1
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
UConn John Dempsey Hospital IV Medication Guidelines
Department of Pharmacy
Pharmacy Website
Medication Shortage Information on Pharmacy Website
This document maintained by the department of pharmacy is meant to act as a guide in the administration of intravenous medications at UConn John Dempsey Hospital. It should be used as
a reference, in combination with other available drug information sources. This document is a guideline and is subject to frequent changes in information. The most recent version will be
available electronically. Always refer to the electronic version for the most updated guidelines. Previously printed copies will likely be older versions. Sound clinical judgment needs to be
considered, along with one’s professional scope of practice. If administration of a medication is found to be outside the scope of this manual, consult current references (professional
journals, Micromedex, Lexi-Comp, American Hospital Formulary Services), unit-specific nursing policies, pharmacy services and Clinical Nurse Specialists. Approval from the Chairman of
the Pharmacy and Therapeutics Committee may be necessary. The Alaris Guardrail software has been updated based on the information included in this document. Please contact pharmacy
for any noted discrepancies. For any further administration information, please consult your floor pharmacist.
This document is the property of the UConn John Dempsey Hospital Department of Pharmacy.
Related Policy: Medication Administration IV Guidelines: Medications Not Listed in JDH IV Medication Guidelines
Table of Contents
Page 2-4: Summary of Changes for current version of IV Guidelines
Page 4: List of Abbreviations & Acyronyms. Medication Administration Guidance During COVID-19 Surge/Overflow (Effective 4/2020)
Page 5 – 7 : Drugs approved for IV PUSH administration for adults by all RNs on all UNITS (except PSY).
Page 8 - 9: Dose Guidelines for IV Titratable Medications
Page 10 - 11 : Extravasation Guidelines
Page 12 – 13: Filter Guidelines
Page 14: Medication Considerations for Midline Catheters Guideline
Page 15 -130: IV Medication Guidelines
Page 130: References
ORIGINAL DATE: 9/9/08
REVISION DATES: 11/1/08, 7/09, 10/09, 12/09, 2/10, 4/10, 5/10, 6/10, 9/10, 1/26/11, 2/15/11, 3/22/11, 4/29/11, 5/2/11, 5/3/11, 5/26/11, 6/30/11, 8/5/11, 8/30/11, 10/19/11, 10/31/11,
11/22/11, 1/01/12, 3/12/12, 4/11/12, 4/18/12, 6/5/12, 7/1/12, 7/13/12, 8/6/12, 8/21/12, 9/6/12, 9/25/12, 2/7/13, 2/27/13, 3/12/13, 3/28/13, 4/10/13, 4/18/13, 4/23/13, 5/10/13, 7/2/13, 8/27/13,
10/31/13, 12/10/13, 2/27/14, 3/6/14, 3/24/14, 4/2/14, 4/4/14, 4/8/14, 4/9/14, 4/11/14, 4/17/14, 4/18/14, 4/28/14, 4/29/14, 4/30/14, 5/6/14, 5/9/14, 6/16/14, 6/18/14, 7/15/14,7/16/14, 7/18/14,
9/2/2014, 9/18/14, 9/24/2014, 10/27/14, 11/7/2014, 11/13/2014, 11/17/2014, 11/24/2014, 11/26/2014, 1/14/2015, 1/15/2015, 2/12/2015, 2/13/2015, 3/9/2015, 3/16/2015, 4/1/2015, 4/6/2015,
4/28/2015, 5/4/2015,5/6/2015, 6/8/2015, 6/16/15, 6/18/15, 6/29/15, 6/30/15, 7/8/2015, 7/17/2015, 8/7/2015, 8/28/2015,9/17/2015, 9/23/2015, 12/7/2015, 12/24/2015, 12/30/2015, 1/11/2016,
1/12/2016, 1/13/2016, 1/25/2016, 2/2/2016, 2/11/2016, 2/26/2016, 3/16/2016, 3/29/2016, 5/13/2016, 6/6/2016, 6/10/2016, 6/16/2016, 6/28/2016, 8/4/2016, 9/21/2016, 10/13/2016,
10/21/2016, 10/31/2016, 11/4/2016, 11/6/16, 11/20/16, 11/21/16, 11/30/16, 1/12/17, 2/15/17, 6/2/2017, 6/29/17, 7/17/17, 7/25/17, 8/3/17, 8/25/17, 8/29/17, 9/5/17, 9/27/17, 10/6/17,
11/13/17, 11/15/17, 12/11/17, 2/2/18, 2/7/18, 3/30/18, 4/28/18, 5/7/18, 5/23/18, 5/31/18, 6/27/18, 6/28/18, 6/29/18, 8/27/18, 12/4/18, 1/3/19, 1/26/19,1/29/19, 5/31/19, 6/17/19, 8/5/19,
11/4/19, 1/29/20, 4/3/20, 4/23/20, 6/11/20, 8/13/20, 11/11/20, 11/25/20, 11/27/20, 2/9/21, 3/26/21, 4/16/21, 4/27/21, 7/27/21, 10/26/21, 1/11/22, 1/25/22, 2/25/22, 3/4/22, 3/15/22, 4/7/22,
5/18/22, 6/29/22, 7/15/22, 10/28/2022, 1/17/2023, 2/8/2023, 4/20/2023, 4/24/2023, 4/28/2023, 5/4/2023, 7/31/2023, 10/26/2023, 11/29/2023
3
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
IV Medication Guidelines Summary of Recent Changes for Revisions (minimum of 3 Months)
Topic Page(s) Comments
Bamlanivimab
13, 30
Added new medication approved at November P&T meeting (11/25/20)
Casirivimab & imdevimab
13, 36
Added new medication approved at November P&T meeting (11/25/20)
Alteplase
14, 20, 21
Added “Avoid in Midline Cath” (11/27/20)
COVID-19 Surge/Overflow
4
Removed example of PACU Surge for HT1-ICU overflow (11/27/20)
Dexmedetomidine
8, 47
Added nursing titration guidance as approved by Critical Care Committee and Medication Safety Committee (2/9/21)
Cisatracurium
8, 43
Added concentration of 200mg/ 100ml (2mg/ml) as approved by Medication Safety Committee (2/9/21)
Tranexamic Acid
139
Changed total volume from 50mL to 100mL for compatability with mini-bag PLUS system (3/26/2021)
Bamlanivimab/Etesevimab
16, 35
Added new medication under EUA (3/26/21)
Bamlanivimab
34
Changed total volume per EUA update to 270mL (3/26/21)
Emergency Department
Resuscitation Room
Medications
5, 11
Added icon to legend and throughout document to show which medications are also found on the Emergency Department Resuscitation Room Medication
list (3/26/21)
Added section after approved at February P&T Meeting (3/26/21)
Bamlanivimab
13, 30
Removed from IVMG due to FDA revoking EUA for monotherapy effective (4/16/2021)
Sodium Bicarbonate
130
Added IVP for indication of urinary alkalinization for patients receiving high dose MTX approved at Med Safety Committee (4/27/2021)
Rasburicase
127
Added UT2 as an approved unit for administration approved at Med Safety Committee (4/27/2021)
Casirivimab/Imdevimab
40
Dosing changed from 2400mg to 1200mg per EUA update (7/27/21)
Bezlotoxumab
17, 36
Added new medication approved at September P&T meeting (10/26/21)
Naloxone
110
UT2 removed as an approved unit for continuous naloxone infusion used for the reversal of narcotics approved at Med Safety Committee (10/26/21)
Lorazepam
98
Indication added for catatonia benzodiazepine challenge approved at Med Safety Committee (10/26/21)
Sotrovimab
17, 133
Added new medication under EUA (1/11/22)
Bamlanivimab/Etesivimab
35
All inpatient units added as approved units for administration per hospital leadership (1/11/22)
Casirivimab/Imdevimab
42
All inpatient units added as approved units for administration per hospital leadership (1/11/22)
Oxytocin
116
UT1-ICU and UT2-IU added for postpartum use of oxytocin approved at Med Safety Committee (1/25/22)
Vancomycin
146
Changed 1000mg final volume from 200mL to 250mL based on product availability (2/25/22)
Gentamicin
77
Added two premix products- 80mg/50mL and 100mg/50mL (2/25/22)
Fosaprepitant
75
Removed 150mg/100mL concentration as not supported by package insert and increased risk of phlebitis (2/25/22)
Levetiracetam
94
Added dosing up to 4.5g x 1 dose for status epilepticus (2/25/22)
Bebtelovimab
36
Added new medication under EUA (3/4/22)
Labetalol
94
Removal of UT3 as an approved unit for IVP labetalol per CNO and Director of Quality (3/15/22)
Vancomycin
147
Changed 1000mg final volume from 250mL to 200mL based on product availability (4/7/22)
Nitroglycerin
115
Corrected typo error for UT2-IU maximum titratrion rate for chest pain is 50 mcg/min (was erroneously 50 mg/min) (5/18/22)
Vasopressin 10, 147
Concentration for continuous infusion updated to reflect new premixed product on formulary, 40 units/100mL (0.4 units/mL). Stability information
removed.
Diazepam
55
Added indication, approved units, and dosing for alcohol withdrawal during time of IV Lorazepam shortage (7/15/22)
Insulin Regular
93
Replaced “protocol” with “guideline” for approved units for indication of hyperglycemia per Med Safety Committee recommendations (10/28/2022)
Nitroglycerin
118
Added clarifying statement to titratable orders on UT-2 (Intermediate) - approved by Med Safety Committee 10/25/2022 (10/28/2022)
4
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Tecovirimat
146
Added new medication approved at September P&T meeting (10/28/2022)
Levetiracetam 104
Updating dilution instructions to remain within recommend concentration limits, updated minimum admin over time for doses > 3750mg, and updated
stability information
Non-formulary restricted
antimicrobials
46, 54, 56,
67, 94, 100,
104, 111,
128,129, 142,
143, 150, 159
Added entries for non-formulary restricted antimicrobial items not already present in guideline based on review of Restricted and Concurrently Monitored
Antimicrobials Clinical Policy (1/17/2023)
Restricted antimicrobials
4, 26, 29, 44,
47-50,53,55,
67
Updated various antimicrobials (added or removed restricted designation, added or removed non-formulary designation, or updated “restricted antibiotic” to
“restricted antimicrobial” to be more in line with Restricted and Concurrently Monitored Antimicrobials Clinical Policy (1/17/2023)
Hydroxocobalamin
88
Added new entry for indications of Cyanide poisoning, and newly approved off label indication for vasoplegia approved P&T (2/8/2023)
Oxytocin
123
Updating dosing information to reflect order changes made to consolidate postpartum third stage management (4/20/2023)
Brivaracetam
5
Added new medication entry approved by P&T in March 2023 (4/24/2023)
OR/PACU
4
Updating OR/PACU designiation by replacing SDS-critical care trained with Pre-op; approved by Med Safety Committee in April (4/28/2023)
UT4-SURGE & UT4-TELE
4
Addition of UT4-SURGE unit to hospital units and included in Med/Surge/Onc pool’ approved by Med Safety Committee in April (4/28/2023)
Enalaprilat
60
Adding UT4-TELE as approved unit (4/28/2023)
Medications allowed on PSY 1, 4, All
Added PSY as a hospital unit and clarified which medications would be allowed to be administered on PSY as approved by the Medication Safety
Committee in April. Mediation NOT allowed on Psy will be designated as “ALL Units (Except Psy)”.
Footnote
All
Added Foot note to all pages referencing nursing policy for items that do not appear within IVMG; approved at Med Safety Committee in July (7/31/2023)
Lacosamide
7
Added IVP administration information; reviewed by Med Safety Committee in July (7/31/2023)
Levetiracetam
7
Added IVP administration information; reviewed by Med Safety Committee in July (7/31/2023)
Alteplase 24, 25
Removed UT2-IU as approved unit for use; approved by Med Safety Committee in July (7/31/2023)
Phentolamine
15, 16
Removing verbiage regarding availability of product (7/31/2023)
Rasburicase
141
Added OP-NCCC as an approved unit for use; approved by Med Safety Committee in July (7/31/2023)
Tocilizumab
154
Added additional inidication and approved units for use; approved by Med Safety Committee in July (7/31/2023)
Tranexamic Acid
156
Added ED as approved unit for use for indication of reduction of bleeding for knee arthroplasty (7/31/2023)
UT-BMT
5
Addition of UT-BMT unit to hospital units and included in Med/Surge/Onc pool; approved by Med Safety Committee in October (10/26/23)
Calcium gluconate
43
Added new concentration of 4g/250mL for apheresis and approved unit of UT-BMT; approved by Med Safety Committee in October (10/26/23)
Lacosamide
108
Updated dosing/admixture instructions to include IVP preferred guidance (10/26/23)
Levetiracetam
109
Updated dosing/admixture instructions to include IVP preferred guidance (10/26/23)
Magnesium sulfate
113
Added UT-BMT as approved unit for use; approved by Med Safety Committee in October (10/26/23)
Meropenem
115
Updated duration of infusion to 30 mins (10/26/23)
Pentamidine
139
Added indication and dosing for PCP prophylaxis and approved unit of UT-BMT (10/26/23)
Tocilizumab
169
Added UT-BMT as approved unit for use; approved by Med Safety Committee in October (10/26/23)
CT7
5
Added CT7 Medical/Surgical unit to list of hospital units and included in Med/Surge/Onc pool; hospital adminstration approval in November (11/29/23)
MS5
5
Added MS5 Medical/Surgical unit to list of hospital units;hospital adiminstration approval in November (11/29/23)
5
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
List of Abbreviations and Acronyms
Hospital Units
Miscellaneous
CCL/EP
Cardiac Catheterization Lab / Electrophysiology
ECHO
Echocardiography Lab
ECT-A
Electroconvulsive Therapy with Anesthesia Present
ED
University Tower Basement Emergency Department
EMU
Epilepsy Monitoring Unit
ENDO
Endoscopy
HD
University Tower 3 Dialysis
UT1-ICU
University Tower 1 Intensive Care Unit
UT2-IU
University Tower 2 Intermediate Unit
UT3-MED
University Tower 3 Medicine Unit
UT3-TELE
University Tower 3 Medicine Unit Patients with Telemetry
UT4-SURGE
University Tower 4 Medicine Surge Unit
UT4-TELE
University Tower 4 Medicine Surge Patients with Telemetry
UT-BMT
University Tower Bone Marrow Transplant
IRAD
Interventional Radiology
UJDH HA
JDH Holding Area – Med/Surg trained
PSY
L&D/OB-GYN
MS5
CT7
Connecticut Tower Psychiatry
Connecticut Tower Labor & Delivery / Obstetrics & Gynecology
Connecticut Tower 5 Medical/Surgical
Connecticut Tower 7 Medical/Surgical
MED/SURG/ONC
University Tower 6 Medical/Surgical/Oncology
University Tower 5 Surgical/Orthopedics
University Tower 4 Medicine Surge
University Tower 3 Medicine
University Tower Bone Marrow Transplant
Connecticut Tower 5 Medical/Surgical
Connecticut Tower 7 Medical/Surgical
OP-CARD
Cardiology Outpatient Clinic
OP-INFC
Outpatient Infusion Center (formerly AACU)
OP-NCCC
Outpatient Neag Comprehensive Cancer Center
OR/PACU
University Tower, Ground OR/PACU/Pre-op
PULM
Pulmonary Outpatient Clinic
UHSC
UConn Health Surgery Center (formerly FSC)
BP
Blood Pressure
C.I.
Continuous Infusion
CRNA
Certified Registered Nurse Anesthetist
D5W
5% Dextrose / Water
I&O
Input & Output
I.I.
Intermittent Infusion
L.D.
Loading Dose
LIP
Licensed Independent Practitioner
NS
Normal Saline
RRT
Rapid Response Team
SW
Sterile Water
TOF
Train of Four
*
On direct order AND in the presence of Anesthesia Provider
Only
Interim guideline for medication administration on Surge / Overflow units during
COVID-19 pandemic: An RN working on an overflow or surge unit may administer
medications that are deemed appropriate by the practitioner for the patient’s level of care and
condition, provided that staff (RNs, Practitioners, Pharmacists) who normally provide care to
that patient population are available as resource.
(Effective 4/2020)
Alerts
LOOK ALIKE / SOUND ALIKE
HIGH ALERT / DOUBLE CHECK
TITRATE MED
NON-FORMULARY
RESTRICTED ANTIMICROBIAL
NOT ON GUARDRAIL
ADS MIXTURE (Due to short stability or emergent need, this is mixed on the hospital unit)
Approved 04/08/2008
Revised: 04/01/11, 03/13/12 4/11/12,
2/27/2014, 11/13/2017, 3/26/2021
6
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Requires Cardiac Monitor/Telemetry
Designates a hazardous medication. See this link for PPE info: Medication Handling Safety
Designates that the product must be filtered during infusion. See filter guidelines on page 12&13.
Designates that the medication is also part of the Emergency Department Resuscitation Room Medication List.
Designates extravasation information can be found on pages 10&11
. Blue indicates cold compress and red indicates warm compress
IV PUSH MEDICATIONS AND DOSES UConn John Dempsey Hospital
DRUGS APPROVED FOR IV PUSH ADMINISTRATION for ADULTS BY ALL RNs on all UNITS (except PSY).
This list is not all inclusive. Consult IV Med Guidelines for further details.
NOTE:
• SWFI (Sterile water for injection) is used in some instances to help minimize osmolality, reconstituting with NS or D5W may produce significant phlebitis, and increase
the risk for extravasation injry.
• Upon mixing , syringe must be properly labeled for administration per policy
• IV push too fast can result in infiltration or systemic reactions such as headache, flushing, tightness in chest. All IV push have Phlebitis risk.
• Undiluted Meds should be flushed slowly with 5 mL NS to avoid rapid infusion of medication that remains in the catheter or tubing.
Related Policies/Links: HAM Policy on Medication Admnistration (Includes Information on Labeling of Syringes)
Nursing Policy on IV Push Medications
Medication Shortage Information on Pharmacy Website
Generic Name/Brand Name
UP TO MAXIMUM
ALLOWABLE DOSE
RECOMMENDED DILUTIONS
FOR ADMINISTRATION
IV PUSH OVER
Comments
AcetaZOLAMIDE (Diamox
®
)
500 mg
Dilute in 10mL NS
1-2 min
Aztreonam (Azactam
®
)
2 gm
1gm in 10 mL SWFI
2gm in 20 mL SWFI
3 – 5 min
As of 4/28/18, use MINI-BAG Plus
Benztropine (Cogentin
®
)
2 mg
Undiluted
1 mg / min
Brivaracetam (Briviact
®
)
100 mg
Undilited
2 – 15 min
If Extravasation,
see Pages 10&11
If Extravasation,
see Pages 10&11
BKC: Dispose in
Black Bin
PBKC: Place Packaging
& Waste in Zip-Lock
and dispose in Black
SPLP/SPC: Place
Packaging & Waste
in Zip-Lock and
return to pharmacy
DEAP: Contact
RPh for Proper
waste disposal
See link for Pharm Waste Info: Pharmaceutical Waste
Avoid in midline cath
Page 15
7
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic Name/Brand Name
UP TO MAXIMUM
ALLOWABLE DOSE
RECOMMENDED DILUTIONS
FOR ADMINISTRATION
IV PUSH OVER
Comments
Bumetanide (Bumex
®
)
2 mg Dilute in 10 mL NS 1 mg / min > 2 mg as IVPB
Butorphanol (Stadol
®
)
2 mg
Undiluted
1 mg / min
Calcitriol (Calcijex
®
)
2 mcg
Undiluted
1 min
Cefepime (Maxipime
®
)
2 gm
1gm in 10 mL SWFI
2gm in 20 mL SWFI
3 – 5 min
As of 4/28/18, use MINI-BAG Plus
Cefotaxime (Claforan
®
)
2 gm
0.5 gm in 10 mL SWFI
1gm in 10 mL SWFI
2gm in 20 mL SWFI
3 – 5 min
Arrthythimias have occurred
following rapid bolus administration
(<60 sec)
As of 4/28/18, use MINI-BAG Plus
or mixture by pharmacy
CefOXitin (Mefoxin
®
)
2 gm 1gm in 10 mL SWFI
2gm in 10 mL SWFI
3 – 5 min As of 4/28/18, use MINI-BAG Plus
Cefuroxime (Zinacef
®
)
1.5 gm
750 mg in 10mL SWFI
1.5 gm in 20mL SWFI
3 – 5 min
As of 4/28/18, use MINI-BAG Plus
Cosyntropin (Cortrosyn
®
)
0. 25 mg
Dilute in 1 mL NS
1 min
Dextrose 50% 25 gm/50 mL Undiluted 1 - 2 min
Dexamethasone (Decadron
®
)
12 mg
Dilute in 5 mL NS
1 - 2 min
> 12 mg as IVPB
Digoxin
0.5 mg
Dilute in 10 mL NS
3 - 5 min
Monitor BP,HR before & after q 15
min x 2
DiphenhydrAMINE (Benadryl
®
)
100 mg
Undiluted
25 mg over 2 - 3 min
50 mg over 2 - 3 min
100 mg over 4 - 5 min
< 25 mg/min
Dihydroergotamine (Migranal
®
)
1 mg
Undiluted
1 – 4 min
Famotidine (Pepcid
®
)
40 mg
20 mg in 10 mL NS
40 mg in 20 mL NS
2 min
Flumazenil (Romazicon
®
)
1 mg
Undiluted
15 - 30 sec
Folic Acid
5 mg
Undiluted
≥ 1 min
Dose ≤ 5mg can be given IV
push.
Furosemide (Lasix
®
)
100 mg
Undiluted
1 – 2 min, given < 40 mg/min
> 100 mg as IVPB
8
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic Name/Brand Name
UP TO MAXIMUM
ALLOWABLE DOSE
RECOMMENDED DILUTIONS
FOR ADMINISTRATION
IV PUSH OVER
Comments
Glucagon 1 mg Undiluted 1 min
Granisetron (Kytril
®
)
1 mg
Undiluted
30 sec
Heparin
10,000 units
Undiluted
1 min
Hydrocortisone (Solu-CORTEF
®
)
500 mg
< 100 mg Undiluted
> 100 mg in 10 mL NS
1 – 2 min
HYDROmorphone (Dilaudid
®
)
2 mg*
Dilute in 10 mL NS
2 - 3 min
Check RR & sedation level in 5-15
mins. *Up to 8 mg in extreme opiate
tolerance (ex: sickle cell)
Iron Sucrose (Venofer®)
200 mg
Undiluted
5 min
As of 4/28/18, can be mixed as an
infusion
Ketorolac (Toradol
®
)
60 mg
Undiluted
1 - 2 min
Lacosamide (Vimpat®)
400 mg
Undiluted
2 – 5 mins
Monitor HR, BP, PR interval
prolongation
LevETIRAcetam (Keppra®)
4500 mg
Undiluted
Doses ≤2000 mg over 2-5 mins
Doses > 2000 mg up to 4500 mg over
5 mins
Monitor vital signs and mental status
Levothyroxine (Synthroid
®
)
200 mcg
Dilute in 10 mL NS
1 - 2 min
LORazepam (Ativan
®
)
4 mg (ETOH W/D)
Diluted in equal volume NS
< 2 mg/min
given no more frequently than
q 15 mins per CIWA protocol
Ex: 4 mg = 2 mL drug + 2 mlL NS
over minimum 2 min
2mg (Other Indications)
Diluted in equal volume NS
< 2 mg/min
Meperidine (Demerol
®
)
Restricted to shivering/rigors or
opioid intolerance/allergies with
notification to pharmacy as such
100 mg
NOTE: 25mg/mL dose only hospital
approved available product
Dilute in 10 mL NS
2 - 3 min
Check RR & sedation level in 5-15
mins
Meropenem (Merrem
®
)
1 gm
0.5 gm in 10 mL SWFI
1 gm in 20 mL SWFI
3 – 5 min
As of 4/28/18, use MINI-BAG Plus
MethylPREDNISolone
(SOLU-Medrol
®
)
125 mg
Undiluted
1 - 2 min
> 125 mg as IVPB
9
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic Name/Brand Name
UP TO MAXIMUM
ALLOWABLE DOSE
RECOMMENDED DILUTIONS
FOR ADMINISTRATION
IV PUSH OVER
Comments
Metoclopramide (Reglan
®
) 10 mg Undiluted 1 - 2 min
Morphine
10 mg*
Dilute in 10 mL NS
2 – 3 min
Check RR & sedation level in 5-15
mins
*Up to < 40 mg in extreme opioid
tolerance (ex: Sickle cell patients)
Naloxone (Narcan
®
)
0.8 mg
Undiluted
15 - 30 sec
For a concentration of 0.04mg/mL:
Mix 1mL naloxone (0.4mg) with 9mL
NS for a total volume 10mL
Ondansetron (Zofran
®
)
12 mg
Dilute in 10 mL NS
1 - 2 min
Palonosetron (Aloxi
®
)
0.25 mg
Undiluted
30 sec
Pantoprazole (Protonix
®
) 80 mg Dilute 40 mg in 10 mL NS
Dilute 80 mg in 20 mL NS
2 - 3 min
Thiamine
100 mg
Undiluted
5 min
Torsemide (Demadex
®
)
< 40 mg
Undiluted
< 20 mg/min
IV TITRATABLE MEDICATION GUIDELINES
These are dosing guidelines only.
Prescriber is required to order each medication with the following parameters:
1. Loading dose if applicable; 2. Initial rate; 3. Titration rate (incr./decr.) with time interval; 4. Maximum Dose; 5. Reason/goal.
Parameters can be modified by the ordering prescriber.
Medication
Admixture Concentration
(s)
Initial Rate of Infusion
Titration Rate
(Increase/Decrease)
Order Reason/Desired
Patient Response
Maximum
Dose for
Specified
Time
Call LIP Parameter
Cisatracurium
(Nimbex
®
)
100 mg/100 mL NS or D5W
(1mg/mL)
200 mg/100 mL NS or D5W
(2mg/mL)
Load: 0.1 - 0. 2 mg/kg then
2 mcg/kg/min
Titrate by:
1 mcg/kg/min q 10 mins
Neuromuscular
Blockade /To achieve
specified Train of four 2
to 3 out of 4
10
mcg/kg/min
Specified Train of four not
achieved at maximum dose
Dexmedetomidine
(Precedex®)
200mcg/50ml NS
(4mcg/ml)
400mcg/100ml NS
(4mcg/ml)
Load: 1mcg/kg over 10
minutes
Then 0.2mcg/kg/hr
Titrate by:
0.1mcg/kg/hr every 30 minutes
Sedation / to achieve
specified sedation level
RASS 0-(-1)
1mcg/kg/hr
Specific sedation not
achieved at maximum dose
10
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
DiltiaZEM
125 mg/125 mL NS or D5W
(1mg/mL)
5 mg/hr Do Not Titrate Rate Control 15 mg/hr
20 mg/hr with Cardiology
input
DOBUTamine
(Dobutrex
®
)
LOOK ALIKE /
SOUND ALIKE
250 mg/250mL D5W
(1 mg/ mL)
500 mg/250mL D5W
(2 mg/ mL)
1000 mg/250mL D5W
(4 mg/ mL)
2.5 mcg/kg/min
Titrate by:
2.5 mcg/kg/min q 5 mins
Decreased CI
To achieve specified
increase in CI , CI > 2 .
0
CSDU: 10
mcg/kg/min
ICU/ED: 20
mcg/kg/min
Specified increase of C I
not achieved at maximum
dose, HR > 140 or
Ventricular
tachyarrhthymias
DOPamine
LOOK ALIKE /
SOUND ALIKE
400mg/ 500 mL D5W
(0.8 mg/mL)
800 mg/500mL D5W
(1.6mg/mL)
Renal : 1 mcg/kg/min
Inotrope : 2 mcg/kg/min,
Pressor: 5 mcg/kg/min.
Renal & Inotrope by:
1 mcg/kg/min q 5-10 min
Pressor by:
2.5 mcg/kg/min q 5 min
Hypotension / Renal
perfusion To achieve
specified U/ O or U/O >
30 mL/hr , or specified
increase in SBP SBP
100-120 or MAP > 60
CSDU- 5
mcg/kg/min
ICU - 30
mcg/kg/min
Specified increase of SBP
or U/O or not achieved at
maximum dose
EPINEPHrine
LOOK ALIKE /
SOUND ALIKE
4mg/250mL D5W
(16 mcg/ml)
8 mg/250mL D5W
(32 mcg/ml)
0.02 mcg/kg/min
Titrate by:
0.02 mcg/kg/min q 5 mins
Hypotension /Low CI /
To achieve specified
increase of SBP, HR
SBP 100-120 or MAP>
60 or CI > 2 . 0
0.2
mcg/kg/min
Specified increase of SBP,
CI or HR not achieved at
maximum dose
Esmolol
(Brevibloc
®
)
2500mg/250mL NS
(10 mg/ml)
Load: 500 mcg/kg over 1 min,
& repeat PRN q 5 mins for a
total of 3 boluses
CI: 50 mcg/kg/min
Titrate by:
50 mcg/kg/min q 5 mins with
reload of 500 mcg/kg over 1 min
Tachycardia/HTN / To
achieve specified
reduction of SBP,HR or
decreases of 15-20%
HR 60-80, SBP 100-120
or MAP> 60
200
mcg/kg/min
Specified decrease of HR or
SBP not achieved at
maximum dose
FentaNYL
2500 mcg/ 250 mL NS
(10 mcg/mL)
25 mcg/hr
Titrate by :
25 mcg/hr q 30 mins
Pain / Sedation To
achieve specified
sedation level Pain
Level as ordered
200 mcg / hr
Specified sedation not
achieved at maximum dose
Labetalol
500 mg/ 500 mL D5W
(1 mg/mL)
1000 mg/ 500 mL D5W
(2 mg/mL)
Load: 5-20 mg over 2 min,
may repeat q 10 mins as 40,
80, 160 mg. max. of 300 mg
for goal BP.
CI: 0. 5 mg/min
Titrate by:
0. 5 mg/min q 15 mins
Hypertension / To
achieve specified
reduction of SBP
SBP 100-120 or MAP >
60 or HR 60-80
2 mg/min =
120 mg/hr
Specified decrease of SBP
or HR not achieved at
maximum dose
11
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
LORazepam
(Ativan
®
)
100mg/100mL D5W
(1mg/mL)
Sedation –Vented Patient/
ETOH W/D 1 mg/hr
Titrate by:
1 mg/hr q 30 minutes
Sedation / To achieve
specified Sedation Level
RASS 0 to -1
15 mg/hr
Specified Sedation not
achieved at maximum dose
Midazolam
100mg/100mL D5W
(1 mg/mL)
0.5 mg/hr
Titrate by :
0.5 mg/hr q 10 mins
Sedation / To achieve
specified Sedation Level
RASS 0 to -1
20 mg/hr
Specified Sedation not
achieved at maximum dose
Milrinone
40mg/200mL D5W
(200mcg/mL)
Bolus of 50 mcg/kg then
C.I.: 0. 375 mcg/kg/min
Do Not Titrate
Decreased CI / to
achieve specified
increased of Cardiac
Output, decrease PAOP,
CI>2
0.75
mcg/kg/min
Specified Increase of CI not
achieved at Maximum Dose
Nitroglycerin
50mg/250mL D5W
(200 mcg/mL)
10 mcg/min
Titrate by:
10 mcg/min q 5 min
CP/ Dyspnea/ HTN / To
achieve specified
decrease of Chest Pain,
SOB Chest Pain Free,
SBP >100 or MAP > 60
200
mcg/min
(50 mcg/min
on UT2-IU)
Specified decrease of chest
pain or SPB not achieved at
maximum dose
Nitroprusside
(Nipride
®
)
50mg/250mL D5W
(200mcg/mL)
100mg/250mL D5W
(400mcg/mL)
0. 3 mcg/kg/min
Titrate by:
0.3 mcg/kg/min q 5 min
Hypertension / To
achieve specified
decrease of SBP 100-
120 or MAP > 60
10
mcg/kg/min
Specified decrease of SBP
not achieved at maximum
dose
Norepinephrine
(Levophed
®
)
4mg/250mL D5W
(16 mcg/mL)
16mg/250mL D5W
(64 mcg/mL)
0.03 mcg/kg/min
Titrate by:
0.03 mcg/kg/min q 2 min
Hypotension /To
achieve specified
increase of SBP.
SBP 100-120 or MAP >
60
0. 3
mcg/kg/min
Specified increase of SBP
not achieved at maximum
dose
Phenylephrine
(Neosynephrine
®
)
10mg/250mL NS
(40 mcg/mL)
40mg/250mL D5W
(160 mcg/mL)
10 mcg/min
Titrate by:
20 mcg/min q 2 minutes to 180
mcg/min, as SBP stabilizes
decrease to 40-60 mcg/min
Hypotension / To
achieve specified
increase of SBP 100-120
or MAP 60-70
180
mcg/min
Specified increase of SBP
not achieved at maximum
dose
Propofol
(Diprivan
®
)
500 mg/50 mL DW
(10 mg/mL)
1,000 mg/100 mL DW
(10 mg/mL)
10 mcg/kg/min
(0.3mg/kg/hr)
Titrate by:
10 mcg/kg/min q 5 minutes &
MD to select Wean or Hold
For Daily Sedation Holiday
Sedation / To achieve
specified sedation level
RASS 0 to -1
50
mcg/kg/min
Specified sedation not
achieved at maximum dose
12
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Vasopressin
(Pitressin
®
)
LOOK ALIKE /
SOUND ALIKE
40 units/ 100 mL NS
(0.4 units/mL)
0. 04 units/min Do Not Titrate
Hypotension / To
achieve specified
increase of SBP 100-120
or MAP > 60
0.04
units/min
Specified increase of SBP
not achieved @ Maximum
Dose
Medication Administration Guidelines: Emergency Department Resuscitation Room Medications
FOR RESUSCITATION ROOM USE ONLY: Considerations for medications in locations other than the Emergency Department should be reviewed upon transfer to another
level of care. This section was added to the Medication IV Guidelines on 3/26/2021 after approval from the Pharmacy & Therapeutics Committee meeting held 2/24/2021.
This list is not all inclusive. Consult IV Med Guidelines for further details.
Medication
Loading Dose/Bolus
Starting Dose
(Continuous
Infusion)
Titration Parameters
Maximum Dose
Vasopressor
DOPamine
X
1-5 mcg/kg/min
1-2.5 mcg/kg/min q 5 minute
30 mcg/kg/min
EPINEPHrine
X
0.02 mcg/kg/min
0.02 mcg/kg/min q 5 minute
0.2 mcg/kg/min
Norepinephrine
Levophed
®
X
0.03 mcg/kg/min
0.03 mcg/kg/min q 2 minute
0.3 mcg/kg/min
Phenylephrine
Neosynephrine
®
X
10 mcg/min
20 mcg/min (~0.05-0.1 mcg/kg/min) q 2 minute
Can decrease to 40-60 mcg/min as SBP
stabilizes
180 mcg/min (~2.5-5
mcg/kg/min)
Cardiac
Clevidipine
Cleviprex
®
X
1-2 mg/hr
Double dose q 90 seconds to desired SBP (i.e.
2mg, then 4mg, then 8mg)
If approaching SBP goal, increase by less than
double the dose q 5-10 minutes
21 mg/hr
DiltiaZEM
Cardizem
®
IV Push: 0.25 mg/kg (~20 mg) over 2 minutes
After 15 minutes, may follow by second 0.35 mg/kg
(~25 mg)
5 mg/hr
Do not titrate. Call MD/LIP for order to
increase/decrease by usual of 5 mg/hr to achieve
rate control if indicated.
15 mg/hr
DOBUTtamine
Dobutrex
®
X
2.5 mcg/kg/min
2.5 mcg/kg/min q 5 minute
20 mcg/kg/min
Esmolol
Brevibloc
®
IV Push: 500 mcg/kg over 1 min
Repeat q5 min PRN for total of 3 boluses
50 mcg/kg/min
50 mcg/kg/min q 5 minute with reload of 500
mcg/kg over 1 minute
200 mcg/kg/min
13
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Labetalol
Normodyne
®
, Trandate
®
IV Push: 5-20 mg over 2 mins
Repeat q 10 mins as 40, 80, 160 mg (max of 300
mg)
0.5 mg/min
0.5 mg/min q 15 minute
2 mg/min = 120 mg/hr
Lidocaine
IV Push (cardiac arrest): 1-1.5 mg/kg (= 50-100) mg
undiluted over 2-3 minutes, may repeat q 3-5
minutes up to 3 mg/kg
Non cardiac arrest (stable VT, wide complex
tachycardia, ectopy): 1-1.5 mg/kg (= 50-100 mg)
undiluted over 2-3 minutes, may repeat at 0.5-0.75
mg/kg q5-10 minutes up to 3 mg/kg
1-4 mg/min
Do not titrate, may repeat bolus dose at 0.5
mg/kg if arrhythmia appears
Bolus: 3 mg/kg
CI: Max 4 mg/min
Milrinone
50 mcg/kg over 10 min
0.375 mcg/kg/min
Do not titrate. MD/LIP order required
0.75 mcg/kg/min
NICARdipine
Cardene
®
X
2.5-5 mg/hr
2.5 mg/hr q 5 minute up to desired BP goal
May decrease rate slowly to 3 mg/hr after
achieving BP control
15 mg/hr
Nitroglycerin
NTG
X
10 mcg/min
(may require
higher doses per
MD for CHF)
10 mcg/min q 5 minute
200 mcg/min
(~50 mcg/min expect
chest pain relief)
Nitroprusside
Nipride
®
X
0.3 mcg/kg/min
0.3 mcg/kg/min q 3-5 minute
10 mcg/kg/min
Procainamide
Slow IV push: 100 mg over 2-3 minutes q 5 minutes
1-6 mg/min
Do not titrate.
Administer bolus until:
1) arrhythmia is controlled
2) hypotension occurs, or
3) qRS complex widens by 50% to a total dose
of 1 gram
Wait 5 to 10 minutes after bolus before starting
CI
Loading dose: 15-18
mg/kg
CI: 9 gm/24 hours
Sedation
Dexmedetomidine
Precedex
®
Load (optional): 1 mcg/kg over 10 mins (caution:
hypotension), then 0.2mcg/kg/hr
0.2-0.7 mcg/kg/hr
0.1mcg/kg/hr q 30 minutes
1 mcg/kg/hr
FentaNYL
IV Push: 12.5-100 mcg IV undiluted (may be 200
mcg for pain control/sedation)
25 mcg/hr
25 mcg/hr q 30 minute
200 mcg/hr
Etomidate (Rapid Sequence
Intubation)
Amidate
®
IV Push: 0.2 – 0.6mg/kg over 30-60 secs
X
X
X
Ketamine
Intubation:
1-2 mg/kg IV/IO
Post Advanced Airway Analgesia & Sedation: 1
mg/kg IBW IV/IO, repeat q5-15 minutes prn
X
X
Sedation
IM: 4 mg/kg (rounded to nearest 50 mg), max single
dose 500 mg (may administer additional 100mg in
5-10 minutes)
For IV bolus dose in
sedation: 2 mg/kg
14
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
IV: 1 mg/kg IV/IO over 2 minutes, may administer
additional 0.5-1 mg/kg IV/IO in 5 minutes
LORazepam
Ativan
®
Agitation/anxiety: < 2 mg (range 0.25-2 mg) diluted
with equal volume NS @ 1 mg/min IV push
Sedation
(mechanically
ventilated): 1
mg/hr
1 mg/hr q 30 minute
Infusion requires 0.22 micron filter
15 mg/hr unless higher
max is ordered by
MD/LIP
Midazolam
Versed
®
IV Push (Conscious sedation): 0.5 - 2 mg over 1-2
minutes, repeat q 2-3 minutes prn
IV Push Loading Dose (sedation following
intubation): 0.5 – 4 mg slowly over 2mins
0.5 mg/hr
0.5 mg/hr q 10 minute
20 mg/hr unless higher
max is ordered by
MD/LIP
Propofol
Diprivan
®
IV Push (sedation): 10-20 mg over 3-5 mins
10 mcg/kg/min
(0.3 mg/kg/hr)
10 mcg/kg/min q 5 minute
50 mcg/kg/min unless
higher max is ordered
by MD/LIP
Paralysis
Succinycholine (Rapid Sequence
Intubation)
Caution Paralyzing Agent: Patient
must be placed on ventilator
following administration if not
already
IV Push by MD/CRNA: 0.5-1 mg/kg undiluted over
15-30 secs
X
X
X
Rocuronium (Rapid Sequence
Intubation)
Caution Paralyzing Agent: Patient
must be placed on ventilator
following administration if not
already
IV Push: 0.6- 1 mg/kg undiluted over 5-10 secs then
5 mcg/kg/min
1 mcg/kg/min q 10 mins or as ordered.
16 mcg/kg/min
Cisatracurium
Nimbex
®
Caution Paralyzing Agent: Patient
must be placed on ventilator
following administration if not
already
IV Push: 0.1-0.2 mg/kg over 5-10 sec
2 mcg/kg/min
1 mcg/kg/min q 10 minute
10 mcg/kg/min unless
higher max is ordered
by MD/LIP
Vecuronium
Caution Paralyzing Agent: Patient
must be placed on ventilator
following administration if not
already
IV Push: 0.1 mg/kg (2-10 mg) over 1-2 mins q 1-2
hours
CI: 1 mg/mL at
0.8-1.2
mcg/kg/min
X
X
Extravasation Guidelines
In the event of an extravasation, the following procedure should be followed:
1. Stop the injection/infusion immediately. Disconnect IV tubing and allow the needle/catheter to stay in place.
2. Slowly aspirate as much drug as possible with 3-5 ml of blood. Do not apply pressure to the area where extravasation has occurred.
15
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
3. Remove IV catheter during aspiration. Use of this site for additional IV access is not recommended.
4. Assess the extravasation site as well as any accompanying symptoms. Consider marking area of discoloration. Notify the LIP promptly.
5. Apply warm or cold compress depending on the drug extravasated (see Table 1). Compresses should be applied for 20 minutes 3-4 times daily for the first 24-48 hours after
extravasation
6. Keep the area elevated for 48 hours to reduce swelling
7. Initiate drug-specific measures in accordance with Table 1.
8. Consider the need for a wound care or plastic surgery consult in the setting of pain and/or tissue breakdown
9. Debridement and excision of necrotic tissue should be evaluated if pain persists for 1 to 2 weeks.
Antidotes:
Hyaluronidase is a protein enzyme that enhances the permeability of tissue, facilitating absorption of extravasated IV fluid. Hyaluronidase is used for vesicant solutions,
hyperosmolar infusates and infusates with extreme pH. It is not appropriate for vasopressor infiltration.
Phentolamine is an alpha-adrenergic blocker that produces peripheral vasodilation by direct relaxation of vascular smooth muscle; the vasodilation reverses local ischemia caused
by vasopressor infiltration. Phentolamine is used for vasoactive infusates.
Nitroglycerin Topical Ointment is also a peripheral vasodilator and can be used to treat vasoactive extravasation.
Terbutaline is a beta
2
-selective adrenergic agonist. It has been used to reverse peripheral ischemia caused by the extravasation of vasoconstrictive agents when phentolamine was
unavailable.
Extravasation by Non-Chemotherapy Medications & Treatment
Generic
Compresses
Antidote Procedure (see next
section for further instructions)
Warm
1
Cold
1
Acyclovir (≥ 7 mg/ml)
X
A
Amiodarone
X
A
Aminophylline
X
A
Calcium salts (> 10%)
to comfort
to comfort
A
Contrast media
X
A
Dextrose (> 10%)
X
A
Dobutamine
X
B
Dopamine
X
B
Doxycycline
X
A
EPINEPHrine
X
B
Esmolol
X
A
Foscarnet
X
A
Ganciclovir
X
A
Mannitol (> 5%)
X
A
Methylene blue
X
B
Norepinephrine
X
B
Oxacillin
X
A
Penicillin
X
A
Phenobarbital
X
A
Phenylephrine
X
B
Phenytoin
X
A
Potassium salts (> 2 mEq/ml)
to comfort
to comfort
A
Promethazine
X
A
Propylene glycol containing medications
2
X
A
Sodium bicarbonate
X
A
16
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
(≥8.4% or (≥ 1 mEq/ml)
Sodium chloride (> 1%)
X
A
Theophylline
X
A
TPN (final concentration of amino acids ≥ 5%
or dextrose ≥ 10%)
X
A
Vancomycin
X
A
Vasopressin
X
B
1 = warm or cold compresses: Gently apply warming pack/heating pad (low setting) OR cold packs/ice wrapped in towel for 20 minutes every 6-8 hours for 24-48 hours. Be
careful to avoid extended exposure to heat/cold that can cause further tissue damage.
2 = propylene glycol containing medications include: Etomidate, Lorazepam, DiazePAM, Nitroglycerin, Digoxin, Phenobarbital.
Procedure A: Administer Hyaluronidase
Hyaluronidase
1. Draw up 1 ml of 150 unit/ml hyaluronidase into a 1-ml syringe.
2. Make 5 subcutaneous injections of 0.2 mL hyaluronidase (150 units/mL) around the edge of the extravasation area using a 25-gauge needle, changing needle with each injection.
***Hyaluronidase should be administered as early as possible, but no later than 1 hour after extravasation
Procedure B: Administer phentolamine, terbutaline or nitroglycerin topical ointment
Phentolamine:
1. Reconstitute phentolamine 5 mg vial with 1 ml of 0.9% sodium chloride, draw into 10mL syringe, and dilute to total of 10mL (0.5mg/mL).
2. Inject the contents as five separate subcutaneous injections around the edge of the extravasation area using a 25-gauge needle, changing the needle with each injection.
Normal skin color should return within one hour,
***Phentolamine should be administered as early as possible, but no later than 12 hours after extravasation.
Terbutaline:
For small/distal extravasations:
1. Dilute terbutaline 1 mg/mL with 1 mL of 0.9% sodium chloride (total volume = 2 mL)
2. Administer multiple subcutaneous injections of approximately 0.25 ml around the edge of the extravasation site using a 25-gauge needle, changing the needle with each
injection.
3. Total volume administered should be in the range of 0.5-1 mL.
For large extravasations:
1. Dilute terbutaline 1 mg/ml with 9 ml of 0.9% sodium chloride (total volume = 10 ml).
2. Administer multiple subcutaneous injections of approximately 0.25 mL around the edge of the extravasation site using a 25-gauge needle, changing the needle with each
injection.
3. Total volume administered should be in the range of 3-10 mL.
Nitroglycerin topical ointment:
1. Apply 1-2 inches of nitroglycerin topical ointment to extravasation site.
2. Allow ointment to remain on the site for 6-8 hours before cleansing.
3. May reapply every 8 hours as needed.
References:
Reynolds P, MacLaren R, Mueller S, et al. Management of extravasation injuries: a focused evaluation of noncytotoxic medications. Pharmacotherapy. 2014;34(6):617-632.
Le A, Patel S. Extravasation of noncytotoxic drugs: a review of the literature. Ann of Pharmacother. 2014;48(7):870-876.
PL Detail-Document, Treatment for Extravasation of Non-Chemo Drugs.
17
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Pharmacist’s Letter/Prescriber’s Letter. December 2011.
Anderson J (2015, April 6). What are Current Recommendations for Treatment of Drug Extravasation? Retrieved from: http://dig.pharm.uic.edu/faq/2015/Jan/faq2.aspx.
Filter Guidelines
This filter guideline does not include chemotherapy agents and is only applicable to items contained within these IV medication guidelines
Basic properties of filtration during drug preparation/administration
Filter infusion sets at UConn Health
• 5 micron filter removes large particles, including glass from ampules
• 1.2 micron filter removes fungi and other particulate contamination
• 0.2 micron filter is designed for sterilization and bacteria retention
Note: 0.2 micron and 0.22 micron filters are indistinguishable. Their performance
is the same, only the difference being the designation of their pore size rating.
• BD SmartSite 0.2 micron low protein binding extension set (latex free, 5mL
fluid path), 20028E
• BD SmartSite 0.2 micron low protein binding filter extension set (latex free,
DEHP free, 5mL fluid path), 20350E
•
Churchill 0.2 micron minibore extension set (DEHP free), Warehouse
961012 (Stocked in pharmacy)
• Interlink 1.2 micron filter (available from pharmacy)
Drug
(Generic Name/Brand Name)
Type of Filter
Comments/Rationale
Compounding (Pharmacy)
Administration on Units
Abatacept (Orencia®)
None
In-line 1.2 micron low sorbing (protein) binding filter
Abciximab (ReoPro)
Aseptically withdraw the required abciximab
dose/volume through a 0.22 micron low protein-
binding syringe filter into a syringe; this applies
to preparation of the bolus dose and the
continuous infusion
If a syringe filter was not used when preparing the
infusion, administer using an in-line 0.2 or 0.22 micron
low protein-binding filter
Agalsidase Beta (Fabrazyme)
Do NOT use filter needle to prepare
May use an in-line 0.22 micron low sorbing (protein)
binding filter
Albumin
None
Manufacturer Dependent:
18
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
CSL Behring: A filter is NOT required (comes in a bottle)
but be sure to open the vent on the tubing.
Octapharma: A filter is NOT required.
Baxter: Use 15 micron IV filter set supplied by Pharmacy
(comes in a bag or bottle)
Alglucosidase Alfa (Myozyme)
None
In-line 0.22 micron low sorbing (protein) binding filter
Alpha-1 Proteinase Inhibitor (Prolastin)
Use filter needle supplied with each vial
Manufacturer dependent:
See individual package insert for each product dispensed
Amiodarone
None
For continuous infusions, use an in-line 0.22 micron filter
Amphotericin B Liposomal (AmBisome)
Withdraw appropriate amount of reconstituted
solution into a syringe, attach a 5-micron filter,
and inject contents of syringe through filter
needle into an appropriate amount of D
5
W
An in-line membrane filter (not less than 1 micron) may
be used
Anti-thymocyte globulin, rabbit
(Thymoglobuin®)
None
An in-line 0.22 micron filter
Bamlanivimab/etesevimab
None
An in-line 0.22 micron filter
Bezlotoxumab (ZINPLAVA®)
None
A 0.2 to 5 micron in-line or add-on filter
Casirivimab/ imdevimab
None
An in-line 0.22 micron filter
Epoprostenol (Flolan®, Veletri®)
None
An extension set with a 0.22 micron filter.
Factor Products
Use filter needle provided by manufacturer
Do not use an in-line filter
Fat Emulsion for TPNs
None
An in-line 1.2 micron or larger filter
Filters < 1.2 micron pore size must not be used.
Golimumab Aria (Simponi Aria®)
None
An in-line 0.22 micron filter
Imiglucerase (Cerezyme®)
None
May use an in-line 0.22 micron low sorbing (protein)
binding filter
Immune Globulin (Gammagard S/D®)
None
15 micron filter for S/D product only for patients with IgA
deficiency
InFLIXimab
None
An in-line, low protein-binding ≤1.2 micron filter
LORazepam
None
An in-line 0.22 micron filter
19
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Mannitol
5 micron filter needle (25% diluted mannitol)
An in-line 0.22 micron filter
Phenytoin
None
An in-line 0.22 micron filter for infusion
Promthrombin Complex Concentrate,
Human (Kcentra®)
Use filter needle provided by manufacturer
None
Sotrovimab
None
An in-line 0.2 micron filter
Total Parenteral Nutrition (TPN)
None
An in-line 0.22 micron filter for infusion
References: Package inserts for applicable products
Medication Considerations for Midline Catheters Guideline
Midline catheters, which vary in length, are inserted via the same veins used for PICC placement in the middle third of the upper arm; however, the midline catheter is advanced
and placed so that the catheter tip is level or near the level of the axilla and distal to the shoulder.
Midline catheters are preferred over PICCs for either: 1. Difficult peripheral venous access and 2. Frequent phlebotomy - for use less than 14 days (Chopra, et al). That said, the
FDA approval for midline catheters is up to 30 days though after the first 14 days there is an increasing risk of catheter clotting/malfunction.
Midline catheters are contraindicated when there is a history of venous thrombosis, restricted blood flow to the extremities, and end-stage renal disease requiring peripheral vein
preservation. Recognize a midline is NOT a central venous access device and should never be used for continuous vesicant infusions, total parental nutrition (TPN),
chemotherapy, solutions greater than 600 mOsm/L, and those infusions that mandate central line-only administration.
When determining the optimal venous access, medications and other infusions should be considered on an individual patient basis. The greatest concern is the potential
extravasation of vesicant drugs, and any drugs known to be irritants should be avoided whenever possible. If central access cannot be obtained, short courses of therapy may be
well tolerated, but risk should be evaluated and staff should be familiar with techniques for the management of extravasation.
The following should also be avoided in midline catheters**: *May be ok with short courses of therapy (not to exceed 3 days) with close monitoring
acyclovir amiodarone alteplase
amphotericin B* ampicillin/sulbactam* azithromycin*
calcium chloride
calcium gluconate
caspofungin*
contrast media nonionic*
dextrose
concentration
≥10%
dobutamine
epinephrine
dexrazoxane* foscarnet*
ganciclovir
mannitol ≥20%
norepinephrine
fosphenytoin*
gentamicin*
iron dextran*
pentamidine pentobarbital phenylephrine
levofloxacin* meropenem* morphine sulfate*
phenytoin promethazine
sodium
bicarbonate
nafcillin* oxacillin* pamidronate*
20
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
sodium chloride
≥3%
TPN, exceeding
600mOsm/L
vasopressin
phenobarbital
potassium chloride
(≥40 mEq)*
protein solutions >5%
sulfamethoxazole/trimethropim*
tobramycin*
vancomycin*
zidovudine*
**This is not a comprehensive list and only provides examples of common medications that should not be administered via midline catheters. For specific drugs not found on this
list, consult Trissel’s Handbook for Injectable drugs, medication package inserts or contact the pharmacy.
References:
1. Integrated Vascular Services LLC. Drugs to be infused through A central line (PICC line). https://www.ivs1.com/images/centralline.pdf. 2006.
2. Visiting Nurse and Hospice Care. Considerations for home infusion therapy. https://www.vnhcsb.org/media/data/papers/pdf/593_25.ApdexD.3.pdf. 2010.
3. Alexandrou, Evan & Ramjan, Lucie & Spencer, Timothy & Frost, Steven & Salamonson, Yenna & Davidson, Patricia & M. Hillman, Ken. (2011). The Use of Midline Catheters in the Adult Acute
Care Setting - Clinical Implications and Recommendations for Practice. Journal of the Association for Vascular Access. 16. 35-41. 10.2309/java.16-1-5.
https://www.researchgate.net/publication/233547486_The_Use_of_Midline_Catheters_in_the_Adult_Acute_Care_Setting_-_Clinical_Implications_and_Recommendations_for_Practice
4. MedComp. Midline education card. https://www.medcompnet.com/products/pdf/brochures/piccs/PN2513_A_UNIVERSAL_PICC_Midline_Education_Card.pdf. Updated 2011. Accessed January
21, 2019.
5. IV Therapy. Intravascular device selection. https://www.iv-therapy.net/pdf/deviceselection.pdf. Accessed January 21, 2019.
Gorski L. A. (2017). Fast Facts for Nurses about Home Infusion Therapy: The Expert's Best Practice Guide in a Nutshell. New York, NY: Springer Publishing Company. [Context Link]
6. Gorski L. A., Hadaway L., Hagle M., McGoldrick M., Orr M., Doellman D. (2016). Infusion therapy standards of practice. Journal of Infusion Nursing, 39(1S), S1-S159. [Context Link]
7. Gorski L.A., Stranz M., and Cook L. et al. Noncytotoxic Vesicant Medications and Solutions. Infusion Nurse Society. 2016.
8. Chopra V, Flanders SA, Saint S, Woller SC, O'Grady NP, Safdar N, et al. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the
RAND/UCLA Appropriateness Method. Ann Intern Med. ;163
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Abatacept
Orencia
®
[immune modulator]
Rheumatoid
Arthritis
OP-INFC
OP-NCCC
I.I.: dose/100mL NS over 30 mins with
an inline 1.2 micron low sorbing
(protein) binding filter
Dose:
Weight < 60 kg = 500 mg
Weight 60-100kg = 750 mg
Weight > 100 kg = 1000 mg
Caution/Warning:
Comments: Use 1.2 micron low sorbing (protein) binding filter.
Drug Interactions:
Monitor: Vital signs before and after infusion.
Side Effects: Increased risk of exacerbation of COPD & other infections.
Possible acute infusion reactions: dizziness, hypertension, and headache were most
commonly reported (1-2%) in association with the reaction.
Stability: 24 hrs at room temperature. Protect from light
21
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Acetaminophen
Ofirmev
®
[analgesic, antipyretic]
Restricted Use
Pain, Fevers
ALL
UNITS
I.I.: Dose infused over 15 mins
Dose:
Adults/adolescents
Weight > 50 kg = 1000 mg q 6 hrs)
Weight < 50 kg = 15 mg/kg q 6 hrs
Max: 4 gm/day
Caution/Warning: Contraindicated in severe liver failure
Comments: Restricted for use patients who can’t take oral, enteral or rectal
acetaminophen. In CPOE, there will be only the opportunity to order as q6hrs x 2 doses
or as one time doses due to restricted formulary status.
1000 mg dose is provided in a bottle with 100 mL of diluent, no further dilution is
required. For lower doses remove excess dose from vial and infuse desired dose over
15 mins (e.g. withdraw 35mL from bottle for 650mg dose).
Since the manufacturer provided bottle of IV Acetaminophen (OFIRMEV) has negative
pressure the following procedure must be followed to assure proper flow.
Step 1: Using the fully extended hanger provided within the secondary IV set, lower
the primary container. Make sure the On-Off clamp of the secondary IV set is closed
prior to proceeding.
Step 2: -Open vent cap on the secondary IV set, and insert spike downward into an
upright vial. Allow the upright container to vent for around 5 seconds (no more hissing
sounds) to ensure the negative pressure is relieved prior to inverting and hanging. Fully
squeeze and hold drip chamber and do not release until after container is inverted and
hung. NOTE: If the vial is inverted when spiked or the vent is opened after the vial is
inverted, this may result in intermittent or poor flow.
Step 3: Hang the vial and fill the drip chamber to fill line. Prime the secondary IV set
by opening the On-Off clamp to purge air. Once air is purged, close the On-Off clamp.
Swab and connect the valve on the primary IV set to the adapter of the purged
secondary IV set. Once connected, release and fully open the On-Off clamp. Adjust
flow rate to administer the contents of the vial IV over 15 minute.
