Using Hospital Pharmacy Reference Tools in IV Therapy Chuck DiTrapano, RPh Pharmacy Supervisor The Reading Hospital and Medical Center

Transition to Hospital Pharmacy Retail Dispensing Prescription order entry Orals, topical, some injectables …. Insurance issues Customer service Compounding? Physician calls Inventory management Hospital Dispensing – 24 hour Drug Formulary Robotics, Automated Dispensing Cabinets BPCV (Barcode Verification) Medication order entry Interaction with nursing / drug administration issues Same as retail + Injectable, infusion therapy, specialty services (chemotherapy, NICU, Pediatrics) Stop order policy Protocols Clinical information systems Clinical services Drug Information Services Physician Order Management (POM)

Transition to Hospital Pharmacy Dispensing Functions Unit Dose (12 / 24 hour) Unit of use systems Floor stock (Automated Dispensing Cabinets- ADC) SureMed, Omnicell, Pyxis Operating Room Learn the acronyms (PACU, ED, ECU,NICU,MICU,SICU,CCU,PICU) Emergency Department (ED) Infusion Therapy Services

Omnicell Medication Dispensing Cabinets

IV Therapy Common Injectable routes of administration Subcutaneous (SubQ, SQ, SC) Intramuscular (IM) Intravenous IV Push IV Intermittent Injection / Infusion IV Infusion

IV Push How fast is too fast for IV push medications? IV Push should be defined by hospital policy Concentration can effect IV rate Midazolam 1mg/mL vs 5 mg/mL Medications that carry risk from rapid administration should be designated by hospital policy as IV Intermittent Infusion (IVPB) Who can administer it?, How much drug can be administered? How fast can it be administered? Is there any monitoring required? Source: ISMP

IV Intermittent Injection / Infusion Intermittent infusion is used when a patient requires medications only at certain times, and does not require additional fluid. It can use the same techniques as an intravenous drip (pump or gravity drip), but after the complete dose of medication has been given, the tubing is disconnected from the IV access device Typical Volumes 25mL, 50mL, 100mL, 150mL Time of Infusion 15 to 60 minutes; typically Heparin Flushing / Central Line SASH Long administration times / impact on nursing Policy on who can administer RN? LPN? Compatibility / Stability / Light Protection

IV Infusion Continuous Infusion LVP – Large Volume Parenteral Taper Typical volumes: 250mL, 500mL, 1000mL Taper Many drugs require titration to clinical response of patient Infusion Lines Peripheral Line Central Line PICC – Peripherally inserted central catheter Compatibility / Stability / Light Protection

IV Infusion (2) Central / Peripheral ? Osmolarity Blood - 280 - 295 mOsm/kg 0.9% Sodium Chloride - 308 mOsm/L. (Isotonic) Dextrose 5% Water – 252 mOsm/L (Isotonic) 0.45% Sodium Chloride – 154 mOsm/L Hypertonic: over 900 mOsm/L Hypotonic – below 150 mOsm/L

IV Therapy Math Infusion Drip Rate Rx: Infusion of D5W 1,000 mL over 8 hours: 1000 mL/hour ÷ 8 hours = 125 mL / HOUR Rx: Infusion of D5W at 50 mL/hour: 1,000 mL ÷ 50 mL / hour = 20 hours / bag

Standard Concentration = 125 mg/125 mL IV Therapy Math mg / HOUR to mL / HOUR Rx: Diltiazem 10 mg/HOUR: Standard Concentration = 125 mg/125 mL (1 mg/mL) 10 mg / Hour ÷ 1 mg / mL = 10 mL / HOUR

Standard Concentration = 500 mg/250 mL IV Therapy Math mg / MINUTE to mL / HOUR Rx: Amiodarone 0.5 mg / MINUTE: Standard Concentration = 500 mg/250 mL (2 mg/mL) 0.5 mg/MINUTE x 60 minutes = 30 mg / HOUR 30 mg / HOUR ÷ 2 mg / mL = 15 mL / HOUR

IV Therapy Math Weight Based mg / kg / HOUR to mL / HOUR Rx: Aminophylline: 0.51 mg/kg/HOUR – pt wt: 80 kg Standard Concentration = 250 mg / 250 mL (1 mg/mL) 0.51 mg/kg/hour x 80 kg = 40.8 mg / hour 40.8 mg / hour ÷ 1 mg / mL = 40.8 mL / hour 41 mL / hour (rounded)

IV Therapy Math Weight Based mcg / kg / MINUTE to mL / HOUR Rx: DOPamine: 10 mcg / kg / minute – 80 kg patient Standard Concentration = 200 mg / 250 mL (0.8 mg/mL) 10 mcg/kg/minute x 80 kg x 60 minutes = 48,000 mcg / hour 0.8mg/mL x 1,000 mcg per mg = 800 mcg/mL 48,000 mcg / hour ÷ 800 mcg / mL = 60 mL / hour

