Transcript Pharmaceutical Aspects of IV Drugs

Pharmaceutical Aspects of
IV Medicine Administration
February 2009
September 2009
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Contents of Session
 The 5 Rights of Medicines Administration
 The 5 Components of Medicines
Administration
 Practitioner Responsibilities
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The Five Rights of
Medicine Administration
1.
2.
3.
4.
5.
Right patient
Right medicine
Right route
Right dose
Right time
……everytime!
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The Five Components of
Medicine Administration
1.
2.
3.
4.
5.
Selection
Prescribing
Preparation
Administration
Monitoring
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Why IV?
 Oral or other route of administration not
suitable or available
eg vomiting, diarrhoea, malabsorption, resting
gastro-intestinal tract, low muscle mass
 Where rapid effect or high/predictable
concentrations essential
 Medicine not effective via other routes eg
gentamicin, benzylpenicillin
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Advantages of IV
 Medicine gets into the circulation quickly
 Rapid effect achieved
 Predictable concentrations achieved i.e. 100%
reaches systemic circulation
 Some medicines cannot be given by another
route eg gentamicin
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Prescribing
 Prescription is clear, unambiguous and legal
 Medicine is essential and appropriate for
patient
 The patient is not allergic to medicine
 Dose, route and rate essential and appropriate
 Medicine is compatible with flush and infusion
fluid
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Medicines Characteristics
 Cytotoxics, TPN – outsourced or made in pharmacy
 Diazepam – must only be administered with extreme
caution and competence
 IV paracetamol reduced dose in patients weighing less
than 50Kgs (dose 15mg/Kg in 40kg patient = 600mg)
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Dose, Route and Rate
 Is route suitable for medicine?
eg vincristine given intrathecally causing death,
cytotoxics given peripherally causing severe
extravasation and loss of limbs
 Is route suitable for required rate?
 Properties of the medicine? eg osmolarity, pH
 What routes are available?
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Concentration, Diluent and Vehicle
Concentration
 Check that the concentration of the drug is within
the recommended range for safety and efficacy
eg erythromycin must be between 1-5mg/ml
Diluent and Vehicle
 Not always the same!
 Check!
eg clarithromycin must be reconstituted with
water but diluted in sodium chloride 0.9%
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Compatibility and Stability
 Instability – modification of the preparation due to
storage conditions resulting in unsuitable product
 Incompatibility – two or more products mixed with
resulting preparation unsuitable for administration
 Results: product becomes toxic, precipitates or
ineffective
 Never add medicines to fluid unless compatibility
assured
 Never mix medicines together unless compatibility
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assured
Compatibility and stability
• Heparin / Aminoglycosides
• Hydrocortisone / flucloxacillan
• Co-amoxiclav - stability when
reconstituted
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3. Preparation:
Factors Affecting Stability
Factor
Effect
Action
Light
 rate of
degradation
Ensure appropriate TPN, Pabrinex®
storage
Temperature
 rate of
degradation /
microbial growth
Ensure appropriate Aciclovir,
storage
insulin, TPN
pH
 rate of
degradation
Add buffer
Amphotericin
Concentration Less stable at
changes in
concentration
Check volume
Amiodarone,
amphotericin
Adsorption
Avoid or minimise
contact
GTN, insulin
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Drug loss into
plastic/glass
Example
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Displacement Volumes and pH
Displacement volume
 volume of fluid displaced by a powder when
reconstituted
 Important when part-vials are used
 Mainly only relevant to paediatrics
pH
 Most medicines are stable at a specific pH
 Rate of degradation often pH dependent
eg amphotericin requires glucose pH>4.2
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Labelling
 All products must be labelled fully
 Complete label before preparing injection
 A record must be kept of all injections
prepared and administered (kardex, infusion
chart or both)
 Bolus drugs …must be administered
immediately on preparation, do not prepare
in advance!
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Sources of Information







IV Drug Monographs/ Medusa website
BNF/BNFC
Product Information Leaflet
Medicines Information
Pharmacist
On-call Pharmacist
University College London Hospitals
Injectable Medicine Administration Guide
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Red Man Syndrome
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Rate of Administration
 Most IV bolus injections over at least 3-5 minutes
 Ensure device is capable of accurate delivery and desired
infusion rate
 95% of IV bolus injections given too fast
Systemic damage
 Furosemide  ototoxicity
 Phenytoin  arrhythmias
 Ranitidine  bradycardia
 Vancomycin  red man
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Local damage
 Pain
 Extravasation
 Phlebitis
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IV Error Potential
 Article in BMJ 2003
- Errors identified in 49% of doses surveyed
- 8% wrong diluent/solvent
- 3% wrong dose prepared
- 3% of doses omitted
- 38% of bolus doses given too fast
- 3% incompatibility
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Professional Responsibility
Prescriber and Administrator
 Prescription is clear, unambiguous and legal
 Medicine is essential and appropriate
 Dose, route and rate is essential and appropriate
 Medicine is compatible with infusion fluid
 Appropriate monitoring requirements are in place
eg ECG machine for potassium infusions
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Professional Responsibility
Nurse
 Must have completed IV Medicines Training Package,
be certified competent and be aware of own limitations
 Training must be recognised by NHSGGC
 Must not administer a drug if doubtful about any aspect
of IV medicine prescription / calculation / preparation /
compatibility / administration / monitoring
 Must ensure that appropriate and current information
sources used
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Professional Responsibility
Pharmacist
 Specialist knowledge
 Access to specialist information
 Can advise and provide support on any aspect of IV
medicine use ie dose, calculations, method and rate of
administration, diluents, stability and incompatibilities
 Can provide advice 24 hours a day via ward
pharmacist, medicines information or on-call
pharmacist
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Remember
If in doubt, don’t administer!
Most important consideration is the
PATIENT
They have to suffer the consequences
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