Pharmaceutical Aspects of IV Medicine Administration

1. Pharmaceutical Aspects of IV Medicine Administration September 2009

2. Contents of Session • The 5 Rights of Medicines Administration • The 5 Components of Medicines Administration • Practitioner Responsibilities

3. The Five Rights of Medicine Administration • Right patient • Right medicine • Right route • Right dose • Right time ……everytime!

4. The Five Components of Medicine Administration • Selection • Prescribing • Preparation • Administration • Monitoring

5. Why IV? • Oral or other route of administration not suitable or available eg vomiting, diarrhoea, malabsorption, resting gastro-intestinal tract, low muscle mass • Where rapid effect or high/predictable concentrations essential • Medicine not effective via other routes eg gentamicin, benzylpenicillin

6. Advantages of IV • Medicine gets into the circulation quickly • Rapid effect achieved • Predictable concentrations achieved i.e. 100% reaches systemic circulation • Some medicines cannot be given by another route eg gentamicin

7. Prescribing • Prescription is clear, unambiguous and legal • Medicine is essential and appropriate for patient • The patient is not allergic to medicine • Dose, route and rate essential and appropriate • Medicine is compatible with flush and infusion fluid

8. Medicines Characteristics • Cytotoxics, TPN – outsourced or made in pharmacy • Diazepam – must only be administered with extreme caution and competence

9. Dose, Route and Rate • Is route suitable for medicine? eg vincristine given intrathecally causing death, cytotoxics given peripherally causing severe extravasation and loss of limbs • Is route suitable for required rate? • Properties of the medicine? eg osmolarity, pH • What routes are available?

10. Concentration, Diluent and Vehicle Concentration • Check that the concentration of the drug is within the recommended range for safety and efficacy eg erythromycin must be between 1-5mg/ml Diluent and Vehicle • Not always the same! • Check! eg clarithromycin must be reconstituted with water but diluted in sodium chloride 0.9%

11. Compatibility and Stability • Instability – modification of the preparation due to storage conditions resulting in unsuitable product • Incompatibility – two or more products mixed with resulting preparation unsuitable for administration • Results: product becomes toxic, precipitates or ineffective • Never add medicines to fluid unless compatibility assured • Never mix medicines together unless compatibility assured

12. Compatibility and stability • Heparin / Aminoglycosides • Hydrocortisone / flucloxacillan • Co-amoxiclav - stability when reconstituted

13. 3. Preparation: Factors Affecting Stability

14. Displacement Volumes and pH Displacement volume • volume of fluid displaced by a powder when reconstituted • Important when part-vials are used • Mainly only relevant to paediatrics pH • Most medicines are stable at a specific pH • Rate of degradation often pH dependent eg amphotericin requires glucose pH>4.2

15. Labelling • All products must be labelled fully • Complete label before preparing injection • A record must be kept of all injections prepared and administered (kardex, infusion chart or both) • Bolus drugs …must be administered immediately on preparation, do not prepare in advance!

16. Sources of Information • IV Drug Monographs/ Medusa website • BNF/BNFC • Product Information Leaflet • Medicines Information • Pharmacist • On-call Pharmacist • University College London Hospitals Injectable Medicine Administration Guide

17. Red Man Syndrome

18. Rate of Administration • Most IV bolus injections over at least 3-5 minutes • Ensure device is capable of accurate delivery and desired infusion rate • 95% of IV bolus injections given too fast Systemic damage • Furosemide  ototoxicity • Phenytoin  arrhythmias • Ranitidine  bradycardia • Vancomycin  red man Local damage • Pain • Extravasation • Phlebitis

19. IV Error Potential • Article in BMJ 2003 - Errors identified in 49% of doses surveyed - 8% wrong diluent/solvent - 3% wrong dose prepared - 3% of doses omitted - 38% of bolus doses given too fast - 3% incompatibility

20. Professional Responsibility Prescriber and Administrator • Prescription is clear, unambiguous and legal • Medicine is essential and appropriate • Dose, route and rate is essential and appropriate • Medicine is compatible with infusion fluid • Appropriate monitoring requirements are in place eg ECG machine for potassium infusions

21. Professional Responsibility Nurse • Must have completed IV Medicines Training Package, be certified competent and be aware of own limitations • Training must be recognised by NHSGGC • Must not administer a drug if doubtful about any aspect of IV medicine prescription / calculation / preparation / compatibility / administration / monitoring • Must ensure that appropriate and current information sources used

22. Professional Responsibility Pharmacist • Specialist knowledge • Access to specialist information • Can advise and provide support on any aspect of IV medicine use ie dose, calculations, method and rate of administration, diluents, stability and incompatibilities • Can provide advice 24 hours a day via ward pharmacist, medicines information or on-call pharmacist

23. Remember If in doubt, don’t administer! Most important consideration is the PATIENT They have to suffer the consequences