CICU STANDARD INTRAVENOUS INFUSIONS CHART

Transcription

1 IU STANDARD INTRAVENOUS INFUSIONS HART Full Title of uideline: Author (include and role): Division & Speciality: Version: 2 Ratified by: Scope (Target audience, state if Trust wide): Review date (when this version goes out of date): Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis): hanges from previous version (not applicable if this is a new guideline, enter below if extensive): Summary of evidence base this ardiac Intensive are Standard Intravenous s hart Emily Payne- Specialist linical Pharmacist ritical are. emily.payne@nuh.nhs.uk Medicine- ardiac Surgery ardiac overnance roup Medical, Nursing and Pharmacy staff working on IU/HDU or ardiac Theatres December 2020 ardiac Surgery Patients See supporting information See references guideline has been created from: This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. aution is advised when using guidelines after the review date or outside of the Trust.

2 ARDIA INTENSIVE ARE STANDARD INTRAVENOUS INFUSIONS HART This guide should only be used in combination with the current Nottingham University Hospitals uide to IV therapy or MEDUSA (National Injectable Medicines uide) and the NUH Medicines ode of Practice. REOMMENDED drug s and dose ranges are specified; departure from these is allowed at the discretion of the prescriber in order to accommodate the needs of the individual patient. Many of the doses and infusion s used are unlicensed. Drug Adrenaline (Epinephrine) 1mg/ml (Epinephrine 1:1000) 4mg in 100ml 0-1 mcg/kg/min an be made double strength (8mg in 100ml) Alfentanil Amiodarone (Loading dose) Amiodarone (24 hr maintenance infusion) Amiodarone (Once daily maintenance dose when oral administration of the loading or maintenance dose is not possible) 25mg in 50ml S,, S / P 0-10mg/hr an make double strength 50mg in 50ml 150mg or 300mg in 25ml Day 1 900mg in 48ml Day 2 onwards 600mg / 900mg in 48ml See below for dosing when the oral route is not available. Desired dose made up to 25ml Infuse over 30mins May be repeated for unresponsive arrhythmias 300mg in 10ml pre-filled syringe may be given ly during a peri-arrest / cardiac arrest only mg over 24 hours Infuse via a syringe driver Infuse over 60 mins For patients <50kg give 5mg/kg, max loading dose is 300mg. Incompatible with Nal 0.9% Max dose in 24hrs: 900mg For low weight (<50kg patients) consider reducing dose to 600mg (based on 15mg/kg) Incompatible with Nal 0.9% onsider this dose once patient is stabilized. 300mg IV is bio-equivalent to 200mg three times daily orally. Tablets can be crushed and dispersed for NT administration.

3 Argatroban 250mg in 2.5ml Atracurium (10mg/ml) alcium chloride 14.7% 10ml=10mmol alcium alcium gluconate 10% 10ml = 2.26mmol alcium 250mg in 250ml S or P See trust wide guideline Heparin-Induced Thrombocytopenia.(HIT) Recommended initial starting rate of 0.5mcg/kg/min (in critically ill patients) Monitored via APTT ratio aiming for times baseline value. (Not exceeding 100 seconds). Measure baseline APTT initially, then monitor as per guideline: es/2444.pdf 500mg in 50ml Neat / P 0-8ml/hour Monitor with a nerve stimulator (TOF). Incompatible with Propofol 5mmol in 30-50ml S preferred Or large S preferred Or large for NEAT infusion Infuse over mins For urgent correction of acute severe hypocalcaemia / tetany or arrhythmias in hyperkalaemia add 10ml in 100ml (2.26mmol) and infuse over 10 mins. Alternatively 10ml (2.26mmol) may be given as a slow bolus over 5 minutes. orrection of severe hypocalcaemia in critical care areas 50ml (11.3mmol) UNDILUTED in a syringe administered over 2 hours with E monitoring For up to 24hours post-op for hypotension. Dr/ANP AVAILABLE. NEVER EXEED a rate 0.5mmol /min. E monitoring essential. Risk of asystole, bradycardia and hypotension with rapid IV administration. Ensure low magnesium levels are corrected. MUST NOT be administered simultaneously with eftriaxone. heck levels two hours post infusion. A trust wide guideline for replacing severe hypocalcaemia using a large volume infusion over 24 hours exists. In practice this is rarely used within critical care due to the volume and need to dedicate an IV line for the infusion period.

