitute with 5 mL of diluent [1,2,3]
Further Dilution
Adult IV Slow bolus : Not required [1,2,3]
IV Intermittent infusion : Dilute to final volume of 50 mL [2,3]
IV Continuous infusion : Dilute to final volume of 100 mL [1,2,3,4]
Paediatrics IV Intermittent infusion : Dilute to final volume of 50 mL to concentration
0.8 mg/mL [3,5,6]
Diluent
NS, D5, Ringer's solution [1,2,3]

Adult IV Slow bolus : ≥ 3 min [1,2,3,4]
IV Intermittent infusion : 10 – 30 min [1,2,3,4]
IV Continuous infusion : Administered at 8 mg/hr [1,2,3,4]
Paediatric IV Intermittent infusion : 10 – 30 min [3,5,6]
Storage & Stability

After NS or 12 hours [1,2,3,4] -
reconstitution Ringer’s Solution
D5 6 hours [2,3,4]
After dilution - -
123 | P a g e
ESOMEPRAZOLE
Remarks
 The reconstituted solution for infusion is clear and colourless to very slightly yellow. Do not
use if the solution is not clear [1]
 Flush IV line prior to and after administration with NS or D5 [1]
References
1．AstraZeneca. Esomeprazole (Nexium) Product Leaflet. Revised date : January 2014
2．Lexi - Comp, Inc. (Lexi-Drugs ®) 2018 Version 4.1.1
3．Truven Health Analytics. (Micromedex®) 2018 Version 2.1.1
4．British National Formulary 74 September 2017 - March 2018
5．British National Formulary For Children 2016 - 2017
6．Lexi - Comp, Inc. (Pediatric & Neonatal Lexi - Drugs®) 2018 Version 2.3.4
124 | P a g e
HIGH ALERT
ETOMIDATE MEDICATION

o Etomidate - Lipuro 20 mg/10 mL
Reconstitution
Not required [1]
Further Dilution
Not required [1]
Diluent
Not required [1]

Adult IV Slow bolus : Over 30 – 60 sec [1,2]
Paediatric IV Slow bolus : Over 30 – 60 sec [3,4] (60 sec for children in whom hypotension
might be hazardous) [3]
Storage & Stability

After Dilution - -
Remarks
 Etomidate-Lipuro NOT LICENSED for children under 6 months except imperative indications
during in-patient treatment. [3]
 Unused portion must be discarded. [1]
 Avoid intra-arterial injection (causes necrosis). Paravenous injection causes strong pain. [1]
 Solution is highly irritating, avoid administration into small vessel [2]
References
1. B.Braun. Etomidate (Etomidate®Lipuro) Product Leaflet. Revised date : 04.2003
125 | P a g e
HANDBOOK OF DRUG RECONSTITUTION & DILUTION TAWAU HOSPITAL 2018 F
FACTOR VIII INHIBITOR
BYPASSING
FRACTION (FEIBA)
o Feiba 500 U
Reconstitution
Reconstitute powder with provided solvent (Sterilized WFI) [1] Refer page 127 & 128.
Further Dilution
Not applicable
Diluent
Not applicable
Administration &Infusion Rate

IV Infusion : Max 2 U/kg/min [1,2]
Storage & Stability

After reconstitution Use within 3 hours [1] -
After dilution - -
Remarks
 Reconstituted solution should NOT be refrigerated and administer within 3 hours [2]
 If refrigerated, allow the powder and solvent to reach room temperature before
reconstituting [1,2]
 USE ONLY included solvent to reconstitute and swirl gently untill all material is dissolved.
DO NOT shake the reconstituted solution [1]
References
1. Baxter. Factor VIII inhibitor bypassing fraction (Feiba). Product leaflet. Revised date : November
2015
126 | P a g e
FACTOR VIII INHIBITOR
BYPASSING
FRACTION (FEIBA)
Reconstitution
1. Warm the unopened solvent vial (sterilized Water
for Injections) to room temperature or max + 37°C if
necessary, for example by using a water bath for
several minutes.
2. Remove the protective caps from the powder vial

and solvent vial and disinfect the rubber stoppers of
both vials. Place the vials on an even surface.
3. Open the packaging of the BAXJECT II Hi-Flow by

pulling off the protective foil without touching the
contents of the package (Fig. a). Do not remove the
transfer system from the package at this point.
4. Turn the package around and press the

transparent plastic pin through the rubber stopper
of the solvent vial (Fig. b). Now remove the
packaging from the BAXJECT II Hi-Flow (Fig. c). Do
not remove the blue protective cap from the
BAXJECT II HiFlow at this point.
5. Now turn the system, consisting of the BAXJECT II

Hi-Flow and the solvent vial, in such a way that the
solvent vial is on top. Press the purple pin of the
BAXJECT II HiFlow through the FEIBA vial. The
solvent is drawn into the FEIBA vial by vacuum (Fig.
d).
6. Swirl, but do not shake the entire system gently

until the powder is dissolved. Make sure that the
FEIBA has been dissolved completely, as active
material may otherwise be retained by the filter in
the system.
127 | P a g e
Reconstitution (continued)
Please take note to use aseptic techniques

throughout the entire procedure. (Step 7- 10)
7. Remove the blue protective cap from the

BAXJECT II Hi-Flow. Tightly connect the syringe to
the BAXJECT II Hi-Flow. DO NOT DRAW AIR INTO
THE SYRINGE. (Fig. e). In order to ensure tight
connection between syringe and BAXJECT II Hi-
Flow, the use of a luer lock syringe is highly
recommended (turn syringe in clockwise direction
until stop position when mounting).
8. Invert the system so that the dissolved product

is on top. Draw the dissolved product into the
syringe by pulling the plunger back SLOWLY and
ensure that the tight connection between BAXJECT
II Hi-Flow and the syringe is maintained throughout
the whole pulling process (Fig. f).
9. Disconnect the syringe.
10. If foaming of the product in the syringe occurs,

wait until the foam is collapsed. Slowly administer
the solution intravenously with the enclosed
infusion set (or disposable needle).
128 | P a g e
F A C T O R V I I I, V O N W I L L E B R A N D
F AC T O R ( A L P H A N A T E )
o Alphanate 250 IU
Reconstitution
Reconstitute with provided diluent. Refer page 130 & 131.
Further Dilution
Not required [1]
Diluent
Not applicable

IV Slow bolus : Administer slowly at a rate not exceeding 10 mL/min [1]
May administer using plastic disposable syringes [1]
Storage & Stability

After dilution - -
Remarks
 Intact Alphanate® should be stored < 30⁰C[ 1]
 Do not refrigerate after reconstitution [1]
References
1. Grifols. Antihaemophilic Factor/Von Willedebrand Factor Complex (Human) (Alphanate®) Product
leaflet. Revised date : October 2013
129 | P a g e
F A C T O R V I I I, V O N W I L L E B R A N D
F AC T O R ( A L P H A N A T E )
Reconstitution
1. Warm the vial and syringe but not above 30°C.
2. Attach the plastic plunger to the syringe

containing diluent.
3. Remove the filter from its packaging. Remove

the grey rubber cap from the syringe tip and then
attach the syringe to the filter.
4. Remove the vial adaptor from its packaging.

Attach the vial adaptor to the syringe-filter
assembly.
5. Remove the plastic flip-top cap from the

concentrate vial and wipe the exposed rubber
with the antiseptic wipe provided.
6. Place the syringe/filter/adaptor assembly over

the top of the concentrate vial and pierce the
stopper with the adaptor needle.
130 | P a g e
7. Transfer all the Water for Injections into the

concentrate vial by depressing the syringe plunger.
8. Gently swirl the vial until all the concentrate has

dissolved. As with other parenteral solutions, do
not use the solution if it is not properly dissolved or
particles are visible.
9. Briefly separate the syringe/filter and

vial/adaptor assemblies to release any vacuum.
10. Invert the concentrate vial and draw up the

solution through the filter into the syringe.
11. Prepare the injection site, separate the

filter/vial adaptor from the syringe. Inject the
solution intravenously using the butterfly needle
provided or a sterile needle.
131 | P a g e
F A C T O R I X, I I, X COMBINATION
(PROTHROMBINEX–VF)
o Prothrombinex® -VF Human Prothrombin Complex Powder for Injection
(500 IU of Factor IX, 500 IU of Factor II, 500 IU of Factor X, low levels of Factor V and VII)
Reconstitution
Reconstitute using provided 20 mL WFI [1] Refer page 133 & 134.
Further Dilution
Not required
Diluent
Not applicable

IV Slow bolus : Administer 3 mL/min or as tolerated by patient [1]
Storage & Stability

After dilution - -
Remarks
 Intact Prothrombinex® -VF to be stored at 2 to 8⁰C in fridge[1]
 Once it has been reconstituted do not refrigerate [1]
 Do not use the Mix2Vial® for injection or administration [1]
 Reconstituted solution must not be added or mixed with any other fluids to be given,
including whole blood [1]
References
1. CSL Behring Australia. Human Prothrombin Complex (Prothrombinex®-VF) Product leaflet.
Revised date : 5 March 2015
132 | P a g e
F A C T O R I X, I I, X C O M B I N A T I O N
(PROTHROMBINEX–VF)
Reconstitution
1. Before reconstitution, allow the vials of
Prothrombinex-VF and provided WFI to reach a
temperature between 20°C and 30°C
2. Remove the caps from the tops of the

Prothrombinex-VF and WFI vials.
3. Apply a suitable antiseptic to the exposed part

of the rubber stoppers of both Prothrombinex® -
VF and WFI and allow to dry.
4. Open the outer package of the Mix2Vial filter

transfer set by peeling away the lid. If the seal of
the lid is not intact or there are any concerns
about the integrity of the Mix2Vial™, do not use it Figure 1
but return it to the appropriate Blood Tranfusion
Service.
Place the WFI 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. See
Figure 1. (20 mL WFI is provided for 500 IU vial)
5. While holding onto the vial of WFI, carefully

remove the outer package from the Mix2Vial™,
being careful to leave the Mix2Vial™attached
firmly to the WFI vial. Ensure that only the
package and not the Mix2Vial™is removed. (Figure
2)
Figure 2
133 | P a g e
6. With the Prothrombinex-VF vial held firmly on a

level surface, invert the WFI with the
Mix2Vial™attached and push the transparent
plastic cannula end of the Mix2Vial™firmly
through the Prothrombinex®-VF stopper. (Figure
3). The water will be drawn into the vial by the
vacuum within. In the unlikely event that the vial
does not contain a vacuum, do not use the
product, but return it to the appropriate Blood
Tranfusion Service.
7. With the WFI 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 Figure 3
usually obtained in 10 minutes or less. The
solution should be used immediately as described
under Administration.
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
(Figure 4), and discard the empty WFI vial and the
blue part of the Mix2Vial™in an appropriate waste
container.
9. To syringe out the contents of Prothrombinex-

VF vial, 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. Once contents has been
transferred into the syringe, firmly hold the barrel Figure 4
of the syringe (keeping the syringe plunger facing
down) and detach the Mix2Vial™fromthe syringe.
134 | P a g e
HIGH ALERT
FENTANYL MEDICATION

o Talgesil 0.1 mg/2 mL
Reconstitution
Not applicable
Further Dilution
IV Slow bolus : Dilute in 5 mL of diluent [2]
Paediatric IV Slow bolus, IV Infusion : Dilute to concentration of 10 mcg/mL [3]
Diluent
NS, WFI, D5 [2,3]

Adult IM [1]
IV Slow bolus : Over 3 - 5 min [2]
Paediatric IV Slow bolus
– Infants, Children and Adolescents : Doses < 5mcg/kg, over 3 - 5 min [3]
: Doses > 5mcg/kg, over 5 - 10 min [3]
IV Infusion
– Neonates : Over 15 - 30 min [3]
Storage & Stability

Remarks
 Rapid administration may cause severe respiratory distress, including apnea [2]
References
1. Duopharma. Fentanyl (Talgesil). Product leaflet
2. I.V. Drug Handbook. The Mcgraw-Hill Companies, Inc. 2010
135 | P a g e
FILGASTRIM
o Neupogen® 30 MU/mL (vial)
o Neupogen® 30 MU/0.5 mL (pre-filled syringe)
Reconstitution
Not applicable
Further Dilution
Adult SC : Undiluted [1]
IV Infusion : Dilute with diluent to a final concentration of ≥ 5 mcg/mL [2,3]

Paediatric IV Infusion : Dilute with diluent to a final concentration of ≥ 15 mcg/mL [4]
Diluent
D5 [2,3]

Method of administration depends on indication
SC [1]
IV Intermittent infusion : Administer over 15 – 30 min [2,3]
IV Continuous infusion : Administer over 4 – 24 hours [2,3]
Storage & Stability

After dilution - 24 hours [1]
Remarks
 Neupogen® 30 MU is equal to 300 mcg. [1, 2,3]
 Store in fridge between 2 – 8 ⁰C [1]
 DO NOT shake & DO NOT mix with other drugs [2,3]
 DO NOT use pre-filled syringe for IV preparation [3]
 ONLY USE D5 as diluent, NS may cause precipitation [2]
 For patients treated with Neupogen diluted to concentration below 15 mcg/mL, Human
Albumin should be added to a final concentration 2 mg/mL [1,3]
Example : In a final injection of 20 mL, total doses of Filgrastrim less than 30 MU (300mcg)
should be given with 0.2 mL of 20% human albumin.
136 | P a g e
FILGASTRIM
References
1. Amgen Inc. Filgastrim (Neupogen®). Product leaflet. Revised date : December 2015
4. BNF for Children (bnf.org) September 2017-18
137 | P a g e
FLUCONAZOLE
o Diflucan 100 mg/50 mL
Reconstitution
Not applicable
Further Dilution
Not applicable
Diluent
Not applicable

IV infusion : Over 1 - 2 hour (Max rate: 200 mg/hr) [2,3]
Storage & Stability

After dilution - -
Remarks
 DO NOT freeze IV infusion [1]
 DO NOT mix with other drugs [2]
 For SINGLE USE only [1]
References
1. Pfizer. Fluconazole (Diflucan). Product leaflet.
138 | P a g e
FLUMAZENIL
o Antabenz Injection 0.5 mg/5 mL
o Flumazenil-hameln 0.5 mg/5 mL Injection
Reconstitution
Not required
Further Dilution
Adult IV Infusion : Dilute 10, 20, 50 mL Flumazenil in 500 mL diluent[2]
Diluent
NS, D5, 1/2NSD2.5 [1,2] or LR Solution [1]

Adult IV Slow bolus : Administer in freely-running IV into large vein over 30 seconds
(for benzodiazepine overdose) and over 15 seconds (for reversal
of conscious sedation and general anaesthesia) [3,4]
IV infusion : 0.1 – 0.4 mg/hr [1,2]

Paediatric IV Slow bolus : Administer over 15 seconds (for reversal of conscious sedation
and general anaesthesia) [2,3,4]
IV Infusion : 0.005 – 0.01 mg/kg/hr [3,4]
Storage & Stability

Conditions Room Temperature ( <25 ⁰C) Fridge ( 2 – 8 ⁰C)
Remarks
 Protect from light and freezing [1,2]
 Not recommended in epileptic patients who have been receiving benzodiazepine treatment
for a prolonged period [1,2]
139 | P a g e
FLUMAZENIL
Remarks
 When Flumazenil is used with neuromuscular blocking agents, it should not be injected until
the effects of neuromuscular blockade have been fully reversed [1]
 Rapid injection of Flumazenil should be avoided in patients with long term exposure to
benzodiazepines ending at any time within weeks preceding Flumazenil administration as it
may produce withdrawal syndrome [1,2]
References
1. Duopharma (M) Sdn. Bhd. Flumazenil (Antabenz Injection) Product leaflet. Revised date: 05/01/2010
2. Hameln Pharmaceuticals. Flumazenil (Flumazenil-hmeln) Product leaflet. Revised date:20/09/2010
4. UpToDate, Inc. ©2011-2018. Version 3.2.0
140 | P a g e
FLUPENTIXOL
o Fluanxol ® Depot 20 mg/mL
Reconstitution
Not required
Further Dilution
Adult Not required
Diluent
Not required.[1]

Adult IM only (into upper outer quadrant of gluteal region) [1] (See Remarks)
Storage & Stability

Conditions Room Temperature (<25 ⁰C)] Fridge ( 2 – 8 ⁰C)
After dilution - -
Remarks
 Injection volumes exceeding 2 mL should be distributed between two injection sites.[1]
 Protect from light.[1]
References
1. H. Lundabeck A/S.Flupentixol decanoate (Fluanxol®Depot). Product leaflet.Revised date : June 2015
141 | P a g e
FLUPHENAZINE DECANOATE
o Monasan Injection 25 mg/mL
Reconstitution
Not required.
Further Dilution
Adult Not required
Diluent
Not required[1]
Adult SC [2,3] (See Remarks)
IM [1,2,3]
Storage & Stability

Conditions Room Temperature (<25⁰C) Fridge ( 2 – 8 ⁰C)
After dilution - -
Remarks
 Only the decanoate formulation may be administered subcutaneously [2,3]
 Protect from light. Avoid freezing [1]
 Discard unused solution after opening [1]
 Use of a wet needle or syringe may cause the solution to become cloudy [1,2,3]
 As this preparation contains benzyl alcohol, its use should be avoided in children under two
years of age [1]
References
1. Duopharma (M) Sdn Bhd. Fluphenazine Decanoate ( Monasan Injection) Product leaflet. Revised
date: 06/07/2011
142 | P a g e
HIGH ALERT
F O N D A P A R I N U X MEDICATION

o Arixtra 2.5 mg/ 0.5 mL Injection
Reconstitution
Not required [1]
Further Dilution
IV Slow bolus : Undiluted [1]
IV Infusion : Dilute to small volume 25 or 50 mL NS [1]
Diluent
NS [1]
Adult SC : Alternate between the left and the right anterolateral and left and
right posterolateral abdominal wall [1]
IV Slow bolus [1]
IV Infusion : Over 1 – 2 min. The intravenous tubing should be well flushed
with saline after injection to ensure the entire medicinal product
is administered [1]
Storage & Stability

Remarks
 Only to be administered as subcutaneous injection or intravenous injection. Must NOT be
administered by intramuscular injection [1]
 Do not expel the air bubble to avoid loss of medicinal product [1]
 For IV administration, add requisite dose to 25 – 50 mL NS and give over 2 minutes for ST-
segment elevation myocardial infarction [2]
 Safety and efficacy under age of 17 has not been established [1]
143 | P a g e
HIGH ALERT
FONDAPARINUX MEDICATION
References
1. Aspen Notre Dame De Bondeville. Fondaparinux (Arixtra®) Product leaflet. Revised date : 9th
June 2014
2. British National Formulary 74. September 2017-March 2018.
144 | P a g e
FRUSEMIDE
o Fusix injection 10 mg/mL in 2 mL ampoule
Reconstitution
Not required [1]
Further Dilution
IV Infusion : Dilute with NS to a concentration ≤ 10 mg/mL [2]
IV Intermittent infusion : May be diluted accordingly [4]
IV Continuous infusion
– Weight < 20kg : 25 mg/kg in 50 mL NS with heparin 1 U/mL [3]
– Weight >20kg : Undiluted 10 mg/mL [3]
Diluent
NS [2]

Adult IV Slow bolus : 20 – 40 mg/min [4]
IV Infusion : Should not exceed rate 4 mg/min [1,2,4]
Paediatric IV Slow bolus : Over 5 - 10 min, max. 0.5 mg/kg/min
(Max. 4 mg/min) [4,5]
IV Intermittent infusion : Over 20 min, at rate 0.01 - 0.05 mg/kg/min [3,4]
IV Continous infusion
– General : 0.1 – 1 mg/kg/hr
OR
– Based on further dilution above,
Weight < 20kg : 0.2 - 2 mL/hr [3]
Weight < 20kg : 0.01 - 0.1 mL/kg/hr [3]
145 | P a g e
FRUSEMIDE
Storage & Stability
After dilution - -
Remarks
 Frusemide injection is a mildly buffered alkaline solution and should not be mixed with
highly acidic solutions.[4] Glucose solutions are unsuitable as diluent [2]
 IV administration rate > 4mg/min increase risk of ototxicity [4]
References
1. SM Pharmaceuticals Sdn Bhd. Frusemide Injection (Fusix) Product leaflet. Revised date : 21 March
2016
3. Drug Doses. Frank Shann’s 17th Edition 2017.
4. Lexi-Comp, Inc. (Lexi-Comp) copyright 2018 Version 1.9.1
5. British National Formulary for Children September 2017-18.
146 | P a g e
HANDBOOK OF DRUG RECONSTITUTION & DILUTION TAWAU HOSPITAL 2018 G
GENTAMICIN
o Garasent 80 mg/2 mL
Reconstitution
Not required [1]
Further Dilution
IV Infusion : Dilute up to 100 – 200 mL of NS or D5
(Concentration ≤ 1 mg/mL) [1]
Paediatric IV Infusion : Dilute to a concentration ≤ 1 mg/mL [1]
Diluent
NS, D5 [1,2,3]

IV Slow bolus : over 2 – 3 min [1]
IV Infusion : Over 20 – 30 min [1]
Paediatric IV Infusion : Over 30 min [3]
Storage & Stability

After dilution - -
Remarks
 Gentamicin is inactivated by solutions containing penicillins. Should NOT be administered
simultaneously nor combined in the intravenous fluid [1]
147 | P a g e
GENTAMICIN
References
1. Duopharma (M) Sdn Bhd. Gentamicin sulphate Injection (Garasent) Product leaflet. Revised date: 16
January 2012.
148 | P a g e
GLUCAGON (LYOPHILISED)
o GlucaGen 1 mg Powder and Solvent for solution for injection
Reconstitution
One vial contain 1 mg glucagon reconstituted with provided solvent to produce 1 mg/mL [1]
Further Dilution
SC, IM, IV Slow bolus : Undiluted [1]
Diluent
Not Applicable [1]

SC [1]
IM [1]
[1]
IV Slow bolus
Storage & Stability

After dilution - -
Remarks
 Store intact vial in fridge (2°C - 8°C) [1]
 In rare cases the reconstituted product shows viscous appearance or insoluble matter, it
should be discarded [1]
 GlucaGen product advise not to be given via intravenous infusion [1]
References
1. Novo Nordisk A/S. Glucagon (GlucaGen) product leaflet. 2003/2010
149 | P a g e
GLUCAGON (LYOPHILISED)
Reconstitution
1. Remove the plastic cap from the vial. Pull the
needle cover off the syringe. Insert the needle
through the rubber stopper (within the marked
circle) of the vial containing GlucaGen® and inject
all the liquid from the syringe into the vial.
2. Without taking the needle out of the vial,

gently shake the vial until the GlucaGen® has
completely dissolved and the solution is clear.
3. Make sure the plunger is completely down.