Check IV Compatibility

Check IV Compatibility

Check IV Compatibility

Drug Information is Alphabetical Contents Product Information pH Osmolarity Administration Stability Light Sensitivity Filtration Compatibility Information by: Mixed in various solutions Mixed with another drug in solution Mixed together in syringe Y-Site Compatibility

Drug Information is Alphabetical Contents Properities Solubility pH pKa General Stability Considerations Stability Reports of Compounded Products Formulations with compounding directions Commercial availability (if applicability)

Drugs Filed by Therapeutic Category Contents Dose & Administration Uses Monitoring Adverse Effects / Precautions Pharmacology Special Considerations / Preparation Solution Compatibility Solution Incompatibility Terminal Injection Site Compatibility Incompatibility Selected References

Usual Dose (Pediatrics) Rate of Administration Drug / Lab Interactions Formulary Section Drugs listed alphabetical Content Drug Monographs Usual Dose (Adults) Usual Dose (Pediatrics) Dose Adjustments Dilution Compatibility Rate of Administration Actions Indications and Uses Contraindications Precautions Drug / Lab Interactions Side Effects Antidote

BAXA COMPOUNDER Automated Infusion Dispensing Barcode Verification

Specialty Populations in Hospital Pharmacy Pediatrics Weight based dosing Double Checks Alternate drug concentrations Dedicated reference sources Standard Infusion Concentrations No “rule of 6 dosing”

Specialty Populations in Hospital Pharmacy NICU Weight based dosing Double Checks Alternate drug concentrations Wide weight fluctuations in patients Dedicated reference sources Standard Infusion Concentrations No “rule of 6 dosing” Specialty Compounding for oral liquids

Typical Pediatric Order Rx: Gentimicin 4 mg/kg, weight= 10.5 kg q24h 4 mg/kg x 10.5 kg = 42 mg Standard Concentration -= 5 mg / mL 42 mg/kg ÷ 5 mg/kg = 8.4 mL Administer 8.4 mL (42 mg) over 30 minutes

Drugs listed alphabetical Content Drug Monographs Formulary Section Drugs listed alphabetical Content Drug Monographs Usual Dose (Adults) Usual Dose (Pediatrics) Dose Adjustments Dilution Compatibility Rate of Administration Actions Indications and Uses Contraindications Precautions Drug / Drug Interactions Drug / Lab Interactions Side Effects Antidote

Dosing for Neonates & Pediatrics Pharmacokinetic information Formulary Section Drugs listed alphabetical Content Drug Monographs Therapeutic Category Dosing for Neonates & Pediatrics Adult Dosing Pharmacokinetic information Contraindications

Drugs listed alphabetical Content Drug Monographs Usual Dose (Pediatrics) Dose Adjustments Maximum dosing IV Push Information Intermittent Infusion Continuous Infusion Maximum concentration Cautions related to IV Administration

Pediatric Medication Order Standard Antibiotic Order Patient: 3 years old, 16.7 kg Rx: Ceftriaxone 800 mg IV q12h Order Verification: Dose Check Dosing Guidelines: ASHP Pediatric Injectable Drugs: Mild to Moderate Infection: 50-75 mg/kg / DOSE every 12 hours Severe Infections: 80-100 mg/kg / DOSE every 12 hours Patient: 800 mg / 16.7 kg = 47.9 mg/kg – OK Administration Information Infuse over 10-30 minutes Dose Preparation Information Single Dose Preparation Bulk Dose Preparation

Drugs Filed by Therapeutic Category Contents Dose & Administration Uses Monitoring Adverse Effects / Precautions Pharmacology Special Considerations / Preparation Solution Compatibility Solution Incompatibility Terminal Injection Site Compatibility Incompatibility Selected References

Specialty Populations in Hospital Pharmacy Chemotherapy Safe Handling High Alert / High Risk Drugs Biological Safety Cabinet Operation Administration Issues Filtration Low absorption tubing / bags Stability Light Sensitivity

Drugs Filed Alphabetically Contents Safe Handling of Chemotherapy Extravasations Procedures Drug Monographs Y-Site Compatibility Patient Education Patient Drug Monographs Combination Regimens Patient Symptom Information

Drug Dosing Pharmacokinetics Renal Dosing Antibiotic Dosing Aminoglycosides Vancomycin Theophylline Digoxin Valproic Acid Renal Dosing Antibiotic Dosing Adjustments

Need Help? Chuck DiTrapano,RPh The Reading Hospital and Medical Center Pharmacy Department ditrapanov@readinghospital.org 610-988-9328