I write in response to your request for information in relation to pharmacy drug guidelines within NHS Lothian.

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1 Lothian NHS Board = Waverley Gate 2-4 Waterloo Place Edinburgh EH1 3EG = Telephone: Dear FREEDOM OF INFORMATION IV POLICIES Date: 03/10/2016 Our Ref: 1110 Enquiries to : Richard Mutch Extension: Direct Line: richard.mutch@nhslothian.scot.nhs.uk I write in response to your request for information in relation to pharmacy drug guidelines within NHS Lothian. Question: I attach a further request under the Freedom of Information (Scotland) Act 2002 seeking the policies and/or guidance in place in 2008 in NHS Lothian hospitals which would deal with: Adult critical care standard intravenous (IV) infusions. Pharmacy drug guidelines which cover the use of Calcium Chloride and Calcium Gluconate. The request is in connection with extravasation procedures and whilst the previously enclosed Guidelines for safe handling of drugs is helpful I am not just seeking cancer specific guidance. Answer: I have been provided with information to help answer your request by the Pharmacy Department of NHS Lothian. Further to your previous request for the versions in place in 2008, the IV guide monograph in place in 2008 for calcium gluconate produced by Medicines Information is enclosed. The intensive care unit (ICU) calcium guideline for NHS Lothian did not become developed until 2010 (enclosed), but prior to that there was an ICU calcium at the Royal Infirmary of Edinburgh (enclosed) that was then developed into the Lothian wide guideline. Please note that NHS Lothian has a policy of not releasing the names and details of staff below Board level, this information has been redacted under Section 38 of the Freedom of Information (Scotland) Act 2002 Personal Information. I hope the information provided helps with your request. If you are unhappy with our response to your request, you do have the right to request us to review it. Your request should be made within 40 working days of receipt of this letter, and we will reply Headquarters Waverley Gate, 2-4 Waterloo Place, Edinburgh EH1 3EG Chair Brian G Houston Chief Executive Tim Davison Lothian NHS Board is the common name of Lothian Health Board

2 Iv policies - September 2016 within 20 working days of receipt. If our decision is unchanged following a review and you remain dissatisfied with this, you then have the right to make a formal complaint to the Scottish Information Commissioner within 6 months of receipt of our Review response. You then have the option to proceed to the Court of Sessions if dissatisfied with the Commissioners decision. If you require a review of our decision to be carried out, please write to the FOI Reviewer at the address at the head of this letter. The review will be undertaken by a Reviewer who was not involved in the original decision-making process. FOI responses (subject to redaction of personal information) may appear on NHS Lothian s Freedom of Information website at: Yours sincerely PROFESSOR ALEX MCMAHON Executive Director, Nursing, Midwifery and AHP's Cc: Chief Executive

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4 FOR ICU USE ONLY CALCIUM PRESENTATION: INDICATION: Reference ranges: Ampoules containing calcium gluconate 10%w/v equivalent to 2.2mmol of calcium per 10ml. Correction of acute hypocalcaemia. ADJUSTED CALCIUM mmol/L IONISED CALCIUM mmol/L NB Lab calcium results are NOW reported corrected for albumin level as Adjusted Calcium. Ionised Ca 2+ may be more relevant especially in liver disease/transplant or massive transfusion. Asymptomatic low calcium levels usually require no treatment discuss with consultant. [For Calcium channel blocker poisoning Follow TOXBASE advice.] DOSE AND ADMINISTRATION: ICU STANDARD INTRAVENOUS INFUSION Peripheral or Central intravenous administration. 4.4mmol Ca 2+ in 100ml glucose 5% over at least 30minutes. Undiluted calcium gluconate 10%w/v can be used, 4.4mmol Ca 2+ slow IV over 5 minutes (preferably via a central catheter as it is irritant to veins). Doses may need to be repeated as required OR followed by continuous infusion. In severe acute hypocalcaemia or tetany: a continuous IV infusion of 0.048mmol/kg/hr can be used with frequent monitoring of serum calcium levels. STABILITY: ADDITIONAL NOTES: Physically and chemically stable for 24 hours at room temperature. Correct concurrent hypomagnesaemia. Necrosing and sloughing if extravasation occurs. Also stable in sodium chloride 0.9% References 1. Handbook on Injectable Drugs. Ed. Trissel L.A. 15 th edition, American Society of Health System Pharmacists Inc. 2. Martindale. The Complete Drug Reference. 35 th edition. Pharmaceutical Press Summary of Product Characteristics. Calcium Gluconate injection BP10% w/v Accessed 13/07/ The Preparation and Administration of Parenteral Medicines, version 4 prepared by; Lothian Medicines Information Service, Department of Pharmacy 5. Adult Medical Emergencies Handbook NHS Lothian University Hospitals Division, Calcium gluconate. Injectable Medicines Guide accessed via 24/11/10 Written by: Anne Neally Approved by: Critical Care Directorate Editorial Board Issue Date: December 2010 Review Date: Decenber 2012 FOR ICU USE ONLY

5 CALCIUM GLUCONATE Drug classification Electrolyte. Presentation Ampoules containing a solution of calcium gluconate 10% w/v, providing 2.2mmol of calcium in 10ml (220micromols/ml) (1). Reconstitution Not applicable. Concentration of final solution Suggested volume for infusion - 100ml. Special note: An infusion is used only for correction of hypocalcaemia NOT for treatment of dangerous hyperkalaemia or emergency treatment of tetany in hypocalcaemia. See information below under section Other recognized routes of administration for treatment of dangerous hyperkalaemia and emergency treatment of tetany in hypocalcaemia. Preferred method of IV administration Intravenous infusion. Infusion fluids Compatible with: Glucose 5% IV infusion (1). Glucose 10% IV infusion (2). Sodium chloride 0.9% IV infusion (1). Stability in solution Prepare immediately before use. Do not use if solution is not clear (1). If precipitate appears discard solution (4). Discard any remaining infusion within 24 hours of preparation (2). Administration rate Administer over at least 30 minutes. Maximum rate of 0.44mmol/min (440micromols/min) (4). Other recognised routes of administration Intramuscular and subcutaneous injections are not recommended since irritation and tissue necrosis can occur (2). For emergency treatment of tetany in hypocalcaemia, the calcium chloride 10% Minijet should be used and is given as an intravenous injection (5). See NHS Lothian Adult Medical Emergencies Handbook for further details. Maximum rate of intravenous injection is 2ml per minute (4). The Preparation and Administration of Parenteral Medicines Lothian Medicines Information Service, Department of Pharmacy Version: 4.0 Monograph: CALGLUC

6 In emergencies, for the treatment of hyperkalaemia, direct intravenous injection of undiluted calcium chloride 10% can be used. 1ml aliquots are given watching the ECG. The amount required for trace to normalize varies from 2 to 3ml to 20ml (5). To be given by doctor - see NHS Lothian Adult Medical Emergencies Handbook for further details. Drug compatibility at Y-site Compatibility with potassium chloride at Y-site: Other drugs should not be co-administered with calcium gluconate without seeking further advice. 40mmol/L potassium chloride in sodium chloride 0.9% IV infusion, compound sodium lactate IV infusion or glucose 5% IV infusion is compatible with calcium gluconate 100mg/ml (2.2mmol/10ml) for up to 4 hours at a Y-site (2). Special notes Stability: Store ampoules below 25 o C and protect from light (1,4). Sodium content: Hazards: Nil (4). If administered too rapidly nausea, vomiting, hot flushes, sweating, hypotension and vasomotor collapse (possibly fatal) may occur (1). Calcium salts are irritant. The infusion site must be monitored regularly to ensure extravasation injury has not occurred (1,4). Other comments: Patients receiving calcium gluconate infusions should have calcium levels monitored regularly. References 1 Calcium Gluconate Injection BP. Hameln Pharmaceuticals Lts. Summary of Product Characteristics. Last updated 03 June Handbook of Injectable Drugs. Ed. Trissel, LA, 14th edition, American Society of Hospital Pharmacists Inc. 3 MHRA Drug Safety Update; 1(4): 5 November Calcium gluconate. Injectable Medicines Guide accessed via 24/6/08 5 Adult Medical Emergencies Handbook Edinburgh:NHS Lothian Available at dult%20medical%20emergencies%20handbook%202007%20-% pdf (Accessed 10 July 2009). The Preparation and Administration of Parenteral Medicines Lothian Medicines Information Service, Department of Pharmacy Version: 4.0 Monograph: CALGLUC