4 lonidine Drug Digoxin 750micrograms (5 amps) in 50ml micrograms in ml Dobutamine 250mg/50ml Neat S, / P 0-2micrograms/kg/hr Monitor for hypotension and bradycardia, consider the need to reduce dose. Risk of accumulation in renal failure, reduce dose and review regularly. S,, S / P Loading dose infused over minutes, maintenance dose infused over 1-2 hours. E monitoring required for loading dose micrograms/ kg/ min 1-2mg/ml may be infused into a large in an emergency post arrest. Dopamine 400mg in 100ml Erythromycin 250mg in 50ml Add 20ml WFI to 1g further dilute with S Esmolol Furosemide (Frusemide) 100mg in 10ml amps for bolus doses only 2.5g in 250ml ready made bag for infusions Already diluted / P preferred Or large 0-10micrograms/kg/min 250mg twice a day as a prokinetic. ive over 20-30mins. Treatment of tachyarrhythmias/hypertension: 80mg bolus over 30 seconds then continuous infusion microgram/kg/min Max 300mcg/kg/min 120mg in 48ml S / P Infused over 24 hours at a rate of 0-2ml/hr On IU often used at lower rates for renal perfusion and to improve urine output. At higher doses used to improve cardiac output. an be used in combination with metoclopramide IV 10mg three times daily for up to 7 days. Stop if watery diarrhea develops. At consultant request only bag is sealed in a moisture barrier overwrap. As such, bags may have moisture apparent when opened.

5 lyceryl trinitrate Heparin sodium Insulin (Human Actrapid) Insulin / Dextrose (Hyperkalaemia) Actrapid insulin Trust wide guideline 50mg in 50ml Neat / P 0-24ml/hr (0-400microgram/min) 30,000 units in 30ml Neat / P Prescribe on and as per NUH heparin chart 50units in 50ml S / P Sliding scale hange infusion at 24 hrs and giving set at 72 hrs. 10units Insulin Actrapid in 50ml 50% glucose preferred or large Infuse over 30 mins Infuse via syringe pump. Use polyethylene extension sets. See Local agreement for nursing staff to adjust infusion rates as per APTT. Refer to VVH prescription and guideline if using heparin for anticoagulation of filter. Each vial should be labelled for individual patient use and stored in patient locker. 28day expiry once opened. onsider need for cardio protection with 10ml alcium gluconate 10% 2.25mmol given over at least 5 mins. Monitor BMs after 15mins, 30mins then hourly. Isoprenaline sulphate Labetalol 2.25mg in 50ml only 300mg in 60ml (5mg/ml) Neat Start at 1.5ml/hr increasing by 1.5ml/hr every 2-3 mins to until satisfactory heart rate achieved or side effects max rate 15ml/hr (Usual dose range micrograms/min) 0 200mg / hr (0-40ml/hr) Unlicensed use of an unlicensed preparation. E monitoring necessary. In an Emergency may be used ly if diluted to 2.25mg in 500ml lucose 5%. If needed 4.5mg in 50ml can be used and rates adjusted accordingly. For Peripheral administration dilute to 1mg/ml with (preferred), or S ontra-indicated in asthmatics an give as intermittent boluses 50mg repeated after 5minutes to a max of 200mg. Average duration of action approx 6 hours.