While keeping the needle in the liquid, slowly
withdraw all the solution back into the syringe.
Do not pull the plunger out of the syringe. It is
important to remove any air bubbles from the
syringe.
4. Make an air shot and inject.
150 | P a g e
HIGH ALERT
GLYCERYL TRINITRATE MEDICATION

o Gitrinil Injection 25 mg/5 mL Ampoule
Reconstitution
Not required
Further Dilution
IV Infusion : Dilute 1 ampoule (50 mg/10 mL) in 500 mL of diluent to obtain final
concentration of 100 mcg/mL. After the initial dosage titration, the amount of
diluent to be added will depend on patient’s fluid requirement and expected
infusion duration. The following concentration can be increase to ≤ 400 mcg/mL
[1]
Diluent
NS, Dextrose BP [1]

IV Infusion : Refer Table page 152
Storage & Stability

Remarks
 Glyceryl trinitrate must be diluted prior infusion [1]
References
1. Duopharma (M) Sdn Bhd. Glyceryl trinitrate (Gitrinil) Injection Product leaflet. Revised date:
2 March 2011.
2. Sarawak Handbook of Medical Emergencies, 3rd Edition. 2011
151 | P a g e
G
HIGH ALERT
GLYCERYL TRINITRATE MEDICATION
Infusion Rate
Glyceryl trinitrate 50 mg in 500 mL NS or D5 (100 mcg/mL) [2]

mcg/min mL/hr mcg/min mL/hr
5 3 110 66
10 6 120 72
15 9 130 78
20 12 140 84
30 18 150 90
40 24 160 96
50 30 170 102
60 36 180 108
70 42 190 114
80 48 200 120
90 54 Note:
100 60 Titrate by 5 – 10 mcg/min at 10 – 15 min intervals [1]
Reference : Sarawak Handbook of Medical Emergencies, 3rd Edition. 2011
152 | P a g e
GLYCOPYRROLATE
o Glycopyrrolate 200 mcg/mL Injection USP
Reconstitution
Not required [1]
Further Dilution
IM : Undiluted [1, 2]
IV Slow bolus : Undiluted [1] or dilute with compatible diluent [1]
Diluent
D5, NS, D10, 1/2NS, LR Solution [1]

IM [1, 2]
IV Slow bolus : 0.2 mg over 1- 2 min [2]
Storage & Stability

After dilution 48 hours[1] -
Remarks
References
1. IMEKS Pharma Sdn Bhd. Glycopyrrolate Injection USP product leaflet. Revised date:
November 2007
153 | P a g e
GOSERELIN ACETATE
o Zoladex 3.6 mg Depot
o Zoladex 10.8 mg Depot
Reconstitution
Not required [1]
Further Dilution
Adult SC : Undiluted [1,2]
Diluent
Not applicable [1,2]
Adult SC : Injected into the anterior abdominal wall [1]
Storage & Stability

After dilution - -
Remarks
 Both strength 3.6 mg and 10.8 mg are NOT indicated for use in children [1]
 10.8 mg strength is NOT indicated for use in female [2]
 Use immediately after opening pouch [1]
 No need to remove bubbles as attempts to do so may displace the content implant [1]
 Rotate injection site to prevent atrophy and nodule formation [3]
References
1. AstraZeneca. Goserelin Acetate (Zoladex) 3.6mg depot injection product leaflet. Revised
date: 17 August 2016.
2. AstraZeneca.Goserelin Acetate (Zoladex) 10.8 mg depot injection product leaflet. Revised
date: July 2012.
154 | P a g e
GRANISETRON
o Kytron 3 mg/3 mL ampoule
Reconstitution
Not required [1]
Further Dilution
Adult IV Slow bolus : Undiluted [1]
IV Infusion : Dilute in 20 – 50 mL infusion fluid [1]
Paediatric IV Infusion : Dilute in 10 – 30 mL infusion fluid [1]
Diluent
NS, 1/5NSD4, D5, LR Solution, Mannitol [1]

Adult IV Slow bolus : Over 30 sec [1]
IV Infusion : Over 5 min [1]
Paediatric IV Infusion : Over 5 min [1]
Storage & Stability

Remarks
 The injectable presentation contains no antimicrobial agent. Use once and discard any
residue [1]
References
1. Duopharma (M) Sdn Bhd. Granisetron Hydrochloride Injection/infusion (Kytron) Product
leaflet. Revised date: 1October 2015.
155 | P a g e
GREEN PIT
HIGH ALERT
VIPER ANTIVENOM MEDICATION

o QSMI Thai Red Cross, Green Pit Viper Antivenin, Purified Aquine Immunoglobulin
Reconstitution
1 vial with 10 mL Sterile WFI. Gently swirl, do NOT shake. Each mL can neutralize 0.7 mg Green
Pit Venom [1]
Further Dilution
Adult IV Infusion : 250 – 500 mL diluent [2]
Paediatric IV Infusion : 5 – 10 mL/kg diluent [2]
Diluent
NS, D5 [2]

IV Infusion : Start slow 1 – 2 mL/min over 10 – 15 min. If there is no adverse reaction,
increase to higher rate 5 – 10 mL/min to complete within period less than 1
hour [1]
Storage & Stability

After dilution - -
Remarks
 Used for envenoming pit vipers in the Trimeresurus complex group [2]
 Give second dose within 1 – 2 hours following first dose if active bleeding persist. If bleeding
stops, further dose can be repeated every 6 hours according to clinical symptoms and serial
blood investigation [2]
References
1. Queen Saovabha Memorial Institute, Green Pit Viper Antivenom product leaflet. Revised
date:
2. Bahagian Perkhidmatan Farmasi Negeri Sabah. Sabah antivenom administration guide
version 1/2014. Revised date: 20 April 2014.
156 | P a g e
HANDBOOK OF DRUG RECONSTITUTION & DILUTION TAWAU HOSPITAL 2018 H
HAEMOPHILUS INFLUENZA
TYPE B CONJUGATE
o HiberixTM 10 mcg vaccine
Reconstitution
Dilute with provided manufacturing diluent [1]
Further Dilution
IM : Undiluted [1]
Diluent
Sterile diluent (saline) [1]

IM : Administer in the anterolateral aspects of thigh in children < 1 year of age or deltoid
muscle of upper arm in patient > 1 year old [2]
Storage & Stability

After dilution - -
Remarks
 Lyophilised vaccines should be store at 2oC to 8oC and protect from light. The lyophilized not
affected by freezing.[1]
 Do not administer additional vaccines or immunoglobulins at the same site or using the
same syringe.[2]
 HiberexTM should not administered intravenously. [1]
 The diluent can be stored in the refrigerator or at ambient temperature and should not be
frozen.[1]
References
1. GlaxoSmithKline Biologicals s.a, Haemophilus influenza type b (Hib) vaccine, product leaflet,
Date of issue 28/05/2009.
157 | P a g e
HALOPERIDOL
o Manace 5 mg/mL ampoule
Reconstitution
Not required [1]
Further Dilution
IM, IV Slow bolus : Undiluted [1,2]
Diluent
Not applicable [1]

IM [1,2]
[1,2]
IV Slow bolus
Storage & Stability

After dilution - -
Remarks
 Do not give decanoate injectable formulation through IV [2]
References
1. Duopharma(M) Sdn Bhd. Haloperidol Injection (Manace) Product leaflet. Revised date: 25
July 2011.
158 | P a g e
HIGH ALERT
HEPARIN MEDICATION

o Heparinol 5000 IU/mL (5 mL)
Reconstitution
Not required [1]
Further Dilution
IV Slow bolus, IV Intermittent infusion : Undiluted [2,5] or dilute in 50 – 100 mL
diluent [2]
IV Continuous infusion : Dilute to 50 – 100 units/mL [3,5]
Paediatric IV Continuous infusion
– Neonates (for Thrombosis treatment) : 1250 units/kg in 50 mL infusion fluid [4]
– Children : Dilute to a concentration of 100 units/mL [2]
Diluent
NS, D5, 1/2NS [1]

Adult SC [5]
IV Intermittent infusion : Over 10 min [3]
IV Continuous infusion : Infusion rate adjust according to dose
(Refer Table on page 161)
Paediatric IV Continuous infusion : Infusion rate adjust according to dose
(Refer Table on page 162)
Storage & Stability

After dilution 24 - 72 hours [5] -
159 | P a g e
HIGH ALERT
HEPARIN MEDICATION
Remarks
 Stability after opening is 28 days if aseptic technique used during heparin withdrawal from
vial via the rubber bung, and at room temperature [1]
References
1. Ain Medicare Sdn Bhd. Heparin Sodium (Heparinol) injection product leaflet. Revised date:
18 September 2013.
2. Web MD, LLC. Medscape App for Android 2017 Version 4.6.1
3. Lexicomp’s Drug reference handbooks. Drug information handbook 20th edition. 2011.
160 | P a g e
HIGH ALERT
HEPARIN MEDICATION
ADULT : Management of Venous Thromboembolism with IV Unfractionated Heparin

Initial Dose 80 IU/kg bolus, then 18 IU/kg/hr
APTT Ratio Action and Dose change Next APTT
< 1.2 80 IU/kg bolus, then increase rate by 4 IU/kg/hr 6 hours
(APTT < 35 sec)
1.2 – 1.5 40 IU/kg bolus, then increase infusion rate by 2 IU/kg/hr 6 hours
(APTT 35 to 45 sec)
1.5 – 2.5 No change 24 hours
(APTT 46 to 70 sec)
2.5 – 3.0 Decrease infusion rate by 2 IU/kg/hr 6 hours
(APTT 71 to 90 sec)
> 3.0 Withold infusion for 1 hour, then decrease infusion rate by 3 IU/kg/hr 6 hours
(APTT > 90 sec)
Reference : Prevention and Treatment of Venous Thromboembolism. Clinical Practise Guideline MOH Malaysia, August 2013.
161 | P a g e
HIGH ALERT
HEPARIN MEDICATION
PAEDIATRIC : Protocol for thrombosis treatment with intravenous unfractionated heparin (UFH) administration
I. Loading dose: UFH 75 units/kg over 10 minutes (requirement is uncertain and has to be individualized)
II. Initial maintainence dose 28 units/kg per hour for infants < 1 year; 20 units/kg for children > 1 year
III. Adjust heparin to maintain APTT of 60 - 85 sec (correlates to anti-Xa level of 0.35 - 0.70)
APTT, sec Bolus, units/kg Hold, min % rate change Repeat APTT
< 50 50 0 +10 4 hours
50 – 59 0 0 +10 4 hours
60 – 85 0 0 0 Next day
86 – 95 0 0 - 10 4 hours
96 – 120 0 30 - 10 4 hours
>120 0 60 - 15 4 hours
IV. Obtain blood for APTT 4 hours after heparin loading dose and 4 hours after every change in the infusion rate
V. When APTT are therapeutic, do a daily FBC and APTT
Reference : Prevention and Treatment of Venous Thromboembolism. Clinical Practise Guideline MOH Malaysia, August 2013.
162 | P a g e
HEPATITIS B VACCINE
o Euvax B 20 mcg/mL
Reconstitution
Not required
Further Dilution
Not required
Diluent
Not required

Adult IM route only [1] : 16 years old & above, administer 1 mL (containing 20 mcg),
preferred site deltoid muscle, [1,2,3]
Paediatric IM route only [1] : Neonates, infant, children & adolescent up to 15 years old,
administer 0.5 mL (containing 10 mcg) [1]
– Neonate, infant & younger children : Recommended site anterolateral thigh [2,3]
– Older children : Recommended site deltoid muscle [2,3]
Storage & Stability

After dilution - -
Remarks
 Store in fridge at 2 – 8 ⁰C.
 Dot not administer at the gluteal (buttock) as vaccine efficacy is reduced [3]
References
1. LG Life Sciences Hepatitis B Vaccine, Recombinant (Euvax B) Product leaflet. Revised date : 9
February 2015
3. British National Formulary 2018
163 | P a g e
HEPATITIS B
IMMUNOGLOBULIN (HUMAN)
o Hepabig 100 IU/0.5 mL
Reconstitution
Not required
Further Dilution
Not required
Diluent
Not required

Adult IM route only [1]
Paediatric IM route only [1]
– Neonates : In neonates who are administered one dose of 1 mL, Hepabig is
injected at two different sites (0.5 mL/site) [1]
Storage & Stability

After dilution - -
Remarks
 Store below 10⁰C without freezing [1]
 Hepabig should be administered intramuscular route only, not intravenously [1]
 This product contains no preservatives, therefore partially used vials should be discarded
immediately [1]
References
1. Green Cross Corp Hepatitis B Immunoglobulin (Human) (Hepabig) Product leaflet. Revised date : 8
July 2016
164 | P a g e
HUMAN ALBUMIN 20%
o Albumex 20 (20 g/100 mL)
Reconstitution
Not required [1]
Further Dilution
IV Infusion : Use undiluted [1]
If lower concentration of Human Albumin required, refer table below
Volume of Human Volume of diluent Final concentration of
Albumin 20% to be added Human Albumin produced
[2]
100 mL 300 mL 5%
Diluent
NS [1,2,3]

Adult Infusion rate depends on indication and clinical situation [2,3]
The following infusion rate is based on undiluted Human Albumin 20% [1]
Hypoproteinemia in IV Infusion : 2 mL/min [1]
acutely ill patient
Shock IV Infusion : 2 – 4 mL/min [1]

(rate may be increased in emergencies)
Burns IV Infusion : 1 mL/min [1]
Paediatric IV infusion : administer at 25% of adult rate [3]
Storage & Stability

After dilution 4 hours after opening [2,3] -
165 | P a g e
HUMAN ALBUMIN 20%
Remarks
 Albumex®20 contains no antimicrobial preservative, therefore must be used immediately
after opening [1]
 Do not use WFI to dilute albumin as this has been associated with hypotonic-associated
hemolysis [1,2,3]
 Do not mix with protein hydrolysates, amino acid solutions, solutions containing alcohol, or
solutions containing drugs that bind to albumin e.g. calcium channel blockers [1]
References
1. CSL Biotherapies Human Albumin (Albumex 20®) Product leaflet. Revised date : March 2012
166 | P a g e
HUMAN CHORIONIC
GONADOTROPHIN
o Pregnyl 5,000 IU
Reconstitution
Reconstitute 5,000 IU with provided 1 mL provided solvent [1]
Further Dilution
Not required
Diluent
Provided solvent [1]

SC [1]
Slow IM [1]
Storage & Stability

After dilution - -
Remarks
 Store intact Pregnyl injection in fridge 2 – 8 ⁰C [1]
References
1. Merck Sharp & Dohme Ltd. Human Chorionic Gonadotrophin (Pregnyl) Product leaflet. Revised date
: 4 August 2015 https://www.medicines.org.uk/emc/product/2220/smpc#STORAGE
167 | P a g e
HUMAN NORMAL
IMMUNOGLOBULIN
o Intragam®P 6% (3 g/50 mL)
Reconstitution
Not required
Further Dilution
IV Infusion : May be infused undiluted, or may be diluted up to 2 parts of diluent [1]
Diluent
NS, D5 [1]
General Dose and rate of infusion depends on indication and clinical conditions
Initial rate 1 mL /min. After 15 min, rates may be gradually increased to max. rate
≤ 3 – 4 mL/min over a further 15 min. Consider reduce infusion rate in elderly
patients and pre-existing renal disease patients [1]
Paediatric Initial and maintenance infusion rate should be consulted with a Paediatrician to
determine the best rate for each neonate/infant/child [2]
Storage & Stability

After dilution - -
Remarks
 Too rapid infusion rate may cause flushing, change in heart rate and blood pressure [1]
 Store intact bottles at 2 to 8 ⁰C (Refrigarate. Do not freeze). Once removed from
refrigeration, store below 25⁰C and use within 3 months. Protect from light [1]
 Intragam®P contains no antimicrobial preservative, therefore must be used immediately
after opening [1]
References
1. CSL Biotherapies Human Normal Immunoglobulin (Intragam®P) Product leaflet. Revised date :
February 2014
2. IVIG Clinical Practice Guideline for Intragam 10% Paediatric infusion rate guide. Updated February
2017. Available at https://www2.health.vic.gov.au/bloodmatters
168 | P a g e
HYDRALAZINE
o Hydralazine Hydrochloride 20 mg/mL
Reconstitution
Reconstitute 20 mg with 1 mL WFI[1,2]
Further Dilution
Adult IM : Use undiluted[3]
IV Slow bolus : Undiluted[1,3] or dilute 5 – 10 mg with 10 mL diluent [4]
IV Infusion : Dilute 20 – 50 mg in 500 mL diluent
(Concentration 40 – 100 mcg/mL) [1,5]
Paediatric IV Slow bolus : Dilute to a concentration 0.5 – 1 mg/mL [2]
IV infusion : After reconstitution, further dilute with NS [2]
No specific guide on amount of diluent to be added
Diluent
NS [1,2,4,5,6]

Adult IM [1]
IV Slow bolus : max. rate ≤ 5 mg/min[3]
IV infusion : Initial rate 50 – 300 mcg/min [1,5]
Maintanance rate 50 – 150 mcg/min [1]
Paediatric IV Slow bolus : Administer over 5 – 20 minutes [2] Max. rate ≤ 5 mg/min [3]
IV infusion
– Neonates : 12.5 – 50 mcg/kg/hr (Max 2 mg/kg/day)[2]
– Children 1 month to 11 years : 12.5 – 50 mcg/kg/hr (Max 3 mg/kg/day)[2]
Storage & Stability

169 | P a g e
HYDRALAZINE
Remarks
 Hydralazine is not compatible with Dextrose infusion solution [1,2] Contact between
hydralazine and glucose causes hydralazine to be rapidly broken down [1,3]
 Reconstituted and diluted hydralazine should be protected from light [1]
 Use hydralazine immediately and discard any remainder [1]
References
1. Ciron Drugs & Pharmaceutical Pvt. Ltd. Hydralazine Product leaflet
2. British National Formulary for Children 2017- 2018
3. LexiComp, Inc. (Lexi-Drugs®) 2018 Version 4.1.1
4. MOH FUKKM Bil 3/2017
5. Sarawak Handbook of Medical Emergencies 3rd Edition 2011
170 | P a g e
HYDROCORTISONE
o Hydrocortisone Sodium Succinate 100 mg
Reconstitution
Reconstitute the vial with ≤ 2 mL WFI (Concentration 50 mg/mL) [1,2]
Further Dilution
IM, IV Slow bolus : Not required [2]
IV Infusion : Dilute to a concentration 1 mg/mL[2]
Diluent
NS, D5[2,3]

IM : Avoid deltoid muscle due to high incidence of subcutaneous atrophy [2]
IV Slow bolus : Administer for at least 30 sec. For doses ≥ 500 mg, administer over 10 min [1,2]
IV Infusion : Administer over 20 - 30 min [2]
Storage & Stability

After reconstitution 24 hours[1] -
After dilution 4 hours[2] -
Remarks
 After reconstitution, protect the solution from light and freezing [1]
References
1. SM Pharmaceutical Hydrocortisone Injection 100 mg BP Product Leaflet Revised date: 20 July 2011
171 | P a g e
HYOSCINE BUTYLBROMIDE
o Copan Hyoscine Butylbromide 20 mg/mL
Reconstitution
Not required
Further Dilution
Adult IM : use undiluted [3]
IV Slow bolus : May be use undiluted [2]
Paediatric IM [4]
IV Slow bolus : There is no specific guide on volume of diluent to be added
Diluent
NS, D5 [4]

Adult IM [4]
IV Slow bolus : Administer at a rate 1 mL/min [2]
Paediatric IM [4]
IV Slow bolus : Adminster over at least 1 min [4]
Storage & Stability

After dilution - -
Remarks
 Infant and children require close monitoring as they are susceptible to the toxic effects of
anticholinergics [1]
172 | P a g e
HYOSCINE BUTYLBROMIDE
References
1. Duopharma (M) Sdn Bhd. Hyoscine Butylbromide (Copan injection) Product leaflet
3. LexiComp, Inc. (Paediatric& Neonatal®) 2018 Version 4.1.1
4. British National Formulary for Children 2017 - 2018
173 | P a g e
HANDBOOK OF DRUG RECONSTITUTION & DILUTION TAWAU HOSPITAL 2018 I
IMIPENEM+CILASTIN
o Tienam® Imipenem 500 mg and Cilastin 500 mg sterile powder for injection
Reconstitution
Reconstitute the vial with 10 mL diluent. Shake well [1]
Further Dilution (based on Imipenem)

Adult IV Intermittent infusion : Dilute with 100 mL diluent [1]
IV Extended infusion : Dilute with 100 - 200 mL NS (Concentration 5 mg/mL)[2]
Paediatric IV Infusion : Dilute with NS to a concentration 5 mg/mL [3]
Diluent
NS, D5, D10, NSD5, 1/2NSD5, 1/4NSD5 [1,2,4]
Administration & Infusion Rate(based on Imipenem)

Adult IV Intermittent infusion : Dose ≤ 500 mg, administer over 20 - 30 min [1]
Dose > 500 mg, administer over 40 - 60 min [1]
IV Extended infusion : Over 4 hours[2]
Paediatric IV Infusion : Dose ≤ 500 mg, administer over 20 - 30 min [3]
Dose > 500 mg, administer over 40 - 60 min [3]
Storage & Stability

Conditions Room Temperature ( 25 ⁰C) Fridge ( 4⁰C)
Remarks
 In patients who develop nausea during the infusion, rate of infusion may be slowed [1]
 Clinical data are insufficient for use in children under 3 months of age, or paediatric with
impaired renal function (Serum Creatinine > 2 mg/dL) [1]
174 | P a g e
IMIPENEM+CILASTIN
References
1. Merck Sharp & Dohme Corp. Imipenem and Cilastin (Tienam) Product Leaflet Revised date:
December 2014
2. Guide to Antimicrobial Therapy in Adult ICU 2017. Malaysian Society of Intensive Care 2017
3. British National Formulary for Children 2017 – 2018
175 | P a g e
INFLUENZA VACCINE
o Influvac 2018 Prefilled syringe 15 mcg/0.5 mL
Reconstitution
Not required
Further Dilution
Not required
Diluent
Not required

Adult Deep SC, IM : 0.5 mL[1]
Paediatric Deep SC, IM[1]
– Children ≥ 36 months : 0.5 mL[1]
– Children 6 to 35 months : 0.25 mL or 0.5 mL[1]
For 0.25 mL dose, push the side of the prefilled syringe
plunger exactly to the edge of the mark so that half of
the volume eliminate. A volume of 0.25 mL vaccine
remains in the syringe for administration [1]
Storage & Stability

Conditions Room Temperature ( 25 ⁰C) Fridge ( 2 - 8⁰C)
-
-
After dilution -
Remarks
 Store intact prefilled syringes in refrigerator 2 - 8⁰C. Do not freeze[1]
 Store in the original package in order to protect from light [1]
 Safety and efficacy in children < 6 months have not been established [1]
References
1. Abbott Biologicals. Influenza A (H1N1), (H3N2), Influenza B-like strain (Influvac 2018)
Product Leaflet Revised date: November 2017
176 | P a g e
HIGH ALERT
INSULIN ISOPHANE MEDICATION

o Insugen®N 100 IU/ML (NPH) 3 ML Penfill.
Reconstitution
[1]
Not required
Further Dilution
[1]
Not required
Diluent
[1]
Not required

SC [1]
Storage & Stability

After dilution - -
Remarks
 Store unopened insulin in fridge at 2 – 8 ⁰C [1]
 Insulin can last up to 42 days when used or stored at room temperature and 36 month
when not in used and stored between 2 – 8 ⁰C [1]
 Insulin suspensions are for subcutaneous use and never to be administered intravenously [1].
 Injection site should be rotated within an anatomic region in order to avoid lipodystrophy [1]
 For intramuscular injection the needle should be kept under the skin for at least 10 second
to make sure the entire dose is injected.
 Do not refrigerate during use of insulin. Kept at room temperature [1]
 Insulin suspension shloud not be used if they do not appear uniformly white and cloudy
after resuspension [1]
References
1. CCM Pharmaceutical Sdn Bhd , Human Recombinant Insulin(Insugen®N) Product leaflet.Revised
Date: May 2016.
177 | P a g e
HIGH ALERT
INSULIN REGULAR MEDICATION

o Insugen® R 100 IU/ML (Regular) 3 ML Penfill.
Reconstitution
Not required [1]
Further Dilution
Adult SC, IV Slow bolus : Undiluted [1]
IV Infusion : Dilute to concentration 1 unit/mL [1]
For example, 50 unit short acting human insulin made up to
50 mL of diluent [2, 3]
Pediatric SC, IV Slow bolus : Undiluted [1]
IV Infusion
– Neonates : 5 units to a final volume of 50 mL diluent, infusion rate
is 0.1 mL/kg/hr [4]
– Child : Dilute to concentration 1 unit/mL [4]
Diluent
NS [2]

Adult SC : Abdominal wall, the thigh, the gluteal or deltoid region [1]
IV Slow bolus : 50 IU /min [2]
[3]
IV Infusion : Refer page 180 on Insulin Infusion Protocol in Adult ICU
Paediatric SC : Abdominal wall, the thigh, the gluteal or deltoid region[1]
IV Intermittent infusion : 0.05 - 0.1 unit/kg, infused over 15 min every 4 to 6
hours. Monitor blood glucose every 30 min to 1 hour
following doses [2]
– Neonates : 0.02 - 0.125 unit/kg/hr [4]
– Child : 0.025 - 0.1 unit/kg/hr [4]
178 | P a g e
HIGH ALERT
INSULIN REGULAR MEDICATION
Storage & Stability

After dilution - -
Remarks
 For IV infusion preparation can keep up to 14 days [2]
 Injection site should be rotated within an anatomic region in order to avoid lipodystrophy [1]
 For intramuscular injection the needle should be kept under the skin for at least 10 second
to make sure the entire dose is injected
 Do not refrigerate during use of insulin. Kept at room temperature [1]
 Any air bubble in cartridge must be removed cartridge and needle by priming before
injection and only use if solution clear and colorless [1]
References
1. CCM Pharmaceutical Sdn Bhd , Human Recombinant Insulin(Insugen®R) Product leaflet.Revised
Date: May 2016.
2. Lexi-Comp, Inc. (Lexi-Drugs©). Lexi-Comp, Inc; Version 4.1.1 2018
3. Management of Type 2 Diabetes mellitus 5th edition .Clinical Practice Guidelines MOH Malaysia, Dec
2015.
4. British National Formulary for Children September 2017-18
5. Management Protocols in ICU August 2012.
179 | P a g e
HIGH ALERT
Insulin Infusion Protocol in Adult ICU [5] MEDICATION
Maintain Blood Glucose Level (BGL) 6 - 10mmol/L
ICU Admission- Perform BGL
If BGL > 10mmol/L (2 consecutive reading 1 hour apart)