Side Effects:
Monitor:
Side Effects:
Stability: Store intact vials at 20°C to 25°C (68°F to 77°F); do not refrigerate or freeze.
Use within 6 hours of opening vial or transferring to another container. Discard any
unused portion; single use vials only.
AcetaZOLAMIDE
Diamox
®
[carbonic anhydrase
inhibitor]
Metabolic Alkalosis
ALL
UNITS
(Except
Psy)
IVPush: 125-500mg dilute with 10 mL
NS over 1-2 mins .
Caution/Warning: Use cautiously in respiratory acidosis & CO
2
retention.
Comments: Reduce interval if CrCl<50 mL/min. Ineffective if CrCl< 10 mL/min.
Drug Interactions:
Monitor: I&O, electrolytes (K+), paresthesias.
Side Effects:
Stability: Stable 3 days if refrigerated, 12 hrs at room temperature.
22
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Acetylcysteine (N-AC)
Acetadote
®
[antidote]
Nov 2017: During
shortage
of SVP
50mL/100mL D5W, only
alternative option is ½ NS
Acetaminophen
overdose
ALL
UNITS
(Except
Psy)
I.I. LD: 150 mg/kg in 500 mL D5W or
½ NS (caution with osmolarity) over 60
mins, then C.I. of 50 mg/kg in 500 mL
D5W or ½ NS (caution with osmolarity)
at 125 mL/hr for 4 hrs, then 100 mg/kg
in 1000 mL D5W or ½ NS (caution with
osmolarity) at 65 mL/hr for 16 hrs. Total
dose = 300 mg/kg over 20 hrs.
Continue for 25-50 hrs if LFT’s show
liver injury or those presenting > 8 hrs
post-ingestion. A toxicology consult is
available at any time by contacting the
Poison Control Center at 1-800-222-
1222.
Note: Fluid restricted pts can receive
lower volumes of fluid. 100 mL with
load dose, 250 ml with 2
nd
dose and 500
mL with 3
rd
dose.
Caution/Warning:
Comments: (Acetaminophen Overdose) Note: Under Guardrail’s as 1
st
, 2
nd
then 3
rd
dose. Pts who ingest more than 150 mg/kg of acetaminophen (10 gm for a 70 kg pt)
within 8 hours or have a 4hr level at the 25% hepatic risk level should receive liver
prophylaxis with oral acetylcysteine for 72 hrs. Pts < 40 kg or fluid restricted can
receive IV Acetadote in 50 % of the stated D5W volumes. Oral therapy has equivalent
efficacy to IV therapy and is preferred over IV use due to the drug delivery to the liver
from the first pass effect. 48 hr IV therapy = 72 hr oral therapy. Oral therapy: 140
mg/kg x 1 dose then 70 mg/kg q 4 hrs for 17 total doses. Dilute in cold beverage. Re-
dose if pt vomits within ½ hr of oral dose. Consider antiemetics (metoclopramide or
ondansetron) if vomiting occurs within 1 hr of oral dosing. Select, low-risk pts may
receive an abbreviated course of oral therapy (minimum of 24 hrs) which has been
shown to be as effective as the 72-hr course. Note: Pts with fulminant hepatic failure
should have therapy continued until recovery or death.
(Renal Protection) Oral/NG acetylcysteine (N-AC) is preferred over IV. IV N-AC is
indicated only if patients can not take oral / NG N-AC.
Risk factors for Contrast-Induced Nephropathy:
Hypotension, CHF, use of IABP, pre-existing renal dysfx-
Cr > 1.5 and/or eGFR < 60 , age > 75 yrs, diabetes, HCT < 39 for men < 36 for women,
dehydration, concomitant use of nephrotoxic drugs- ACEI’s, Aminoglycosides, loop
diuretics, NSAID’s.
High Risk Pts include: > 2 of above risk factors or eGFR < 30 mL/min.
Caution with the use of aggressive hydration and sodium bicarbonate in pts with acute
CHF/pulmonary edema or hyponatremia.
Sodium Bicarbonate 150 mEq in 1 L of D5W as 3 mL/kg bolus 1 hr prior to procedure
AND 1 ml/kg/hr during and for 6 hrs post-procedure is an option with N-AC.
Drug Interactions:
Monitor:
Side Effects: IV use can cause anaphylactoid reactions, N/V, itching, flushing or
hypotension. Management of anaphylactoid reactions: consider oral therapy. Flushing:
no specific treatment. Urticaria: continue treatment if needed and DiphenhydrAMINE
1mg/kg max 50 mg IV. Angioedema: stop or slow infusion, DiphenhydrAMINE1mg/kg
max 50 mg IV and restart treatment if no symptoms. Life-Threatening: Stop med, treat
symptomatically, reassess need for med.
Stability: Use one vial IV Acetadote to admix the # 4 doses of diluted 600-1200 mg IV
acetylcysteine/ 50 mL D5W and use a 24 hr expiration dating on the final diluted
solutions and can be stored at room temperature.
The package insert states that acetylcysteine is stable for 24 hours at room temperature
in sodium chloride 0.45% (To ensure tolerance of the infusion, osmolarity should be
adjusted to a physiologically safe level – 7mg/mL Osmolarity in
1
/
2
NS: 245 mOsmol/L,
24mg/mL Osmolarity in
1
/
2
NS: 466 mOsmol/L)
Renal protection
ALL
UNITS
(Except
Psy)
I.I.: 600 (preferred dose) - 1200 mg in
50 mL D5W or ½ NS (caution with
osmolarity) over 10-15 mins bid x 4
doses, optimally 2 doses the day before
contrast procedure and 2 doses after the
contrast procedure.
Emergent Procedure:
600 mg X 1 dose before procedure and
continue 3 doses q 12 hrs post procedure.
Hydration is highly recommended: NS or
0.45% saline at 1 mL/kg/hr or 0.5
mL/kg/hr in patients with overt heart
failure or EF < 40%. Start 12 hours
before procedure and continue for 12 hrs
post-procedure (total of 24hrs). For
emergent procedure, fluid bolus of 0.5 –
1 L prior to procedure. Hydration
depends on clinical status.
23
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Acyclovir
Zovirax
®
[antiviral]
Nov 2017: During
shortage
of SVP
50mL/100mL D5W, use
NS
Anti-viral- herpes
simplex, zoster
encephalitis
ALL
UNITS
I.I.: 5-10 mg/kg q 8 hr over > 1 hr.
Doses:
< 350 mg / 50 mL NS or D5W over 1 hr.
351-700 / 100 mL NS or D5W over 1 hr.
> 700 mg / 250 mL NS or D5W over 1
hr.
Max. Conc. 7 mg/mL
Patient must have adequate hydration
(e.g. IVFs) while on this medication.
Dose on ideal body weight. If patients
total body weight is less than ideal body
weight, use total body weight.
Caution/Warning:
Comments: Dose reductions required in renal failure (<50mL/min). Maintain
hydration.
Drug Interactions:
Monitor: SrCr.
Side Effects: Phlebitis, rash.
Stability: Keep bag at room temperature to avoid precipitation, administer in separate
IV line. Do not refrigerate. Reconstitute 500 mg vial w 10 mL SW and 1000 mg vial
with 20 mL SW. Do not reconstitute with bacteriostatic water.
P&T Therapeutic Interchange List See Appendix XV for Dose and Renal dose
Adjustment
Adenosine
Adenocard
®
[antiarrhythmic]
Antiarrhythmic
Agent for SVT
In presence
of Critical
Care RN or
Action RN
and LIP
during
RRT/Code,
ALL
UNITS
OR/PACU
UHSC
IV Push (Peripheral line): SVT Initial
dose: 6 mg rapid undiluted over 1 -3 secs
at lowest port and rapid flush with 20 mL
NS. After 1-2 mins if PSVT persists
give 12 mg rapid IV Push undiluted over
1 -3 secs and may repeat 12 mg in 1-2
mins if needed. Max dose = 30 mg
IV Push (Central line): Use 50 % of
peripheral dose. SVT Initial dose: 3 mg
rapid undiluted over 1 -3 secs at lowest
port and rapid flush w 20 mL NS. After
1-2 mins if PSVT persists give 6 mg
rapid IV Push undiluted over 1 -3 secs,
may repeat 6 mg in 1-2 mins if needed.
Max dose = 30 mg
Caution/Warning:
Comments: With appropriate monitoring, may be given by the MD/LIP as a diagnostic
intervention. Theophylline & caffeine antagonizes effects. Persantine potentiates
effects.
When administered through a central venous line, adenosine has a faster onset of action
and may be subjected to less degradation as compared to administration through a
peripheral line so use 50% of dose that would administer peripherally.
Drug Interactions:
Monitor: Patient must be on a continuous cardiac monitor/telemetry. Requires code
cart, defibrillator at bedside.
Side Effects: Transient AV block, chest pain, bronchospasm, palpitations, headache,
flushing, dyspnea.
Stability: Store at room temperature. Do not refrigerate; crystallization may occur (may
dissolve by warming to room temperature).
If Extravasation,
see Page 10
Avoid in midline cath see
Page 14
24
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Agalsidase beta
Fabrazyme
®
[endocrine-metabolic agent]
Fabray Disease
OP-INFC
OP-NCCC
I.I.: 1 mg/kg IV in 500 mL NS q 2 wks,
infuse over 1.5 -3 hrs as tolerated
Caution/Warning:
Comments: May administer through in-line low protein-binding 0.22 micron filter.
Drug Interactions:
Monitor: Report any signs of respiratory infection to MD/LIP before initiating
infusion. V/S pre-infusion and 1 min after infusion.
Side Effects:
Stability: Stable for 24 hrs if refrigerated.
Albumin
[volume expander]
(see comments)
Hypovolemia,
shock, renal failure,
cirrhosis & burns
ALL
UNITS
(Except
Psy)
I.I.:
25% at max of 2-3 mL/min or over 15-30
min
5% at max of 2-4 mL/min or over 15-30
min
(see comments section for information if
a filter is needed or not needed as this is
dependent upon the product used)
Caution/Warning:
Comments: A filter is NOT required for CSL Behring product (comes in a bottle) but
be sure to open the vent on the tubing. A filter is NOT required for Octapharma
product. Use 15 micron IV filter set supplied by Pharmacy for Baxter Product (comes in
a bag or bottle) ONLY. Filter Information Link
Max. Dose 250 gm over 48 hrs. May infuse more rapidly in emergency.
Drug Interactions:
Monitor: for rare anaphylactoid reactions: urticaria, skin rash, pruritus, edema,
hypotension and bronchospasm. May cause nausea, vomiting, increased salivation,
chills and febrile reactions.
Side Effects:
Stability: Discard unused solution after 4 hrs.
Alglucosidase alpha
Myozyme
®
[enzyme replacement]
Pompe disease
OP-INFC
OP-NCCC
I.I.: 20 mg/kg over 4 hrs, start @
1mg/kg/hr for 1
st
30 min then
3 mg/kg/hr next 30 min then
5 mg/kg/hr next 30 min then
7 mg/kg/hr for duration of infusion
Caution/Warning:
Comments: Requires 0.22 micron low protein binding filter & light protection overlap.
May require filter change if occlusion alarms. No titration needed with MD/LIP
orders.
Drug Interactions:
Monitor: V/S pre-infusion and with q step increase, & post-infusion and hourly until
discharge. If reaction, stop infusion and call MD/LIP. Requires MD/LIP order to
resume.
Side Effects:
Stability:
25
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Allopurinol
[xanthine oxidase inhibitor]
Gout,
Tumor Lysis
syndrome
ALL
UNITS
(Except
Psy)
I.I.: Gout: 100 -300 mg daily over 30
minutes.
Tumor Lysis: 200-400 mg/m
2
/day -
should be initiated at 24-48 hours before
the start of chemotherapy known to
cause tumor lysis (including
adrenocorticosteroids).
Caution/Warning:
Comments: IV daily dose can be administered as a single infusion or in equally divided
doses at 6-, 8-, or 12-hour intervals. Maintain urine output > 2 liters/ day and maintain
neutral or slightly alkaline urine is desirable.
Drug Interactions:
Monitor:
Side Effects: CV- arteritis, vasculitis Derm.: various types of skin rashes, fever, chills,
arthralgia, pruritus, Blood disorders
Stability: Reconstitute each 500 mg vial with 25 mL of sterile water for injection.
Solution should be clear and almost colorless with only slight opalescence. Dilute to < 6
mg/ml concentration with 0.9% NaCl or D5W. Administer within 10 hr of
reconstitution; do not refrigerate. Do not administer solutions that are discolored or
contain particulate matter
Alpha1- proteinase
inhibitor
Aralast NP®
[antitrypsin deficiency
agent]
Alpha1- proteinase
inhibitor deficiency
OP-INFC
I.I.: 60 mg/kg weekly infused at a rate
of ≤ 0.2 mL/kg/min (Aralast NP®)
Caution/Warning:
Comments:
Drug Interactions:
Monitor: Vital signs during infusion. Monitor for anaphylactic reaction.
Side Effects:
Stability: 3 hours from preparation
Alpha 1-Proteinase
inhibitor
Prolastin
®
[blood modifier agent]
(manf dependent)
Alpha1-Antitrypsin
def.
OP-INFC
OP-NCCC
I.I.: 60-120 mg/kg ,infuse over 60-120
mins, start at 50 mL/hr for 15 mins then
increase per order.
Caution/Warning:
Comments: Pharmacy to use filter needle supplied with each vial.
Drug Interactions:
Monitor: Baseline V/S, 15 mins after start, then 15 mins after infusion is complete.
Side Effects:
Stability:
26
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Alprostadil
Prostin VR
®
[Prostaglandin E]
TITRATE MED
Raynaud’s disease
UT1-ICU
UT2-IU
OP-INFC
OP-NCCC
C.I.: 500 mcg/ 500 mL NS (1 mcg/ml)
Start @ 2 ng/kg/min x 2 hrs, if tolerated
increase to 4ng/kg/min x 2 hrs, if
tolerated increase to 6 ng/kg/min x 2 hrs,
if tolerated increase to 8 ng/kg/min x 1-2
hrs - NS @ 50 mL/hr to be infused
separately is recommended to decrease
blood viscosity and improve
microcirculation.
Caution/Warning:
Comments: Via peripheral vein unless a central line is needed for access. The optimal
rate is one that produces vasodilation as evidenced by increased skin temp and
improved digit color without side effects.
Drug Interactions:
Monitor: Document V/S (BP, HR, RR) q 15 mins x 1 hr then q 20-30 mins after initial
rate changes, once stable infusion rate V/S may be done 1 hr, affected extremity temp &
size of ulceration & gangrene, affected area appearance - color, pain, discomfort. Hold
infusion if hypotension (SBP<90) & call MD/LIP. PRN prochlorperazine, loperamide,
acetaminophen and/or narcotics may be required for drug related side effects or disease
symptoms.
Side Effects: Hypotension, bradycardia/tachycardia, flushing dizziness, nausea &
vomiting, diarrhea & headaches. If significant changes in V/S, decrease infusion rate &
call MD/LIP.
Stability:
Alteplase = TPA
Activase
®
Cathflo Activase
®
[tissue plasminogen
activator]
HIGH ALERT / DOUBLE
CHECK
MI
CCL/EP
ED
UT1-ICU
OR/PACU
I.I.: Mix 100 mg/ 100 mL SW (1mg/mL)
with IV Push 15mg (15mL) over 1-2
minutes then
If weight:
< 67 kg: 0.75mg/kg (not > 50mg) over
30 mins, then 0.5 mg/kg (not > 35mg)
over 1 hr with a total dose including
bolus not to exceed 100mg
> 67 kg: 50 mg over 30 mins, then 35mg
over 60 mins with a total dose of 100mg
including the bolus
Caution/Warning: Contraindications include active internal bleeding, hypersensitivity
to alteplase, severe uncontrolled hypertension, recent intracranial or intraspinal surgery
or trauma (within 3 months), intracranial neoplasm, arteriovenous malformation,
aneurysm, known bleeding diathesis, history of cerebrovascular accident, history of
intracranial hemorrhage (ischemic stroke), seizure at the onset of stroke (ischemic
stroke), platelet count less than 100,000/mm
3
(ischemic stroke) and administration of
heparin within 48 hours preceding the onset of stroke and have an elevated activated
partial thromboplastin time at presentation (ischemic stroke).
Comments: Use dedicated line. See protocols for each indication.
Drug Interactions:
BKC: Dispose in
Black Bin
27
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
(Activase® including bolus
dosing)
Alteplase = TPA
Activase
®
Cathflo Activase
®
Acute stroke
ED
UT1-ICU
OR/PACU
ALL
UNITS by
Critical
Care RN
during
Stroke
Alert/RRT
I.I.: (Stroke Kit) 100 mg/100mL SW
(1mg/mL) as 0.9 mg/kg (90 mg max)
with 10% of total dose as IV Push over
1-2 mins then remainder of total dose as
CI over 60 mins. Alteplase (t-PA) for
Acute Stroke must be administered
within 3 hours of the onset of signs and
symptoms. Run infusion on a primary
line and flush line after infusion.
• Ischemic and Hemorrhagic
Stroke HAM CCG Protocol
• Pharmacist Instructions for
Stroke Kit
• Alteplase Dosing Chart
• Alteplase on Guardrails
Monitor: for bleeding, hypotension. Monitoring for use with MI and to assess for
evidence of cardiac reperfusion includes resolution of chest pain, resolution of baseline
EKG changes, appearance of reperfusion arrhythmias (e.g. accelerated idioventricular
rhythm, bradycardia, nonsustained ventricular tachycardia), cardiac enzyme washout
phenomenon (earlier CPK peak), reduced total CPK release and preserved left
ventricular function.
Related Policies: Policies put with corresponding diagnosis. Refer to Nephrology for
specific protocols for infusions of alteplase for clotted arterial or venous lines/grafts.
Side Effects:
Stability: Dilute with Sterile Water without preservative and prepare just before use. 8
hrs at room temperature for final solution per package insert. Dilution with Normal
Saline has a 24 hour expiration per reference: Semba, Charles et al. “Alteplase: Stability
and Bioactivity after Dilution in Normal Saline Solution” Journal of Vascular and
Interventional Radiology. Vol 14, Issue 1, Jan 2003: 99-102
Information on Alteplase continues on the nex
t page.
See prior page for comments on Alteplase.
Pulmonary
Embolism
ED
UT1-ICU
OR/PACU
I.I.: 100 mg/100 mL SW over 2 hr, then
start IV heparin.
Pulmonary
Embolism
Catheter Directed
Treatment
ED
UT1-ICU
OR/PACU
I.I.: Catheter directed infusion
Bilateral: 12.5mg/125mL infused at
10mL/hr for 12 hours (with Heparin
25,000 units/500mL at 500 units/hr)
Unilateral: 25mg/250mL infused at
10mL/hr for 24 hours (with Heparin
25,000 units/500mL at 500 units/hr)
Reference:
A Prospective, Single-Arm, Multicenter
Trial of Ultrasound-Facilitated, Catheter-Directed, Low-
Dose Fibrinolysis for Acute Massive and Submassive
Pulmonary Embolism: The SEATTLE II Study
Peripheral Artery
Occlusion
ED
UT1-ICU
IRAD
OR/PACU
I.I.: Catheter directed infusion of 15 mg
in 500 mL NS (0.03mg/mL) with a rate
from 0.5mg/hr (16.7ml/hr) to 1 mg/hr
(33.3mL/hr)
Empyema
ALL
UNITS
(Except
Psy)
Via Chest Tube:
10 mg in 50 mL NS (syringe) via chest
tube, may flush chest tube with 50 mL
NS, roll pt. to ensure distribution and
clamp with water seal for 4 hrs and may
be repeated daily (usually 2-4 doses
required
Avoid in midline cath
Page 15
28
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
[tissue plasminogen
activator]
HIGH ALERT / DOUBLE
CHECK
(Activase® including bolus
dosing)
complicated deep venous
thrombosis by vascular
surgery, using a Trellis
device/thrombectomy with
thrombolytic alteplase or
management of peripheral
arterial occlusion
LIP on the
sterile field
during
procedures
Catheter directed bolus
administration: 2 mg vial or multiples
of 2mg in the procedural area
immediately before use. (Add 2.2 mL
SWFI to vial; do not shake. Final
concentration: 1 mg/mL.)
Clotted catheters
ALL
UNITS
(Except
Psy)
Via Clotted Catheters: Cathflo 2mg/ 2
mL draw up with a 10 ml syringe.
Studies have indicated that needle
Central venous catheters: instill volume
to fill catheter and dwell 30 mins before
aspirating, if not patent increase dwell
time to 2 hrs, If catheter function has
been restored, aspirate 4-5 mL of blood
to remove alteplase and residual clot, and
gently irrigate the catheter with 0.9% NS
HD access Grafts: instill 2 mg/ 2ml
HD Cath Cond.: add volume to fill
arterial and veno catheter then aspirate &
discard before next dialysis
Amikacin
Amikin
®
[aminoglycoside]
RESTRICTED
ANTIMICROBIAL
Nov 2017: During
shortage
of SVP
50mL/100mL D5W, use
NS
Bacterial infection
ALL
UNITS
(Except
Psy)
I.I.: 15 mg/kg/day (maximum 1500
mg/day) mixed in 100 mL NS or D5W
and administer over 30 -60 mins.
Caution/Warning:
Comments: Pharmacy to mix. Dose based on weight, renal function & diagnosis. Dose
divided q 8 to 12 hrs. Contact RPh for assistance in dosing. Trough before 3
rd
dose, or
10 hrs random after 1
st
dose if using daily dosing.
Drug Interactions:
Monitor:
Side effects:
Stability:
Avoid in midline cath
Page 15
29
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Aminocaproic acid
Amicar
®
[plasmin inhibitor]
Systemic hemostatic
UT1-ICU
OR/PACU
I.I. LD (Cardiopulmonary bypass): 50-
80 mg/kg over 20-30 mins, then C.I.:
25-30 mg/kg/hr PLUS 10 mg/kg in the
priming solution of the cardiopulmonary
bypass pump AS
I.I. LD: 5 gm / 250 mL D5W or NS over
1st hr then 5 gm/ 250 mL D5W or NS at
50 mL/hr for 5 hrs then reassess need.
C.I.: Maintenance dose of 1-2 gm/hr.
Dilute 20 gm in 1000 mL D5W or NS
(2Gm/100 mL) and infuse at 50-
100 mL/hr
Systemic hemostatic:
I.I. LD (Systemic hemostatic): 4-5 gm /
250 mL D5W or NS over 1st hr then 1
gm/hr
with maximum of 30 gm/ 24 hrs, 10
gm/ 500 mL D5W or NS at 50 mL/hr x 6-
8
hrs then reassess need.
Caution/Warning:
Comments: Avoid rapid IV push to lower risk of hypotension, bradycardia &
arrhythmias
Drug Interactions:
Monitor:
Side Effects: Dizziness, headache, monitor HR, BP, coag’s and for bleeding. Use
cautiously in renal /hepatic disease. Max 30 gm/day = 1.25gm/hr.
Stability:
Aminophylline
[methylxanthine]
Bronchodilator
ALL
UNITS
(Except
Psy)
I.I. LD: 5.7 mg/kg in 100 mL NS or
D5W over 30-60 mins, max < 25mg/min
C. I. : 1 g Aminophylline/500 mL NS or
D5W
0.25mg/kg/hr Cardiac, Hepatic, etc
0.38 mg/kg/hr adults >60
0.51 mg/kg/hr adults 16-60
Caution/Warning:
Comments: Aminophylline 1 g/500 mL D5W = Theophylline 800 mg/500 mL D5W
(Theophylline is 80% of Aminophylline dose). Doses should be individualized based on
peak serum concentrations and should be based on ideal body weight. The treatment of
asthma exacerbations with aminophylline is not supported or recommended by current
clinical practice guidelines.
Therapeutic range of 5-20 mcg/ml.
Draw level 24-48 hrs after starting or dose change.
Drug Interactions:
Monitor:
Side Effects:
Stability:
Reversal of
vasodilation with
Persantine nuclear
stress test
CCL/EP
IV Push: 125 mg over 20 secs, may
repeat X 1
For prevention of
bradyarrhythmias
induced by rheolytic
thrombectomy.
CCL/EP
IV Push: 125 mg over 20 secs, may
repeat X 1
If Extravasation,
see Pages 10&11
30
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Amiodarone
Cordarone
®
[class 3 antiarrhythmic]
Atrial Fib./Flutter,
V. Tachy.,
V. Fib.
ED
UT1-ICU
UT2-IU
OR/PACU
In presence
of Critical
Care RN or
Action RN
and LIP
during
RRT/Code,
ALL
UNITS
Atrial Fib./Flutter & Ventricular
Arrhythmias
I.I. LD: 150mg in 100 mL D5W over 10
mins then
C.I.: 450mg/250mL D5W (1.8mg/mL) at
1mg/min (33.3mL/hr) for 6 hrs then 0.5
mg/min (16.7mL/hr) for 18 hrs
With consent of cardiology or EP
MD/LIP’s: Higher dose of 2 mg/min
may be used for atrial flutter, recent
onset a. fib, ventricular tachycardia
Pulseless V. Tach/ shock-refractory V.
Fib (Cardiac Arrest)
IV Push LD: Cardiac arrest: 300mg
over 3-5 mins.
For all above indications if recurrent/
refractory arrhythmias may be treated
with a 2nd dose of 150 mg over 10 mins
then follow CI as above.
Caution/Warning:
Comments:
Pharmacy Admixture: Mix continuous infusion in D5W polyolefin bags.
Central line preferred due to high rate of phlebitis with peripheral veins. Use
volumetric infusion pump. For C.I., use an in-line 0.22 micron filter. Evaluate for
change to oral therapy after 24 hrs infusion. No tapering needed. Start oral dose prior to
discontinue continuous infusion.
Drug Interactions: Drug interactions with amiodarone can occur up to 4-5 months
after discontinuation of chronic amiodarone dosing and up to 2 months after a single
dose due to the extremely long half-life of the med.
Monitor: Continuous EKG, BP & HR every 5 minutes pre and post bolus and
initiation of continuous infusion then every 4 hours and PRN. QT interval at initiation
and every 4 hours (notify practitioner if QT interval lengthens to > 500 milliseconds or
defined parameter.
Side Effects: Hypotension - manage by reduce rate by 50%, if unresolved hold therapy
and then restart at the lower rate. Try volume expansion. May need vasopressors.
QTc prolongation, Bradycardia & AV block: slow rate or DC
Asystole, cardiogenic shock, CHF, inc. LFT’s, VT, Pul. Disorders
Contra: cardiogenic shock, marked sinus bradycardia, 2
nd
or 3
rd
degree AV block unless
a functioning pacemaker is available.
Stability:
Ammonium chloride
[urinary acidifier]
For severe
hypochloremic
Metabolic Acidosis
UT1-ICU
C.I.: Calculated mEq added to NS to a
concentration < 0.4 mEq/ml 100 to 200
mEq to 500 to 1000 mL isotonic 0.9%
NS.
Do not exceed 5 milliliters/minute
Caution/Warnings:
Comments: Not with significant renal or hepatic disease
Drug Interactions:
Monitor: CL, ABG’s, serum ammonium if renal disease. Local irritation, diaphoresis,
vomiting.
Side effects:
Stability:
If Extravasation,
see Pages 10&11
Avoid in midline cath see
Page 14
31
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Amphotericin B
Conventional
Fungizone
®
LOOK ALIKE / SOUND
ALIKE
RESTRICTED
ANTIMICROBIAL
[antifungal]
Fungal infection
ALL
UNITS
(Except
Psy)
I.I. Test Dose NOT REQUIRED
I.I.: 0.3-1 mg/kg/day or 1.5 mg/kg every
other day in 500 mL D5W over 2-6 hrs
Max concentration of 0.1 mg/ml via
peripheral line and 0.25 mg/ml via
central line. Flush line with D5W only.
Dosing is based on total body weight and
adjusted body weight in obesity.
Caution/Warnings:
Comments: Central line is preferred. Flush line with D5W. Incompatible with NS.
May premedicate with Meperidine to lessen shivering, chills and rigors that may occur
within the first hour of infusion. Have available: acetaminophen, diphenhydramine, +/-
hydrocortisone, oxygen and suction apparatus to lessen reactions.
Drug Interactions:
Monitor: V/S q 15 mins for 1
st
hr & q hr until completion, temp, HR, BP, RR,
electrolytes, Cr. Assess pt for fever, chills, rigors & signs/symptoms of respiratory
distress q hr during infusion. Provide comfort measures for fever, chills or rigors (extra
blankets, distraction, reassurance that the reactions will subside after infusion. Monitor
& record I&O q 2-4 hrs. Monitor serum electrolytes, BUN, creatinine and magnesium.
Side Effects: Fever, chills, nausea & vomiting, urticaria, headache, headache;
Myalgias/arthralgias Thrombophlebitis pain secondary to thrombophlebitis,
Nephrotoxicity, weight gain, fluid imbalances; Respiratory distress: tachypnea,
shortness of breath, wheezing, bronchospasms; Cardiovascular: hypotension,
tachycardia; Electrolyte balance: hypokalemia, hypomagnesemia; GI manifestations:
anorexia, nausea, vomiting, diarrhea.
Stability: 24 hrs at room temperature
Amphotericin Liposomal
AmBisome
®
[antifungal]
LOOK ALIKE / SOUND
ALIKE
RESTRICTED
ANTIMICROBIAL
Aspergillosis
Invasive Candidiasis
Inf. Disease
Restricted
ALL
UNITS
(Except
Psy)
I.I. Test Dose NOT REQUIRED
I.I.: 3- 5 mg/kg daily (1-2 mg/mL conc
in D5W) over 2 hrs. Flush line with
D5W only.
Dosing is based on total body weight and
adjusted body weight in obesity.
Caution/Warning:
Comments: Pharmacy to filter with 5 micron filter provided with med. Invert bag to
remix several times prior to hanging & during infusion. Incompatible with NS. Keep
refrigerated until hung. Stable 48 hrs in refrigerator and an additional 6 hrs at room
temperature. Protect from light. May premedicate with acetaminophen,
diphenhydramine, +/- hydrocortisone to lessen reactions. Treat rigors with meperidine.
Central line is preferred. Flush line with D5W. Do not filter
Drug Interactions:
Monitor: V/S q1 hr x 2 hrs - temp, HR, BP, RR, electrolytes, Cr., s&s’s of reactions.
Vitals signs can be discontinued if the patient hasn’t had a reaction or significant change
in BP or HR.
Side Effects:
Stability:
Ampicillin
[antibiotic]
ADS MIXTURE
Bacterial Infection
ALL
UNITS
I.I.:
1 gm in 100 mL NS ( Minibag Plus)
over 30 mins (concentration 10mg/mL),
2 gm in 100 mL NS (Minibag Plus) over
30 mins (concentration 20mg/mL).
Use within 1 hr of reconstitution
Caution/Warning:
Comments: Do not mix with D5W. Reduce dose and frequency with renal failure.
Incompatible with Gentamicin & tobramycin.
Contraindications: severe anaphylaxis to Penicillin (Type 1 PCN allergy).
Drug Interactions:
Monitor:
Side Effects:
Stability: If mixed by pharmacy: 8 Hours at room temperature and 24 hours under
refrigeration (concentration 30mg/mL) or 48 hours (concentrations up to 20 mg/mL)
Avoid in midline cath see
Page 14 (may be ok w/
short course)
32
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Ampicillin/ sulbactam
Unasyn
®
[antibiotic]
ADS MIXTURE
Bacterial Infection
ALL
UNITS
(Except
Psy)
I.I.:
1.5 gm in 100 mL NS (Minibag Plus)
over 20-30 mins
3 gm in 100 mL NS ( Minibag Plus) over
20-30 mins
Use within 1 hr of reconstitution.
Caution/Warning:
Comments: Do not mix with D5W. Reduce dose and frequency with renal failure.
Incompatible with Gentamicin & tobramycin.
Contraindications: severe anaphylaxis to Penicillin (Type 1 PCN allergy).
Drug Interactions:
Monitor:
Side Effects:
Stability: If mixed by pharmacy: Solutions made in NS are stable up to 72 hours when
refrigerated.
Angiotensin II
Brand Name Giapreza
®
TITRATE MED
[Vasoactive agent]
Septic or other
distributive shock
UT1 - ICU
C.I.: 2.5mg in 500ml NS (5,000ng/ml)
or 2.5mg in 250ml NS (10,000ng/ml)
Initial: 20 ng/kg/minute; monitor
response and titrate every 5 minutes by
increments of up to 15 ng/kg/minute as
needed. Once the underlying shock has
sufficiently improved, down-titrate every
5 to 15 minutes by increments of up to
15 ng/kg/minute based on response.
Doses as low as 1.25 ng/kg/minute may
be used.
Maximum initial dose: 80 ng/kg/minute
during the first 3 hours of treatment.
Maximum maintenance dose: 40
ng/kg/minute.
Caution/Warning: There are no known contraindications. Thrombosis events have
been reported with use; use concurrent VTE prophylaxis as appropriate.
Comments: No renal or hepatic dose adjustments.
Drug Interactions: ARBs may diminish therapeutic effects and ACE-inhibitors may
enhance therapeutic effects.
Monitor: BP response
Side Effects: Cardiovascular: Thrombosis (13%), Tachycardia (9%), deep vein
thrombosis (4%), peripheral ischemia (4%)
Central nervous system: Delirium (6%)
Endocrine & metabolic: Acidosis (6%), hyperglycemia (4%) Hematologic & oncologic:
Thrombocytopenia (10%)
Infection: Fungal Infection (6%)
Stability: Vials to be stored under refridgeration. Once diluted, can be stored at room
temperature or under refrigeration up to 24 hours.
Antithrombin III
Thrombate III
[coagulation inhibitor]
Antithrombin III
deficiency,
Hereditary -
Thromboembolic
disorder
ALL
UNITS
(Except
Psy)
I.I.: 3,000-8,000 units daily or
q 12 hrs infused over 10-60 mins
Caution/Warning:
Comments:
Drug Interactions:
Monitor:
Side Effects:
Stability:
Antithymocyte globulin
Thymoglobulin
[immune suppressant]
Prevent Transplant
rejection
ALL
UNITS
(Except
Psy)
Usual dose: 1.5 mg/kg/day
I.I.: Reconstitute 25 mg with 5 mL
Sterile water, further dilute in 50 mL NS
or D5W.
Caution/Warning:
Comments: Nursing to use in-line 0.22 micron filter sent supplied by Pharmacy with
product.
Drug Interactions:
Monitor:
Side Effects:
Stability:
Avoid in midline cath see
Page 14 (may be ok w/
short course)
33
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Aprepitant
Cinvanti®
[P/NK1 receptor
Antagonist]
Prevention of
Chemotherapy
induced nausea and
vomiting
ALL
UNITS
(Except
Psy)
IV Push: over 2 minutes approximately
30min prior to chemo. Flush infusion
line with NS before and after
administration.
Caution/Warning:
Comments:
Drug Interactions:
Monitor:
Side Effects:
Stability:
34
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Argatroban
[anticoagulant-direct
thrombin inhibitor]
HIGH ALERT / DOUBLE
CHECK
Treatment of
Heparin Induced
thrombocytopenia
UT1-ICU
UT2-IU
MED/
SURG/
ONC
250 mg/ 250 mL NS (1mg/1 ml, 1000 mcg/ml)
No initial bolus dose required.
The below nomograms are not nursing
protocols but guidelines. MD/LIP must be
contacted for any dosing adjustments. Consult
UConn Anticoagulation Guidelines on
pharmacy website for further information.
Draw an aPTT 2 hrs after initiation of infusion
times two and 2 hrs after each dose change
times two, then follow the titrating chart below
using the patient’s baseline aPTT value in all
of the subsequent titration calculations
C.I: Initial dose of 2 mcg/kg/min. Titrate to
maintain aPTT 1.5-3 times patient’s baseline
or 1.5-3 times mean of lab control range (27
sec). Goal aPTT 40-70 sec.
C.I. for: patients with CHF, multiple organ
system failure, severe anasarca or post cardiac
surgery. Reduce initial dose to 1 mcg/kg/min.
Titrate to maintain aPTT 1.5-3 times patient’s
baseline or 1.5-3 times mean of lab control
range (27 sec). Goal aPTT 40-70 sec.
C.I. for: Patients Moderate Hepatic
Impairment (Child-Pugh Grade A or B) or
Bilirubin >1.5. Reduce initial dose to
0.5mcg/kg/min. Titrate to maintain aPTT 1.5-
3 times patient’s baseline or 1.5-3 times mean
of lab control range (27 sec). Goal aPTT 40-70
sec.
Do not USE in severe Hepatic Impairment
Caution/Warning:
Comments: NOTE: Use Bivalirudin with Heparin Induced Thrombocytopenia + ACS.
Patient at intermediate to high risk for HIT: Unexplained Platelet Count decline > 30-50% within 5-
10 days of heparin or LMWH use, or <1 day with heparin/LMWH exposure in last 3 months,
suspected or proven new thrombosis, erythematous or necrosis of skin with SC Heparin or
enoxaparin, acute systemic reaction after Heparin bolus. Discontinue all sources of heparin (IV,
SC, heparin coated catheters & flushes) & LMWH’s. Requires RN/LPN verification double check
on MAR. Child-Pugh score is recommended to assess liver function. Dose reduction is indicated
with moderate to severe liver dysfunction. Not renally cleared. No initial dose adjustment with
renal impairment, in absence of factors requiring dose reduction as listed. Can cause false
elevations of INR so refer to references for transition to warfarin. Adjust dose for approximate goal
of INR 4-5 during first 5 days of concomitant argatroban and warfarin therapy.
Drug Interactions:
Monitor: aPTT, bleeding risk, reduce dose in hepatic dysfunction. Hepatic elimination.
Warfarin Overlap with Argatroban
Note: Argatroban will significantly elevate and provide false PT/INR values. Follow warfarin
dosing guideline below when determining adjustment of warfarin dosing.
If planning to start a patient on warfarin therapy after platelet count has recovered, continue non
heparin anticoagulant until the platelet count has reached stable plateau, the INR has reached the
intended target range, and have a minimum overlap of at least 5 days between the non heparin
anticoagulant and warfarin therapy. Initiate warfarin only when the platelet count has
substantially recovered to ≥ 150,000 cells/mm
3
or greater
Obtain a baseline PT/INR prior to starting the warfarin. Do not give a loading dose of warfarin.
Prescribers may order warfarin daily at a low, maintenance daily dose (≤5 mg). Consider starting
with a lower daily dose (e.g. 2.5mg) in elderly patients, patients with hepatic impairment, heart
failure, malnutrition or receiving interacting medications.
Adjust warfarin dose for approximate goal of INR 4-5 during the first 5 days of concomitant
argatroban and warfarin therapy.
If argatroban dose is ≤ 2 mcg/kg/min . INR should be measured daily
• If INR ≤ 4, continue combined warfarin and Argatroban therapy, recheck in 24 hours
• If INR >4, Argatroban can be stopped
• After Argatroban stopped, repeat INR measurement in 4-6hrs
• Below therapeutic range (e.g. INR <2): Resume Argatroban therapy at the previous rate
and repeat above steps the following day
• Desired INR therapeutic range (e.g. INR 2-3) and minimum of 5 days overlap:
Discontinue Argatroban
If argatroban dose is >2 mcg/kg/min . INR should be measured daily
• If INR ≤ 4, continue combined warfarin and Argatroban therapy, recheck in 24 hours
• If INR >4, Argatroban can be temporarily reduced to 2mcg/kg/min
• Obtain INR in 4-6 hours, if INR > 4, stop Argatroban
• After Argatroban stopped, repeat INR measurement in 4-6 hours
• Below therapeutic range (e.g. INR<2): Resume Argatroban therapy at the previous rate
prior to reducing dose and repeat above steps the following day
• Desired INR therapeutic range (e.g. INR 2-3) and minimum of 5 days overlap:
Discontinue Argatroban
Related Policies:
• Medications: High Alert, Double Check of
Side Effects:
Stability: Stable in NS for 24 hrs at room temperature.
BKC: Dispose in
Black Bin
35
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Atropine Sulfate
[anti-cholinergic]
Bradycardia,
asystole, slow PEA
ECT-A
ED
ENDO
UT1-ICU
UT2-IU
IRAD
OP-CARD
OR/PACU
UHSC
In presence
of Critical
Care RN or
Action RN
and LIP
during
RRT/Code,
ALL
UNITS
IV Push: 0.5- 1 mg undiluted over 1-2
min
Caution/Warning:Monitor: EKG, HR for PVC, VT
Comments: Flush with 20cc NS.
Drug Interactions:
Monitor:
Side Effects:
Stability:
AzaTHIOprine
Imuran
®
[antimetabolite]
Renal transplant
immuno-
suppressant
ALL
UNITS
(Except
Psy)
I.I.: Dilute 3-5 mg/kg dose x1 then 1-3
mg/kg/day in 50 mL D5W over 30-60
mins
Caution/Warning :
Comments: Maximum concentration of 10 mg/ml.
Reduce dose for renal failure. Dose based on IBW, stop if WBC < 3,000. Hazardous
medication precautions. Carcinogen. Pregnancy Category D. Wear nitrile gloves while
handling. Gowns should be utilized for incidental exposure to hazardous drugs. Dispose
in hazardous waste container. Refer to the UConn hazardous drug safety handling for
further information: Medication Handling Safety
Drug Interactions:
Monitor: CBC, LFT’s, signs of liver failure, bleeding
Side Effects:
Stability:
Azithromycin
Zithromax
®
[antibiotic]
Bacterial Infection
ALL
UNITS
I.I.: 500 mg in 250 mL D5W over 60
mins
Caution/Warning:
Comments: Pharmacy to admix non emergent doses. Vials are in Pyxis for 1st doses.
Stable 24 hrs @ room temperature, 7 days refrigerated
No dose adjustment in renal failure
Drug Interactions:
Monitor:
Side Effects:
Stability:
Avoid in midline cath see
Page 14 (may be ok w/
short course)
36
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Aztreonam
Azactam
®
[antibiotic]
ADS MIXTURE
Bacterial Infection
ALL
UNITS
(Except
Psy)
I.I.:
1 gm in 100 mL NS (Minibag Plus) over
20-30 mins (concentration 10mg/mL)
2 gm in 100 mL NS (Minibag Plus) over
60 mins (concentration 20mg/mL)
IV Push (when a shortage
):
1 gm in 10 mL SWFI over 3 – 5 min
2 gm in 20 mL SWFI over 3 – 5 min
Caution/Warning: IV Push too fast can result in infiltration or systemic reaction such
as headache, flushing, tightness in chest. All IV Push have Phlebitis Risk. Flush slowly
after medication administration.
Comments: Reduce dose in renal failure
Drug Interactions:
Monitor:
Side Effects: Rare cross sensitivity w PCN/Ceph allergies
Stability: If mixed by pharmacy, solutions with concentration not exceeding 20mg/mL
should be used within 48 hours at room temp or within 7 days if refrigerated.
Trimethoprim (TMP)
Sulfamethoxazole (SMX)
Bactrim/Septra
®
[antibiotic]
Bacterial Infection
ALL
UNITS
(Except
Psy)
I.I.: dose based on TMP component
< 80 mg TMP in 100 mL D5W over 1 hr
81-120 mg TMP in 150 mL D5W over
1.5 hrs
121-240 mg TMP in 250 mL D5W over
1.5 hrs
241-450mg TMP in 500 mL D5W over
2 hrs
Non PCP: 10 mg/kg/day given q 6-
12 hrs
PCP:5-20 mg/kg/day given q6hrs
Caution/Warning:
Comments: Nursing to admix due to limited stability (6 hours at room
temperature). Mix immediately prior to use
Dosing is based on TMP component
5 mL = 80 mg trimethoprim & 400 mg sulfamethoxazole
Mix immediately prior to use.
Reduce dose w renal impairment.
Drug Interactions:
Monitor: CBC, Cr, K+, LFTs, for skin rashes
Side effects: rash, immune hypersensitivity reactions, hyponatremia, thrombocytopenia,
pancytopenia, hemolysis, hyperkalemia
Stability:
37
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Bamlanivimab/etesevimab
[Monoclonal Antibody
(mAb)]
RESTRICTED
ANTIVIRAL
FDA issued
Emergency Use
Authorization
(EUA): Mild-to-
moderate COVID-
19 in adults and
pediatric patients
with positive results
of direct SARS-
COV-2 viral testing,
and who are at high
risk for progression
to severe COVID-
19, including
hospitalization or
death.
ALL
UNITS
(Except
Psy)
I.I. Single IV infusion of 2100 mg
bamlanivimab and etesevimab in 310
mL. Note that this single infusion
contains 700mg of bamlanivimab and
1400mg of etesevimab mixed in one
infusion bag.
For patients weighing < 50 kg: Infuse
over 70 minutes
For patients weighing ≥ 50 kg: Infuse
over 60 minutes
Using Polyvinylchloride (PVC) infusion
set containing a 0.20/0.22 micron in-line
polyethersulfone (PES) filter attach the
infusion set to the IV bag. Prime the
infusion set. Administer using weight-
based infusion times above. Once
infusion is complete, flush the infusion
line to ensure delivery of the required
dose. Discard unused product. Clinically
monitor patients during administration
and observe patients for at least 1 hour
after infusion is complete.
Caution/Warning:
There is a potential for serious hypersensitivity reaction, including anaphylaxis, with
administration of bamlanivimab/etesevimab. If signs and symptoms of a clinically
significant hypersensitivity reaction or anaphylaxis occur, immediately discontinue
administration and initiate appropriate medications and/or supportive care. Infusion-
related reactions have been observed with administration of bamlanivimab/etesevimab.
Drug Interactions:
Bamlanivimab and etesevimab are not renally excreted or metabolized by cytochrome
P450 enzymes; therefore, interactions with concomitant medications that are renally
excreted or that are substrates, inducers, or inhibitors of cytochrome P450 enzymes are
unlikely.
Monitor:
Clinically monitor patients during infusion and observe patients for at least 1 hour after
infusion is complete
Side Effects:
Based on Phase 2 data from the BLAZE-1, nausea was the most commonly reported
adverse event, reported by 4% of subjects in both bamlanivimab/etesevimab treatment
and placebo groups. Pruritus and pyrexia were more frequently reported from subjects
treated with both bamlanivimab/etesevimab (2% and 1%) compared to placebo (1% and
0%, respectively). Based on Phase 3 Data from the BLAZE-1 trial, the most common
adverse events were nausea, dizziness, and rash. These events each occurred in 1% of
subjects treated with bamlanivimab/etesevimab and in 1% of placebo subjects.
Stability:
Diluted infusion solution should be administered immediately. If immediate
administration is not possible, store diluted bamlanivimab/etesevimab infusion solution
for up to 24 hours refrigerated at 2°C to 8°C (36°F to 46°F) or up to 7 hours at 20°C to
25°C (68°F to 77°F), including infusion time. If refrigerated, allow infusion solution to
warm to room temperature for ~20 minutes prior to administration.
38
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Bebtelovimab
LY-CoV1404
[Biologic, Monoclonal
Antibody]
RESTRICTED
ANTIVIRAL
FDA issued
Emergency Use
Authorization
(EUA): Mild-to-
moderate
coronavirus disease
2019 (COVID-
2019) in adults and
pediatric patients
(12 years of age and
older weighing at
least 40kg) with
positive results
of direct SARS-
COV-2 viral testing
and who are at high
risk for progression
to severe COVID-
19, including
hospitalization or
death
ALL
UNITS
(Except
Psy)
IV Push: 175mg undiluted over > 30
seconds
Use polycarbonate and polyvinylchloride
without di-ethylhexylphthalate (DEHP)
syringe extension set for administration.
Prime the extension set prior to
administration. Once IV injection is
complete, flush the tubing with 0.9%
Sodium Chloride
Clinically monitor patients for possible
infusion-related reactions during
administration and observe patients for at
least 1 hour after injection
Caution/Warning:
There is a potential for serious hypersensitivity reactions, including anaphylaxis. If
signs and symptoms of a clinically significant hypersensitivity reaction or anaphylaxis
occur, immediately discontinue administration and initiate appropriate medications
and/or supportive care
Drug Interactions:
Bebtelovimab is not renally excreted or metabolized by cytochrome P450 enzymes;
therefore, interactions with concomitant medications that are renally excreted or that are
substrates, inducers, or inhibitors of cytochrome P450 enzymes are unlikely
Monitor:
Clinically monitor patients during administration and for at least 1 hour after
administration is completed
Side Effects:
The most common treatment-emergent adverse events observed in subjects treated with
bebtelovimab, alone or in combination with bamlanivimab and etesevimab, at the
authorized dose or higher, included nausea (0.8%), rash (0.8%), vomiting (0.7%),
pruritus (0.3%) and infusion-related reactions (0.3%)
Stability:
Store unopened vials in a refrigerator at 2°C to 8°C (36°F to 46°F) in the original carton
to protect from light. Do not freeze, shake or expose to direct light
Belimumab
Benlysta
®
[human IGG1 antibody]
Lupus erythematous
ALL
UNITS
(Except
Psy)
I.I.: 10 mg/kg IV q 2 weeks x 3, then q 4
weeks
Caution/Warning:
Comments: Advise patient that live vaccines are not to be taken during therapy, and for
at least 30 days before, due to potential interference with immunization response.
Instruct female patients of childbearing age to avoid getting pregnant during therapy
and for 4 months after finishing treatment by using adequate contraception.
Drug Interactions:
Monitor:
Side effects: possible hypersensitivity reactions (e.g., pruritus, hypotension,
angioedema, urticaria, bradycardia, myalgia, headache or hypotension) - consider
premedication for potential infusion and hypersensitivity reactions. Use is not
recommended during an infection. May cause nausea, diarrhea, insomnia, fever,
migraine or pain in the limbs.
Stability:
39
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Benztropine
Cogentin
®
[centrally-acting
anticholinergic agent]
Acute dystonic
reactions
ALL
UNITS
(Except
Psy)
IV Push: 1-2 mg undiluted over 1 mg /
min
Caution/Warning:
Comments: To reverse drug-induced extrapyramidal reactions including dystonic
reactions, alathisia, and parkinsonian symptoms.
Drug Interactions:
Monitor:
Side Effects: Potential: Confusion, Disorientated, Drug-induced psychosis,
Hyperpyrexia, Visual hallucinations, nervousness, tachycardia
Stability:
Bezlotoxumab
ZINPLAVA®
[Monoclonal]
Adjunct therapy in
prevention
recurrence of CDI in
patients treated with
standard of care
antibiotics
OP-INFC
I.I.: 10mg/kg over 60 minutes
Compatible in NS or D5W to a final
concentration between 1 to 10 mg/mL.
Infuse over 60 minutes through a sterile,
nonpyrogenic, low-protein binding 0.2 to
5 micron in-line or add-on filter. Do not
administer as an IV push or bolus.
Caution/Warning: Do not use if discoloration or particulate matter present. Monitor
for infusion related pyrexia, nausea/vomiting.
Drug Interactions:
Monitor: Monitor for worsening heart failure, infection, and respiratory failure in
patients with underlying heart failure.
Side Effects:
Stability: Solutions diluted for infusions may be stored at (1) room temperature for up
to 16 hours or (2) refrigerated (2°C to 8°C) for up to 24 hours. If refrigerated, allow
intravenous bag to come to room temperature prior to administration.
40
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Bivalirudin
Angiomax
®
[anticoagulant- direct
thrombin inhibitor]
Percutaneous
Transluminal
Angioplasty
PCI/PTCA
CCL/EP
UT1-ICU
UT2-IU
IRAD
LIP on the
sterile field
during
procedures
IV Push: 0.75 mg/kg then
C.I.: 1.75 mg/kg/hr for the duration of
the procedure, mix 250 mg with 5 mL
SW then dilute in 100 mL NS/D5W
(2.5mg/mL). See comments section for
rate reduction for patients with renal
impairment.
Caution/Warning:
Comments: Replaces IV Heparin & usually without 2b3A inhibitor.
If CrCl <30 mL/min: same bolus dose then C.I. of 1 mg/kg/hr. If dialysis-dependent
patient: same bolus dose then C.I. of 0.25mg/kg/hr
Note: If pt arrives on unit post PCI with a C.I. at the higher Cath Lab dose of 1.75
mg/kg/hr, call MD/LIP regarding potential discontinuation of med or possible need for
lower C.I. at 0.2 mg/kg/hr to finish current bag for up to 20 hrs.
Drug Interactions:
Monitor: ACT, BP, HR, Bleeding. Check ACT or aPTT 5 mins after bolus.
Medication is not a vesicant.
Side Effects:
Stability: Diluted Bivalirudin vials 250mg/5mL may be stored at 2 to 8°C for up to 24
hours. Diluted Bivalirudin (0.5 to 5mg/mL) is stable at room temperature for up to 24
hours
BOLUS OFF BAG:
Upon new EMR April
2018, ability to bolus
from continuous
infusion bag via Alaris
Pump Guardrails.
41
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Bumetanide
Bumex
®
[Loop diuretic]
Nov 2017: During
shortage
of SVP
50mL/100mL D5W, use
NS
Edema, CHF
Edema, CHF
ALL
UNITS
(Except
Psy)
IV Push: < 2 mg dilute in 10 mL NS at
< 1 mg/min, flush with 5 mL NS
Caution/Warning:
Comments: Pharmacy to admix non-stat doses > 2 mg. Pharmacy Info: Final
Conc= 0.25 mg/mL by adding undiluted (0.25 mg/mL) to IV empty bag to cover for 24
hrs
1 mg bumetanide = 40 mg furosemide
Drug Interactions:
Monitor: BP; May cause hyperglycemia - monitor glucose levels, renal function.
Monitor potassium and digoxin levels - may increase risk of digoxin toxicity.
Side Effects:
Stability: Stable for 24 hrs at Room temperature or refrigerated.
I.I.: > 2 – 4 mg in 50 mL NS or D5W
over 15- 30 mins
C.I.: 0.5 - 2 mg / hr
Max dose/hr = 4 mg/hr
Concentration :
2.5 mg/ 100 mL NS or D5W or
5mg/100mL NS or D5W
Butorphanol
Stadol
®
[opioid agonist/antagonist]
Mixed opioid
agonist /antagonist
ALL
UNITS
(Except
Psy)
IV Push: 0.5- 2mg undiluted , over 1
mg / min q 3-4 hrs PRN pain
Caution/Warning:
Comments: Reduce dose in renal or hepatic failure. Avoid in patients taking chronic
opioids.
Drug Interactions:
Monitor: BP, HR, RR, sedation, pain relief
Side Effects:
Stability:
42
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
C1 Esterase Inhibitor
(Human)
Berinert®
[C1 Esterase Inhibitor]
Hereditary
Angioedema (Adult
and Pediatric)
ALL
UNITS
(Except
Psy)
IV Push: 20IU/kg infused at a rate of
4mL/minute
(Prefer to round up to the nearest vial
size as approved per P&T. e.g.
Administer 1000 units if weight is ≤50
kg. Administer 1500 units if weight is
>50 kg and ≤75 kg. Administer 2000
units if weight is >75 kg and ≤100 kg.
Administer 2500 units if weight is >100
kg.)
Caution/Warning:
Comments: Reconstitute using provided Mix2Vial® transfer set or a commercially
available double ended needle and vented filter spike.
If multiple vials necessary may be pooled into single-syringe. More than three vials will
be prepared by pharmacy.
Drug Interactions:
Monitor:
Side Effects: Possible hypersensitivity reaction, increased risk of thromboembolic
events, and transmission of infectious agents
Stability: Once reconstituted must be administered within 8 hours and stored at room
temperature. Do not refrigerate or freeze the reconstituted solution
Caffeine and sodium
benzoate
[methylxanthine]
post dural puncture
headache
ALL
UNITS
(Except
Psy)
I.I.: Post dural puncture
headache is
300–500 mg in 1 liter NS over 1 hr,
Follow with 1000 mL NS; infuse over 1
hour. May administer I.M. undiluted.
Caution/Warning:
Comments: Pharmacy to admix. Use caffeine and sodium benzoate product.
500 mg caffeine and sodium benzoate = 250 mg caffeine.
Drug Interactions:
Monitor:
Side Effects: central
nervous system toxicity and atrial fibrillation
Stability:
Caffeine withdrawal
or migraine
headaches
ALL
UNITS
(Except
Psy)
I.I.: 30-100 mg in 250 mL NS over 30-
60 mins
Calcitonin
Miacalcin
®
[calcium regulator]
ALL
UNITS
(Except
Psy)
I.I.: 4 units/kg in 100 mL NS, over 30-60
mins
Caution/Warning:
Comments: Dispense in Glass bottle
Drug Interactions:
Monitor:
Side Effects:
Stability:
Calcitriol
Calcijex
®
[vitamin D]
Hypoparathyroid
Hypocalcemia
ALL
UNITS
(Except
Psy)
IV Push: 1- 2 mcg undiluted over 1 min
Caution/Warning:
Comments:
Drug Interactions:
Monitor: Ca++, Phos, Mag, Alk phos
Side Effects:
Stability:
43
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Calcium Chloride
10%
1 amp (10mL) = 1 gm
Calcium Chloride
= 273 mg Ca++
= 13.6mEq Calcium++
[parenteral mineral]
Cardiac
resuscitation or
Calcium channel
blocker toxicity
In presence
of Critical
Care RN or
Action RN
and LIP
during
RRT/Code,
ALL
UNITS
IV Push: 500 mg - 2 grams undiluted
rapid administration during Code Blue
Caution/Warning:
Comments: Large vein preferred
Use calcium gluconate for Calcium replacement and Hyperkalemia.
Incompatible w Bicarbonate & Phosphate
Drug Interactions:
Monitor: EKG, BP, HR, IV site for extravasation
Side Effects:
Stability:
Calcium Gluconate
10%
1 amp (10 mL) =1 gm
Calcium Gluconate
= 93 mg Ca++
= 4.65mEq Ca++
Nov 2017: During
shortage
of SVP
50mL/100mL D5W, use
NS
Calcium
replacement
ALL
UNITS
(Except
Psy)
I.I.: 1 gm Cal. Gluc. = 4.6mEq in 50 mL
NS or D5W over 30 -60 mins. For a 2
gm dose, repeat the 1 gm dose
Caution/Warning:
Comments: Calcium gluconate 1 gm in 50 mLD5W available as premix. For 2 gm
doses use #2 Calcium gluconate 1 gm in 50 mL D5W. Do not infuse via same line as
phosphate or bicarbonate containing solutions. Consult MD/LIP and/or RPh for change
to oral calcium or if IV calcium is required change antibiotic. For Calcium
replacement. Check compatibilities before mixing with other medications. Target level
Total Ca++ 1.1-1.3. May be given by slow IV Push undiluted in emergencies.