6 Levosimendan Lidocaine (Lignocaine) (loading dose) Lidocaine (Lignocaine) (infusion) Magnesium sulphate 50% 2mmol /ml (1g= 4mmol) Metaraminol 12.5mg in 250ml (50micrograms/ml) Already in solution 1% (10mg/ml) or 2% (20mg/ml) 0.2% (2mg/ml) or 0.4% (4mg/ml) in 500ml 5% glucose ready made bags for infusions Arrhythmias / Hypomagnesaemia 8-16mmol in 100ml 20mg in 40ml (or 10mg in 20ml if likely short duration of infusion) preferred Or large Refer to separate levosimendan guideline / P Ventricular arrhythmias: Direct injection: mg (1mg/kg) at a rate of 25-50mg per minute, usually followed by infusion. If an intravenous infusion is not immediately available the initial intravenous injection of mg can be repeated if necessary once or twice at intervals of not less than 10 minutes. Maximum dose 300mg in 1 hour. Already diluted (S for flushes) / P Following a bolus injection usual infusion rate is 4 mg/minute for 30 minutes, 2 mg/minute for 2 hours, then 1 mg/minute; reduce further if infusion continued beyond 24 hours S,, S / P Over 1 hour or S preferred or large 0 10mg/hr (0-20ml/hr) Usual starting rate 0.5mg/hr (=1ml/hr), titrate at 10 minute intervals Intravenous administration of lidocaine is a high risk intervention and should only be used by specialist medical staff competent in its use-. E monitoring is required. Intravenous administration of lidocaine is a high risk intervention and should only be used by specialist medical staff competent in its use. E monitoring is required. Bolus dose usually given by Dr/ANP prior to initiating an infusion. Emergency use prior to V line insertion.

7 Midazolam Drug Milrinone Morphine Naloxone Trust wide guideline Noradrenaline BASE (Norepinephrine) 4mg in 4ml amp 1mg/ml or 2mg/ml Loading dose: dilute dose to 10ml. ontinuous infusion: 10mg in 50ml (200mcg/ml) 1mg/ml or 2mg/ml 4mg (10x 400mcg) made up to 20ml S,, S / P 0-20mg/hr Adjunct in patients requiring sedation. Avoid Y site administration with Hartmann s solution due to decreased potency of the infusion. Accumulates in renal failure, review the dose administered regularly. S, preferred or large Loading dose of 50micrograms/kg over 10mins, then a continuous infusion of 0.375micrograms/kg/min- 0.75micrograms/kg/min Total daily dose should not exceed 1.13mg/kg. Usually for up to 12 hours following cardiac surgery. S,, S / P 0-20mg/hr onsider in patients who require prolonged sedation. S, preferred or large 4mg in 100ml Refer to guideline For EMERENY USE : 5 x 400mcg Naloxone amps kept in anaphylaxis/over sedation box on arrest trolley. Dosing cards in the box. es/trust%20wide/trust%20wide/205 0.pdf PD exists for nurses to give slow IV bolus in 100mcg aliquots prior to the arrival of medical staff: ees/medicines_management_committ ee/patient%20roup%20directions/tr ustwide%2014%20%20naloxone%20 PD%20Feb%2015.pdf 0-1 micrograms/kg/min Noradrenaline Acid tartrate 2mg/ml is equivalent to 1mg /ml of Noradrenaline BASE an be made double strength 8mg in 100ml.

8 Omeprazole (High dose infusion) Phenytoin (Loading dose) Phenytoin (Maintenance once daily) Potassium chloride PFS Local agreement for nurse administration Potassium acid phosphate (potassium dihydrogen phosphate) 13.6% w/v soon Stat dose 80mg in 250ml infused over 1 hour Followed by 80mg in 250ml For doses up to 1g dilute in 100ml. For doses over 1g dilute in 250ml. (Max 10mg/ml. Min 2mg/ml). Dose in 50ml. (Max 10mg/mL) S preferred (see comments) / P 20mmol in 20ml Neat 30mmol in 100ml S Stat dose followed by 8mg/hr (25ml/hr) for 72hrs S / P Over mins. Max rate 50mg/min. Administration should commence immediately after the mixture has been prepared and must be completed within one hour. S / P Over mins Max rate 50mg/min. Administration should commence immediately after the mixture has been prepared and must be completed within one hour. See potassium guideline Infuse over 4 hours If prepared in S then 12 hour expiry. If prepared in then only 6 hour expiry, Loading dose 20mg/kg (max 2g) based on actual body weight BP and E monitoring recommended. Observe infusion to ensure no crystal formation. Incompatible with glucose. Starting dose 3-4mg/kg/day. Average sized pts often receive 300mg daily ive as once daily IV infusion. Not N in patients with 24 hour feeding +/- sliding scale insulin. Requires record of administration to be made in ward potassium register. onsider oral Sando K (12mmol per tablet) two when required if patient absorbing. 1ml of injection also contains 1mmol Potassium. Requires record of administration to be made in ward potassium register. onsider N Phosphate Sandoz if absorbing (16.1mmol per tablet).