Start insulin infusion
BGL monitoring: Initially every hour until glucose is within goal for 2 hours, then every 2 – 4 hours
Check serum potassium at least every 12 hours
Initial Bolus
BGL Bolus Start insulin
infusion with
Instruction: Compare mmol/L Unit IV
Scale 2
the current BGL range > 15 2
to the previous BGL 10.1 - 14.9 1
range
If the current BGL,
range Blood Scale
1.Lower: Stay in the Glucose 1 2 3 4 5 6 7 8
same column mmol/L Units/hr
2.The Same Or Higher: >22.1 3.0 4.0 5.0 6.0 7.0 8.0 10.0 11.0
Move to the first right 18.1 - 22 2.5 3.5 4.0 5.0 6.0 6.0 8.0 9.0
column with higher 14.1 - 18 2.0 3.0 3.0 4.0 5.0 5.0 6.0 7.0
infusion rate 12.1 - 14 1.5 2.5 2.5 3.0 4.0 4.0 4.0 5.0
When BGL is within 10.1 - 12 1.0 2.0 2.0 2.0 3.0 3.0 3.0 4.0
target: Do not change 8.1 - 10 1.0 1.0 1.5 1.5 2.0 2.0 2.5 3.0
columns 6.1 - 8 0.5 1.0 1.0 1.0 1.5 1.5 2.0 2.0
When BGL 4-6mmol/L: 4.1 - 6 0.5 0.5 0.5 0.5 1.0 1.0 1.5 1.5
Move to the first left <4 Cease IV insulin infusion and inform doctor. Treat BGL<3.5
column with lower
infusion rate
Inform doctor if:

BGL Dextrose Action 1. BGL < 3.5 mmol/L
mmol/L 50% 2. Serum potassium < 3.5 mmol/L
1.5 - 3.5 25 mL -Repeat BGL in 15 minutes 3. BGL >10mmol/L for 2 consecutive
(12.5 g) IV -Repeat as necessary measurement
push -Restart insulin infusion if 4. Infusion rate is < 0.5 Units/hr for
<1.5 50 mL (25 g) BGL > 10 for 2 consecutive 2 consecutive measurement (to
IV push reading using first left column stop infusion)
with lower infusion rate
180 | P a g e
I
INSULIN REGULAR
HIGH ALERT
+ ISOPHANE MEDICATION

o Insugen® 30/70 100 IU/ML (Biphasic) 3 ML Penfill
Reconstitution
[1]
Not required
Further Dilution
[1]
Not required
Diluent
Not required [1]

SC [1]
Storage & Stability

After dilution - -
Remarks
 Insulin suspensions are for subcutaneous use and never to be administered intravenously [1]
 Injection site should be rotated within an anatomic region in order to avoid lipodystrophy[1]
 Do not refrigerate during use of insulin. Kept at room temperature[1]
 Insulin suspension shloud not be used if they do not appear uniformly white and cloudy
after resuspension[1]
References
1. CCM Pharmaceutical Sdn Bhd , Human Recombinant Insulin(Insugen®30/70) Product leaflet.Revised
Date: May 2016
181 | P a g e
IRON DEXTRAN
o CosmoFer® 50 mg/mL (2 mL amp)
Reconstitution
[1, 2]
Not required
Further Dilution
See Administration & Infusion rate
Diluent
NS, D5 [1, 2]
Calculation
Total Iron Deficit (mg) = Body Weight (kg) x [Target Hb - Actual Hb) (g/dL)] x 2.4 + mg iron for
iron stores [3]
Body Weight Mg iron for iron stores

< 35 kg 15 mg/kg body weight
> 35 kg 500 mg

Deep IM : A test dose of iron dextran corresponding to 25mg iron or equal to 0.5ml solution
must be administered. If no adverse reactions are seen after 60 minutes, the
remaining dose can be given [4]
Administer undiluted in doses up to 100 mg iron daily into alternate buttocks, by

injection deep intramuscular using the Z-track technique, slowly and smoothly [1,3]
182 | P a g e
IRON DEXTRAN
IV injection [1,3]
IV Slow bolus IV infusion Total Dose Infusion
Test Dose Administered the first Administer the first Administer the first
25 mg over 1 - 2 min 25 mg over 15 min 25 mg over 15 min
Determined dosage (see

Dose 100 - 200 mg (2 – 4 mL) 100 - 200 mg (2 – 4 mL) Calculation)
iron iron (max per dose:
20 mg/kg)
Volume of
Diluent 10 - 20 mL 100 mL 500 mL
Rate Inject slowly over 1 - 2 min Infuse over at least 30 Infuse over 4 – 6 hr
min
Storage & Stability

After dilution Use immediately[1] -
Remarks
 Following test dose, administer the remaining portion of dose after 15 min if there are no
adverse reactions [1]
 Discontinue oral iron preparations before starting IV therapy as concomitant use can cause
the absorption of oral iron to be reduced [1]
 Oral iron not to be given until 5 days of last injection [1]
References
1. Pharmacosmos, Iron Dextran (Cosmofer®) Product Leaflet. Revised Date:June 2015
3. A.Menarini Singapore Pte Ltd,Iron Dextran 50mg/ml (Cosmofer®) Product Information. Revised
Date: August 2015.
4. Pharmacosmos A/S, Iron Dextran (Cosmofer®) Product Information. Revised Date: July 2009
183 | P a g e
IRON SUCROSE
o Venofer® 100 mg/5 mL
Reconstitution
Not required [1]
Further Dilution
IV infusion : Dilute 100 mg (5 mL) in 100 mL of diluent [1]
OR
Dilute 500 mg (25 mL) in 500 mL of diluent [1]
The diluted solution must appear as brown and clear[1]
Diluent
NS [1, 2]
Calculation
Total Iron Deficit (mg) = Body Weight (kg) x [Target Hb-Actual Hb) (g/dl)] x 2.4 + mg iron for
iron stores [1]
Body Weight Target Hb Mg iron for iron stores

< 35 kg 130 g/L 15 mg/kg body weight
≥ 35 kg 150 g/L 500 mg

Test dose [1]
Weight Test Dose
Children < 14 kg 1.5 mg iron/kg
Children > 14 kg & Adult 1 mL (20 mg)
Administration Administer
IV Drip Infusion The first 20 mg iron of the therapeutic dose should be infused over
15 min as a test dose
IV Slow bolus Administer 1 mL over 1 - 2 min and observe for 15 min
IV Slow bolus (Undiluted) [1]

Administer 100 mg iron (5 mL) in at least 5 min or 200 mg (10 mL) over 10 min
Maximum tolerated dose per day, given not more than 3 times per week:
- 200 mg iron (10mL) injected over 10 min
184 | P a g e
IRON SUCROSE
IV Infusion [1, 2]
Dose 100 mg 200 mg 300 mg 400 mg 500 mg
Administer Over 15 min 30 min 1½ hour 2 ½ hour 3 ½ hour
As IV infusion, maximum tolerated single dose per day given NOT more than once per week:
Weight <70kg >70kg

Maximum dose/week 7 mg iron/kg (max 500mg) 500mg
Storage & Stability

7 days [2]
Remarks
 Venofer must only be mixed with sterile 0.9% Sodium Chloride solution [1]
 Venofer must not be used for intramuscular injection[1]
 For stability reason, dilutions to lower Venofer concentration are not permissible[1]
 Before administration of the first therapeutic dose, a test dose should be given. If any
allergic reactions or intolerance occurs during administration, the therapy must stopped
immediately[1]
References
1. Fresenius Medical Care Malaysia Sdn Bhd. Iron Sucrose (Venofer®) Product Leaflet. Revised Date:NA
2. Lexi-Comp, Inc. (Lexi-Drugs®). Lexi-Comp, Inc Version 4.1.1 2018
185 | P a g e
HIGH ALERT
ISOPRENALINE MEDICATION

o Isuprel™ 0.2 mg/mL
Reconstitution
Not required [1]
Further Dilution
Route Dilution
SC No further dilution required [1]
IM
Intracardiac
IV Slow bolus Dilute 1 mL with 10 mL diluent [1]
IV Infusion Shock and hypo Dilute 5 mL (1 mg) in 500 mL of D5 [1]
perfusion states Concentration up to 10 times greater have been
used when limitation of volume is essential [1]
Heart block, Adam- Dilute 10 mL (2 mg) in 500 mL of D5 [1]
Stokes attack and
cardiac arrest
Diluent
NS, D5 [1, 2]
SC
IM
Intracardiac
IV Slow bolus Heart block, Adam- Intial : 0.02 – 0.06 mg (1 – 3 mL of diluted solution)
Stokes attack and Subsequent : 0.01 – 0.2 mg
Cardiac Arrest (0.5 – 10 mL of diluted solution) [1]
Bronchospasm Initial : 0.01 – 0.02 mg
occurring during (0.5 – 1 mL of diluted solution)
anaesthesia Dose may be repeated when necessary [1]
186 | P a g e
HIGH ALERT
ISOPRENALINE MEDICATION
IV Infusion [1] Shock and Hypo 0.5 – 5 mcg/min (0.25 – 2.5 mL of diluted solution)
perfusion states Rates over 30 mcg/min have been used in advanced
stages of shock [1]
Heart block, Adam- 5 mcg/min (1.25 mL of diluted solution per min) [1]
Stokes attack and
cardiac arrest
Storage & Stability

After dilution - -
Remarks
 In shock and hypo perfusion state the IV infusion rate should be adjusted based on heart
rate, central venous pressure, systemic blood pressure and urine flow. If heart rate > 110
bpm, it may be advisable to decrease or temporarily discontinue the infusion [1]
 The usual route of administration is by IV infusion or IV bolus injection. In dire emergencies,

the drug may be administered by intracardiac injection. If time is not of the utmost
importance, initial therapy by IM or SC injection is preferred [1]
References
1. Hospira. Isoprenaline (IsuprelTM) Product Leaflet. Revised date: 23 July 2014
187 | P a g e
HANDBOOK OF DRUG RECONSTITUTION & DILUTION TAWAU HOSPITAL 2018 K
KANAMYCIN
o Kanamycin Sulphate Meiji 1 g/3 mL
Reconstitution
Not required [1, 2]
Further Dilution
IM : Undiluted {1, 2]
IV Infusion : Diluted 1 g in 200 – 400 mL of diluent [2]
Preparation should be appear clear and pale yellow sterile solution [1]
Diluent
NS, D5 [2]

IM : Deeply in upper outer quadrant of the gluteal muscle [2]
IV Infusion : Run over 30 - 60 min [2]
Storage & Stability

-
After dilution -
Remarks
-
References
1. Thai Meiji Pharmaceutical Co.,Ltd . Kanamycin Sulphate Injection. Product Leaflet. Revised Date:NA
188 | P a g e
HIGH ALERT
KETAMINE MEDICATION

o Ketamine Injection Fresenius 10 mg/mL (20 mL per amp)
Reconstitution
Not required [1]
Further Dilution
Adult IM, IV Slow bolus : Undiluted [1]
IV infusion : Dilute 1 ampoule (200 mg/20 mL) with 180 mL of diluent
(Concentration 1 mg/mL) [1] Max. concentration may up to
2 mg/mL for fluid restriction cases [2]
Pediatrics IM : Undiluted[1]
IV Slow bolus : Dilute 100 mg/mL to concentration < 50 mg/mL [3]
[3]
IV Infusion : Dilute to concentration of 1 mg/mL
Diluent
NS, D5 [1]

Adult IM : Inject deep into large muscle mass [2]
IV Slow bolus : Undiluted over 60 sec or at 0.5 mg/kg/min [1,2]
IV Infusion : Administer at 1 – 5 mg/kg/hr [1]
Pediatrics IM : Inject deep into large muscle mass [2]
IV Slow bolus
– Neonates & children : 1 – 2 mg/kg over at least 60 sec [2,3]
IV Infusion
– Neonates : 8 mcg/kg/min, adjusted up to 30 mcg/kg/min [3]
– Children : 10 – 45 mcg/kg/min [3]
Storage & Stability

189 | P a g e
HIGH ALERT
KETAMINE MEDICATION
Remarks
 Do not mix with barbiturates or diazepam (precipitation may occur) [2]
References
1. Fresenius Kabi. Ketamine (Ketamine Fresenius) Product leaflet. Revised date: 15 January 2009
190 | P a g e
HANDBOOK OF DRUG RECONSTITUTION & DILUTION TAWAU HOSPITAL 2018 L
HIGH ALERT
LABETALOL MEDICATION

o Labetalol Hydrochloride 25 mg/5 mL Injection
o TrandateTM 5 mg/mL (25 mg/5 mL) Injection
Reconstitution
[1, 2]
Not required
Further Dilution
IV Slow bolus : Undiluted [1,2]
IV Infusion : Dilute to final concentration up to 2 mg/mL [1,2,3,4]
In paediatric patient with fluid restriction, may be given undiluted, preferably

through a central venous catheter [4]
Diluent
NS, D5 [1, 2]

Adult IV Slow bolus Administer 50 mg over at least 1 min [1,2]
Dose can be repeated every 5 min until desired blood pressure is
achieved. Max. dose is 200 mg (40 mL) [1,2]
[1]
IV Infusion Hypertension Crisis Administer 0.5 – 2 mg/min
Hypertension in Administer 20 mg/hr. Max dose is
Pregnancy 160 mg/hr. However higher doses maybe
necessary [1]
Pediatric IV Slow bolus : Dose may administer undiluted over 2 min.
Max. to 10 mg/min [2,3]
IV Infusion
– Neonates : 0.5 mg/kg/hr (Max. per dose 4 mg/kg/hr) [4]
– Child 1 month to 11 years : Initially 0.5 - 1 mg/kg/hr
(Max. per dose 3 mg/kg/hr [4]
– Child 12 to 17 years : Initially 30 – 120 mg/hr. Initiate at lower end of
Dose range and titrate up slowly using infusion
pump [3, 4]
191 | P a g e
HIGH ALERT
LABETALOL MEDICATION
Storage & Stability

Remarks
 Do not mix with Sodium Bicarbonate Injection BP 4.2% [1, 2]
 Patient should always receive the drug whilst in the supine or left lateral position. Patient
should remain supine after IV injection for at least 3 hours [1, 2]
References
1. Pharmaniaga Lifescience Sdn Bhd.Labetalol HCI Product leaflet. Revised Date: 19 April 2017
2. Aspen Bad Oldesloe GmbH. Labetalol HCl (Trandate™) Product leaflet. Revised Date : Jun 2011
3. Lexi-Comp, Inc. (Lexi-Drugs®). Lexi-Comp, Inc; Version 4.1.1 2018
192 | P a g e
LEUPRORLIDE
o Lucrin® Depot 3.75 mg
o Lucrin® Depot 11.25 mg
Reconstitution
Lucrin®
a. Depot 3.75 mg-Using a syringe with a 22 gauge needle syringe, withdraw 1 ml of
diluents from the ampoule and inject it into the vial [1]
b. Depot 11.25 mg-Using a syringe with a 23 gauge needle syringe, withdraws 2 mL of

diluents from the ampoule and injects it into the vial [2]
Shake well to thoroughly disperse particles to obtain a uniform suspension. The suspension will
appear milk [1, 2]
Withdraw the entire contents of the vial into the syringe and inject it at the time of
reconstitution [1, 2]
Further Dilution
Not required [1]
Diluent
Provided by the manufacturer [1]

SC [1,2]
IM [1,2]
Storage & Stability

After reconstitution Use immediately [1,2] -
24 hour [1,2]
After dilution - -
193 | P a g e
LEUPRORLIDE
Remarks (continued)
 Aspirated blood would be visible just below the luer lock connection if a blood vessel is
accidently penetrated. If present, blood can be seen through the transparent hub of the
needle. [1]
 Leuprolide Acetate for Depot suspension must be administered under the supervision of a
physician. [1, 2]
 When two injections are required to achieve the desired total dosage, they should be
administered at the same time [1]
 Once reconstitution with the sterile diluents, the suspension should be administered
immediately. However, the suspension is considered stable for up to 24 hours at 25⁰C [1]
References
1. Takeda Chemical Industries,Ltd Japan , Leuprolide Acetate (LUCRIN®) Product leaflet. Revised Date:
Jan 2015.
2. Takeda Chemical Industries,Ltd Japan , Leuprolide Acetate (LUCRIN®) Product leaflet Revised Date:
Jan 2015.
194 | P a g e
LIGNOCAINE 2% HIGH ALERT
(WITH PRESERVATIVE) MEDICATION

o Lakan 200 mg/10 mL Injection – With Preservative
Reconstitution
Not required [1]
Further Dilution
Not required [1]
Diluent
Not required [1]

SC [1]
IM [1]
Storage & Stability

After dilution - -
Remarks
 Not for Intravenous use [1]
 Preservative: Methyl Paraben 0.1% w/v [1]
 Stability after opening: Store in refrigerator for not more than 4 weeks. Do not freeze.
Discard if physical changes observed [1]
References
2. Duopharma, Lignocaine Hydrochloride 2% Inj. (LAKAN) Product Leaflet. Revised date: 21
August 2014
195 | P a g e
LIGNOCAINE 2%
HIGH ALERT
(PRESERVATIVE FREE) MEDICATION

o Injecsol Lig2 100 mg/5 mL – Preservative Free
Reconstitution
Not required [1]
Further Dilution
Not required [1]
Diluent
Not required [1]

SC [1]
IM [1]
IV Slow bolus : Run 25 - 50 mg/min (1.25 - 2.5 mL/min) [1]
Storage & Stability

After dilution - -
Remarks
 Lignocaine caused precipitation of amphotericin, methohexital sodium and sulfadiazine
sodium in glucose injection [1]
 Admixtures of lignocaine and glyceryltrinitrate should be avoided [1]
References
1. Ain Medicare, Lignocaine Hydrochloride Injection 2% w/v (Injecsol Lig2) Product Leaflet.
Revised date: 28 June 2016
196 | P a g e
HIGH ALERT
LIGNOCAINE 10% MEDICATION

o Lignocaine HCl-Fresenius 10 % Injection 500 mg/5 mL
Reconstitution
Not required [1]
Further Dilution
Not required [1]
Diluent
WFI, D5 [1]

IM : Undiluted [1]
IV Slow bolus : Undiluted administer over 2 min (Infusion rate: 1 – 4mg/min) [1]
Storage & Stability

After dilution - -
Remarks
 For single use only. Discard any unused portion [1]
 IM should be given into the deltoid muscle [1]
References
1. Bodene (PTY) Ltd, Lignocaine HCl-Fresenius 10% Injection Product Leaflet. Revised date:
January 2006
197 | P a g e
LINEZOLID
o Zyvox 2 mg/mL
Reconstitution
Not required [1]
Further Dilution
Not required [1]
Diluent
D5, NS, LR [1]

IV Infusion : Over 30 – 120 min [2,3]
Storage & Stability

After dilution - -
Remarks
 Single use, ready to use infusion bag [1]
 Do not use this intravenous bag in series connection [1]
References
1. Fresenius Kabi Norge AS, Linezolid 2 mg/mL (Zyvox) Product leaflet Revised date: July 2008
2. Lexi-Comp, Inc,(Lexi-Drugs®) 2018 Version 4.1.1
3. Lexi-Comp, Inc. (Pediatric & Neonatal Lexi-Drugs®) 2018 Version 4.1.1
198 | P a g e
HANDBOOK OF DRUG RECONSTITUTION & DILUTION TAWAU HOSPITAL 2018 M
HIGH ALERT
MAGNESIUM SULPHATE MEDICATION

o DBL TM Magnesium Sulfate Concentrated Injection 2.465 g /5 mL (50%)
Each mL contains 2 mmol (4 mEq) Magnesium ions and 2 mmol of (4 mEq) sulfate ions [1]
OR 1 ampoule of Magnesium sulphate = 2.465 g/5 mL = 10 mmol Mg2+/ 5 mL [4,5]
Reconstitution
Not required [1]
Further Dilution
Adult IM : Undiluted (Concentration : 50%) [1,2]
OR
Dilute 1 ampoule with 5 mL diluent (Concentration : 25%) [1]
IV : Dilute 1 ampoule with at least 7.5 mL diluent (Concentration is ≤ 20%) [1,2,6]
Paediatric IM : Dilute 1 ampoule with 7.5 mL diluent (Concentration : 20%) [1,2,6]
IV : Dilute 1 ampoule with at least 7.5 mL diluent (Concentration is ≤ 20%) [1,2,6]
Diluent
NS, D5, NSD5, LR [1]

Adult Asthma (Acute severe
IV Slow bolus : Over 20 – 60 min [2,7]
exacerbation)
IV Slow bolus : Initially given over 5 – 15 min,
Prevention of seizures in pre- followed by
eclampsia IV Infusion : 1 g/hr over 24 hours [7]
IV Slow bolus : Initially given over 5 – 15 min,
Treatment of seizure and followed by
prevention of seizure recurrence IV Infusion : 1 g/hr over 24 hours, if s
in eclampsia seizure recurs, increase
infusion rate to 1.5 – 2 g/hr[7]
Emergency treatment of serious
arrhythmias
IV Infusion : 10 mmol in 20 mL NS run
Hypomagnesemia (Without over 1 hour, or
symptoms) 20 mmol in 40 mL NS run
over 2 hours [4]
199 | P a g e
HIGH ALERT
MAGNESIUM SULPHATE MEDICATION

Paediatric Acute or Pulseless torsades, IV Slow bolus : Over several minutes [3,6]
emergency Ventricular Tachycardia
therapy Hypomagnesemia, IV Slow bolus : 10 – 20 min [3,6]
torsades with pulse
Status asthmaticus IV Slow bolus : 15 – 30 min [3,6]
Hypomagnesemia IV Infusion : 1 – 4 hours
(max. 125 mg/kg/hr) [3]
Storage & Stability

Remarks
-
References
1. Hospira Australia Pty Ltd, Magnesium Sulphate BP (DBL TM Magnesium Sulfate Concentrated
Injection) Product Leaflet. Revised date: 01 October 2014
4. Critical Care Pharmacy Handbook 2013 3rd Edition 2013
6. Truven Health Analytics. Micromedex Version 1.17
200 | P a g e
MEDROXYPROGESTERONE
o Condep Injection 50 mg/mL (3 mL vial)
Reconstitution
Not required [1]
Further Dilution
Not required [1]
Diluent
Not required [1]

IM [1]
Storage & Stability

After dilution - -
References
1. Duopharma, Medroxyprogesterone Acetate 50 mg (Condep Injection 50 mg/mL) Product
leaflet. Revised date: 17 January 2011
201 | P a g e
MENINGOCOCCAL VACCINE
o Menveo ® 0.5 mL
Reconstitution
Reconstitute with provided solvent [1]
Further Dilution
Not required [1]
Diluent
Not required [1]

IM : Deltoid muscle [1, 2]
Storage & Stability

After reconstitution Use immediately (within 8 hours) [2] -
After dilution - -
Remarks
 Store intact MENVEO in refrigerator at 2 – 8 ⁰C. Do not freeze. Protect from light [1]
 This vaccine may be administered to individuals 2 to 55 years of age [1]
 Should not be given by subcutaneous, intravenous or intradermally [2]
References
1. Norvatis Vaccine and Diagnostics Inc, Meninggococcal Group A,C,W135 and Y conjugate
vaccine (Menveo ®) Revised date: November 2012
202 | P a g e
MEROPENEM
o Nuronem Injection 500 mg
o Nuronem Injection 1 g
Reconstitution
Reconstitute powder with WFI (Concentration : 50 mg/mL). Constituted solutions are clear and
colourless or pale yellow [1]
Further Dilution
Adult IV Infusion : Dilute 500 - 1000 mg with 50 – 200 mL diluent [1]
IV Extended infusion[4] : Dose 500 – 1000 mg dilute in 50 mL NS
Dose 2000 mg dilute in 100 mL NS
Paediatric IV Slow bolus, IV Infusion : Dilute to a concentration 1 – 20 mg/mL [2]
Diluent
NS, D5, NSD5, 1/4NSD5, D10, [1, 2]