Drug Interactions:
Monitor: IV site for extravasation, Ca++, Phos, HR, BP. May require cardiac
monitoring/telemetry determined by MD
Side Effects:
Stability:
Information on Calcium Gluconate 10% continues on the next page.
ED
UT1-ICU
UT2-IU
L&D/
OB-GYN
UT-BMT
C.I.: 10gm in 500mL D5W or NS over
12- 24 hrs
Do not exceed 200mg (1mEq)/min
C.I: 4gm in 250 mL NS over 6 hours.
during peripheral blood stem ccell
(PBSC) apheresis. Max rate = 85 mL/hr.
Avoid in midline cath see
Page 14
Avoid in midline cath see
Page 14
44
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Calcium Gluconate
10%
1 amp (10 mL) =1 gm
Calcium Gluconate
= 93 mg Ca++
= 4.65mEq Ca++
Hyperkalemia
ALL
UNITS
(Except
Psy)
Calcium Gluconate 1 gm in 50 mL NS or
D5W X 1-2 doses over 30 minutes each
dose.
See previous page for comments on Calcium Gluconate 10%.
Caution/Warning:
Comments: May require cardiac monitoring/telemetry determined by LIP. The
recommendation for patients with K+ > 7 and ECG evidence of severe hyperkalemia is
1 gm/ 100 mL over 2 to 5 minutes with continuous ECG monitoring
Treatment of Hyperkalemia: Follow MD orders:
1.Stop K+ infusions and oral therapy and Contact MD/LIP to
Discontinue K+ infusions.
2. Consider Calcium Gluconate IV Push: 10-20 mL of 10% over 2 mins or
1 gm in 50 mL D5W X 1-2 doses over 5-10 mins)
3. Dextrose IV Push ( 50 mL of D50 IV Push) undiluted over 1-2 mins
4. Regular Insulin IV Push ( 10 units)
5. Bicarbonate IVP (50 mEq= 50 mL of 8.4% over 2 mins
6. B2 adrenergics-albuterol nebs (10-20 mg = 12-24 mL nebulized);
7. Loop diuretics
8. Na Polystyrene (15-60 gm)
9. Hemodialysis
Drug Interactions:
Monitor:
Side Effects:
Stability:
see Pages 10&11
If Extravasation,
Avoid in midline cath see
Page 14
45
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Cangrelor
KENGREAL®
Reversible ADP P2Y
12
inhibitor
BOLUS OFF BAG
: Upon
new EMR April 2018,
ability to bolus from
continuous infusion bag via
Alaris Pump Guardrails.
Adjunct therapy to
PCI for reducing the
risk of
periprocedural MI,
repeat coronary
revascularization,
ST in patients in
who have not been
treated with a P2Y
12
platelet inhibitor
and are not being
given a glycoprotein
IIb/IIIa inhibitor
CATH
LAB
Dilute a 50mg vial in 250ml of 0.9%
NS or 5% d5w (Concentration
200mcg/ml)
Bolus: 30 mcg/kg
Bolus from bag; never from reconstituted
vial, use manual IV push or pump to
administer the bolus volume in less than
1 minute, ensure bolus is completely
administered before the start of PCI.
C.I.: 4 mcg/kg/min
Begin infusion immediately after the
bolus and continue for at least 2 hours or
the duration of the procedure, whichever
is longer.
200 mcg/mL](bolus) + [()/(200
mcg/mL)] (C.I.)
Caution/Warning: Bleeding/cangrelor is contraindicated in patients with significant
active bleeding
Comments: Reconstitute by adding 5 mL of sterile water for injection to one 50 mg
vial. Swirl gently until all material is dissolved; avoid vigorous mixing and allow any
foam to settle.
Reconstituted cangrelor will be a clear, colorless to pale yellow solution. Product should
not contain particulate matter. Do not use reconstituted solution of cangrelor without
further dilution. Discard any unused portion of reconstituted solution remaining in the
vial. Dose adjustment is not required in elderly patients (>/=75 years) or in patients
with renal or hepatic insufficiency.
Drug Interactions: Thienopyridines (clopidgrel and prasugrel)—do not administer
during cangrelor infusion, only administered when infusion is discontinued. Once
cangrelor is discontinued, there is no antiplatelet effect after an hour. To maintain
platelet inhibition after discontinuation of cangrelor infusion, an oral P2Y
12
platelet
inhibitor should be administered
Monitor: For side effects and timing of oral antiplatelet (clopidogrel and prasugrel)
administration.
Side Effects: bleeding, hypersensitivity, decreased renal function, dyspnea
Stability: Diluted cangrelor is stable at room temperature for up to 12 hours in 5%
dextrose injection and 24 hours in normal saline.
46
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Casirivimab and
imdevimab
[Monoclonal Antibody
(mAb)]
RESTRICTED
ANTIVIRAL
FDA issued
Emergency Use
Authorization
(EUA): Mild-to-
moderate COVID-
19 in adults and
pediatric patients
with positive results
of direct SARS-
COV-2 viral testing,
and who are at high
risk for progression
to severe COVID-
19, including
hospitalization or
death.
ALL
UNITS
(Except
Psy)
I.I. Single IV infusion of 1200 mg
casirivimab and imdevimab in 260 mL
NS administered over at least 60
minutes. Note that this single infusion
contains 600mg of casirivimab and
600mg of imdevimab mixed in one
infusion bag.
Using Polyvinylchloride (PVC) infusion
set containing a 0.20/0.22 micron in-line
polyethersulfone (PES) filter attach the
infusion set to the IV bag. Prime the
infusion set. Administer over at least 60
minutes. Once infusion is complete, flush
the infusion line to ensure delivery of the
required dose. Discard unused product.
Clinically monitor patients during
administration and observe patients for at
least 1 hour after infusion is complete.
Caution/Warning:
There is a potential for serious hypersensitivity reaction, including anaphylaxis, with
administration of casirivimab and imdevimab. If signs and symptoms of a clinically
significant hypersensitivity reaction or anaphylaxis occur, immediately discontinue
administration and initiate appropriate medications and/or supportive care. Infusion-
related reactions have been observed with administration of casirivimab and
imdevimab.
Drug Interactions:
Casirivimab and imdevimab are not renally excreted or metabolized by cytochrome
P450 enzymes; therefore, interactions with concomitant medications that are renally
excreted or that are substrates, inducers, or inhibitors of cytochrome P450 enzymes are
unlikely.
Monitor:
Clinically monitor patients during infusion and observe patients for at least 1 hour after
infusion is complete
Side Effects:
From clinical trials, the adverse events collected were infusion-related reactions and
hypersensitivity reactions of moderate severity. Serious adverse events were reported in
4 subjects (1.6%) in the casirivimab and imdevimab 2,400 mg group, 2 subjects (0.8%)
in the casirivimab and imdevimab 8,000 mg group, and 6 subjects (2.3%) in the placebo
group. None of the SAEs were considered to be related to study drug. SAEs that were
reported as Grade 3 or 4 adverse events were pneumonia, hyperglycemia, nausea and
vomiting (2,400 mg casirivimab and imdevimab), intestinal obstruction and dyspnea
(8,000 mg casirivimab and imdevimab) and COVID-19, pneumonia and hypoxia
(placebo). Casirivimab and imdevimab are not authorized at the 8,000 mg dose (4,000
mg casirivimab and 4,000 mg imdevimab). One anaphylactic reaction was reported in
the clinical program
Stability:
Diluted infusion solution should be administered immediately. If immediate
administration is not possible, store diluted casirivimab and imdevimab infusion
solutions for up to 36 hours refrigerated at 2°C to 8°C (36°F to 46°F) or up to 4 hours at
20°C to 25°C (68°F to 77°F), including infusion time. If refrigerated, allow infusion
solution to warm to room temperature for ~30 minutes prior to administration.
47
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Caspofungin
Cancidas
®
[antifungal]
RESTRICTED
ANTIMICROBIAL
Fungemia
ALL
UNITS
(Except
Psy)
I.I. LD: 70 mg/ 250 mL NS over 1 hr
then
Maintenance: 50 mg/ 250 mL NS over 1
hr, in 100 mL for fluid restricted pts
Caution/Warning:
Comments: Pharmacy to admix. Stable 24 hrs @ room temperature, 48 hrs
refrigerated.
Reduce dose to 35 mg in mod-severe hepatic disease. Do not mix with any other
medications.
Drug Interactions:
Monitor: for histamine reaction.
Side Effects: hypokalemia, GI, inc. in ALT/AST, phlebitis, headache.
Stability:
CeFAZolin
Ancef/Kefzol
®
[cephalosporin -1
st
generation]
ADS MIXTURE
Bacterial Infection
UJDH HA
OR/PACU
UHSC
IV Push: Pre-mixed 1 gm in 10 mL
sterile water, over 1-2 mins
Caution/Warning: Patients with a documented allergy (urticaria, anaphylactoid or
anaphylaxis) to penicillins or B-Lactam antibiotics should not receive a cephalosporin
antibiotic due to a 6-8% risk of cross-allergenicity.
Comments: Surgery Prophylaxis: 3 total doses includes 1 pre-op dose & 2 post-op
doses, reduce dose or interval for renal failure.
Drug Interactions:
Monitor:
Side Effects:
Stability:
ALL
UNITS
(Except
Psy)
I.I.: 0.5 gm in 50 mL 15-30 mins q8hrs.
I.I.: 1 gm in 100 mL NS (Minibag Plus)
or 2 gm in 100 mL NS over 30 mins q 8
hrs.
I.I. Alternative: 2gm in 50mL D5W
Duplex Premix over 30 mins q 8 hrs
I.I.: 1.5gm in 50mL NS over 30 mins
I.I.: 3gm in 100mL NS over 30 mins
IV Push (Alternative when products
not available):
0.5 gm in 10 mL SWFI over 3 – 5 min
1 gm in 10 mL SWFI over 3 – 5 min
1.5 gm in 15 mL SWFI over 3 – 5 min
48
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
CefoTEtan
[anaerobic cephalosporin-
2
nd
generation]
Bacterial Infection
ALL
UNITS
(Except
Psy)
I.I.: 1-2 gm in 50 mL over 30 mins q 6
hrs
Caution/Warning: Allergy: Patients with a documented allergy (urticaria,
anaphylactoid or anaphylaxis) to penicillins or B-Lactam antibiotics should not receive
a cephalosporin antibiotic due to a 6-8% risk of cross-allergenicity. If not available use
cefOXitin.
Comments:
Drug Interactions:
Monitor:
Side Effects:
Stability:
Cefepime
Maxipime
®
[antibiotic]
ADS MIXTURE
Bacterial Infection
Anti-pseudomonal
Anti-pseudomonas
Note: replaces
cefTAZidime
Feb 2012 for all
adult patients except
NICU (exception:
Cefepime
medication
shortage)
ALL
UNITS
I.I.:
1 gm in 100 mL NS (Minibag Plus) over
30 mins q 12 hrs
2 gm in 100 mL NS (Minibag Plus) over
30 mins q 12 hrs
IV Push (when a shortage
):
1 gm in 10 mL SWFI over 3 – 5 min
2 gm in 20 mL SWFI over 3 – 5 min
Caution/Warning: IV Push too fast can result in infiltration or systemic reaction such
as headache, flushing, tightness in chest. All IV Push have Phlebitis Risk. Flush slowly
after medication administration.
Allergy: Patients with a documented allergy (urticaria, anaphylactoid or anaphylaxis) to
penicillins or B-Lactam antibiotics should not receive a cephalosporin antibiotic due to
a 6-8% risk of cross-allergenicity
Comments: Caution with Penicillin or Cephalosporin allergies.Reduce dose and
interval with CrCl< 60 mL/min.
Drug Interactions:
Monitor:
Side Effects:
Stability:
49
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Cefiderocol
Fetroja®
[cephalosporin antibiotic]
RESTRICTED
ANTIMICROBIAL
NON-FORMULARY
Bacterial Infections
Documented or
suspected
complicated urinary
tract infections or
pneumonia caused
by highly resistant
multi-drug resistant
organisms (e.g.,
Extended-Spectrum
Beta-Lactamase
(ESBL)-Positive
strain,
carbapenemase-
producing
Enterobacterales,
multidrug-resistant
P. aeruginosa)
AND/OR with
limited or no
alternative treatment
options (due to
allergies and/or
resistance patterns)
ALL
UNITS
(Except
Psy)
I.I.: 750mg-2000mg in 100mL NS or
D5W over 3 hours
Pneumonia, hospital-acquired or
ventilator-associated & Urinary tract
infection, complicated: 2 g q8 hours
Reconstitute 1 g vial with 10 mL of NS
or D5W; gently shake to dissolve. Allow
the vial to stand until the foaming
generated on the surface has disappeared
(typically within 2 minutes). The final
volume of the reconstituted solution is
~11.2 mL with a concentration of 0.089
g/mL
Volume to Withdraw from
Reconstituted Vial
750mg
8.4 mL
1g
11.2 mL
[entire contents of
1 vial]
1.5g
16.8 mL
2g
22.4 mL [entire
contents of 2
vials]
Caution/Warning: β-lactam hypersensitivity history
May result in fungal or bacterial superinfection (e.g. Clostridium difficile)
Hemolytic anemia and renal impairment related neurotoxicity risk.
Comments: CrCl ≥120 mL/minute: 2 g every 6 hours.
CrCl 60 to <120 mL/minute: 2 g every 8 hours.
CrCl 30 to <60 mL/minute: 1.5 g every 8 hours.
CrCl 15 to <30 mL/minute: 1 g every 8 hours.
CrCl <15 mL/minute: 750 mg every 12 hours
HD, intermittent (TIW): Dialyzable (~60% in a 3- to 4-hour hemodialysis session): 750
mg every 12 hours; dose should be given immediately after HD on dialysis days.
Drug interactions: may decrease the effectiveness of BCG, Cholera, and Typhoid
vaccines May increase the effectiveness of warfarin. May increase the nephrotoxicity of
aminoglycosides. Chloramphenicol may decrease the effectiveness of this product.
Monitoring: Monitor serum creatinine and creatinine clearance daily in patients with
unstable renal function. Monitor for anaphylaxis initially; LFTs; infusion site reaction
Related Policies: Restricted and Concurrently-Monitored Antimicrobials
Side Effects: diarrhea, nausea, and headache, and pyrexia
Stability: Store intact vials at 2°C to 8°C (36°F to 46°F). Protect from light.
Reconstituted vials may be stored at room temperature for ≤1 hour. Diluted solutions
for infusion may be stored at room temperature for ≤6 hours or at 2°C to 8°C (36°F to
46°F) for ≤24 hours (and protected from light). Infusion should be completed within 6
hours after removal from refrigeration.
Cefotaxime
Claforan-R
[cephalosporin- 3
rd
generation]
Alternative antibiotic
could be considered as this
is primarily used in NICU
ADS MIXTURE
Bacterial Infection
ALL
UNITS
(Except
Psy)
I.I.:
500mg - 1gm / 50 mL NS or D5W over
15-20 mins.
2 gm/ 100 mL NS (Minibag Plus) over
30 mins.
Frequency based on renal function and
infection severity
IV Push (when a shortage
):
0.5 gm in 10 mL SWFI over 3 – 5 min
1 gm in 10 mL SWFI over 3 – 5 min
2 gm in 20 mL SWFI over 3 – 5 min
Caution/Warning: IV Push too fast can result in infiltration or systemic reaction such
as headache, flushing, tightness in chest. All IV Push have Phlebitis Risk. Flush slowly
after medication administration. Arrythmias have occurred following rapid bolus
administration (<60 sec).
Caution with Penicillin or Cephalosporin allergies.
Allergy: Patients with a documented allergy (urticaria, anaphylactoid or anaphylaxis) to
penicillins or B-Lactam antibiotics should not receive a cephalosporin antibiotic due to
a
6-8% risk of cross-allergenicity.
Comments:
Drug Interactions:
Monitor:
Side Effects:
Stability: room temperature= 12 hrs, refrigeration= 3 days
50
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
CefOXitin
[anaerobic cephalosporin-
2
nd
generation]
ADS MIXTURE
Bacterial Infection
ALL
UNITS
(Except
Psy)
I.I.: 1 or 2 gm in 100 mL NS (Minibag
Plus) over 30 mins q 6 hrs
IV Push (when a shortage
):
1 gm in 10 mL SWFI over 3 – 5 min
2 gm in 10 mL SWFI over 3 – 5 min
Caution/Warning: IV Push too fast can result in infiltration or systemic reaction such
as headache, flushing, tightness in chest. All IV Push have Phlebitis Risk. Flush slowly
after medication administration.
Allergy: Patients with a documented allergy (urticaria, anaphylactoid or anaphylaxis) to
penicillins or B-Lactam antibiotics should not receive a cephalosporin antibiotic due to
a 6- 8% risk of cross-allergenicity
Comments:
Drug Interactions:
Monitor:
Side Effects:
Stability: If pharmacy mix: 18 hours at room temperature and 48 hours under
refrigeration
Ceftaroline
Teflaro
®
[cephalosporin-5
th
generation]
RESTRICTED
ANTIMICROBIAL
NON-FORMULARY
Bacterial Infection-
MRSA
ALL
UNITS
(Except
Psy)
I.I.: 600 mg / 250 mL NS over 1 hour
q 12 h
Caution/Warning:
Comments: Use the constituted solution in the infusion bag within 6 hours when stored
at room temperature or within 24 hours when refrigerated at 2 to 8 degrees.
Drug Interactions:
Monitor:
Side Effects:
Stability:
51
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
CefTAZidime
Fortaz
®
[Cephalosporin 3
rd
Generation]
ADS MIXTURE
Bacterial Infection
Note: Replaced by
cefepime Feb 2012
for all adult patients
except NICU
(exception:
Cefepime
medication
shortage)
ALL
UNITS
(Except
Psy)
I.I.:
500 mg in 50mL NS over 15-20 mins
1gm in 100 mL NS (Minibag Plus) over
15-20 mins
2 gm in 100 mL NS (Minibag Plus) over
30 mins q 8 hrs
IV Push (when a shortage
):
1 gm in 10 mL SWFI over 3 – 5 min
2 gm in 10 mL SWFI over 3 – 5 min
Caution/Warning: IV Push too fast can result in infiltration or systemic reaction such
as headache, flushing, tightness in chest. All IV Push have Phlebitis Risk. Flush slowly
after medication administration.
Comments: Reduce dose or interval for CRF. Allergy: Patients with a documented
allergy (urticaria, anaphylactoid or anaphylaxis) to penicillins or B-Lactam antibiotics
should not receive a cephalosporin antibiotic due to a 6-8% risk of cross-allergenicity.
Automatic Therapeutic Substitution For Cefepime Orders during Medication
Shortage:
Cefepime 2gm q8 hrs
Ceftazidime 2g q8 hrs
Cefepime 2gm q 12hrs
Ceftazidime 2gm q12hrs
Cefepime 2gm q 24 hrs
Ceftazidime 2gm q24hrs
Cefepime 1gm q 8 hrs
Ceftazidime 1gm q8 hrs
Cefepime 1gm q 12 hrs
Ceftazidime 1gm q12hrs
Cefepime 1gm q 24 hrs
Ceftazidime 1gm q24hrs
Cefepime 1 gm post Dialysis
Ceftazidime 1gm post dialysis
Drug Interactions:
Monitor:
Side Effects:
Stability: If pharmacy mix: 12 hours at room temperature and 72 hours under
refrigeration
CefTAZidime/
Avibactam
Avycaz
®
[Cephalosporin 3
rd
Generation/
β-lactamase
inhibitor]
RESTRICTED
ANTIMICROBIAL
NON-FORMULARY
ADS MIXTURE
Treatment of
complicated intra-
abdominal
infections
(in combination
with metronidazole)
and complicated
urinary tract
infections (including
pyelonephritis)
caused
by
Enterobacteriacae
and Pseudomonas
aeruginosa
organisms
including some
multi-drug resistant
and extended-
spectrum
beta-lactamase
(ESBL) strains.
ALL
UNITS
(Except
Psy)
I.I.:
2.5 gm (2gm/0.5gm) in 100mL NS
(minibag plus) over 2 hrs
0.94 (0.75gm/0.19gm) – 1.25gm
(1gm/0.25gm) in 100mL NS over 2 hrs
Volume to Withdraw from
Reconstituted Vial
2.5gm
(2gm/0.5gm)
12mL (Entire
contents)
1.25 Gm
(1gm/0.25gm)
6mL (1/2 vial
contents)
0.94 Gm
(0.75gm/0.19gm)
4.5mL
Caution/Warning: β-lactam hypersensitivity history
May result in fungal or bacterial superinfection (e.g. Clostridium difficile)
Hemolytic anemia and renal impairment related neurotoxicity risk
Comments: CrCl 31 to 50 mL/min: 1.25 g every 8 hours
CrCl 16 to 30 mL/min: 0.94 g every 12 hours
CrCl 6 to 15 mL/min: 0.94 g every 24 hours
CrCl 5 mL/min or less: 0.94 g every 48 hours
ESRD on dialysis: dose based on residual kidney function
Drug Interactions: may decrease the effectiveness of BCG and Typhoid vaccines. May
increase the effectiveness of warfarin. May increase the nephrotoxicity of
aminoglycosides. Chloramphenicol may decrease the effectiveness of this product.
Monitoring: Monitor serum creatinine and creatinine clearance daily in patients with
unstable renal function. Monitor for anaphylaxis initially.
Side Effects: diarrhea, nausea, and headache, and pyrexia
Stability: Store intact vials at 25°C (77°F) away from light.
Admixed solutions are stable up to 12 hours at 20°C to 25°C and 24 hours at 2°C to
8°C. Use solutions previously stored at 2°C to 8°C (36°F to 46°F) within 12 hours of
subsequent storage at 20°C to 25°C (68°F to 77°F).
52
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Ceftolozane/
Tazobactam
Zerbaxa®
[Cephalosporin 5
th
Generation/
β-lactamase
inhibitor]
RESTRICTED
ANTIMICROBIAL
NON-FORMULARY
ADS MIXTURE
Treatment of
complicated intra-
abdominal
infections (in
combination with
metronidazole)
and complicated
urinary tract
infections
(including
pyelonephritis)
caused by
Enterobacteriacae
and Pseudomonas
aeruginosa
organisms including
some multi-drug
resistant and
extended-spectrum
beta-lactamase
(ESBL) strains.
ALL
UNITS
(Except
Psy)
I.I.: 1.5gm (1gm/0.5gm) in 100mL NS
(minibag plus when off shortage) over 60
mins
150mg (100mg/50mg)-750mg
(500mg/250mg) in 100mL NS over 60
mins
Volume to Withdraw from
Reconstituted Vial
1.5gm
(1gm/0.5gm)
11.4mL
(Entire
contents)
750mg
(500mg/250mg)
5.7mL
375mg
(250mg/125mg)
2.9mL
150mg
(100mg/50mg)
1.2mL
Caution/Warning: β-lactam hypersensitivity history
May result in fungal or bacterial superinfection (e.g. Clostridium difficile)
Comments: CrCl 30 to 50 mL/min: 750 mg every 8 hours
CrCl 15 to 29 mL/min: 375 mg every 8 hours
ESRD on dialysis: 750 mg once immediately post dialysis then 150 mg every 8 hours
Drug Interactions: may decrease the effectiveness of BCG and Typhoid vaccines. May
increase the effectiveness of warfarin.
Monitoring: Monitor serum creatinine and creatinine clearance in patients with
unstable renal function.
Side Effects: diarrhea, nausea, and headache, and pyrexia
Stability: Use within 24 hours after dilution at room temperature or within 7 days at
2°C to 8°C (36°F to 46°F)
CefTRIAXone
Rocephin
®
[cephalosporin- 3
rd
generation]
ADS MIXTURE
Bacterial Infection
ALL
UNITS
I.I.:
1 gm in 100mL NS (Minibag Plus) or
Duplex bag over 30 mins daily or q 12
hrs
2 gm in 100 mL NS (Minibag Plus) or
Duplex bag over 30 mins daily or q 12
hrs
IV Push (Alternative when products
not available):
1 gm in 10 mL SWFI over 3 – 5 min
2 gm in 20 mL SWFI over 3 – 5 min
Caution/Warning:
Comments: Com. Acq. Pneumonia: 1gm IV daily. Allergy: Patients with a
documented allergy (urticaria, anaphylactoid or anaphylaxis) to penicillins or B-Lactam
antibiotics should not receive a cephalosporin antibiotic due to a 6-8% risk of cross-
allergenicity.
Duplex bag instructions: Click Link for Instructions for Duplex Bag Admixture
Drug Interactions:
Monitor:
Side Effects:
Stability:
53
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Cefuroxime
Zinacef
®
[cephalosporin- 2
nd
generation]
ADS MIXTURE
Bacterial Infection
ALL
UNITS
(Except
Psy)
I.I.: 750-1500mg in 100 mL (Minibag
Plus) over 30mins q 8 hrs
IV Push (when a shortage
):
750 mg in 10 mL SWFI over 3 – 5 min
1.5 gm in 20 mL SWFI over 3 – 5 min
Caution/Warning: IV Push too fast can result in infiltration or systemic reaction such
as headache, flushing, tightness in chest. All IV Push have Phlebitis Risk. Flush slowly
after medication administration.
Comments: Reduce dose or interval for CRF. Allergy: Patients with a documented
allergy (urticaria, anaphylactoid or anaphylaxis) to penicillins or B-Lactam antibiotics
should not receive a cephalosporin antibiotic due to a 6-8% risk of cross-allergenicity.
Drug Interactions:
Monitor:
Side Effects:
Stability: Stable 48 hrs at room temperature, 30 days refrigerated.
Chlorothiazide
Diuril
®
[thiazide diuretic]
Nov 2017: During
shortage
of SVP
50mL/100mL D5W, use
NS
Edema
ALL
UNITS
(Except
Psy)
I.I.: 500 – 1000 mg in 50 mL NS or
D5W over 15 -30 mins
Caution/Warning:
Comments: Avoid extravasation. Pharmacy to mix.
Drug Interactions:
Monitor:
Side Effects:
Stability:
ChlorproMAZINE
Thorazine
®
[antipsychotic]
Hiccups/
Agitation/
Confusion
ALL
UNITS
(Except
Psy)
I.I.: 12.5 - 50 mg in 50 mL NS over < 1
mg / min
Caution/Warning:
Comments: Not IV Push.
Drug Interactions:
Monitor: for sedation, hypotension, EPS, may lower seizure threshold.
Side Effects:
Stability:
Cidofovir
Vistide
®
[antiviral agent]
RESTRICTED
ANTIMICROBIAL
CMV retinitis
HSV infection,
acyclovir resistant
ALL
UNITS
(Except
Psy)
I.I.: 5mg/kg/dose in 100 mL NS over
60 min. Hydrate with 1 L of NS IV over
1-2 hours immediately prior to cidofovir
infusion.
Caution/Warning: Pre-medicate prior to each infusion with hydration. Administer with
concomitant probenecid.
Comments:
Drug Interactions:
Monitor: SrCr, Urine Protein (at baseline and within 48 hours of each dose), WBC
w/diff, intraocular pressure and visual acuity, signs and symptoms of uveitis/iritis;
metabolic acidosis.
Side Effects:
Stability: 24 hours refrigerated.
54
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Ciprofloxacin
Cipro
®
[quinolone antibiotic]
NON-FORMULARY
Bacterial Infections
ALL
UNITS
(Except
Psy)
I.I.: 200-400 mg as Premix over 60
mins
Caution/Warning:
Comments: Reduced dose / interval in renal dysfunction. Too rapid administration can
cause hypotension.
Drug Interactions:
Monitor:
Side Effects: Phlebitis, dizziness, tremor, arthralgia, headache, inj.site inflammation,
QTc prolongation.
Stability:
Cisatracurium
Nimbex
®
[neuromuscular blocker]
TITRATE MED
Nov 2017: During
shortage
of SVP
50mL/100mL D5W, use
NS
Skeletal muscle
relaxant for
Mech. ventilation
ED
UT1-ICU
OR/PACU
LD IV Push: 0.1 -0.2 mg/kg undiluted
over 5-10 secs then
C.I.: 100 mg/ 100 mL (1mg/ml) or 200
mg/ 100ml (2mg/ml) NS or D5W
1-10 mcg/kg/min. Start @ 2 mcg/kg/min
and Titrate by 1 mcg/kg/min q 10 mins
or as ordered to achieve Train of Four 2-
3 out of 4 or as ordered.
Max: 10 mcg/kg/min unless higher max.
is ordered by MD/LIP
Catuion/Warning:
Comments: Pt MUST be on a ventilator.
CI requires MD/LIP order for therapeutic goal (ex: Train of Four) or reason. Titrate per
order to goal. Requires an analgesic and sedative.
Drug Interactions:
Monitor: train of four, RR, BP, HR, apnea, resp. depression.
Related Policies:
• Neuromuscular Blocking Agents (NMBA): IV Administration
Side Efects:
Stability: Stable for 14 days refrigerated. Stable for 24 hours at room temperature.
10mL vial contains a preservative. Xu et al. Stability of cisatracurium besylate in vials,
syringes, and infusion admixtures. Am J Health-Syst Pham 1998: 55:1037-41
Clevidipine
Cleviprex
®
[antihypertensive, calcium
channel blocker]
Reduction of blood
pressure when oral
therapy is not
feasible or not
desirable.
Cath Lab,
ICU, ED,
OR
Initial dose: Infusion at 1-2 mg/hour.
Titration: The dose may be doubled at
short (90 second) intervals. A 1-2
mg/hour increase will generally produce
an additional 2-4 mmHg decrease in
systolic pressure.
Maintenance dose: Desired therapeutic
response for most patients occurs at
doses of 4-6 mg/hour.
Caution/Warning: hypotension and reflex tachycardia, lipid intake, negative inotropy,
beta blocker withdrawal, and rebound hypertension
Drug Interactions: No major drug interactions
Monitor: blood pressure and heart rate
Side Effects: headache, nausea, and vomiting.
Stability: Store clevidipine vials in the refrigerator between 2-8°C (36°F to 46°F) and
keep in original cartons to protect from light. Vials in cartons may be transferred to
25°C (77°F, USP controlled room temperature) for a period not to exceed 2 months.
55
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Clindamycin
Cleocin
®
[antibiotic]
Bacterial Infection
ALL
UNITS
I.I.:
300 mg/ 50 mL NS or D5W over 30
mins
600 & 900 mg / 50 mL NS or D5W over
30 mins q 8 hrs
Caution/Warning:
Comments: Compatible with Gentamicin. 900 mg option for Toxoplamosis, Pelvic
Inflammatory Disease, Pre-operative dosing.
Drug Interactions:
Monitor:
Side Effects:
Stability:
Colistimethate
Colistin
®
[antibiotic]
RESTRICTED
ANTIMICROBIAL
Bacterial Infection
ALL
UNITS
(Except
Psy)
I.I.: 2.5 – 5mg /kg/day in 2-3 divided
doses in 50 mL D5W over 30 mins
Dosing is based on Ideal or Actual body
weight (whatever is lower).
Caution/Warning:
Comments: Pharmacy to mix
Drug Interactions:
Monitor:
Side Effects: neurotoxicity, renal toxicity
Stability:
Conivaptan
Vaprisol
®
[vasopressin receptor
antagonist]
NON-FORMULARY
Euvolemic &
hypervolemic
hyponatremia
ALL
UNITS
(Except
Psy)
I.I.: LD: 20 mg/ 100 mL D5W over 30
mins then continue once or twice daily
for 1 to 2 days or as a CI
C.I.: 20 mg/ 250 ml D5W over 24 hrs X
2-4 days max.
Caution/Warning: Avoid rapid correction of serum Na +. Decrease dose in renal
dysfunction.
Comments: Pharmacy: use filter needle when drawing up from glass ampule
Drug Interactions:
Monitor:
Side effects: Injection site: phlebitis, pyrexia, hypokalemia, Headache, neuro side
effects from rapid Na+ correction.
Stability:
Copper
Cupric Chloride
[Trace Element]
Copper Deficiency
ALL
UNITS
(Except
Psy)
I.I.: 0.3-4mg in 250mL NS over 2- 4 hrs
Caution/Warning: Must be diluted. Do not administer IM or by direct IV injection;
acidic pH of the solution may cause tissue irritation.
Comments: For parenteral nutrition per ASPEN, 0.3-0.5mg/day. Per manufacturer’s
product labeling, 0.5-1.5 mg/day. Each mL of 0.4mg/mL copper solution contains 1.07
mg cupric chloride, dihydrate and 9 mg sodium chloride. The solution contains no
bacteriostat, antimicrobial agent or added buffer.
Drug Interactions:
Monitor:
Side Effects:
Stability: Must dilute in a volume ≥100 mL.
Reference: Copper Deficiency Clinical Review Wake Forest School of Med
56
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Cosyntropin
Cortrosyn
®
[diagnostic agent]
Diagnosis of
adrenocortical
insufficiency
ALL
UNITS
(Except
Psy)
IV Push: < 0.25 mg= 250 mcg dilute
with 1 mL NS over 1 min, flush with 5
mL NS
Caution/Warning:
Comments: edema, dizziness. Draw baseline serum cortisol then 30 and 60 mins after
dose
Drug Interactions:
Monitor:
Side Effects:
Stability:
Co-trimazole
Trimethoprim (TMP)
Sulfamethoxazole (SMX)
Bactrim/Septra
®
[antibiotic]
Bacterial Infection
ALL
UNITS
(Except
Psy)
I.I.:
Sepsis/Meningitis/PCP:
15-20 mg/kg/day as TMP divided q 6 hrs
Non PCP:10 mg/kg/day as TMP divided
q 6-12 hrs
0-80 mg TMP in 100 mL D5W over 1 hr
81-120 mg TMP in 150 mL D5W over
1.5 hrs
121-240 mg TMP in 250 mL D5W over
1.5 hrs
241-450mg TMP in 500 mL D5W over
2 hrs
Caution/Warning:
Comments: Nursing to mix due to short stability (6 hours at room temperature)
Dosing is based on TMP component 5 mL = 80 mg trimethoprim & 400 mg
sulfamethoxazole. Reduce dose with renal impairment.
Drug Interactions:
Monitor: CBC, Cr, K+, for skin rashes
Side effects: rash, immune hypersensitivity reactions, hyponatremia, thrombocytopenia,
pancytopenia, hemolysis, hyperkalemia
Stability:
Crizanlizumab-tmca
Adakveo®
[monoclonal antibody, anti-
P selectin]
Reduce frequency
of vaso-occlusive
crises in sickle cell
disease patients >
16 years of age
SICKLE
I.I.: 5 mg/kg once every 2 weeks for 2
doses (at week 0 and week 2), followed
by 5 mg/kg once every 4 weeks
thereafter in 100mL NS or D5W. Infuse
over 30 minutes through a sterile,
nonpyrogenic 0.2-micron inline filter.
After infusion is complete, flush the line
with ≥25 mL of NS or D5W. Do not mix
or administer with other medications.
Caution/Warning: infusion related reactions may occur within 24 hours of infusion.
May interefere with automated platelet counts (clumping) when blood samples are
collected in tubes containing EDTA
Comments:
Drug Interactions:
Monitor:
Side effects: fever, chills, fatigue, dizziness, pruritus, sweating
Stability: do not shake diluted solutions. Infusion must be completed within 4.5 hours
of preparation (if stored at room temperature) or 24 hours (if refrigerated)
Crotalide polyvalent
Immune fab
Crofab
®
[antivenom]
Snake bites
UT1-ICU
I.I.: 4-6 vials in 250 mL NS over 1 hr
Caution/Warning:
Comments:
Drug Interactions:
Monitor:
Side Effects:
Stability:
BKC: Dispose in
Black Bin
57
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
CycloSPORINE
SandIMMUNE
®
[immunosuppressant]
Severe Ulcerative
colitis, ORGAN
REJECTION
PROPHYLAXIS
ALL
UNITS
(Except
Psy)
I.I. or C.I.: 1- 6 mg/kg/day mixed as 1-2
mg/ml D5W or NS, give over 2-6 hrs
Caution/Warning:
Comments: Must be put in polyolefin bag with NS or D5W at conc. of 2mg/ml and
stable for 12 hrs at room temperature. IV doses of cycloSPORINE are about 1/3 of the
oral dose. Hazardous medication precautions. Carcinogen. Pregnancy Category C. Wear
nitrile gloves while handling. Gowns should be utilized for incidental exposure to
hazardous drugs. Dispose in hazardous waste container. Refer to the UConn hazardous
drug safety handling for further information:
Medication Handling Safety
Drug Interactions:
Monitor:
Side Effects:
Stability:
Dalbavancin
Dalvance®
[glycopeptide antibiotic]
RESTRICTED
ANTIMICROBIAL
NON-FORMULARY
Bacterial Infections
Documented or
suspected skin &
skin structure
infection (given as a
single-dose
treatment), bone
infection, or
endocarditis caused
by caused by MRSA
in a patient
intolerant to or not
responding
clinically to
vancomycin,
daptomycin,
ceftaroline, or
linezolid
Patient who needs
long-term anti-
MRSA therapy for
above infections in
the outpatient
setting for whom
traditional
outpatient parenteral
antibiotic therapy
(“OPAT”) and/or
adherence to oral
therapy is not
possible)
ALL
UNITS
(Except
Psy)
I.I.: IV infusion: 500 to 1,500 mg in 100
to 1,500 mL (concentration of 1 to 5
mg/mL) of D5W over 30 minutes
- If a common IV line is being used to
administer other drugs in addition to
dalbavancin, the line should be flushed
before and after each infusion with D5W.
Caution/Warning: Glycopeptide hypersensitivity history
May result in fungal or bacterial superinfection (e.g. Clostridium difficile)
Use with caution in patients with moderate to severe hepatic impairment (Child-Pugh
class B or C)
Rapid intravenous infusions (<30 minutes) may cause reactions that resemble
vancomycin infusion reaction (formerly "red man syndrome") (eg, flushing of the upper
body, urticaria, pruritus, rash). Stopping or slowing the infusion may result in cessation
of these reactions
Comments: CrCl ≥30 mL/minute: No dosage adjustment necessary.
CrCl <30 mL/minute (not on regularly scheduled dialysis): Single-dose regimen:
1.125 g as a single dose. Two-dose regimen: 750 mg as a single dose initially, followed
by 375 mg as a single dose 1 week later.
HD (regularly scheduled): No dosage adjustment necessary; administer without regard
to timing of hemodialysis.
Drug interactions: may decrease the effectiveness of BCG, Cholera, and Typhoid
vaccines. May diminish the therapeutic effect of Immune Checkpoint Inhibitors Monitor
serum creatinine and creatinine clearance daily in patients with unstable renal function.
Monitor for anaphylaxis initially.
Monitoring: Baseline BUN, Scr, and LFTsMonitor renal function.
Related Policies: Restricted and Concurrently- Monitored Antimicrobials
Side Effects: Pruritis, nausea, vomiting, headache
Stability: Store intact vials at 25°C (77°F); excursions are permitted between 15°C and
30°C (59°F and 86°F). Reconstituted vials and diluted solution in D5W may be stored
refrigerated at 2°C to 8°C (36°F to 46°F) or at room temperature 20°C to 25°C (68°F to
77°F). Do not freeze. The total time from reconstitution to dilution to administration
should be ≤48 hours.
BKC: Dispose in
Black Bin
58
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Dantrolene
Ryanodex®
[skeletal muscle relaxant]
Malignant
Hyperthermia Crisis
Neuro-Malignant
syndrome
UT1-ICU
OR/PACU
UHSC
MH Prevention: 2.5 mg/kg IV over at
least 1 minute, starting 75 minutes before
surgery - certain patients may require
additional doses during surgery
MH Treatment: 1 mg/kg IV push,
repeat if signs continue - MAX
cumulative dose = 10 mg/kg
Administer into IV catheter with
continuous sodium chloride 0.9% IV or
dextrose 5% injection or into an
indwelling catheter after ensuring its
patency. Flush the line after
administration.
Caution/Warning:
Comments: Avoid extraversion. Protect from light.
Reconstitute each 250 mg vial with 5 mL sterile water for injection = 50 mg/mL
shake vial to yield orange color. Inspect for particulates.
Drug Interactions:
Monitor: performance, cardiac, BP
Stability: Stable for 6 hrs at room temperature
Related Policies:
• Malignant Hyperthermia (MH): Perioperative Care of Patients with
• Malignant Hyperthermia Association of the United States Website
DAPTOmycin
Cubicin
®
[antibiotic]
RESTRICTED
ANTIMICROBIAL
Antibiotic
ALL
UNITS
(Except
Psy)
I.I.: 4 mg/kg in 50 mL NS only, give
over 30 mins
I.I. (Bacteremia): 6 mg/kg in 50 mL NS
only, give over 30 mins
Dosing is based on Ideal Body Weight
(IBW). If the patient’s actual Total Body
Weight (TBW) is less than IBW, then the
patient’s daptomycin dose should be
calculated using TBW.
Caution/Warning:
Comments: Pharmacy to admix. Adjust dose in renal impairment
Drug Interactions:
Monitor:
Side Effects:
Stability: Stable for 12 hrs at room temperature, 48 hrs in refrigerator
Related Policies:
Daptomycin Dose Rounding by Pharmacy (See Appendix of Therapeutic
Interchange List)
• P&T Therapeutic Interchange List
Deferoxamine
Desferal
®
[iron chelator]
Iron Toxicity
ALL
UNITS
(Except
Psy)
I.I.: 500 mg- 2 gm in 500 mL D5W or
NS, infusion rate should NOT exceed 15
mg/kg/hr although rates up to 40-50
mg/kg/hr maybe attempted in pts with
massive iron intoxication , Infusion time
= 12 hrs.
SC Infusion: 500 mg – 3 gm, as 200
mg/mL conc. with option of adding
Hydrocortisone 10-20 mg, given over
10-16 hrs/day.
Caution/Warning:
Comments: Stable for 24 hrs @ Room Temperature
SC Use: Dispense as syringe, connect via butterfly needle and given via PCA pump for
SC use. Protect from light. Pharmacy: Reconstitute 500 mg vial with 5 mL of sterile
water. = 95 mg/ml, reduce dose w Crcl<10 mL/min. Change SC site, tubing and syringe
q 72 hrs.
Drug Interactions:
Side Effects: Urticaria, hypotension, shock following rapid IV. Adverse ocular effects
from long term deferoxamine therapy may include decreased visual acuity, blurred
vision, night blindness, impairment or loss of color vision, optic neuropathy, and retinal
pigmentation changes.
Stability:
59
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Delafloxacin
Baxdela®
[Fluoroquinolone antibiotic]
RESTRICTED
ANTIMICROBIAL
NON-FORMULARY
Bacterial Infections
Documented or
suspected infection
caused by MRSA or
Vancomycin-
Resistant
Enterococci (VRE)
in a patient
intolerant to or not
responding
clinically to other
formulary /
formulary-restricted
options
Patient receiving
delafloxacin prior to
admission to UConn
Health John
Dempsey Hospital
ALL
UNITS
(Except
Psy)
I.I.: IV infusion over 60 minutes.
-Do not administer with any solution
containing multivalent cations (eg,
calcium and magnesium) through the
same IV line.
-Do not co-infuse with other
medications.
-If a common IV line is being used to
administer other drugs in addition to
delafloxacin, the line should be flushed
before and after each infusion with NS or
D5W
Caution/Warning:
Boxed warning: tendinopathy and tendon rupture, peripheral neuropathy, and CNS
effects; may exacerbate muscle weakness in patients with myasthenia gravis
Aortic aneurysm and dissection, disturbances in glucose regulation, Hypersensitivity
reactions; May result in fungal or bacterial superinfection (e.g. Clostridium difficile)
Comments: eGFR 30 to 89 mL/minute/1.73 m2: No dosage adjustment
eGFR 15 to 29 mL/minute/1.73 m2: 200 mg every 12 hours
eGFR <15 mL/minute/1.73 m2: Use is not recommended.
ESRD on hemodialysis: Use is not recommended.
Drug interactions: may decrease the effectiveness of BCG, Cholera, and Typhoid
vaccines. may enhance the QTc-prolonging effect of other agents
Monitoring: WBC, signs of infection, serum creatinine; signs and symptoms of
disordered glucose regulation, renal function tests, and LFTs with prolonged therapy
Related Policies: Restricted and Concurrently- Monitored Antimicrobials
Side Effects: nausea, vomiting, headache, increased transaminases/hepatotoxicity
Stability: Store at 20°C to 25°C (68°F to 77°F); excursions permitted to 15°C to 30°C
(59°F to 86°F). The reconstituted powder may be stored under refrigeration (2°C to 8°C
[36°F to 46°F]) or at 20°C to 25°C (68°F to 77°F) for up to 24 hours and then further
diluted for IV infusion. The reconstituted solution in the infusion bag may be stored
under refrigeration (2°C to 8°C [36°F to 46°F]) or at 20°C to 25°C (68°F to 77°F) for
up to 24 hours. Do not freeze.
Desmopressin
DDAVP
[vasopressin]
Control of surgical
hemorrhage , uremic
bleeding,
Hemophilia A, Von
Willeb.
ALL
UNITS
(Except
Psy)
I.I.: 0.3 mcg/kg diluted in 50 mL NS,
over 15- 30 mins
Caution/Warning:
Comments: Contraindications: Crcl < 50 mL/min. The comparable IV dose is about
1/10 the intranasal dose.
Drug Interactions:
Monitor: BP, HR, Lytes, SOB
Side Effects:
Stability:
Diabetes Insipidus
ALL
UNITS
(Except
Psy)
IV Push: 1-4 mcg diluted in 10 mL NS
over 1 min
60
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Dexamethasone
Decadron
®
[adrenal glucocorticoid]
Nov 2017: During
shortage
of SVP
50mL/100mL D5W, use
NS
Anti-inflamma
tory,
Antiemetic
ALL
UNITS
(Except
Psy)
IV Push: < 12 mg dilute with 5 mL NS
over 1-2
mins, flush with 5 mL NS.
I.I.: doses > 12 mg in 50 mL NS or
D5W over 10-15 mins
Caution/Warning:
Comments: Rapid administration may cause perianal discomfort. Pharmacy info:
Anti-inflammatory potencies: Dexamethasone 4mg = 2 0 mg MethylPREDNISolone
Drug Interactions:
Monitor: Hyperglycemia
Side Effects: Tingling, sodium & fluid retention, inc. glucose, Neuropsychiatric
symptoms- sleep disturbances.
Stability (pharmacy mix >12mg doses): 14 days at room temperature
Dexmedetomidine
Precedex
®
[alpha-2 adrenergic agonist]
TITRATE MED
ICU sedation
UT1-ICU
I.I. LD: 1 mcg/kg infused over 10
minutes then
C.I.: 0.2-1 mcg/kg/hr , max; @
1.5mcg/kg/hr
-Nurse may titrate per MD order up to
1mcg/kg/hr.
-Dose increases >1mcg/kg/hr require
MD rate change order.
200 mcg / 50 mL NS (4 mcg/mL)
400 mcg / 100 mL NS (4 mcg/mL)
Caution/Warning:
Comments: Use beyond 5 days, provider should consider risks vs. benefits.
CI requires MD/LIP order for therapeutic goal (ex: RASS or explanation of desired
level of sedation) or reason. Titrate per protocol to goal.
Infusions are reserved for ICU patients both intubated and extubated patients with
continuous monitoring of oximetry and capnography. Dexmedetomidine infusions are
permitted in monitored extubated ICU patients who:
a.) still need sedation after extubation
b.) for ETOH withdrawal or
c.) for patients, NOT previously intubated, requiring sedation.
Notify practitioner if unable to achieve desired level of sedation at the ordered
maximum dose.
Drug Interactions:
Monitor: BP (hypotension), HR (bradycardia), RR, injection site, mental status,
allergic/anaphylactic reaction, nausea/vomiting.
Monitor (Specific to Continous Infusion): BP, RR and sedation score every 1-2 hours
and more frequently during active titration, continuous HR monitoring, injection site,
mental status, continuous pulse ox and capnography (if not mechanically ventilated).
Side Effects: Hypotension, Bradycardia, Hypertension.
Stability:
BOLUS OFF BAG:
Upon new EMR April
2018, ability to bolus
from continuous
infusion bag via Alaris
Pump Guardrails.
61
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Dextran 10% Dextran 40
in 5 % Dextrose
(10% LMD)
LOOK ALIKE / SOUND
ALIKE
Thrombosis
Prophylaxis status
post vascular
surgery
Note: Not
recommended for
DVT/PE
prophylaxis by 2008
ACCP
ALL
UNITS
(Except
Psy)
I.I.: 500 milliliters (mL) of dextran 40
(100 mL/hour) during the procedure,
followed by another 500 mL (75
mL/hour) immediately after, then equal
amounts for three consecutive days.
Caution/Warning:
Comments:
Drug Interactions:
Monitor:
Side effects: Rarely: hypotension- monitor BP q 4 hr during infusion.
Rarely anaphlactoid like reactions: flushing, erythema, or urticaria; a "strange" feeling;
lumbar pain; fever and/or shivering; mild to severe hyptension; gastrointestinal
disturbances; respiratory distress; bronchospasm; and/or cardiac or respiratory arrest.
Stability:
Dextrose 50%
D50
50 mL= 25 gms
Carbohydrate
Hypoglycemia
ALL
UNITS
IV Push: 25 grams=50mL of 50%
undiluted over 1-2 mins , flush with 5
mL NS, may repeat as ordered
Caution/Warning:
Comments: Be sure of good IV access to prevent extravasation. Do not use if solution
is cloudy.
Treatment of Hyperkalemia: Follow MD orders:
1.Stop K+ infusions and oral therapy and Contact MD/LIP to
Discontinue K+ infusions.
2. Consider Calcium Gluconate IV Push: 10-20 mL of 10% over 2 mins or
1 gm in 50 mL D5W X 1-2 doses over 5-10 mins)
3. Dextrose IV Push ( 50 mL of D50 IV Push) undiluted over 1-2 mins
4. Regular Insulin IV Push ( 10 units)
5. Bicarbonate IVP (50 mEq= 50 mL of 8.4% over 2 mins
6. B2 adrenergics-albuterol nebs (10-20 mg = 12-24 mL nebulized);
7. Loop diuretics
8. Na Polystyrene (15-60 gms)
9. Hemodialysis
Drug Interactions:
Monitor: Blood glucose
Side Effects:
Stability:
Hyperkalemia
ALL
UNITS
(Except
Psy)
IV Push: 25 grams=50 mL of 50%
undiluted over 1-2 mins with 10 units
regular insulin IVPush and if ordered :
Calcium Gluconate IVPush: 10-20 mL
of 10% over 2 mins to antagonize
membrane effects, with bicarb when
ordered, & with Albuterol 2.5 mg/ 3 mL
via neb when ordered
DiazePAM
Valium
®
[benzodiazepine]
Anticonvulsant,
Sedation,
Anti-anxiety,
Muscle relaxant
ED
EMU
ENDO
UT1-ICU
IRAD
L&D/
OB-GYN
OR/PACU
LIP on
other units
IV Push: 5-10mg undiluted at 5mg/min
q 5-15 mins as necessary up to a max.
dose of 30 mg & may repeat in 2-4 hrs if
needed for treatment of seizures, OR
After 1
st
dose wait 2 mins, then give a 2
nd
dose to total of 10 mg, may repeat in 2-4
hrs up to 30 mg in a 8 hr period
Caution/Warning:
Comments: Do not inject into small veins. If direct injection is not feasible, may
inject through infusion tubing as close as possible to the vein insertion. Avoid
extravasation.
Flush before & after with NS. Not for procedural sedation. Not compatible with any
other drugs or solutions.Not for Syringe infusion due to incompatibility with other
solutions
Drug Interactions:
Monitor: BP, sedation, resp. depression, IV site.
Flumazenil must be readily available for reversal of benzodiazepine toxicity.
Side Effects:
If Extravasation,
see Pages 10&11
Avoid in midline cath see
Page 14
Avoid in midline cath see
Page 14
If Extravasation,
see Pages 10&11
DEAP: Contact
RPh for Proper
waste disposal
62
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Alcohol withdrawal
(in response to IV
lorazepam shortage)
ED
UT1-ICU
UT2-IU
IV Push: 20mg undiluted at a max rate
of 5mg/min (over at least 4 minutes) x 1
dose; follow with 10mg (over at least 2
minutes) q1h x 3 doses starting 1 hour
after the initial 20mg dose; follow with
10mg q4h as needed for CIWA>10
Stability:
Digoxin
Lanoxin
®
[cardiac glycoside]
(Digitalizing/Loading Dose)
CHF, A. Fib.
ALL
UNITS
(Except
Psy)
IV Push: ≤ 0.5MG dilute in 10 mL NS
over 3-5 mins, flush with 5 mL NS
Caution/Warning:
Comments: DIGITALIZING/ LOADING DOSE – Pt must be on a continuous
cardiac monitor/telemetry. Give ½ total, ¼ of total x 2 doses given 6 hrs apart.
Amiodarone & DiltiaZEM inc. dig. Levels. No loading dose change in patients with
renal failure. Note: Adult & pediatric strengths
Drug Interactions:
Monitor: BP and HR; baseline and periodic ECG monitoring. Monitor HR & BP
before and q 15 mins x 2.
Side Effects:
Stability:
Digoxin immune
FAB
Digifab
®
[digitalis antidote]
Digoxin toxicity
ED
HT1-ICU
1. Acute ingestion of unknown amount
of digoxin and digoxin level not
available: 10 vials= 400 mg
intravenous in 50 mL NS over 30-60
mins. A repeat dose may be
administered but requires MD
evaluation.
2. Acute ingestion of known amount of
digoxin: # vials of DIGIFAB ® = mg
total digoxin body load X 0.8 / 0. 5
mg of dig bound/vial (Round up to
nearest whole vial). Product is mixed
in an appropriate volume of NS.
3. Chronic ingestion acute distress with
no steady state dig level known: 6
vials. Product is mixed in an
appropriate volume of NS.
4. Chronic ingestion, steady state dig
level known: # vials= dig level
(ng/ml) x weight in kg / 100 (Round
up to nearest whole vial). Product is
mixed in an appropriate volume of
NS.
Caution/Warning:
Comments: Cardiac monitor/telemetry is required.
No filter required for Digifab
®
infusion
Each vial = 40 mg will bind 0.5 mg digoxin
Check K+, dig level prior to 1
st
dose.
Dig levels will be inaccurate for 1 week.
Drug Interactions:
Monitor: Check K+, dig level prior to 1
st
dose. Monitor for hypokalemia and
exacerbations, caused by digoxin withdrawal, of low CP, CHF, or rapid ventricular rate
in patients with afib. Digoxin level should be drawn prior to digoxin immune fab
administration as they rise after therapy and should not be used to guide continuing
therapy. Dig levels will be inaccurate for 1 week.
Side Effects: Fever, allergic reactions (Due to potential for severe allergic reactions
medications for anaphylaxis management should be readily available.)
Stability: Compatible in 0.9% NaCl to a max conc of 10mg/ml. No known common
compatibilities. Use reconstituted product immediately.
BKC: Dispose in
Black Bin
63
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Dihydroergotamine
[ergot alkaloid]
Migraines
ALL
UNITS
(Except
Psy)
IV Push (preffered): 0.5-1 mg over 1-4
mins
OR
I.I. (not preffered; give IV Push if
possible): 0.5-1 mg in 50 mL NS over
15-30 mins
Caution/Warning:
Comments: No greater than 2mg/ 24 hrs or 6 mg/wk.
Do not use within 24 hrs of serotonin agonists or if MAOI’s within last 2 weeks.
Contraindications: Severe CRF, HTN, Ischemic Disease
Drug Interactions:
Monitor:
Side Effects:
Stability:
DiltiaZEM
Cardizem
®
[Calcium
Channel Blocker]
TITRATE MED
(Do Not Titrate without
order)
Nov 2017: During
shortage
of SVP
50mL/100mL D5W, use
NS
A. Fib/Flutter,
PSVT
ED
UT1-ICU
UT2-IU
OR/PACU
UHSC
In presence
of Critical
Care RN or
Action RN
and LIP
during
RRT/Code,
ALL
UNITS
IV Push: A.fib/flutter: initial dose
0.25mg/kg undiluted (average 20mg)
over 2mins- may repeat in 15 min at a
dose of 20-25 mg (0.35 mg/kg) over 2
mins
Caution/Warnings: Cautious use with IV Beta Blockers. Do not use CCB’s for wide
QRS tachy’s of unknown origin.
Comments: Patient must be on a bedside cardiac monitor/telemetry for IV Push/C.I.
Requires MD/LIP order for adjustments.
Do not titrate. Call MD/LIP for changes.
Infusions of 3,5,7,11 mg/hr are equivalent to 120,180,240, 360 mg PO daily of regular
or SR. Discontinue continuous infusion 1 hour after first oral dose.
Drug Interactions:
Monitor: EKG, BP & HR every 15 minutes x 2 than every 30 minutes x 2 after IVP or
C.I. or rate change, arrhythmias, CHF, Bradycardia.
Side Effects: edema, bradycardia, hypotension, flushing, palpitations
Stability: Store in refrigerator at 2°C to 8°C (36°F to 46°F); do not freeze. May be
stored at room temperature for up to 1 month. Following dilution to ≤1 mg/mL with
D
5
½ NS, D
5
W, or NS, solution is stable for 24 hours at room temperature or under
refrigeration.
ED
UT1-ICU
UT2-IU
OR/PACU
UHSC
In presence
of Critical
Care RN or
Action RN
and LIP
during
RRT/Code,
ALL
UNITS
C.I.: 125 mg / 125 mL NS or D5W
(1mg/ mL) by adding 125mg (25mL) of
diltia
ZEM to 100 mL NS or D5W
Start @ 5mg/hr to achieve rate control
and Do Not titrate. Call MD/LIP for
order to increase/decrease by usual of 5
mg/hr to achieve rate control if indicated.
Usual max. is 15 mg/hr. Higher doses up
to a Maximum of 20 mg/hr may be
indicated and a cardiology consult is
recommended.
BOLUS OFF BAG:
Upon new EMR April
2018, ability to bolus
from continuous
infusion bag via Alaris
Pump Guardrails.