9 Propofol 2% Rocuronium Sodium Nitroprusside 20mg/ml Neat / P 0-15ml/hr Max 4mg/kg/hr 500mg in 50ml Neat preferred or large 50mg in 50ml Initial bolus dose of 0.5mg/kg followed by an infusion 0 8ml/hr Hypertensive crisis start micrograms/kg/hr Increase by 30 micrograms/kg/hr every 5 minutes onsider lower starting doses if on other antihypertensives (maintain on lowest dose possible average 180micrograms/kg/hr) Range 30micrograms/kg/hrmax 480micrograms/kg/hr. If BP not controlled after 10 mins at max dose review and stop the infusion. hange giving set and syringe every 24 hours In obese patients the dose should be calculated using ideal body weight. Monitor with a nerve stimulator (TOF). Establish TOF prior to the bolus dose. Protect from light cover infusion and wrap giving set in foil/ silver wrapper provided. Freshly prepared solution has faint orange-brown colour. Only discard if highly coloured. stable for 24 hours. Avoid abrupt withdrawal; reduce over minimum of mins. For administration dilute to 50mg/250ml with. onsider checking cyanide levels if patient is showing signs of suspected toxicity. Test not carried out on site and may take up to 14 days for assay result to get back. Thiocyanate levels accumulate in renal failure, consider checking thiocyante levels if patient has been receiving high infusion rate for longer than 3 days duration or is showing signs of suspected toxicity. Test not carried out on site and may take up to 6 days for assay result to get back. If toxicity is suspected consider discussing with NPIS for advice.

10 Vasopressin -Argipressin (Pitressin) soon 40 units made up to 100ml units/min (1.5ml - 15ml/hr) Used for vasodilatory shock after cardiopulmonary bypass. Unless otherwise stated all infusions should be changed after 24 hours. Abbreviations = entral venous catheter, Femoral or long line P = Peripheral line Fluids S= Sodium chloride 0.9% = lucose 5% S = lucose 4% / Sodium chloride 0.18% H = ompound sodium lactate solution (Hartmann s) Nursing staff may prepare and administer all infusions listed in the ardiac Intensive are standard infusions chart against a valid prescription. For infusion s and s outside those listed in the table please contact the ritical are Pharmacist or on call pharmacist for advice. References The following references have been used for all drugs listed except where referred to specialist guidelines. Refer to individual guideline for reference details. BNF- British National Formulary accessed online at November 2017 SP- Summary of Product haracteristics for individual drugs accessed online at November 2017 Medusa- Injectable Medicines uide accessed online at November 2017 Handbook of Drugs in Intensive are - Paw, H; Handbook of Drugs in Intensive are [Fourth Edition] ambridge University press [2010] Injectable Medicines Administration uide- Pharmacy Department University ollege London Hospitals, Injectable Medicines Administration uide [Third Edition] Wiley Blackwell [2010] NUH uide to Adult ritical are Standard Intravenous s- Elizabeth Jamieson October

11 Document control/ supporting information for this clinical document Title: ardiac Intensive are Standard Intravenous s hart Approval: v. Approved by: Approval Date: ardiac overnance group December 2017 Superseded version dated 2012 Version History and Practice hanges/ Amendments Issue Date Version omments December Argatroban added and Danaparoid deleted. New agent for the management of heparin induced thrombocytopenia Atracurium max rate changed to match critical care guidelines. alcium chloride added. alcium gluconate entry updated to match critical care guidelines. Digoxin removed the need for doctor in attendance for the first dose. Dobutamine changed to 250mg/50ml vials as first choice in medusa. Furosemide infusion updated to match current practice on IU. Labetalol removed doctor available. hanged dosage range to 0-200mg /hr with higher doses rarely used in aortic dissection. Levosimendan monograph added. Metaraminol changed to 0.5mg/ml to mirror theatres practice. Naloxone updated PD dose details and quantity in boxes. Link added for PD Omeprazole monograph added. Rocuronium monograph added. Added information for all drugs where DERS programme available on the alaris volumetric pump.