Adult IV Slow bolus : Administer over 3 - 5 min [3]
IV Extended Infusion : Administer over 4 hours [4]
Paediatric IV Slow bolus : Administer over 3 - 5 min [2]
IV Infusion
– Age < 3 months : Administer over 30 min [2]
– Age ≥ 3 months, Children & Adolescents : Administer over 15 – 30 min [2]
203 | P a g e
MEROPENEM
Storage & Stability
Conditions Room Temperature (<25 ⁰C) Fridge ( 4 ⁰C)
NS 8 hours 48 hours
D5 3 hours 14 hours
After
NSD5 3 hours 14 hours
dilution [1]
1/4NSD5 3 hours 14 hours
D10 2 hours 8 hours
Remarks

For single use [1]
References
1. Ranbaxy Laboratories Limited, Meropenem for Injection (Nuronem Injection 500 mg / 1 g)
Product Leaflet. Revised date: August 2009
4. Malaysian Society of Intensive Care: Guide to Antimicrobial Therapy in the Adult ICU 2017
204 | P a g e
METHYLENE BLUE 1%
o Methylene Blue Injection, USP 1%
o Methylthioninium Chloride Injection 1% w/v
Reconstitution
Not required [1, 2]
Further Dilution
Not required [1, 2]
OR
May be diluted in 50 mL D5 to avoid local pain, especially in pediatric patients [4]
Diluent
D5 [4]

IV Infusion (Treatment of drug-induced methaemoglobinemia) : Administer over 5 - 30 min [1,
2, 4]
Storage & Stability

Remarks
 Should not be given by subcutaneous or intrathecal injection [1,3,4]
 Do not mix with NS [4]
References
1. Taylor Pharmaceuticals, Methylene Blue Injection 1% Product Leaflet. Revised date: March
2006
2. Martindale Pharmaceuticals Ltd, Methylthioninium Chloride Injectionw/v Product Leaflet.
Revised date: June 2008
205 | P a g e
METHYLPREDNISOLONE
o Solu-MedrolTM 1000 mg
Reconstitution
Dilute 1000 mg of Methylprednisolone with provided solvent (15.6 mL) [1]
Further Dilution
Adult IV Slow bolus, IV Infusion : Maybe further diluted with D5 or NS [1]
Paediatric IV Infusion : Dilute with 100 mL diluent
(Max. concentration : 10 mg/mL) [3]
Diluent
NS, D5, NSD5 [1]

Adult General IM : Avoid injection into the deltoid muscle due to
high incident of subcutaneous atrophy [2]
IV Slow bolus : Dose ≤ 250mg, administer over at least 5 min [1]
IV Infusion : Dose > 250mg, administer over at least 30 min [1]
Acute IV Slow bolus : 30 mg/kg over 15 min, followed in 45 min by
Spinal IV Continuous infusion : 5.4 mg/kg/hr for 23 hours (begin treatment
Injury within 8 hours of injury) [1,2]
Paediatric General IM : Avoid injection into the deltoid muscle due to high
incident of subcutaneous atrophy [3]
IV Infusion [3]:
– Low dose ( ≤ 1.8 mg/kg or ≤ 125 mg/dose), over 3 - 15 min
– Moderate dose ( ≥ 2 mg/kg or 250 mg/dose), over 15 - 30 min
– High dose( ≥ 15 mg/kg or ≥ 500 mg/dose), over 30 – 60 min
– Dose ≥ 1000mg, over 60 min
Acute IV Slow bolus : 30 mg/kg over 15 min, followed in 45 min by

Spinal IV Continuous infusion : 5.4 mg/kg/hr for 23 hours (begin treatment
Injury within 8 hr of injury) [1,3]
206 | P a g e
METHYLPREDNISOLONE
Storage & Stability
Remarks
 Diluent for Solu-Medrol TM 1000 mg contain Benzyl alcohol (140.4 mg) – WFI [1]
 Should administer separately from other compounds that are administered via the IV route
of administration [1]
 Formulations containing benzyl alcohol should not to be used in neonates [2]
 Neonates should only receive doses reconstituted with preservative free Sterile WFI [2]
References
1. Pfizer, Methylprednisolone (Solu-MedrolTM) Product Leaflet. Revised date : -
207 | P a g e
METOCLOPRAMIDE
o PULIN Injection ‘Yung Shin’ 10 mg/2 mL
Reconstitution
Not required [1]
Further Dilution
Dose ≤ 10 mg : No further dilution needed [2, 4,5]
Dose > 10 mg : Dilute with 50 mL compatible solution [2,4,5]
Diluent
NS, D5, 1/2NSD5, LR, Mannitol 20% [2, 4]

IM [1, 2,3]
IV Slow bolus : For doses ≤ 10mg administer over 1 - 2 min [2,3]
IV Infusion : For dose ≥ 10mg, administer ≥ 15 min [2]
Storage & Stability

After Normal light 24 hours -
[2]
dilution Protected from light 48 hours
Remarks
 Contain benzyl alcohol, avoided use in children < 2 years old. Not to be used in neonates [1]
 Not recommended for the first trimester of pregnancy [1]
208 | P a g e
METOCLOPRAMIDE
References
1. Yung Shin Pharmaceutical LTD, Metoclopramide 10 mg/2 mL Injection. Product Leaflet.
Revised date : -
3. Paediatric Formulary Committee. BNF for Children 2017-2018. London: BMJ Group
Pharmaceutical Press, and RCPCH Publications; 2017
4. Trissel LA. Handbook on Injectable Drugs. 11th ed. Bethesda, MD: American Society of
Health-System Pharmacists; 2001.
209 | P a g e
METRONIDAZOLE
o Metronol 0.5 % w/v Injection
Reconstitution
Not required [1]
Further Dilution
Not required [1]
Diluent
Not required [1]

IV Infusion : Administer over 20 – 60 min [1, 2]
Storage & Stability

After dilution - -
Remarks
 Discard any unused drug after infusion [1]
 Avoid contact of drug solution with equipment containing aluminum [2]
References
1. Ain Medicare, Metronidazole 0.5% w/v Injection (Metronol ® ) Product Leaflet. Revised
date: 20 November 2006
210 | P a g e
HIGH ALERT
MIDAZOLAM MEDICATION

o Domi 5 mg/mL
o Domi 15 mg/3 mL
Reconstitution
Not required
Further Dilution
[1]
Adult IV Slow bolus : Dilute with diluent to a concentration of 1 - 5 mg/mL
IV Infusion : Dilute with diluent to a final concentration of 1 mg/mL [1]
Paediatric IV infusion : Dilute with diluent to a final concentration of 0.5 mg/mL [1]
– Neonates and children <15 kg : Dilute to a max. concentration of 1 mg/mL [3]
– Neonatal intensive care : Dilute 15 mg/kg body weight to a final volume of
50 mL with infusion fluid. An IV infusion rate of
0.1 mL/hr provides a dose of 30 mcg/kg/hr[3]
Diluent
NS, D5, D10, Ringer’s Solution, LR Solution [1]

Adult IM
IV Slow bolus Induction of Administer 0.15 - 0.2 mg/kg (10 - 15 mg) at rate
anaesthesia of 2.5 mg/10 sec [1] or 5 - 30 sec bolus [2]
Sedation Administer over 2 - 5 min [1, 2,] Wait an additional

≥ 2 min to fully evaluate the sedation effect [1,2]
IV Infusion Sedation in Administer at 0.03 - 0.2 mg/kg/hr [1]

ICU
211 | P a g e
HIGH ALERT

Paediatric IV Slow bolus Induction of – Child 7 to 17 years :
anaesthesia Initially 150 mcg/kg (Max. per dose 7.5 mg),
dose to be given in steps of 50 mcg/kg (Max.
per dose 2.5 mg) over 2 - 5 min, wait for 2 - 5
min for subsequent dosing, then 50 mcg/kg
every 2 min (Max. per dose 2.5 mg). If required,
may use max. dose of 500 mcg/kg per course
(Max. dose 25 mg per course) [3]
Sedation of – Child 6 months to 11 years :

patient Initially 50 - 200 mcg/kg, to be administered
receiving over at least 3 min, followed by IV Continuous
intensive care infusion 30 - 120 mcg/kg/hr, adjusted according
to response [3]
IV Continuous Status Initially 150 - 200 mcg/kg, followed by 60

infusion epilepticus, mcg/kg/hr increased in steps of 60 mcg/kg/hr
Febrile every 15 min (Max. dose 300 mcg/kg/hr) until
convulsions seizure controlled [3]
Sedation of – Neonates up to 32 weeks corrected gestational

patient age :
receiving 60 mcg/kg/hr for 24 hours then reduced to
intensive care 30mcg/kg/hr, max. duration 4 days [3]
– Neonate 32 weeks corrected gestational age

& above :
60 mcg/kg/hour maximum duration 4days [3]
– Neonates and child 1 to 5 months :

60 mcg/kg/hr [3]
Storage & Stability

After dilution - -
212 | P a g e
HIGH ALERT
Remarks
 May be mixed in the same syringe with frequently used premedicants: Morphine Sulphate,
Pethidine, Atropine Sulphate or Scopolamine. [1,2,4]
References
1. Duopharma (M) SB. Midazaolam (Domi Injection) Product Leaflet. Revised date: 14 April 2009
2. Drug Information Handbook with International Trade Names Index, 17th Edition, Lexi Comp Inc,
2008-2009.
3. BNF for Children (BNFC) 2017-2018, page 215-216
4. Drug Doses, Frank Shann, 17th editon, 2017, page 70
213 | P a g e
HIGH ALERT
MORPHINE SULPHATE MEDICATION

o Morphine Sulphate Injection 10 mg/mL (Preservative Free)
Reconstitution
Not required
Further Dilution
Adult SC, IM : Undiluted [1]
IV Slow bolus : Dilute 1 ampoule (10 mg/mL) with 2 - 20 mL of diluent

(Concentration : 0.5 - 5 mg/mL).[1] May also be given undiluted [2]
IV infusion : Dilute 1 ampoule (10 mg/mL) with 10 - 100 mL diluent

(Concentration : 0.1 - 1 mg/mL)
Usual infusion concentration : 1 mg/mL [1]
Paediatrics SC, IM : Undiluted [1]
IV Slow bolus : Dilute 1 ampoule (10 mg/mL) with 2 - 20 mL of diluent

(Concentration : 0.5 - 5 mg/mL) [1] May also be given undiluted [2]
IV Infusion : Dilute with D5 or D10 or NS [3]

– Neonates intensive care : Dilute 2.5 mg/kg body weight to a final volume of
50 mL with infusion fluid; an IV Infusion rate of 0.1
mL/hour provides a dose of 5 mcg/kg/hr [3]
Diluent
NS [1,2,3,4], D5 [1,2]
214 | P a g e
HIGH ALERT

Adult SC [1]
IM [1]
IV Slow bolus : Administer over 4 - 5 min [2,3]
IV infusion : Administer using infusion pump or PCA pump. Titrate dosage to
provide adequate pain relief [1,2]
Paediatric SC
– Neonates : Initially 100 mcg/kg every 6 hours [3]
– Child 1 to 5 months : 100 - 200 mcg/kg every 6 hours [3]
– Child 6 months to 1 year : 100 - 200 mcg/kg every 4 hours [3]
– Child 2 to 11 years : Initially 200 mcg/kg every 4 hours [3]
IM [4]
IV infusion
– Neonates : Initially 50 mcg/kg every 6 hours, adjusted according
to response, dose to be administered over at least 5
min. Alternatively by IV Continuous infusion initially
50 mcg/kg, dose to be administered over at least 5
min, followed by IV Continuous infusion 5 – 20
mcg/kg/hr, adjusted according to response [3]
– Child 1 to 5 months : 100 mcg/kg every 6 hours, adjusted according to

response, dose to be administered over at least 5
min, followed by IV Continuous infusion 10 - 30
– Child 6 month to 11 years : 100 mcg/kg every 4 hours, adjusted according to

response, dose to be administered over at least 5
min, followed by IV Continuous infusion 20 – 30
215 | P a g e
HIGH ALERT
Storage & Stability

After dilution - -
Remarks
 Repeated IM injection is not recommended due to painful administration, variable
adsorption and lag time to peak effect. [2]
 Repeated SC administration causes local tissue irritation, pain and induration. [2]
References
1. Duopharma (M) SdnBhd. Morphine (Injection Morphine Sulphate Bp 10 mg/ml) Product Leaflet.
Revised date: 14 April 2009
2008-2009.
216 | P a g e
HANDBOOK OF DRUG RECONSTITUTION & DILUTION TAWAU HOSPITAL 2018 N
HIGH ALERT
NALBUPHINE MEDICATION

o Intapan Injection 10 mg/mL
o Intapan Injection 100 mg/10 mL
Reconstitution
Not required
Further Dilution
Not required [1]
Diluent
Not required [1]

Adult SC [1]
IM [1]
IV Slow bolus : Administer undiluted over 2 – 3 min [2]
Larger induction doses should be administered over 10 – 15 min [1]
Paediatric SC [3]
IM [3]
IV Slow bolus : Administer over 15 min [3]
Storage & Stability

After dilution - -
Remarks
 Preparation contains Sodium Metabisulphite, may cause allergy-type reactions.
References
1. Duopharma: Nalbuphine Hydrochloride Inj. (Intapan) Product Leaflet. Revised Date: 18 June 2010.
2008-2009.
3. Drug Doses, Frank Shann, 17th Editon, 2017, page 73
217 | P a g e
NALOXONE
o Mapin 0.4 mg/mL
Reconstitution
Not required [1]
Further Dilution
IV Slow bolus : Use undiluted or dilute 0.4 mg (1 ampoule) with 9 mL diluent to a
total volume of 10 mL (40 mcg/mL) [1]
IV Infusion : Dilute 2 mg (5 ampoules) in 500 mL of diluent (4 mcg/mL) [1]
Paediatric IV Slow bolus Reversal of Dilute 0.4 mg to 20 mL diluent [3]
postoperative
respiratory depression
Opioid overdose Dilute 0.4 mg to 10 mL diluent [3]
IV Infusion Dilute 2 mg (5 ampoules) in 500 mL of diluent (4 mcg/mL) [1]
Diluent
NS, D5 [1]

Adult SC [1]
IM [1]
IV Slow bolus : Administer doses of 0.4 mg or less (undiluted) by direct injection
over 30 sec [2]
IV Infusion : As prescribed by doctor, titrated based on patient’s response [1,2]
Paediatric IV Slow bolus Reversal of 1 mcg/kg over 30 sec and may repeat
postoperative intervals of 2 - 3 min [4]
respiratory depression
Opioid overdose 100 mcg/kg over 30 sec and may repeat
intervals of 1 min to a max. of 2 mg
IV Infusion Using an infusion pump, adjust rate according to response [4]
SC, IM If an IV route of administration is not available, naloxone may be
administered SC or IM in divided dose. [1] If necessary, naloxone
can be diluted with sterile WFI [1]
218 | P a g e
NALOXONE
Storage & Stability
Remarks
 The most rapid onset is achieved by IV administration and is recommended in emergency
situations [1]
References
1. Duopharma (M) Sdn Bhd. Naloxone Hydrochloride. Mapin Injection Product Leaflet; Revised
date: 15 Feb 2012
2. Drug Information Handbook with International Trade Names Index, 17th Edition, Lexi Comp
Inc, 2008-2009.
4. BNF for Children (BNFC) 2017-2018, page 813
219 | P a g e
NEOSTIGMINE
o Setisin Injection 2.5 mg/mL
Reconstitution
Not required [1]
Further Dilution
Adult Not required [1]
Paediatric IV Slow bolus : Use 0.5 mL of Neostigmine (Strength 2.5 mg/mL) +
0.5 mL of Atropine (Strength 0.6 mg/mL) + 0.5 mL of NS [3]
Diluent
D5, NS [4]

Adult IM, SC [1]
IV Slow bolus : Administer over 1 min [1]

Paediatric SC, IM [1] Myasthenia – Neonates :
gravis 150 mcg/kg every 6 - 8 hours, to be given 30
min before feeds, the increased if necessary up
to 300 mcg/kg every 4 hours [4]
– Child 1 month to 11years :

200 – 500 mcg, dose may repeat at suitable
intervals over 24 hours [4]
IV Slow bolus Reversal of non- – Neonates :

depolarizing 50 mcg/kg to be given over 1 min after or with
(competitive) glycopyrronium or atropine, followed by 25
neuromuscular mcg/kg if required [4]
blockade
– Child 1 month to 11 years :
50 mcg/kg (Max. per dose 2.4 mg) to be given
over 1 min after or with glycopyrronium or
atropine, then 25 mcg/kg if required [4]
220 | P a g e
NEOSTIGMINE
Storage & Stability
After dilution - -
Remarks
 Neostigmine may prolong the depolarizing neuromuscular blocking agents of
suxamethonium and prolonged apnea [1]
References
1. Duopharma (M) Sdn Bhd. Neostigmine Methylsulphate BP. Setisin Injection Product Leaflet;
Revised date: 26 July 2011
Inc, 2008-2009.
4. BNF for Children (BNFC) 2017-2018, page 619
221 | P a g e
HIGH ALERT
NORADRENALINE MEDICATION

o Cardiamed 4 mg/4 mL
o Levophed 4 mg/4 mL
Reconstitution
Not required [1]
Further Dilution
Adult IV Continuous infusion
Single strength : Dilute 1 ampoule in 50 mL diluent (80 mcg/mL) [1]
Double strength : Dilute 2 ampoule in 50 mL diluent (160 mcg/mL) [1]
Max concentration: 32 mg/50 mL) [1]
Paediatric IV Continuous infusion : Dilute to a max. concentration of Noradrenaline (base)
40 mcg/mL (higher concentration can be used if fluid-
restricted) with diluent [4]
– Neonates intensive care : Dilute 600 mcg (base)/kg body-weight to a final volume
of 50 mL with infusion fluid
(Max. concentration: 40 mcg/mL) [3,4]
Diluent
NS, D5, NSD5 [1,2]
Calculation
Example : Doctor ordered IV Noradrenaline 0.05 mcg/kg/min. Patient’s weight is 70 kg. What is
the infusion rate?
1000 mcg/mg
= 0.05 x 70 x 60
1000
= 0.21 mg/hr
b. Determine concentration (mg/mL) = 0.16 mg/mL (if double strength is used)

c. Calculate infusion rate (mL/hr) = Dose (mg/hr)
= 0.21
0.16
≈ 1.3 mL/hr
222 | P a g e
HIGH ALERT

Adult IV Continuous infusion : 8 – 12 mcg/min; maintenance dose 2 – 4 mcg/min [1,2]
For rate of infusion, refer page 224 – 225
Must always be administered through a dedicated lumen
of a central line [1]
Paediatric IV Continuous infusion
– Neonate intensive care and child : 20 – 100 nanograms/kg/min (Max.
concentration of 40 mcg/mL; maximum per
dose 1 mcg/kg/min). Higher concentration
can be used if fluid restriction [3,4]
Central line administration is preferred [2,4]
Storage & Stability

After dilution Use immediately [1,5] -
Remarks
 Dosage administration requires the use of an infusion pump. [2]
 Infusions of noradrenaline should be reduced gradually, avoiding abrupt withdrawal. [1]
References
1. Duopharma (M) Sdn Bhd. Cardiamed Injection 1 mg/ 1ml, Product Leaflet; Revised date: 05
August 2010
Inc, 2008-2009.
3. Drug Doses, Frank Shann, 17th edition, 2017, page 74
5. Hospira. Levophed 4mg/4ml Injection USP. Product Leaflet Code: 25INS000003MY.
223 | P a g e
N
HIGH ALERT
Infusion Rate
ADULT : Single strength Noradrenaline 4 mg in 50 mL NS or D5 (80 mcg/mL; through central line)

mcg/kg/min mL/hr
0.1 3 3.4 3.8 4.1 4.5 4.9 5.3 5.6 6 6.4 6.8 7.1
0.2 6 6.8 7.5 8.3 9 9.8 10.5 11.3 12 12.8 13.5 14.3
0.3 9 10.1 11.3 12.4 13.5 14.6 15.8 16.9 18 19.1 20.3 21.4
0.4 12 13.5 15 16.5 18 19.5 21 22.5 24 25.5 27 28.5
0.5 15 16.9 18.8 20.6 22.5 24.4 26.3 28.1 30 31.9 33.8 35.6
0.6 18 20.3 22.5 24.8 27 29.3 31.5 33.8 36 38.3 40.5 42.8
0.7 21 23.6 26.3 28.9 31.5 34.1 36.8 39.4 42 44.6 47.3 49.9
0.8 24 27 30 33 36 39 42 45 48 51 54 57
0.9 27 30.4 33.8 37.1 40.5 43.9 47.3 50.6 54 57.4 60.8 64.1
1 30 33.8 37.5 41.3 45 48.8 52.5 56.3 60 63.8 67.5 71.3
1.1 33 37.1 41.3 45.4 49.5 53.6 57.8 61.9 66 70.1 74.3 78.4
1.2 36 40.5 45 49.5 54 58.5 63 67.5 72 76.5 81 85.5
1.3 39 43.9 48.8 53.6 58.5 63.4 68.3 73.1 78 82.9 87.8 92.6
1.4 42 47.3 52.5 57.8 63 68.3 73.5 78.8 84 89.3 94.5 99.8
1.5 45 50.6 56.3 61.9 67.5 73.1 78.8 84.4 90 95.6 101.3 106.9
224 | P a g e
N
HIGH ALERT
Infusion Rate
ADULT : Double strength Noradrenaline 8 mg in 50 mL NS or D5 (160 mcg/mL; through central line)

mcg/kg/min mL/hr
0.1 1.5 1.7 1.9 2.1 2.3 2.4 2.6 2.8 3 3.2 3.4 3.6
0.2 3 3.4 3.8 4.1 4.5 4.9 5.3 5.6 6 6.4 6.8 7.1
0.3 4.5 5.1 5.6 6.2 6.8 7.3 7.9 8.4 9 9.6 10.1 10.7
0.4 6 6.8 7.5 8.3 9 9.8 10.5 11.3 12 12.8 13.5 14.3
0.5 7.5 8.4 9.4 10.3 11.3 12.2 13.1 14.1 15 15.9 16.9 17.8
0.6 9 10.1 11.3 12.4 13.5 14.6 15.8 16.9 18 19.1 20.3 21.4
0.7 10.5 11.8 13.1 14.4 15.8 17.1 18.4 19.7 21 22.3 23.6 24.9
0.8 12 13.5 15 16.5 18 19.5 21 22.5 24 25.5 27 28.5
0.9 13.5 15.2 16.9 18.6 20.3 21.9 23.6 25.3 27 28.7 30.4 32.1
1 15 16.9 18.8 20.6 22.5 24.4 26.3 28.1 30 31.9 33.8 35.6
1.1 16.5 18.6 20.6 22.7 24.8 26.8 28.9 30.9 33 35.1 37.1 39.2
1.2 18 20.3 22.5 24.8 27 29.3 31.5 33.8 36 38.3 40.5 42.8
1.3 19.5 21.9 24.4 26.8 29.3 31.7 34.1 36.6 39 41.4 43.9 46.3
1.4 21 23.6 26.3 28.9 31.5 34.1 36.8 39.4 42 44.6 47.3 49.9
1.5 22.5 25.3 28.1 30.9 33.8 36.6 39.4 42.2 45 47.8 50.6 53.4
225 | P a g e
HANDBOOK OF DRUG RECONSTITUTION & DILUTION TAWAU HOSPITAL 2018 O
OCTREOTIDE
o Sandostatin® 0.1 mg/mL
o Octride injection 100 mcg/mL
Reconstitution
Not required [1]
Further Dilution
Adult SC, IV Slow bolus : Undiluted [1,2]
IV Continuous infusion : One 0.5 mg ampoule dissolved in 60 mL diluent [1,2]
Paediatrics SC : Undiluted [1]

IV Slow bolus & IV Continuous infusion : Dilute with diluent to a concentration
of 10 - 50% [1,4]
Diluent
D5, NSD5, [1,2] NS [4]