64
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
DimenhyDRINATE
Dramamine
®
[antihistamine]
Motion sickness -
prevention/treatmen
t
ALL
UNITS
(Except
Psy)
I.I.: 25-50 mg diluted with 50 mL NS ,
over 10-15 mins
Caution/Warning:
Comments:
Drug Interactions:
Monitor:
Side Effects:
Stability:
DiphenydrAMINE
Benadryl
®
[antihistamine]
Nov 2017: During
shortage
of SVP,
medication will be given
IV Push
Pruritus
Allergic reactions
ALL
UNITS
IV Push: < 50mg Undiluted given over
2-3 mins, flush with 5 mL NS
Doses >50mg-100mg administer at a rate
≤ 25 mg/minute (e.g. 100mg over 4-5
minutes)
Caution/Warning: IV Push too fast can result in infiltration or systemic reaction such
as headache, flushing, tightness in chest. All IV Push have Phlebitis Risk. Flush slowly
after medication administration.
Comments: Consider nalbuphine (mixed opiate agonist/antagonist) for pruritus due to
systemic opioids. Lower dose in geriatric population and renal failure. May be given
with metoclopramide in same syringe.
Drug Interactions:
Monitor:
Side Effects: Sedation, dizziness. Benadryl is a respiratory stimulant not a respiratory
depressant. Can cause drying of oral secretions and urinary retention in high doses.
Monitor for sleep disturbances, Parkinson symptoms- motor restlessness, dyskinesias,
and tardive dyskinesias.
Stability:
ALL
UNITS
For patients
with Opioid
induced
pruritus
I.I: : 50 mg dilute with 50 mL D5W or
NS, over 15-20 mins
(During Shortage, Premix
Diphenhydramine will be used only in
the Sickle Cell Clinic, other units should
administer IV Push)
Dipyridamole
Persantine
®
[vasodilator]
Evaluation of
coronary artery
disease
EP lab
CCL
I.I.: 0.57mg/kg diluted as a 1:2 ratio in
NS or D5W. Total volume should be
approx 20-50 mL.
Caution/Warning:
Comments:
Drug Interactions:
Monitor: BP, HR, ECG, respiration
Side Effects:
Stability:
65
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
DOBUtamine
Dobutrex
®
[adrenergic agonist]
TITRATE MED
(except UT2-IU)
LOOK ALIKE / SOUND
ALIKE
CHF, Shock
ED
UT1-ICU
UT2-IU
OP-CARD
OR/PACU
C.I.:
Low : 250 mg/250mL D5W (1mg/mL)
Mid : 500 mg/250mL D5W (2mg/mL)
High : 1000 mg/250mL D5W (4mg/mL)
Start @ 2.5mcg/kg/min and adjust by 2.5
mcg/kg/min q 5 mins to achieve goal CI
> 2.0 or MAP, desired BP. Usual dose
range: 2-20 mcg/kg/min
Max Dose:
UT2-IU: 10 mcg/kg/min-
Do Not Titrate
UT1-ICU/ED, Cardiology: 20
mcg/kg/min up to 40 mcg/kg/min if
MD/LIP ordered
Caution/Warning:
Comments: Central vein preferred except in emergencies. Cardiac monitor unless
outpatient maintenance infusion.
Requires MD/LIP order for therapeutic goal (ex: BP, HR, MAP) or reason. Titrate per
order to goal. Exp. date for pre-mix bag if bag is out of protective overwrap = 14 days.
Correct low BP before use. Avoid when SBP< 90-100. Tachyphylaxis with use > 4-7
days. Taper to DC.
Drug Interactions:
Monitor: EKG, Urine O., K+, chest pain, angina, mental acuity, rhythm changes, h/a.
Monitor IV site for extravasation. BP & HR with each dose change until desired
effect/dose attached, then q 1-2 hours or as ordered. Hemodynamic parameters if
titrating to CO/CI.
Side effects: Ectopic beats, tachycardia, angina pain, palpitations, hypo-hypertension,
headache.
Stability: Incompatible w bicarbonate.
DOPamine
[adrenergic agonist-
inotrope]
TITRATE MED
(except UT2-IU)
LOOK ALIKE / SOUND
ALIKE
Hypotension &
shock
ED
UT1-ICU
UT2-IU
IRAD
OR/PACU
C.I.:
Low:
400mg/500mL D5W (0.8 mg/mL)
High:
800mg/500mL D5W (1.6 mg/mL)
Renal Dose: 1-5 mcg/kg/min
Cardiac Dose: 5-10 mcg/kg/min
Vasopressor Dose: 10-20 mcg/kg/min
Renal/Cardiac.:Titrate by 1mcg/kg/min
q10-30 min
Vasopressor: Start @ 5 mcg/kg/min and
titrate by 2.5 mcg/kg/min q 5 mins to
achieve increase in SBP to 100-120 or
MAP> 60 or U/O or > 30 mL/hr, or as
ordered.
Max. Dose:
UT2-IU, MSDU: 5 mcg/kg/min
Do Not Titrate
UT1-ICU: 30 mcg/kg/min- unless higher
max. is ordered by MD/LIP for up to 50
mcg/kg/min
Caution/Warning:
Comments: Central vein preferred except in emergencies.
Requires MD/LIP order for therapeutic goal (ex: BP, HR, MAP) or reason. Titrate per
order to goal.Taper to DC.
Drug Interactions:
Monitor: IV site for extravasation. EKG, Urine output every 1-2 hours or hourly if
strict I&O. BP & HR with each dose changed until desired effect/dose attained then
every 1-2 hours or as ordered. Hemodynamic parameters if titrating to hemodynamic
effect.
Side effects: Ectopic beats, n/v, chest pain,
tachy, hypo-hypertension, tremor, anxiety, headaches, resp. difficulty.
Stability: Exp. date for pre-mix bag if bag is out of protective overwrap = 14 days.
Bicarbonate will inactivate DOPamine.
If Extravasation,
see Pages 10&11
If Extravasation,
see Pages 10&11
Avoid in midline cath see
Page 14
66
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Doxycycline
[antibiotic]
Bacterial Infection
ALL
UNITS
I.I.:
100mg /250mL D5W/ NS over 2 hrs q
12 hrs
200 mg/250 mL D5W/ NS over 2 hrs q
12hr
Caution/Warning:
Comments: Pharmacy to mix. Avoid extravasation. May cause severe vein irritation.
Central line is preferred.
Drug Interactions:
Monitor:
Side Effects:
Stability: Solutions are stable for 12 hrs @ Room Temperature, 72 hours if refrigerated
and protected from light.
Eccalantide
Kalbitor
®
[kallikrein inhibitor]
Hereditary
angioedema
ED
UT1-ICU
UT2-IU
Acute Attacks: 30 mg SC in three 10 mg
(1 mL) injections using the same or in
different anatomic locations (abdomen,
thigh, upper arm; an additional dose of
30 mg may be administered within a 24
hr period if attack persists
Caution/Warning:
Comments: Available in ED and Pharmacy
Drug Interactions:
Monitor: Monitor patients for improvement in symptoms of acute attacks of hereditary
angioedema and above side effects.
Side effects: local injection site reactions: local pruritus, erythema, pain, irritation,
urticarial. Possible hypersensitivity reactions including anaphylaxis.
Stability:
Eculizumab
Soliris
®
[monoclonal antibody]
Atypical hemolytic
uremic syndrome
Paroxysmal
nocturnal
hemoglobinuria
OP-INFC
I.I.: 300 mg to a total volume of 60 mL,
600 mg in a total volume of 120 mL, 900
mg in a total volume of 180 mL, or 1,200
mg to a total volume of 240 mL over 35
minutes. Do not exceed a maximum 2
hour duration of infusion.
Caution/Warning:
Comments: Allow to reach room temperature prior to administration.
Drug Interactions:
Monitor: CBC w/diff, LDH, SrCr, AST, U/A, meningococcal infection, infusion
reaction
Side Effects:
Stability: 24 hours refrigerated or room temperature. Do not shake.
Enalaprilat
Vasotec
®
[ACE Inhibitor]
Nov 2017: During
shortage
of SVP
50mL/100mL D5W, use
NS
Hypertension
Hypertension
ALL
UNITS
(Except
Psy)
I.I.: 0.625 – 5 mg in 50 mL NS or D5W
over 10-15 mins
Caution/Warning:
Comments: Dosage must be reduced with renal impairment. Hypotension is more
common when hyponatremia is present.The dose for pt's being converted from oral to
IV is the same total dose per day.
Drug Interactions:
Monitor: BP q 1 hr x 2, K+, BUN, Cr. Blood pressure per unit standards.
Side Effects:
Stability: Stable for 24 hrs @ R.T.
ED
UT1-ICU
UT2-IU
UT3-TELE
UT4-TELE
OR/PACU
IV Push: 0.625- 5 mg diluted in 5 mL
NS over 2-3 mins
If Extravasation,
see Pages 10&11
67
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
ePHEDrine
[sympathomimetic]
LOOK ALIKE / SOUND
ALIKE
Vasoconstrictor,
bronchodilator
ECT-A
ED
ENDO
UT1-ICU
UT2-IU
IRAD
OR/PACU
UHSC
IV Push: 5-25mg/dose undiluted over 2
mins, titrate to response. Do Not Exceed
150 mg in 24 hrs
Caution/Warning:
Comments:
Drug Interactions:
Monitor: Cardiac monitor/telemetry is required. Monitor BP, HR, U/O.
Side Effects: Palpitation, arrhythmias, tachycardia, increased BP, anxiety, tremors.
Stability:
EPINEPHrine
[sympathomimetic]
TITRATE MED
LOOK ALIKE / SOUND
ALIKE
Anaphylaxis,
cardiac arrest,
symptomatic
bradycardia,
bronchocon-
striction
ECT-A
ED
UT1-ICU
UT2-IU
IRAD
OR/PACU
In presence
of Critical
Care RN or
Action RN
and LIP
during
RRT/Code,
ALL
UNITS
IV Push ACLS: 1 mg , may repeat q 3-
5 mins
IV Push Anaphylaxis: 0.3- 0.5mg ,
repeat q 5-10 mins
Caution/Warning:
Comments: ACLS: 10mL of 1:10,000=1mg/10mL Syringe, follow with NS flush.
C.I.: Continuous Infusion requires MD/LIP order for therapeutic goal (ex:
BP, HR, MAP) or reason. Titrate per order to goal.Cardiac monitor/telemetry is
required. Central line preferred.
Anaphylaxis: Note: Pre-filled syringes (Epi-Pen) 0.3 mg IM for adults with
anaphylaxis.
Pre-filled syringes (Epi-Pen) 0.15 mg IM for children under 40 pounds with
anaphylaxis. For anaphylaxis with severe Hypotension: Use 0.3-0.5 mL (0.3-0.5mg) of
1:10,000= 0.1mg/ml if IV ordered
Drug Interactions:
Monitor: EKG, HR, BP. For C.I.: BP and HR with each dose change until desired
effect/dose attained, then q30 min x2 and then hourly if stable. Hemodynamic
parameters if titrating to hemodynamic effect. Urine output every 1 to 2 hours; hourly if
strict I&O. IV site for extravasation.
Side effects: Tachycardia, arrhythmias, hypertension, decreased renal blood flow,
dizziness, headache, anxiety.
Stability: Bicarbonate will inactivate EPINEPHrine. Stability when mixed by JDH
pharmacy when Protected from Light in refrigerator is 14 days. Protect from light.
Discard vials or solutions if turns pink or brown.
BKC: Dispose in
Black Bin
If Extravasation,
see Pages 10&11
68
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
ED
UT1-ICU
OR/PACU
C.I.:
Low: 4 mg in 250mL D5W [Premix] or
NS (16mcg/mL)
High: 8 mg in 250mL D5W or NS
(32 mcg/mL)
Inotrope: Start at 0.02 mcg/kg/min,
titrate by 0.02 mcg/kg/min q 5 mins to
achieve increase of SBP to 100-120 or
MAP>60 or Cardiac Index > 2.0 as
ordered by MD/LIP.
Max: 0.2 mcg/kg/min unless MD/LIP
orders higher max.
Vasoconstriction:
>0.2mcg/kg/min, titrate to desired
response
EndoTracheal: 2-2.5 mg diluted in 10mL
NS
Reference on stability: The stability of four catecholamines in 5% glucose infusions. J
Clin Phar Ther. 1991 Oct;16(5):337-40
Premix products not mixed by JDH pharmacy are good for 45 days at room
temperature.
Avoid in midline cath see
Page 14
69
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Epoprostenol for inj.
Veletri
®
(Flolan
®
is no
longer on formulary)
Room temperature
stable
[vasodilator & inhibitor of
platelet aggregation]
HIGH ALERT / DOUBLE
CHECK
(during transition)
Pulmonary Arterial
Hypertension
NYHA Class III &
IV
ED
UT1-ICU
UT2-IU
IRAD
OR/PACU
C.I.:
Usual initiation rate: 2 ng/kg/min.
Maintenance rate: 2- 150 ng/kg/min.
Some patients may require higher doses.
Mixed in CADD pump reservoir in a
dose (mg)/100mL with Sterile water or
Epoprostenon diluent as diluent. Higher
concentrations may be prepared for
patients who receive Veletri ® long-
term.
Patients own infusion may be
administered until Pharmacy sends the
initial infusion plus a backup for
emergency use.
Initially may be infused with Alaris
pump in new patient or if CADD is not
available.
Rate changes by practitioner only based
on symptoms not weight changes.
CADD pump will read rate as
mL/24hrs versus Alaris as mL/hr.
Requires Pharmacy admixture based on
current admixture and dosing
information obtained by calling the
patient’s speciality pharmacy (e.g
Accredo 1-866-344-4874 or CVS
Caremark 1-877-242-2738).
Infusion rate in mL/24 hr with CADD
pump =
dose (ng/kg/min) X Wt.(kg) X 60 mins
÷Final conc. (ng/mL)= mL/hr
mL/hr x 24= mL/24hr
Dose Calculator and Pharmacy
Worksheet for Dosing Calculation:
Epoprostenol Calculator
Epoprostenol Pharmacy Worksheet
Caution/Warning: Comments: RPh or Practitioner must call the patient’s speciality
pharmacy to verify current concentration, dose delivered, and dosing weight (not current
weight). Orders must be written in ng/kg/min, concentration of the CI (ng/mL) and mL/24 in
CADD pump and mL/hr via Alaris Pump by Practitioner and verified by RPh and RN.
Central line is preferred. CI requires use of a CADD pump. A second CADD must be
admixed for possible emergency use. The concentration may be increased to facilitate the 100
mL CADD bag size limit. After reconstitution with diluentsVeletri ® must be administered
through a sterile 0.22 micron filter. The CADD pump is sent by pharmacy with an extension
set that has a 0.2 micron filter (REF 21-7106-24). Change tubing three times per week.
Procedure: Cassettes MUST BE numbered in sequence. Coordination must be done with
nursing and pharmacy staff to prevent waste. The back-up bag is delivered once the new
cassette is hung.
Day 1: Make two Epoprostenol per MD/LIP order and first bag sent to nursing unit for
immediate patient use. Second bag stored in pharmacy refrigerator until the first cassette is
running then bring to the nursing unit refrigerator Day 2: Use second bag Epoprostenol in
nursing unit refrigerator 24 hrs after first bag is dispensed. Mix third bag and store for next
day’s dose Day 3 and subsequent days: Continue sequence Day of Discharge: Discard extra
cassette. A back-up peripheral line designated for emergent (lost access or dysfunctional
line) use must be present at all times. The line must have NO piggyback meds, NO blood
draws and NO flushing. A tag should be placed on the line indicating: “Epoprostenol: DO
NOT FLUSH”.
Med has a short half-life (approximately 3-5 minutes); therefore, the continuous infusion
must not be interrupted or stopped. Abrupt withdrawal or sudden large reductions in dosage
even for several minutes can precipitate symptoms associated with rebound PAH (dyspnea,
dizziness, asthenia). Do not slow or stop infusion without Pulmonary order and guidance.
Drug Interactions: Concomitant use with anticoagulants (warfarin, enoxaparin, dalteparin,
lepirudin, argatroban) or antiplatelet agents (NSAIDS, salicylates) may increase risk of
bleeding. Diuretics, antihypertensives, vasodilators may result in added reductions in BP
when given with epoprostenol.
Monitor: S&S’s of PAH: chest pain, dyspnea, palpitations, orthopnea, syncope. Monitor for
changes in Pulmonary function dyspnea, syncope, chest pain, flushing, tachycardia, hypoxia,
nausea/vomiting, hypotension.
Monitor for side effects of insufficient medication: cyanosis, chest pain, cough,
fatigue/weakness, palpitations, shortness of breath.
Monitor for excess medication: diarrhea, headache, lightheadedness/fainting, nausea,
vomiting
Monitor for side effects of chronic medication: depression, diarrhea, jaw pain, hypotension,
muscle pain, sensitivity to light, ascites.
Related Policies:
• Epoprostenol Sodium (Flolan) / Epoprostenol for Injection (Veletri) / Treprostinil
Sodium (Remodulin) Transition to New Med, Route, and/or New Central Line
• Epoprostenol Pharmacy Policy and Procedure
• Medications: High Alert, Double Check of
Side Effects:
Stability: No ice packs are required due to enhanced stability due to higher PH from
arginine. Light protection required for drug stability. All reconstituted solutions must be
stored in a refrigerator until time of use. See below table for maximum duration of
administration (hours) at room temperature for fully diluted solutions in the drug delivery
reservoir.
SPLP/SPC: Place
Packaging & Waste
in Zip-Lock and
return to pharmacy
70
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Eptifibatide
Integrilin
®
[platelet (G2b3a) inhibitor]
ACS:Unstable
angina or non-Q
wave MI
ED
UT1-ICU
UT2-IU
OR/PACU
IV Push Bolus (Normal Renal
Function): 180mcg/kg over 1-2 mins
using 20mg/10 mL vial
C.I. (Normal Renal Function): Premix
of 75mg/100 mL at 2mcg/kg/min up to
72 hrs or as directed
IVPush Bolus (Renal Function
<50mL/min): 180mcg/kg over 1-2 mins
using 20mg/10 mL vial
C.I. (Renal Function < 50mL/min):
Premix of 75mg/100 mL at 1mcg/kg/min
up to 72 hrs or as directed
Caution/Warning:
Comments: Requires RN/LPN verification double check on MAR.
. Use vented set.
Reduce dose for creatinine >2 (if CrCl is unavailable). Compatible with alteplase,
DOBUTtamine heparin, lidocaine, morphine, nitroglyerin, potassium. Not compatible
with furosemide.
Drug Interactions:
Monitor: Bleeding, thrombocytopenia, anaphylaxis. Avoid unnecessary arterial &
venipunctures. Cardiac monitor/telemetry is required.
Side Effects:
Stability: Must be refrigerated until used
PCI Procedure
CCL/EP
IV Push Bolus (Normal Renal
Function): 180mcg/kg over 1-2 mins
using 20mg/10 mL vial. 2
nd
bolus 10
mins after 1
st
bolus
C.I.(Normal Renal Function):
Premix= 7 5mg/100 mL at 2 mcg/kg/min
up to discharge, or for 18-24 hrs or as
directed. Minimum 12 hr infusion.
IV Push Bolus (Renal Function
<50mL/min): 180mcg/kg over 1-2 mins
using 20 mg/10 mL vial. 2
nd
bolus 10
mins after 1
st
bolus
C.I.(Renal Function < 50mL/min):
Premix= 75mg/100 mL at 1mcg/kg/min
up to discharge, or for 18-24 hrs or as
directed. Minimum 12 hr infusion.
71
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Eravacycline
Xerava®
[tetracycline antibiotic]
RESTRICTED
ANTIMICROBIAL
NON-FORMULARY
Bacterial Infections
Documented or
suspected infection
caused by a proven-
susceptible
multidrug-resistant
gram-positive or
gram-negative
pathogen for which
other formulary /
restricted formulary
agents are inactive
Salvage therapy for
certain non-TB
Mycobacteria
Patient receiving
eravacycline prior to
admission to UConn
Health John
Dempsey Hospital
ALL
UNITS
(Except
Psy)
I.I.: Infuse over ~60 minutes through
dedicated line or via Y-site.
-If the same IV line is used for sequential
infusion of several drugs, flush line with
NS before and after eravacycline
administration.
-Do not mix with other drugs or add to
solutions containing other drugs.
Caution/Warning:
Hypersensitivity reactions; May result in fungal or bacterial superinfection (e.g.
Clostridium difficile); antianabolic effects: hepatotoxicity; pancreatitis;
photosensitivity; pseudotumor cerebri
Comments: Altered kidney function: no dosage adjustment necessary.
Hepatic Impairment: Mild to moderate impairment (Child-Pugh class A or B): No
dosage adjustment necessary
Severe impairment (Child-Pugh class C): 1 mg/kg every 12 hours on day 1, then 1
mg/kg every 24 hours
Concomitant use of strong CYP3A inducer: 1.5 mg/kg every 12 hours
Drug interactions: may decrease the effectiveness of BCG, Cholera, and Typhoid
vaccines; may enhance the adverse/toxic effect of Retinoic Acid Derivatives; CYP3A4
Inducers (Strong) may decrease the serum concentration of eravacycline
Monitoring: Monitor hepatic function periodically
Related Policies: Restricted and Concurrently- Monitored Antimicrobials
Side Effects: Hypotension nausea, vomiting, diarrhea; infusion site reaction, wound
dehiscence
Stability: Store intact vials in original carton at 2°C to 8°C (36°F to 46°F).
Reconstituted vial may be stored at room temperature (≤25°C [77°F]) but must be
further diluted within 1 hour. Diluted solutions for infusion may be stored at room
temperature (≤25°C [77°F]) for up to 24 hours or refrigerated (2°C to 8°C [36°F to
46°F]) for up to 10 days. Do not freeze.
Ertapenem
INVanz
®
[antibiotic]
RESTRICTED
ANTIMICROBIAL
ADS MIXTURE
Bacterial infections
ALL
UNITS
(Except
Psy)
I.I.: 1000 mg in 100 mL NS (Minibag
Plus) over 30 mins daily.
Caution/Warning: Caution if prior anaphylactic reactions to beta-lactams.
Comments: CrCl< 30 mL/min- 500 mg daily. Do not mix with other medications or use
diluents containing dextrose.
Drug Interactions:
Monitor:
Side Effects:
Stability: If mixed by pharmacy, 6 hours room temp or 24 hours refrigerated (used
within 4 hours after removal from refrigeration)
Erythromycin
[antibiotic]
Bacterial Infection,
Gastroparesis
ALL
UNITS
(Except
Psy)
I.I.: 250-1000 mg in NS over 60 min
(concentration between 1-5mg/mL)
Gastroparesis Agent: 3mg/kg (usual
doses 125- 250 mg) in NS (concentration
between 1-5 mg/mL)
Caution/Warning:
Comments: Central line is recommended due to phlebitis risk.
Drug Interactions:
Monitor:
Side Effects: Phlebitis, abdominal Pain, N/V
Stability: Stable for 24 hrs @ Room Temperature with NS or 7 days in refrigerator. If
D5W is used must be buffered.
72
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Erythropoietin
Procrit
®
or Epogen
®
[RBC stimulator]
Anemia assoc. with
CRF & malignance
ALL
UNITS
(Except
Psy)
IV Push: 1,000-20,000 units undiluted
over > 1 min.
SC preferred
Caution/Warning:
Comments: Flush before and after w NS. No not dilute.
Do Not Shake Vial. More effective when given subcutaneously. Withhold dose if Hg >
12g/dl- increased risk of thrombotic event, may exacerbate Hypertension, CHF,
seizures.
Drug Interactions:
Monitor:
Side Effects:
Stability:
Esmolol
Brevibloc
®
[beta blocker]
TITRATE MED
PSVT, Rate control
for Afib, A.Flutter
ED
UT1-ICU
IRAD
OR/PACU
IVPush LD: PSVT: load 500 mcg/kg
(remove dose from pre-mix bag) over
1min then
C.I.: Pre-Mix 2500 mg/250 mL NS = 10
mg/ml
Start @ 50 mcg/kg/min X 5 mins & if
desired HR (goal HR reduction of 15-
20%) is
not achieved by 5 mins, repeat above LD
& inc. CI by 50 mcg/kg/min to 100
mcg/kg/min for 5 mins. May repeat
above LD and CI in increments of 50
mcg/kg/min until therapeutic response
(decrease of HR to 60-80 or SBP to 100-
120) or as ordered. Max of 200
mcg/kg/min, unless higher max. is
ordered.
Caution/Warning:
Comments: Use 25 mg /5 ml for bolus only.
CI requires MD/LIP order for therapeutic goal (ex: BP, HR, MAP) or reason. Titrate per
order to goal.
Central line preferred but peripheral line for emergencies until central line can be
inserted. Calculation of drip rate (mL/hr)= wt (kg) X mcg/min X 0.006.
Maximum duration is 48 hours.
Decrease rate by 50% after administration of alternative antiarrhythmic. Titrate off
slowly.
Drug Interactions:
Monitor: EKG, BP and HR every 5 minutes for first 30 minutes and during active
titration then hourly once stable.
If SBP <90 or more than 30 mmHg drop in BP decrease infusion to last level. Continue
decreasing rate until BP stabilizes. If hypotension is severe, stop infusion and notify
MD/LIP. Monitor for signs of decreased C.O., BP, U/O, mental acuity. Bradycardia
may require atropine on pacing.
Side Effects: hypotension, bradycardia, chest pain, CHF, bronchospasm, nausea &
vomiting
Stability:
Esomeprazole
NexIUM
®
[Proton Pump Inhibitor]
Stress ulcer
Prophylaxis, GERD,
PUD
ALL
UNITS
(Except
Psy)
IV Push: 40mg dilute with 5mL NS over
3-5 min, flush with 5 mL NS.
Severe hepatic failure 20mg
OR
I.I.: doses > 40 mg in 50 mL NS over
10-15 mins
Caution/Warning:
Comments: May store at room temperature. H2 antagonists (famotidine) should be
considered for Stress Ulcer Prophylaxis unless the patient has an active upper GI bleed
or a Hx of GI bleeding.
Drug Interactions:
Monitor:
Side Effects:
Stability:
If Extravasation,
see Pages 10&11
BOLUS OFF BAG:
Upon new EMR April
2018, ability to bolus
from continuous
infusion bag via Alaris
Pump Guardrails.
73
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Variceal UGIB
ALL
UNITS
(Except
Psy)
I.I. LD: 80 mg in 100 mL NS over 15-
20 minutes then
C.I.: 80 mg in 250 mL NS at 8 mg/hr
(25mL/hr) for 24- 48
with switch to IV Intermittent or oral
40- 80 mg po bid
Caution/Warning:
Comments:
Drug Interactions:
Monitor:
Side Effects:
Stability: 48 hrs at room temperature, 5 days if refrigerated
Estrogens Conjugated
Premarin
®
[estrogen]
Nov 2017: During
shortage
of SVP
50mL/100mL D5W, use
NS
Uterine bleed
Uremic bleeding
ALL
UNITS
(Except
Psy)
I.I.: 25 mg diluted in 50 mL NS or D5W
over 20-30 mins may repeat in 6-12 hr
I.I.: 0.6 mg/kg/day diluted in 50 mL NS
or D5W over 20-30 mins x 3-5 days
Caution/Warning:
Comments: Reconstitute with 5 mL of sterile water. May cause flushing if given too
rapid.
Drug Interactions:
Monitor: control of bleeding, nausea & vomiting
Side Effects:
Stability:
Ethacrynic acid
Edecrin
®
[loop diuretic]
Nov 2017: During
shortage
of SVP
50mL/100mL D5W, use
NS
Edema, CHF
ED
UT1-ICU
UT2-IU
OR/PACU
IV Push: 0.5-1 mg/kg over 2-5 min
Caution/Warning:
Comments:
Drug Interactions:
Monitor: BP & HR during rapid administration
Side Effects: Hypotension, h/a, dizziness, hypovolemia, muscle cramps, hyperuricemia,
hyperglycemia, hypokalemia, hypocalcemia, metabolic alkalosis.
Stability:
ALL
UNITS
(Except
Psy)
I.I.: 0.5-1 mg/kg in 50 mL NS or D5W
over 15-2 0 mins
74
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Ethanol
NOT ON GUARDRAIL
Alcohol withdrawal
syndrome (AWS) if
resistant to
benzodiazepines
Or if benzodiapines
might mask neuro
assessments.
UT1-ICU
OR/PACU
C.I.: 1. Initiate ethanol infusion at
1 mL/kg/hr (10% ethyl alcohol in D5W,
NS or ½ NS), via a peripheral or central
venous line. If the pt’s BAL is
unmeasurable at the time of the initiation
of the infusion, a loading dose equal to
0.5-1 mL/kg of 10% ethyl alcohol should
be given.
The MD/LIP should adjust the Ethanol
dosage according to the pt’s clinical
condition.
Dose: initial bolus of 0.5-1.0 mL/kg of
10%, followed by an increase in drip rate
of 10-20 mL/hr q 4-6 hrs. One or max.
two additional boluses of 0.5-1 mL/kg
can be given if the pt’s clinical condition
warrants additional ethanol prior to the
next increase in the rate of infusion.
The pt generally should not receive >
than 100 mL/hr of 10% solution.
Usual duration of infusion is 6-7 days as
the pt is detoxified.
Caution/Warning: Caution should be exercised for the following clinical conditions:
Type II diabetics (NIDDM) receiving sulfonylureas such as glyBURIDE or glipiZIDE
(hypoglycemia), and metFORMIN (lactic acidosis), gout, pts receiving a continuous
infusion of LORazepam to prevent development of alcohol withdrawal syndrome.
(LORazepam may only be administered on a prn basis for treatment of anxiety).
Comments:
Inclusion Criteria: Pts consuming large quantities of alcohol on a chronic basis, pts
receiving narcotic-based analgesia, or those with compromised respiratory function
when use of benzodiazepines may predispose a pt to severe respiratory depression.
With Ethanol infusion the goal is to administer a non-sedating dose to prevent Alcohol
Withdrawal Syndrome (AWS) and Delirium Tremens.
Ideally, the BAL should remain at very low-to-undetectable levels (i.e. BAL < 20
mg/dL), however rare pts may require a higher BAL for control of their AWS.
Exclusion Criteria:
Active pancreatitis, Active upper GI bleed, Pregnancy, Acute subdural hematoma,
pts receiving any of the following medications with Disulfiram-like (Antabuse®)
effects: Bromocriptine (Parlodel®), Cefoperazone (Cefobid®), Griseofulvin,
MetroNIDAZOLE (Flagyl®), or Procarbazine (Matulane®), Chronic alcoholic end-
organ diseases; cirrhosis, portal hypertension, pancreatitis, cardiomyopathy,
thrombocytopenia due to splenomegaly, evidence of bone marrow suppression, chronic
myopathy, chronic neuropathy, and Wernicke’s or Korsakoff’s syndrome.
Drug Interactions:
Monitor: Per CIWA Protocol. During AWS pts may have fevers & tachycardia.
Signs & Symptoms of alcohol withdrawal should be assessed and documented q 2-4
hrs. Notify MD/LIP if BAL>50 mg/dl.
Side Effects:
Stability:
Etomidate
Amidate
®
[sedative,/hypnotic/ general
anesthetic]
ER intubation
In presence
of Critical
Care RN or
Action RN
and
LIP/CRNA
for
emergency
intubation,
ALL
UNITS
IV Push: 0.2 – 0.6mg/kg over 30-60 secs
Caution/Warning:
Comments: IN PRESENCE OF LIP/CRNA.. Full resp. support must be available.
Monitor EKG, BP, HR, O2 sat. Monitor for apnea, laryngospasm, tachycardia,
bradycardia. Can cause transient venous irritation. Available in Intubation Kit in
nursing unit Pyxis.
Drug Interactions:
Monitor:
Side Effects:
Stability:
If Extravasation,
see Pages 10&11
75
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Factor VII (7)
Novoseven RT
®
[coagulation factor VII]
FACTOR VII
deficiency –
Bleeding
/ surgery
ALL
UNITS
(Except
Psy)
IV Push: 15-30 mcg/ kg over 2-5 mins q
4-6 hrs until hemostasis
CI: 15-20 mcg/kg/hr in NS over 12 hrs
Caution/Warning:
Comments: Nursing to reconstitute bolus doses. Pharmacy will pool bolus doses if
more than 3 vials. Follow Package Insert instructions for reconstitution. Bring factor
system to Room Temperature, remove caps from vials, wipe with alcohol swab, to
avoid foaming inject specified volume of histidine diluent slowly against wall of vial-
not directly into powder, gently swirl vial to dissolve contents until clear colorless
solution.
Swirl vial. Do not shake vial. Do not use inline filter. Flush lines with NS.
Frequency & duration of use varies.
Drug Interactions:
Monitor: Document baseline TPR and BP on flowsheet, assess pt’s prior experience
with Factor VII administration and ask about any possible past reactions, instruct the pt
about the infusion and the signs and symptoms to report to the RN/LPN, administer the
Factor VII as ordered, document TPR and BP 15 minutes after the start of the infusion
and then hourly for the duration of the infusion, if temp increases more than 1.8°F or
1°C from baseline, stop the infusion and notify the LIP, observe for and report signs of
anaphylaxis (urticaria, chest tightness, rash, pruritus, edema, shock, dyspnea). If
present, stop the infusion, notify the MD/LIP if any signs are present and continue to
document. VS q 15 minutes as ordered and assess pt as condition warrants. The risk of
anaphylaxis is low.
Dose, frequency and duration varies with pt weight, extent & type of bleed, levels.
The risk of anaphylaxis is low.
Side Effects: nausea, inj. site pain, fever, chills, headache.
Uncommon: allergic/anaphylactic reactions (urticaria, chills, chest tightness, rash,
pruritus, edema), thrombosis, bleeding, fever, arthralgia.
Stop if acute hypersensitivity reaction
Stability: Administer within 3 hrs after reconstitution.
Related Guideline: UConn John Dempsey Hospital Factor Brochure
Inhibitors to Factor
VIII or IX- bleeding
Episodes
IV Push: 90 mcg/ kg over 2-5 mins q
2hrs until hemostasis- modify for
severity of bleed +/or response
Inhibitors to Factor
VIII or IX- surgical
bleeding or
Treatment of severe
bleeding due to
Disseminated
Intravascular
coagulation
IV Push: Bolus dosing:90 mcg/ kg over
2-5 mins immediately prior to surgery.
Minor surgery: continue q 2hrs X 48 hrs
then q 2-6 hrs until hemostasis. Major
surgery q 2hrs x 5 days then q 4 hrs until
healed .
C.I.: Mix desired total mg needed per
12 hr period with the factor VIIA diluent
only to give a conc. of 1mg/ml in a 60
mL syringe.
Administer desired mg/hr= mL/hr via the
PCA Guardrail using a PCA pump.
Prime line and infuse maintenance IVF’s
as close to venous access site as feasible.
Solution is stable for 24 hrs at room
temperature.
76
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Factor VIII (8)
Von Willebrand factor (V.
W. F.)
Humate-P
®
[antihemophilic agent]
Bleeding in
V.W.Deficiency
ALL
UNITS
(Except
Psy)
IV Push: 40-80 units V.W.F: RCO = 17-
33 Int. units of factor VIII)
Dose: 15-75 Int. unit FactorVIII/ kg q 8-
12 hrs, repeat until hemostasis or
appropriate elevation in V.W.F: RCO,
VWF contents vary with batch. Use
Humate only for V.W. deficiency.
Caution/Warning:
Comments: Nursing to reconstitute bolus doses. Pharmacy will pool bolus doses if
more than 3 vials. Follow Package Insert instructions for reconstitution.
Reconstitution: bring factor system to Room Temperature, remove caps from vials,
wipe with alcohol swab, pierce the Sterile Water vial with blue tip of transfer device or
with, pull off remaining clear package, turn Sterile Water vial with device and pierce
factor powder vial, when Sterile Water is empty unscrew counterclockwise the Sterile
Water vial with blue portion, draw air into empty syringe and then screw into the white
portion of system by turning it clockwise, push air into vial and then turn upside down
to withdraw solution into syringe. The contents of more than 1 vial of factor may be
combined into the same syringe.
Swirl vial, do not shake vial. Do not use inline filter.
Administer within 3 hrs after reconstitution.
Flush lines with NS
Recombinate: follow above procedure, pierce the Sterile Water vial with clear tip of
transfer device, turn Sterile Water vial with device and pierce factor powder vial, when
powder is dissolved take off blue cap and draw up factor with a syringe. The contents of
more than 1 vial of factor may be combined into the same syringe
Drug Interactions:
Monitor: Document baseline TPR and BP on flowsheet, assess pt’s prior experience
with Factor VIII administration and ask about any possible past reactions, instruct the pt
about the infusion and the signs and symptoms to report to the RN/LPN,. administer the
Factor VIII as ordered, document TPR and BP 15 minutes after the start of the infusion
and then hourly for the duration of the infusion, if temp increases more than 1.8°F or
1°C from baseline, stop the infusion and notify the LIP, observe for and report signs of
anaphylaxis (urticaria, chest tightness, rash, pruritus, edema, shock, dyspnea). If
present, stop the infusion, notify the MD/LIP if any signs are present and continue to
document. VS q 15 minutes as ordered and assess pt as condition warrants.
The risk of anaphylaxis is low.
Dose, frequency and duration varies with pt weight, extent & type of bleed, levels.
Side Effects: nausea, inj. site pain, fever, chills, headache.
Uncommon: allergic/anaphylactic reactions thrombosis, bleeding, arthralgia.
Stability:
Related Guideline: UConn John Dempsey Hospital Factor Brochure
Surgical bleeding in
V W deficiency
IV Push: 60 int. unit/kg – over 3-20
mins, max. @ 4mL/min
40-80 units V.W.F: RCO = 17-33 Int.
units of factor VIII) about 2-2.4 int.
Bleeding in
Hemophilia A
IV Slow Push: Undiluted 15-50 Int.
units/kg or max. @ 10 mL/min unless
ordered as IV Push, then may repeat q 8-
12 hrs.
Higher dose for life threatening bleeding.
C.I.: contact Pharmacy Dept.
Diluted to 10 units/ml NS with rate based
on weight and labs, infuse within 12 hrs
of admixing.
Do not use Recombinate-
®
in
V. W. disease.
Keep refrigerated until use.
77
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Factor IX (9)
Benefix
®
[antihemophilic agent]
Bleeding in
Hemophilia B, with
inhibitors to factor
VIII
ALL
UNITS
(Except
Psy)
IV Push: moderate hemorrhage (desire
levels to 25% to 50% of normal Factor
IX level), 25-50 international units/kg q
12 to 24 hours for 2 to 7 days, @ 2-4
mL/min, then may repeat q 8-12 hrs
Caution/Warning:
Comments: Nursing to reconstitute bolus doses. Pharmacy will pool bolus doses if
more than 3 vials. Follow Package Insert instructions for reconstitution. Bring vial(s)
system to Room Temperature., remove caps from vials, wipe vials with alcohol, remove
plastic cover from short end of double-needle and insert into diluent vial, remove cap
from the long end of needle and insert into the powder vial, to avoid foaming allow the
diluent transfer to contact vial wall not the powder, vacuum will
withdraw the diluent into the concentrate vial, swirl vial, do not shake vial, and then
using a desired syringe remove dissolved Factor IX. The contents of more than 1 vial of
coagulant complex may be combined into the same syringe. Do not use inline filter.
Administer within 3 hrs after reconstitution. Flush lines with NS.
Drug Interactions:
Monitor: Document baseline TPR and BP on flowsheet, assess pt’s prior experience
with Factor IX administration and ask about any possible past reactions, instruct the pt
about the infusion and the signs and symptoms to report to the RN/LPN, . administer the
Factor IX as ordered, document TPR and BP 15 minutes after the start of the infusion
and then hourly for the duration of the infusion, if temp increases more than 1.8°F or
1°C from baseline, stop the infusion and notify the LIP, observe for and report signs of
anaphylaxis (urticaria, chest tightness, rash, pruritus, edema, shock, dyspnea). If
present, stop the infusion, notify the MD/LIP if any signs are present and continue to
document. VS q 15 minutes as ordered and assess pt as condition warrants. The risk of
anaphylaxis is low.
Side Effects: nausea, inj. site pain, fever, chills, headache.
Uncommon: allergic/anaphylactic reactions (urticaria, chills, chest tightness, rash,
pruritus, edema), thrombosis, bleeding, fever, arthralgia. Stop if acute hypersensitivity
reaction.
Stability:
Related Guideline: UConn John Dempsey Hospital Factor Brochure
Surgery or major
trauma
ALL
UNITS
(Except
Psy)
IV Push: desire levels to 50-100% of
normal Factor IX level- 50-100 unit/kg
pre-op and q 12-24 hrs
Keep refrigerated until use.
78
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
ANTI-INHIBITOR
COAGULANT
COMPLEX
Feiba
®
Autoplex
[antihemophilic agent]
Hemophilia A or B
Hemorrhage with
inhibitors of Factor
VIII, XI, or XII -
ALL
UNITS
(Except
Psy)
IV Push: 25 to 100 Units/kilogram, max
rate of 2 units/kg/min. Max. dose = 200
unit/kg.
Joint hemorrhage: 50 units/kg (up to 100
units/kg) q 12 hrs
Mucous membrane bleed: 50 units/kg q 6
hrs
Soft tissue hem.: 100 units/kg q 12 hrs
(max)
Severe hem.: 100 units/kg q 12 hrs up to
q 6 hrs
Keep vials refrigerated until use
Caution/Warning:
Comments: Nursing to reconstitute bolus doses. Pharmacy will pool bolus doses if
more than 3 vials. Follow Package Insert instructions for reconstitution. Bring vial(s)
system to Room Temperature, remove caps from vials, wipe vials with alcohol, open
package of device by peeling away the lid, pierce the Sterile Water diluent vial w tip of
transfer device, pull off remaining clear package, turn Sterile Waater vial with device
and pierce factor powder vial, vacuum will draw the diluent into the concentrate vial,
swirl vial, do not shake vial, turn the device handle down towards the complex vial and
remove the cap of syringe connections, draw air into the syringe and connect to device,
inject air into the concentrate, turn system upside down and draw concentrate into the
syringe, attach desired syringe to side port and remove contents. The contents of more
than 1 vial of coagulant complex may be combined into the same syringe. Do not use
inline filter. Administer within 3 hrs after reconstitution. Flush lines with NS.
Drug Interactions:
Monitor: Document baseline TPR and BP on flowsheet, assess pt’s prior experience
with ANTI-INHIBITOR COAGULANT COMPLEX administration and ask about any
possible past reactions, instruct the pt about the infusion and the signs and symptoms to
report to the RN/LPN,. administer the ANTI-INHIBITOR COAGULANT COMPLEX
as ordered, document TPR and BP 15 minutes after the start of the infusion and then
hourly for the duration of the infusion, if temp increases more than 1.8°F or 1°C from
baseline, stop the infusion and notify the LIP, observe for and report signs of
anaphylaxis (urticaria, chest tightness, rash, pruritus, edema, shock, dyspnea). If
present, stop the infusion, notify the MD/LIP if any signs are present and continue to
document. VS q 15 minutes as ordered and assess pt as condition warrants. The risk of
anaphylaxis is low.
Side Effects: nausea, inj. site pain, fever, chills, headache.
Uncommon: allergic/anaphylactic reactions (urticaria, chills, chest tightness, rash,
pruritus, edema), thrombosis, bleeding, fever, arthralgia. Stop if acute hypersensitivity
reaction
Stability:
Related Guideline: UConn John Dempsey Hospital Factor Brochure
79
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Famotidine
Pepcid
®
[histamine H2 antagonist]
Stress Ulcer
Prophylaxis,
Duodenal ulcer,
GERD
ALL
UNITS
IV Push: 20 mg dilute with 10 mL NS
over 1-2 mins, flush with 5 mL NS, daily
– q 12 hrs
40 mg dilute with 20 mL NS over 1-2
mins, flush with 5 mL NS, daily – q 12
hrs
I.I.: (non-preferred method of
administration) 40 mg in 50 mL NS or
D5W over 10-15 min-
Caution/Warning: IV Push too fast can result in infiltration or systemic reaction such
as headache, flushing, tightness in chest. All IV Push have Phlebitis Risk. Flush slowly
after medication administration.
Comments: Increase interval for renal impairment.
Drug Interactions:
Monitor: Platelet’s, mental status changes.
Side Effects:
Stability:
Fat Emulsion
20 %
Calories for TPN
ALL
UNITS
(Except
Psy)
I.I.: 250 mL of 20% over 12 hrs (20
mL/hr)
Caution/Warning:
Comments: Infused separately from AA/Dextrose/Electrolytes 20% provides 2
kcal/ml.
Infuse with a 1.2 micron filter. Filters < 1.2 micron pore size must not be used.
Not to infuse > 12 hrs to lessen risk of bacterial/fungal growth.
Drug Interactions:
Monitor:
Side Effects:
Stability:
80
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Treating Local
anesthetic toxicity-
Notify Anesthesia/
Medical
team/Pharmacy stat
ALL
UNITS
(Except
Psy)
Bolus: 1.5 mL/kg administered over 1
minute, followed immediately by
C.I.: 0.25 mL/kg/min . Continue chest
compressions (lipid must circulate).
Repeat the bolus 1-2 times as needed for
persistent asystole, pulseless electrical
activity, or re-emergence of
hemodynamic instability. Increase the
infusion rate to 0.5 mL/kg/minute if
hemodynamic instability persists or
recurs. Continue the infusion for at least
10 minutes after hemodynamic stability
is restored; discontinue within 1 hour, if
possible
Caution/Warning:
Comments: Notify Anesthesia/Medical team/Pharmacy STAT
Airway management: Ventilate with 100 % Oxygen
Seizure suppression: LORazepam IV
Basic & Advanced Life support may require prolonged effort.
Continue CI for Local anesthetic toxicity for at least 10 mins after attaining circulatory
stability. Max: 10 mL/kg (70kg=350 mL) over first 30 mins. Avoid vasopressin, Beta
blockers, calcium channel blockers, or local anesthetics. Complete a SI Report.
Infuse with a 1.2 micron filter. Filters < 1.2 micron pore size must not be used.
Drug Interactions:
Monitor:
Side Effects:
Stability:
FentaNYL
[opioid analgesic]
LOOK ALIKE / SOUND
ALIKE
TITRATE MED
Moderate Conscious
sedation, General
anesthetic
CCL/EP
ECT-A
ED
ENDO
UT1-ICU
IRAD
OP-CARD
OR/PACU
UHSC
IV Push: 12.5-100 mcg undiluted over
< 1min
Analgesia for opioid tolerant patient’s refractory to other narcotics or severe
allergy to morphine/HYDROmorphone derivatives.
Comments on all routes of Administration of FentaNYL:
Caution/Warning: FentaNYL is 100 times as potent as Morphine.
Comments: Requires RN/LPN verification double check on MAR for Infusions,
Epidural & PCA only.
FentaNYL 100 mcg = Morphine 10 mg = HYDROmorphone 1.5 mg.
81
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
HIGH ALERT / DOUBLE
CHECK
Pain Control,
Sedation (Opioid
tolerant patients
refractory to other
narcotics or severe
allergy to morphine/
HYDROmorphone
derivatives)
ED
UT1-ICU
OR/PACU
UHSC
SICKLE
IV Push: 12.5 - 200 mcg undiluted over
< 1min
Decrease dose in renal failure & elderly.
Naloxone must be readily available as a reversal agent for opioid induced respiratory
depression.
Consider any specific patient risk factors that may contribute to unintended respiratory
depression and/or excessive sedation levels. Risk factors may include but are not
limited to: age > 55 years; preexisting pulmonary or hepato-renal disease; known or
suspected sleep-disordered breathing problems; anatomic oral or airway abnormalities;
and comorbidities of systemic disease, renal/hepatic impairment.
Drug Interactions:
Monitor: Pain relief, pulse oximetry, level of consciousness, RR & depth, HR, BP,
mental status, nausea/vomiting.
Related Policy:
• Medication: High Alert, Double Check of
Side Effects: Somnolence, coma, resp. depression, CNS depression, arrhythmias,
hypotension, bradycardia, pruritus, nausea & vomiting
Stability:
Pain Control,
Epidural
ALL
UNITS
(Except
Psy)
Requires Continuous Capnography
(Exception L&D)
Epidural: per standard order with
Bupivacaine 0.1%
Pharmacy prepares:
4 mcg/mL Normal Saline (Surgical
Patients) 2 mcg/mL Normal Saline (L&D
Patients)
See above comments on FentaNYL.
Related Policies:
• Pain: Epidural Infusion and Patient Controlled Epidural Analgesia
(PCEA): Care of the Patient Receiving
• Epidural Anesthesia: Care of the Obstetric Patient
Information on FentaNYL continues on the next page.
FentaNYL
[opioid analgesic]
LOOK ALIKE / SOUND
ALIKE
TITRATE MED
HIGH ALERT / DOUBLE
CHECK
Pain control, reduce
work of breathing,
Sedation
UT1-ICU
ALL
UNITS
(Except
Psy) for end
of life
comfort
care
C.I.: for Analgesia for opioid tolerant
patients refractory to other narcotics or
severe allergy to morphine derivatives.
Requires Continuous Capnography.
C.I.: 2500 mcg/250 mL NS = 10
mcg/ml.
Start @ 25 mcg/hr, and may titrate if
ordered by 25 mcg/hr q 30 mins or as
ordered to desired sedation (to ordered
pain scale or RASS of -1 to -2 or),
analgesia and reduced work of breathing.
Max.= 200 mcg/hr, unless MD/LIP
orders higher max.
See prior page for comments on FentaNYL.
Related Policies:
• Pain (Acute): Continuous Opioid Infusions and Patient Controlled
Analgesia (PCA): Care of the Patient Receiving
Exceptions to continuous capnography monitoring:
1) Patient on mechanical ventilation
2) End-of-life comfort care (e.g. hospice, comfort measures only)
82
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Pain Control,
Sedation, PCA
Bolus Mode Only
ALL
UNITS
(Except
Psy)
PCA Bolus Mode only
PCA: Opioid Naïve Patients
Low Concentration:
500mcg/50mL NS = 10mcg/mL
PCA: Opioid Tolerant Patients
High Concentration
2500mcg/50mL NS = 50mcg/mL
See prior page for comments on FentaNYL.
PCA bolus doses for patients who do not need the continuous basal infusion and do not
have continuous capnography.
Use the 10 mcg/mL concentration unless consumption exceeds reasonable rate of PCA
change. If patients dosing requires a higher concentration specific MD/LIP orders must
be written and Pharmacy must be consulted & Nurse Manager/designee notified.
High Dose narcotic syringe may be obtained in one of two ways:
1. Via hand delivery by the pharmacist/and or designee to the RN caring
for the patient. The RN must sign a the delivery receipt for hand
delivered doses.
2. Via an automated dispensing cabinet in designated areas. The RN must
scan the product prior to removal.
Related Policies:
• Pain (Acute): Continuous Opioid Infusions and Patient Controlled
Analgesia (PCA): Care of the Patient Receiving
• Sickle Cell Crisis: Use of Fentanyl in a Continuous + PCA Infusion for
Opioid Tolerant Patients with Sickle Cell Anemia
Information on FentaNYL continues on the next page.
83
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
FentaNYL
[opioid analgesic]
LOOK ALIKE / SOUND
ALIKE
TITRATE MED
HIGH ALERT / DOUBLE
CHECK
Pain Control,
Sedation, PCA
Dual Mode (Basal
Infusion & Bolus)
ALL
UNITS
(Except
Psy)
PCA Dual Mode (Basal infusion &
bolus)
Requires Continuous Capnography
PCA: Opioid Naïve Patients
Low Concentration:
500mcg/50mL NS = 10mcg/mL
PCA: Opioid Tolerant Patients
High Concentration:
2500mcg/50mL NS = 50mcg/mL
See page 54 for comments on FentaNYL.
The FentaNYL continuous + PCA cannot be titrated. Any changes in the dose will
require a new order by the MD/LIP. Dose determined by MD’s/LIP’s/ RPh.
Use the 10 mcg/mL concentration unless consumption exceeds reasonable rate of PCA
change. If patients dosing requires a higher concentration specific MD/LIP orders must
be written and Pharmacy must be consulted & Nurse Manager/designee notified.
High Dose narcotic syringe may be obtained in one of two ways:
1. Via hand delivery by the pharmacist/and or designee to the RN caring
for the patient. The RN must sign a the delivery receipt for hand
delivered doses.
2. Via an automated dispensing cabinet in designated areas. The RN must
scan the product prior to removal.
Related Policies:
• Pain (Acute): Continuous Opioid Infusions and Patient Controlled
Analgesia (PCA): Care of the Patient Receiving
• Sickle Cell Crisis: Use of FentaNYL in a Continuous + PCA Infusion for
Opioid Tolerant Patients with Sickle Cell Anemia
Exceptions to continuous capnography monitoring:
1) Patient on mechanical ventilation
2) End-of-life comfort care (e.g. hospice, comfort measures only)
Ferumoxytol
Feraheme
®
[iron salt]
Iron deficiency
anemia
OP-INFC
I.I.: 510 mg/100 mL NS over at least 15
minutes
Caution/Warning: Patient should be in a reclined or semi-reclined position during the
infusion.
Comments:
Drug Interactions:
Monitor: Infusion reactions during infusion and for at least 30 minutes after infusion
Side Effects:
Stability: 4 hrs at room temperature
Filgrastim
Neupogen
®
[granulocyte
colony
stimulating factor]
Neutropenia
ALL
UNITS
(Except
Psy)
NOTE: See tbo-Filgrastim (Granix
®
)
section as Filgrastim is only on
formulary for the NICU and oncology
patients who are receiving STEM cell
transplants.
Caution/Warning:
Comments: IV only if SC not feasible. More effective when given subcutaneously.
Flush before and after with D5W not NS.
Do not dilute with saline at any time as product may precipitate.
Drug Interactions:
Monitor:
Side effects: RARE: ARDS and splenic rupture.
Stability:
84
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Fluconazole
Diflucan
®
[antifungal]
Fungal Infection
ALL
UNITS
I.I.: Pre-Mix
100 mg / 50 mL over 1hr
200 mg/ 100 mL Premix over 1hr
400 mg/ 100 mL Premix over 2hr
Caution/Warning:
Comments: Dose based on diagnosis and renal function .
Drug Interactions:
Monitor:
Side effects: May cause abdominal pain, diarrhea, nausea.
Possible QT prolongation with high doses and high risk patients. Leukopenia, including
agranulocytosis and neutropenia, has been reported.
Stability: 100 mg dose: 30 hrs at room temperature, 7 days refrigerated. Do not
refrigerate.
Flumazenil
Romazicon
®
[benzodiazepine antagonist]
Reversal of
benzodiazepine in
conscious sedation
ALL
UNITS
(in the
presence of
critical care
when given
on Psy)
IV Push: Initial dose of 0.2 mg. Repeat
0.2 mg every minute to a maximum of 4
doses. Maximum total cumulative dose
of 1 mg. Given undiluted over 15-30
seconds.
Caution/Warning: Flumazenil is a short-acting agent that reverses benzodiazepine-
induced sedation. Re-sedation may occur due to its short duration of action; therefore
additional doses may be necessary. The duration of action of flumazenil is usually less
than 1 hour. The effects of flumazenil may wear off before a long-acting
benzodiazepine is completely cleared from the body. In general, if a patient shows no
signs of sedation within 2 hours after a 1-mg dose of flumazenil, serious resedation at a
later time is unlikely. An adequate period of observation must be provided for any
patient in whom either long-acting benzodiazepines (such as diazePAM) or large doses
of short-acting benzodiazepines (such as > 10 mg of midazolam) have been used.
Comments: Compatible with D5W, LR, and NS solutions.
Drug Interactions:
Monitor: for extravasation into peripheral tissues.
Side Effects: Hypotension, bradycardia, agitation, anxiety. Return of sedation. Risk of
Seizures if patient on chronic benzo’s, Tri Cyclic Antidepressants, cocaine, bupropion .
Stability:
Benzodiazepine
overdose
ALL
UNITS
(in the
presence of
critical care
when given
on Psy)
IV Push: Initial dose of 0.2 mg. If the
desired level of consciousness is not
obtained 30 seconds after the dose, 0.3
mg can be given. Repeat dose of 0.5 mg
at 1 minute intervals. Maximum
cumulative dose of 3 mg. Patients with a
partial response at 3 mg may require
(rare) additional titration up to a total
dose of 5 mg. If a patient has not
responded 5 minutes after cumulative
dose of 5 mg, the major cause of sedation
is not likely due to benzodiazepines.
Given undiluted over 15-30 seconds.
UT1-ICU
C.I.: 2.5mg/ 250 mL D5W or NS
85
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Folic Acid
[vitamin]
Vitamin deficiency
ALL
UNITS
IV Push (consider IM or Oral if able
to switch order): up to and including 1
mg diluted in 3-5 mL NS over 1 min
I.I.: < 1 mg in large volume IVF’s
Caution/Warning: IV Push too fast can result in infiltration or systemic reaction such
as headache, flushing, tightness in chest. All IV Push have Phlebitis Risk. Flush slowly
after medication administration
Comments: Protect from light.
Drug Interactions:
Monitor:
Side Effects:
Stability:
Fomepizole
Antizol
®
[alcohol dehydrogenase
inhibitor]
Nov 2017: During
shortage
of SVP
50mL/100mL D5W, use
NS
Ethylene Glycol or
methanol ingestion
ED
UT1-ICU
LD: 15 mg/kg in 100 mL NS or D5W
over 30 mins, then in 12 hours start 10
mg/kg q 12 hrs x 4 doses, then 15 mg/kg
q 12 hr thereafter until ethylene glycol
levels < 20 mg/dl & pt. is asymptomatic
with normal PH
Caution/Warning:
Comments: Fomepizole is dialyzable and is given q 4 hr during HD.
Monitor plasma/urinary osmolarity, ethylene glycol levels, lytes, ABG’s, fomepizole
levels desired 100-300 umol/L = 8-25 mg/L.
Drug Interactions:
Monitor:
Side Effects:
Stability:
Fosapreptitant
Emend
®
[P/NK1 receptor
Antagonist]
Prevention of
Chemotherapy
induced nausea and
vomiting
ALL
UNITS
(Except
Psy)
I.I.: 150 mg/250 mL NS over 30 mins
Caution/Warning:
Comments:
Drug Interactions:
Monitor:
Side Effects:
Stability: 48 hrs at room temperature or refrigerated
Foscarnet
Foscavir
®
NON-FORMULARY
ALL
UNITS
(Except
Psy)
I.I.: 50-120 mg/kg diluted to 12mg/mL
peripheral or 24 mg/mL centrally in
D5W/NS over 60 mins
NOTE (9/27/17): Medication taken off
hospital formulary
Caution/Warning:
Comments: Max. of 12 mg/mL via Peripheral line. Max. of 24 mg/mL via Central
line. Hydration of 1 Liter with dose is suggested. Max. rate: 1mg/kg/min. Handle as
cytotoxic.
