1. Preparing & administering Infusions Mark Tomlin Consultant Pharmacist: Critical Care Southampton University Hospitals NHS Trust

2. Why Parenteral? Rapid onset of action Achieving high blood/tissue concentrations Reliability Initial loading

3. Whether an alternative route should be considered? Injections are expensive and hazardous IM, SC may be painful or have erratic absorption Oral route may be unavailable, but consider NG, NJ, PEG/J Nausea, vomiting, diarrhoea, ileostomy, gut surgery Rectal inappropriate clinically/pharmaceutical Transdermal

4. What route ? CentralOr peripheral

5. What route ? Central Measuring CVP, PAWP Concentrates in fluid restricted patients Too irritant peripherally Slow and risky to gain access – needs experience & practice Or peripheral Easy and safer access Large volumes Familiar route

6. Where to prepare? Treatment Room Aseptic Suite in Pharmacy (CIVAS) Toilet Theatres

7. When to prepare ? Immediately before Use Before the weekend A week before you need it Before they go to theatre 24 hours before you need it

8. How to prepare & administer Reconstituting Cefuroxime 750mg vial Administering Metronidazole 500mg IV Preparing Rifampicin IV Diluting Propofol Piggy – backing Y –site into a running infusion How to find the correct diluent Lignocaine, Saline, Water, Potassium Potassium

9. What IV fluid - 1 ? Crystalloidor colloid?

10. What IV fluid - 1 ? Crystalloid Most familiar Cheap May need large volumes Relatively slow increase in CVP Will move out of vascular space or colloid? HDU/ITU and critically ill only Expensive Rapid increase in CVP Small volumes Water redistribution out of tissues

11. What IV fluid - 2 ? Saline, Glucose or Dextrose/saline What strength ? The list of choices Serum sodium Diabetes Acid-base

12. Fluid balance A simple question of input equal to output A straight question of 3L in, and 3L out A question of giving sufficient fluid to achieve 1mg/kg/hr urine output A complex balance of forces to achieve a urine output of about 1mg/kg/hr (assuming normal renal function) without causing heart failure, pulmonary or peripheral oedema Achieving an adequate urine output (accounting for other losses) with a maintenance dose, and giving treatment doses to sustain BP&CO Giving a fluid challenge to ask the question about whether the patient is adequately filled (BP, CRT)

13. Problems with infusions and fluids Forget it is still running ! Incorrect calculation Wrong dose Wrong rate Wrong concentration(Flolan) Wrong infusion device or Wrong set-up Changes - equipment, rates & concentrations The F word and when to use it?