Adult SC : Rotate injection site [1,2,3]
IV Continuous Bleeding from 25 mcg/hr for 5 days (25 - 50 mcg/hr)
[1]
oesophageal or gastric
infusion
varices
226 | P a g e
OCTREOTIDE
Paediatric SC Persistent – Neonates :
hyperinsulinaemic Initially 2 - 5 mcg/kg every 6 - 8 hours,
hypoglycaemia adjusted according to response (Max.
unresponsive to 7 mcg/kg every 4 hours) [5]
diazoxide and glucose
– Child :
Initially 1 - 2 mcg/kg every 4 - 6 hours,
adjusted according to response (Max.
7 mcg/kg every 4 hours) [5]
IV Continuous Bleeding from – Child :

infusion oesophageal or gastric 1 mcg/kg/hr, higher doses may be
varices required initially, when no active
bleeding reduce dose over 24 hours;
usual max 50 mcg/hr [5]
Storage & Stability

Remarks
 Intact Ocreotide vials/ampoule must be stored at 2 – 8 ⁰C. Do not freeze [1]
 To reduce local discomfort, it is recommended that the solution should be at room
temperature before injection. [1]
 Ampoules should be opened just prior to administration, and any unused portion discarded.
[1]
References
1. Novartis Pharma, Sandostatin Antigrowth Hormone, Product Leaflet; Revised date:
December 2014.
2. Sun pharmaceutical ind. Ltd, octride injection 100 mcg/ml product leaflet, revised date: 22
April 2014
Inc, 2008-2009.
227 | P a g e
OMEPRAZOLE
o Vaxcel Omeprazole 40 mg Injection
Reconstitution
Reconstitute 40 mg with 10 mL provided solvent. Concentration : 4 mg/mL [1]
Further Dilution
Adult IV Intermittent infusion,
IV Continuous Infusion : Dilute to a concentration of 400 mcg/mL with diluent [5]
Paediatric IV Intermittent infusion : Dilute reconstituted solution to a concentration of
400 mcg/mL with diluent [4]
Diluent
D5, NSD5 [1,2], NS [4]

Adult IV Slow bolus : At least 2.5 min and with max. rate 4 mL/min [1]
OR
Administer over 5 min [5]
IV Intermittent infusion : 20 - 30 min [2]
For peptic ulcer bleeding : Initially 80 mg over 40 – 60 min, followed by [5]
IV Continuous infusion at rate 8 mg/hr [2]
Paediatric IV Slow bolus : 5 min [3,4]
IV Intermittent infusion : 20 - 30 min [4]
Storage & Stability

Remarks
 No other solvent may be used for reconstitution. [1]
228 | P a g e
OMEPRAZOLE
References
1. Kontra Pharma (M) Sdn Bhd. Vaxcel Omperazole 40 mg Injection Product Leaflet; Revised
date: NA
Inc, 2008-2009.
5. British National Formulary 73
229 | P a g e
ONDANSETRON
o Ondansetron Kabi 2 mg/mL Injection
o Each ampoule contains 4 mg Ondansetron
Reconstitution
Not required [1]
Further Dilution
Adult IM (Dose ≤ 8 mg) : Undiluted [1,2]
IV Slow bolus (Dose ≤ 8 mg) : Undiluted [1,2]
IV Infusion (Dose > 8 mg) : Dilute the required dose in 50 - 100 mL diluent [2]
Paediatric IV Slow bolus : Undiluted [3,4]
IV Infusion : Dilute to a concentration of 320 - 640 mcg/mL [4]
Diluent
NS, D5, Mannitol 10%, LR Solution [1,2]

Adult IM (Dose ≤ 8 mg) : Over 5 min [2]
IV Slow bolus (Dose ≤ 8 mg) : Over 5 min [1,2]
IV Intermittent infusion (Dose > 8 mg and ≤ 32 mg) [1,2] : Not less than 15 min [1,2]
Continuous IVI (Dose > 8 mg and ≤ 32 mg) : 1 mg/hr for 24 hours [1,2]
Paediatric IV Slow bolus : At least 30 sec [3,4]
IV Infusion : At least 15 min {Max. 32 mg per day) [4]
Storage & Stability

230 | P a g e
ONDANSETRON
Remarks
-
References
1. Fresenius Kabi Malaysia Sdn Bhd. Ondansetron Kabi 2 mg/ml solution for Injection Product
Leaflet; Revised date: 3 Sep 2012
Inc, 2008-2009.
231 | P a g e
HIGH ALERT
OXYTOCIN MEDICATION

o Udoxan injection 10 IU/mL
Reconstitution
Not required [1]
Further Dilution
Adult IV infusion Induction and Dilute 10 IU to 1000 mL diluent to yield
Enhancement of Oxytocin 0.01 IU/mL (10 mIU/mL) [1,2]
Labor
Postpartum uterine Dilute 10 - 40 IU to running IV Infusion
bleeding (Max. 40 IU/1000 mL) [1,2]
Diluent
NS, D5, Isotonic electrolyte solution [1,2]

Adult IV infusion Induction and Administer at 1 - 4 mU/min (0.1 - 0.4
Enhancement of mL/min or 2 - 8 drops/min). Increase rate
Labor gradually at intervals of not shorter than 20
min. Max rate: 20 mU/min (2 ml/min or 40
drops/min) [1,2]
Postpartum Administer 5 - 10 IU at a rate sufficient to

uterine bleeding sustain uterine contraction and control
uterine atony. Maximum cumulative dose:
40 units [2]
Intramurally Caesarian section 5 IU intramurally after delivery of the fetus

[1]
Storage & Stability

After dilution - -
232 | P a g e
HIGH ALERT
OXYTOCIN MEDICATION
Remarks
 Store at 2 – 8 ⁰C. Protect from light. Do not freeze [1]
 To ensure even mixing of the drip solution, the bottle or bag must be turned upside down
several times before use [1,2]
 IV administration requires the use of an infusion pump or by drip infusion [1,2]
References
1. Fresenius Kabi Malaysia Sdn Bhd. Ondansetron Kabi 2 mg/ml solution for Injection Product
Leaflet; Revised date: 3 Sep 2012
Inc, 2008-2009.
233 | P a g e
HIGH ALERT
O X Y T O C I N+E R G O M E T R I N E MEDICATION

o Syntometrine ® 5 IU/500 mcg (Oxytocin 5 IU & Ergometrine Maleate 0.5 mg/mL)
Reconstitution
Not required [1]
Further Dilution
Not required [1]
Diluent
Not required [1]

Adult IM : Maximum 3 doses (3 mL) within 24 hours [1]
IV Slow bolus Limited for cases of 0.5 - 1 mL [1]
severe haemorrhage
due to uterine atony
Storage & Stability

After dilution - -
Remarks
 Store at 2 – 8 ⁰C. Protect from light. [1]
 Product should not be exposed to sunlight [1]
References
1. Alliance Pharmaceuticals Limited, Oxytocin & Ergometrine (Syntometrine) Product Leaflet.
Revised date: May 2014
234 | P a g e
HANDBOOK OF DRUG RECONSTITUTION & DILUTION TAWAU HOSPITAL 2018 P
PALIPERIDONE
o INVEGA ® SUSTENNA 150 mg paliperidone as 234 mg paliperidone palmitate
(Prolonged-Release Suspension for Intramuscular Injection)
Reconstitution
Not required [1]
Further Dilution
Not required [1]
Diluent
Not required [1]

Adult IM : Inject slowly, deep into the muscle. Avoid inadvertent injection into a blood
vessel [1]
Storage & Stability

-
After dilution -
Remarks
 Administration should be in a single injection [1]
 Do not administer the dose in divided injections [1]
 Do not administer intravascularly or subcutaneously [1]
 Administration should be made into the upper-outer quadrant of the gluteal area. Gluteal
injections should be alternated between the two gluteal muscles. [1]
 Do not store above 30˚C [1]
References
1. Johnson & Johnson Sdn Bhd (INVEGA ® SUSTENNA (150 mg paliperidone as 234 mg paliperidone
palmitate) Prolonged-Release Suspension for Intramuscular Injection) Product Leaflet. Revised date:
10 January 2017
235 | P a g e
PALIVIZUMAB
o Synagis® Palivizumab 100 mg
Reconstitution
Reconstitute powder with 1 mL WFI. Concentration : 100 mg/mL [1,2]
Further Dilution
Paediatric Not Applicable
Diluent
Not Applicable

Paediatric IM [1,2,3]
Storage & Stability

After reconstitution Immediately [1] -
After dilution Not Applicable Not Applicable
Remarks
 Synagis® (Palivizumab) should be stored between 2 and 8°C in its original container [1]
 Do not freeze [1]
 Injection volumes over 1 mL should be given as a divided dose [1,2,3]
 The gluteal muscle should not be used routinely as an injection site because of the risk of
damage to the sciatic nerve [1,2]
 Single-use vial. Do not re-enter the vial after withdrawal of drug. Discard unused contents
[1,2]
 Do not dilute the product. Do not shake vial [1,2]
References
1. Boehringer Ingelheim (BI) Pharma KG. Palivizumab (Synagis®) Product Leaflet. Revised Date: 9 April
2018
2. Wolters Kluwer Health. UpToDate® Mobile app. Version 3.2.0
236 | P a g e
PAMIDRONATE
o Pamisol 30 mg/10 mL
Reconstitution
Reconstitute powder with 10 mL WFI. Concentration : 3 mg/mL [1,2]
Further Dilution
Adult IV Infusion Bone metastases with Dilute 90 mg in 500 mL diluent
multiple myeloma,
Tumour Induced
Hypercalcaemia
Bone metastases with Dilute 90 mg in 250 mL diluent

metastatic breast cancer
Paget’s disease of bone Dilute 60 mg in 250 – 1000 mL diluent [2]

Concentration should not exceed 90
mg/L [1]
Diluent
NS, D5, [1,2] 1/2NS [2,3]

Adult IV Infusion Bone metastases with Over 4 hours [1]
multiple myeloma, Max. infusion rate of 1 mg/min[1]
Tumour Induced
Hypercalcaemia
Bone metastases with Over 2 hours [1]

metastatic breast cancer Max. infusion rate of 1 mg/min[1]
Paget’s disease of bone Over 4 hours [1,2]
Max. infusion rate of 15 – 30 mg over 2
hours [1]
237 | P a g e
PAMIDRONATE
Storage & Stability
After reconstitution Use immediately [1] 24 hours [1,2]
Remarks
 Never be give as a bolus injection since severe local reaction and thrombophlebitis may
occur as a result of high local concentration[1]
 A maximum concentration rate of 20mg/hr is recommended in patient with mild to
moderate renal and hepatic impairment.[1,3]
References
1. Hospira. Disodium Pamidronate (Pamisol TM) Product leaflet. Revised Date : 1 October 2014
2. McGraw Hill’s IV Drug Handbook 2010 (Mobile App) Version 8.0.249
238 | P a g e
PANTOPRAZOLE
o Vaxcel® Pantoprazole 40 mg
Reconstitution
Reconstitute powder with 10 mL NS (Concentration : 4 mg/mL) [1,2,3]
Further Dilution
Adult IV Slow bolus : Undiluted [1]
IV Intermittent infusion,
IV Continuous infusion : Dilute 40 mg with 100 mL diluent
(Concentration : 0.4 mg/mL) [1]
IV Intermittent infusion : Dilute 40 mg with 50 - 100 mL diluent
(Concentration : 0.4 – 0.8 mg/mL) [3]
Diluent
NS, D5 [1,2] , LR Solution [2,3]

Adult IV Slow bolus : Over 2 min [1]
IV Intermittent infusion : Over 15 min [1,2,3]
IV Continuous infusion : 8 mg/hr for 3 – 5 days [4]
Paediatric IV Slow bolus : Over 2 min [3]
IV Intermittent infusion : Over 15 min [3]
Storage & Stability

Remarks
 Flush IV line before and after administration with either NS, D5 or LR Solution [2]
 Do not administer through same line with other IV Solution [2]
239 | P a g e
PANTOPRAZOLE
References
1. Kontra Pharma Sdn Bhd. Vaxcel® Pantoprazole 40mg Injection Product leaflet. Revised date : 18
October 2016
4. Sarawak Handbook of Medical Emergencies, 3rd edition 2011
240 | P a g e
PARACETAMOL
o Paracetamol Kabi 10 mg/mL Solution for Infusion
Reconstitution
Not Applicable
Further Dilution
Paediatrics IV Infusion : Volume to be administered dilute in diluent up to one tenth
(One volume Paracetamol into nine volumes diluent) [1]
Diluent
NS, D5 [1]

Paediatrics IV Infusion : Over 15 min [1,2,3]
Storage & Stability

After opening 24 hours [1] -
After reconstitution Not applicable Not applicable
After dilution < 1 hour [1] -
Remarks
 Diluted solution of Paracetamol should be used within the hour following its preparation
(infusion time included)
 Discard any unused portion; single-use vials only [3]
References
1. Fresenius Kabi Austria Gmbh. Paracetamol Kabi. Product leaflet. Date of Revision : June 2014
241 | P a g e
PARECOXIB
o Dynastat® 40 mg powder for solution for injection
Reconstitution
Reconstitute powder with 2 mL NS, bacteriostatic NSD5, D5, 1/2NS [1]
Further Dilution
Adult Not Applicable

Adult Deep IM [1]
IV Slow bolus [1]
Storage & Stability

24 hours if reconstituted in controlled
and validated aseptic condition [1]
After dilution Not Applicable Not Applicable
Remarks
 Use of Lactated Ringer’s Injection or 5% Dextrose in Lactated Ringer’s Injection are not
recommended for reconstitution as they will cause drug to precipitate from solution.
 Use of Water for Injection is not recommended for reconstitution as the resulting solution is
not isotonic [1]
References
1. Pfizer. Parecoxib (Dynastat®) Product leaflet. Revised date : 26 October 2015
242 | P a g e
PENTAMIDINE
o DBL Pentamidine Isethionate Injection 300 mg
Reconstitution
For IM : Reconstitute powder with 3 mL WFI. Concentration: 100 mg/mL [1]
For IV : Reconstitute powder with 3 - 5 mL WFI or D5. Concentration: 60 – 100 mg/mL [1,2,3]
Further Dilution
IV Infusion : Dilute in 50 – 250 ml diluent [2,3] (Concentration : 2.5 -5 mg/mL)
Diluent
NS, D5 [1,3]

Deep IM [2,3,4]
IV Infusion : Administer over 60 – 120 min [2,3,4]
Storage & Stability

After reconstitution 48 hours (Protected from light) [1] 48 hours [1]
After dilution -
(Concentration : 1 – 2.5 mg/mL D5) 24 hours[1]
Remarks
 Do not reconstitute with NS as precipitation will occur [1]
 Injection should not be given as a slow IV Infusion with patient in a supine position in order
to reduce the incident of sudden severe hypotension [1,2,3]
 Direct IV bolus or rapid administration must not be used [1]
References
4. Phelps, Stephanie J. Pediatric Injectable Drugs: The Teddy Bear Book 2013
243 | P a g e
HIGH ALERT
PETHIDINE MEDICATION

o Duopharma Pethidine 100 mg/2 mL
Reconstitution
Not Applicable
Further Dilution
IV Slow bolus : Use undiluted, or preferably dilute in 5 mL diluent [2]
IV Infusion : Dilute each 10 mg in 1 mL diluent (Concentration : 10 mg/mL) [3]
Paediatrics SC, IM : Undiluted[1,3]
IV Slow bolus : Dilute in 5 mL diluent [2]
IV Infusion : Dilute each 10 mg in 1 mL diluent (Concentration : 10 mg/mL) [3]
Diluent
NS, 1/2NS, D5, LR Solution, [1] D2.5, D10, Dextrose Saline Solution combination [2]

Adult SC [1,3]
IM [1,3]
[1,3]
IV Slow bolus
IV Continuous infusion : 15 – 35 mg/hr [4]
Paediatric SC [1,3]
IM [1,3]
IV Slow bolus : Over at least 5 min [3]
IV Continuous Infusion : 0.1 – 0.4 mg/kg/hr [5]
244 | P a g e
HIGH ALERT
PETHIDINE MEDICATION
Storage & Stability

After reconstitution Not Applicable Not Applicable
After dilution - -
Remarks
 Pethidine should not be administered intravenously unless a narcotic antagonist and the
facilities for assisted or controlled respiratory are immediately available [1,2]
 Ensure patient is lying down during IV administration [1,2,3]
References
1. Duopharma. Pethidine 100 mg/2 mL Product leaflet. Revised date : 17 July 2006
5. MIMS Gateway Online 2018
245 | P a g e
PHENOBARBITONE
o Martindale Pharmaceutical Phenobarbital Sodium 200 mg/mL
Reconstitution
Not Applicable
Further Dilution
Adult SC, IM : Undiluted[1]
IV Slow bolus : Dilute in 10 times its own volume of WFI [1] Dilute in up to 10 mL
WFI [3]
Paediatrics IM : Undiluted[1]
IV Slow bolus : Dilute in 10 times its own volume of WFI [1]
OR
Dilute in up to 10 mL WFI [3]
Diluent
WFI [1,3]

Adult SC [1]
IM [1,2]
IV Slow bolus : Max. rate 60 mg/min [1,2,3]
Paediatric IM [1]
IV Slow bolus : Max. rate 1 mg/kg/min (30 mg/min) [2]
Storage & Stability

After dilution - -
246 | P a g e
PHENOBARBITONE
Remarks
 Store below 25°C. Protect from light [1]
 Single use only. Discard any portion after opening [1]
 For IM administration, inject deep into muscle. Do not exceed 5mL per injection site due to
potential for tissue irritation [2]
 Subcutaneous administration of Phenobarbitone is not recommended [2,3]
 Rapid injection may cause respiratory depression [3]
References
1. Martindale Pharmaceutical Phenobarbital Sodium 200mg/1ml Product leaflet. Revised date :
October 2011.
247 | P a g e
HIGH ALERT
PHENYLEPHRINE MEDICATION

o Frenin Phenylephrine 10 mg/mL
Reconstitution
Not Applicable
Further Dilution
Adult IV Slow bolus : Dilute 1 mL of 10 mg/mL solution with 9 mL WFI [1]
IV Infusion : Dilute 10 mg in 500 mL of diluent
OR
Dilute 50 mg in 500 mL of diluent
OR
Dilute 100 mg in 500 mL of diluent
(Concentration : 20 – 200 mcg/mL) [2]
Administration via central line is preferred [4]
Paediatric SC, IM : Undiluted [3,4]
IV Infusion : Dilute to form concentration of 20 mcg/mL, 40 mcg/mL
or 60 mcg/mL [2] Administer via central venous catheter [4,5]
Diluent
D5, NS [1]

Adult IV Slow bolus : Over 20 - 30 sec [2]
Septic shock IV Infusion : 0.4 – 9.1 mcg/kg/min [2]
Severe hypotension, IV Infusion : 0.1 – 10 mcg/kg/min [2]
Cardiogenic shock
Hypotension during IV Infusion : 10 – 35 mcg/min adjusted according to
anesthesia blood pressure goal (Max. 200 mcg/min) [2]
Paediatric Hypotension during SC [3,4]
anesthesia
IM [3,4]
Hypotension, IV Slow bolus : Over 20 - 30 sec [2]
Shock
IV Infusion : 0.1 – 0.5 mcg/kg/min titrated to desired
response (Max. for shock or intraoperative
hypotension: 2 mcg/kg/min) (Max. for
infundibular spasm: 5 mcg/kg/min) [2]
Administer via central venous catheter [4,5]
248 | P a g e
HIGH ALERT
PHENYLEPHRINE MEDICATION
Storage & Stability

Remarks
 Do not withdraw IV Infusion of Phenylephrine abruptly [1]
 Discard unused portion after opening [1]
 Maximum dose of 500 mcg for IM and SC administration for hypotension during spinal
anesthesia in paediatric [4]
 Maximum dose of 5000 mcg for IM and SC administration for hypotension, low cardiac
output in paediatric [4]
References
3. Phelps, Stephanie J. Pediatric Injectable Drugs: The Teddy Bear Book 2013
4. Wolters Kluwer Health. Lexi Comp 2018 Mobile Apps Version 4.1.1
249 | P a g e
PHENYTOIN
o Dilantin Phenytoin Sodium 250 mg/5 mL
Reconstitution
Not Applicable
Further Dilution
IV Infusion : Dilute in 50 – 100 mL of NS (Max. concentration : 10 mg/mL) [1]
Paediatric IV Infusion : Dilution range from 1 – 10 mg/mL [4]
Diluent
NS, [1] LR Solution [4] (See remarks)

Adult Neurosurgery IM [1]
Status IV Slow bolus, IV Infusion : Max. rate of 50 mg/min [1]
epilepticus
Paediatric IV Infusion : Max. rate 1 - 2 mg/kg/min [1]

OR
Max. rate 1 - 3 mg/kg/min (Max. 50 mg/min) [2,3]
Storage & Stability

After opening Suitable for use as long as they remain free of haziness and
precipitate [1,3]
[1,3]
After dilution 1 hour Should not be refrigerated [1]
250 | P a g e
PHENYTOIN
Remarks
 Each injection of parenteral phenytoin should then be followed by a flush of sterile saline
throught the same catheter to avoid local venous irritation due to alkalinity of the solution
[1]
 Diluted Phenytoin should not be refrigerated [1]

 Because of the risk of local toxicity, IV Phenytoin should be administered directly into a
large peripheral or central vein through a large-gauge catheter [1]
 Be aware that if solution is refrigerated or frozen, precipitate may form- but that this will
dissolve when solution stands at room temperature [3]
 Solution may appear slightly faintly yellow, but this does not affect potency [3]
 Although approved for IM use, IM administration is not recommended, due to erratic
absorption and pain on injection [4]
 Do not administer IV into dorsal handveins because “purple gloce syndrome may occur [3]
References
1. Pfizer. Phenytoin Sodium (Dilantin®) 250mg/5ml Product leaflet.
251 | P a g e
PIPERACILLIN+TAZOBACTAM
o AUROTAZ-P Powder For Injection 4.5 g
Reconstitution
Reconstitute powder with 20 mL WFI or NS (Concentration : 225 mg/mL) [1]
Further Dilution
Adult IV Infusion : Dilute in at least 50 mL WFI or 50 - 150 mL NS or D5 [1,4]
Paediatric IV Infusion : Dilute in NS or D5 to concentration of 15 – 90 mg/mL[5]
Diluent
NS, Sterile WFI, D5 [1]

Adult IV Slow bolus : Over 3 – 5 min [1]
IV Intermittent infusion : Over 20 – 30 min [1]
IV Extended infusion : Administer over 4 hours [2]
Paediatric IV Intermittent infusion : Over 20 – 30 min [1]
IV Extended infusion : Administer over 3 - 4 hours [2]
Storage & Stability

After reconstitution Use Immediately [1] 24 hours [1]
After dilution - -
Remarks
 LR Solution is not compatible with piperacillin and tazobactam [1]
References
1. Aurobindo Pharma Ltd. Piperacillin and Tazobactam ( AUROTAZ-P) Product leaflet. Revised Date:
April 2016
5. British National Formulary for Children September 2016-2017
252 | P a g e
PNEUMOCOCCAL VACCINE
o PNEUMOVAX® 23 Pneumococcal Vaccine, Polyvalent 0.5 mL Prefilled syringe
Reconstitution
Not Applicable
Further Dilution
Not Applicable
Diluent
Not Applicable

Adult SC [1]
IM [1]
Paediatric Not recommended for use in children less than 2 years of age [1]
– Child > 2 years :
SC [1]
IM [1]
Storage & Stability

-
After dilution -
Remarks
 Store pre-filled syringe at 2 – 8 °C [1]
 Do not inject intravenously or intradermally [1]
 Pre-filled syringe for single use only [1]
References
1. Merck, Sharp & Dohme. Pneumococcal Vaccine, Polyvalent (PNEUMOVAX® 23) Product
Leaflet.
253 | P a g e
HIGH ALERT
POTASSIUM CHLORIDE MEDICATION

o Injecsol K10 Potassium Chloride 10 % w/v Injection BP
(Each 10 mL contains 13.4 mmol Potassium ions and 13.4 mmol Chloride ions)
Reconstitution
Not required [1]
Further Dilution
Adult IV Infusion : Dilute 1 vial (10ml) with not less than 500 mL of diluent [1]
(Max. concentration: 40 mmol/L)
Paediatric IV Infusion : Dilute to a concentration with not less than 50 times of its volume
with diluent[2] (Max. concentration: 40 mmol/L)
Diluent
NS, 1/2NS [1]

Adult Serum Potassium IV Infusion : Rate of infusion should not exceed
above 2.5 mmol/L 10 mmol/hour. The total dose should not
exceed 200 mmol/24 hours [1]
Serum Potassium IV Infusion : Via CENTRAL LINE, rate of infusion is 20 - 40
less than 2 mmol/L mmol/hr, up to 400 mmol/24 hours [1]
Paediatric IV Infusion : 1 - 2 mmol/kg daily to a maximum of 40 mmol/dose
(Max. infusion rate: 0.2 mmol/kg/hr) [2]
Storage & Stability