Drug Interactions:
Monitor:
Side Effects:
Stability: 24 hrs at room temperature
Avoid in midline cath see
Page 14 (may be ok w/
short course)
If Extravasation,
see Pages 10&11
86
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Fosphenytoin
Cerebyx
®
[anti-seizure]
LOOK ALIKE / SOUND
ALIKE
Status epilepticus
ALL
UNITS
(Except
Psy)
I.I.: LD: 15-20 mg Phenytoin
equivalents (PE) /kg in NS at rate of 100-
150 PE/ min in conc. of 1-25 PE/mL.
DNE rate of 100-150 mg PE/min. For
dilution: ≤ 1250mg in 50 mL, > 1250mg
in 100 mL,
> 2500mg in 250 mL
I.I.: Maintenance: 4-6 mg PE/kg/day
divided in 1-3 doses per day at rate of
100-150 PE/ min. For dilution: ≤
1250mg in 50 mL, > 1250mg in 100 mL,
> 2500mg in 250 mL
Caution/Warning:
Comments: Fosphenytoin 75 mg= Phenytoin equiv 50 mg
Use dedicated line. Monitor BP, HR. Can be given IV or IM.
Less venous irritation than Phenytoin. May be preferred in patients with no venous
access (give IM) to those with PVD.
No Filter needed. Conversion from fosphenytoin to phenytoin is complete 2 hours after
intravenous administration.
Refer to the UConn hazardous drug safety handling for further information:
Medication
Handling Safety
Drug Interactions:
Monitor:
Side Effects:
Stability:
Furosemide
Lasix
®
[loop diuretic]
Nov 2017: During
shortage
of SVP
50mL/100mL D5W, use
NS
Edema, CHF
ALL
UNITS
(Except
Psy)
IV Push: < 100 mg undiluted over 1-2
mins given < 40 mg/min, flush with 5
mL NS.
Caution/Warnings: fluid/electrolyte loss (if given in excessive amounts, furosemide,
similar to other loop diuretics, can lead to profound diuresis, resulting in fluid and
electrolyte depletion. Close medical supervision and dose evaluation are required),
nephrotoxicity, ototoxicity, hyperuricemia
Comments: Furosemide 40 mg = Bumetanide 1mg = Torsemide 20 mg
Contraindications: hypersensitivity to furosemide, anuria
Drug Interactions:
Monitor: BP & HR during continuous infusions.
Side effects: Hypotension, headache, dizziness, hypovolemia, muscle cramps,
hyperuricemia, hyperglycemia, hypokalemia, hypocalcemia, metabolic alkalosis.
Ototoxicity can occur with high IV push doses.
Stability:
CI: 24 hrs at room temperature
Protect from light.
Do not refrigerate CI’s.
I.I.: >100 mg in 50 mL NS or D5W
only over 15- 30 mins
C.I.: 1 - 40 mg/ hr in NS or D5W with
concentration of 1mg/mL or 2 mg/mL
Avoid in midline cath see
Page 14 (may be ok w/
short course)
87
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Ganciclovir
Cytoven
®
[antiviral]
CMV Infection
ALL
UNITS
(Except
Psy)
I.I.: 2-6 mg/kg in 100mL NS or D5W
over 60 mins
Max. conc. = 10 mg/mL
Dosing is based on Ideal Body Weight
(IBW).
Pharmacy must provide infusion bag
spiked and with tubing already attached
in a ready to use fashion for proper
medication handling safety.
Caution/Warning:
Comments: Pharmacy mixes.
Hazardous medication precautions. Clinical studies involving animals exposed to
Ganciclovir, indicate carcinogenic effects and adverse effects on the reproductive
system. Wear nitrile gloves while handling. Gowns should be utilized for incidental
exposure to hazardous drugs. Dispose in hazardous waste container. Refer to the UConn
hazardous drug safety handling for further information: Medication Handling Safety
Drug Interactions:
Monitor:
Side Effects:
Stability: Refrigerate until ready to use. Stable for 7 days in refrigerator
Gentamicin
[antibiotic]
Bacterial Infection
ALL
UNITS
(Except
Psy)
I.I.(Traditional dosing): 3-5 mg/kg/day
in NS or D5W given q8-12h.
Gentamicin premix as 80 mg/ 50 mL,
100 mg/ 50mL, and 120 mg/ 100 mL
I.I. (Once daily dosing): per protocol-
doses up to 800 mg in 50 mL NS or
D5W over 30 mins q daily or doses up to
200 mg in 50 mL over 30 mins q 8-12 hr
Caution/Warning:
Comments: Pharmacy mixes. Consult unit RPh for assistance in dosing multiple doses
per day or once daily dosing. Modify dose or interval for renal impairment. Trough
levels recommended for monitoring.Renal and/or ototoxic.
Drug Interactions:
Monitor:
Side Effects:
Stability: 24 hrs at room temperature or 48 hrs in refrigerator
Glucagon
[antihypoglycemic]
Nov 2017: During
shortage
of SVP
50mL/100mL D5W, use
NS
Antihypoglycemic
ALL
UNITS
IV Push: < 1 mg undiluted over 1 min,
flush with 5 mL NS.
Caution/Warning:
Comments: Dissolve with Sterile water not with manufacturer’s phenol containing
diluent. Solution should be clear and water like. Use immediately.May cause nausea and
vomiting.
Drug Interactions:
Monitor:
Side Effects:
Stability:
Radiologic Exam
IV Push: Radiologic exam:1- 2 mg
undiluted over 1 min
If Extravasation,
see Pages 10&11
Avoid in midline cath see
Page 14 (may be ok w/
short course)
Avoid in midline cath see
Page 14
88
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Reversal of
Beta/Calcium
Blocker toxicity
ED
UT1-ICU
UT2-IU
IV Push: Initial bolus dose of 1-10 mg ,
may repeat in 10 mins.
C.I.: 1 - 5 mg/hr or 0.07 mg/kg/hour as
5 mg / 100 mL NS or D5W
For BB or CCB toxicity must be on cardiac monitor/telemetry.
Contraindications: Pheochromocytoma , Insulinoma due to risk of severe
hypertension.
Glucarpidase
Voraxaze
®
[Antidote]
Treatment of toxic
[MTX], defined as
>1um/L, in patients
with delayed
clearance
ICU, UT6
I.I.: 50u/kg IV over 5 minutes
Caution/Warning: allergic reactions possibly
Comments: IV line should be flushed before and after administration of Voraxaze
Drug Interactions: do not administer leucovorin 2 hours before or after administration of
Voraxaze
Monitor: methotrexate concentrations, use chromatographic method for first 48 hours
Side Effects: nausea (2%), vomiting (2%), flushing (2%), hypotension (1%)
Stability: once reconstituted, use immediately or store in refrigeration for up to 4 hours
ORDERING AND PROCUREMENT STEPS Same Day and Emergency Orders
Process (after hours):
• Contact On-Call Service after hours at 1-800-746-6273 available 24/7 After hours
is defined as after 6:30 p.m. Monday through Thursday, after 6 p.m. on Friday,
and 24 hours Saturday and Sunday and holidays.
• Monday through Friday during regular ASD Healthcare operating hours, for same
day and emergency hours you may call Customer Service at 1-800-746-6273.
• Provide account number, account name, call back number, and contact person
(ASD account #: 252764)
• On Call will contact the ASD Rep On Call
• ASD Rep On Call will call account back to obtain order
• ASD Rep will process order, contact ASD Distribution Center to coordinate
delivery
• ASD Rep will call account back with eta and tracking information
o ETA usually within 14 hours of placing order
Glycopyrrolate
Robinul
®
[anticholinergic]
Premedication for
anesthetic,
procedure, Reversal
of neuro-muscular
blockade
UT1-ICU
UT2-IU
OR/PACU
UHSC
ALL
UNITS
(Except
Psy) for end
of life
comfort
care
IV Push: 0.1-0.4mg undiluted over <1
min
Caution/Warnings: bronchospasm, cardiac arrhythmias, drowsiness/blurred vision,
cardiovascular disease, hypertension, hyperthyroidism
Comments: May administer undiluted. May also be administered via the tubing of a
running I.V. infusion of a compatible solution. May be administered in the same syringe
with neostigmine or pyridostigmine
Contraindications: medical conditions that preclude use of anticholinergic medication;
severe ulcerative colitis, toxic megacolon complicating ulcerative colitis, paralytic ileus,
obstructive disease of GI tract (eg, pyloric stenosis), intestinal atony in the elderly or
debilitated patient; unstable cardiovascular status in acute hemorrhage; narrow-angle
glaucoma; acute hemorrhage; tachycardia; obstructive uropathy; myasthenia gravis
Drug Interactions:
Monitor: Heart rate, anticholinergic effects, bowel sounds; bowel movements, effects
on drooling
SPLP/SPC: Place
Packaging & Waste
in Zip-Lock and
return to pharmacy
89
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
ALL
UNITS
(Except
Psy)
I.I: in 50 mL NS over 10-20 mins
Side effects: flushing, vomiting, urinary tract infections, constipation, bradyarrhythmia,
tachycardia, ventricular fibrillation, malignant hyperthermia, respiratory arrest.
Stability: Stable in D51/2NS, D5W, D10W, NS, R; incompatible in LR.
Golimumab Aria
Simponi Aria
®
[immune modulator]
Rheumatoid
Arthritis (in
combination with
methotrexate)
OP-INFC
I.I.: 2mg/kg diluted in 100mL of NS
over 30 minutes.
Administer with 0.22 micron filter only.
Caution/Warning: Opportunistic infections due to bacterial, mycobacterial, invasive
fungal, viral, or parasitic organisms including aspergillosis, blastomycosis, candidiasis,
coccidioidomycosis, histoplasmosis, legionellosis, listeriosis, pneumocystosis, and
tuberculosis have been reported with TNF-blockers.
Comments: Administer with 0.22 micron filter only.
Drug Interactions:
Monitor: CBC with differential, latent TB screening (prior to initiating and periodically
during therapy), HBV screening (prior to initiating), during and for several months
following therapy [HBV carriers], monitor improvement of symptoms and physical
function assessments, signs/symptoms of infection (prior to, during, and following
therapy), signs/symptoms/worsening of heart failure signs and symptoms of
hypersensitivity reaction, symptoms of lupus-like syndrome, signs/symptoms of
malignancy (eg, splenomegaly, hepatomegaly, abdominal pain, persistent fever, night
sweats, weight loss) including periodic skin examination
Side Effects: upper respiratory tract infection, viral infection, bronchitis, hypertension,
rash
Stability: Store intact vials and syringes refrigerated; do not freeze. Do not shake.
Protect from light. I.V.: Solutions diluted for infusion may be stored at room
temperature for 4 hours.
Granisetron
Kytril
®
[5HT3 antagonist]
NON-FORMULARY
Consider Use of
Ondansetron
Antiemetic
Antagonist-Chemo
only
ALL
UNITS
(Except
Psy)
IV Push: 1mg undiluted over 30 sec,
flush with 5 mL NS.
OR
I.I. (non-preferred method of
administration): 1 mg in 50 mL NS or
D5W over 10-20 mins
Caution/Warning:
Comments:
Drug Interactions:
Monitor:
Side effects : RARE- headache, dizziness. Watch for fever, rash, pruritus, and
restlessness.
Stability:
90
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Haloperidol
Haldol
®
[antipsychotic]
Nov 2017: During
shortage
of SVP
50mL/100mL D5W, use
D5W (not compatabile in
NS)
Agitation/
Aggression/
End of life comfort
care
ED
UT1-ICU
UT2-IU
OR/PACU
ALL
UNITS
(Except
Psy) for end
of life
comfort
care
Oral or IM preferred
IV Push: 0.5-5mg undiluted over 1-2
mins
I.I.: up to 10mg in 50 ml D5W over 30
mins
Caution/Warning: Contraindications include history of Extrapyramidal movements
[EPS]. Use lowest dose especially for elderly and consider oral or IM dosing in elderly
to control symptoms.
Oral to IV conversion (approximate): oral dose x 0.625 = daily IV dose.
Other routes: IM. Oral to IV conversion (approximate): oral dose x 0.625 = daily IV
dose
Other alternatives; oral/IM haloperidol, LORazepam. Correct K & Mg deficiencies if
haloperidol is not an emergency. Do not give decanoate form IV.
Comments: Applies to non-end of life comfort care patients: Recommend baseline
Magnesium, potassium and calcium and replace any deficiencies before IV haloperidol
is administered to lessen the risk of QTC prolongation and tachyarrthymias/torsade’s de
pointe.
Recommend baseline EKG for QTc. (Avoid if QTc > 470 msec in women & > 450
msec in men or if patient is on interacting meds.)
Drug Interactions:
Monitor: Monitor for EPS, NMS. Low risk of EPS, Tardive dyskinesia and neuroleptic
malignant syndrome with short term use.
Daily EKG / continuous cardiac monitoring/telemetry is recommended (excludes
end of life comfort care patients).
Side Effects:
Stability: Incompatible with Heparin. NS solutions should not be used due to reports of
decreased stability and incompatibility.
Agitation/
Aggression
ALL
UNITS
Oral or IM preferred.
I.I.: up to 5 mg in 50 ml D5W over 30
mins
Agitation/
Aggression/ ICU
Psychosis
UT1-ICU
C.I.: 100 mg/100 mL D5W: Rates of 1-
25 mg/hour
An initial bolus dose of 10 milligrams
followed by continuous infusion
beginning 3-25 milligrams/hr for
severely agitated patients.
91
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Heparin
[anticoagulant]
HIGH ALERT / DOUBLE
CHECK
LOOK ALIKE / SOUND
ALIKE
DVT/PE, Cardiac,
Ischemic Stroke,
Ultrafiltration/
DIC
ALL
UNITS
(Except
Psy)
IV Push: per protocols
C.I.: 25,000 units in 500 mL D5W (50
units/mL)or ½ NS infused per protocols
See dosing Nomograms
1. High Intensity- DVT/PE
2. Low Intensity-
Cardiac/Interventional/Stroke
3. Ultrafiltration
Impella Device: 25,000 units in 500mL
D5W (50 units/mL) as machine purge
solution
Caution/Warning: Bleeding, Heparin Induced Thrombocytopenia (HIT),bleeding,
heparin resistance, hyperkalemia, hypersensitivity reactions
Comments: Requires RN/LPN verification double check on MAR. Pharmacy mixes
Impella device solution and have it available for use within an hour.
Drug Interactions:
Monitor: hemoglobin, hematocrit, signs of bleeding, fecal occult blood test, aPTT (or
antifactor Xa activity levels), platelet counts
Related Policies:
Refer to Protocols. May give bolus dose IV Push. Use with caution if pt has active or
recent bleed, severe HTN, endocarditis.
• Medications: High Alert, Double Check of
• Intravenous Low Intensity Heparin Nomogram
• Intravenous High Intensity Heparin Nomogram
Side Effects:
Stability:
Stability at room temperature and refrigeration:
• Prepared bag: 24-72 hours (specific to solution, concentration, and/or study
conditions)
• Premixed bag: After seal is broken, 4 days.
• Out of overwrap stability: 30 days
Hetastarch 6%
Hespan
®
[non-protein colloid]
LOOK ALIKE / SOUND
ALIKE
Volume expansion
for Shock
ALL
UNITS
(Except
Psy)
C.I.: dose and rate depend on fluid losses
and BP. Usual dose: 500 -1000 mL
infused 0.5- 4 hrs.
Caution/Warning:
Comments:
Drug Interactions:
Monitor:
Side effects: Immune hypersensitivity reaction
Contraindications: severe bleeding disorders, renal failure with oliguria or anuria not
related to hypovolemia. May increase risk of bleeding in select patients.
Stability:
92
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
HydrALAZINE
Apresoline
®
[peripheral vasodilator]
LOOK ALIKE / SOUND
ALIKE
Anti-hypertensive,
Essential HTN
emergency
ECT-A
ED
ENDO
UT1-ICU
UT2-IU
IRAD
OR/PACU
IV Push: up to 20mg bolus
undiluted or in 5 mL NS over 1-2 mins .
Caution/Warning:
Comments: Pt must be on a cardiac monitor/telemetry for IV Push excluding
L&D/OB-GYN.
Decrease dose in geriatric population & decrease frequency in renal impairment.
Will form precipitate with heparin so flush line with NS. Flush line with NS since will
form precipitate with heparin. The fall in blood pressure begins within 10 to 30 minutes
and lasts from two to four hours.
Drug Interactions:
Monitor: BP and HR, Record baseline blood pressure parameters prior to
administration. Cardiac monitoring is not required for intermittent infusion or IV Push
for L&D/OB-GYN. Consider cardiac monitoring in cardiac patients or those with
hypotension or tachycardia. BP & HR Q5 min x 20 mins during IV push loading dose.
For continuous Infusion monitor BP and HR Q30 min during hydrALAZINE
maintenance.
Side effects: Hypotension, tachycardia, flushing, edema, malaise, fever
Stability:
ALL
UNITS
(Except
Psy)
I.I: up to 20 mg in 50 mL NS over 15-30
mins
L&D/OB-
GYN
IV push: 5-10 undiluted over 2 minutes,
followed at 20-40 minute intervals by
doses of 5-10mg. Maximum total
cumulative dose of 25 mg
C.I.: 100 mg/500 mL= 0.2 mg/ml, start
@ 50 mcg/min and adjust per MD order
up to 400 mcg/min
Hydrocortisone Succinate
Solu-CORTEF
®
[adrenal glucocorticoid]
Anti-inflammatory
ALL
UNITS
(Except
Psy)
IV Push:
Max dose: 500mg
≤ 100mg undiluted over 1-2 min
> 100 mg dilute in 10 mL NS over 1-2
mins
Caution/Warning:
Comments:
Drug Interactions:
Monitor: Fluid & electrolytes changes, hyperglycemia, hypertension, leukocytosis,
mental status changes, pancreatitis, muscle weakness, CHF.May mask signs of
infection.
Restlessness and psychosis in high doses.
Side Effects:
Stability:
93
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
ED
ENDO
UT1-ICU
UT2-IU
OR/PACU
IVPush: Doses up to 10 gms undiluted
< 1 min
HYDROmorphone
Dilaudid
®
[opioid analgesic]
LOOK ALIKE / SOUND
ALIKE
TITRATE MED
(CI/PCA)
HIGH ALERT / DOUBLE
CHECK
Pain Control
ALL
UNITS
(Except
Psy)
For Opioid Naïve & Average Patients
IV Push: Doses < 2mg, dilute in 10 mL
NS, over 2-3 mins.
Comments on all routes of Administration of HYDROmorphone
Requires RN/LPN verification double check on MAR for Infusions, Epidural & PCA
only.
Caution/Warning: HYDROmorphone is 5-6 times as potent as Morphine.
HYDROmorphone IV 1.5 mg = Morphine IV 10 mg = FentaNYL IV 100 mcg.
Naloxone must be readily available as a reversal agent for opioid induced respiratory
depression. Consider any specific patient risk factors that may contribute to unintended
respiratory depression and/or excessive sedation levels.
Comments: Risk factors may include but are not limited to: age > 55 years; pre-
existing pulmonary or hepato-renal disease; known or
suspected sleep-disordered breathing problems; anatomic oral or airway abnormalities;
and comorbidities of systemic disease, renal/hepatic impairment.
Drug Interactions:
Monitor: Pain relief, pulse oximetry, level of consciousness, RR & depth, HR, BP,
mental status, nausea/vomiting. Check RR & sedation level in 5-15 mins.
Related Policies:
• Medication: High Alert, Double Check of
Side effects: Somnolence, coma, respiratory depression, CNS depression, arrhythmias,
hypotension, bradycardia, pruritus, nausea & vomiting
Stability:
Pain Control
(Opioid tolerant
patients)
ALL
UNITS
(Except
Psy)
For Opioid Tolerant Patients
IV Push: up to < 8 mg in 10 mL NS,
over
2-3 mins.
Pain Control
ED
ENDO
UT1-ICU
OR/PACU
UHSC
IV Push: Doses < 4 mg, dilute in 10
mL NS, over 2-3 mins
94
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
HYDROmorphone
Dilaudid
®
[opioid analgesic]
LOOK ALIKE / SOUND
ALIKE
TITRATE MED
(CI/PCA)
HIGH ALERT / DOUBLE
CHECK
Nov 2017: During shortage
of SVP 50mL/100mL
D5W, use NS for infusions
Pain control,
epidural
ALL
UNITS
(Except
Psy)
Epidural
Requires Continuous Capnography
(Exception L&D)
Standard:
HYDROmorphone 10mcg/mL with
Bupivicaine 0.1% in 250mL NS
See above comments on HYDROmorphone.
Related Policies:
• Pain: Epidural Infusion and Patient Controlled Epidural Analgesia
(PCEA): Care of the Patient Receiving
Information on HYDROmorphone continues on the next page.
Pain control
ALL
UNITS
(Except
Psy)
CI: Opioid Naïve Patients
Low Concentration:
20mg/100mL NS or D5W = 0.2mg/mL
CI: Opioid Tolerant Patients
High Concentration:
100mg/100mL NS or D5W = 1mg/mL
See prior page for comments on HYDROmorphone.
CI: Use the low concentration (0.2mg/mL) unless consumption exceeds reasonable rate
of bag change. Alternative is 50mg/250mL D5W (0.2mg/mL). If patients dosing or if
fluid restriction requires a higher concentration specific MD/LIP orders must be written
and Pharmacy must be consulted & Nurse Manager/designee notified. Rate of dose
escalation must be specified for all CIs. CI is a titrate med if ordered as such.
Related Policies:
• Pain (Acute): Continuous Opioid Infusions and Patient Controlled
Analgesia (PCA): Care of the Patient Receiving
• Sickle Cell Pain: Pain Management Using High Dose Continuous & PCA
Narcotic Infusions
Pain Control,
Sedation, PCA
Bolus Mode Only
ALL
UNITS
(Except
Psy)
PCA: Opioid Naïve Patients
Low Concentration:
10mg/50mL D5W = 0.2mg/mL
PCA: Opioid Tolerant Patients
High Concentration
50mg/50mL D5W = 1mg/mL
See prior page for comments on HYDROmorphone.
PCA bolus doses for patients who do not need the continuous basal infusion and do not
have continuous capnography.
Use the 0.2mg/mL concentration unless consumption exceeds reasonable rate of PCA
change. If patients dosing requires a higher concentration specific MD/LIP orders must
be written and Pharmacy must be consulted & Nurse Manager/designee notified.
High Dose narcotic syringe may be obtained in one of two ways:
1. Via hand delivery by the pharmacist/and or designee to the RN caring
for the patient. The RN must sign a the delivery receipt for hand
delivered doses.
2. Via an automated dispensing cabinet in designated areas. The RN must
scan the product prior to removal.
Related Policies:
• Pain (Acute): Continuous Opioid Infusions and Patient Controlled
Analgesia (PCA): Care of the Patient Receiving
Information on HYDROmorphone continues on the next page.
95
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
HYDROmorphone
Dilaudid
®
[opioid analgesic]
LOOK ALIKE / SOUND
ALIKE
HIGH ALERT / DOUBLE
CHECK
Pain Control, PCA
Dual Mode (Basal
Infusion & Bolus)
ALL
UNITS
(Except
Psy) with
Continuous
Capno-
graphy
PCA Dual Mode (Basal infusion &
bolus)
Requires Continuous Capnography
PCA: Opioid naïve paints
Low Concentration:
10mg/50mL D5W = 0.2mg/mL
PCA: Opioid Tolerant Patients
High Concentration
50mg/50mL D5W = 1mg/mL
See prior page for comments on HYDROmorphone.
Use the 0.2mg/mL concentration unless consumption exceeds reasonable rate of PCA
change. If patients dosing requires a higher concentration specific MD/LIP orders must
be written and Pharmacy must be consulted & Nurse Manager/designee notified.
High Dose narcotic syringe may be obtained in one of two ways:
1. Via hand delivery by the pharmacist/and or designee to the RN caring
for the patient. The RN must sign a the delivery receipt for hand
delivered doses.
2. Via an automated dispensing cabinet in designated areas. The RN must
scan the product prior to removal.
Related Policies:
• Pain (Acute): Continuous Opioid Infusions and Patient Controlled
Analgesia (PCA): Care of the Patient Receiving
Exceptions to continuous capnography monitoring:
1) Patient on mechanical ventilation
2) End-of-life care (e.g. hospice, comfort measures only)
Information on HYDROmorphone continues on the next page.
Pain Control, PCA
SC Route
ALL
UNITS
(Except
Psy) with
Continuous
Capno-
graphy
PCA SC Route
Requires Continuous Capnography
Indicated for control of sickle cell pain
when oral or IV routes can’t be utilized
Goal: improved pain control
PCA SC:
Concentration:
10mg/mL
30mL of HYDROmorphone drawn up
into a 60mL syringe
See page 60 for comments on HYDROmorphone.
High Dose narcotic syringe may be obtained in one of two ways:
1. Via hand delivery by the pharmacist/and or designee to the RN caring
for the patient. The RN must sign a the delivery receipt for hand
delivered doses.
2. Via an automated dispensing cabinet in designated areas. The RN must
scan the product prior to removal.
Related Policies:
• Pain (Acute): Continuous Opioid Infusions and Patient Controlled
Analgesia (PCA): Care of the Patient Receiving
Exceptions to continuous capnography monitoring:
1) Patient on mechanical ventilation
2) End-of-life care (e.g. hospice, comfort measures only)
96
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Hydroxocobalamin
Cyanokit®
[Cyanide Antidote]
Cyanide poisoning
ED
ICU
I.I. 5g as single infusion over 15 min;
may repeat a second 5 g dose over 15 min
to 2 hours for a total dose of 10 g
depending on severity of poisoning and
clinical response.
Reconstitution with 0.9% NS preferred
(LR & D5W also found to be
compatible).
Caution/Warning: Use caution in patients with known anaphylactic reactions to either
hydroxocobalamin or cyanocobalamin. Substantial increases in blood pressure may
occur following Cyanokit administration.
Comments: The recommended diluent is 0.9% Sodium Chloride injection. Diluent is
not included with Cyanokit. Each Cyanokit vial consists of 5g of lyophilized
hydroxocobalamin dark red crystalline powder for injection. Each vial contains
hydroxocobalamin 25 mg/mL after reconstitution.
Drug Interactions: N/A
Monitor: Blood pressure and heart rate during and after infusion, serum lactates levels,
venous-arterial PO
2
gradient, renal function, and pretreatment cyanide levels.
Side Effects: transient chromaturia, erythema, rash, increased blood pressure, nausea,
headache, and injection site reactions.
Stability: Store at 25°C (77°F) with excursions permitted to 15-30°C (59 to 86°F).
Once reconstituted, stable for up to 6 hours at temps not exceeding 40°C (104°F). Do
not freeze. Any reconstituted product not used by 6 hours should be discarded.
Note: there are no monitoring parameters listed in drug databases specific to the off-
label indication of vasoplegia
Vasoplegia/
Vasoplegic
Syndrome
(off-label)
ICU
OR/PACU
IV: 5 to 10 g over 10 to 15 minutes.
Reconstitution with 0.9% NS preferred
(LR & D5W also found to be
compatible).
Ibutilide
Corvert
®
[class lll– anti-arrhythmic]
Recent onset
A. Fib.
Ordered by
Cardiology
Attending
or card.
Fellow or
in EP by
LIP and
must be
present
during RN
administrati
on in CC
Cluster,
Cath Lab or
EPS.
1. Magnesium-within normal limits, give
magnesium 2gm/100NS over 10 mins
before Ibutilide
2. Ibutilide
PT’s > 60 kg: II: 1 mg/50 ml D5W /
NS over 10 mins
PT’s < 60 kg: II: 0.01 mg/kg/50 ml
D5W / NS over 10 mins
Note: Lower doses should be considered
if used via a central line
3. Repeat Magnesium dose to start
10 mins after ibutilide & give
over 30- 60 mins
4. A 2
nd
dose may be admin. 10
mins after the 1
st
dose if A. Fib.
persists.
Caution/Warning:
Comments: Criteria for Use:
Baseline Lab values: K+ > 4.0, Mg & Calcium -wnl, EKG w QTc < 450 msec or < 500
msec if on amiodarone, no Hx of Polymorphic VT’s, consider not using if on meds that
prolong the QTc interval- erythromycin, clarith., azole abx’s, phenothiazines, TCA’s,
consider anticoagulation for several weeks if a. fib. duration is > 3-4 days.
No dose adj. with renal or hepatic impairment
Drug Interactions:
Monitor required, have intracardiac pacer, a cardioverter/ defibrillator and meds for
sustained. V. T’s available during and after use of ibutilide.
Monitor V/S q 5 mins during infusion and up to 10 minutes after completion of the
infusion, then q 30 minutes X2.
12 lead EKG for baseline and 4 hrs after infusion. Stop the infusion as soon as the
presenting arrhythmia is terminated of if new or worsened ventricular arrhythmia
develops during the infusion, or for significantly prolonged QT interval.
Use with extreme caution if C1A anti-arrhythmics have been used due to prolonged Qtc
intervals and risk of pro-arrhythmic events.
Side Effects:
Stability:
97
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
IdaruCIZUmab
Praxbind
®
[dabigatran reversal agent]
This agent is restricted for
use ONLY in patients with
a history of recent use of
dabigatran
AND
Life-threatening or
significant bleeding
OR
Need for emergency
surgery/urgent procedures
Reversal of
anticoagulation
effects caused by
dabigatran when
needed for
emergency surgery/
urgent procedures or
in life-threatening or
uncontrolled
bleeding
ALL
UNITS
(Except Psy)
5g given once. Dose is provided as two
separate 50-ml vials each containing
2.5g.
IV Push (preferred): Inject the contents
of both vials (5g/100mls) via syringe.
Infusion: Hang both vials and administer
5g as two consecutive infusions (two
2.5g/50ml vials)
No rate of administration has been
recommended by the manufacturer. Dose
may be administered as quickly as
tolerated.
Caution/Warning: Use with caution in patients with a history of Hereditary Fructose
intolerance. No dosing adjustments recommended for special populations.
Comments: Each package contains two 50ml vials each containing 2.5g. A patient
should receive the content of both vials (5g/100ml total) for one dose.
Dabigatran-treated patients have underlying diseases predisposing them to
thromboembolic events. Reversing dabigatran therapy exposes patients to the
thrombotic risk of their underlying disease. To reduce risk, resumption of
anticoagulant therapy should be considered as soon as medically appropriate.
Drug Interactions: None identified
Monitor: Coagulation parameters (e.g. aPTT) have been observed in a limited number
of patients. If reappearance of clinically relevant bleeding or need for additional
emergency surgery/urgent procedure with elevated parameted, an additional full dose
may be considered.
Side Effects: headache, hypokalemia, delirium, constipation, pyrexia, pneumonia,
immunogenicity
Stability: Store in refrigerator at 2°C to 8°C. Do not freeze. Do not shake. Once
solution is removed from the vial it is only good for 1 hour.
Administration: A pre-existing IV line may be used for administration. The line must
be flushed with 0.9% sodium chloride prior to infusion. No other infusion should be
administered in parallel via the same intravenous access.
Imiglucerase
Cerezyme
®
[enzyme]
Gaucher Disease
OP-INFC
I.I.: 2.5 -60 units/kg once a week or q 4
weeks in 100mL NS and infuse over 1-2
hours. May used an in-line filter, low
protein-binding 0.22 micron filter during
infusion.
Caution/Warning:
Comments: Each vial of imiglucerase (Cerezyme (TM)) contains 212 units of enzyme
which provides a withdrawal dose of 200 units
Drug Interactions:
Monitor: V/S pre-infusion and 15 mins post-infusion.
Side Effects:
Stability: Solution diluted for infusion in NS is stable for up to 24 hours when stored
under refrigeration.
98
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Imipenem-cilastatin-
Relebactam
Recarbrio®
[carbapenem/β-lactamase
inhibitor]
RESTRICTED
ANTIMICROBIAL
NON-FORMULARY
Bacterial Infections
Documented or
suspected infection
caused by a
multidrug-resistant
gram-negative
pathogen (e.g.,
Extended-Spectrum
Beta-Lactamase
(ESBL)-Positive
strain, multidrug-
resistant (MDR) P.
aeruginosa or other
MDR gram-negative
pathogen not
susceptible to other
usual treatment
options [e.g.,
Ceftolozane/tazobac
tam,
Ceftazidime/avibact
am, etc.])
Patient receiving
medication prior to
admission to UConn
Health John
Dempsey Hospital
ALL
UNITS
(Except
Psy)
I.I.: Infuse over 30 minutes.
Withdraw two 10 mL aliquots of diluent
from a 100 mL infusion bag containing
an appropriate diluent (NS, D5W, D5NS,
D51/2NS, or D51/4NS). Constitute vial
with one 10 mL aliquot of diluent; shake
well and transfer to the remaining 80 mL
of the infusion bag. Add the second 10
mL aliquot of diluent to the vial; shake
well and repeat transfer to the infusion
solution. Agitate the resulting mixture
until clear; constituted solution ranges
from colorless to yellow.
For patients with renal impairment,
prepare a reduced dose by preparing 100
mL of solution containing 1.25 g
(imipenem 500 mg, cilastatin 500 mg,
relebactam 250 mg) as directed above,
then withdraw and discard excess
solution as follows:
- 1 g (imipenem 400 mg, cilastatin 400
mg, relebactam 200 mg) dose: Withdraw
and discard 20 mL (resulting volume to
administer: 80 mL).
- 750 mg (imipenem 300 mg, cilastatin
300 mg, relebactam 150 mg) dose:
Withdraw and discard 40 mL (resulting
volume to administer: 60 mL).
- 500 mg (imipenem 200 mg, cilastatin
200 mg, relebactam 100 mg) dose:
Withdraw and discard 60 mL (resulting
volume to administer: 40 mL).
Caution/Warning:
Hypersensitivity reactions; May result in fungal or bacterial superinfection (e.g.
Clostridium difficile); CNS effects: Carbapenems have been associated with CNS
adverse effects, including confusional states and seizures (myoclonic)
Comments: CrCl ≥90 mL/minute: No dosage adjustment necessary.
CrCl 60 to 89 mL/minute: 1 g every 6 hours.
CrCl 30 to 59 mL/minute: 750 mg every 6 hours.
CrCl 15 to 29 mL/minute: 500 mg every 6 hours.
CrCl <15 mL/minute: Do not administer unless HD is instituted within 48 hours.
HD: 500 mg every 6 hours; administer after HD and at intervals timed from the end of
that HD session.
Peritoneal dialysis: Use is not recommended
Drug interactions: may decrease the effectiveness of BCG, Cholera, and Typhoid
vaccines; may decrease the serum concentration of valproate products; ganciclovir-
Valganciclovir may enhance the risk of seizures
Monitoring: Periodic renal function tests; signs of hypersensitivity/anaphylaxis
Related Policies: Restricted and Concurrently- Monitored Antimicrobials
Side Effects: anemia; increased LFTs; hypokalemia; hyponatremia; constipation;
diarrhea
Stability: Store intact vials at 20°C to 25°C (68°F to 77°F), excursions permitted
between 15°C to 30°C (59°F to 86°F). Reconstituted and further diluted solution in
infusion bags may be stored for ≤2 hours at room temperature (up to 30°C [86°F]) or
≤24 hours under refrigeration (2°C to 8°C [36°F to 46°F]); do not freeze.
99
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Immune Globulin
Privigen
Gammagard S/D
Gamunex-C
NON-FORMULARY
[immune serum]
(Gammagard S/D)
Primary Immune
def’s, Autoimmune
ITP, IDP=
Inflammatory
demyelinating
polyradiculoneuropat
hy
ALL
UNITS
(Except
Psy)
(Should not
be given in
ED unless
urgent/
emergent
situation and
unit has
approved to
infuse there
as preferred
to be
administered
on hospital
units)
Dosing: Consult references
I.I.: consult individual product guides
and for inpatient units contact your floor
pharmacist to provide titration
information as it is dependent upon
individual products.
Consult specific product information for
filtration requirements. Current
formulary product is Privigen 10% that
does not require filtration. Gammagard
S/D for pt’s with IgA deficiency requires
15micron filter. Gamunex-C does not
require filtration.
Maximum rate is dependent on current
formulary product, disease state and renal
function.
Pharmacy Infusion Rate Calculator for
IVIG
Privigen Infusion
Rate
Brochure
Gammagard S/D Package Insert
Gamunex-C Package Insert
Caution/Warning:
Comments: Privigen
®
is supplied as individual bottles of Privigen
®
for total dose to be
infused. Use separate IV line. No not shake. Stable for 7 days if refrigerated.
Refrigerate. Hydration is recommended before use to lower risk of renal toxicity in pts
with pre-existing renal insufficiency, diabetes mellitus, age greater than 65, volume
depletion, sepsis, paraproteinemia, or pts receiving known nephrotoxic drugs.
Contra: history of severe systemic allergic reaction to IVIG
Drug Interactions:
Monitor : V/S (T,P,R,BP) pre-infusion and before each rate change or a minimum of q
30 mins while the rate is being increased. Once the maximum rate is reached, vital
signs should be taken hourly until six hours into the infusion If the infusion continues
beyond six hours once the max rate is reached, vital signs should be taken q 4 hours or
per MD/LIP order for the remainder of the infusion.
Side Effects: Allergic hypersensitivity reactions: sudden resp. difficulty, tachycardia,
hypotension, flushing, C-V & resp. collapse. Tx as anaphylactic reaction.
Infusion-related symptoms- muscle pain, malaise, headache, chills, flushing, low back
pain, joint pain, fever, tightness of the chest, and nausea. May be pretreated with a
nonsteroidal anti-inflammatory agent and antihistamine, along with slowing or
interrupting the infusion as needed. Rate related SE’s: Do not shake.
Stability:
100
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
InFLIXimab
Remicade
®
[monoclonal antibody]
LOOK ALIKE / SOUND
ALIKE
Crohn’s, Ulcerative
Colitis, Rheum.
Arthritis, Psoriasis
ALL
UNITS
(Except
Psy)
I.I.: 3 mg-10 mg/kg diluted to 250
mLwith NS over 2-3 hrs using in-line low
protein binding 1.2 micron filter.
Start @ 10 mL/hr X 15 mins, then
Inc. to 20 mL/hr X 15 mins, then
Inc. to 40 mL/hr X 15 mins, then
Inc. to 80 mL/hr X 15 mins, then
Inc. to 150 mL/hr X 15 mins, then
Inc. to 250 mL/hr for duration of
infusion. Slow infusion for new
complaints, stop and notify MD/LIP if
dyspnea, hypotension, chest pain, muscle
swelling, chills, fever, angioedema, or
pruritus.
Caution/Warning:
Comments: Assess for S/S of infection. Report if present and consider holding
infusion.
Review medical record for TB testing, if not tested notify MD/LIP before infusion is
prepared. Do not shake. Use within 3 hrs of preparation.
Nursing to use in-line 0.22 micron low protein binding filter dispended with product by
pharmacy
Drug Interactions:
Monitor: V/S pre-infusion, q 30-60 mins during infusion.
Side Effects: Mild and transient Acute reactions: urticaria, dyspnea, hypotension,
fever, chills, chest pain, headache. If occur lower infusion rate , dc infusion and tx with
antihistamines. Pts with a hx of these reactions can be pretreated with hydrocortisone
100 mg IV, diphenhydAMINE 25 mg IV, neb-albuterol 0.5 ml, EPINEPHrine 1:1000
0.3 ml SC, acetaminophen and for rigors meperidine 25 mg in 10 mL NS over 1 min.
Stability: Must begin infusion within 3 hours of reconstitution
inFLIXimab-dyyb
inFLIXimab-dyyb
®
[biosimilar monoclonal
antibody]
LOOK ALIKE / SOUND
ALIKE
Crohn’s, Ulcerative
Colitis, Rheum.
Arthritis, Psoriasis
ALL
UNITS
(Except
Psy)
I.I.: 3 mg-10 mg/kg diluted to 250
mLwith NS over 2-3 hrs using in-line low
protein binding 1.2 micron filter.
Start @ 10 mL/hr X 15 mins, then
Inc. to 20 mL/hr X 15 mins, then
Inc. to 40 mL/hr X 15 mins, then
Inc. to 80 mL/hr X 15 mins, then
Inc. to 150 mL/hr X 15 mins, then
Inc. to 250 mL/hr for duration of
infusion. Slow infusion for new
complaints, stop and notify MD/LIP if
dyspnea, hypotension, chest pain, muscle
swelling, chills, fever, angioedema, or
pruritus.
Caution/Warning:
Comments: Assess for S/S of infection. Report if present and consider holding
infusion.
Review medical record for TB testing, if not tested notify MD/LIP before infusion is
prepared. Do not shake. Use within 3 hrs of preparation.
Nursing to use in-line 0.22 micron low protein binding filter dispended with product by
pharmacy
Drug Interactions:
Monitor: V/S pre-infusion, q 30-60 mins during infusion.
Side Effects: Mild and transient Acute reactions: urticaria, dyspnea, hypotension,
fever, chills, chest pain, headache. If occur lower infusion rate , dc infusion and tx with
antihistamines. Pts with a hx of these reactions can be pretreated with hydrocortisone
100 mg IV, diphenhydAMINE 25 mg IV, neb-albuterol 0.5 ml, EPINEPHrine 1:1000
0.3 ml SC, acetaminophen and for rigors meperidine 25 mg in 10 mL NS over 1 min.
Stability: Must begin infusion within 3 hours of reconstitution
101
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Insulin-Regular
[antidiabetic agent]
HIGH ALERT / DOUBLE
CHECK
Hyperglycemia
ALL
UNITS
IV Push: all doses undiluted, flush with
NS over < 1 min
Caution/Warning:
Comments : Only regular Insulin may be given IV. Requires RN/LPN verification double
check on MAR. Review information on next page for insulin inititation and maintenance.
Drug Interactions:
Monitor:
Glucose must be monitored (by either glucose meter or lab draw) at least q 6 hrs or as
ordered by the practitioner. Must be checked by a second RN or LPN for correct medication,
dose, and rate of infusion. The double check must be done when initiating the insulin
infusion and with every dose change. Refer to the policy Medications: Double Check, for
double check guidelines and documentation of the double check.
CLINICAL ASSESSMENT AND CARE:
1. Prior to Starting Infusion:
a. Obtain baseline laboratory data as ordered.
102
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Hyperglycemia
UT1-ICU
(guideline)
UT2-IU
(no
guideline)
L&D
(guideline)
C.I. : 100 units / 100 mL NS (1unit/mL)
Ordered as units/hr in EMR (Note that L
& D and ICU have their own protocols
for administration)
Other Dosing Info : 0.05-0.1 units/kg/hr
(see next page for further information)
b. Obtain insulin drip from pharmacy. The standard dilution for insulin is 1 unit per mL.
c. Prime the IV tubing and flush through an extra 10-15ml. Insulin binds to new IV tubing
when an infusion is started or tubing is changed. There is approximately 16% loss if flushing
is not done. This can cause false elevations of insulin requirements until the insulin saturates
the binding to the tubing. Monitor for hypoglycemia.
Reference: Goldberg et al. “Waste not, want not”: determing the optimal priming volume for
intravenous insulin infusions. Diabetes Technol Ther. 2006 Oct;8(5):598-601
2. During the Infusion:
a. Monitor the patient's blood glucose (from lab draws or glucose meter) every 1-6 hours,
depending on patient response to infusion and LIP orders.
b. Notify practitioner of all results outside of parameters.
3. Nursing Considerations:
a. Beta Blockers, MAO inhibitors, salicylates and tetracycline increase the hypoglycemic
effect of insulin.
b. Corticosteroids and thiazide decrease insulin's effect. A change in the corticosteroid
dosage can cause wide fluctuations in blood glucose levels.
REPORTABLE CONDITIONS:
1. Blood glucose levels outside ordered parameters.
2. Significant differences between glucometer and lab value results.
Side effects: Hypoglycemia.
Stability: CI: 24 hrs at room temperature. 7 days under refrigeration.
Reference on stability: Evaluation of the maximum beyond-use-date stability of regular
human insulin extemporaneously prepared in 0.9% sodium chloride in a polyvinyl chloride
bag. Diabetes Metab Syndro Obes. 2013; 6: 389-392.
Related Policies:
• Medications: High Alert, Double Check of
Information on Insulin Regular continues on the next page.
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Insulin-Regular
[antidiabetic agent]
HIGH ALERT / DOUBLE
CHECK
Hyperkalemia
ALL
UNITS
(except
Psy)
IV Push: 10 units regular insulin in 10
mL NS
See prior page for comments on Insulin Regular.
Treatment of Hyperkalemia: Follow MD orders:
1.Stop K+ infusions and oral therapy and Contact MD/LIP to
Discontinue K+ infusions.
2. Consider Calcium Gluconate IV Push: 10-20 mL of 10% over 2 mins or
1 gm in 50 mL D5W X 1-2 doses over 5-10 mins)
3. Dextrose IV Push ( 50 mL of D50 IV Push) undiluted over 1-2 mins
4. Regular Insulin IV Push ( 10 units)
5. Bicarbonate IVP (50 mEq= 50 mL of 8.4% over 2 mins
6. B2 adrenergics-albuterol nebs (10-20 mg = 12-24 mL nebulized);
7. Loop diuretics
8. Na Polystyrene (15-60 gms)
9. Hemodialysis
Iron Dextran
Imferon
®
50 mg iron / ml
[parenteral mineral]
Iron Deficiency
Anemia
ALL
UNITS
(Except
Psy)
I.I. (Test dose): 25 mg in 50 mL NS over
5-10 mins
I.I.: up to 1000 mg in 250 mL NS over 1-
2 hrs
Caution/Warning:
Comments: Stable for 7 days if refrigerated. Iron sucrose is the preferred agent with lower
risk of acute reactions
Drug Interactions:
Monitor: H&H, serum ferritin, Iron sat, V/S’s. Outpatients should remain for ½ hour post
infusion to be monitored for signs and symptoms of a reaction.
Side Effects: Allergic hypersensitivity reactions: sudden resp. difficulty, tachycardia,
hypotension, flushing, c-v & resp. collapse. DC infusion & Tx as anaphylactic reaction.
Delayed reactions: arthralgia, backache, myalgia, urticaria, flushing, dizziness, malaise,
headache, chills, fever, chills, tightness of the chest, and nausea.
Stability:
Iron Gluconate
Ferrlecit
®
12.5 mg iron / ml
[parenteral mineral]
Iron Deficiency
Anemia
ALL
UNITS
(Except
Psy)
I.I.: Restricted to 125 mg in 100 mL NS
over 90 mins.
Caution/Warning:
Comments: Has lower rate of acute hypersensitivity anaphylactic reactions than iron
dextran (listed above).
Drug Interactions:
Monitor: H&H, serum ferritin, Iron sat, V/S’s. Outpatients should remain for ½ hour
post infusion to be monitored for signs and symptoms of a reaction.
Side Effects: Delayed reactions: arthralgia, backache, myalgia, urticaria, flushing,
dizziness, malaise, headache, chills, fever, chills, tightness of the chest, and nausea.
Allergic hypersensitivity reactions: sudden resp. difficulty, tachycardia, hypotension,
flushing, c-v & resp. collapse. Incidence is reported less than dextran and comparable
to iron sucrose.
Stability:
Avoid in midline cath see
Page 14 (may be ok w/
short course)
104
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Iron Sucrose
Venofer
®
20 mg iron / ml
[parenteral mineral]
Iron Deficiency
Anemia
ALL INPT
UNITS
(Except
Psy) and
for any
patient on
hemo-
dialysis
I.I.:
100 mg in 100 mL NS over 15 -30 mins
200 mg / 100 mL NS over 30-60 mins
300 mg / 250 mL NS over 90 mins
400 mg / 250 mL NS over 150 mins
start slowly and increase as tolerated
IVPush: 100-200 mg undiluted over 5
mins
Caution/Warning: IV Push too fast can result in infiltration or systemic reaction such
as headache, flushing, tightness in chest. All IV Push have Phlebitis Risk. Flush slowly
after medication administration
Comments: Has lower rate of acute hypersensitivity anaphylactic reactions than iron
dextran (listed above).
Drug Interactions:
Monitor: H&H, serum ferritin, Iron sat, V/S’s. Outpatients should remain for ½ hour
post infusion to be monitored for signs and symptoms of a reaction.
Side Effects: Delayed reactions: arthralgia, backache, myalgia, urticaria, flushing,
dizziness, malaise, headache, chills, fever, chills, tightness of the chest, and nausea.
Stability: diluted IV solutions are stable for 7 days in refrigerator
Injectafer® is iron sucrose product for use in the outpatient setting ONLY.
Isavuconazole
Isavuconazonium sulfate,
Cresemba®
[azole-derivative antifungal]
RESTRICTED
ANTIMICROBIAL
NON-FORMULARY
Fungal Infections
Documented or
suspected infection
caused by
Aspergillus spp. or
another
voriconazole-
susceptible mold in
a patient who (1)
cannot receive
voriconazole,
Documented or
suspected infection
caused by a mold
where
isavuconazole is
expected/documente
d to have “best”
activity
Patient receiving
medication prior to
admission to UConn
Health John
Dempsey Hospital
ALL
UNITS
(Except
Psy)
I.I.: Infuse over a minimum of 1 hour;
must be administered via an infusion set
with an in-line filter (pore size 0.2 to 1.2
micron).
-Flush line with NS or D5W before and
after infusion.
-Do not administer as an IV bolus
injection.
-Do not mix or infuse with other
medications.
Aspergillosis, invasive/Mucormycosis:
-Initial: 372 mg (isavuconazole 200 mg)
every 8 hours for 6 doses;
-Maintenance: 372 mg (isavuconazole
200 mg) once daily Start maintenance
dose 12 to 24 hours after the last loading
dose.
Caution/Warning:
Hypersensitivity reactions; abnormal liver function; infusion related reaction
Comments: Altered kidney and liver function: No dosage adjustment necessary.
Drug interactions: CYP3A4 Inducers (Strong) may decrease isavuconazole serum
concentrations
Monitoring: Hypersensitivity reactions with initial doses, LFTs at baseline and
periodically during therapy; Infusion-related reactions (eg hypotension, dyspnea, chills,
dizziness, paresthesias, hypoesthesia) during IV infusion.
Related Policies: Restricted and Concurrently- Monitored Antimicrobials
Side Effects: Peripheral edema; headache; fatigue; insomnia; hypokalemia; nausea;
vomiting; diarrhea; abdominal pain; constipation; increased liver enzymes; dyspnea;
cough
Stability: Store intact vials at 2°C to 8°C (36°F to 46°F). Following reconstitution of
the vial with SWFI, use the solution immediately, or stored below 25°C for a maximum
of 1 hour prior to preparation of the admixed solution in NS or D5W. The admixed
infusion solution should be kept for not more than 6 hours at (20°C to 25°C [68°F to
77°F]) or 24 hours at 2°C to 8°C (36°F to 46°F) prior to use. Do not freeze.
105
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Isoniazid
Nydrazid
®
[antitubercular]
Tuberculosis
ALL
UNITS
(Except
Psy)
I.I.: 150-300 mg 50 mL D5W over 60
mins
Caution/Warning:
Comments: Pharmacy to admix.
Drug Interactions:
Monitor:
Side Effects:
Stability:
Isoproterenol
Isuprel
®
[sympathomimetic]
Bradycardia (Acute
Symptomatic),
Cardiogenic shock
UT1-ICU
I.I.: 1 mg/ 250 mL D5W (4 mcg/mL) at
1 mcg/min (15mL/hr) to 10 mcg/min
Caution/warning:
Comments: Titrate to heart rate, rhythm response, BP
Drug Interactions:
Monitor:
Side Effects:
Stability:
Ketamine
[anesthetic adjunct]
Anesthesia
ED
OR/PACU
UHSC
I.I.: doses per Anesthesia or ED MD’s
Caution/Warning: Ketamine can produce severe dysphoric and hallucinogenic
sensations/reaction so the use of a benzodiazepine or low dose haloperidol in patients
receiving ketamine could be considered. Known contraindications to ketamine are
hypersensitivity to ketamine and any conditions where a significant elevation of blood
106
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Adjuvant therapy to
control severe pain/
Chronic Cancer
Pain/ Sickle Cell
Pain
UT1-ICU
C.I. (Pain): 100 mg/100 mL NS
(1mg/mL) or 250mg/250ml NS
(1mg/mL)
All changes in rate require a separate
order
Starting rate of 0.05mg/kg/hr to
1mg/kg/hr
pressure is hazardous which include Intracranial hypertension, Cerebral aneurysms and
raised intraocular pressure. Ketamine may exacerbate pulmonary hypertension and
psychiatric disorders (psychomimetic effects are more pronounced in the presence of
schizophrenia and delirium). Ketamine should be used with caution in the presence of
ischaemic heart disease because of the risk of increased heart rate and blood pressure.
Comments : Infusion should be titrated to pain effect or adverse effects. It patient
experiences adverse effects prior to acceptable pain relief; the drug should not be
continued. Ketamine is an anaesthetic agent known to have analgesic properties in sub-
anaesthetic doses. Ketamine analgesia is mediated by its effect on the N-methyl-D-
aspartate (NMDA) receptor where it blocks excitatory nerve activity involved in pain
transmission. Ketamine is administered in combination with other analgesics, may
improve pain and reduce opioid requirements.
Drug Interactions:
Monitor: C.I.:All patient must be observed for psychomimetic reactions – e.g.
unpleasant dreams, vivid imagery and hallucinations, alterations in perception
described as “floating in space” or as a “feeling of unreality”. Blood pressure as can
cause hypertension. Call MD if BP exceeds SBP> 140 and/or DBP> 90. Respiratory
depression/apnea.
Patients must be either vented or on continuous capnography
Side Effects: blood pressure elevation, psychomimetic reactions (hallucations which
may require a benzodiazepine along with dose reduction), respiratory depression.
Stability: C.I.: Stable if stored at room temperature or refrigerator. (See last reference
below)
REFERENCES
• Campbell-Fleming, JM, Williams, A. (2008) The use of ketamine as adjuvant therapy to control severe
pain, Clinical Journal of Oncology Nursing, Vol.12, No.1, pp. 102-7.
• Craven, R. (2007) Ketamine, Journal of Anaesthesia, Vol.62, No.1, pp.48-53.
• Immelseher S., Durieux M., 2005, Ketamine for Perioperative Pain Management, Anaesthesiology,
102(1): 211-20.
• Hocking G., Cousins M.J., 2003, Ketamine in Chronic Pain Management: An Evidence-Based Review,
Anesth Analg, 97:1730-9.
• Kronenberg, R.H. (2002) Ketamine as an analgesic: parenteral, oral, rectal, subcutaneous, transdermal
and intranasal administration, Journal of Pain Palliative Care Pharmacotherapy, Vol.16, No. 3, pp.27-35.
• Liu, S.S. & Wu, C.L. (2007) The effect of analgesic technique on postoperative patient-reported
outcomes including analgesia: a systematic review, Anaesthesia & Analgesia, Vol.105, No.3, pp.789-808.
• Subramaniam K., Subramanium B., Steinbrook R.A., Ketamine as Adjuvant Analgesic to Opioids: A
Quantitative and Qualitative Systematic Review. Anesth Analg 2004; 99:482-95.
• Stucki MC, Fleury-Souverain S, Sautter AM, et al: Development of ready-to-use ketamine
hydrochloride syringes for safe use in post-operative pain. Eur J Hosp Pharm Sci: 2008. 14: 14-8
Sedation in UT1-
ICU
UT1-ICU
C.I. (Sedation): 100 mg/100 mL NS
(1mg/mL) or 250mg/250ml NS
(1mg/mL), 500mg/250ml NS (2mg/mL)
All changes in rate require a separate
order
0.1 to 0.5 mg/kg over 2 to 3 minutes,
followed by continuous infusion of 0.05
to 2.5 mg/kg/hr, with rate adjustment
every 5 to 20 minutes. Doses up to
4.5mg/kg/hr have been documented as
needed for sedation.
BOLUS OFF BAG:
Upon new EMR April
2018, ability to bolus
from continuous
infusion bag via Alaris
Pump Guardrails.
107
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Ketorolac
Toradol
®
[NSAID]
Anti-inflammatory,
Non-Narcotic
Analgesic
ALL
UNITS
(Except
Psy)
IV Push (preferred): < 60mg undiluted
over 1-2 mins
Age<65 30 mg then 30 mg q6h
Age>65, renally impaired or wt
< 50kg: 15 mg then 15 mg q6h
I.I. (non-preferred method of
administration): 15-30 mg in 50 mL NS
or D5W over 10-15 mins, 60 mg/50mL
NS or D5W over 15 mins
Caution/Warning: IV Push too fast can result in infiltration or systemic reaction such
as headache, flushing, tightness in chest. All IV Push have Phlebitis Risk. Flush slowly
after medication administration.
Avoid in aspirin allergic pts. Caution use in hepatic dysfunction.
Comments: Avoid use in renal failure. PO/IV combined use limited to 5 days.
Contraindications: severe renal impairment.
Has same GI complications as p.o. NSAIDs.
Drug Interactions:
Monitor:
Side Effects: Nausea/vomiting, GI bleeding, decreased renal function, fluid retention.
Stability:
Labetalol
Normodyne
®
Trandate
®
[Alpha/Beta-adrenergic
blocker]
TITRATE MED
Hypertension
ED
ENDO
UT1-ICU
UT2-IU
IRAD
L&D/
OB-GYN
OR/PACU
UHSC
IV Push: 5 -20mg undiluted over 2
mins, if required follow with a 2nd dose
of 10-20 mg in 10 mins, and if a
satisfactory response is not obtained in 10
mins follow with a 3rd dose of 20-40 mg
in 10 mins.
Caution/Warning:
Comments:Not recommended for rate control.
Bedside Cardiac monitoring/telemetry is required for IV Push or infusion for patients
other than L&D patients.
IV Push: B/P & HR should be measure immediately before, and 5 minutes and 10
minutes after the initial dose. The maximum effect usually occurs within 5 minutes of
each injection.
