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Using Hospital Pharmacy Reference Tools in IV Therapy
Chuck DiTrapano, RPh Pharmacy Supervisor The Reading Hospital and Medical Center
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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)
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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
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Omnicell Medication Dispensing Cabinets
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IV Therapy Common Injectable routes of administration
Subcutaneous (SubQ, SQ, SC) Intramuscular (IM) Intravenous IV Push IV Intermittent Injection / Infusion IV Infusion
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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
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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
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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
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IV Infusion (2) Central / Peripheral ? Osmolarity
Blood mOsm/kg 0.9% Sodium Chloride 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
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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
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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
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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
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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)
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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
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Check IV Compatibility
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Check IV Compatibility
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Check IV Compatibility
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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
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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)
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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
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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
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BAXA COMPOUNDER Automated Infusion Dispensing Barcode Verification
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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”
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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
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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
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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
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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
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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
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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: mg/kg / DOSE every 12 hours Severe Infections: mg/kg / DOSE every 12 hours Patient: 800 mg / 16.7 kg = 47.9 mg/kg – OK Administration Information Infuse over minutes Dose Preparation Information Single Dose Preparation Bulk Dose Preparation
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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
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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
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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
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Drug Dosing Pharmacokinetics Renal Dosing Antibiotic Dosing
Aminoglycosides Vancomycin Theophylline Digoxin Valproic Acid Renal Dosing Antibiotic Dosing Adjustments
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Need Help? Chuck DiTrapano,RPh The Reading Hospital and Medical Center
Pharmacy Department
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