After dilution 24 hours -
Remarks
 Must not be injected undiluted
 Too rapid infusion rate may cause extravasation, hyperkalemia, local pain [1]
254 | P a g e
HIGH ALERT
POTASSIUM CHLORIDE MEDICATION
References
1. Ain Medicare Sdn Bhd. Potassium Chloride 10% w/v Injection BP (Injecsol K10) Product Leaflet.
Revised date: 30 June 2011
255 | P a g e
POTASSIUM DIHYDROGEN
HIGH ALERT
PHOSPHATE MEDICATION

o DBL Potassium Dihydrogen Phosphate Concentrated Injection 1.361 g/10 mL
(Each 10 mL contains 10 mmol Potassium ions, 10 mmol Phosphate ions & 20 mmol
Hydrogen ions)
Reconstitution
Not required [1]
Further Dilution
Adult IV Infusion : Dilute in 500 – 1000 mL diluent [1]
OR
Dilute 10 mmol with 100 mL [2] OR 250 mL diluent [4]
Alternatively, For Peripheral Line should not exceed 6.7 mmol potassium
phosphate in 100 mL [3] OR 10 mmol in 250 mL [4]
For CENTRAL LINE should not exceed 26.8 mmol potassium
phosphate in 100 mL [3]
Paediatric IV Infusion : Via Peripheral line, dilute < 2.5 mmol in 50 mL with diluent [1]
Via CENTRAL LINE, dilute < 6 mmol in 50 mL [3]
Diluent
NS, 1/2 NS, D5, D10 [1]

Adult IV Infusion : Over 4 - 6 hours (Max. dose: 1 mmol/kg given over 8 – 12 hours for
serum phosphorus < 1.5 mg/dL) [3]
Paediatric IV Infusion : 0.08 - 0.36 mmol/kg (Max. 10 mmol) over 6 hours at a rate of
0.06 mmol/kg/hr (Max. rate : 0.2 mmol/kg/hr) [1,3]
Storage & Stability

After dilution Use Immediately Use Immediately
256 | P a g e
POTASSIUM DIHYDROGEN
HIGH ALERT
PHOSPHATE MEDICATION
Remarks
 Must be diluted before use [2]
References
1. Hospira Australia Ltd. DBLTM Potassium Dihydrogen Phosphate Concentrated Injection Product
Leaflet. Revised date : 1 October 2014
2. Critical Care Pharmacy Handbook 2013.
4. Dilution Guide for High Alert Medication Pharmaceutical Services Division 2011
257 | P a g e
PRALIDOXIME
o Pampara Injection 500 mg/20 mL
Reconstitution
Not required [1]
Further Dilution
Adult IM : Use undiluted
IV Slow bolus, IV Infusion : Dilute 1 - 2 g in 100 mL diluent [1]
Paediatric IV Slow bolus : Dilute 1 g with 20 mL WFI (50 mg/mL), then further
dilute with NS to final concentration 10 - 20 mg/mL[1]
Diluent
NS, 1/2NS [2]

Adult SC, IM, IV Slow bolus : Over 5 – 10 min (Max : 12 g/24 hours)
IV Infusion : Over 15 – 30min
Paediatric IV Infusion
– Loading dose : 25 – 50 mg/kg over 30 min (Max : 2 g/dose) [1,3]
– Maintenance : repeat dose 1 – 2 hours and at 10 – 12 hours intervals as
needed for symptoms control (Max : 12 g/24 hours) until
nicotinic signs resolves [1] OR
– Maintenance infusion : 10 – 20 mg/kg/hr (Max. infusion rate < 200 mg/min) [3]
Storage & Stability

After dilution - -
Remarks
 Pralidoxime is preferably to give over slow infusion to avoid certain side effects such as
tarchycardia, laryngospasm, muscle rigidity.
258 | P a g e
PRALIDOXIME
References
1. Paediatric Protocol for Malaysian Hospitals 3rd Edition. KKM.
2. Averroes Pharmaceutical Sdn. Bhd. PamparaPralidoxime Chloride 500mg/20ml Injection Product
Leaflet. Revised on April 2006.
259 | P a g e
PROCHLORPERAZINE MESYLATE
o Lartil Injection 12.5 mg/mL
Reconstitution
Not required [1]
Further Dilution
Adult IM, IV Slow bolus : Not required [1]
IV Infusion : 20 mg (base) dilute in no less than 1 L of diluent [1,2]
Paediatric IM : Not required [3]
IV Slow bolus : No information on amount of diluent to be added
Diluent
NS, 1/2NS, D5 [1]

Adult IM [1]
IV Slow bolus : Over 3 – 5 min at a rate < 5 mg/mL/min [1]
IV Infusion : Over 15 – 30 min
Paediatric IM [2]
IV Slow bolus : Over 5 – 10 min (Max. rate : 5 mg/min) [2,3]
Storage & Stability

After dilution Use Immediately [1] -
Remarks
 The preparation contains sulphite that may cause allergic type reactions including
anaphylactic symptoms or less severe asthmatic episodes.
 It should be avoided in patients with renal dysfunction, Parkinson’s disease,
hypothyroidism, pheochromocytoma, myasthenia gravis, prostate hypertrophy[1]
 Patient must remain lying down for 30 minutes to reduce risk of hypotension [2]
260 | P a g e
PROCHLORPERAZINE MESYLATE
References
1. Duopharma (M) Sdn Bhd. Prochlorperazine (Lartil) Product Leaflet. Revised on 27 January 2012.
3. British National Formulary for Children 2016-2017.
261 | P a g e
PROCYCLIDINE
o KemadrinTM 10 mg/2 mL Injection
Reconstitution
Not required [1]
Further Dilution
[1]
Not required
Diluent
Not required [1]

Adult IM : 5 - 10mg/dose, repeated after 20 min
(Max. dose: 20 mg/24 hours) [1]
IV Slow bolus : 5 – 10 mg/dose (Max. 30 mg/24 hours) [2]
Paediatric IM [3]
Storage & Stability

After dilution - -
Remarks
 Not licensed to use in children [3]
References
1. Auden Mckenzie. Procyclidine (KemadrinTM) Product Leaflet. Revised on 13 May 2011.
3. British National Formulary for Children 2016-2017.
262 | P a g e
HIGH ALERT
PROMETHAZINE MEDICATION

o Promethazine HCL-Fresenius 50 mg/2 mL Injection
Reconstitution
Not required [1]
Further Dilution
IM : Undiluted [1]
IV Slow bolus : Can be given undiluted at concentration of 25 mg/mL [1]
IV Infusion : Dilute 50 mg with 10 mL of diluent (Concentration : 2.5 mg/mL) [1]
Diluent
WFI, NS, 1/2NS, D5, D10 [1]

IM, IV Slow bolus : Should not exceed 25 mg/min [1]
Storage & Stability

After dilution Use Immediately [1] -
Remarks
 Should not be used in paediatric patients less than 2 years old due to potential of fatal
respiratory depression [1]
 Should not be given via subcutaneously [1]
References
1. Fresenius Kabi. Promethazine 50 mg/2 mL (Promethazine HCl-Fresenius 50mg/2ml Injection) Product
Leaflet. Revised. June 2013.
263 | P a g e
HIGH ALERT
PROPOFOL MEDICATION

o Fresofol 1% MCT/LCT Emulsion Injection 10 mg/mL (Each vial contains of 200 mg
Propofol)
Reconstitution
Not required [1]
Further Dilution
1 part with 4 parts of diluent (Min. concentration: 2 mg/mL) [1] OR May give undiluted. [1]
Diluent
NS, D5 [1]

Adult General IV Infusion
Anaesthesia – Induction : 1 – 2.5 mg/kg run to approximately 20 – 40 mg
every 10 sec [1]
– Maintenance : 4 – 12 mg/kg/hr [1]
Intensive IV Infusion : 0.3 – 4 mg/kg/hr
Care Sedation
Paediatric General IV Infusion
Anaesthesia – Under 8 years old, Induction : 3 mg/kg [1]
Maintenance : 9 – 15 mg/kg/hr (must not
exceed 60minute use) [1]
– Over 8 years old, Induction : 2.5 mg/kg [1]
Maintenance : 9 – 15 mg/kg/hr [1]
Storage & Stability

Remarks
 The undiluted Propofol 1% via infusion system must not exceed 12hours.
 Duration of administration must not exceed 7days.
 Must not use for sedation for patient less than 16 years old
 Administration of the emulsion must not be delayed after opening of the ampoule
264 | P a g e
HIGH ALERT
PROPOFOL MEDICATION
References
1. Fresenius Kabi. Propofol 10mg/ml (Fresofol 1 % MCT/LCT Emulsion for Injection or Infusion) Product
Leaflet. Revised September 2006.
265 | P a g e
HIGH ALERT
PROPRANOLOL MEDICATION

o Properol Injection BP 1 mg/mL
Reconstitution
Not required [1]
Further Dilution
Not required [1]
Diluent
NS, D5, 1/2NS [1]

Adult IV Slow bolus
– Conscious patient : 1 mg/min, repeat every 2min to a max of 10 mg [1]
– Under anesthesia : 1 mg/min, repeat every 2 min to a max. of 5 mg [1]
Paediatric IV Slow bolus : 0.025 - 0.05 mg/kg under ECG control, repeated
3 - 4 times daily [1]
Storage & Stability

-
After dilution -
Remarks
-
References
1. Samarth Life Sciences Pvt Ltd. Propranolol (Properol Injection BP 1 mg/mL) Product Leaflet. Revised
Sept 2012.
266 | P a g e
PROTAMINE SULPHATE
o ProSulf 10 mg/mL
Reconstitution
Not Required [1]
Further Dilution
Not Required [1]
Diluent
Not Required [1]

IV Slow bolus : Administered over 10 min. Max. 50mg in any one dose [1]
Storage & Stability

After dilution - -
Remarks
 Should not be used if it is discoloured or has gone cloudy [1]
 Too rapid administration may cause severe hypotension and anaphylactoid reactions [1]
 Caution for those at increased risk of allergic reaction to protamine [1]
 Further doses may be needed because protamine cleared faster than heparin [1]
 A dose of 1 mg neutralizes 100 units of heparin given subcutaneously [1]
 Signs of overdose include hypotension, slow heart rate, shortness of breath, unexplained
bleeding, facial flushing, dyspnea nausea, vomiting, generalized weakness [1]
References
1. Wockhardt: Protamine Sulphate 10 mg/mL Solution for Injection Product Leaflet. Revised date: 17
September 2010
267 | P a g e
HANDBOOK OF DRUG RECONSTITUTION & DILUTION TAWAU HOSPITAL 2018 Q
QUADRIVALENT SEASONAL
INFLUENZA VACCINE
o FluQuadriTM Quadrivalent Influenza Vaccine Types A and B Subvirion
Reconstitution
Prefilled syringe. Shake the syringe. Inspect visually for particulate matter and discoloration
prior to administration [1]
Further Dilution
Not Required [1]
Diluent
Not Required [1]
Administration
Adult IM only. Inject into deltoid muscle.
Paediatric IM only.
– Age 6 to 11 months : Inject into anterolateral region of the thigh muscle [1]
– Age 12 to 35 months : Inject into anterolateral region of the thigh muscle or to
deltoid muscle if muscle mass is adequate [1]
– Age ≥ 36 months : Inject into deltoid muscle [1]
Storage & Stability

-
After dilution -
Remarks
 Store FluQadri in fridge at 2 – 8 ⁰C. Do not freeze [1]
 Do not administer intravenously, intradermally or subcutaneously [1]
 Should not combined through reconsitution or mixed with any other vaccine [1]
References
1. Sanofi Pasteur. Quadrivalent Influenza Vaccine Types A and B subvirion (Inactivated) 2017-2018
Formula. FluQuadriTM Product Leaflet;
268 | P a g e
HANDBOOK OF DRUG RECONSTITUTION & DILUTION TAWAU HOSPITAL 2018 R
RABIES VACCINE
o Verorab 0.5 mL
o Contains of inactivated Rabies virus WISTAR Rabies PM/W138 1503-3M strain
Reconstitution
Inject the content of the prefilled syringe into vial of powder. Reconstitute powder with given
solvent. Shake gently to obtain a homogenous vaccine suspension. Reconstituted vaccine
appears as limpid homogenous liquid.[1]
Further Dilution
Not Required
Vaccination Regime
Essen Regime Day 0, Day 3, Day 7, Day 14 & Day 28 : 0.5 mL of Verorab [1]
Zagreb Regime Day 0 : 0.5 mL of Verorab into right deltoid region and 0.5 mL into
(ADULT ONLY) left deltoid region
Day 7 & Day 21 : 0.5 mL of Verorab into deltoid region [1]
Administration
Adult IM only. Inject into deltoid muscle [1]
Paediatric IM only. Inject into anterolateral region of the thigh muscle[1]
Storage & Stability

After reconstitution Use Immediately -
-
After dilution -
Remarks
 Store in a refridgerator at 2 – 8 ⁰C. Do not freeze [1]
 Do not inject via IV route, ensure that the needle does not penetrate a blood vessel before
vaccine injection [1]
 Must not be injected at buttock region.
References
1. Sanofi Pasteur. Rabies Vaccine For Human Use, Prepared on Cell Cultures (Inactivated). Verorab
Product Leaflet; Revised date: 25 August 2015.
269 | P a g e
RANITIDINE
o Ameket Ranitidine 50 mg/2 mL Injection
Reconstitution
Not Required
Further Dilution
Adult IM : Administer undiluted [1]
IV Slow bolus : Dilute to a total of 20 mL [1]
(Max. concentration: 2.5 mg/mL) [1]
IV Intermittent infusion : Dilute to a total of 100 mL [1]
IV Continuous infusion : Dilute to a total of 100 mL [1]
Paediatric Dilute to a concentration ≤ 2.5mg/mL [3]
Diluent
NS, 1/2NS, D5, Sodium lactate compound [1]

Adult General IV Slow bolus : Over 5 min [1]
IV Intermittent infusion : Over 15 - 20 min [1]
IV Continuous infusion : Run at rate of 6.25 mg/hr [1]
For gastric IV Continuous infusion : 1 mg/kg/hr up to 2.5mg/kg/hr
hypersecretory (Max. 220 mg/hr) [2]
conditions
Paediatric IV Slow bolus : 1 mg/kg (Max. 50 mg/dose) at rate of 25 mg/hr [3]
Storage & Stability

Remarks
 Unused admixtures with infusion fluid should be discarded 24 hours after preparations [1]
270 | P a g e
RANITIDINE
References
1. SM Pharmaceuticals SDN. BHD. Ameket (Ranitidine) Injection 2ml product leaflet. Revised date on
the 27/12/2011
2. Lexi-Comp, Inc. (Lexi-Drugs) 2018 Version 4.1.1
271 | P a g e
P
HIGH ALERT
R EMIFENTANIL MEDICATION

o Ultiva Remifentanil hydrochloride 5 mg lyophilized powder
Reconstitution
Reconstitute powder with 1 mL of diluent per 1 mg (Concentration : 1 mg/mL) [1]
Further Dilution
Adult IV Slow bolus,
IV Continuous infusion : Dilute to a final concentration of 20 – 250 mcg/mL;
50 mcg/mL is recommended for adults [1]
Paediatric IV Slow bolus : Required to be further diluted prior to administration.
However, there is no information on specific amount of
diluent to be added.
– Age < 1 year old : Required to be further diluted prior to administration.
However, there is no information on specific amount of
diluent to be added.
– Age > 1 year old : Dilute to a concentration of 20 – 25 mcg/mL [1,2]
Diluent
NS, 1/2NS, D5, NSD5, WFI, LR Solution [1]

Adult IV Slow bolus : Administer over 30 – 60 sec (0.5 - 1 mcg/kg/min)
IV Continuous infusion Local or Regional 0.1 mcg/kg/min; 5 min prior to
Anesthetic Block
procedure [1]
After Local 0.025 - 0.2 mcg/kg/min [1]

Anesthetic
Paediatric IV Slow bolus : Administer over 30 – 60 sec (1 mcg/kg/min)
– Neonates to 2 months : 0.4 - 1.0 mcg/kg/min [1,2]
– Age > 2 months : 0.05 - 1.3 mcg/kg/min [1]
272 | P a g e
P
HIGH ALERT
R EMIFENTANIL MEDICATION
Storage & Stability

After NS, 1/2NS, 24 hours -
reconstitution [1] NSD5,WFI
LR Solution 4 hours
After NS. 1/2NS, 24 hours -
dilution [1] NSD5,WFI
LR Solution 4 hours
Remarks
 ULTIVA should not be administered without dilution[1]
 Clearance rate for neonate is 2 times higher than young adults[1]
 Contraindicated for epidural or intrathecal administration due to presence of glycine in the
formulation [1]
 Skeletal muscle rigidity can be caused by Ultiva and is related to the dose and speed of
administration after single dose of >1mcg/min administered over 30 - 60sec or infusion of
> 0.1 mcg/kg/min [1]
References
1. GlaxoSmithKline. Remifentanil (Ultiva) Product Leaflet. Revised on 25 September 2014.
273 | P a g e
HIGH ALERT
ROCURONIUM MEDICATION

o Rocuronium Kabi 10 mg/mL (5 mL)
Reconstitution
Not required
Further Dilution
Adult IV Bolus : Undiluted [2]
IV Infusion : Further dilute with compatible diluent at concentration up to
5 mg/mL [2]
Paediatric IV Bolus : Undiluted [2]
IV Infusion : Further dilute with compatible diluent to a final concentration of
0.5 – 5 mg/mL [2]
Diluent
NS, D5 [1]

IV Bolus [2]
IV Infusion : Loading dose 0.6mg/kg [1,3]
Maintain neuromuscular block : 0.3 - 0.6 mg/kg/hr [1,3]
Under inhalation anaesthesia : 0.3 - 0.4 mg/kg/hr [1,3]
Storage & Stability

After dilution Use immediately, 24 hours [1] -
Remarks
 Store intact vial in a refrigerator 2 – 8 ⁰C [1]
 For obese & overweight patients (actual body weight ≥ 30% ideal body weight), dose
according to Ideal body weight. [1]
References
1. Fresenius Kabi. Rocuronium bromide (Rocuronium Kabi®) Product leaflet. Revised date : April 2015
274 | P a g e
HIGH ALERT
ROPIVACAINE MEDICATION

o Naropin® 2 mg/mL (0.2%)
o Naropin® 7.5 mg/mL (0.75%)
Reconstitution
Not required
Further Dilution
Not required
Diluent
Not required

Adult Naropin® 2 mg/mL Acute pain Continuous epidural infusion :
management Administer over 12 – 20 mg/hr (up to 28
mg/hr for postoperative pain
management) [1]
Naropin® 7.5 mg/mL Surgical Lumbar epidural, Thoracic epidural and

Anaesthesia Field block [1]
Paediatric Naropin® 2 mg/mL Acute pain Continuous epidural infusion :

management (Infusion up to 72 hours)
(peri- and – Age > 30 days old & up to 6 months :
postoperative) infuse at 0.2 mg/kg/hr [1]
– Age 6 months up to 12 years:
Infuse at 0.4 mg/kg/hr [1]
Storage & Stability

After dilution - -
275 | P a g e
HIGH ALERT
ROPIVACAINE MEDICATION
Remarks
 Naropin® solution for injection contains no preservative and is intended for single-use only.
Remaining solution must be discarded [1]
 To avoid intravascular injection, aspiration should be repeated prior to and during
administration of the main dose; inject slowly or in incremental doses at rate of 25 -30
mg/min. Monitor closely patient’s vital functions and maintain verbal contact [1]
 When an epidural dose is to be injected, a preceding test dose of 3-5mL Lidocaine
(Lignocaine) with Adrenaline (Xylocaine® 1-2% with Adrenaline 1:200,000) is recommended
[1]
References
1. AstraZeneca. Ropivacaine hydrochloride (Naropin®) Product leaflet. Revised date : August 2012
276 | P a g e
HANDBOOK OF DRUG RECONSTITUTION & DILUTION TAWAU HOSPITAL 2018 S
SALBUTAMOL
o Salbutamol Injection “Yung Shin” 0.5 mg/mL
Reconstitution
Not required
Further Dilution
IV Slow Bolus : Dilute 1 amp (0.5 mg/mL) into 10 mL WFI (Final concentration
50 mcg/mL) [3]
IV Infusion General : Dilute 5 mg into 500 mL WFI, NS or D5 [2,3
Preterm labour : Dilute 10 mg (20 ampoule) with 30 mL D5
(Final concentration : 200 mcg/mL) [3]
Paediatric IV Slow Bolus : Further dilute with compatible diluent to concentration
≤ 50 mcg/mL [4]
IV Infusion : Further dilute with compatible diluent to a concentration of
200 mcg/mL [4] . Fluid restricted patients may use undiluted,
administer through central venous catheter (Off-label) [4]
Diluent
NS, D5 [1]

Adult SC [1]
IM [1]
IV Slow Bolus [3]
IV Infusion General : Administer at rate of 3 – 20 mcg/min. [1,2,3]
Faster rates have been used in respiratory
failure [3]
Preterm labour : Administer at rate of 10 – 45 mcg/min. Do not
infuse for more than 48 hours [3]
277 | P a g e
SALBUTAMOL
Paediatric IV Slow Bolus : Administer at rate of ≤ 50 mcg/mL given over 5 min [4]
IV Infusion : Administer at rate of 0.3 - 0.6 mL/kg/hr (5 – 10 mcg/kg/min) for
1 hour, then 0.06 - 0.12 mL/kg/hr (1 – 2 mcg/kg/min) [5]
Storage & Stability

Remarks
 Do not inject undiluted for IV administration. Reduce concentration by at least 50% before
infusing. [2]
References
1. Yung Shin Pharmaceutical. Salbutamol Injection “Yung Shin” 0.5mg/mL Product Leaflet
5. Frank Shann Drug Doses 17th Edition 2017
278 | P a g e
SODIUM BICARBONATE
o Pharmaniaga Sodium Bicarbonate 8.4% w/v Injection (10 mEq/10 mL= 10 mmol/10 mL)
Reconstitution
Not required
Further Dilution
Adult IV Infusion : Dilute 10 mL of 8.4% w/v Sodium Bicarbonate with 60 mL diluent
(isotonic solution 1.2 %) [5]
OR
Dilute 10 mL of 8.4% w/v Sodium Bicarbonate with 54.6 mL
diluent (isotonic solution 1.3 %) [5]
OR
Dilute 10 mL of 8.4% w/v Sodium Bicarbonate with 46 mL diluent
(isotonic solution 1.5 %) [1]
Paediatric IV Slow Bolus
– Neonates and infants : Dilute 1 mEq/mL solution 1:1 with WFI [2]
– Children & Adolescents : Use 1 mEq/mL solution
IV Infusion : Dilute with D5 to a max. concentration of 0.5 mEq/mL[2]
Diluent
NS, D5, WFI [1,3]

Adult Cardiac arrest IV Slow Bolus : Administer 1 mEq/kg initially, then 0.5
mEq/kg may be repeated every 10 min of
continued arrest [1]
Cardiac arrest due IV Slow bolus : 50 mEq (50 mmoL) run over 5 min [3,4]
to hyperkalemia
Metabolic IV Infusion : Administer 2 – 5 mEq/kg run over 4 - 8

acidosis, Urinary hours [1]
alkaliser
279 | P a g e
SODIUM BICARBONATE
– Neonates & Infants : Administer slowly (Max. rate : 10 mEq/min) [2]
– Children & Adolescents : Administer 1 mEq/mL solution slowly [2]
IV Infusion : Administer over 2 – 8 hours (Max. rate : 1 mEq/kg/hr)
[2]
Storage & Stability

After dilution - -
Remarks
 Sodium Bicarbonate 8.4% w/v Injection is equivalent to 1mEq/mL (1mmol/mL) [1]
[3]
 Sodium bicarbonate 84mg is equal to 1mEq each of both sodium and bicarbonate
References
1. Pharmaniaga LifeScience Sdn Bhd. Pharmaniaga Sodium Bicarbonate 8.4% w/v Injection Product
leaflet. Revised date : 22 June 2015
4. Critical Care Pharmacy Handbook 2013
280 | P a g e
SODIUM GLYCEROPHOSPHATE
o Glycophos® 20 mmoL/20 mL
(1 mL of Glycophos® corresponds to 1 mmoL of phosphate and 2 mmoL of sodium) [1]
Reconstitution
Not required
Further Dilution
IV Infusion : Dilute 1 amp with 100 mL of compatible diluent [2]
Diluent
NS, D5 [1]

IV Infusion : Administer over 8 hours [1]
Storage & Stability

Remarks
 Glycophos® must not be given undiluted [1]
References
1. Fresenius Kabi New Zealand. Fresenius Kabi (Glycophos®) Product leaflet. Revised date : 22 March
2017
2. Fresenius Kabi (Glycophos®) Admixing Guide & Compatibility Question & Answer dated 2/8/2017
281 | P a g e
SODIUM VALPROATE
o Epilim® Intravenous 400 mg
Reconstitution
Reconstitute with the solvent provided (4 mL), concentration: 95 mg/mL [1]
Further Dilution
IV Infusion : Dilute reconstituted solution into 50 mL compatible diluent [2]
Diluent
NS, D5, NSD5 [1]

Adult IV Slow Bolus : Administer over 3 – 5 min [1]
IV Infusion : Administer over 1 hour at rate ≤ 20 mg/min [2,3]
Paediatric Rapid IV Loading Dose : Administer at rate of 1.5 – 3 mg/kg/min [2]
IV Infusion : Administer over 1 hour (Max rate : 20 mg/min) [2]
Storage & Stability

After dilution - 24 hours [1]
Remarks
 Should not be administered via the same IV line as other IV additives [1]
References
1. Sanofi-Aventis Sodium Valproate (Epilim®) Intravenous Product leaflet. Revised date : May 2014
282 | P a g e
SOMATROPIN
o Saizen® 8 mg click.easy®
Reconstitution
Reconstitute with the provided bacteriostatic solvent cartridge (Concentration: 5.83 mg/mL) [1]
Refer page 284 - 286
Further Dilution
Not required
Diluent
0.3% w/v Metacresol solution in WFI (bacteriostatic solvent) [1]

[1]
SC
Storage & Stability

After reconstitution - 28 days
After dilution - -
Remarks
 Saizen® is recommended to be administer at bedtime [1]
 Use of the devices by children should always be made under adult’s supervision [1]
References
1. Merck Serono S.p.A. Somatropin (Saizen® 8 mg click.easy®) Product leaflet. Revised date: April
2013
283 | P a g e
SOMATROPIN
Reconstitution
1. Stand the click.easy® on a flat, non-slippery

surface, with the Saizen® vial on the bottom.
2. While holding the click.easy® in a standing

position, push down on the end cap using the
flat of your hand to move the main housing
over the vial container.
3. Turn the end cap clockwise until the green

square can be seen in the rectangular opening.
Note: DO NOT overturn the end cap. If the end

is turned too far, the device could jam during
the next step.
4. Slowly push down on the end cap over 10

seconds to transfer the diluent into the
cartridge. Keep pushing until it will go no
further and the green square appears at the
upper end of the rectangular opening.
Note: If you are unable to transfer the diluent

into the powder, do not apply force. After
verifying that you have performed the previous
steps correctly and the components are
properly aligned, let the entire device sit in the
refrigerator, and try again at a later time. A
lower temperature may resolve this problem.
284 | P a g e
5. Swirl gently and wait for any foam to subside. Do

not shake click.easy®.
Note: You may need to let the solution stand for a

few minutes until the Saizen® powder dissolves.
6. Turn your click.easy® upside down so the

Saizen® vial is now on top.
7. Slowly pull down on the end cap until all the

solution is transferred into the diluent cartridge.
8. Look for air bubbles at the top of the cartridge.