If desired response is not obtained, additional doses (i.e. 40, 80, 160 mg) may be given,
at 10 minute intervals per MD/LIP order, to a cumulative maximum dose of 300 mg.
Each successive dose is usually double the amount of the prior dose.
Notify the physician/LIP if the specified SBP or HR is not achieved at the maximum
dose, or if significant hypotension (BP < 90), decreased HR (< 60), intolerable
dizziness, seizure activity, or an abnormal glucose occurs .
CI: requires MD/LIP order for therapeutic goal (ex: BP, HR, MAP) or reason. Titrate
per order to goal.
Notify the physician/LIP if the specified SBP or HR is not Maintain HOB no > 30
degrees up to 3 hours after titration is completed due to potential orthostatic changes.
achieved at the maximum dose, or if significant hypotension (BP < 90), decreased HR
(< 60), intolerable dizziness, seizure activity, or an abnormal glucose occurs .
ED
ENDO
UT1-ICU
IRAD
OR/PACU
UHSC
C.I.: Titrate Med if ordered
500 mg/ 500 mL D5W or NS (1
mg/mL)* This Concentration will not be
available in EPIC starting April 2018
1000 mg/ 500 mL D5W or NS (2 mg/ml)
to start at 0.5 mg/min, if increase is
needed re-bolus before increasing CI by
0.5 mg/min q 15-30 minutes to decrease
SBP to 100-120 or MAP > 60 or HR 60-
80 or as ordered. Max. of 2-3 mg/min =
120-180 mg/hr unless higher max. is
ordered by MD/LIP.
108
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
L&D/
OB-GYN
IV Push: Begin with 5- 20 mg undiluted
over 2 mins, if required follow with a 2nd
dose of 10-20 mg in 10-mins, and if a
satisfactory response is not obtained in 10
mins follow with a 3rd dose of 10-20 mg.
Maintain HOB no > 30 degrees up to 3 hours after titration is completed due to
potential orthostatic changes.
Potential Complications:
a. Do not use in patients with a history of bronchial asthma.
b. Use cautiously in patients with CHF, chronic bronchitis and emphysema.
c. Bronchospasm may occur, which may necessitate the administration of
EPINEPHrine and/or an aerosolized beta
2
– agonist per MD/LIP order.
d. If severe hypotension or bradycardia occurs, stop the infusion and notify MD/LIP.
e. Excessive bradycardia may be treated with atropine or EPINEPHrine per MD/LIP
order.
f. The beta adrenergic blockage reduces the release of insulin in response to
hyperglycemia. It also may prevent the appearance of premonitory signs and symptoms
of hypoglycemia. It is recommended that a serum glucose or a fingerstick glucose be
checked every 6 hours.
Drug Interactions:
Monitor: Frequent BP monitoring is necessary, as rapid falls in either systolic or
diastolic blood pressure may occur. Monitor patient’s BP every 15 minutes during
titration until patient's BP is within desired parameters and then monitor patient’s BP.
and HR every 1 hour and prn.
Side effects: fatigue, dizziness, hypotension, bradycardia, n/v, bronchospasm .
Stability: Stable for 72 hrs if refrigerated. Also stable in D5W. Incompatible with
bicarbonate.
Lacosamide
Vimpat®
[Anticonvulsant]
NON-FORMULARY
Adjunctively or as
monotherapy for
partial seizures in
patients over 17
years old when oral
administration is
temporarily
unavailable
ALL
UNITS
(Except
Psy)
IV Push (Preferred): Up to 400 mg
undiluted over 2-5 mins
I.I.: in 50 mL NS or D5W over 30-60
mins. (Package insert does not specify
volume)
Initial dosing of 50mg IV BID; increase
weekly by 100mg/day given in two
divided doses. Maintenance doses of 200-
400 mg/day given twice daily.
Caution/Warning: may cause or worsen PR interval prolongation
Comments: CrCl less than 30 mL/min: MAX 300 mg/day
Mild to moderate liver dysfunction: MAX 300 mg/day
Severe liver dysfunction: DO NOT USE
Drug Interactions: orlistat and ketorolac may decrease effectiveness of lacosamide
Use with other PR prolonging drugs may potentiate cardiac effects
Monitoring: ECG at baseline and at maintenance
Side Effects: nausea, dizziness, diplopia, A fib, suicidal ideation
Stability: if diluted, store at room temperature and administer within 4hours of dilution
(24hours per Canadian package insert)
BOLUS OFF BAG:
Upon new EMR April
2018, ability to bolus
from continuous
infusion bag via Alaris
Pump Guardrails.
109
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Lefamulin
Xenleta®
[antibiotic]
RESTRICTED
ANTIMICROBIAL
NON-FORMULARY
Bacterial Infections
Patient with
community-
acquired pneumonia
for which no other
formulary /
restricted non-
formulary treatment
options exist
Patient receiving
lefamulin prior to
admission to UConn
Health John
Dempsey Hospital
ALL
UNITS
(Except
Psy)
I.I.: Infuse over 60 minutes.
Note: Injection solution in vials must be
further diluted with supplied diluent prior
to administration
Prior to administration, dilute entire 15
mL lefamulin vial into the provided
diluent bag (250 mL of 10 mM citrate
buffered NS). Mix thoroughly.
Caution/Warning:
May result in fungal or bacterial superinfection (e.g. Clostridium difficile); QT
prolongation; Hepatic impairment
Comments: Altered kidney: No dosage adjustment necessary.
Hepatic Impairment: Mild to moderate impairment (Child-Pugh class A or B): No
dosage adjustment necessary.
Severe impairment (Child-Pugh class C): 150 mg every 24 hours.
Drug interactions: Substrate of CYP3A4 (major), P-glycoprotein/ABCB1 (major);
Inhibits CYP3A4 (moderate)
Monitoring: Hepatic function; ECG in patients predisposed to or with risk factors for
QT prolongation; pregnancy status in females of reproductive potential
Related Policies: Restricted and Concurrently- Monitored Antimicrobials
Side Effects: diarrhea
Stability: Injection: Store vials refrigerated at 2°C to 8°C (36°F to 46°F); do not freeze.
Store diluent bags in protective overwrap at 2°C to 25°C (36°F to 77°F). After dilution,
lefamulin may be stored for ≤24 hours at room temperature and ≤48 hours refrigerated
at 2°C to 8°C (36°F to 46°F).
Leucovorin
[methotrexate rescue]
Chemo adjunct
Megaloblastic
anemia
ALL
UNITS
(Except
Psy)
IV Push: 10-20 mg/ 20 mL NS over 1-2
mins
I.I.: 20mg-499mg in 50 mL NS/D5W
over 15 mins, > 500 mgin 250 mL
NS/D5W over 30-120 min, max 160
mg/min
Caution/Warning:
Comments: Protect from light after reconstitution. Refrigerate.
Drug Interactions:
Monitor:
Side Effects:
Stability:
LevETIRAcetam
Keppra
®
[anticonvulsant]
Nov 2017: During
shortage
of SVP
50mL/100mL D5W, use
NS
Seizures
ALL
UNITS
IV Push (Preferred): Up to 4500 mg
undilted over 2-5 mins.
Doses ≤2000 mg over 2-5 mins
Doses > 2000 mg up to 4500 mg over
5 mins
I.I.: 500 – 1500 mg in 100 mL NS or
D5W over 15 mins. Doses >1500mg in
250 mL NS or D5W over 15 mins. Doses
> 3750 mg in 300 mL NS or D5W over
20 mins. A single dose of up to 4500mg
in 300mL NS or D5W over 20 mins may
be used for status epilepticus.
Caution/Warning:
Comments:Reduce dose for renal insufficiency.
Drug Interactions:
Monitor : for seizure activity & CNS changes.
Side Effects:
Stability: 4 hrs at room temperature
110
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
LevOCARNitine
Carnitor
®
[dietary supplement]
Carnitine deficiency
ALL
UNITS
(Except
Psy)
IV Push (Dialysis): 10-20 mg/kg after
each dialysis session over 2-3 minutes
IV Push (Carnitine deficiency): Bolus
over 2-3 minutes
I.I.: in 500 mL NS over 60 min.
Caution/Warning: Use with caution in patients with seizure disorders or in those at
risk of seizures; both new-onset seizure activity as well an increased frequency and/or
severity of seizures has been observed.
Comments:
Drug Interactions:
Monitor: Valproic Acid toxicity: Evaluate valproic acid concentrations (every 4-6
hours until a downward trend is observed).
Side Effects:
Stability: Room Temperature: 24 hours
LevoFLOXacin
Levaquin
®
[antibiotic]
Bacterial Infections
ALL
UNITS
I.I.: 250-500 mg Premixed over 60 mins
750 mg Premixed over 90 mins
Caution/Warning:
Comments : Too rapid administration can cause hypotension.
Drug Interactions:
Monitor:
Side effects: Phlebitis, dizziness, tremor, arthralgia, headache, inj.site inflammation,
QTc prolongation.Reduced dose / interval in renal dysfunction.
Stability:
Levothyroxine
Synthroid
®
[thyroxine replacement]
Hypothyroid,
Myxedema coma
ALL
UNITS
IV Push: < 200 mcg dilute with 10 mL
NS given over 1-2 mins, flush with 5 mL
NS.
Maintenance Dose 12.5 – 400 mcg
Myxedema coma – Initial dose 200
500mcg, Day 2 100-300mcg
Caution/Warning:
Comments: Reconstitute 100 mcg vial with 5 ml preservative free NS only= 20
mcg/mL, shake well, use immediately (manufacturer labeling suggests reconstituted
vial is stable for 4 hours). Discard any unused portions.
Note: during shortage Endocrine consult is required for extended interval dosing to
conserve supplies.
The IV dose of levothyroxine is 50-80% of the expected or previously established oral
dose.
Contraindications: Acute MI, untreated angina, untreated HTN, adrenal insufficiency
Drug Interactions:
Monitor:
Side Effects:
Stability:
ALL
UNITS
(Except
Psy)
I.I.: dose in 50 mL D5W / NS over 10-15
min
Avoid in midline cath see
Page 14 (may be ok w/
short course)
111
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Lidocaine
[antiarrhythmic]
Arrhythmias
ED
UT1-ICU
UT2-IU
IRAD
OR/PACU
UHSC
.
IVPush: Cardiac Arrest: from VT/VF
1-1.5 mg/kg=50 -100mg undiluted over
2-3 mins , may repeat in 3-5 mins, max.
of 3 mg/kg
IVPush: Non arrested pt: Stable VT,
wide c. tachy’s, ectopy: 1-1.5 mg/kg=50-
100mg undiluted over 2-3 mins, repeat at
0.5-0.75 mg/kg q 5- 10 mins, max total
dose of 3 mg/kg
ET: 2-4 mg/kg diluted in 10 mL NS
CI: 2 grams/ 500 mL D5W premix= 4
mg/ml @ 1-4 mg/min. Max 4 mg/min,
may bolus @ 0.5 mg/kg while on CI if
arrhythmia reappears
Caution/Warning:
Comments: Exp. Date for pre-mix bag if bag is out of protective overwrap = 14 days.
Must be on monitor.
Prophylactic dose in AMI not recommended.
Reduce dose in renal, hepatic, left v. dysfunction
Anticipate effect within 30 minutes of bolus and start of infusion; notify MD/LIP if not
seen. No tapering needed due to long half-life.
Drug Interactions:
Monitor: EKG for reduced or increased ventricular dysrhythmia every 12 hours and as
needed. BP & HR pre and post bolus and initiation of C.I with every 5 to 15 minute
assessment of VS and rhythm. Check every 2 to 4 hours for possible toxic side effects.
Side Effects:
Stability:
Linezolid
Zyvox
®
[antibiotic]
RESTRICTED
ANTIMICROBIAL
Bacterial
Infections
(MRSA/VRE)
ALL
UNITS
(Except
Psy)
I.I.: 600 mg/ 300 mL over 60 mins
Caution/Warning:
Comments: Store at Room Temperature. Dose adjustment not required in renal
failure.
Drug Interactions:
Monitor:
Side Effects: Nausea, diarrhea, myelosuppression, including anemia,
thrombocytopenia, leukopenia, pure red cell aplasia, and pancytopenia, severe lactic
acidosis, headache, Inc. LFT’s, Serotonin syndrome – review drug interactions
Stability:
BOLUS OFF BAG:
Upon new EMR April
2018, ability to bolus
from continuous
infusion bag via Alaris
Pump Guardrails.
112
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
LORazepam
Ativan
®
[benzodiazepine]
TITRATE MED
Anti-seizure-Status
epilepticus,
Anxiety,
CIWA Protocol
ALL
UNITS
(Except
Psy)
IV Push (ETOH Withdrawal):
< 4 mg diluted with equal volume NS,
given at 2 mg/min, flush with 5 mL NS.
Example: 4 mg = 2 mL of drug + 2 mL
NS = 4 mL total given over minimum of
2 mins
Anxiety/agitation:
Maximum dose for IV Push: 4 mg given
no more frequently than q 15 min per
CIWA protocol
NOTE: LORazepam dosage may exceed
guideline limits at provider’s discretion
for ETOH withdrawal since this is just a
guideline. Should be diluted to an equal
volume of NS or D5W for a
concentration of 1mg/mL for
administration. Maximum infusion rate of
2mg/min. Areas of a higher actuity (e.g.
ED, UT1-ICU, UT2-IU) may have orders
reflective of these higher doses such as
10mg given IV push over 5 minutes
(2mg/min) on UT2-IU.
Caution/Warning: Flumazenil must be readily available for reversal of
benzodiazepine toxicity.
Comments: Use lower doses in elderly patients. LORazepam dosage may exceed
guideline limits at provider’s discretion for ETOH withdrawal. Should be diluted to an
equal volume of NS or D5W for a concentration of 1mg/mL for administration.
Maximum infusion rate of 2mg/min. IM LORazepam should not be diluted.
For CI requires MD/LIP order for therapeutic goal (ex: RASS or explanation of desired
level of sedation) or reason. Titrate per protocol to goal. Consider adjunctive valproic
acid. When LORazepam CI approaches 10 mg/hr risk of metabolic acidosis increases.
Midazolam infusions may be used as an alternative to LORazepam infusions during
LORazepam shortages.
Drug Interactions:
Monitor: BP, RR, inj. Site, mental status.
Related Policies:
• CIWA-Ar – Alcohol Withdrawal Prevention Protocol (Clinical Institute
Withdrawal Assessment for Alcohol)
Side Effects: hypotension, persistent sedation, resp. depression, apnea, pain at inj. Site
, thrombophlebitis.
Stability: Stable for 7 days if refrigerated. Use glass bottles or polyolefin bag for CI’s-
stable for 24 hrs. Use standard conc. Of 1 mg/ 1 ml. Monitor for precipitation. Use
0.22 micron filter.
IV Push (Anxiety, agitation):
< 2 mg diluted with equal volume NS,
given at 1 mg/min, flush with 5 mL NS.
Example: 2 mg = 1 mL of drug + 1 mL
NS = 2mL total given over minimum of 2
mins.
IV Push (Seizure): < 10 mg or 0.1
mg/kg diluted with equal volume NS and
may repeat dose in 5 to 15 min if needed
for treatment of seizures.
If Extravasation,
see Pages 10&11
113
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Sedation for
Vented patient/
ETOH withdrawal if
refractory to or
impractical to use of
intermittent IV push
ED
UT1-ICU
OR/PACU
ALL
UNITS
(Except
Psy) for end
of life
comfort
care
C.I.: 100 mg/ 100 mL D5W (1mg/mL)
only in Non-PVC container to minimize
absorption and loss of LORazepam.
Start at 1 mg/hr & titrate by 1mg/hr q 30
mins to achieve sedation with RASS of 0
to -,1or as MD/LIP orders. Max: 15
mg/hr unless higher maximum is ordered
by MD/LIP. Titrate per Order. Infuse
with 0.22 micron filter.
Catatonia
benzodiazepine
challenge
ALL
UNITS
IV Push: 0.5-2mg up to three times a day
diluted in equal volume NS. Do not
exceed 2mg/min.
IV preferred for initial dosing with switch
to oral as patient improves.
Magnesium Sulfate
1gm (2mL) of 50% is
8 mEq Mag++
[electrolyte]
Nov 2017: During
shortage
of SVP
50mL/100mL D5W, use
NS (if premix not
available)
Electrolyte
deficiency
ALL
UNITS
(Except
Psy)
I.I.:
1 gm (8mEq) in 100 mL D5W over 30-60
mins
Caution/Warning:
Comments: Magnesium sulfate 1 gm available as premix.
For Magnesium sulfate 2 gm use 2 bags of the 1Gm premixes.
ICU has 2 gm/50 mL Premix bags available.
Rapid infusions may cause Cardiovascular toxicity, CNS and Respiratory depression.
Use with caution in patients with renal failure.
Drug Interactions:
Monitor:
Side Effects:
Stability:
UT1-ICU
UT-BMT
ICU or UT-BMT Only I.I.: 2 gm in
50mL D5W over 60 mins
Ventricular
tachycardia with
Torsade de pointes
ED
UT1-ICU
UT2-IU
OR/PACU
In presence
of Critical
Care RN or
Action RN
and LIP
during
RRT/Code,
ALL
UNITS
IV Push: 1-2 gm or 1 gm / 100 mL
D5W for 2 doses over 1 -2 mins for
Torsade de pointes, may need
C.I.: 0.5 gm – 1 gm/hr for 5 to 48 hrs
114
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Preeclampsia
HIGH ALERT
/ DOUBLE
CHECK
ED
L&D
UT1-ICU
OR/PACU
I.I. LD (4 gm): 4 gm/100 mL
set volume at 100 mL, rate at 300 mL/hr
administer over 20 minutes
C.I. (2 gm/hr) 20g/500 mL (0.04 g/mL)
Set volume for 1000mL, dose at
2 gm/hour, rate at 50 mL/hr
C.I. (1 gm/hr) 20g/500 mL (0.04 g/mL)
Set volume for 1000mL, dose at
1 gm/hour, rate at 25 mL/hr
L&D Caution/Warning:
Comments: Magnesium sulfate 4 gm and 6 gm available as premix.
Recommended therapeutic magnesium levels for pre-eclampsia/seizure prophylaxis
between 4.8-8.4 mg/dL (4-7 mEq/L)
In pre-term patients (less than 32 weeks gestation) magnesium sulfate may be
administered for fetal neuroprotection.
Drug Interactions:
Monitor: For signs of Magnesium toxicity. Discontinue magnesium sulfate infusion
and obtain a STAT serum magnesium level in the following situations: hypotension,
new-onset loss of DTRs, respiratory depression, respiratory arrest, oliguria, shortness of
breath, chest pains.
Side Effects:
Stability:
Fetal
Neuroprotection
and/or Tocolysis
HIGH ALERT
/ DOUBLE
CHECK
Dose 4-6 gm IV bolus over 20-30
minutes, followed by maintenance
infusion
I.I. LD (6 gm): 6 gm/100 mL
set volume at 100 mL/hr, rate at 200
mL/hr administer over 30 minutes
Mannitol
[osmotic diuretic]
Inc. CNS pressure,
Inc. Intraocular
pressure
ALL
UNITS
(Except
Psy)
I.I.: 0.25 – 2 Gm/kg (12.5 – 200 Gm)
over 30-60 mins with an in-line filter.
Caution/Warning: Vesicant. Caution in CRF & CHF pts due to volume & electrolyte
shifts.
Comments :Must use an in-line filter. A 5 micron filter is used for compounding
25%. A 0.22 micron filter is used for administration. Do not refrigerate. Available in
vials as 25% (12.5gm/50ml). Do not mix with blood, do not add Sodium or potassium.
Contraindications: severe renal failure, active intracranial bleeding.
Note: for infusions containing 20% or more of mannitol at concentrations of 15% or
greater, mannitol may crystallize at low temperatures.
Drug Interactions:
Monitor: Lytes, Bun/Cr, fluid balance, pulse oximetry/EKG monitoring
Side Effects:
Stability: Stable for 24 hrs @ Room Temperature or warmer.
Renal Prophylaxis
w chemotherapy
ALL
UNITS
(Except
Psy)
I.I.: 12.5 – 100 Gm using 20% premix
250 ml bag (50 Gms) over 30-90 mins
with an in-line filter.
Oliguria
ALL
UNITS
(Except
Psy)
I.I.: 12.5 – 100 Gm using 20% premix
250 ml bag (50 Gms) over 30-90 mins
with an in-line filter.
If Extravasation,
see Pages 10&11
≥20%: Avoid in midline
cath see Page 14
115
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Meperidine
Demerol
®
[opioid analgesic]
Shivering/ rigors/
intermittent doses
restricted to opioid
intolerance and
short term therapy
without renal failure
ALL
UNITS
(Except
Psy)
IV Push: ≤ 100mg diluted with 10 mL
NS over 2-3 mins
(As of June 2009, P&T approved 25mg
dose only for shivering/rigors. Contact
Pharmacy if use for another indication)
Caution/Warning: As of June 2009, only approved for 25mg injection for
shivering/rigors. Covert other meperidine injection or oral dose to equivalent
injection or oral dose of morphine or HYDROmorphone.
Comments : Not indicated for chronic pain.
Consider other narcotic analgesics for acute pain. For PCA -Requires RN/LPN
verification double check on MAR. May precipitate with Heparin, so flush prior &
after with NS. Contraindications: pts taking MAOI’s, in renal failure and caution in
elderly due to accumulation of normeperidine which can cause myoclonus & seizures.
Drug Interactions:
Monitor: for pain relief, respiratory depression, loss of consciousness, N/V, CNS
changes. Naloxone must be readily available as a reversal agent for opioid induced
respiratory depression. Check RR & sedation level in 5-15 mins.
Side Effects:
Stability:
PCA-restricted to
opioid intolerance
and short term
therapy without
renal failure
ALL
UNITS
(Except
Psy)
PCA (10 mg/ml conc) with pharmacy
approval
Meropenem
Merrem
®
[antibiotic]
RESTRICTED
ANTIMICROBIAL
ADS MIXTURE
Bacterial Infection
ALL
UNITS
(Except
Psy)
I.I.: 500-1000 mg in 100 mL NS
(Minibag Plus) over 30 mins.
Empiric or documented Pseudomonas A.
infections in non-neutropenia: 1gm q 8
hrs or 500 mg q 6 hrs
Bacterial meningitis or patients >50%
over Ideal Body Weight, Severe edema,
pancreatitis, CNS infections, neutropenic
hosts: 2 Gm doses q 8 hrs infused over 2
hrs for better efficacy.
Non-pseudomonas Infections in non-
neutropenia: 500 mg q 8 hr.
IV Push (when a shortage):
0.5 Gm in 10 mL SWFI
1 Gm in 20 mL SWFI
Caution/Warning:
Comments: Pharmacy to admix.
Use undiluted reconstituted product within 2 hrs of mixing. Reduce dose with renal
insufficiency. HD dosing: 1 gm q 24 hrs after HD. Peritoneal Dosing- 1 gm q 48hrs
CVVHD- same as if CrCl > 50 mL/min. May increase seizure risk if Hx of seizures.
Contraindications: patients with anaphylaxis to beta lactams.
Drug Interactions:
Monitor: renal fx, CBC.
Side Effects:
Stability: in NS: 6 hrs @ room temperature, 5 days if refrigerated.
Avoid in midline cath see
Page 14 (may be ok w/
short course)
116
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Meropenem-vaborbactam
Vabomere®
RESTRICTED
ANTIMICROBIAL
NON-FORMULARY
Bacterial Infections
Documented or
suspected infection
caused by a
multidrug-resistant
gram-negative
pathogen (e.g.,
Extended-Spectrum
Beta-Lactamase
(ESBL)-Positive
strain, multidrug-
resistant (MDR) P.
aeruginosa or other
MDR gram-negative
pathogen not
susceptible to other
usual treatment
options [e.g.,
Ceftolozane/tazobac
tam,
Ceftazidime/avibact
am, etc.])
Patient receiving
medication prior to
admission to UConn
Health John
Dempsey Hospital
ALL
UNITS
(Except
Psy)
I.I.: Administer by IV infusion over 3
hours
Note: Reserve for patients with or at risk
for extensively drug-resistant pathogens
(nonsusceptible to ≥1 agent in all but 2 or
fewer antimicrobial classes) (eg,
carbapenem-resistant Enterobacterales)
Caution/Warning:
Hypersensitivity reactions; May result in fungal or bacterial superinfection (e.g.
Clostridium difficile); CNS effects: Carbapenems have been associated with CNS
adverse effects, including confusional states and seizures (myoclonic)
Comments: Altered kidney function:
eGFR ≥50 to 130 mL/minute/1.73 m2: No dosage adjustment necessary.
eGFR 30 to 49 mL/minute/1.73 m2: 2 g every 8 hours.
eGFR 15 to 29 mL/minute/1.73 m2: 2 g every 12 hours.
eGFR <15 mL/minute/1.73 m2: 1 g every 12 hours
HD: 1 g every 12 hours; when scheduled doses fall on dialysis days, administer one of
the two doses after the hemodialysis session
Drug interactions: may decrease the effectiveness of BCG, Cholera, and Typhoid
vaccines; may decrease the serum concentration of valproate products
Monitoring: signs of hypersensitivity reaction, including anaphylaxis and serious skin
reactions. Periodically monitor renal function; in patients with changing renal function,
monitor serum creatinine and eGFR at least daily.
Related Policies: Restricted and Concurrently- Monitored Antimicrobials
Side Effects: headache; diarrhea; nausea; increased LFTs
Stability: Store intact vials at 20°C to 25°C (68°F to 77°F); excursions are permitted to
15°C to 30°C (59°F to 86°F). Diluted solution for infusion is stable for 4 hours at room
temperature or 22 hours when stored at 2°C to 8°C (36°F to 46°F).
Mesna
Mesnex
®
[hemorrhagic cystitis
inhibitor]
Urinary Protectant
with Ifosfamide &
cyclophosphamide
ALL
UNITS
(Except
Psy)
I.I.: see Chemo protocol for dose in 100
mL diluent over 5-30 mins
Caution/Warning:
Comments: Verification of orders must be done by a chemotherapy competent nurse
when used as part of a chemotherapy regimen. Compatible with Ifosfamide &
cyclophosphamide.
Drug Interactions:
Monitor:
Side Effects:
Stability: Stable in syringe for 9 days. Pharmacy: Vials may be used for 8 days.
117
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Methadone
[opioid analgesic]
Opioid
maintenance, pain
ALL
UNITS
(Except
Psy)
I.I.: dose in 50 mL NS over 10-15 mins
Caution/Warning:
Comments: Not appropriate for most patients due to long duration of action and
complex pharmacokinetics may result in cumulative sedation
Caution for dosage conversion consult RPh. Reduce dose in renal failure. QTC
prolongation.
Drug Interactions:
Monitor: for pain relief, respiratory & CNS depression, loss of consciousness, N/V,
CNS changes.
Side Effects:
Stability:
Methohexital
Brevital
®
[barbiturate anesthetic]
Anesthesia
ECT-A
IV Syringe: 100 mg/10 mL premix
Caution/Warning:
Comments:
Drug Interactions:
Monitor:
Side Effects:
Stability:
Methyldopa
[alpha-adrenergic agonist]
Hypertension
ALL
UNITS
(Except
Psy)
I.I.: 250-500 mg in 100 mL D5W over 60
mins, > 500 mg in 250 mL D5W over 60
mins
Caution/Warning:
Comments: Caution in elderly or renal impairment.
Drug Interactions:
Monitor: BP during infusion, CBC, LFT’s.
Side Effects:
Stability:
Methylene Blue
Methemo-
globinemia,
Ifosamide toxicity
ALL
UNITS
(Except
Psy)
IV Push: over 3-5 mins
Caution/Warning:
Comments: Not to be used for adding to enteral feeds for detecting leaks.
Drug Interactions:
Monitor:
Side Effects:
Stability:
If Extravasation,
see Pages 10&11
118
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Methylergonovine
Methergine
®
[ergot alkaloid]
Postpartum
hemorrhage,
associated with
uterine atony or
subinvolution
L&D
IV Push: 0. 2 mg over 1-3 mins
Caution/Warning:
Comments:
Drug Interactions:
Monitor:
Side Effects:
Stability:
MethylPREDNISolone
Sodium Succinate
SOLU-Medrol
®
[adrenal glucocorticoid]
LOOK ALIKE / SOUND
ALIKE
Anti-
Inflammatory
agent
ALL
UNITS
(Except
Psy)
IV Push: doses < 125 mg undiluted over
1-2 mins.
I.I.: mix in 100 mL of D5W or NS
- Doses > 125 mg but < 250 mg,
administer over 15-60 mins
- Doses ≥ 250 mg, administer over 30-60
mins
Caution/Warning:
Comments: Stable for 24 hrs @ R.T. Only the succinate form can be given IV,
Rapid administration of high doses can cause circulatory collapse
Drug Interactions:
Monitor: electrolytes Na+ and K+, glucose, CNS changes
Side Effects:
Stability:
ED
UT1-ICU
UT2-IU
OR/PACU
Spinal Cord Injury protocol:
I.I. LD: 30 mg/kg in 100 mL NS or D5W
over 15 mins, then wait 45 mins to start
maintenance infusion C.I. at 5.4
mg/kg/hr for 23 hrs (when < 3 hrs post
injury or x 47 hrs (when > 3 hrs-8 hrs
post injury Round all doses to nearest 50
mg, use separate IV line.
Metoclopramide
Reglan
®
[antiemetic, dopamine
antagonist]
Nov 2017: During
shortage
of SVP
50mL/100mL D5W, use
NS
Antiemetic
GI Stimulant
ALL
UNITS
(Except
Psy)
IV Push: < 10 mg undiluted given over
1-2 mins, flush with 5 mL NS.
I.I. (ED-Migraines): 10-20 mg in 50
mL NS or D5W over 5-10 mins.
Caution/Warning:
Comments: Reduce dose to 5mg in renal failure & with elderly. Can be admixed in
same syringe with diphenhydramine.
Contraindications: Pheochromocytoma, Seizure disorder.
Drug Interactions:
Monitor:
Side Effects: Sedation, diarrhea. Chronic use of metoclopramide has been linked to
tardive dyskinesia, which may include involuntary and repetitive movements of the
body.
Stability:
119
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Metoprolol Tartrate
Lopressor
®
[beta blocker]
Rate control-Atrial
Fib., Unstable
angina,
hypertension
ALL
UNITS
(Except
Psy)
IV Push:
1.25 – 10 mg undiluted over 1-2 mins q
4, 6 , or 8 hrs
Caution/Warning:
Comments:
Contraindications: Pheochromocytoma, Heart block, Cardiac failure.
Drug Interactions:
Monitor: Patient must be on a bedside cardiac monitor or telemetry for IV Push.
Cardiac monitor or telemetry is not required for Intermittent slow administration
Check BP& HR 15 mins before & after med. Obtain hold parameters. Elderly may
require lower doses.
Side Effects: Common: Bradycardia, hypotension Serious: Bronchospasm, heart
block
Stability:
Acute MI
ALL
UNITS
(Except
Psy)
IV Push: 5 mg undiluted over 1-2
mins q 5 mins x 3 doses if tolerated
Maintenance dose:
Rate control-A. Fib.,
Unstable angina,
hypertension
ALL
UNITS
(Except
Psy)
I.I.: < 2.5 - 10 mg in 50 mL NS/D5W @
rate of 1 mg/min or over 10 - 20 mins
MetroNIDAZOLE
Flagyl
®
[antibiotic]
LOOK ALIKE / SOUND
ALIKE
Oct 2017: Alternative
must be considered if
shortage. Restrict to
severe-complicated C.diff.
Click Here for Info
Anaerobic Bacterial
Infection
ALL
UNITS
(Except
Psy)
I.I.: 500 mg in 100 mL Premix q 8 hrs
over 60 mins
Caution/Warning:
Comments: Usual doses 500 mg q 8 hr, 500 mg IV q12hr.
Educate patients to Avoid alcohol to prevent antabuse reaction (N/V, flushing). Do not
refrigerate.
Drug Interactions:
Monitor:
Side Effects: Loss of appetite, nausea/vomiting, metallic taste, headache
Stability:
120
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Midazolam
Versed
®
[short-acting
benzodiazepine]
TITRATE MED
Nov 2017: During
shortage
of SVP
50mL/100mL D5W, use
NS
Conscious sedation
ECT-A
ED
ENDO
UT1-ICU
IRAD
OP-CARD
OR/PACU
UHSC
Slow IV Push: 0.5- 2 mg over 1- 2 mins–
and repeat small doses. q 2-3 mins prn to
desired sedation. Doses as low as 1 mg
may achieve the desired effect for
conscious sedation.
Caution/Warning:
Comments: Reduce dose with Liver/Renal failure or if pt. is on narcotics or other
sedatives.
CI requires MD/LIP order for therapeutic goal (ex: RASS or explanation of desired
level of sedation) or reason. Titrate per protocol to goal.
Infusions are reserved for ICU patients both intubated and extubated patients with
continuous monitoring of oximetry and capnography. Midazolam infusions are
permitted in monitored extubated ICU patients who a. still need sedation after
extubation or b. for ETOH withdrawal when metabolic acidosis is present from high
dose LORazepam.
Flumazenil must be readily available for reversal of benzodiazepine toxicity. Notify
practitioner if unable to achieve desired level of sedation at the ordered maximum dose.
ETOH withdrawal/Sedation: Midazolam infusions may be used as an alternative to
LORazepam infusions during LORazepam shortages. Midazolam equivalency to
LORazepam is difficult to predict. Conversion ratio of 1:2-3 from LORazepam to
Midazolam when used for sedation or treating ETOH withdrawal symptoms.
Drug Interactions:
Monitor (General/Per Moderate Sedation Guidelines): BP (hypotension), RR,
injection site, mental status, allergic/anaphylactic reaction, nausea/vomiting
Monitor (Specific to Continous Infusion): BP, RR and sedation score (RASS) with
each adjustment and every 1-2 hours once sedation is achieved, injection site (central
line is preferred), mental status, continuous pulse ox and capnography if not
mechanically ventilated.
Side Effects: hypotension, resp. depression, apnea, pain at injection site ,
thrombophlebitis. Transitition to an oral benzodiazepine may be needed to avoid
withdrawal symptoms.
Stability:
ICU sedation
UT1-ICU
In presence
of Critical
Care RN or
Action RN
and LIP
during
RRT/Code,
ALL
UNITS
IV Push LD: 0.01 to 0.05 mg/kg or 0.5 –
4 mg slowly over 2mins
C.I.: 50 mg/50 mL D5W or NS or 100
mg/ 100 mL D5W or NS (1mg/mL)
Initial 0.02-0.1 mg/kg/hr = 0.5- 2 mg/hr,
titrate by 0.5 mg/hr q 10 mins to achieve
sedation with RASS of 0 to -1, or per
MD/LIP orders. Titrate Med if ordered.
ETOH withdrawal if
refractory to or
impractical to use
intermittent IV push
ED
UT1-ICU
C.I.: 50 mg/50 mL D5W or NS or 100
mg/ 100 mL D5W or NS (1mg/mL)
Start at 1 mg/hr & titrate by 1mg/hr q 30
mins to achieve sedation with RASS of 0
to -1, or as MD/LIP orders. Max of 20
mg/hr, unless higher max.is ordered by
MD/LIP. Titrate per Order.
121
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Milrinone
[phosphodiesterase
inhibitor]
TITRATE MED
Cardiogenic shock
UT1-ICU
UT2-IU
OR/PACU
I.I. LD: 50 mcg/kg slowly over 10 mins
then
C.I.: 40mg/200mL D5W Premix
(200mcg/mL) start @ 0.375 mcg/kg/min
and do not Titrate unless ordered by
MD/LIP. Desired response shoud be
increase of cardiac output , CI > 2, and
decrease PAOP.
Caution/Warning:
Comments: Patient must be on a cardiac monitor/telemetry.
CI requires MD/LIP order for therapeutic goal (ex: BP, HR, MAP, Cardiac Index) or
reason. Due to long half-life of 2-3 hrs expect a duration of action up to 6-8 hrs after
the drip is DC’d. Incompatible with furosemide. Reduce dose in renal dysfunction
Drug Interactions:
Monitor: BP & HR pre and post loading dose and initiation of C.I. every 5 to 10
minutes then hourly until stable then every 2-4 hours or as ordered. Hemodynamic
parameters for desired effect. Urine output every 2 hours. After discontinuation,
monitor BP & HR every 2 hours for 8 hours.
Side Effects: Ventricular arrhythmias, hypotension, angina.
Stability:
BOLUS OFF BAG:
Upon new EMR April
2018, ability to bolus
from continuous
infusion bag via Alaris
Pump Guardrails.
122
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Morphine
Sulfate
[opioid analgesic]
LOOK ALIKE / SOUND
ALIKE
TITRATE MED
(CI/PCA)
HIGH ALERT / DOUBLE
CHECK
Pain Control
ALL
UNITS
(Except
Psy)
For Opioid Naïve & Average Patients
IV Push: Doses < 10mg, dilute in 10mL
NS, over 2-3 mins.
Comments on all routes of Administration of Morphine Sulfate
Requires RN/LPN verification double check on MAR for Infusions, Epidural & PCA
only.
Caution/Warning: Naloxone must be readily available as a reversal agent for opioid
induced respiratory depression. Consider any specific patient risk factors that may
contribute to unintended respiratory depression and/or excessive sedation levels. Risk
factors may include but are not limited to: age > 55 years; preexisting pulmonary or
hepato-renal disease; known or suspected sleep-disordered breathing problems;
anatomic oral or airway abnormalities; and comorbidities of systemic disease,
renal/hepatic impairment.
Comments:
Monitor: Pain relief, pulse oximetry, level of consciousness, RR & depth, HR, BP,
mental status, nausea/vomiting. Check RR & sedation level in 5-15 mins.
Related Policy:
• Medication: High Alert, Double Check of
Side effects: Somnolence, coma, respiratory depression, CNS depression, arrhythmias,
hypotension, bradycardia, pruritus, nausea & vomiting
Stability:
Pain Control
(Opioid tolerant
patients)
ALL
UNITS
(Except
Psy)
For Opioid Tolerant Patients
IV Push: up to < 40 mg , dilute in 10mL
NS, over 2-3 mins.
Pain control
ALL
UNITS
(Except
Psy)
CI: Opioid Naïve Patients
Low Concentration:
100mg/100mL NS/D5W = 1mg/mL
CI: Opioid Tolerant Patients
High Concentration
500mg/100mL D5W/NS = 5mg/mL
See above for comments on Morphine Sulfate.
CI: Use the low concentration (1mg/mL) unless consumption exceeds reasonable rate
of bag change. If patients dosing or if fluid restriction requires a higher concentration
specific MD/LIP orders must be written and Pharmacy must be consulted & Nurse
Manager/designee notified. Rate of dose escalation must be specified for all CIs. CI is a
titrate med if ordered as such.
Related Policies:
• Pain (Acute): Continuous Opioid Infusions and Patient Controlled
Analgesia (PCA): Care of the Patient Receiving
• Sickle Cell Pain: Pain Management Using High Dose Continuous &
PCA Narcotic Infusions
Information on Morphine continues on the next page.
Avoid in midline cath see
Page 14 (may be ok w/
short course)
123
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Morphine
Sulfate
[opioid analgesic]
LOOK ALIKE / SOUND
ALIKE
TITRATE MED
(CI/PCA)
HIGH ALERT / DOUBLE
CHECK
Pain Control, PCA
Bolus Mode Only
ALL
UNITS
(Except
Psy)
PCA: Bolus Mode Only.
PCA: Opioid Naïve Patients
Low Concentration:
50mg/50mL NS = 1mg/mL
PCA: Opioid Tolerant Patients
High Concentration
250mg/50mL NS = 5mg/mL
See prior page for comments on Morphine Sulfate.
PCA bolus doses for patients who do not need the continuous basal infusion and do not
have continuous capnography.
Use the 1 mg/mL concentration unless consumption exceeds reasonable rate of PCA
change.
High Dose narcotic syringe may be obtained in one of two ways:
1. Via hand delivery by the pharmacist/and or designee to the RN caring
for the patient. The RN must sign a the delivery receipt for hand
delivered doses.
2. Via an automated dispensing cabinet in designated areas. The RN must
scan the product prior to removal.
Related Policies:
• Pain (Acute): Continuous Opioid Infusions and Patient Controlled
Analgesia (PCA): Care of the Patient Receiving
Pain Control, PCA
Dual Mode (Basal
Infusion & Bolus)
All Units
(Except
Psy) with
Continuous
Capno-
graphy
PCA Dual Mode (Basal infusion &
bolus)
Requires Continuous Capnography
PCA: Opioid Naïve Patients
Low Concentration:
50mg/50mL NS = 1mg/mL
PCA: Opioid Tolerant Patients
High Concentration
250mg/50mL NS = 5mg/mL
See prior page for comments on Morphine Sulfate.
Use the 1 mg/mL concentration unless consumption exceeds reasonable rate of PCA
change.
High Dose narcotic syringe may be obtained in one of two ways:
1. Via hand delivery by the pharmacist/and or designee to the RN caring
for the patient. The RN must sign a the delivery receipt for hand
delivered doses.
2. Via an automated dispensing cabinet in designated areas. The RN must
scan the product prior to removal.
Related Policies:
• Pain (Acute): Continuous Opioid Infusions and Patient Controlled
Analgesia (PCA): Care of the Patient Receiving
Exceptions to continuous capnography monitoring:
1) Patient on mechanical ventilation
2) End-of-life care (e.g. hospice, comfort measures only)
124
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Multivitamin
Vitamin deficiency
ALL
UNITS
C.I.: 1 vial of vial one and 1 vial of vial
two for a total of 10 mL to at least 500
mL of IVF over at least 1 hr
Caution/Warning:
Comments: 1 vial of water soluble & 1 vial of fat soluble vitamins= 1 vial of MVI
Drug Interactions:
Monitor:
Side Effects:
Stability: Stable for 48 hrs @ R.T.
Mycophenolic acid
Cellcept
®
[immune suppressant]
Prophylaxis against
cardiac, renal or
liver transplant
rejection
ALL
UNITS
(Except
Psy)
I.I.:
1 Gm in 150 mL D5W, 1. 5Gm in 250
mL D5W, given over 2 hrs.
Cardiac transplant rejection; Prophylaxis:
1.5 Gm IV/ORAL twice daily
Liver transplant rejection; Prophylaxis
1 Gm IV twice daily
Renal transplant rejection; Prophylaxis
1 Gm IV/ORAL twice daily
Caution/Warning:
Comments: Switch to oral therapy as soon as it can be tolerated by the pt. Negative
serum or urine pregnancy test (sensitivity of at least 25 mIU/mL) within 1 week prior to
initiation in all women of childbearing age required. Consult references for dose
reduction in renal failure. Hazardous medication precautions. Increased risk of
congenital malformations. Pregnancy Category D. Wear nitrile gloves while handling.
Gowns should be utilized for incidental exposure to hazardous drugs. Dispose in
hazardous waste container. Refer to the UConn hazardous drug safety handling for
further information:
Medication Handling Safety
Drug Interactions:
Monitor:
Side Effects: Possible Serious side effects: Anemia, Gastric ulcer, Gastrointestinal
hemorrhage, Gastrointestinal perforation, Leukopenia, Malignant epithelial neoplasm
of skin, non-melanoma, Malignant lymphoma, Neutropenic disorder (Severe),
Opportunistic infection, Pleural effusion, Progressive multifocal, leukoencephalopathy,
Pulmonary fibrosis, Sepsis, Thrombocytopenia. Others include: Hypotension,
peripheral edema, hypo/hyperkalemia, hyperglycemia, hypocalcemia, h
ypomagnesemia, GI- abd pain, diarrhea/constipation, N/V, abnormal LFT’s, headache,
tremors, inc. BUN/Cr, Dyspnea, cough.
Stability: Only stable for 4 hrs.
Nafcillin
[antibiotic]
ADS MIXTURE
Bacterial Infection
ALL
UNITS
(Except
Psy)
I.I.: 1-2 Gm in 100 mL NS (Minibag
Plus) over 30 -60 mins q 4-6 hrs.
Caution/Warning:
Comments: Contraindications: Type 1 hypersensitivity to Penicillin or Cephalosporins
Drug Interactions:
Monitor:
Side Effects:
Stability: If mixed by pharmacy: 24 hrs at room temperature, 7 days if refrigerated
If Extravasation, see
Pages 10&11 to follow
Oxacillin guidance
Avoid in midline cath see
Page 14 (may be ok w/
short course)
BKC: Dispose in
Black Bin
125
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Nalbuphine Hydrochloride
Nubain
®
[opioid analgesic]
Pain
Pruritis while on
Epidural
ALL
UNITS
(Except
Psy)
I.I.: Pruritus: 2.5-5mg IV push undiluted
over at least 2 to 3 minutes.
Pain: 10 mg IV push undiluted over at
least 2 to 3 minutes. May titrate to
appropriate effect. Maximum dose in
nonopioid tolerant patients: 20mg/dose;
160mg/day.
Caution/Warning:
Comments: Other routes: IM, SubQ. Reserve nalbuphine for use in patients for whom
alternative treatment options (eg, nonopioid analgesics) are ineffective, not tolerated, or
would be otherwise inadequate to provide sufficient management of pain. Taper may be
required for discontinuation of therapy for pain. For use in surgical anesthesia
supplement, dose of 0.3 to 3 mg/kg administered over 10 to 15 minutes. Recommended
to reduce dose in hepatic or renal insufficiency.
Drug Interactions:
Monitor:
Side Effects: similar to other narcotics.
Stability:
126
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Naloxone
Narcan
®
[narcotic antagonist]
Reversal of
narcotics
ALL
UNITS
IV Push:
Full Reversal: 0.4 mg undiluted over
15-30 secs, flush with 5 mL NS, may
repeat q 2 mins as needed.
Partial Reversal: For 0.04 mg dose: mix
1mL naloxone with 9mL NS for
0.04mg/mL. 0.04mg over 15-30 secs,
flush with 5mL NS, may repeat q2 mins
as needed. Use lower doses in patients
who are opioid dependent to avoid
sudden withdrawal.
Caution/Warning:
Comments: Stable for 24 hrs in refrigerator.
Continuous infusions may be required to reverse long acting narcotics.
Use cautiously if seizure history, avoid if meperidine induced seizures.
If no response after 10 mg, check for other causes.
Drug Interactions:
Monitor: BP, HR, RR, return of sedation.
Side effects: opioid withdrawal (nausea/vomiting, sweating, tachycardia,
tremulousness, cardiovascular changes), pulmonary edema, arrhythmias, hyper/hypo-
tension
Stability:
Reversal of
narcotics
ED
UT1-ICU
OR/PACU
C.I. (for initial positive response but
patient reverses to sedative state or if
patient is on long acting narcotics, start
ASAP):
4 mg/ 250mL D5W or NS (16 mcg/mL) ,
at usual rate of 0.4 mg/hr or 2/3 rd’s of
initial bolus doses required in 1 hr for
reversal or 0.0025 mg/kg/hr.
Recommended maintenance rate after pt
is arousable is 0.04-0.08 mg/hr (2.5-
5mL/hr).
May need additional IV bolus doses after the CI is initiated.
Use Pulse Oximetry with CI
127
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Pruritus (itching)
with narcotics if
antihistamines
fail to control
symptoms
ALL
UNITS
(Except
Psy)
C.I.: 0.5 mg / 250 mL D5W or NS (2
mcg/ml) infuse @ 0.25 mcg /kg/hr to
reduce symptoms of pruritus without
causing an increase in pain.
Comments: The incidence of pruritus, nausea and vomiting and urinary retention are
likely more frequent with morphine than HYDROmorphone or FentaNYL. Monitor for
relief of pruritus and pain control per standard pain assessments and frequencies. Doses
up to 2.4mcg/kg/hr have been reported in literature (see references). Not for use in
patients receiving prn opioids only.
References:
Greenwald PW, Provartaris J, Coffey J, et al. Low-dose naloxone does not improve
morphine-induced nausea, vomiting and pruritus. Amer J Emerg Med. 2005;23:35-9.
Maxwell LG, Kauffmann SC, Bitzer S, et al. The effects of a small-dose naloxone
infusion on opioid-induced side effects and analgesia in children and adolescents
treated with intravenous patient-controlled analgesia: a double-blind, prospective,
randomized, controlled study. Anest Analg. 2005;100:953-8.
Koch J, Manworren R, Clark L, et al. Pilot study of continuous co-infusion of morphine
and naloxone in children with sickle cell pain crisis. Am J Hematol. 2008;83:728-31.
Gan T, Ginsberg B, Glass PS, et al. Opioid-sparing effects of a low-dose infusion of
naloxone in patient-administered morphine sulfate. Anesthesiology. 1997;87(5):1075-
81.
Kjellberg F and Tramer MR. Pharmacological control of opioid-induced pruritus: a
quantitative systematic review of randomized trials. Eur J Anaesthesiol. 2001;18:346-
57.
128
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Natalizumab
Tysabri
®
[recombinant
immunoglobulin-4 (IgG4)
monoclonal antibody
directed against alpha(4)
integrin]
Crohn's disease
(Moderate to
Severe)
Multiple sclerosis
MED/
SURG/
ONC
OP-INFC
OP-NCCC
I.I.: 3-6 mg/kg per monthly treatment or
300 mg / 100 mL NS IV given over
approximately 1 hr, repeat every 4 weeks
(28 days)
Caution/Warning:
Comments: Natalizumab dosing should be withheld immediately at the first sign or
symptoms suggestive of Progressive multifocal leukoencephalopathy (PML) which is a
an opportunistic viral infection of the brain that usually leads to death or severe
disability. PML may manifest as progressive weakness on one side of the body or
clumsiness of limbs, disturbance of vision, confusion, and personality changes.
Concurrent corticosteroids, antineoplastic, immunosuppressant, or immunomodulator
therapy can increase risk of PML.
MD evaluation: for Multiple Sclerosis
1) MRI (number of new gadolinium-enhancing lesions); prior to therapy and
periodically (e.g., monthly or bimonthly)
2) Evaluate, as required by TOUCH (TM) Prescribing Program, 3 and 6 months after
the first infusion and every 6 months thereafter [1]
3) Signs of clinical relapse
4) Improvement in disability (e.g., Kurtzke Expanded Disability Status Scale)
5) Well-being/quality of life assessments (interview
Pharmacy: Available via restricted distribution program called the TOUCH™
Prescribing Program. To prepare the solution for infusion, withdraw 15 mL concentrate
from the single-use vial and admix with 100 mL NS. Infuse over 1 hr. Gently invert
the solution to mix; do not shake. Following dilution, natalizumab should be used
immediately or kept under refrigeration and used within 8 hours.
Drug Interactions:
Monitor: Observe the patient during infusion and for 1 hour after the infusion is
complete. Discontinue the infusion at any sign or symptom of a hypersensitivity
reaction (urticaria, pruritus, dizziness, headache, rigors). No other medications should
be mixed with natalizumab or injected into a side port of the infusion
Side effects: Hypersensitivity reactions: Anaphylaxis/anaphylactoid – bronchospasm,
headache, dizziness, fatigue, urticaria, pruritus, rigors, abdominal discomfort, nausea
and headache.
Infection Risk of Respiratory & Urinary tract , opportunistic infections, Arthalgias.
CNS Progressive multifocal leukoencephalopathy (PML)- may include depression, ,
drowsiness, inattentiveness, Babinski sign , inability to sit or stand, tendency to fall to
left side, impaired cognition, disabling hemiparesis, depressive and aggressive episodes,
and dysarthric speech.
Antibody-positive to natalizumab included hypertension and tachycardia, along with
infusion reactions, myalgia, dyspnea, and anxiety.
Stability:
129
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Neostigmine
[acetylcholinesterase
inhibitor]
Reversal agent
for depolarizing
muscle relaxants
ECT-A
HT1-ICU
OR/PACU
UHSC
IV Push: 0.05 mg/kg or 0.5-2 mg
undiluted over < 2-3 mins
Caution/Warning:
Comments: Reduce for renal impairment, elderly.
Max. of 10 mg/24hrs for Treatment of Myasthenia Gravis & 5mg for reversal of
neuromuscular blockers. Monitor required.
Drug Interactions:
Monitor:
Side Effects: Bradycardia, A-V block, bronchoconstriction, inc. salivation, N/V,
diarrhea, diaphoresis, muscle spasms. Atropine or glycopyrrolate must be at bedside to
treat bradycardia.
Stability:
Colonic Pseudo-
obstruction,
Myasthenia Gravis
MD/LIP
only in
HT1-ICU
HT2-INT
IV Push: 0.5-2.5 mg IV
NiCARdipine
Cardene
®
[Calcium Channel Blocker]
TITRATE MED
Acute HTN
encephalopathies
Arterial
hypertension in
acute ischemic/
hemorrhagic
stroke
ED
UT1-ICU
C.I.: 20 mg/ 200 mL D5W Premix (0.1
mg/mL).
Initiate at 2.5 - 5 mg /hr, increase by 2.5
mg/hr q 5 mins up to desired BP goal
(25% reduction of MAP) or a max of 15
mg/hr. After achieving BP control
decrease rate slowly to 3mg/hr and adjust
to BP goals. Titrate med if ordered as
such.
Caution/Warning:
Comments: Central vein is preferred due to irritation with peripheral veins. Change IV
site q 12hrs if given via peripheral line. CI requires MD/LIP order for therapeutic goal
(ex: BP, HR, MAP, Cardiac Index) or reason. Titrate per order to goal. Start lowest
dose with elderly. Incompatible with furosemide & heparin. Avoid excessive
reductions in dose to lower risk of precipitating renal, cerebral or coronary ischemia.
May worsen ischemia & CHF in CAD pts.
Drug Interactions:
Monitor: Monitor BP, EKG, HR.
Side Effects: hypotension, edema, flushing, Vent. Premature Contractions, tachycardia,
& EKG changes, chest pain.
Stability: Stable for 24 hrs at room temperature if mixed.
130
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Nitroglycerin
NTG
[vasodilator]
TITRATE MED
Pulmonary HTN,
CHG w/ AMI,
Angina, HTN crisis
Nitroglycerin may
be titrated on UT2-
IU (Intermediate)
only for indication
of chest pain, with a
maximum titration
dose of 50 mcg/min.
For all other
indications, provider
must adjust rate per
order up to a
maximum dose of
50 mcg/min
ED
UT1-ICU
UT2-IU
OR/PACU
C.I.: 50 mg/ 250 mL D5W (200 mcg/ml)
Start at 10 mcg/min, increase by 10
mcg/min q 5 mins to usual desired relief
of chest pain, decrease of SBP to 100-
120 or MAP > 60, or as ordered. Max of
200 mcg/min in UT1-ICU, ED, PACU
unless MD/LIP orders higher.
Recommended > 50 mcg/min for
coronary vasodilation if patient tolerates.
Max of 50 mcg/min in UT2-IU.
Titrate Med if ordered as such.
Caution/Warning:
Comments: Pt must be on a cardiac monitor/telemetry. Use glass bottle.
CI requires MD/LIP order for therapeutic goal (ex: BP, HR, MAP, Cardiac Index,
PAOP) or reason. Titrate per order to goal. Do not start if SBP < 90 or PAOP <
12.
Contraindications: head trauma or CNS hemorrhage. Tolerance develops in 24-48 hrs.
Titrate off slowly and if asymptomatic can taper at the same dose as upward titration.
Also, titrate dose down if headache is severe and patient remains pain free.
Compatible w Amiodarone, DOBUTamine, DOPamine, Heparin, DiltiaZEM, Esmolol,
Furosemide
Drug Interactions:
Monitor: BP, HR, PAOP. For C.I.: BP & HR every 5-10 minutes with each dose
titration until positive response then once stable every 30 minutes x 2 then every 1-2
hours. If initiated for chest pain, monitor severity and characteristics of pain with each
titration. If SBP < 90 or decreases by 30 mmHg or more decrease rate to prior dose.
Continue to evaluate and decrease rate until BP stabilizes. Stop infusion if severe
hypotension occurs.
Side effects: hypotension, headache, flushing, dizziness, reflex tachycardia, bradycardia
(may require atropine), n/v, restlessness, diaphoresis, abd. Pain
Stability:
Syringe 100mcg/mL stability for CCL is 7 days refrigerated and protected from light.
References:
https://www.ijpc.com/Abstracts/Abstract.cfm?ABS=3750
Driver, PS. Jarvi EJ, Gratzer PL. Stability of nitroglycerin as nitroglycerin concentrate for
injection stored in plastic syringes Am J Health Syst Pharm December 1, 1993 50:2561-2563
Prevention of
arterial spasm in
catheters
CCL/EP
IRAD
OR/PACU
Catheter: (Diamondback 360 System by
CSI). 1000mL NS with 20mL of Viper
Slide (lubricant ), 5mg of Nitroglycerin,
and 5mg of verapamil (or nicardipine).
Vasodilator
CCL/EP
OR/PACU
Syringe: Pharmacy prepares
100mcg/mL, 20mL syringes for use in
the cath lab and as well for use in the
OR.
If Extravasation,
see Pages 10&11
BKC: Dispose in
Black Bin
131
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Nitroprusside
Nipride
®
[vasodilator]
TITRATE MED
Hypertensive Crisis
Pul. HTN
Intracranial
Hemorrhage
ED
UT1-ICU
OR/PACU
C.I.: 50 mg/ 250 mL D5W (200
mcg/ml) or
100 mg/ 250 mL D5W (400
mcg/ml)
Start at 0.3 mcg/kg/min, increase by 0.3
mcg/kg/min q 5 mins to usual desired
decrease of SBP to 100-120 or MAP>60
, or as ordered.
Max dose: 10 mcg/kg/min, unless
MD/LIP orders higher max.
Extreme HTN emergency doses up to 10
mcg/kg/min can be used for < 10 mins
Titrate med if ordered as such.
Caution/Warning:
Comments: Pt must be on a cardiac monitor/telemetry. CI requires MD/LIP order for
therapeutic goal (ex: BP, HR, MAP, Cardiac Index) or reason. Titrate to goal per order.
May consider to slow the rate of infusion if nausea and vomiting. If hypotension occurs,
decrease rate to prior level. Stop for severe hypotension. Notify MD/LIP is desired
response not achieved at maximum dose.
Avoid in Aortic stenosis, coarctation of aorta. Use with caution in hepatic/renal disease.
Risk of cyanide toxicity @ mod-high doses. Consider use of Thiosulfate 1 gm per 100
mg of Nitroprusside. Consult Pharmacy. Consult references for antidotes with
thiocyanate toxicity. Incompatible with NS.
