Title of Guideline (must include the word Guideline (not protocol, policy, procedure etc) Contact Name and Job Title (author) Cardiac Catheter Lab IV Medicines Guideline Helen Buxton ( Senior Cath Lab Nurse) Lou Beaumont ( Cardiology Pharmacist) Directorate & Speciality CAS Cardiology Date of submission Jan 2015 Date on which guideline must be reviewed Jan 2020 Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis) Patients undergoing procedures in the cardiac catheter labs - City Campus Version 1 Abstract Key Words Statement of the evidence base of the guideline has the guideline been peer reviewed by colleagues? IV Medication Guide Cath Lab IV drugs cath labs expert committee reports or opinions and / or clinical experiences of respected authorities Evidence base: (1-6) 1 NICE Guidance, Royal College Guideline, SIGN (please state which source). 2a 2b 3a 3b meta analysis of randomised controlled trials at least one randomised controlled trial at least one well-designed controlled study without randomisation at least one other type of well-designed quasi-experimental study 4 well designed non-experimental descriptive studies (ie comparative / correlation and case studies) 5 expert committee reports or opinions and / or clinical experiences of respected authorities 6 recommended best practise based on the clinical experience of the guideline developer Consultation Process Target audience MMC, Cardiology Pharmacy, Head of Service, Lead consultant cath labs, Cardiology Governance. Cardiac Cath Lab Nurses. 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. Caution is advised when using guidelines after the review date.
Method of by Abciximab (ReoPro ) Dr solution 10mg in 5mL. Pre filter into syringe using a 0.22 micron filter. Inject over 1 minute. G, S Pre filter solution using 0.22micron filter when infusion prepared. Infused usually at a rate of 7.5 micrograms/kg/hour. (up to maximum of 600 micrograms/hour.) The infusion is prepared in a 50mL syringe. A syringe pump or volumetric pump should be used to control the infusion rate See prescription chart in the appendix.
Method of by Adrenaline (Epinephrine) Dr unless local agreement solution 1 in 10,000 (1mg in 10mL) in prefilled syringe (and 1mL and 10mL ampoules) Amiodarone Dr solution 150mg in 3mL. Prefilled syringe 300mg in 10mL for cardiopulmonary resuscitation CPR For cardiac arrest: Inject rapidly. Administer via a central line or into a large peripheral vein. If injection administered via a peripheral vein it should be followed by a 20mL flush of S. Resuscitation: preferably use prefilled syringe and give as fast as possible (followed by flush). In extreme clinical emergencies: inject over a minimum of 3 with close ECG monitoring. (if pre-filled syringe unavailable the dose may be drawn from the ampoule(s) and diluted with 10-20mL G). G ONLY Administered into central vein using a volumetric pump. Loading dose: add required dose to 250mL G and give over 30 initially via volumetric pump. Alternatively administer loading dose in 25mL G over 30 using a syringe pump. Maintenance dose: add required dose to 500mL G and give over 24 hours via volumetric pump. Concentration must not be less than 0.6mg per ml. Alternatively administer maintenance dose in 48mL G over 24 hours using a syringe pump. Amiodarone should only be diluted with Glucose 5%. Do not mix with Sodium Chloride 0.9%. Flush with Glucose 5% only. Intravenous Amiodarone should be administered via a central venous catheter. Amiodarone given peripherally may result in serious tissue damage. In exceptional situations when placement of a central line is not possible, is high risk or will delay vital treatment, a peripheral line with good blood flow (such as antecubital fossa) may be used via a large bore cannula. Under no circumstances administer more than 2mg per ml by the peripheral route.