Remove air bubbles by slowly pushing the end cap
back up until the air bubble is gone.
9. Once all the solution is transferred and there are

no air bubbles in the cartridge, stop moving the
end cap.
285 | P a g e
10. Squeeze the two cartridge grips and unscrew

the end cap until it completely detaches and falls
into your hand.
Note: The cap must be unscrewed completely

without pulling down, until only the end cap comes
off. Do not pull end cap off.
11. Lift out the cartridge.
12. Peel off the outer label from the cartridge.
13. Write the mixing date in the white box on the

cartridge.
14. Inspect your Saizen®. Liquid should be clear and

free of particles. If the liquid is cloudy or contains
particles, call patient services.
15. Now you are ready to insert your cartridge into

your injection device. Mixed cartridge should be
used within 28 days (2 - 8oC) after mixing.
286 | P a g e
HIGH ALERT
STREPTOKINASE MEDICATION

o Biofactor Streptokinase 1 500 000 IU (equivalent to 1.5 MIU)
Reconstitution
Reconstitute with 4 – 5 mL NS or WFI [1] The solution should be swirled gently to facilitate
reconstitution, but care should be taken to avoid foaming [1,2] Slight flocculation (thin
transparent fibers) may occur but does not interfere with safe use of the solution [2]
Reconstituted solution with NS can be filtered using 0.8-micron filter [2]
Further Dilution
Adult IV Infusion : Dilute reconstituted solution into 50 – 200 mL of compatible diluent
[1]
Diluent
NS, D5, Ringer-lactate solution [1]

Adult Myocardial infarction IV Infusion : 1.5 MIU Streptokinase infused over 1 hour
[1,3]
Pulmonary embolism IV Infusion : 250,000 IU infused over 30 min then

100,000 IU/hr (up to 12 – 72 hour) [3]
Storage & Stability

Remarks
 Freeze dried powder should be stored below 25⁰C and should not be frozen [1]
 Do not use drop-counting infusion methods, since drug may alter drop size [2]
287 | P a g e
HIGH ALERT
STREPTOKINASE MEDICATION
References
1. Biofactor GmbH. Biofactor Streptokinase 1 500 000 Product leaflet. Revised date : July 2009
3. Blue Book Bil.3 2017
288 | P a g e
STREPTOMYCIN
o Streptin Injection 1 g
Reconstitution
Reconstitute with 4.2 - 4.5 mL of compatible diluent (concentration: 200 mg/mL) or 3.2 - 3.5 mL
(Concentration: 250 mg/mL) [1]
Further Dilution
IV Infusion : Further dilute dose to concentration of 5 – 10 mg/mL in compatible diluent [2]
Diluent
For IM : NS or WFI [1]
For IV : NS or D5 [2]

Adult IM : Inject deep IM into large muscle mass; mid lateral thigh muscle or
upper buttocks [1]
IV Infusion : Administer over 1 hour [2]
Paediatric IM : Inject deep IM into large muscle mass; mid lateral thigh muscle [1]
IV Infusion : Administer over 1hr [2]
Storage & Stability

After dilution - -
Remarks
-
References
1. SM Pharmaceuticals SDN BHD. Streptomycin Sulfate (Streptin Injection) Product leaflet. Revised
date : 14 October 2010
289 | P a g e
SUGAMMADEX
o Bridion® 200 mg/2 mL
Reconstitution
Not required
Further Dilution
Adult Not required
Diluent
Not required
Adult IV Bolus : Administer over 10 sec [1]
Storage & Stability

After dilution - -
Remarks
 Flush the IV line with NS if administered in same IV line as other products [1,2]
 The product should be used within 5 days if not protected from light [1,2]
 Efficacy of Sugammadex in paediatric patient is not established [1]
References
1. Merck Sharp & Dohme Corp.(USA). Sugammadex Sodium (Bridion®) Product leaflet. Revised date :
June 2017
290 | P a g e
HIGH ALERT
SUXAMETHONIUM MEDICATION

o Suxamethonium Chloride Fresenius 100 mg/2 mL
Reconstitution
Not required
Further Dilution
Adult IV Bolus : Undiluted [2,4]
IV Infusion : Dilute with 500 – 1000 mL of compatible diluent
(Final concentration : 1 - 2 mg/mL) [3,4]
Paediatric IM : Undiluted
IV Bolus : Undiluted or dilute with compatible diluent [5]
IV Infusion : No information on amount of diluent
Diluent
NS, D5 [1,3,4,5]

Adult IV Bolus : Administer by rapid IV injection (10 - 30sec) [2,4]
IV Infusion : Administer at rate of 2.5 – 4 mg/min. Max total dose: 500 mg/hr [1]
Paediatric IM : Administer deep IM only when IV is not accessible (usually for
infants and older children) [1,2] Max total dose: 150 mg [1,4]
IV Bolus : Administer undiluted by rapid IV injection (10 – 30 sec) [2,4]
IV Infusion : Administer with a proportionately lower initial infusion rate based
on body weight [1]
Storage & Stability

291 | P a g e
HIGH ALERT
SUXAMETHONIUM MEDICATION
Remarks
 Store intact vial in refridgerator 2 – 8 ⁰C. Protect from light [1]
 The infusion rate should be adjusted according to the response of individual patients [1]
 The dosage is as for adults when children is given via IV infusion [1]
References
1. Fresenius-Kabi. Suxamethonium Chloride Fresenius Product leaflet. Revised date : June 2016
4. Medscape WebMD, LLC. 2017 Version 4.6.3
292 | P a g e
SYNTHETIC ACTH
(TETRACOSACTRIN ACETATE)
o Synacthen 250 mcg/mL
Reconstitution
Not required
Further Dilution
Not required
Diluent
Not required

IM [1]
IV Slow bolus [1]
Storage & Stability

After opening Use immediately [1] -
After dilution - -
Remarks
 Store at 20C – 80C. Do not freeze. Protect from light [1]
References
1. Sigma-Tau Industrie Farmaceutiche Riunite S.p.A. Tetracosactide acetate ( Synacthen ® ) Product
leaflet. Revised date: April 2015
293 | P a g e
HANDBOOK OF DRUG RECONSTITUTION & DILUTION TAWAU HOSPITAL 2018 T
HIGH ALERT
TERLIPRESSIN MEDICATION

o Glypressin 1 mg
Reconstitution
Reconstitute with the solvent provided (5 mL) [1]
Further Dilution
Not required
Diluent
Not required

IV Slow bolus [1]
Storage & Stability

After dilution - -
Remarks
 Store in the original package at 150C – 250C. [1]
References
9. Ferring International Center S.A. Terlipressin acetate ( Glypressin®) Product leaflet. Revised date:
September 2012.
294 | P a g e
TESTOSTERONE ENANTATE
o Jenasteron 250 mg/mL
Reconstitution
Not required
Further Dilution
Not required
Diluent
Not required

IM : Inject slowly and deeply into the gluteal muscle [2]
Storage & Stability

After dilution - -
Remarks
 Store below 250C. Protect from light. [1]
References
1. Jesalis Pharma GmbH. Testosterone enantate ( Jenasteron®) Product leaflet. Revised date:
November 2015
295 | P a g e
TETANUS IMMUNOGLOBULIN
HUMAN
o Igantet 250 IU/mL
Reconstitution
Not required
Further Dilution
Not required
Diluent
Not required

SC [1]
IM : Inject deeply and slowly in deltoid muscle of the upper arm or lateral thigh muscle [1,2]
Storage & Stability

After dilution - -
Remarks
 Do not inject IM into the gluteal area due to the risk of sciatic nerve damage [2]
 In cases where IM injections are contraindicated (e.g. clotting disorders), the drug can be
administered via SC route [1]
 If large total doses (≥ 5 mL) are required, administer in divided doses at different sites. [1]
 Tetanus immunoglobulin and vaccine should be administered using different syringes,
needles and injection sites [1]
 The product should be warmed to room temperature or body temperature before use. [1]
 Store between 20C – 80C [1]
296 | P a g e
TETANUS IMMUNOGLOBULIN
HUMAN
References
1. Instituto Grifols, S. A. Human antitetanus immunoglobulin 250 IU ( Igantet®) Product leaflet. Revided
date: May 2005
297 | P a g e
TETANUS TOXOID
o TT Vaccine 0.5 mL
Reconstitution
Not required
Further Dilution
Not required
Diluent
Not required

IM : (See remarks) Preferred injection site is in the mid-lateral aspect of the thigh or the
deltoid [1,2]
Storage & Stability
After dilution - -
Remarks
 The vaccine vial should be shaken well to homogenize the suspension before use. Discard
vial if vaccine cannot be resuspended. [1,2]
 Store at 20C – 80C. Do not freeze. Protect from light. [1]
 Multi-dose vials from which one or more doses of vaccine have been withdrawn during an
immunization session may be used in subsequent session for up to a maximum of 4 weeks.
 Do not inject into the gluteal area or areas containing a major nerve trunk. [2]
 Tetanus immunoglobulin and vaccine should be administered using different syringes,
needles and injection sites. [2]
 Based on the Vaccine Vial Monitor (VVM), the vaccine can be used if the colour of central
square is lighter than that of the ring: [1]
SAFE for use Do NOT use
298 | P a g e
TETANUS TOXOID
References
1. Propharm. Adsorbed tetanus vaccine ( TT Vaccine®) Product insert. Revised date: 1 August 2016
299 | P a g e
THIAMINE
o Benerva® 100 mg/mL
Reconstitution
Not required
Further Dilution
Not required
Diluent
Not required

IM [1]
Storage & Stability

After dilution - -
Remarks
 It should not be mixed in the same syringe with penicillin, phenylbutazone or
propyphenazone because precipitation may occur. [1]
 In Wernicke-Korsakoff syndrome, thiamine should be administered prior to parenteral
glucose solutions to prevent acute Wernicke encephalopathy. [2]
References
1. Teofarma. Thiamine ( Benerva®) Product leaflet. Revised date: Not available
300 | P a g e
HIGH ALERT
THIOPENTAL MEDICATION

o Pentotex 0.5 g Injection
Reconstitution
IV Slow bolus : Reconstitute with WFI, NS or D5 [1]
IV Infusion : Reconstitute with NS or D5 [1,2]
Further Dilution
IV Slow bolus : Dilute to a concentration of 50 mg/mL (5%) or 25 mg/mL (2.5%) of solution [1]
IV Infusion : Dilute to a concentration of 2 mg/mL (0.2%) or 4 mg/mL (0.4%) of solution [1]
Diluent
IV Slow bolus : WFI, NS or D5 [1]
IV Infusion : NS or D5 [1,2]

IV Slow bolus : Over 10 – 15 sec [1]
IV Infusion : Adjust accordingly [2]
Storage & Stability

After reconstitution Use promptly [1] 24 hours [1]
After dilution - -
Remarks
 Do not use WFI as diluent in IV infusion as hemolysis will occur. [2]
 Solutions of suxamethonium, tubocurarine or other drugs which have an acidic pH should
not be mixed with thiopental solutions. [1]
References
1. Duopharma. Thiopental sodium (Pentotex®) Product leaflet. Revised date: 11 April 2008
2. McGraw Hill’s IV Drug Handbook 2010
301 | P a g e
TRAMADOL
o Acugesic 50 mg/mL
Reconstitution
Not required.
Further Dilution
Not required [1]
Diluent
Not required [1]

Adult IM [1,2]
IV Slow bolus : Over 2 - 3 min [2]
Storage & Stability

After dilution - -
Remarks
-
References
1. Duopharma. Tramadol (Acugesic®) Product leaflet. Revised date : 07 January 2013
2. British National Fomrulary 73rd Edition page 435
302 | P a g e
HIGH ALERT
TRANEXAMIC ACID MEDICATION

o Tren 500 mg/ 5 mL
Reconstitution
Not required
Further Dilution
Undiluted
Diluent
Not required

IV Slow bolus : Over 5 - 10 min [1] (Max. rate: 100 mg/min) [2]
Storage & Stability

Conditions Room Temperature (< 25 ⁰C) Fridge ( 2 – 8 ⁰C)
After dilution - -
Remarks
 Do not inject more rapidly than 1 ml/min to avoid hypotension [2]
References
1. Y.S.P Ind.Co.Ltd. Tranexamic Acid ( Tren®) Product leaflet.
303 | P a g e
TRIAMCINOLONE ACETONIDE
o Sivkort 40 mg/mL
Reconstitution
Not required. Shake well before use to ensure suspension is uniform. Inspect visually to ensure
no clumping; administer immediately after withdrawal. [1,2,3]
Further Dilution
Not required
Diluent
Not required [1]

Adult IM : Deeply into gluteal muscle [1]
Intra-articular, Intrabursal : Into tendon, sheaths or ganglia. Administer as
prescribed dose. [1]
Intradermal : Administer as prescribed dose.
Storage & Stability

After dilution - -
Remarks
 Strictly aseptic technique is MANDATORY. [1]
 Do not administer as IV or via epidural or intrathecal route. [2,3]
 Not for newborn, premature infants, and children under 6 years old as this preparation
contains benzyl alcohol. [1]
 Protect from light. Do not freeze. [1]
304 | P a g e
TRIAMCINOLONE ACETONIDE
References
1. Siu Guan Chem. Ind. Co. Ltd. Triamcinolone ( Sivkort ®) Product leaflet. Revised date : July 2008
305 | P a g e
TRIMETHOPRIM +
SULPHAMETHOXAZOLE
o DBLTM Sulfamethoxazole 400 mg & Trimethoprim 80 mg concentrate injection /5 mL
Reconstitution
Not required [1]
Further Dilution
Adult IV Infusion : Dilute 1 mL with 25 - 30 mL diluent [1]
Paediatric IV Infusion : Dilute 1 mL with 25 - 30 mL diluent [1]
Diluent
[1]
NS, D5, D10, 1/2NS, LR

Adult IV Infusion : Over 60 - 90 min [1,2,3] (see remarks)
Paediatric IV Infusion : Over 60 - 90 min [1,2,3] (see remarks)
Storage & Stability

Remarks
 Protect from light. [1]
 Do not give IM. [2,3]
 When admixed with Hartmann’s injection, DBLTM Hospira Sulfamethoxazole / Trimethoprim
injection BP found to be stable for 8 hours at a 1 in 25 dilution and for 24 hours at a 1 in 35
dilution. [1]
 Recommended that infusion of Sulfamethoxazole/Trimethoprim be commenced within half
an hour of preparation and the duration of infusion should not exceed 1.5 hours. [1]
306 | P a g e
TRIMETHOPRIM +
SULPHAMETHOXAZOLE
References
1. Hameln Pharmaceuticals GmbH. Sulfamethoxazole/Trimethoprim. Product leaflet. Revised date:
01 December 2012
307 | P a g e
TUBERCULIN PPD
o 2 TU Tuberculin PPD / 0.1 mL, pack size 2 mL
Reconstitution
Not required.
Further Dilution
Undiluted
Diluent
Not required

Intradermal (intracutaneous) : In the middle third of forearm (palm up) > 2 inches from
elbow, wrist, or other injection site. If neither arm can be
used, may administer to back of shoulder [1,2,3]
Storage & Stability

Conditions Room Temperature (<25 ⁰C) Fridge ( 2 – 8 ⁰C) [1]
After dilution - -
Remarks
 Store Teberculin PPD at 2 – 8 ⁰C. Do not freeze [1]
 Do not administer IV, IM or Subcutaneous. [1,2,3]
 The vial should be used within 30 days once the vial is in use. [1]
 Protect from light and heat. Do not Freeze. Exposure to light and freezing in a refrigerator
will result in loss of potencty of Tuberculin. [1]
References
1. ArkrayHealthcare. Tuberculin. Product leaflet. Revised date : June 2017, version 1.0
308 | P a g e
HANDBOOK OF DRUG RECONSTITUTION & DILUTION TAWAU HOSPITAL 2018 U
HIGH ALERT
UROKINASE MEDICATION

o Urokinase – GCC inj 6000 IU
Reconstitution
Reconstitute powder with small amount of WFI [1] or NS. [1, 3]
Further Dilution
Adult Deep Vein Thrombosis Dilute loading dose with 15 mL diluent [1]
Pulmonary embolism Dilute loading dose with 15 mL diluent [1]
Or
Undiluted [1]
Peripheral vascular Dilute 500,000 IU in 200 mL diluent (Concentration:
occlusion 2500 IU/mL) [1]
Hyphaema Dilute 5000 IU with 2 ml diluent. [1]
Clotted arterio-venous Affected limb of shunt: Dilute 5000 – 25000 IU with 2-3
shunts ml diluents. [1]
Venous side: dilute 5000 IU with 200 ml diluents. [1]

Paediatric Thrombosis IV Slow bolus : dilute loading dose with 15 ml diluent [1]
Occluded arteriovenous Undiluted [3]
shunts, catheters, and
indwelling central lines
Empyema Thoracis Intrapleural
For weight < 10 kg : Dilute 10,000 IU in 40 mL diluent [4]
For weight > 10 kg : Dilute 40,000 IU in 40 mL diluent [4]
Diluent
NS [1]
309 | P a g e
HIGH ALERT

Adult Deep Vein Thrombosis Initial loading dose IV Slow bolus over 10 min followed
by IV Infusion over 12 - 24 hours [1]
Pulmonary embolism Initial loading IV Slow bolus over 10 min followed by
IV Infusion over 12 hours [1]
OR
50 mL bolus into pulmonary artery, repeated up to 3
doses, at 24 hour intervals. [1]
Peripheral vascular Infused into the clots at the dose rate of 4000 IU/min
occlusion (96 mL/hr) for 2 hours followed by repeated
angiography. [1]
This may repeated up to 4 times if antegrade flow has
not occurred
After lysing: infused at a dose rate of 1000 IU/min
(0.4 mL) until it is completely lysed.
Hyphaema The solution is injected and withdrawn repeatedly with
minimal pressure, the clots disintegration begins within
5 mins [1]
If residual clot remains: a small quantity of solution (e.g.

0.3 mL) may be left in the anterior chamber to facilitate
further dissolution the clots over next 24 - 48 hours. [1]
Clotted arterio-venous Instilled into the affected limb of the shunt then
shunts clamped off for 2 – 4 hours. This may be repeated if
necessary. [1]
Venous side: run over 30 mins (less satisfactory than

the use of more concentrated solution). [1]
Paediatric Thrombosis – Neonates : Administer as IV Slow bolus over 20 min
then followed by IV infusion over
6 - 12 hours [2]
Occluded arteriovenous Inject directly into occluded catheter or central line,
shunts, catheters, and dilute dose in NS to fill catheter dead space only. Leave
indwelling central lines for 20-60 mins then aspirate the lysate and flush with
NS. [3]
310 | P a g e
HIGH ALERT

Paediatric Empyema Thoracis Intrapleural :
Instillation of the fibrinolytic agent. Clamp of the chest
drainage for 4 hours. During the period of clamping,
ambulate the patient or reposition the patient
regularly. After 4 hours, release the clamp and drain the
fluid. [4]
Storage & Stability

After dilution - -
Remarks
 If bleeding occurs following systemic use, the infusion should be stopped immediately. [1]
 Contraindicated in pregnancy and the immediate post-partum period. [1]
 In patient with severe hypotension (with systolic BP> 200mmHg and/or diastolic BP>120
mmHg), administration of urokinase inj carries the risk of cerebral haemorrhage. [1]
References
1. GreenCrossCooperation. Urokinase (Urokinase – GCC inj). Product leaflet.
2. Paediatric protocols for Malaysian Hospitals, 3rd ed., KKM. Pg. 85-89.
3. BNF Children 2017-2018, pg .86
4. A Consensus Guideline From The Paediatric Empyema Working Group. Approach and Management
of Empyema Thoracis in Children. Kementerian Kesihatan Malaysia.2013
311 | P a g e
HANDBOOK OF DRUG RECONSTITUTION & DILUTION TAWAU HOSPITAL 2018 V
VANCOMYCIN
o Vancotex® (Vancomycin Hydrochloride) 500 mg
Reconstitution
Reconstitute powder with 10ml WFI or NS. Concentration: 50 mg/mL [1]
Further Dilution
Adult IV Infusion : Dilute 500 mg with 100 mL diluent [1]
Dilute 1000 mg with 200 mL diluent (Concentration : 5 mg/mL) [1,2,3]
Paediatric IV Infusion : Dilute 500 mg with 100 mL diluent [1]
Dilute 1000 mg with 200 mL diluent (Concentration : 5 mg/mL) [1,2,3]
Diluent
NS, D5 [1]

Adult IV Infusion : Dose < 1 g , infuse over 60 min [1]
Dose ≥ 1 g , infuse over 90 - 120 min (see remarks)
Paediatric IV Infusion : Dose < 1 g, infuse over 60 min [1]
Dose ≥ 1 g, infuse over 90 - 120 min (see remarks)
Storage & Stability

After reconstitution Use immediately [1] 14 days [1]
After dilution - 14 days [1]
Remarks
 Recommended infusion period of ≥ 30 min for every 500 mg administered. [2,3]
 Rapid IV administration (eg. over less than 60 min) may result in hypotension, flushing,
erythema, urticaria, pruritus, and rarely cardiac arrest. [2]
 A concentration up to 10 mg/mL may be used in adult in need of fluid restriction but
increased risk of infusion-related effects. Not for IM administration. [2,3]
 Protect from light. Do not freeze. [1]
312 | P a g e
VANCOMYCIN
References
1. Fisiopharma S.r.L. Vancomycin ( Vancotex ®) Product leaflet. Revised date: 22 March 2017
313 | P a g e
HIGH ALERT
VERAPAMIL MEDICATION

o Verpamil 5 mg/2 mL
Reconstitution
Not required
Further Dilution
Adult IV Slow bolus : Undiluted
IV Infusion : Dilute 5 – 10 mg with diluent [1]
[1]
Paediatric IV Slow bolus : Undiluted
Diluent
NS, D5 [1]

Adult IV Slow bolus : Administer undiluted over 1 - 2 min [1,2,3]
In Elderly patients, administer over 2 - 3 min [1,2,3]
IV Infusion : After dilution, administer at rate 5 - 10 mg/hr [1]

– Infants : Over ≥ 5 min [1]
Storage & Stability

Remarks
 Total daily intraveous dose should not exceed 100 mg. [1]
 During administration, continuous electrocardiographic and blood pressure monitoring are
required. [1]
314 | P a g e
HIGH ALERT
VERAPAMIL MEDICATION
References
1. OrionCorporation. Verapamil Hydrochloride (Verpamil®). Product leaflet. Revised date : July 2009
4. Mc Graw-Hill’s I.V. Drug Handbook. (2009)
315 | P a g e
VITAMIN K1
HIGH ALERT
(PHYTOMENADIONE) MEDICATION

o Kisan 1 mg/mL (Benzyl Alcohol Free)
o Kisan 10 mg/mL (contains Benzyl Alcohol 9 mg/ml). For ADULT only.
Reconstitution
Not required
Further Dilution
Adult Undiluted [1,2]
Paediatric Undiluted [1,2]
Diluent
Not Applicable

Adult PO [1,2]
IM, IV Slow bolus : Administer ≤ 1 mg/min [1,2,3,4]
Paediatric SC, IM, IV Slow bolus : Administer ≤ 1 mg/min [1,2,3,4] (See remarks)
Storage & Stability

-
After dilution -
Remarks
 Use only 1 mg/mL ampoules in children < 2 years old. [1]
 IM administration for prophylaxis and treatment of hemorrhagic disease of newborn. [1]
 INTRAVENOUS route should be restricted to emergency cases to reverse anticoagulation
and situations where other routes are not feasible. [1,2,3,4]
 Protect from light. [1,2]
 Do not freeze. [1]
316 | P a g e
VITAMIN K1
HIGH ALERT
(PHYTOMENADIONE) MEDICATION
References
1. Duopharma. Phytomenadione ( Kisan ®) 1 mg/mL. Product leaflet. Revised date : 02 February 2013
2. Duopharma. Phytomenadione ( Kisan ®) 10 mg/mL. Product leaflet. Revised date : 05 September
2008
317 | P a g e
HANDBOOK OF DRUG RECONSTITUTION & DILUTION TAWAU HOSPITAL 2018 Z
ZIDOVUDINE
o Retrovir 200 mg/20 mL solution
Reconstitution
Not required
Further Dilution
Adult IV Infusion : Dilute 200 mg with 50 - 100 mL diluent [1]
(Concentration : 2 mg/mL or 4 mg/mL) [1]
Paediatric IV Infusion : Dilute 200 mg with 50 - 100 mL diluent [1]
(Concentration : 2 mg/mL or 4 mg/mL) [1]
Diluent
D5 [1]

Adult IV Infusion General : Over 1 hour [1,3]
Pregnant woman
(during labor and delivery) : Infuse loading dose over 1 hour,
followed by continuous infusion
(1 mg/kg/hour) delivery [2,3]
Paediatric IV Infusion : Over 1 hour [1,3]
Storage & Stability

Remarks
 Must dilute prior to administration. [1]
 Avoid rapid infusion or bolus injection. Do not administer IM. [1,2,3]
 Use immediately prior to administration and any unused portion of the vial should be
discarded. [1]
318 | P a g e
ZIDOVUDINE
References
1. GlaxoWellcome. Zidovudine ( Retrovir ®) Product leaflet. Revised date : 09 July 2014
319 | P a g e
ZOLEDRONIC ACID
o Zometa ® 4 mg/5 mL concentrate for solution for infusion
o Zometa ® 4 mg/100 mL solution for infusion
Reconstitution
Not required
Further Dilution
Adult IV Infusion : Dilute Zometa 4 mg/5 mL concentrate with 100 mL diluent [1]
Diluent
NS, D5 [1]
Adult IV Infusion : Administer ≥ 15 min [1,2,3]
Storage & Stability

-
After dilution 24 hours [1]
Remarks
 Zometa ® 4 mg/100 mL solution for infusion should not be mixed with other infusion
solutions and should be administered as a single intravenous solution in a separate infusion
line. [1]
 Patient must hydrate well prior to and following administration of Zometa ®. [1]
 If refrigerated, the solution must be allowed to reach room temperature before administer.
[1,2,3]
References
1. Norvatis. Zoledronic acid ( Zometa ®) Product leaflet. Revised date : August 2015
320 | P a g e
ZUCLOPENTHIXOL DECANOATE
o Clopixol® Depot 200 mg/mL, as decanoate (Zuclopenthixol 144.4 mg/mL)
Reconstitution
Not required
Further Dilution
Diluent
Not required

Adult IM : Administer Into upper outer quadrant of gluteal region [1,2,3]
Storage & Stability

After dilution - -
Remarks
 Injection volumes > 2 mL should be distributed between 2 injection sites. [1,2,3]
 Not recommended in children use. [1]
References
1. H.Lundbeck Demark. Zuclopenthixol ( Clopixol ®) Product leaflet. Revised date : July 2015
321 | P a g e
APPENDICES
 ABBREVIATIONS LIST FOR APPENDICES

 DEXTROSE PREPARATION CALCULATION
- Example A
- Example B
 DEXTROSE PREPARATION TABLE
 SALINE & DEXTROSE PREPARATION CALCULATION
- Example C
- Example D
- Example E
 SALINE & DEXTROSE PREPARATION TABLE
322 | P a g e
ABBREVIATIONS LIST FOR APPENDICES

1/2NS Sodium chloride 0.45% 1/5NS Sodium chloride 0.18 %
1/2NSD5% Sodium chloride 0.45% + Dextrose 5% 1/5NSD5% Sodium chloride 0.18 % + Dextrose 5 %
1/2NSD7.5% Sodium chloride 0.45% + Dextrose 7.5% 1/5NSD7.5% Sodium chloride 0.18 % + Dextrose 7.5 %
1/2NSD12.5% Sodium chloride 0.45% + Dextrose 12.5% 1/5NSD12.5 Sodium chloride 0.18 % + Dextrose 12.5 %
1/2NSD17.5 Sodium chloride 0.45% + Dextrose 17.5% 1/5NSD17.5% Sodium chloride 0.18 % + Dextrose 17.5 %
1/4NS Sodium chloride 0.225% 3/4NS Sodium chloride 0.675 %

1/4NSD7.5% Sodium chloride 0.225% + Dextrose 7.5% 3/4NSD7.5% Sodium chloride 0.675 % + Dextrose 7.5 %
1/4NSD12.5 Sodium chloride 0.225% + Dextrose 12.5% 3/4NSD12.5% Sodium chloride 0.675 % + Dextrose 12.5 %
1/4NSD17.5% Sodium chloride 0.225% + Dextrose 17.5% 3/4NSD17.5 Sodium chloride 0.675 % + Dextrose 17.5 %
323 | P a g e
ABBREVIATIONS LIST FOR APPENDICES

1/5NS Sodium chloride 0.18 % D5% Dextrose 5 %
1/5NSD5% Sodium chloride 0.18 % + Dextrose 5 % D7.5% Dextrose 7.5 %
1/5NSD7.5% Sodium chloride 0.18 % + Dextrose 7.5 % D10% Dextrose 10 %
1/5NSD12.5 Sodium chloride 0.18 % + Dextrose 12.5 % D15% Dextrose 15 %
1/5NSD17.5% Sodium chloride 0.18 % + Dextrose 17.5 % D20% Dextrose 20 %
1/5NSD20% Sodium chloride 0.18 % + Dextrose 20 % D25% Dextrose 25 %
1/5NSD25% Sodium chloride 0.18 % + Dextrose 25 % D50% Dextrose 50 %
3/4NS Sodium chloride 0.675 % NaCl 3% Sodium chloride 3 %

3/4NSD5% Sodium chloride 0.675 % + Dextrose 5 % NSD5% Sodium chloride 0.9 % + Dextrose 5%
3/4NSD7.5% Sodium chloride 0.675 % + Dextrose 7.5 % NSD7.5% Sodium chloride 0.9 % + Dextrose 7.5%
3/4NSD10% Sodium chloride 0.675 % + Dextrose 10 % NSD10% Sodium chloride 0.9 % + Dextrose 10 %
3/4NSD12.5% Sodium chloride 0.675 % + Dextrose 12.5 % NSD12.5 Sodium chloride 0.9 % + Dextrose 12.5 %
3/4NSD17.5 Sodium chloride 0.675 % + Dextrose 17.5 % NSD17.5% Sodium chloride 0.9 % + Dextrose 17.5 %
324 | P a g e
DEXTROSE PREPARATIONS
Calculation
Preparation Example A
How to prepare Dextrose 12.5 % in 500 mL from using commercially available strength of Dextrose 10 % & Dextrose 50 % ?
By using Alligation Method (tick-tac-toe),
Available Dextrose Strength Concentration to be prepared Proportion required Calculate volume to be syringed out (mL)
10 % 50 – 12.5 = 37.5 37.5
500 = 468.75
40
12.5 %
50 % 12.5 – 10 = 2.5 2.5
500 = 31.25
40
Total 37.5 + 2.5 = 40 468.75 + 31.25 = 500
From the calculation above, 468.75 mL of Dextrose 10 % & 31.25 mL of Dextrose 50 % makes up to 500 mL of Dextrose 12.5 %.
However, the numbers are inconvenient to be syringe out.
∴ The figures are rounded to 469 mL of Dextrose 10% and 31 mL of Dextrose 50%.
Counter-checking Preparation Example A
Preparation : Dextrose 12.5 % = 12.5 g of Dextrose in 100 mL of water
.
In 500 mL, amount of dextrose required is = 62.5 g
Fact Calculated amount of Dextrose obtained (g)

Dextrose 10 % = 10 g of Dextrose in 100 mL water 469
= 46.9
= 50 g of Dextrose in 500 mL water 500
= 15.5
Total 62.4 g (± 0.1 g)
325 | P a g e
Calculation
Preparation Example B
How to prepare Dextrose 12.5% in 500 mL from using commercially available strength of Dextrose 5 % & Dextrose 50 % ?
By using Alligation Method (tick-tac-toe),
Available Dextrose Strength Concentration to be prepared Proportion required Calculate volume to be syringed out (mL)
5% 50 – 12.5 = 37.5 37.5
500 = 416.667
45
12.5%
50 % 12.5 – 5 = 7.5 7.5
500 = 83.333
45
Total 37.5 + 7.5 = 45 416.667 + 83.333 = 500
From the calculation above, 416.667 mL of Dextrose 5 % and 83.333 mL of Dextrose 50 % makes up to 500 mL of Dextrose 12.5 %.
However, the numbers are inconvenient to be syringe out.
∴ The figures are rounded to 417 mL of Dextrose 5 % and 83 mL of Dextrose 50 %.
Counter-checking Preparation Example B
Preparation : Dextrose 12.5 % = 12.5 g of Dextrose in 100 mL of water
.
In 500 mL, amount of dextrose required is = 62.5 g
Fact Calculated amount of Dextrose obtained (g)

= 20.85
= 41.5
Total 62.35 g (± 0.15 g)
326 | P a g e
Preparation
Dextrose 12 % 12.5 % 15 % 17.5 % 20 % 25 % 30 % 35 % 40 %
USE Dextrose 475 mL 469 mL 438 mL 406 mL 375 mL 312 mL 250 mL 188 mL 125 mL
10 % (47.5 g) (46.9 g) (43.8 g) (40.6 g) (37.5 g) (31.2 g) (25 g) (18.8 g) (12.5 g)
ADD Dextrose 25 mL 31 mL 62 mL 94 mL 125 mL 188 mL 250 mL 312 mL 375 mL

HAM
50 % (12.5 g) (15.5 g) (31 g) (47 g) (62.5 g) (94 g) (125 g) (156 g) (187.5 g)
Total
500 mL 500 mL 500 mL 500 mL 500 mL 500 mL 500 mL 500 mL 500 mL
Volume
Preparation
Dextrose 7.5 % 10 % 12.5 % 15 % 17.5 % 20 % 25 % 30 % 35 % 40 %
USE Dextrose 472 mL 444 mL 417 mL 389 mL 361 mL 333 mL 278 mL 222 mL 167 mL 111 mL
5% (23.6 g) (22.2 g) (20.85 g) (19.45 g) (18.05 g) (16.65 g) (13.9 g) (11.1 g) (8.35 g) (5.55 g)
ADD Dextrose 28 mL 56 mL 83 mL 111 mL 139 mL 167 mL 222 mL 278 mL 333 mL 389 mL

HAM
50 % (14 g) (28 g) (41.5 g) (55.5 g) (69.5 g) (83.5 g) (111 g) (139 g) (166.5 g) (194.5 g)
Total
500 mL 500 mL 500 mL 500 mL 500 mL 500 mL 500 mL 500 mL 500 mL 500 mL
Volume
Use IMMEDIATELY after prepared.
Kindly Label the preparation on the bottle properly.
Disclaimer: This IV drip dilution guide is intended to facilitate IV drip preparation process by the user(s). This is not a complete drug information
and dosing resource.
327 | P a g e
HANDBOOK OF DRUG RECONSTITUTION & DILUTION TAWAU HOSPITAL 2018 SD
SALINE & DEXTROSE PREPARATIONS
Calculation
Preparation Example C
How to prepare 1/4Normal Saline 0.9% with Dextrose 25 % in 500 mL from using commercially available strength of
Sodium Chloride 3%, Dextrose 50 % and Sterile Water for Injection?
By using Proportionality Method, determine the volume of Sodium Chloride 3 % required.
Fact Calculated volume of Sodium Chloride 3 % to be syringed

out (mL)
1/4Normal Saline 0.9 % = 0.225 g of Sodium Chloride in 100 mL water
= 1.125 g of Sodium Chloride in 500 mL water 1.125
500 = 37.5
Sodium Chloride 3 % = 3 g of Sodium Chloride in 100 mL water 15
= 15 g of Sodium Chloride in 500 mL water
However, the number 37.5 mL are inconvenient to be syringe out.
∴ The figure is rounded to 38 mL of Sodium Chloride 3 %.
By using Proportionality Method, determine the volume of Dextrose 50 % required.
Fact Calculated volume of Dextrose 50 % to be syringed out (mL)

Dextrose 25 % = 25 g of Dextrose in 100 mL water
500 = 250 mL
= 250 g of Dextrose in 500 mL water
Make up the total volume with Sterile Water for Injection = 500 – 38 – 250
= 212 mL
328 | P a g e
Calculation
Preparation Example D
Normal Saline 0.9 %, Dextrose 50 % and Sterile Water for Injection?
By using Proportionality Method, determine the volume of Normal Saline 0.9 %required.
Fact Calculated volume of Normal Saline 0.9 % to be syringe out

(mL)
500 = 125 mL
Normal Saline 0.9 % = 0.9 g of Sodium Chloride in 100 mL water 4.5
= 4.5 g of Sodium Chloride in 500 mL water

500 = 250 mL
= 125 mL
329 | P a g e
Calculation
Preparation Example E
1/2Normal Saline 0.9 %, Dextrose 50 % and Sterile Water for Injection?
By using Proportionality Method, determine the volume of 1/2Normal Saline 0.9 %required.
Fact Calculated volume of 1/2Normal Saline 0.9 % to be syringe

out (mL)
500 = 250 mL
1/2Normal Saline 0.9 % = 0.45 g of Sodium Chloride in 100 mL water 2.25
= 2.25 g of Sodium Chloride in 500 mL water

500 = 250 mL
= 0 mL
330 | P a g e
Important : Disclaimer : This IV drip dilution guide is intended to facilitate IV drip
a) Final Volume of the IV Drip should be 500 mL preparation process by the user(s). This is not a complete
b) Use immediately after preparation drug information and dosing resource.
(Please label preparation properly on the bottle)
IV Drip NSD25% NSD20% NSD17.5% NSD15% NSD12.5% NSD10% NSD7.5% NSD5%

HAM NaCl 3% 150 mL 150 mL 150 mL 150 mL 150 mL 150 mL 150 mL 150 mL
HAM D50% 250 mL 200 mL 175 mL 150 mL 125 mL 100 mL 75 mL 50 Ml
WFI 100 mL 150 mL 175 mL 200 mL 225 mL 250 mL 275 mL 300 mL
Total volume 500 mL 500 mL 500 mL 500 mL 500 mL 500 mL 500 mL 500 mL
IV Drip 3/4NSD25% 3/4NSD20% 3/4NSD17.5% 3/4NSD15% 3/4NSD12.5% 3/4NSD10% 3/4NSD7.5% 3/4NSD5%

HAM D50% 250 mL 200 mL 175 mL 150 mL 125 mL 100 mL 75 mL 50 mL

331 | P a g e

HAM
D50% 250 mL 200 mL 175 mL 150 mL 125 mL 100 mL 75 mL 50 mL


NS 375 mL 375 mL 375 mL 375 mL
HAM D50% 125 mL 100 mL 75 mL 50 mL
WFI 0 mL 25 mL 50 mL 75 mL
Total volume 500 mL 500 mL 500 mL 500 mL
332 | P a g e

NS 250 mL 250 mL 250 mL 250 mL 250 mL 250ml 250ml 250ml
WFI 0 mL 50 mL 75 mL 100 mL 125ml 150ml 175ml 200ml

NS 125 mL 125 mL 125 mL 125 mL 125 mL 125 mL 125 mL 125 mL

NS 100 mL 100 mL 100 mL 100 mL 100 mL 100 mL 100 mL 100 mL
333 | P a g e

1/2NS 250 mL 250 mL 250 mL 250 mL 250 mL 250 mL 250 mL 250 mL

1/2NS 200 mL 200 mL 200 mL 200 mL 200 mL 200 mL 200 mL 200 mL
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QUICK REFERENCE
List of drugs that require Central Line/Central Venous Catheter consideration
Disclaimer : This list is not exhaustive
Drugs Page number

Adrenaline 22 - 26
Amiodarone 32 - 33
Dobutamine 105 - 107
Dopamine 108 - 111
Labetalol 191 - 192
Noradrenaline 222 - 225
Phenylephrine 248 - 249
Potassium Dihydrogen Phosphate 256 - 257
List of drugs that are provided with running rate

(commonly administered as Continuous Intravenous Infusion)
Disclaimer : Applicability of the running rate provided must be checked and agreed by
treating physician for appropriateness on indication and dose, depending on patients’
clinical condition
Drugs Page number

Adrenaline 25 - 26
Dobutamine 107
Dopamine 110 - 111
Glyceryl Trinitrate 152
Heparin 161
Insulin 180
Noradrenaline 224 - 225
Frank Shann : Calculation of the Composition of Drug Infusions 26
(in 50 mL Syringe Pump) - PAEDIATRICS
335 | P a g e
QUICK REFERENCE
List of drugs whereby the manufacturer provides an expected resulting colour after
reconstitution and/or dilution.
Disclaimer : Information provided depends on product trade name, manufacturer and

technique used to prepare the drug. Hence, users must always check the trade name
and manufacturer of product given in this handbook and the product that is being use.
Drugs Page number

Amphotericin B 35 - 36
Antivenin Serum Snake Polyvalent 44
Cefuroxime 79
Dantrolene 91
Esomeprazole 123 - 124
Leuprolide 193 - 194
Meropenem 203 - 204
Rabies Vaccine 269
List of drugs whereby the manufacturer provides a specific technique during preparation
Disclaimer : Information provided depends on product trade name, manufacturer and

technique used to prepare the drug. Hence, users must always check the trade name
and manufacturer of product given in this handbook and the product that is being use.
Drugs Page number

Cobra Antivenom 88
Dexmedetomidine 99
Factor IX, II, X Combination (Prothrombinex-VF) 133 – 134
Factor VII, von Willebrand Factor (Alphanate) 130 – 131
Factor VIII Inhibitor bypassing factor (Feiba) 127 – 128
Glucagon (Lypophylised) 150
Green Pit Viper Antivenom 156
Imipenem + Cilastin 174 - 175
Quadrivalent Seasonal Influenza 268
Somatrophin 284 – 286
336 | P a g e
ack page design
Copyright Jabatan Farmasi

Hospital Tawau
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Peti Surat No. 67
http://htwu.moh.gov.my

Reconstitution and Dilution

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Reconstitution and Dilution

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HANDBOOK OF DRUG RECONSTITUTION & DILUTION TAWAU HOSPITAL 2018

General Guide for Healthcare

DR. NORLIMAH ARSAD

MEDICAL & DENTAL ADVISORY COMMITTEE, TAWAU HOSPITAL

Coordinator Diana Muhd Rizal Drug Information Services Pharmacist

Committee Ahmad Shauqey Adnin Hasnam Total Parenteral Nutrition Pharmacist

Dr. Baskaran Subramaniam Head of Pathology Department,

Dr. Chung Yaw Yee Head of Medical Department,

Dr. Hairudin Achmad Head of Radiology & Imaging Department,

Dr. Khairuddin Othman Head of Ophthalmology Department,

Dr. Maria Elina Zaid Head of Paediatric Department, Paediatrician

Dr. Naveen Vijayasingham Head of Orthopedic Department,

Dr. Saridah Mahdah Head of Oral & Maxillofacial Department,

Dr. Sein Win Head of Anaesthesia & Intensive Care

Dr. Siti Noor Fadhlina Head of Psychiatry Department,

Dr. Syed Zaifullah Syed Head of Otorhinolaryngology Department,

All Praise be to God, The All Almighty, The All Knowing.

I would like to thank Puan Halimah Lego,

My appreciation and thank you

Diana Muhd Rizal

12th July 2018

HOW TO USE THE BOOK

High Alert Medications are indicated next to the title page

2. To avoid contamination, the solutions should be used immediately after reconstitution or

4. Injections should be discarded if they contain particulate, discolored or become turbid.

< Less than

ERYTHROPOIETIN ALFA 119

INSULIN REGULAR + ISOPHANE 181

 ABBREVIATIONS LIST FOR APPENDICES 323

QUICK REFERENCE 335

Storage & Stability

Prevention of Contrast Induced Nephropathy : 600 - 1200 mg in 100 mL D5 [4-6]

Administration & Infusion Rate

Prevention of Contrast Induced Nephropathy [4-6]

Storage & Stability

Administration & Infusion Rate

Storage & Stability

Administration & Infusion Rate

Storage & Stability

Brand Name & Strength

Administration & Infusion Rate

Storage & Stability

Brand Name & Strength

a. Determine dose (mg/hr) = Dose (mcg/kg/min) x BW (kg) x 60 min/hr

b. Determine concentration = 0.06 mg/mL (if dilute 3 mg in 50 mL diluent)

c. Calculate infusion rate (mL/hr) = Dose (mg/hr) ______

Administration & Infusion Rate

IV Slow bolus : 1 mg in 10 mL NS (Concentration: 100 mcg/mL) [4]

IV Slow bolus : 1 mg in 10 mL NS (Concentration: 100 mcg/mL) [4]

IV Infusion : Up to 1.5 mcg/kg/min via central venous catheter [3]

Storage & Stability

 For cardiopulmonary resuscitation with intravenous use in adults, administration through a

Infusion Rate Guide

ADULT : Adrenaline 3 mg in 50 mL NS/D5 (60 mcg/mL; through central line) [5]

0.1 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5 9 9.5

0.3 12 13.5 15 16.5 18 19.5 21 22.5 24 25.5 27 28.5

0.5 20 22.5 25 27.5 30 32.5 35 37.5 40 42.5 45 47.5

0.7 28 31.5 35 38.5 42 45.5 49 52.5 56 59.5 63 66.5

0.9 36 40.5 45 49.5 54 58.5 63 67.5 72 76.5 81 85.5

Reference : Shann F. Drug Doses. 17th ed. Victoria: 2017

Administration & Infusion Rate

Storage & Stability

Administration & Infusion Rate