Keep supine or limit HOB elevation to 30 degrees.
Drug Interactions:
Monitor: EKG, BP & HR with each titration then hourly once desired response
obtained (Continuous blood pressure monitoring via a-line is preferable, otherwise, non-
invasive blood pressure monitoring may be used), Renal function
Side Effects: hypotension, dizziness, headache, flushing, thiocyanate levels (should be
< 10 mg/dL) for prolonged tx > 24-48 hrs. Monitor for metabolic acidosis
Stability: Stable for 7 days at room temperature. Protect from light by using black bag
from manufacturer.
Norepinephrine
Levophed
®
[sympathomimetic,
vasopressor]
TITRATE MED
Severe hypotension
or Shock
ED
UT1-ICU
OR/PACU
C.I.: in D5W (preferred) or NS
Low: 4 mg/250 mL D5W [Premix] (16
mcg/mL)
High: 16 mg/ 250 mL D5W (64
mcg/mL)
Pharmacy to label as above
Start at 0.03 mcg/kg/min and titrate by
0.03 mcg/kg/min q 2 mins, titrate to
achieve usual increase in SBP to 100-120
or MAP > 60, or as ordered. Max dose:
0.3 mcg/kg/min, unless MD/LIP orders
higher max. Titrate Med if ordered as
such.
Caution/Warning:
Comments: Patient must be on a cardiac monitor/telemetry. CI requires MD/LIP order
for therapeutic goal (ex: BP, HR, MAP, Cardiac Index) or reason. Titrate per order to
goal. Central line is preferred. Notify MD/LIP is desired response not achieved at
maximum dose.
Drug Interactions:
Monitor: EKG, BP, HR, RR, U/O, per. Circulation. For C.I.: BP&HR with each
titration then every 30 minutes x 2, every 1-2 hours once desired response obtained. IV
site for extravasation. Urine output every 1 to 2 hours; hourly if strict I&O.
Side Effects: hypertension, palpitations, tachycardia, angina, gangrene at peripheral site
Extravasation can cause tissue necrosis.
Stability: Bicarbonate will inactivate norepinephrine. Stable when mixed by JDH
pharmacy and protected from light in refrigerator for 14 days and 24 hours at room
tempertature. Syringe stability: 14 day expiration under refrigeration, 2 day expiration if
left out of fridge. Protect from light.
Reference on stability: The stability of four catecholamines in 5% glucose infusions. J Clin Phar Ther. 1991 Oct;16(5):337-
40
Premix products not mixed by JDH pharmacy are good for 45 days at room
temperature.
Syringes for OR Area (ePHEDrine
Shortage replacement): 20mcg/10mL
(2mcg/mL) syringes
If Extravasation,
see Pages 10&11
Avoid in midline cath see
Page 14
132
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Ocrelizumab
Ocrevus
®
[monoclonal antibody]
Crohn’s Disease
OP-INFC
I.I.:
First 2 infusions (300 mg dose): 300
mg/250mL NS: Begin infusion at 30
mL/hour; increase by 30 mL/hour every
30 minutes to a maximum rate of 180
mL/hour with an inline 0.2 micron low
sorbing (protein) binding filter. Infusion
duration is 2.5 hours or longer.
Subsequent infusions (600 mg dose):
600 mg/500mL NS: Begin infusion at 40
mL/hour; increase by 40 mL/hour every
30 minutes to a maximum rate of 200
mL/hour with an inline 0.2 micron low
sorbing (protein) binding filter
. Infusion
duration is 3.5 hours or longer.
Caution/Warning: Premedicate prior to each infusion with steroid, antihistamine and
may also consider acetaminophen.
Comments: Use 0.2 micron low sorbing (protein) binding filter. Do not infuse in the
same IV line with other agents.
Drug Interactions:
Monitor: Infusion reactions during infusion and for at least 1 hour following the end of
infusion. Signs/symptoms infection, malignancy and progressive multifocal
leukoencephalopathy.
Side Effects:
Stability: 8 hrs at room temperature; 24 hours refrigerated. Do not freeze. Do not shake.
Octreotide
SandoSTATIN
®
[somatostatin]
Carcinoid
Syndrome
ALL
UNITS
(Except
Psy)
IV Push: 50-500 mcg then
I.I.: 50 mcg/hr for 8- 24 hrs
Caution/Warning:
Comments: Refrigerate ampules/vials until used.
IV push administration may result in increased gastrointestinal adverse effects.
Octreotide may be given as a rapid IV bolus in an emergency situation (e.g. Carcinoid
crisis). Can elevate serum glucose in NIDDM and lower serum glucose in IDDM.
Clearance of drug reduced by 50% in dialysis patients.
Protect C.I. from Light.
Drug Interactions:
Monitor:
Side Effects: flushing, edema, headache, dizziness, glucose changes, nausea,
bradycardia, QTC prolongation.
Stability:
Diarrhea
IV Push: dose undiluted or in 5mL NS
over 3 mins
I.I.: 50-200 mcg q 8 hrs in 50 mL NS
over 10- 20 mins
Esophageal bleeding
C.I.: 500 mcg/100mL NS (5 mcg/mL)
start at 25 mcg/hr (5 mL/hr)
1,250 mcg/250mL NS (5 mcg/mL) at
50 mcg/hr (10 mL/hr)
Ondansetron
Zofran
®
[5HT3 antagonist]
Antiemetic
ALL
UNITS
IV Push: < 12 mg dilute with 5 mL NS
given over 1-2 min, flush with 5 mL NS-
given q 6-8 hrs prn n/v.
Caution/Warning:
Comments: Pharmacy to admix doses > 12 mg/ 50 mL D5W
Severe Hepatic Impaired do not exceed 8mg/day
Drug Interactions:
Monitor: for fever, rash, pruritus, and restlessness
Side Effects: RARE- headache, dizziness
Stability:
ALL
UNITS
(Except
Psy)
I.I.: > 12 mg/ 50 mL NS/D5W over 5
mins
Chemotherapy Induced Emesis: 8-20 mg
or 0.15 mg/kg in 50-100 mL NS/D5W
over 2-15 mins
133
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Omadacycline
Nuzyra®
[tetracycline antibiotic]
RESTRICTED
ANTIMICROBIAL
NON-FORMULARY
Bacterial Infections
Documented or
suspected infection
caused by a proven-
susceptible
multidrug-resistant
gram-positive or
gram-negative
pathogen for which
other formulary /
restricted formulary
agents are inactive
Salvage therapy for
certain non-TB
Mycobacteria
Patient receiving
omadacycline prior
to admission to
UConn Health John
Dempsey Hospital
ALL
UNITS
(Except
Psy)
I.I.: If stored under refrigeration, allow
diluted infusion solution to reach room
temperature prior to infusion.
-Infuse 200 mg dose over a total of 60
minutes and 100 mg dose over a total of
30 minutes through a dedicated line or
Y-site
-If no dedicated line available, flush line
with NS or D5W before and after
infusion of omadacycline
Caution/Warning:
May result in fungal or bacterial superinfection (e.g. Clostridium difficile); QT
prolongation; Hepatic impairment
Comments: Altered kidney, Hepatic Impairment: No dosage adjustment necessary
Drug interactions: Substrate of P-glycoprotein/ABCB1 (minor); may decrease the
effectiveness of BCG, Cholera, and Typhoid vaccines; may enhance the adverse/toxic
effect of Retinoic Acid Derivatives
Monitoring: Periodic renal and hepatic function tests
Related Policies: Restricted and Concurrently- Monitored Antimicrobials
Side Effects: nausea; vomiting
Stability: Store intact vials and tablets at 20°C to 25°C (68°F to 77°F); excursions
permitted to 15°C to 30°C (59°F to 86°F). Diluted infusion solutions are stable for 24
hours at room temperature (≤25°C) or for 7 days when refrigerated (2°C to 8°C). Do not
freeze.
134
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Oritavancin
Orbactiv®
[glycopeptide antibiotic]
RESTRICTED
ANTIMICROBIAL
NON-FORMULARY
Bacterial Infections
Documented or
suspected skin &
skin structure
infection (given as a
single-dose
treatment), bone
infection, or
endocarditis caused
by caused by MRSA
in a patient
intolerant to or not
responding
clinically to
vancomycin,
daptomycin,
ceftaroline, or
linezolid
Patient who needs
long-term anti-
MRSA therapy for
above infections in
the outpatient
setting for whom
traditional
outpatient parenteral
antibiotic therapy
(“OPAT”) and/or
adherence to oral
therapy is not
possible
ALL
UNITS
(Except
Psy)
I.I.: Infuse over 3 hours.
-If a common IV line is being used to
administer other drugs in addition to
oritavancin, the line should be flushed
before and after each infusion with D5W.
Caution/Warning:
May result in fungal or bacterial superinfection (e.g. Clostridium difficile);
hypersensitivity reaction; infusion reactions; osteomyelitis
Comments: Altered kidney, Hepatic Impairment: No dosage adjustment necessary
Drug interactions: may artificially increase the results of laboratory tests commonly
used to monitor IV heparin effectiveness; may decrease the effectiveness of BCG and
Cholera vaccines
Monitoring:
Baseline serum urea nitrogen, Scr, and LFTs
Related Policies: Restricted and Concurrently- Monitored Antimicrobials
Side Effects: nausea; vomiting; diarrhea; headache
Stability: Store intact vials at 20ºC to 25ºC (68ºF to 77ºF); excursions are permitted
between 15ºC to 30ºC (59ºF to 86ºF). Reconstituted vials and solution diluted in D5W
may be stored refrigerated at 2°C to 8°C (36°F to 46°F) for 12 hours or at room
temperature 20°C to 25°C (68°F to 77°F) for 6 hours. The total time from reconstitution
and dilution to completed administration should be ≤6 hours at room temperature or ≤12
hours if refrigerated.
135
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Oxacillin
[antibiotic]
ADS MIXTURE
Bacterial Infection
ALL
UNITS
(Except
Psy)
I.I.: 1-2 Gm in 100 mL NS (Minibag
Plus) over 30 -60 mins q 4-6 hrs.
Caution/Warning:
Comments: Contraindications: Type 1 hypersensitivity to Penicillin or Cephalosporins
Drug Interactions:
Monitor:
Side Effects:
Stability: If mixed by pharmacy: 4 days at room temperature, 7 days if refrigerated
Oxytocin
Pitocin
®
TITRATE MED
Uterine contractions
for Labor &
increase tone to
limit postpartum
bleeding
L&D
OR/PACU
UHSC
C.I.: 30 units/ 500 mL (60 milli-
units/mL) start at 2 milli-units/min and
increase by 2 milli-units/min every 30
min per protocol or as ordered by the LIP
until an adequate labor pattern is
established.
Caution/Warning:
Comments : Compatible in D5W, NS, LR.
Drug Interactions:
Monitor: uterine contractions, HR, BP, intrauterine pressure, I/O’s.
Side Effects: Uterine tachystole, hypertonus, fetal bradycardias, n/v,
Stability:
If Extravasation,
see Pages 10&11
Avoid in midline cath see
Page 14 (may be ok w/
short course)
136
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
LOOK ALIKE / SOUND
ALIKE
HIGH ALERT /
DOUBLE CHECK
[uterine stimulant]
Change in concentration
and administration for
PPH prevention
anticipated start date
12/10/2018
Postpartum third
stage management
L&D
OR/PACU
UHSC
UT1-ICU
UT2-IU
C.I.: 30 units/500 mL (60 milli-
units/mL)
Adminsiter 10 units over 10 minutes
(999 mL/hr for 10 minutes) via a bolus
from infusion bag, followed by 20 units
over 4 hours (83.33 mL/hr for 4 hours)
Palonosetron
Aloxi
®
[5HT3 antagonist]
Antiemetic for
Chemotherapy
ALL
UNITS
(Except
Psy)
IV Push: < 0.25 mg undiluted given
over 30 sec, flush with 5 mL NS.
Caution/Warning:
Comments:
Drug Interactions:
Monitor:
Side Effects:
Stability:
BOLUS OFF BAG:
ability to bolus from
continuous infusion bag
via Alaris Pump
Guardrails for
Prevention of
Hemorrhage in Third
Stage of Labor for
Vaginal Birth
137
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Pamidronate
Aredia
®
[inpatient IV
Biphosphonate]
Hypercalcemia
associated with
malignancy, MM,
Paget’s disease
ALL
UNITS
(Except
Psy)
I.I.: 30, 60 or 90 mg in 500-1000 mL
D5W or NS or 0.45% over 2-4 hrs
Caution/Warning:
Comments: Formulary Inpatient IV Biphosphonate. Minimum 7 days between doses.
Zoledronic acid (Zometa-
®
) for outpatient. Hydration is recommended.
Drug Interactions
Monitor: Ca++. P, Mg, BUN, Cr, phlebitis, hypersensitivity rxn’s, malaise, GI-n/v,
bone pain.
Side Effects: Vein irritation, hypersensitivity reactions, CNS- malaise, fever,
N/anorexia, bone pain
Stability:
Pancuronium
Pavulon
®
[neuromuscular blocking
agent]
Paralytic for
intubation
MD/LIP in
ED
UT1-ICU
OR/PACU
IV Push: 0.04 – 0.1mg/kg undiluted
over 1-2 mins with additional doses at 60
min intervals.
Caution/Warning:
Comments: Pt MUST be on a ventilator. Must be sedation before use. Consider
analgesia. Reduce dose in renal impairment & w elderly.
Contra: with steroids due to high risk for prolonged neuro-muscular blockade.
Drug Interactions:
Monitor: TOF, HR, BP, Pulse Ox.
Related Policies:
• Neuromuscular Blocking Agents (NMBA): IV Administration
Side Effects: Tachycardia
Stability:
Pantoprazole
Protonix
®
[Proton Pump Inhibitor]
Stress ulcer
Prophylaxis, GERD,
PUD
ALL
UNITS
IV Push: 20-40mg dilute with 10 mL NS
administered over 2-3 min, flush with 5
mL NS.
80 mg dilute with 20mL NS
administered over 2-3 min, flush with 5
mL NS
I.I. (non-preferred method of
adminstration): doses > 40 mg in 100
mL NS over 10-15 mins
Caution/Warning: IV Push too fast can result in infiltration or systemic reaction such
as headache, flushing, tightness in chest. All IV Push have Phlebitis Risk. Flush slowly
after medication administration
Comments: H2 antagonists (famotidine) should be considered for Stress Ulcer
Prophylaxis unless the patient has an active upper GI bleed or a history of GI bleeding.
Drug Interactions:
Monitor:
Side Effects:
Stability: May store at room temperature. Infusion 80 mg/ 250 mL NS is stable for 2
days at room temperature, 14 days refrigerated.
Avoid in midline cath see
Page 14 (may be ok w/
short course)
138
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Pantoprazole
Protonix
®
[Proton Pump Inhibitor]
Upper GI Bleed
(UGIB)
ALL
UNITS
(except
Psy)
LD (UGIB) IV Push: 80 mg dilute with
20mL NS administered over 2-3 min,
flush with 5 mL NS
LD (UGIB) (non-preferred method of
administration): 80 mg in 100 mL NS
over 15-20 minutes then
C.I. (UBIG): 80 mg in 250 mL NS at 8
mg/hr (25 mL/hr) for 24- 48 hrs with
switch to IV Intermittent or oral 40- 80
mg po bid
Pegloticase
Krystexxa
®
[anti-gout]
Tophaceous Gout
refractory to
standard agents
OP-INFC
I.I.: 8 mg (2mL) in 250 mL NS, infuse
over a minimum of 2 hrs
Caution/Warning:
Comments: Requires pretreatment with corticosteroid ( methylPREDNISolone) &
antihistamine ( diphenhydrAMINE).
Drug Interactions:
Monitor: Signs and symptoms of anaphylaxis or delayed infusion reactions can be seen
during or after the infusion. For infusion reactions slow or stop the infusion and restart at
a slower rate.
Side Effects
Stability: after dilution is stable for 4 hrs at room temperature or refrigerated
Penicillin K+
[antibiotic]
Minibag Plus bag for 5
MU (Other doses may
require evaluation if D5W
shortage)
ADS MIXTURE
Bacterial Infection
ALL
UNITS
(Except
Psy)
I.I.: 1, 2, 4 million units / 50 mL D5W
(NS – see stability info) over 30-60 mins
3 million units pre-mix given q 4 to 6 hrs
in 50 mL D5W over 30-60 mins
5 million units/100 mL NS (minibag
plus) over 30-60 minutes
Caution/Warning: Penicillin or Severe Type 1 Hypersensitivity/Anaphylaxis to
Cephalosporins. Hyperkalemia with Penicillin K+ doses. Pen K+ has 1.7 mEq K/ 1
million units
Comments: Benzathine PCN & Procaine PCN not IV.
Drug Interactions:
Monitor:
Side Effects:
Stability: Admixed D5W: room temperature= 24 hrs, refrigeration= 7 days
Per Trissel’s (NS)
Pen G K+ 20,000 units/mL in NS stable for 24hrs RT, 4 days Fridge
Pen G K+ 40,000 units/mL in NS stable for 24hrs RT and Fridge
Pen G K+ 100,000 units/mL in NS stable 7 days Fridge, RT stability was 18% loss in 2
days
If Extravasation,
see Pages 10&11
139
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Pencillin Na+
[antibiotic]
Minibag Plus bag for 5
MU (Other doses may
require evaluation if D5W
shortage)
ADS MIXTURE
Bacterial Infection
ALL
UNITS
(Except
Psy)
I.I.: 1, 2, 4, 5 million units / 50 mL D5W
over 30-60 mins
5 million units/100 mL NS (minibag
plus) over 30-60 minutes
Caution/Warning: Penicillin or Severe Type 1 Hypersensitivity/Anaphylaxis to
Cephalosporins.
Comments: Benzathine PCN & Procaine PCN not IV.
Drug Interactions:
Monitor:
Side Effects:
Stability: Admixed D5W: room temperature= 24 hrs, refrigeration= 7 days
Per Trissel’s (NS)
Pen G Na+ 50,000 units/mL in NS stable for 28 days Fridge
Pen G Na+ 80,000 units/mL in NS stable for 48 hours Fridge
Pentamidine
[antiprotozoal]
PCP
PCP Prophylaxis
ALL
UNITS
(Except
Psy)
UT-BMT
I.I.: 4mg/kg/daily in 250 mL D5W over
60 mins
I.I: 300mg in 250 mL D5W over 60 mins
Caution/Warning:
Comments: Pharmacy admix. Use Pentam. Dilute to < 6 mg/mL.
Drug Interactions:
Monitor:
Side Effects: Hypotension
Stability: Stable for 24 hrs in refrigerator.
PENTobarbital
Nembutal®
[barbiturate]
Mgt. of inc.
intracranial
pressure, status
epileticus
UT1-ICU
OR/PACU
I.I. (Status Epilepticus): 10-15 mg/kg in
100 mL D5W or NS over 1 hr then
CI: 0.5 mg/kg/hr
Caution/Warning:
Comments: Pt MUST be on a ventilator.Consider continuous EEG monitoring. Taper
gradually to DC.
Drug Interactions:
Monitor: temp, RR, BP, HR, mental status.
If Extravasation,
see Pages 10&11
Avoid in midline cath see
Page 14
140
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
LOOK ALIKE / SOUND
ALIKE
Nov 2017: During shortage
of SVP 50mL/100mL
D5W, use NS
UT1-ICU
I.I. LD: 10-15 mg/kg over 1 -2 hrs then
C.I.: 1-3 mg/kg/hr
PENTobarbital. Coma
Side Effects: hypothermia, hypotension, resp. depression.
Stability:
DEAP: Contact
RPh for Proper
waste disposal
Avoid in midline cath see
Page 14
141
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Peramivir
Rapivab
®
[antiviral agent]
RESTRICTED
ANTIMICROBIAL
NON-FORMULARY
Nov 2017: During shortage
of SVP 50mL/100mL
D5W, use NS
Influenza
ALL
UNITS
(Except
Psy)
I.I.: 600 mg in 100 mL NS or D5W
over 15-30 minutes
Caution/Warning: Dermatologic reactions (eg, erythema multiforme, Stevens-Johnson
syndrome); Hypersensitivity reactions; Neuropsychiatric events
Comments:
Uncomplicated influenza:
-CrCl ≥50 mL/min: No dosage adjustment necessary
-CrCl 30 to 49 mL/min: 200 mg as a single dose
-CrCl 10 to 29 mL/min: 100 mg as a single dose
-ESRD requiring intermittent hemodialysis (IHD): 100 mg as a single dose,
administered after dialysis
Hospitalized patients with influenza:
-CrCl ≥50 mL/min: 600 mg once daily
-CrCl 31 to 49 mL/min: 150 mg once daily
-CrCl 10 to 30 mL/min: 100 mg once daily
-CrCl <10 mL/min (not on renal replacement therapy): 100 mg once daily on day 1,
then 15 mg once daily beginning on day 2
-ESRD requiring intermittent hemodialysis (IHD): 100 mg on day 1, then 100 mg given
2 hours after each dialysis session
Drug interactions: May diminish the therapeutic effect of Influenza Virus Vaccine
(Live/Attenuated)
-Avoid administration of live influenza virus vaccine (LAIV) within 2 weeks before or
48 hours after administration of antiviral agents.
-Consider avoiding LAIV if peramivir was given within the last 5 days or baloxavir was
given within the last 17 days
Monitoring: Baseline BUN and serum creatinine, neurologic abnormalities (eg,
abnormal behavior), rash after administration
Related Policies: Restricted and Concurrently- Monitored Antimicrobials
Side Effects: constipation, nausea, diarrhea, neutropenia, increased serum glucose,
increased LFTs
Stability: Store intact vials in original carton at 20°C to 25°C (68°F to 77°F);
excursions are permitted between 15°C and 30°C (59°F and 86°F). After dilution,
administer immediately or store at 2°C to 8°C (36°F to 46°F) for up to 24 hours.
Discard unused diluted solution after 24 hours.
PERFLUTREN LIPID
MICROSPHERE
Definity
®
[radiological contrast media]
To prolong contrast
enhancement with
ECHO
ECHO
UT1-ICU
UT2-IU
UT3-MED
Withdraw 1.3 mL (1.43 mg) of definity
and dilute with 8.7 mL NS= 10 mL total.
Administer initial IV injection of up to 2
mL over 30-60 secs. May repeat until
optimal image is obtained.
Max dose: 20 mL in one patient study.
Caution/Warning:
Comments: Follow manufacturer directions for preparation and handling.
Dilute entire vial of Definity
®
1.3 mL with 8.7 mL NS = 10 mL.
Drug Interactions:
Monitor:
Side Effects: Hypersensitivity reactions: urticaria, pruritus, dizziness, chest pain,
dyspnea, back pain, Headaches, anaphylaxis.
Stability:
Related Policies:
142
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
PERFLUTREN LIPID
MICROSPHERE
Optison
®
[radiological contrast media]
To prolong contrast
enhancement with
ECHO
ECHO
Initial dose: 0. 5ml flush with NS
Do not exceed 1 ml over 1 sec
May repeat until optimal image is
achieved.
Max dose: 8.7 ml in one patient study.
Do not exceed 5 mL in any 10 min study.
Caution/Warning:
Comments: Follow manufacturer directions for preparation and handling.
Dilute entire vial of Optison
Drug Interactions:
Monitor:
Side Effects:
Hypersensitivity reactions: urticaria, pruritus, dizziness, chest pain, dyspnea, back pain
Headaches, anaphylaxis.
DiphenhydrAMINE 25 mg IV for rash.
For anaphylaxis:
DiphenhydrAMINE 25 mg IV x 1 for rash or anaphylaxis
MethylPREDNISolone 125 mg IV x 1 for anaphylaxis
EPINEPHrine ) 0.3 ml SC x 1 for anaphylaxis
Stability:
PHENobarbitol
[barbiturate]
LOOK ALIKE / SOUND
ALIKE
Status Epilepticus
with repeat dosing
ED
UT1-ICU
UT2-IU
I.I.: Status epilepticus: 10-20 mg/kg in
50 mL NS over 10-15 mins. May repeat
with 5 mg/kg q 15- 30 mins. Max 40
mg/kg/day DNE: 50 mg/min
Caution/Warning: For emergency situations only. Avoid extravasation/alkaline.
Additional respiratory support may be required particularly when maximizing loading
dose or if concurrent sedative therapy. Repeat doses administered sooner than 10 to 15
minutes may not allow adequate time for peak CNS concentrations to be achieved and
may lead to CNS depression.
Comments: Reduce dose in renal/liver failure and the elderly. Therapeutic range: 15-40
mcg/mL.
Drug Interactions:
Monitor: temp, RR, BP, HR, mental status, PHENobarbital level
Side effects: drowsiness, residual sedation, apnea, headache, vertigo, resp. depression,
hypotension, coma.
Stability: Protect from light. Stable for 14 days at room temperature.
Anticonvulsant
ALL
UNITS
(Except
Psy)
I.I.: Status epilepticus: 10-20 mg/kg in
50 mL NS over 10- 15 mins
I.I.: Maintenance dose: 1-3 mg/kg/day in
divided doses in 50 mL NS over 10-15
mins DNE: 50 mg/min
DEAP: Contact
RPh for Proper
waste disposal
If Extravasation,
see Pages 10&11
Avoid in midline cath see
Page 14
143
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Phentolamine
[alpha blocker, antidote]
Prevention and
management of
hypertensive episodes
associated with
pheomchromocytoma
OR/PACU
Preoperative: 5 mg IV as rapid IV
injection 1-2 hours before surgery, repeat if
needed
Intraoperative: 5 mg IV as rapid IV
injection as indicated to prevent or control
paroxysms of hypertension, tachycardia,
respiratory depression, convulsions, or
other effects of epinephrine toxicity
associated with tumor manipulation
Mix: Reconstitute a 5 mg vial with 1 mL
SWFI.
Caution/Warning: contraindications include hypersensitivity to phentolamine, myocardial
infarction, history of myocardial infarction, coronary insufficiency, angina, or other evidence
suggestive of coronary artery disease. Tachycardia and cardia arrhythmias may occur.
Comments:
Drug Interactions: use caution with other alpha adrenergic agents
Monitor: Blood pressure, heart rate, assess for orthostasis
Side Effects: bradycardia, hypo/hypertension, MI, cerebrovascular spasm, nausea, cardiac
arrhythmia, dizziness, flushing
Stability: Reconstituted solution should be used immediately after preparation, however are
stable at room temperature for 48 hours or 1 week if stored between 2-8°C
Phenylephrine
Neosynephrine
®
[sympathomimetic,
vasopressor]
TITRATE MED
Severe hypotension
or Shock
ECT-A
ED
UT1-ICU
OR/PACU
CATH
LAB
(for Cath
Lab under
direct
supervision
of
physician)
C.I.: in NS (preferred) or D5W
Low: 10 mg/250 mL NS [Premix]
(40mcg/mL)
High: 40 mg/250 mL D5W (160
mcg/mL)
Start at 10 mcg/min and titrate by 20
mcg/min q 2 mins to usual desired
increase of SBP to 100-120 or MAP 60-
70. Max :180 mcg/min, unless MD//LIP
orders higher max. dose. Once BP
stabilizes decrease to 40-80 mcg/min.
Titrate Med if ordered as such.
Caution/Warning:
Comments : Patient must be on a cardiac monitor/telemetry. C.I. requires MD/LIP
order for therapeutic goal (ex: BP, HR, MAP, Cardiac Index) or reason. Titrate per
order to goal. Taper discontinuation can be at same dose as upward titration.
Central line is preferred. Extravasation can cause tissue necrosis.
Drug Interactions:
Monitor: RR, EKG, IV site every 1-2 hours for infiltration, BP&HR with each dose
adjustment until desired effect achieved then every 1-2 hours. U/O every 1-2 hours;
hourly if strict I&O.
Side effects: Vasoconstriction, hypertension, reflex bradycardia decreased renal
perfusion, arrhythmias
Stability: Stable when mixed by JDH pharmacy and protected from light at room
temperature for 14 days. Syringe stability when compounded by JDH pharmacy: 14 day
expiration under refrigeration, 2 day expiration if left out of fridge.
Reference for stability: Chemical stability of Phenylephrine HCL after reconstitution in 0.9% sodium
chloride injection for infusion. International Journal of Pharmaceutical Compounding. Vol 8 No 2
March/April 2004.
Premix products not mixed by JDH pharmacy are good for 45 days at room
temperature.
Syringes for OR Area (ePHEDrine
Shortage replacement)/ECT-A:
400mcg/10mL (40mcg/mL) syringes
Phenytoin
Dilantin
®
Anticonvulsant
ED
UT1-ICU
UT2-IU
IV Push: doses <100 mg undiluted over
3-5 mins or at rate of 25 mg/min , no
filter needed if given undiluted.
Caution/Warning:
Comments:
Loading Dose:15-20 mg/kg at a max. rate< 50 mg/min
Maintenance: 5-7 mg/kg/day in 2-3 divided doses.
Load Level: 2-4 hrs post IV load or 24 hrs post PO load
If Extravasation,
see Pages 10&11
If Extravasation,
see Pages 10&11
Avoid in midline cath see
Page 14
144
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
ADS MIXTURE
ALL
UNITS
(Except
Psy)
I.I.: up to 500 mg in 100 mL NS over
30mins with 0. 2 micron filter
> 500 mg in 250 mL NS over 30- 60
mins with 0.2 micron filter
Maintenance Levels: at steady state 10-21 days, 2-4 days post load to estimate of
accumulation or deficiency of fixed maintenance.dose , if suspect sub therapeutic
response (seizures) or toxicity.
Therapeutic Range: 10-20 mg/ml
Dosing; for each μg/mLdesired increase in the phenytoin serum level, increase the
loading dose by 0.75 mg/kg. Do Not Exceed 50 mg/min. Nursing to use 0. 2 micron
filter. NS only. Flush before and after with NS. Incompatible in D5W and with other
meds. Central line is preferred.
To minimize extravasation: dilute med, NS flush before and after med, give slowly,
avoid small hand, wrist or foot veins.
Refer to the UConn hazardous drug safety handling for further information:
Medication
Handling Safety
Drug Interactions:
Monitor: for dose related side effects: drowsiness, confusion, nystagmus, ataxia,
slurred speech, nausea, mental changes, hypotension, resp. depression, coma.
Non-dose related: IV site for extravasation, medication induced Lupus Erythromatosis.
Corrected Phenytoin=Measured Level /(0.2 x albumin)+ 0.1
Consider fosphenytoin for pts with poor venous access.
Side Effects:
Stability: Administration should commence immediately after the mixture has been
prepared and must be completed within 1 to 4 hours.
Phosphate (K
+
or Na
+
)
Phosphorous
replacement
ALL
UNITS
(Except
Psy)
I.I.:
15 mM in 250mL D5W over 3-4 hrs
15mM as Pre mix
30 mM – Follow the 1
st
- 15 mM dose
with a 2
nd
- 15mM over 3-
4 hrs
Caution/Warning:
Comments: Do not infuse via same line as calcium containing solutions.
Each 3 mM of K Phosphate has 4.4 mEq of K
Each 3 mM of Na Phosphate has 4 mEq of Na
Drug Interactions:
Monitor: P, K, Ca, Na
Side Effects:
Stability:
Physostigmine
[cholinergic,
parasympathomimetic]
Reversal agent
for non-depola-
rizing muscle
agents
MD/LIP
only in
UT1-ICU
OR/PACU
UHSC
IV Push: 1
st
dose: 0.5-1 mg up to 20 mg
over > 2-5 min, may repeat q 20 mins
until response or side effects
Caution/Warning:
Comments : Atropine or glycopyrrolate must be at bedside to treat bradycardia
Drug Interactions:
Monitor: EKG, Vitals, bradycardia, AV Block, hypersalivation, inc. salivation,
diaphoresis, N/V, diarrhea, resp. distress, muscle spasms.
Side Effects:
Stability:
BKC: Dispose in
Black Bin
Avoid in midline cath see
Page 14
145
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Phytonadione
[Vitamin K, coagulant]
Bleeding with
elevated INR
ALL
UNITS
(Except
Psy)
I.I.: 1- 10 mg in 50 mL NS or D5W
over 30 Mins
SC: 1-10 mg
Caution/Warning:
Comments: Rapid IV Push or infusions can cause hypotension and or anaphylactoid
reactions. Hypotension is less with I.I. than IV Push. Low doses and slow infusion rates
of vitamin K are recommended to prevent overcorrection which can lead to refractory
states and systemic reactions. IV reserved for situations where other routes not feasible
(oral). IV route is preferred over SC route.
Drug Interactions:
Monitor: BP, INR, bleeding.
Side Effects:
Stability: Stable for 24 hrs in refrigerator. Protect from light.
146
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Piperacillin/
Tazobactam
Zosyn
®
[antibiotic]
ADS MIXTURE
Bacterial Infection
ALL
UNITS
I.I.: 2.25 and 4.5 gm Premix over 30
mins q 6, 8 or 12 hr depending on renal
function.
3.375 gm/ 100 mL NS (Minibag Plus
/ADD-Vantage) over 30 mins q 6, 8 or
12 hr depending on renal function.
Caution/Warning:
Comments: Contraindications: Penicillin allergy & caution with Cephalosporin
allergy.
Reduce dose or interval in renal failure. Do not mix with gentamicin or tobramycin.
1gm has 2.8 mEq Na. MD/LIP to Monitor Cr, CBC
Instructions for Use of the ADD-Vantage® System
Click Here For Instructions To Use ADD-Vantage
To Open Diluent Container:
Peel overwrap from the corner and remove container. Some opacity of the plastic
due to moisture absorption during the sterilization process may be observed.
This is normal and does not affect the solution quality or safety. The opacity will
diminish gradually.
To Assemble Vial and Flexible Diluent Container (Use Aseptic Technique):
1. Remove the protective covers from the top of the vial and the vial port on the
diluent container as follows:
A. To remove the breakaway vial cap, swing the pull ring over the top of the
vial and pull down far enough to start the opening (SEE FIGURE 1.), then
pull straight up to remove the cap. (SEE FIGURE 2.) NOTE: Do not access
vial with syringe.
B. To remove the vial port cover, grasp the tab on the pull ring, pull up to break
the three tie strings, then pull back to remove the cover. (SEE FIGURE 3.)
2. Screw the vial into the vial port until it will go no further. THE VIAL MUST BE
SCREWED IN TIGHTLY TO ASSURE A SEAL. This occurs approximately 1/2 turn
(180°) after the first audible click. (SEE FIGURE 4.) The clicking sound does
not assure a seal; the vial must be turned as far as it will go. NOTE: Once vial
is seated, do not attempt to remove. (SEE FIGURE 4.)
3. Recheck the vial to assure that it is tight by trying to turn it further in the direction
of assembly.
Drug Interactions:
Monitor:
Side Effects:
147
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Stability: Stable for 24 hrs at room temperature or 7 days in refrigerator
Plazomicin
Zemdri®
[aminoglycoside antibiotic]
RESTRICTED
ANTIMICROBIAL
NON-FORMULARY
Bacterial Infections
Patient with a
complicated UTI
caused by a highly
multidrug-resistant
gram negative
bacteria for which
no other formulary /
restricted non-
formulary treatment
options exist
ALL
UNITS
(Except
Psy)
I.I.: Infuse over 30 minutes.
For patients with TBW greater than ideal
body weight (IBW) by ≥25%, use 40%
adjusted body weight (ABW) for dosing.
IV: Dilute in NS or LR to total volume of
50 mL (maximum concentration: 45
mg/mL)._
Caution/Warning:
Boxed warnings: Nephrotoxicity; ototoxicity; neuromuscular blockade; fetal harm
May result in fungal or bacterial superinfection (e.g. Clostridium difficile);
hypersensitivity reaction
Comments: CrCl ≥60 mL/minute: No dosage adjustment necessary.
CrCl 30 to <60 mL/minute: 10 mg/kg every 24 hours
CrCl 15 to <30 mL/minute: 10 mg/kg every 48 hours
Drug interactions: Cisplatin may enhance the nephrotoxic and neurotoxic effect of
Aminoglycosides; Foscarnet, mannitol, and vancomycin may enhance the nephrotoxic
effect of Aminoglycosides
Monitoring:
For patients with CrCl ≥15 mL/minute to <90 mL/minute, measure plasma trough
concentration within 30 minutes prior to second dose. If trough concentration is ≥3
mcg/mL, extend dosing interval by 1.5 fold (ie, from every 24 hours to 36 hours or from
every 48 hours to 72 hours).
Urinalysis, urine output, BUN, Scr (prior to initiation of therapy and daily during
therapy), plasma plazomicin trough (for patients with CrCl <90 mL/min); symptoms of
ototoxicity or neuromuscular blockade
Related Policies: Restricted and Concurrently- Monitored Antimicrobials
Side Effects: nephrotoxicity; ototoxicity; diarrhea
Stability: Store intact vials refrigerated at 2°C to 8°C (36°F to 46°F). IV infusion
solutions mixed in NS or LR at concentrations of 2.5 to 45 mg/mL are stable for 24
hours at room temperature or ≤7 days refrigerated.
148
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Posaconazole
Noxafil®
[azole antifungal]
RESTRICTED
ANTIMICROBIAL
NON-FORMULARY
Fungal Infections
Documented or
suspected infection
caused by
Aspergillus spp. or
another
voriconazole-
susceptible mold in
a patient who (1)
cannot receive
voriconazole,
Documented or
suspected infection
caused by a mold
where posaconazole
is
expected/documente
d to have “best”
activity
Patient receiving
medication prior to
admission to UConn
Health John
Dempsey Hospital
ALL
UNITS
(Except
Psy)
I.I.: Infuse over 90 minutes via a central
venous line.
-Do not administer IV push or bolus.
-Must be infused through an in-line filter
(0.22 micron polyethersulfone [PES] or
polyvinylidene difluoride [PVDF]).
Infusion through a peripheral line should
only be used as a one-time infusion over
30 minutes in a patient who will be
receiving a central venous line for
subsequent doses, or to bridge a period
during which a central venous line is to
be replaced or is in use for another
infusion. May be an irritant. Note: In
clinical trials, multiple peripheral
infusions given through the same vein
resulted in infusion-site reactions.
Caution/Warning:
Hepatic dysfunction has occurred, ranging from mild/moderate increases of ALT, AST,
alkaline phosphatase, total bilirubin, and/or clinical hepatitis to severe reactions;
Arrhythmias: Use caution in patients with an increased risk of arrhythmia (long QT
syndrome, concurrent QTc-prolonging drugs metabolized through CYP3A4,
hypokalemia); Electrolyte abnormalities
Comments: Do not use injection in patients with eGFR <50 mL/minute/1.73 m2, unless
risk/benefit has been assessed.
Drug interactions: Posaconazole is a strong CYP3A4 and P-gP/ABCB1 inhibitor and
may increase serum concentrations of their substrates; alcohol may increase the
concentration of posaconazole
Monitoring: Obtain LFTs, renal function tests (especially patients on IV therapy if
eGFR <50 mL/minute/1.73 m2), electrolytes, and CBC at baseline and occasionally
during ongoing therapy. Correct electrolyte abnormalities prior to initiating therapy.
Obtain ECG (patients with concomitant medications or conditions that prolong the QT);
Monitor IV site for thrombophlebitis.
Related Policies: Restricted and Concurrently- Monitored Antimicrobials
Side Effects: thrombophlebitis; pruritus; rash; electrolyte abnormalities; increased
LFTs; headache; cough; fever
Stability: Store intact vials at 2°C to 8°C (36°F to 46°F). Diluted solution for infusion
may be stored for ≤24 hours at 2°C to 8°C (36°F to 46°F).
Potassium Chloride
[electrolyte replacement]
If on shortage, here is
guidance on alternatives:
Click Here for Info
Hypokalemia
ALL
UNITS
(Except
Psy)
I.I. (Peripheral Line): 10 mEq/100mL
over 1 hour to minimize site Burning/
Phlebitis.
These guidelines are the usual recommended doses and times of infusion for Potassium
but they are not definitive in all clinical situations.
Caution/Warning: Do NOT administer undiluted or I.V. push; inappropriate parenteral
administration may be fatal. Always administer potassium further diluted; refer to
appropriate dilution and administration rate recommendations.
Close monitoring of serum potassium concentrations is needed to avoid hyperkalemia.
Comments:
Low magnesium needs correction with hypokalemia for proper K+ correction.
Recheck K+ level 1- 4 hrs after treatment.
Pain & venous irritation can be minimized by administering IVPB K+ with a running
IVF’s. 10mEq of Potassium Chloride should raise serum K+ by ~0.1mEq/L (Reference:
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/485434
). Below is a
simplified formula to calculate potassium deficit:
Goal K – Serum K x 100 = Total mEq KCL
SrCr
HT1-ICU
I.I. (Peripheral Line): Max: 20
mEq/100 mL over 1 hour IVPB with
continuous IVF’s infusing is
recommended.
ALL
UNITS
(Except
Psy)
C.I. (Peripheral Line): Max: 40 mEq /
Liter. Reassess need for replacement
see Pages 10&11
If Extravasation,
≥40 mEq: Avoid in
midline cath see Page 14
(may be ok w/ short
course)
149
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
ALL
UNITS
(Except
Psy)
I.I (Central Line): 10- 20 mEq/100mL
over 1 hr.
I.I. (Central Line, Rapid response or
code or life threatening arrhythmias
with hypokalemia):
Max. Rate: 20 mEq /100 mL over 0.5 hr
Cardiac monitor/telemetry required with
rates > (greater than) 20 mEq/hr.
C.I. (Central Line): Max: 80 mEq/ Liter
Cardiac monitor/telemetry required with rates > (greater than) 20 mEq/hr.
Monitor:
Hypokalemia: Report signs: ileus, muscle weakness, hypoactive DTR’s, prolonged QT
or prominent U wave.
Hyperkalemia: Report signs: numbness, tingling, flaccid paralysis, AV block, QRS
widening > 25% of baseline.
Side Effects: rash, hyperkalemia
Stability: Store at room temperature; do not freeze. Use only clear solutions. Use
admixtures within 24 hours.
Potassium Phosphate
[electrolyte replacement]
Hypophosphatemia
ALL
UNITS
(Except
Psy)
I.I.:
15 mM in 250mL NS or D5W over 3. 3 -
6 hrs
For 30 mM – Follow the 1
st
15 mM dose
with a 2
ND
15mM over 3 . 3 -
6 hrs
Caution/Warning:
Comments : Pharmacy mixes but also available as pre-mix as 15 mM in 250 mL NS.
For 30 mM doses use two of the 15 mM premix doses.
Do not infuse via same line as calcium containing solutions. DNE: 7 mmol/hr
Each 3 mM of K Phosphate has 4.4 mEq of K
Drug Interactions:
Monitor:
Side Effects:
Stability:
Procainamide
[antiarrhythmic]
Advanced cardiac
life support -
Ventricular
arrhythmia
Ventricular
arrhythmia, Life-
threatening
ED
UT1-ICU
UT2-IU
Slow IV Push (Load): 1000 mg/250mL
NS at 100 mg over 2-3 mins q 5 mins
until rhythm is controlled or
hypotension, QRS is prolonged > 50% or
a total of 15- 18 mg/kg total dose is
given then
C.I. : 2000 mg/500 mL NS (4mg/mL) at
maintenance of 1- 6 mg/min with
maximum of 9 grams/ 24 hrs. Wait 5 to
10 minutes after bolus before starting
C.I.
Caution/Warning:
Comments : Stable for 24 hrs @ R.T. 12 lead Cardiac monitor/telemetry required.
In cardiac or renal dysfunction, reduce LD to 12 mg/kg and CI to 1-2 mg/min.
Drug Interactions:
Monitor: Proarrhthymic esp. in AMI, hypokalemia or hypomagnesemia, Can cause
AV block, rarely V. Fib. Monitor BP, HR & EKG interval every 5-10 minutes during
bolus then BP, HR & EKG interval every 2-4 hours. Monitor rhythm and BP while
tapering and after discontinuation.
MD/LIP to Monitor: Procainamide ( 4-10) and NAPA (10-30-active metabolite) levels.
Side Effects: GI distress, CNS disturbances, seizures
Stability:
CCL/EP
C.I.: 10mg/kg in 100mL NS over 30 min
Reference:
http://circ.ahajournals.org/content/106/19
/2514.full
see Pages 10&11
If Extravasation,
BOLUS OFF BAG:
Upon new EMR April
2018, ability to bolus
from continuous
infusion bag via Alaris
Pump Guardrails.
150
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Prochlorperazine
Compazine
®
[antiemetic, phenothiazine]
Phenothiazine Anti-
emetic
ALL
UNITS
(Except
Psy)
IV Push: No
I.I.: doses up to 10mg in 50 mL NS over
15-30 mins
Caution/Warning: Caution with seizures.
Comments: Not recommended for IV use due to High risk for resp. depression,
hypotension, sedation, EPS.
Drug Interactions:
Monitor:
Side Effects:
Stability:
Promethazine
Phenergan
®
[antihistamine,
phenothiazine]
Anti-emetic
ALL
UNITS
(Except
Psy)
IV Push: No
I.I.: 12.5 – 25 mg in 50mL of D5W or
NS given over 15-30min
6.25-12.5 mg in 50 mL D5W or NS
given over 15-30min (elderly dose)
Caution/Warning:
Comments: IM or PO preferred. High Risk for extravasation and tissue damage.
Use lowest dose possible to minimize adverse CNS side effects.
• Administer through large-bore vein only, no hand, wrist or foot vein. Central vein
preferred.
• Assure patent venous access and administer into tubing of a running IV due to
high risk of extravasation tissue damage. Discontinue at once if extravasation
occurs.
• Check patency of access site.
• Educate patient to inform a health care professional if they experience pain or
burning during or after injection
• No IV Push due to high risk for respiratorydepression, delirium, hypotension,
sedation, EPS, & extravasation. Use IVPB, PO or IM.
For adverse EPS: DiphenhydrAMINE 12.5- 25mg IVP or Benztropine 0.5-1mg IM
Drug Interactions:
Monitor:
Side Effects:
Stability:
If Extravasation,
see Pages 10&11
Avoid in midline cath see
Page 14
151
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Propofol
[sedative, anesthetic]
HIGH ALERT / DOUBLE
CHECK
TITRATE MED
Sedation of
Intubated patients
ECT-A
ED
UT1-ICU
OR/PACU
in presence
of MD/LIP
for
intubation
IV Push: 10-20 mg over 3-5 mins
Use in an emergency to rapidly increase
depth of sedation (e.g. to gain ventilatory
control) in pts who are hemodynamically
stable and when hypotension is unlikely
to occur.
Caution/Warning: Propofol-related infusion syndrome (PRIS)
Contraindications: Hypersensitivity to propofol or any component of the formulation;
hypersensitivity to eggs, egg products, soybeans, or soy products
Comments: Patient MUST be on a ventilator since causes respiratory depression
(exception: conscious sedation in presence of an anesthesiologist).
Use Sedation Holiday (daily awakening)/Spontaneous Breathing Trial (SBT) as
indicated.
In order to screen for potential vent weaning, propofol should be titrated to achieve a
RASS of 0 (alert/calm).
Daily evaluation of level of sedation/CNS function is necessary to determine the
minimum dose of Propofol required to achieve the desired level of sedation.
Consider concomitant narcotic analgesia.
Intralipid content should be considered as part of nutritional intake.
Follow specific orders for weaning: discontinue infusion 10-15 minutes prior to
extubation (Except in case of hypotension/severe reaction, avoid abrupt
discontinuation).
Replace bottle and tubing q 12hr to decrease fungal contamination using strict aseptic
technique. Chlorhexidine will be used as the prep for any access to the bottle, IV tubing
or access port in which the med is to be infused using strict aseptic technique.
Caution in hypertriglyeridemic pancreatitis
IV Push Emergency Use only & in the presence of the MD/APRN
Monitor: BP, RR, Sedation score every 1-2 hours and more frequently during active
titration. Continuous BP monitoring via arterial line is preferrabl during continuous
infusion. Monitor for hypotension after IV Push doses. Administration site. Triglyceride
level q 2-3 days
Side Effects: hypotension, bradycardia, MI depression, flushing, rash, hyperlipidemia,
phlebitis.
If mild hypotension develops, decrease infusion rate, elevate lower extremeties and
notify provider.
If clinically significant hypotension/cardiovascular depression occurs, administer IV
fluids or vasopressor therapy per orders and discontinue the infusion.
Stability: refrigeration is not required. Do not freeze. If transferred to a syringe or other
container prior to administration, use within 6 hours. If used directly from vial/prefilled
syringe, use within 12 hours. Shake well before use. Do not use if there is evidence of
separation of phases of emulsion.
ED
UT1-ICU
OR/PACU
UHSC
C.I.: 1% (10 mg / mL) Premix
(500mg/50mL D5W or 1000mg/100mL
D5W)
Start at 10 mcg/kg/min, titrate by 10
mcg/kg/min q 5 mins to achieve desired
sedation with RASS 0 to -1 or as
ordered by MD/LIP. Max dose is 50
mcg/kg/min, unless MD/LIP orders
higher max. Titrate Med if ordered as
such.
Protamine
[heparin antagonist]
Reversal of elevated
aPTT from heparin.
ALL
UNITS
(Except
Psy)
I.I.: 10-50 mg in 50 mL NS over 10-15
mins
100 mg in 50 mL over 20-30 mins
Caution/Warning:
Comments: Rapid administration may cause severe hypertension/hypotension and
anaphylactoid reactions. Each mg neutralizes 100 units of heparin infused in last 2 hrs.
obtain PTT 5-15 min after protamine. If 30-60 mins have elapsed before starting
protamine: use 0.5-0.75mg/ 100 units of heparin given in preceding 2 hrs. If > 2 hrs
have elapsed: use 0.25-0.375 mg/100 units. Monitor thrombin time with open heart
patients.
Drug Interactions:
Monitor:
BOLUS OFF BAG:
Upon new EMR April
2018, ability to bolus
from continuous
infusion bag via Alaris
Pump Guardrails.
152
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Regional line
reversal of Heparin
with CVVH
UT1-ICU
UT2-ICU
C.I.: 250mg/ 250 mL NS at rate
prescribed
Side Effects:
Stability: Stable for 24 hrs at room temperature.
153
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Prothrombin Complex
Concentrate
Kcentra
®
[vitamin K antagonist]
Formulary Restricted:
PCC-Kcentra® is approved
for neurosurgery for severe,
life-threatening bleeds such
as pre-op need for
intracranial hemorrhage.
Other major bleeding
situations other require a
HEME/ONC consult for
Kcentra® approval. If
HEME/ONC attending
approves the use of
Kcentra® in the situation
he/she must directly
communicate to pharmacist
the approval, patient name,
situation and dose.
Kcentra® may also be
ordered by an Emergency
Medicine ATTENDING or
Trauma Service
ATTENDING or Critical
Care ATTENDING.
Change in administration
anticipated start date
12/10/2018
urgent reversal of
acquired
coagulation factor
deficiency induced
by vitamin K
antagonist therapy
in adult patients
with acute major
bleeding.
Bleeding in the
setting of direct
acting oral
anticoagulant use
ALL
UNITS
(Except
Psy)
I.I 1500 units once if INR is above 1.4;
repeat INR should be obtained 30
minutes after administration. If INR has
not declined adequalty, an additional
1000 units may be adminsitered.
Currently, JDH Pharmacy stocks
Kcentra® 500 unit product which is
reconstituted with 20mL of Sterile Water
of Injection provided in the box. Doses
should be pooled into a bag. Maximum
infusion rate is 8.4mL/min.
Dosing for bleeding in the setting of
direct acting oral anticoagulant (DOAC)
use is 25 units/kg, rounded to the nearest
500 with a maximum of 2500 units. See
below dosing chart for guidance.
Vitamin K administration not needed in
the setting of DOAC use.
Caution/Warning: Arterial and venous thromboembolic complications. Patients being
treated with Vitamin K antagonists (VKA) therapy have underlying disease states that
predispose them to thromboembolic events. Potential benefits of reversing VKA should
be weighed against the potential risks of thromboembolic events (TE), especially in
patients with the history of a thromboembolic event.
Comments: Administer vitamin K concurrently with Kcentra® to maintain vitamin K-
dependent clotting factors once the effects of Kcentra® have diminished. Single-use
only; do not reuse. Contains no preservatives.
Reconstitute using aseptic technique with
20mL of diluent provided with the kit; reconstituted Kcentra® should be colorless, clear
to slightly opalescent, and free from visible particles. Pharmacy will pool bolus doses in
a bag. Once reconstituted Kcentra® should not be further diluted, i.e. should not be
added to an infusion bag of fluid. Do not mix Kcentra® with other medicinal products.
Kcentra® requires a dedicated line for administration; flush the line prior to
administration. Because concurrent therapy with intravenous vitamin K is required, two
peripheral lines should be placed prior to administration. If placing two lines is not
possible, Kcentra® should be administered first, the line adequately flushed, and
vitamin K administered immediately afterward. After the infusion of Kcentra® is
complete, remove the empty bag and hang a 50mL NS bag using the same tubing. Run
at the same rate as the Kcentra® infusion up to a maximum rate of 8.4 mL/min
(~500mL/hr).
Kcentra Reconstitution Video
Drug Interactions:
Monitor: INR (baseline and at 30 minutes post dose); clinical response during and after
treatment
Side Effects: hypotension/hypertension, tachycardia, n/v, arthralgia, headache,
thromboembolic disorder, pulmonary embolism, hypersensitivity reaction,
hypervolemia, mental status changes
Stability: Do not freeze. Do not further dilute. Store at 2°C to 25°C (35°F to 77°F).
Protect from light. Reconstituted product may be stored at 2°C to 25°C (35°F to 77°F)
and used within 4 hours following reconstitution. If cooled, warm to 20°C to 25°C
(68°F to 77°F) prior to administration. A stability and compatibility study showed
activity levels of Kcentra® were unaffected when mixed with LR or NS through a y-
site infusion line set-up. Stability of Kcentra® was not influenced following storage in
an infusion bag (IntraVia container, Baxter) for up to 24 hours.
Herzog E, Niebl P, Beyerle A, Treutlein M, Albers M, Omert L, Hood C. Stability of 4F-PCC after co-administration with
crystalloid solutions [poster]. Presented at: American College of Clinical Pharmacy Annual Meeting; Phoenix, AZ. October
7-10, 2017.
Kcentra Manufacturer Website
Kcentra® Hotline 1-855-452-3687
154
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Pyridoxine
[vitamin B6]
Vit B6 dependency
or deficiency states,
Vomiting
In pregnancy
ALL
UNITS
(Except
Psy)
I.I.: 25-100 mg in 50 mL D5W or NS
over 10-15 mins
Caution/Warning:
Comments: Pyridoxine dependency syndrome 10 to 250 mg daily. Vitamin B6
deficiency; 25 mg/day for 3 weeks, followed by maintenance therapy with 1.5 to 5
mg/day in a multivitamin preparation.
Drug Interactions:
Monitor:
Side Effects:
Stability:
Rasburicase
Elitek®
[Urate oxidase]
Hyperuricemia
associated
With Tumor Lysis
Syndrome (TLS)
UT1-ICU
UT2
ONC
MS-5
OP-NCCC
I.I.: 3 or 6mg/50ml NS over 30 mins.
Protect from light
Caution/Warning: Contraindicated in patients with G6PD-deficiency. May cause
severe hypersensitivity reactions.
Comments: Uric acid blood samples should be drawn in pre-chilled heparinized tubes,
stored in ice water bath and brought to the lab immediately to prevent uric acid from
degrading.
Drug Interactions:
Monitor: Uric acid levels, K+, Ca+, Phospherous
Side Effects: Anaphylaxis (<1%), Hemolysis (<1%), and Methemoglobinemia (<1%)
Stability: Stable for 24 hours at room temperature
Regadenoson
Lexiscan
®
[diagnostic agent]
Non-exercise stress
testing
CCL
IV Push: 15 sec IV
Caution/Warning:
Comments:
Drug Interactions:
Monitor:
Side Effects:
Stability:
Remdesivir
Remdesivir
®
RESTRICTED
ANTIMICROBIAL
[Antiviral]
Coronavirus disease
2019 (COVID-19),
severe
ALL
UNITS(Exc
ept Psy)
I.I. LD: 200 mg in 250 mL NS over 30-
120 minutes
Maintenance dose:
100 mg in 250 mL NS over 30-120 mins
x 9 days if mechanically ventilated OR x
4 days if not mechanically ventilated
Caution/Warning: Inspect product visually for particulate matter and discoloration
prior to administration.
Comments: Do not administered simultaneously with any other medication or IV
solution other than NS; After infusion is complete, flush with at least 30 mL of NS
Drug Interactions: unknown
Monitor: LFTs, CBC, renal function and serum chemistries; signs and symptoms of
infusion reaction
Side Effects: infusion related reactions, transaminase elevations,
Stability: prepared diluted solution is stable for 4 hours at room temperature or 24
hours in the refrigerator
Remifentanil
Ultiva®
[Analgesic, Opioid]
Anethesia
ECT-A
OR/PACU
Caution/Warning:
Comments:
Drug Interactions:
Monitor:
Side Effects:
Stability:
SPLP/SPC: Place
Packaging & Waste
in Zip-Lock and
return to pharmacy
155
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Reslizumab
Cinqair®
[Interleukin-5 receptor
antagonist; monoclonal
antibody]
Add-on
maintenance
treatment of severe
asthma in adults
with an eosinophilic
phenotype
OP-INFC
I.I.: 3 mg/kg in 50 mL NS over 20-50
mins
Administer with 0.22 micron filter only.
Caution/Warning: anaphylaxis, malignancies; not for the treatment of acute asthma
symptoms or status asthmaticus; helminth infections in patients who are at risk.
Comments: Administer with a 0.2 micron in-line filter; do not administer other
medications through the same line concomitantly
Drug Interactions:
Monitor: anaphylaxis/hypersensitivity reactions during and after infusion; peak flow,
and/or other pulmonary function tests; signs of infections
Side Effects:
Stability: Store intact vials in the refrigerator, protect from light in original package. Do
not freeze or shake. Administer immediately after reconstitution. Reconstituted product
may be stored in the fridge or at room temperature for up to 16 hours.
RifAMPin
Rifadin
®
[antibiotic]
Bacterial Infection
ALL
UNITS
(Except
Psy)
I.I.: Doses up to 600 mg in 500 mL NS
over 3 hrs
Caution/Warning:
Comments: Pharmacy admix. Dilute to max. of 6mg/ml & administer within 24 hrs of
preparation. Avoid extravasation. Central line is preferred. Adjust for renal
dysfunction. Can increase metabolism of some meds. Caution may stain clothing.