Method of by Aspirin UNLICENSED Add 5mL WFI to each 500mg vial Inject over 3-5 G,S Add required dose to 100-250mL bag of infusion fluid and infuse over 20. Atenolol Dr solution 5mg in 10mL May be further diluted to a convenient volume and injected at a rate of 1mg per minute G, S, GS Withdraw dose required and further dilute in 50-100mL bag of infusion fluid and infuse over 20. Doctor should be in attendance for infusion. ECG monitoring required. Monitor blood pressure and heart rate. Atropine Dr solution 600 micrograms in 1mL Inject over 3-5 G, S Preferably administer via a large peripheral vein (or central venous catheter) to avoid potential venous irritation as the preparation has a low ph Chlorphenamine (Chlorpheniramine) solution 10mg in 1mL Inject over at least 1 minute. G, S
Method of by Cyclizine solution 50mg in 1mL. Dilute to 10mL with WFI, G or S, before injection. Inject over 3-5 G, S Diazepam emulsion (Diazemuls) Dobutamine Dr solution 10mg in 2mL ampoule Further dilute with 8mL S to give 1mg/mL solution 250mg in 20mL ampoules. Further dilute for infusion Inject at a maximum rate of 1mL per minute into a large vein G ONLY For continuous intravenous infusion: add 2-8mL to 100mL G to give concentration of 100-400 micrograms in 1mL. Maximum concentration 200mg in 500mL Volumetric pump required. G, S Further dilute for infusion with S or G. Suggested dilution: withdraw 40mL from a 500mL bag then add 2 ampoules (500mg) to the bag. This gives a 1mg per ml solution. In fluid restricted patients: refer to Critical Care guidelines. Rate of varies according to indication. Administer using a volumetric pump (or syringe pump if fluid restricted). Note: contraindicated in patients allergic to egg or soyabean. Some adsorption to plastic. Should be used within 6 hours. Reversal agent of sedative effects of Diazepam solution is FLUMAZENIL. Please see flumazenil for methods. Preferably administer via a central venous catheter or large peripheral vein to avoid potential venous irritation as the preparation has a low ph. Solution may turn slightly pink in prepared solutions, but no significant loss of potency is associated with this change. ECG monitoring required. SEE APPENDIX FOR CENTRAL INFUSION GUIDE
Method of by Dopamine solution 200mg in 5mL, 800mg in 5mL ampoules. Further dilute for infusion G, S Further dilute for infusion with S or G. Suggested dilutions: Peripheral : withdraw 20mL infusion fluid from a 500mL bag, add 800mg dopamine to give a 1.6mg per ml solution. Central vein : withdraw 40mL from a 500mL bag, then add 1600mg dopamine to give a 3.2mg per ml solution. restricted: refer to local protocols. Administer using a volumetric pump or syringe pump. Rate according to indication. Preferably administer via a central venous catheter or large peripheral vein to avoid potential venous irritation as the preparation has a low ph. Do not use concentration greater than 2mg per ml for peripheral. ECG monitoring required. SEE APPENDIX FOR CENTRAL AND PERIPHERAL INFUSION GUIDE. Eptifibatide solution 20mg in 10mL vial solution 75mg in 100mL vial Inject required dose over 1-2 S flush See prescription chart in the appendix. Infuse at a rate of 2micrograms/kg/minute using a volumetric pump
Method of by Flecainide Dr solution 150mg in 15mL ampoule Flucloxacillin This is a PENICILLINcheck allergy status of patient before Add 10mL WFI to 250mg and 500mg vial. Add 20mL WFI to 1g vial. Flumazenil Dr solution 500 micrograms in 5mL ampoule Over at least 10-30 For doses up to 1g: Inject over 3-4 Inject required dose over 15 seconds. Further doses may be given at 60 second intervals if required. G (G flush) S, G (S preferred) May be diluted in 20mL to 500mL of G and given as an infusion using volumetric pump. Rate of infusion depends on indication. For doses above 1g: add the required dose to 100mL infusion fluid and infuse over 30-60. G, S Dilute to a convenient volume with S or G and infuse via a syringe pump (Usual rate 100-400micrograms per hour). ECG monitoring required for bolus dose Preferably administer via a large peripheral vein (or central venous catheter) Flumazenil is the reversal agent for Diazemuls and should be available when these drugs are used.
using a side arm of a giving set or into indwelling cannula without further dilution Furosemide Gentamicin up to 50mg More than 50mg For once daily dosing For tds dosing solution 20mg in 2mL, 50mg in 5mL and 250mg in 25mL ampoules. solution 80mg in 2mL and 20mg in 2mL vials Required dose may be further diluted with S. Inject at a rate not exceeding 4mg per minute, i.e. give 20mg over 5. Inject slowly over 3-5 ). Can be with 10-20mL S or G to aid slow S ONLY Method of by container (Doctor does not need to be in attendance unless stated. Nurse can administer by infusion if instruction in this column) Further dilute in 50mL to 250mL of S. Infuse using a syringe pump or volumetric pump. Do not exceed a rate of 4mg per minute. S, G Add required dose to 100mL of infusion fluid and infuse over 60 For infusion dilute with 50-100mL S or G and administer over 20-30 Additional Information NOTE: Levels should be monitored. See antibiotic intranet site for further information.
using a side arm of a giving set or into indwelling cannula without further dilution Glucose 50% Dr solution Heparin solution 5000units in 5mL solution 10,000units in 10mL and 20,000units in 20mL ampoules Small volume only. Inject over at least 5 mins. When used for the emergency treatment of hypoglycaemia may be administered slowly into a large peripheral vein. Inject over 3-5 as a loading dose prior to infusion Method of by container (Doctor does not need to be in attendance unless stated. Nurse can administer by infusion if instruction in this column) Central line preferred. For short infusions (e.g. 30 ) with insulin to treat hyperkalaemia, peripheral vein has been used. Additional Information Glucose 20% is less irritant and can be given via a peripheral vein for several hours. G, S See heparin intravenous infusion protocol for further information Infuse using a syringe pump at a rate according to APTT ratio. The concentration used for infusion must always be 1000units per ml
Compatibl e Method of by Heparin flushes Flush solution. 5000 units/5ml G, S For use in the cardiac catheter lab as an intra-arterial flush by the operator. Also for the flushing of Catheters and wires pre- insertion into arterial sheath. Further dilute 5000 units of Heparin in 500mL Normal saline 0.9%. Protamine is the reversal agent for Heparin and should be readily available when this drug is being used. Please see Protamine for methods. Hydrocortisone sodium succinate (Solu- Cortef ) Isoprenaline UNLICENSED Add 2mL WFI to 100mg vial Inject over 1-10 G, S Further dilute for infusion to 100-1000mL. The final concentration should be no greater than 1mg per 1ml. Infuse over 20-30 using a volumetric pump. Please see appendix for information on.
Method of by Isosorbide Dinitrate solution 1mg/mL (0.1%)(various sizes). Further dilute for infusion G, S Dilute to 1mg in 2mL in syringe pump.(ie dilute with equal volume) Variable rate of infusion according to blood pressure and patient response. See guideline for use including monitoring requirements and Y-site incompatibilities. DO NOT add to PVC containers. Metoclopramide solution. 0.5mg per ml (50mL bottle)(0.05%) Preferred product as no required. solution 10mg in 2mL (Also 20mL Maxolon 'High dose' ampoules). Inject 10mg in 2mL preparation over 1-2 Infuse using a syringe pump (no needed). G, S, GS, H Dilute the high dose Maxolon (up to 2mg/kg) with at least 50mL infusion fluid. Infuse over at least 15. May be given by continuous infusion
Method of by Midazolam Dr solution 5mg in 5mL ampoule (conscious sedation), 10mg in 2mL ampoule (palliative care usually given by subcutaneous injection or infusion) Dose/rate according to indication. G, S, GS Infuse continuously using syringe pump. Standard concentration for infusion 1mg in 1mL Caution-Risk of overdose when administering for conscious sedation. Preferably administer via a large peripheral vein (or central venous catheter) to avoid potential venous irritation as the preparation has a low ph. Reversal agent of sedative effects of Midazolam solution is Flumazenil. Please see Flumazenil for methods. Morphine Sulphate Dr unless local agreement solution 10mg in 1mL. Further dilute with 9mL S to give 1mg/mL Over 5 G, S, GS, H May be infused continuously using syringe pump with adequate monitoring respiratory rate. Patient controlled analgesia prepared as for infusion. Reversal agent of opioid induced respiratory depression is Naloxone. Please see Naloxone for methods.
Method of by Naloxone Ondansetron Protamine Sulphate Dr solution 400micrograms in 1mL ampoule solution 4mg in 2mL and 8mg in 4mL ampoules solution 50mg in 5mL ampoule Dose may be diluted to a convenient volume with WFI, S or G and injected over 30 seconds. This may be repeated if necessary. Inject over 3-5 Inject over 10 G, S For reversal of opiate induced respiratory depression: Add 2mg (5 ampoules of naloxone 400micrograms in 1mL) to 500ml of infusion fluid. For emergency treatment of opioid overdose: Dilute 4mg in 20mL or 10mg in 50mL and infuse via a syringe pump (unlicensed concentration) G, S,H Dilute in 50-100mL of infusion fluid and infuse over 15. For continuous infusion dilute as above and infuse at a rate of 1mg per hour using a volumetric pump. In patients age 65 years or older, all intravenous doses for prevention of Chemotherapy Induced Nausea and Vomiting should be diluted in 50 100 ml S or other compatible fluid and infused over at least 15 Maximum of 50mg given in one dose.
Method of by Teicoplanin Tirofiban (Aggrastat ) Solution for infusion (250mL bag) Add diluent provided (WFI) to 200mg and 400mg vial. Reconstitute each drug vial with the entire vial of WFI. Slowly inject the WFI down the vial wall, swirl gently or roll to ensure the powder fully dissolves. If a froth forms, leave for 15 to settle. Ready prepared solution for infusion 12.5mg in 250mL (50micrograms per ml). Inject over 3-5. G,S,GS, H May be further diluted and infused over 30. G, S Loading infusion rate followed by maintenance infusion rate according to body weight. Maximum duration of treatment should not exceed 108 hours. See prescription chart in the appendix.
Method of by Vancomycin Add 10mL WFI to each 500mg vial. Add 20mL WFI to each 1g vial. Further dilute for infusion. Verapamil Dr solution 5mg in 2mL Inject 5-10mg over 2-3. Observe continuously and monitor ECG and blood pressure. G, S Dilute 1g in 250mL infusion fluid. Maximum concentration is 5mg per ml. (10mg per ml in fluid restriction but increased risk of infusion related effects). Infuse at a rate not exceeding 10mg per minute using a volumetric pump (i.e. 1g over at least 100 ). G, S NOTE: Levels should be monitored. See antibiotic intranet site for further information. Preferably administer via a large peripheral vein (or central venous catheter) to avoid potential venous irritation as the preparation has a low ph.