Causes red-brown colored stool, sweat, body fluids. Remove contacts during use to
avoid permanent staining.
Drug Interactions:
Monitor:
Side Effects:
Stability: As of July 2018, the storage of reconstituted vials was changed from 24 hours
to 30 hours at room temperature, the stability when admixed in D5W was changed from
4 hours to 8 hours, and the stability when admixed in NS from 24 hours to 6 hours
riTUXimab
Rituxan
®
[monoclonal antibody]
LOOK ALIKE / SOUND
ALIKE
Non-Hodgkin’s
lymphoma, Chronic
lymphoid leukemia/
Rheumatoid arthritis
(RA)
ALL
UNITS
(Except
Psy)
I.I.: 375 mg/m
2
IV infusion to a final
concentration of 1 mg/mL NS, start @ 50
mL/hr, if tolerated increase by 50 mL/hr
q 30 mins to max. of 400 mL/hr until
completed.
Caution/Warning:
Comments: Premedication with acetaminophen, DiphenhydrAMINE & corticosteroid
should be considered before each infusion of riTUXimab, as well as withholding of
antihypertensive agents 12 hours prior to riTUXimab administration. Dose for
Rheumatoid Arthritis is 1000mg.
Drug Interactions:
Monitor: CBC, Renal Fx, BP, HR
Side Effects: Infusion related reactions, severe mucocutaneous reactions, hypotension,
neutropenia, N/V, thrombocytopenia. If hypersensitivity or an infusion-related event
develops, the infusion should be temporarily slowed or interrupted.
Stability: Infusion solutions are stable for 24 hrs at refrigerator temps then another 24
hrs at room temperature
156
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Rocuronium
Zemuron
®
[neuromuscular blocker]
TITRATE MED
Skeletal muscle
relaxant for
Mech. ventilation
ECT-A
ED
UT1-ICU
OR/PACU
UHSC
IV Push LD: 0.6- 1 mg/kg undiluted
over 5-10 secs then
C.I.: 500 mg/ 100 mL D5W or NS
(5mg/mL)
5-16 mcg/kg/min. Start @ 5 mcg/kg/min
and Titrate by 1 mcg/kg/min q 10 mins
or as ordered to achieve Train of Four 2-
3 out of 4 or as ordered.
Max: 16 mcg/kg/min unless higher max.
is ordered by MD/LIP
Caution/Warning:
Comments: Use in ICU when other NMB’s (cisatracurium or vecuronium) are not
available. Has rapid onset and intermediate duration of action and low cardiovascular
side effects similar to cisatracurium. Pt MUST be on a ventilator.
CI requires MD/LIP order for therapeutic goal (ex: Train of Four) or reason. Titrate per
order to goal. Stable for 24 hrs at room temperature. Requires an analgesic and
sedative.
Drug Interactions:
Monitor: train of four, RR,BP,HR, apnea, resp. depression.
Related Policies:
• Neuromuscular Blocking Agents (NMBA): IV Administration
Side Effects:
Stability:
Sarilumab
Kevzara®
[Monoclonal antibody]
RESTRICTED
ANTIMICROBIAL
NON-FORMULARY
COVID-19
Infections
Treatment of severe
COVID-19 infection
in patient on either
“high-flow” oxygen
therapy or
mechanical
ventilation when
tocilizumab is
unavailable
Only requires ID
approval for the
indication of
COVID-19
infection.
ALL
UNITS
(Except
Psy)
I.I.: Using SUBQ formulation, dilute in
100 mL NS and administer over 1 hour
IV: 400 mg once, as part of an
appropriate combination regimen
Caution/Warning:
Boxed warnings: Active TB; invasive fungal infections; opportunistic infections
Hypersensitivity reactions
Comments: CrCl 30 to 90 mL/minute: No dosage adjustment necessary.
CrCl <30 mL/minute: No dosage adjustments provided in the manufacturer's labeling.
Not recommended for use in patients with active hepatic disease or hepatic impairment
Drug interactions: Avoid concomitant use with immunosuppressants and DMARDs;
may reduce the efficacy of some vaccinations; May decrease concentrations of CYP2C9
and 3A4 substrates
Monitoring:
Latent TB screening prior to therapy initiation; neutrophils, platelets, ALT/AST,
signs/symptoms of infection (prior to, during, and after therapy), hypersensitivity
reaction, and GI perforation.
Related Policies: Restricted and Concurrently- Monitored Antimicrobials
Side Effects: Increased LFTs, injection site pruritus
Stability: Store at 2°C to 8°C (36°F to 46°F) in original carton to protect from light. Do
not freeze or shake. May store at ≤25°C (77°F) for ≤14 days. Do not store at >25°C
(77°F). After removal from the refrigerator, use within 14 days or discard.
Scopolamine
[anticholinergic]
Pre-Op Sedation
IRAD
OR/PACU
UHSC
IV Push: 0.3-0.6 mg Over < 1 min
Caution/Warning:
Comments:
Drug Interactions:
Monitor:
Side effects: Tachycardia, hypotension, dizziness, dry mouth
Stability:
157
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Secretin
Chirhostim
®
[endocrine-metabolic agent]
Diagnostic Agent
ALL
UNITS
(Except
Psy)
IV Push: 0.2 – 0.4 mcg/kg 2 mcg/mL 1
min
Caution/Warning:
Comments:
Drug Interactions:
Monitor:
Side Effects:
Stability:
Sincalide
Kinevac
®
[diagnostic agent]
Gall Bladder
ENDO
IV Push: 0.02 mcg/kg ( 1.4 mcg/70 kg)
over 30-60 secs depending on procedure.
If a satisfactory contraction of the
gallbladder does not occur in 15 mins, a
2
nd
dose of 0.04 mcg/kg may be given.
I.I.: To reduce intestinal side effects an
IV infusion of 0.12 mcg/kg in 100 mL
NS may be given at 2 mL/min.
Caution/Warning:
Comments: See specific protocols for each procedure. Contraindications: bowel
obstruction.
Drug Interactions:
Monitor:
Side Effects: abd. Pain, cramps, N, dizziness.
Stability:
Pancreatic Studies
I.I.: For Secretin-Kinevac test of
pancreatic function, a Kinevac dose 0.04
mcg/kg IV over 30 min, starting 30 min
after the initiation of secretin 0.25
units/kg IV over 60 min
Sodium Bicarbonate 8.4%
[systemic alkalinizer]
October 2018: During
shortage
of Sodium
Bicarbonate, use Sodium
Acetate for infusions.
Metabolic Acidosis
In presence
of Critical
Care RN or
Action RN
and LIP
during
RRT/Code,
ALL
UNITS
IVPush (Codes): 0.5- 1mEq /kg Over <
1 min
IV Push (ICU): over <1 min
Caution/Warning:
Comments: Do not piggyback with Calcium solutions.
May cause hypernatremia, hypokalemia, hypocalcemia, met. Alkalosis, CHF, edema.
Drug Interactions:
Monitor: ABG’s & Lytes, urine pH when being used for urinary alkalinization in
patients receiving high dose methotrexate
Side Effects:
Stability: 24 hours at room temperature and 7 days refrigerated
Metabolic Acidosis
ALL
UNITS
(Except
Psy)
C.I.: 50-150 mEq/L D5W , rate
determined by base deficit & MD/LIP
If Extravasation,
see Pages 10&11
158
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Reference: Sodium Acetate
as a Replacement for
Sodium Bicarbonate in
Medical Toxicology: a
Review
Urinary
Alkalinization for
patients receiving
high-dose
methotrexate
UT1, UT6,
MS5
IVPush: 50 mEq given over 1-2 min
Contrast Dye
Induced Renal
Failure Prevention
ALL
UNITS
(Except
Psy)
I.I.: 150 mEq/ 1 Liter D5W @ 150
mL/hr x 1 L
Hyperkalemia
ALL
UNITS
(Except
Psy)
IV Push 50 mEq (50 mL) over 1-2 mins
Treatment of Hyperkalemia: Follow MD orders:
1.Stop K+ infusions and oral therapy and Contact MD/LIP to
Discontinue K+ infusions.
2. Consider Calcium Gluconate IV Push: 10-20 mL of 10% over 2 mins or
1 gm in 50 mL D5W or NS X 1-2 doses over 5-10 mins)
3. Dextrose IV Push ( 50 mL of D50 IV Push) undiluted over 1-2 mins
4. Regular Insulin IV Push ( 10 units)
5. Bicarbonate IVP (50 mEq= 50 mL of 8.4% over 2 mins
6. B2 adrenergics-albuterol nebs (10-20 mg = 12-24 mL nebulized);
7. Loop diuretics
8. Na Polystyrene (15-60 gms)
9. Hemodialysis
Avoid in midline cath see
Page 14
159
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Sodium chloride 3%
To reduce increase
in Intracranial
Pressure (ICP) &
Cerebral edema
UT1-ICU
UT2-IU
(May start
emergently
in patients
on other
units
followed by
immediate
transfer to
approved
unit for
use.)
I.I. LD: 300 mL of 3 % sodium chloride
as a bolus over 15-20 mins then
C.I.: 40-70 mL/hr with goal of serum
sodium 150 to 155 mEq/L (or per MD
order). Maximum rate for peripheral
lines of 75 mL/hr; rates of infusion >
75mL/hr are allowed via central venous
access.
Caution/Warning:
Comments:
-Requires IV Pump.
-Central line preferred. If a central line cannot be obtained a large bore peripheral line
may be used for up to five days with daily site changes and RN assessment of the
peripheral vein for inflammation and phlebitis q shift. Rate of infusion for peripheral
lines should not exceed 75 mL/hr.
-HT1-ICU Only: for patients without central access who require higher rates of
infusion, a second peripheral line may be placed at a rate not to exceed 75 mL/hr for up
to 12 hours. Central access must then be obtained for further administration.
-Na level >160 mEq/L evaluate risk versus benefit
-Blood for testing should NOT be drawn via the central line through which the 3%
sodium chloride is infusing.
-Send labs as Stat
-Consider free water restriction
-Consult Neurology for assistance
Drug Interactions:
Monitor:
-Signs & symptoms of hemolysis, pulmonary edema.
-ICP and/or clinical response with neurological status exam q 1-2 hours
-Na, K, CL, Glucose, osmolarity
-Serum sodium, chloride, osmolality to be checked one hour after bolus than every 4
hours for 24 hours
-Natriuresis/Diuresis: input/output q 1 hour and daily weight
-V/S: BP (hypotension) , HR, RR, O2 Sat q 1 hour
Side Effects: hypernatremia, hyperchloremic acidosis, fluid overload and electrolyte
abnormalities, “rebound” cerebral edema, central pontine myelinolysis
Stability:
Information on Sodium chloride 3% continues on the next page.
If Extravasation,
see Pages 10&11
Avoid in midline cath see
Page 14
160
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Sodium chloride 3%
Severe Symptomatic
Hyponatremia
Serum Na+ < 120
UT1-ICU
UT2-IU
(May start
emergently
in patients
on other
units
followed by
immediate
transfer to
approved
unit for
use.)
Therapy should be guided by frequent
monitoring of plasma sodium
concentration.
Severe hyponatremia is defined as a
plasma concentration below 120mEq/L.
In the absence of urinary loss of water,
1ml of 3% saline per kg of body weight
will increase the plasma sodium
concentration approximately 1mEq/L.
Acute hyponatremia (duration less than 2
days) should be corrected over hours.
Avoid increasing plasma sodium
concentration by greater than 10mEq/L
per day:
-100ml bolus of 3% saline q 10 min
times three as needed for severe
symptoms
-goal to increase plasma sodium
concentration by 4-6 mEq/L in first 6
hours.
Chronic hyponatremia (unknown
duration or greater or equal to 2 days)
should be corrected over days. Avoid
increasing plasma sodium concentration
by greater than 8mEq/L per day:
-slow infusion (determine rate based on
body weight and 24 hour sodium goal)
-may need 100ml bolus of 3% saline for
seizures
-goal to increase sodium concentration
by 4-6 mEq/L in first 24 hours
See prior page for comments on Sodium chloride 3%.
Caution/Warning:
-Use caution with patients with congestive heart failure, renal insufficiency, and sodium
retention disorders.
-The administration of 3% sodium chloride injection in hyponatremia has been
associated with vein damage, pulmonary edema, CNS complications and volume
overload.
Comments:
-Serum Sodium increase > 0.5 mEq/L/hr - Notify MD/LIP.
-Rapid correction (increase in Na+ greater than 10mEq/L in 24 hrs) is associated with
osmotic demyelination syndrome with neurologic events including flaccid paralysis,
dysphagia, palsy, lethargy, coma and seizures. Stop infusion immediately and contact
MD/LIP immediately if any of these are observed.
-Orders must specify specific volume to be infused over a specific number of hours or a
rate as mL/hr for a specific number of hours.
-3% NaCl has 513 mEq/L NaCl & 1027 mOsmol/L
-2 mL of 3% NaCl = 1 mEq Na
Monitor:
-Signs & symptoms of hemolysis, pulmonary edema.
-Neurological status exam q 1-2 hours
-Na, K, CL, Glucose, osmolarity
-Serum sodium, chloride, osmolality to be checked after bolus doses and every 2-4
hours with infusions
-Natriuresis/Diuresis: input/output q 1 hour and daily weight
-V/S: BP (hypotension) , HR, RR, O2 Sat q 2-4 hours
Side Effects: hypernatremia, hyperchloremic acidosis, fluid overload and electrolyte
abnormalities.
Reference: Sterns R H. Disorders of Plasma Sodium – Causes, Consequences, and
Correction. N Engl J Med 2015;372;55-65.
If Extravasation,
see Pages 10&11
Avoid in midline cath see
Page 14
161
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Sodium Chloride 23.4%
[concentrated electrolyte]
HIGH ALERT / DOUBLE
CHECK
Increased
Intracranial pressure
ED
UT1-ICU
OR
(LIP Admin
Only)
I.I.: 30 mL given over 2-20 minutes
Caution/Warning: Monitor serum sodium to avoid sodium toxicity, vesicant
Comments: Administered via central line by a LIP only
Side Effects: If extravasation occurs, stop infusion immediately and disconnect (leave
cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line);
initiate hyaluronidase antidote (if indicated); remove needle/cannula; elevate extremity.
Apply dry cold compresses
Stability: Store at room temperature. Use only clear solutions.
Sodium Phosphate
[electrolyte replacement]
Hypophosphatemia
ALL
UNITS
(Except
Psy)
I.I.: 15 mM in 250mL D5W Premix over
3. 3 - 4 hrs
For 30 mM – Follow the 1
st
15 mM dose
with a 2
ND
15mM over 3. 3 -
6 hrs
Caution/Warning:
Comments: Do not infuse via same line as calcium containing solutions. Do not
exceed 7 mmol/hr. Each 3 mM of Na Phosphate has 4 mEq of Na
Drug Interactions:
Monitor:
Side Effects:
Stability:
Sodium Thiosulfate
[antidote, Calciphylaxis (off-
label use)]
Calciphylaxis (off-
label use)
ALL
UNITS
(Except
Psy)
I.I.: 25 g in 200 mL NS over 60 min
(confirmed preparation with Fresenius
Medical Care as to dilute 100mL of the
drug in an additional 100mL of NS)
Caution/Warning:
Comments:
Drug Interactions:
Monitor:
Side Effects:
Stability: 24 hours (Reference: Physico-Chemical Stability of Sodium Thiosulfate
Infusion Solutions in Polyolefin Bags at Room Temperature over a Period of 24 Hours)
References:
Unexpectedly Severe Metabolic Acidosis Associated with Sodium Thiosulfate Therapy
in a Patient with Calcific Uremic Arteriolopathy
Sodium Thiosulfate Therapy for Calcific Uremic Arteriolopathy
Avoid in midline cath see
Page 14
162
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Sotrovimab
VIR-7831
[Biologic, Monoclonal
Antibody]
RESTRICTED
ANTIVIRAL
FDA issued
Emergency Use
Authorization
(EUA): Mild-to-
moderate COVID-
19 in adults and
pediatric patients
with positive results
of direct SARS-
COV-2 viral testing,
and who are at high
risk for progression
to severe COVID-
19, including
hospitalization or
death.
ALL
UNITS
(Except
Psy)
I.I.: 500mg in 108mL NS over 30 min
through an intravenous line containing a
sterile 0.2 micron polyethersulfone (PES)
filter.
Do not administer simultaneously with
any other medication. The compatibility
of sotrovimab with IV solutions and
medications other than 0.9% Sodium
Chloride Injection is not known. Once
infusion is complete, flush the tubing
with 0.9% Sodium Chloride.
Clinically monitor patients during
infusion and observe patients for at least
1 hour after infusion is complete.
Caution/Warning:
There is a potential for serious hypersensitivity reactions, including anaphylaxis, with
administration of sotrovimab. If signs and symptoms of a clinically significant
hypersensitivity reaction or anaphylaxis occur, immediately discontinue administration
and initiate appropriate medications and/or supportive care. In addition, infusion-related
reactions have been observed with administration.
Drug Interactions:
Clinical drug-drug interaction studies have not been performed with sotrovimab.
Sotrovimab is not renally excreted or metabolized by cytochrome P450 (CYP) enzymes;
therefore, interactions with concomitant medications that are renally excreted or that are
substrates, inducers, or inhibitors of CYP enzymes are unlikely.
Monitor:
Clinically monitor patients during infusion and observe patients for at least 1 hour after
infusion is complete.
Side Effects:
The most common treatment-emergent adverse events observed in the sotrovimab
treatment group in COMET-ICE were rash (2%) and diarrhea (1%), all of which were
Grade 1 (mild) or Grade 2 (moderate). No other treatment-emergent adverse events
were reported at a higher rate with sotrovimab compared to placebo.
Stability:
Refrigerate unopened Sotrovimab vials at 2°C to 8°C (36°F to 46°F) in the original
carton. Do not freeze, shake, or expose to direct light.
SUFentanil
[opioid analgesic]
Pain control
OR/PACU
C.I. 250 mcg in 25 mL NS at 0.2 – 1
mcg/kg/hr
Caution/Warning:
Comments:
Drug Interactions:
Monitor:
Side Effects:
Stability:
163
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Succinylcholine
[neuromuscular blocker]
Skeletal muscle
relaxant for
intubation
In presence
of Critical
Care RN or
Action RN
and
LIP/CRNA
for
emergency
intubation,
ALL
UNITS
IV Push by MD/CRNA:
0.5-1 mg/kg undiluted over 15-30 secs
Caution/Warning:
Comments: In presence of MD/CRNA for intubation only. Atropine pretreatment may
be needed to treat bradycardia. Do not administer with hyperkalemia. Consider
analgesia and sedation before use. Quick onset, short duration.
Drug Interactions:
Monitor:
Related Policies:
• Neuromuscular Blocking Agents (NMBA): IV Administration
Side Effects: Hypotension, flushing, hyperkalemia, bradycardia, Consider sedation and
analgesia before use.
Stability: Vials stored in intubation kit are good for 8 months at room temperature per
reference: Adnet et al. “Stability of succinylcholine solutions stored at room
temperature studied by nuclear magnetic resonance spectroscopy”
Emerg Med J
2007;24:3 168-169 doi:10.1136/emj.2006.041053
Sugammadex
Bridion
®
[binding agent for
steroidal
neuromuscular blockers
]
Reversal agent
for depolarizing
muscle relaxants
vecuronium and
rocuronium
ECT-A
UT1-ICU
OR/PACU
UHSC
IV Push:
(dose based on actual body weight)
Administer bolus over 10 seconds.
Rocuronium and vecuronium reversal:
-4 mg/kg, if spontaneous recovery of
twitch response reaches 1-2 post-tetanic
counts and there are no twitch responses
to train-of-four stimulation.
-2 mg/kg, if spontaneous recovery of the
twitch response has reached the
reappearance of the second twitch in
response to train-of-four stimulation.
Only rocuronium:
-16mg/kg, if there is a clinical need to
reverse neuromuscular blockade within 3
minutes of administration of a single
dose of 1.2 mg/kg of rocuronium.
Caution/Warning: Patients with CrCl< 30 mls/min should not receive sugammadex.
Monitor patients with severe hepatic impairment since this population has not been
thoroughly studied. Interacts with oral contraceptives, binding to progestogen and
potentially estrogen, decreasing efficacy; patients on oral contraceptives should use
non-hormonal back-up contraception for 7 days after receiving sugammadex.
Comments: Do not mix with other agents prior to administration. Flush the infusion
line with NS between administration of sugammadex and other agents. May inject into
the line of a running infusion of NS, D5W, 1/2NSD2.5W, Lactated Ringers, Ringers
solution, or D5NS.
Side Effects: Common- nausea (23-26%), vomiting (11-15%), headache (5-10%)
Serious- hypersensitivity (7-9%), prolonged QT (6%), increased aPPT/PTT/INR up to 1
hour after administration (1-2%), recurrence of neuromuscular blockade (<1%),
anaphylaxis (0.3%)
Monitor: Monitor the train of four to assess reversal. Monitor renal function. Monitor
for anaphylactoid reactions.
Stability: Store intact vials at controlled room temperature and protect from light.
164
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Tacrolimus
Prograf
®
[immunosuppressant]
Prevent organ
transplant rejection
ALL
UNITS
(Except
Psy)
I.I.: 0.01 to 0.05 mg/kg/day ( 0.5 – 2 mg
in 100 mL NS or D5W IV , > 2 mg in
250 mL NS or D5W over 24 hrs )
Final conc.:
0.004-0.02 mg/mL
If IV administration is necessary,
administer by continuous infusion only
over 24 hours. Do not use PVC tubing
when administering diluted solutions.
Adsorption of the drug to PVC tubing
may become clinically significant with
low concentrations. Reference:
Lexicomp
Caution/Warning:
Comments: Stable for 24 hrs @ R.T. In Glass or polyolefin. Switch to oral therapy as
soon as tolerated. Hazardous medication precautions. Increased risk of lymphomas and
other malignacies. Reproductive effects seen in lab studies. Pregnancy Category C.
Wear nitrile gloves while handling. Gowns should be utilized for incidental exposure to
hazardous drugs. Dispose in hazardous waste container. Refer to the UConn hazardous
drug safety handling for further information:
Medication Handling Safety
Drug Interactions:
Monitor:
Side Effects: anaphylaxis, thrombocytopenia, leukopenia, nephrotoxicity, severe HTN,
hyperkalemia, seizures, neurotoxicity, immunosupression, infections, malignancy, QT
prolongation, cardiac hypertrophy, pericardial effusion. Common side effects: GI- abd.
Pain, diarrhea, anorexia; CNS-headache, insomnia, asthenia, fever, hypomagnesemia,
hyperglycemia, anemia, inc. LFT’s, per. edema, inc. BUN/Cr, cough. CycloSPORINE
should not be administered concomitantly with tacrolimus. Increases in trough
cycloSPORINE levels associated with elevations in serum creatinine have been
observed with the combination
Stability: stored in glass or polyethylene containers, and discarded after 24 hours
Tbo-filgrastim
Granix ®
[granulocyte
colony
stimulating factor]
Neutropenia
ALL
UNITS
(Except
Psy)
I.I.: 300-480 mcg in D5W only (not
NS) with minimum conc. of 5 mcg/ mL
(recommended is 5-15mcg/mL) over 15-
20 mins
Caution/Warning: Do not administer earlier than 24 hours after or in the 24 hours
prior to cytotoxic chemotherapy.
Comments: IV only if SC not feasible. More effective when given subcutaneously.
Flush before and after with D5W not NS.
Do not dilute with saline at any time as product may precipitate.
Drug Interactions:
Monitor:
Side effects: RARE: ARDS and splenic rupture.
Stability:
BKC: Dispose in
Black Bin
165
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Tecovirimat
TPOXX
[antiviral agent]
Monkeypox
(off-label use)
ALL
UNITS
(Except
Psy)
I.I.:
35 to <120 kg: 200 mg in 60 mL of NS
or D5W every 12 hours
≥120 kg: 300 mg in 90 mL of NS or
D5W every 12 hours
Administration:
Administer TPOXX injection by IV
infusion over 6 hours via an infusion
pump.
NOT FOR IV BOLUS INJECTION.
Administer via syringe pump. Not
compatible in infusion bags.
Caution/Warning:
Hypoglycemia: Coadministration with repaglinide may cause hypoglycemia. Monitor
blood glucose and monitor for hypoglycemic symptoms during co-administration.
Risks with hydroxypropyl-β-cyclodextrin excipient for patients with renal insufficiency
Drug Interactions:
Weak inducer of cytochrome P450 (CYP)3A and a weak inhibitor of CYP2C8 and
CYP2C19.
Monitor: Blood glucose, symptoms of hypoglycemia (when coadministered with
repaglinide); CrCl in patients receiving IV therapy prior to initiation and as clinically
appropriate.
Side Effects: Pain, redness, swelling, or other reaction where the injection was given,
headache.
Stability: The diluted TPOXX injection may be stored refrigerated (2°C - 8°C) for up
to 24 hours or at room temperature (15°C - 25°C) for up to 4 hours.
Tedizolid
Sivextro®
[Oxazolidinone antibiotic]
RESTRICTED
ANTIMICROBIAL
NON-FORMULARY
Bacterial Infections
Documented or
suspected skin &
skin-structure
infection caused by
VRE or MRSA in a
patient intolerant to
or not responding
clinically to
vancomycin or other
formulary anti-
MRSA/anti-VRE
antibiotics who
cannot take
linezolid due to high
risk of MAOI drug
interactions
Patient receiving
medication prior to
admission to UConn
Health John
Dempsey Hospital
ALL
UNITS
(Except
Psy)
I.I.: Administer as an IV infusion over 1
hour; do not administer as an IV push or
bolus.
-Not for intra-arterial, IM, intrathecal,
intraperitoneal, or subcutaneous
administration.
-If the same intravenous line is to be
used for sequential infusion of other
drugs or solutions, the line should be
flushed with NS before and after
tedizolid infusion
Caution/Warning:
May result in fungal or bacterial superinfection (e.g. Clostridium difficile);
Neutropenia: Not recommended for use in patients with neutrophil counts <1000
cells/mm
3
Comments: No dosage adjustment necessary for impaired kidney or hepatic function.
Drug interactions: may decrease the effectiveness of BCG and Cholera vaccines;
cladribine, dipyrone, and fexinidazole may enhance the myelosuppressive effect; may
increase concentration of pazopanib and topotecan
Monitoring:
Baseline complete blood count (CBC) with differential
Related Policies: Restricted and Concurrently- Monitored Antimicrobials
Side Effects: nausea; vomiting; diarrhea; decreased platelet counts; headache
Stability: Store at 20°C to 25°C (68°F to 77°F); excursions are permitted between 15°C
and 30°C (59°F and 86°F) The total storage time of the reconstituted solution should not
exceed 24 hours at either room temperature or under refrigeration at 2°C to 8°C (36°F
to 46°F)
166
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Tenecteplase
TNKase®
[Fibrinolytic]
HIGH ALERT / DOUBLE
CHECK
LOOK ALIKE / SOUND
ALIKE
STEMI
ED
UT-ICU
Dosing:
Administer as a single bolus over 5
seconds:
<60 kg: 30 mg
≥60 to <70 kg: 35 mg
≥70 to <80 kg: 40 mg
≥80 to <90 kg: 45 mg
≥90 kg: 50 mg
Admixture Information
Reconstitute using the supplied 10 mL
syringe with TwinPak Dual Cannula
Device and 10 mL sterile water for
injection. Do not shake when
reconstituting. Slight foaming is normal
and will dissipate if left standing for
several minutes. The reconstituted
solution is 5 mg/mL. Any unused
solution should be discarded.
Caution/Warnings:
Arrhythmias, internal bleeding, hypersensitivity reactions, thromboembolic events
Monitoring:
CBC, aPTT, signs and symptoms of bleeding, ECG monitoring
Side effects:
Bleeding, cardiac arrhythmias, allergic reactions
Stability:
Store under refrigeration of 2°C to 8°C (36°F to 46°F) or at room temperature; do not
exceed 30°C (86°F). If reconstituted and not used immediately, store in refrigerator and
use within 8 hours.
Teprotumumab-trbw
Tepezza®
[Monoclonal Antibody]
Treatment of
Thyroid Eye
Disease
OP-INFC
IV Infusion:
10 mg/kg once followed by 20 mg/kg
every 3 weeks for a total of 8 infusions
Administration:
Administer over 90 minutes for the first
two infusions; may reduce infusion time
to 60 minutes for subsequent infusions if
well tolerated.
Do NOT administer as IV push or bolus
Do NOT infuse concomitantly with other
agents
Mix: Remove a volume of 0.9% Sodium
Chloride equivalent to the required
volume of reconstituted Tepezza®
solution to be placed into the infusion
bag. Final infusion solution should have
a total volume of 100 mL (for less than
1800 mg dose) or 250 mL (for 1800 mg
and greater dose)
Caution/Warning: Infusion related reactions may occur within 1.5 hours after infusion
Comments: Infusion reactions are usually mild or moderate in severity and can be
managed with corticosteroids and antihistamines. In patients who experience an
infusion related reaction, consideration should be given to pre-medicating with an
antihistamine, antipyretic, corticosteroid and/or administering all subsequent infusions
at a slower rate
Drug Interactions: No major drug interactions
Monitor: Infusion related reactions
Side Effects: increased blood pressure, feeling hot, tachycardia, dyspnea, headache,
muscular pain
Stability: Store Tepezza® vials in original carton in the refrigerator between 2°C to
8°C (36°F to 46°F). Protect from light. Do not freeze.
Combined storage time of reconstituted vial and diluted solution in the infusion bag
containing 0.9% Sodium Chloride should not exceed 4 hours at room temperature 20°C
to 25°C (68°F to 77°F) or up to 48 hours under refrigerated conditions 2°C to 8°C (36°F
to 46°F) protected from light. Do not freeze.
If refrigerated prior to administration, allow the diluted solution to reach room
temperature prior to infusion.
167
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Terbutaline
Brethine
®
[beta-2 adrenergic agonist]
Nov 2017: During shortage
of SVP 50mL/100mL
D5W, use NS
Tocolysis
Priapism
L&D/OB-
GYN
IV Push: 0.25 mg undiluted over 15 sec
Caution/Warning:
Comments: Preferred route is SC.
Drug Interactions:
Monitor: BP, HR, RR, FHR per protocol.
Side Effects:
Stability:
ED
I.I.: 0.25 – 0.5 MG mg in 50 mL NS or
D5W
Comments: Resolution of priapism can occur within 4-5 mins following injection.
Monitor: Assess HR, BP, RR before and after dose.
Side Effects: CV- PALPITATIONS, TACHYCARDIA, increases in EJECTION
FRACTION, increases in CARDIAC OUTPUT, GI-NAUSEA and VOMITING ,
CNS- HEADACHE, NERVOUSNESS, DIZZINESS, SOMNOLENCE, and
INSOMNIA, Tremors
Thiamine
[vitamin B]
Vitamin deficiency
ALL
UNITS
IV Push (can also consider IM or Oral
if possible): 100mg IV over 5 min
I.I. (non-prefferred method of
administration): 100 mg in 50 mL D5W
or NS over 30-40 mins
C.I.: in IVF’s
Caution/Warning: IV Push too fast can result in infiltration or systemic reaction such
as headache, flushing, tightness in chest. All IV Push have Phlebitis Risk. Flush slowly
after medication administration
Comments:
Drug Interactions:
Monitor:
Side Effects:
168
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Wernicke’s
Encephalopathy:
I.I.: 500mg in 100mL NS or D5W over
30-40 mins for 2 to 3 days
Stability: Stable for 24 hours at room temperature
References on Wernicke’s Encephalopathy:
Parrish, C. Wernicke’s Encephalopathy: Role of Thiamine. Practical Gastroenterology.
June 2009: 21-30
Thomson, A et al. The royal college physicians report on alcohol: guidelines for
managing wernicke’s encephalopathy in the accident and emergency department.
Alcohol and Alcoholism (2002) 37 (6): 513-521.
Tigecycline
[antibiotic]
RESTRICTED
ANTIMICROBIAL
Infections (CAP,
Intra-abdominal,
skin & structure)
ALL
UNITS
(Except
Psy)
I.I.: Initial: 100 mg x1 dose then 50 mg/
100 mL NS or D5W. q 12 hours for 5-14
days, Infuse over 30-60 minutes through
dedicated line or via Y-site
Caution/Warning:
Comments: Pharmacy to mix.Severe hepatic impairment (Child-Pugh class C):
Initial: 100 mg single dose; Maintenance: 25 mg q 12 hours
Drug Interactions:
Monitor:
Side Effects:
Stability:
Reconstituted solution may be stored at room temperature for up to 6 hours or up to 24
hours if further diluted in a compatible I.V. solution. Alternatively, may be stored
refrigerated at 2°C to 8°C (36°F to 46°F) for up to 48 hours following immediate
transfer
of the reconstituted solution into NS or D
5
W. Reconstituted solution should be yellow-
orange; discard if not this color.
Tobramycin
[antibiotic]
RESTRICTED
ANTIMICROBIAL
NON-FORMULARY
Nov 2017: During shortage
of SVP 50mL/100mL
D5W, use NS
Bacterial Infection
ALL
UNITS
(Except
Psy)
I.I.: Traditional dosing: 1-2 mg/kg q 8-
12 hrs in 50 mL NS or D5W over 30-60
mins
Once daily dosing: per protocol- 2-7
mg/kg/day depending on site of infection
and renal function in 100 mL NS or
D5W over 30-60 mins q daily
Caution/Warning:
Comments: Pharmacy to mix. Consult unit RPh for dosing & monitoring. Modify
dose or interval for renal impairment. Peak & Trough levels recommended for
monitoring of traditional dosing. Monitor trough with once daily dosing. Renal and
ototoxic with high troughs for extended periods.
Drug Interactions:
Monitor:
Side Effects:
Stability: 24 hrs at room temperature, 14 days refrigerated.
Avoid in midline cath see
Page 14 (may be ok w/
short course)
169
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Tocilizumab
Actemra
®
[monoclonal antibody]
Rheumatoid arthritis
(Moderate to
Severe)
**Cytokine release
syndrome associated
with COVID-19
infection
Cytokine release
syndrome associated
with bispecific T
cell engager (BiTE)
or other cellular
therapies
ALL
UNITS
(Except
Psy)
UT1-ICU
UT1-ICU
UT2-IU
ED
UT6
UT-BMT
I.I.: 4 mg/kg IV infusion over 1 hr q 4-
wk; increase to 8 mg/kg based on clinical
response; doses exceeding 800 mg per
infusion are not recommended.
I.I.: 400mg IV once infused over 1 hour.
A second dose may be considered for
administration 8-12 hours after the first
dose if no clinical improvement. The
maximum total dose administered per
patient should not exceed 800mg.
I.I: 8 mg/kg (max 800mg) IV over 1
hour. If clinicial improvement dose not
occur within 8 to 24 hours of dose, up to
3 additional doses may be administered
(with at least an 8-hour interval between
consecutive doses)
Caution/Warning:
Comments: Pharmacy: From a 100 milliliters infusion bag or bottle, withdraw a
volume of 0.9% Sodium Chloride Injection equal to the volume of tocilizumab solution
required for the patients dose. Slowly add tocilizumab and mix gently by inverting the
bag to avoid foaming. Patients should be closely monitored for the development of
signs and symptoms of infection during and after treatment with tocilizumab
Drug Interactions:
Monitor: ALT & AST , CBC q 4-8 weeks
Side effects: Signs and symptoms of infusion reactions, skin reactions, including rash,
pruritus, and urticaria
Stability:
**COVID-19 Considerations: if vials for IV infusion are unavailable during the
COVID-19 pandemic, the P&T Committee has approved the utilization of prefilled
syringes for subcutaneous use in order to compound doses for IV infusion. This is a
Category 1 substitution which allows pharmacists to adjust orders for 400mg IV once to
486mg IV once for the first dose (utilizing 3 of the subcutaneous prefilled syringes).
When a second dose is indicated, pharmacists may adjust the dose to 324mg IV once
(utilizing 2 of the subcutaneous prefilled syringes). All doses will be diluted in 100mL
of Sodium Chloride 0.9% and infused over 60 minutes.
Torsemide
Demadex
®
[loop diuretic]
Edema, CHF
ALL
UNITS
(Except
Psy)
IV Push: < 40 mg undiluted
given < 20 mg/min, flush with 5 mL
NS.
Caution/Warning:
Comments: Pharmacy to mix.
Torsemide 20 mg= Furosemide 40 mg= Bumetanide 1mg
Drug Interactions:
Monitor: BP & HR during rapid administration
Side effects: Hypotension, h/a, dizziness, hypovolemia, muscle cramps, hyperuricemia,
hyperglycemia, hypokalemia, hypocalcemia, metabolic alkalosis.
Stability: 24 hrs at Room Temperature. Protect from light. Do not refrigerate.
ALL
UNITS
(Except
Psy)
I.I.: >40 - 100mg in 50 mL D5W
only over 15- 30 mins
170
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
ED
UT1-ICU
UT2-IU
OP-CARD
OR/PACU
IV Push: up to 50 mg undiluted
over 1-2 mins
C.I.: 1 - 20 mg/ hr in D5W
Tranexamic acid
[hemostatic]
Hemophilia-
hemorrhage
ALL
UNITS
(Except
Psy)
I.I.: up to 2000 mg in 100 mL NS over
30 mins, Max. rate = 100 mg/min
Caution/Warning:
Comments: Usual dose: 10 mg/kg. Increase interval for renal impairment.
Drug Interactions:
Monitor:
Side Effects:
Stability:
Postpartum
Hemorrhage
L&D/
OB-GYN
I.I.: 1000mg in 100mL NS over 10
minutes given within 3 hours of vaginal
birth or c-section; if bleeding continues
after 30 minutes or stops and restarts
within 24 hours after the first dose, a
second dose of 1,000 mg may be given.
Open Heart
UT1-ICU
Pre-op/post-op: 100 mg/kg IV pre-op,
then 50 mg/kg IV post-op, OR
15 mg/kg IV followed by
I.I.: 1 mg/kg/hr for 5-6 hours started
prior to initiating coronary bypass
171
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Reduce bleeding for
Orthopedic
Hip/Knee
arhtroplasty
OR/PACU
ED
Pre-Op (total hip/total knee): Usual
dose: 1gm (10 mL) mixed with 10 mL
NS for a total volume 20 mL given pre-
op and may repeat intra-op IV
Intra-op (total hip/total knee with
history of stent/cardiac disease that
precludes IV use): 1gm (10mL) mixed
in 250 mL NS to applied at the time of
wound closure
172
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Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Treprostinil
Remodulin
®
[prostaglandin, vasodilator]
HIGH ALERT / DOUBLE
CHECK
(during transition)
Pul Artery
Hypertension (PAH)
With NYHA class
II-IV symptoms
ED
HT1-ICU
HT2-INT
IRAD
OR/PACU
C. I. (IV): Usual initiation rate of 2 - 6
ng/kg/min.
Maintenance CI at 2- 500 ng/kg/min.
Continuous IV via ambulatory infusion
pump with special syringe with rate set
as mcL/hr or as mL/hr with Alaris
infusion pump.
The therapeutic potency of treprostinol is
less than that of epoprostenol thus
acceptable starting rates of treprostinol
IV are 2-3 times the starting doses of
epoprostenol. Titration q 6 -24 hrs based
on therapeutic response and/or side
effects.
Patients with mild to moderate hepatic
impairment or those who cannot tolerate
the usual rate due to systemic effects
might benefit from a reduced starting
dose or slower titration.
Requires Pharmacy admixture based on
current admixture and dosing
information obtained by calling the
patient’s speciality pharmacy (e.g
Accredo 1-866-344-4874 or CVS
Caremark 1-877-242-2738).
Initially may be infused with Alaris
pump in new patient or pump not
available.
Rate changes by practitioner only based
on symptoms not weight changes.
Calculation is based on patient’s dosing
weight and drug concentration.
Pharmacy Worksheet for Dosing
Calculation:
Treprostinil Pharmacy Worksheet
Caution/Warning: Do not slow or stop infusion without Pulmonary order and guidance
since this may be life-threatening.
Comments: RPh or Practitioner must call the patient’s speciality pharmacy to verify
current concentration, dose delivered, and dosing weight (not current weight). Orders
must be written in ng/kg/min, concentration of the CI (ng/mL) and mcL/hr in CRONO5
pump and mL/hr via Alaris Pump by Practitioner and verified by RPh and RN.
Procedure: IV administration: prepare a 50 mL volume of diluted treprostinil infusion.
Determine the dose (in mg) needed based on the pt’s total body weight and the infusion
rate (ng/kg/min): (no dose adjustment needed for obesity)
Sudden withdrawal or large reductions in dosage may result in worsening of pulmonary
arterial hypertension symptoms.
If a patient is admitted the process of conversion to the JDH pump and guardrail system
Concomitant use with anticoagulants (warfarin, enoxaparin, dalteparin, lepirudin,
argatroban) or antiplatelet agents (NSAIDS, salicylates) may increase risk of bleeding.
Diuretics, antihypertensives, vasodilators may result in added reductions in BP when
given with epoprostenol.
Advantages over epoprostenol: longer half-life so sudden interruption of therapy less
dangerous, easier preparation as no reconstitution, less patient manipulation as change
reservoirs every 2 days, no ice packs and light protection required.
Drug Interactions:
Monitor: for S&S’s of PAH: chest pain, dyspnea, palpitations, orthopnea, syncope.
Monitor for side effects of insufficient med: cyanosis, chest pain, cough,
fatigue/weakness, palpitations, sob.
Monitor for excess med: diarrhea, headache, lightheadedness/fainting, nausea, vomiting
Monitor for side effects : inj. Site pain , infusion site reactions: rash, erythema or
induration,, others: headache, diarrhea, nausea, jaw pain, hypotension, and edema.
Related Policies:
• Epoprostenol Sodium (Flolan) / Epoprostenol for Injection (Veletri) / Treprostinil
Sodium (Remodulin) Transition to New Med, Route, and/or New Central Line
• Treprostinil Pharmacy Policy and Procedure
• Medications: High Alert, Double Check of
Side Effects:
Stability: Solutions expire at 48 hrs at room temperature
Information on SC Treprostinil is found on the next page.
BKC: Dispose in
Black Bin
173
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Treprostinil
Remodulin
®
[prostaglandin, vasodilator]
HIGH ALERT / DOUBLE
CHECK
Pul Artery
Hypertension (PAH)
With NYHA class
II-IV symptoms
ED
HT1-ICU
HT2-INT
IRAD
OR/PACU
C. I. (SC): Usual initiation rate of 2 - 6
ng/kg/min.
Maintenance CI at 2- 500 ng/kg/min.
Continuous IV via ambulatory infusion
pump with special syringe with rate set
as mL/hr or as mL/hr with Alaris
infusion pump.
The therapeutic potency of treprostinol is
less than that of epoprostenol thus
acceptable starting rates of treprostinol
SC are 2-3 times the starting doses of
epoprostenol. Titration q 6 -24 hrs based
on therapeutic response and/or side
effects.
Patients with mild to moderate hepatic
impairment or those who cannot tolerate
the usual rate due to systemic effects
might benefit from a reduced starting
dose or slower titration.
Requires Pharmacy admixture based on
current admixture and dosing
information obtained by calling the
patient’s speciality pharmacy (e.g
Accredo 1-866-344-4874 or CVS
Caremark 1-877-242-2738).
Rate changes by practitioner only based
on symptoms not weight changes.
Calculation is based on patient’s dosing
weight and drug concentration.
Pharmacy Worksheet for Dosing
Calculation:
Treprostinil Pharmacy Worksheet
Information on IV Treprostinil is found on the prior page
Caution/Warning: Do not slow or stop infusion without Pulmonary order and guidance
since this may be life-threatening.
Comments: RPh or Practitioner must call the patient’s speciality pharmacy to verify
current concentration, dose delivered, and dosing weight (not current weight). Orders
must be written in ng/kg/min, concentration of the CI (ng/mL) and mL/hr for a
subcutaneous pump by Practitioner and verified by RPh and RN.
Syringes are changed q 3 days
Procedure: SC administration: prepare the intended volume treprostinil.
Determine the dose (in mg) needed based on the patient’s dosing weight and the
infusion rate (ng/kg/min).
Sudden withdrawal or large reductions in dosage may result in worsening of pulmonary
arterial hypertension symptoms.
Advantages over epoprostenol: longer half-life so sudden interruption of therapy less
dangerous, easier preparation as no reconstitution, less patient manipulation as change
reservoirs every 2 days, no ice packs and light protection required.
Drug Interactions:
Monitor: for S&S’s of PAH: chest pain, dyspnea, palpitations, orthopnea, syncope.
Monitor for side effects of insufficient med: cyanosis, chest pain, cough,
fatigue/weakness, palpitations, sob.
Monitor for excess med: diarrhea, headache, lightheadedness/fainting, nausea, vomiting
Monitor for side effects : inj. Site pain , infusion site reactions: rash, erythema or
induration,, others: headache, diarrhea, nausea, jaw pain, hypotension, and edema.
Related Policies:
• Medications: High Alert, Double Check of
• Treprostinil Pharmacy Policy and Procedure
• Remodulin (Treprostinil): Continuous Subcutaneous Administration
Side Effects:
Stability: Solutions expire at 48 hrs at room temperature
174
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Trimethoprim (TMP)
Sulfamethoxazole (SMX)
Bactrim/Septra
®
[antibiotic]
Bacterial Infection
ALL
UNITS
(Except
Psy)
I.I.:
Sepsis/Meningitis/PCP:
15-20 mg/kg/day as TMP divided q 6 hrs
Non PCP:10 mg/kg/day as TMP divided
q 6-12 hrs
0-80 mg TMP in 100 mL D5W
over 1 hr
81-120 mg TMP in 150 mL D5W
over 1.5 hrs
121-240 mg TMP in 250 mL D5W
over 1.5 hrs
241-450mg TMP in 500 mL D5W
over 2 hrs
Dosing is based on Ideal Body Weight.
Consider Adjusted body weight in
obesity.
Caution/Warning:
Comments: Nursing to admix due to limited stability (6 hours at room
temperature). Mix immediately prior to use
Dosing is based on TMP component
5 mL = 80 mg trimethoprim & 400 mg sulfamethoxazole
Mix immediately prior to use.
Reduce dose w renal impairment.
Drug Interactions:
Monitor: CBC, Cr, K+, LFTs, for skin rashes
Side effects: rash, immune hypersensitivity reactions, hyponatremia, thrombocytopenia,
pancytopenia, hemolysis, hyperkalemia
Stability:
Ustekinumab
Stelera
®
[monoclonal antibody]
Crohn’s Disease
OP-INFC
I.I.: dose/250mL NS over 1 hour with an
inline 0.2 micron low sorbing (protein)
binding filter
Dose:
Weight ≤ 55 kg = 260 mg
Weight 56-85 kg = 390 mg
Weight > 85 kg = 520 mg
Caution/Warning: Perform tuberculosis screening prior to initiating and periodically
during therapy. An FDA-approved medication guide must be dispensed with this
medication:
Ustekinumab Medication Guide
Comments: Use 0.2 micron low sorbing (protein) binding filter. Do not infuse in the
same IV line with other agents.
Drug Interactions:
Monitor: CBC, ustekinumab-antibody formation, signs/symptoms infection.
Side Effects:
Stability: 4 hrs at room temperature.
Valproic acid
Depacon
®
[anticonvulsant]
Nov 2017: During shortage
of SVP 50mL/100mL
D5W, use NS
Seizures,
Behavioral
management
ALL
UNITS
I.I.: 10-15 mg/kg/day given 2-3 x a day
as 125-1000 mg in 100 mL NS or D5W
over 60 mins, increase at 1 week
intervals by 5-10 mg/kg/day until the
desired therapeutic effect is reached or
adverse effects occur
Caution/Warning:
Comments: Pharmacy admix.
Drug Interactions :
Monitor : level
Side effects: nausea, vomiting, somnolence, sedation, bleeding, increase in LFT’s,
pancreatitis
Stability: Stable 24 hrs @ Room Temperature
BKC: Dispose in
Black Bin
Avoid in midline cath see
Page 14 (may be ok w/
short course)
175
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Vancomycin
[antibiotic]
Gram Positives
Infections
ALL
UNITS
I.I.:
Dosing is based on Total Body Weight.
500 mg/100 mL D5W or NS over 1 hr
750 mg/250 mL NS over 1hr
1000 mg /200 mL D5W premix over 1 hr
1250 mg /250 mL NS premix over 2 hrs
1500 mg/250 mL NS premix over 2 hrs
1750 mg/250 mL NS over 2 hrs
2000 mg/250 mL NS over 2.5hrs
2250 mg/250 mL NS over 2.5hrs
2500mg/250 mL NS over 2.5 hrs
Caution/Warning: nephrotoxicity, neurotoxicity, neutropenia, ototoxicity, Rapid I.V.
administration may result in hypotension, flushing, erythema, urticaria, and/or pruritus
Comments: Pharmacy admix. Consult Unit RPh for assistance in dosing and
monitoring.
Slow or stop infusion if flushing or hypotension develops. HD patients: random levels
after dialysis.
Drug Interactions:
Monitor: Periodic renal function tests, urinalysis, WBC; serum trough vancomycin
concentrations in select patients (eg, aggressive dosing, unstable renal function,
concurrent nephrotoxins, prolonged courses)
Related Policies:
Pharmacist is responsible for ordering troughs
Side Effects: Red man’s syndrome (infuse slowly), eosinophilia
Stability: Reconstituted 500 mg and 1 g vials are stable for at either room temperature
or under refrigeration for 14 days. Note: Vials contain no bacteriostatic agent. Solutions
diluted for administration in either D5W or NS are stable under refrigeration for 14 days
or at room temperature for 7 days
Vasopressin
Pitressin
®
[vasoconstrictor]
LOOK ALIKE / SOUND
ALIKE
TITRATE MED
Vasodilatory shock
In presence
of Critical
Care RN or
Action RN
and LIP
during
RRT/Code,
ALL
UNITS
IV Push: Cardiac Arrest- pulseless VT,
VFIB: 40 units x 1 per ACLS
Caution/Warning:
Comments: CI for sepsis is non-titrable and requires MD/LIP order for changes in rate.
Drug Interactions:
Monitor: BP, urine Na & sp. Gr. , serum osm., I/O’s
Side effects: May provoke angina in pt’s w CAD and may cause water retention,
bradycardia, MI, hypertension, arrhythmias, bronchospasm and neuromuscular diseases.
Stability:
Vasodilatory shock
UT1-ICU
In presence
of Critical
Care RN or
Action RN
and LIP
during
RRT/Code,
ALL
UNITS
C.I.: 40 units / 100 mL NS (0.4
units/mL), 0.04 unit/min, = 6 mL/hr,
Do Not Titrate
Esophageal variceal
bleed
UT1-ICU
Esophageal varices CI: 0.2 -0.4
unit/min= 30-60 mL/hr with 200 units/
500 mL NS= 0.4 units/ml, titrate to max.
of 1 unit/min, when bleeding stops
continue for 12 hrs then taper off within
24-48 hrs
If Extravasation,
see Pages 10&11
If Extravasation,
see Pages 10&11
Avoid in midline cath see
Page 14 (may be ok w/
short course)
Avoid in midline cath see
Page 14
176
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Vecuronium
[neuromuscular blocker]
Intubation & for
Mech. Ventilation
ECT-A
ED
UT1-ICU
OR/PACU
UHSC
IV Push: Load Dose: 0.1 mg/kg (2-
10mg) over 1-2 mins, q 1-2 hrs
C.I.: 100 mg/ 100 mL = 1 mg/ mL at
0.8- 1.2 mcg/kg/min
Caution/Warning:
Comments: Pt MUST be on a ventilator. Must be sedation before use. Consider
analgesia. Renal failure & hepatic dysfunction can prolong blockade.
Contra: with steroids due to high risk for prolonged neuro-muscular blockade
Drug Interactions:
Monitor: TOF, HR, BP, electrolytes
Related Policies:
• Neuromuscular Blocking Agents (NMBA): IV Administration
Side Effects:
Stability:
Verapamil
Calan/Isoptin
®
[Calcium Channel Blocker]
SVT, AFib.,
Hypertension
UT1-ICU
IV Push: 2.5 -10 mg over at least 2
mins, repeat dose x 1 if no response in
15-30 mins
C.I. : 50-100 mg/250 mL at 2-10 mg/hr
Caution/Warning:
Comments:
Drug Interactions:
Monitor: EKG, HR, BP
Side effects: bradycardia, AV block, V-Fib., asystole, hypotension.
Stability:
Prevention of
arterial spasm in
catheters
CCL/EP
IRAD
OR/PACU
Catheter: (Diamondback 360 System by
CSI). 1000mL NS with 20mL of Viper
Slide (lubricant ), 5mg of Nitroglycerin,
and 5mg of verapamil.
Voriconazole
VFend
®
[antifungal]
RESTRICTED
ANTIMICROBIAL
Anti-fungal
Aspergillosis,
invasive, including
disseminated and
extrapulmonary
infection:
ALL
UNITS
(Except
Psy)
I.I.: Initial: Loading dose: 6 mg/kg q 12
hours for 2 doses; followed by
maintenance dose of 4 mg/kg q 12 hours
1
st
& 2
nd
Load doses in 250 mL
D5W/NS over 2 hrs then maintenance
dosing in 100 mL over 1.5 hr.
Duration of therapy should be a
minimum of 6-12 weeks or throughout
period of immunosuppression.
Dosing is based on Ideal Body Weight
(IBW). Can consider adjusted if obese
and life-threatening.
Caution/Warning:
Comments: Hazardous medication precautions. Pregnancy Category D. May cause
fetal harm. Wear nitrile gloves while handling. Gowns should be utilized for incidental
exposure to hazardous drugs. Dispose in hazardous waste container. Refer to the UConn
hazardous drug safety handling for further information:
Medication Handling Safety
Drug Interactions:
Monitor:
Side Effects:
Stability:
Vitamin - multiple
Vitamin deficiency
ALL
UNITS
C.I.: 1 vial of MVI-12 to at least 500 mL
of IVF
Caution/Warning:
Comments: Stable for 48 hrs at room temperature. 1 vial of water soluble & 1 vial of
fat soluble vitamins= 1 vial of MVI
Drug Interactions:
Monitor:
Side Effects:
Stability:
177
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
Zidovudine
Retrovir
®
AZT
[anti-retroviral]
Prevent viral
transmission to
infant
L&D/OB-
GYN
I.I. LD: 400mg/100mL D5W/NS
(4mg/mL) at 2mg/kg/hr x 1 hr
I.I.: 400mg/100mL D5W/NS (4mg/mL)
at 1 mg/kg/hr until cord is clamped or a
minimum of 3 hr before C/S or vag.
delivery
Caution/Warning:
Comments: Pharmacy can provide one bag for loading and maintenance dose as
loading can be administered via bolus off bag. Maximum.concentration is 4 mg/ml.
Use dedicated line. Adjust for renal dysfunction.
Refer to the UConn hazardous drug safety handling for further information: Medication
Handling Safety
Drug Interactions:
Monitor:
Side Effects:
Stability: Stable for 8 hrs at room temperature and 24 hrs in refrigerator.
Zoledronic acid
Reclast
®
Zometa
®
Osteoporosis
Reclast ®
Given Yearly
OP-INFC
OP-NCCC
I.I.: 5 mg in 100 mL D5W or NS over
20-30 mins
Caution/Warning:
Comments: Minimum 7 days between doses. Hydration is recommended. Do not
administer. V&S pre & post infusion.
Avoid in midline cath see
Page 14 (may be ok w/
short course)
BOLUS OFF BAG:
Upon new EMR April
2018, ability to bolus
and chart from
continuous infusion bag
via Alaris Pump
Guardrails. Able to do
with Zidovudine on
Alaris as of 6/2017.
178
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
Generic name
Brand name
Med Class
Indications
Approved
Units for
Use
Dosing/Admixture Information
Caution/Warning / Comments / Monitoring / Related Policies / Side Effects /
Stability
[bisphosphonate, calcium
regulator]
Hypercalcemia ass.
with malignancy,
Multiple myeloma,
Paget’s disease
Zometa®
OP-NCCC
I.I.: 4 mg in 100 mL NS , infuse at 300
mL/hr over 20 minutes
Dose should be adjusted based on renal function. No dosage adjustment need for renal
impairment for treatment of hypercalcemia of malignancy. Pharmacist has ability to
make renal-based adjustments to the dosage regimen.
For CrCl > 60 mL/min: 4 mg
For CrCl 50-60 mL/min: 3.5 mg
For CrCl 40-49 mL/min: 3.3 mg
For CrCl 30-39 mL/min: 3 mg
Refer to the UConn hazardous drug safety handling for further information:
Medication
Handling Safety
Drug Interactions:
Monitor: Ca++. P, Mg, BUN, Cr, phlebitis, hypersensitivity rxn’s, malaise, GI-n/v,
bone pain. Consider acetaminophen or ibuprofen to reduce incidence of acute-phase
reaction symptoms. Reduce dose for CrCl < 60 mL/min for Multiple myeloma &
Metastatic bone lesions from solid tumors
Side Effects: Vein irritation, hypersensitivity reactions, CNS- malaise, fever,
N/anorexia, bone pain.
Stability:
References
• Lexicomp 2017 Wolters Kluwer Clinical Drug Information, Inc
• Micromedex Ann Arbor (MI): Truven Health Analytics
• DailyMed for individual FDA package inserts https://dailymed.nlm.nih.gov/
179
Refer to Policy Number 08-052: Medication Administration for questions or concerns if unable to locate item in this guidance document.
FINAL APPROVALS:
1. Bruce T. Liang, MD (Signed) 12/14/2023
Bruce T. Liang, MD Date
Interim Chief Executive Officer & EVP for Health Affairs
Dean, School of Medicine
2. Anne Horbatuck (Signed) 12/11/2023
Anne D. Horbatuck, RN, BSN, MBA Date
Clinical Policy Committee Co-Chair
3. Scott Allen, MD (Signed) 12/13/2023
Scott Allen, MD Date
Clinical Policy Committee Co-Chair
4. Caryl Ryan (Signed) 12/13/2023
Caryl Ryan, MS, BSN, RN Date
Chief Operating Officer, JDH
VP Quality and Patient Services & Chief Nursing Officer
REVSION HISTORY:
Date Issued: 08/25/2023
Date Revised: 10/26/2023, 12/14/2023
Date Reviewed:
