Intravenous Medicine Administration Table
1. Introduction
1.1. The table on the following pages details appropriate methods of intravenous administration for all medicines except cytotoxics (see local policy) which can be given by this route and which are stocked in Imperial College Healthcare NHS Trust.
1.2 The table contains information which is included in each product 'Summary of product characteristics', or information which is used in general practice. There will be times when a patient's clinical status justifies a change from instructions in the table. In this situation, the nurse/midwife or medical practitioner should contact the Pharmacy Medicine Information department or on call pharmacist for instructions on how to administer the relevant medicine.
1.3 Medicines can be administered intravenously via a peripheral or a central line unless the table specifically states otherwise.
1.4 Manufacturers may occasionally use European notation in the 'Summary of product characteristics' and package insert. A decimal point may be used in place of a comma, which is the normal UK convention. e.g.
UK notation:-
One thousand micrograms in 1ml is expressed as 1,000micrograms/1ml
European notation:-
One thousand micrograms in 1ml may be expressed as 1.000micrograms/1ml
1.5 The current Guidelines for Intravenous Medicine Administration are available on the intranet;
Hammersmith Hospitals:
Open Source on the Trust Intranet:
Select in order:
A-Z Departments
Pharmacy
Medicines Policy
Section 6: Intravenous Medicine Administration
St Mary’s Hospital:
Find Documents
“Medicines Policy”
Section 8: Administration of Medicine
2. Information about the Table
General
2.1. Definition
The Table is a collection of monographs describing the most suitable preparation and administration of intravenous medicines available in the Trust. The relevant monograph should be consulted before prescribing or commencing preparation of any intravenous medicine. It is important to read the WHOLE MONOGRAPH for a drug in order to ensure that details described in the comments column are not missed.
2.2. Formulary status
Inclusion of a monograph in the Table does not imply approval by the New Drugs Panel nor inclusion in the Trust Formulary.
2.3. Paediatrics
The Table includes guidance notes on intravenous medicine administration to adults and children. In general, the same principles apply to children and to adults. However, the doses and dose volumes used are smaller.
2.4. Neonates
This patient group may have specific information relevant to them available. Please refer to either:
o Queen Charlottes neonatal formulary
o St Mary's neonatal formulary
2.5. Brands and generics
Where information varies between different brands, this is indicated in the Table. In the case of generic products, information relates to the product(s) being purchased by the Trust at the time of print. If a product is subsequently purchased from another manufacturer, minor differences of information e.g. sodium content may exist.
2.6. Consistency with Trust protocols
Every effort has been made to ensure that the Table is in line with Trust policies, guidelines and protocols that contain recommendations on IV use, in order to ensure consistency of messages on IVs.
2.7. Updating
It is aimed to update and reprint the IV Guide on a regular basis. The most up to date version is available on the hospital intranet.
2.8. Feedback
Feedback from users is invited in order to assist in improving its usefulness. Feedback should be directed to Medicines Information in Pharmacy.
2.9. When to seek help
The ward pharmacist or Medicines Information should be contacted for instructions on prescribing, preparation and administration when: -
· A medicine is not included in the Table.
· A patient's clinical status may justify a change from guidance in the Table.
Wherever possible, written guidance should be obtained.
2.10. Abbreviations and units used in the Table are standardised in accordance with the BNF guidelines on prescription writing.
Specific
2.11. Licensing status
If a product does not hold a current manufacturer's product licence or is routinely administered by a method that is not covered by the product licence, this is noted in the Table.
2.12. Preferred route
If there is more than one method of IV administration, and one method is preferred over the other (e.g. infusion as opposed to IV bolus), this is noted in the Table. If the IV route is not the preferred route of administration for a particular product, the alternative route is stated.
2.13. Displacement values are provided for products that require reconstitution. Where displacement values vary between brands, this is noted, e.g. ceftazidime.
2.14. Administration via a central venous catheter
The Table indicates when an IV medicine should be administered via a central venous catheter.
2.15. Use of infusion pumps
When the rate of an infusion should be controlled by an infusion pump, this is noted in the Table.
2.16. Filters
Infusions should preferably be administered via an administration set incorporating a filter. Most administration sets within the Trust incorporate a 15-micron filter. The Table specifies when any other size of filter is required e.g. infliximab.
2.17. Rate of administration
If a rate of administration is specified in the Table this refers to the rate suitable for a patient with normal renal and hepatic function. Where renal and hepatic function is impaired the product literature should be checked so that an appropriate adjustment can be made.
2.18. Compatibilities
Compatibility information is mainly based on physical compatibility i.e. no visible sign of incompatibility after four hours. When stated as compatible in the table it is assumed that medicines are being mixed at a 3-way tap close to the canula and NOT in an infusion bag, burette or syringe. The information is provided as a guide only, since varying the medicine concentrations used may produce signs of incompatibility (for example cloudiness, change in colour, haze or a precipitate forming), in some circumstances. Only compatibilities used in practice are listed in the Table. The ward pharmacist or Medicines Information should be contacted about compatibilities not described in the Table or for further information about those included.
2.19. Infusion expiry
This refers to the physical and chemical stability of the medicine after dilution in one of the diluents specified in the Table and storage at room temperature (25°C or below). Where an infusion expiry recommends "use immediately after dilution", this is generally because stability data at room temperature has not been proven. The maximum expiry given to infusions after preparation in near patient areas is 24 hours, for microbial reasons. It should be emphasised that although infusions may have a maximum 24 hours shelf life, lines and administration sets must be routinely replaced every 72 hours. See Trust Policy for exceptions to this general guidance.
2.20. pH and its relevance
pH values have been included in the Table to help predict possible physical incompatibilities among medicines where no compatibility information is available. It is advisable not to mix medicines with widely differing pH values as this may produce signs of incompatibility.
2.21. Protection from light
When an infusion needs protection from light whilst in use on the ward, this is noted in the Table.
2.22. Monitoring and adverse effects
The Table includes adverse effects that may occur as a direct result of administering the medicine by the IV route. Not all adverse effects that may occur are included; refer to the relevant summary of product characteristics (SPC) for a more complete list. The monitoring suggested relates to that which may be considered necessary to detect any adverse effect occurring as a result of the intravenous administration of the medicine. The monitoring suggested may not be possible in all clinical areas.
2.23. Extravasation
Where an IV medicine has potential to cause tissue damage when extravasated, this is noted in the Table.
2.24. Sodium content
This is expressed in mmols per vial size (mg). This information is particularly important in those patients who are sodium restricted or in paediatric/neonatal patients.
2.25. Prepared by Pharmacy
Where an IV medicine is prepared by Pharmacy in order to minimize handling risks to staff or because it is specified in the summary of product characteristics (SPC) this is indicated in the Table e.g. ganciclovir
2.26. Personal protection
Where personal protection measures are required when handling particular IV medicines (e.g.azathioprine), this is noted in the Table as 'always handle as for cytotoxics'. Please refer to the Cytotoxics Policy for further guidance.
2.27. Handling when pregnant or breastfeeding
If the handling of a particular medicine should be avoided by staff if pregnant or breastfeeding (e.g. ribavirin) this is stated in the Table.
3. The ‘IV Guide’
3.1. The ‘IV Guide’ has been produced by the collaboration of pharmacists in approximately 80 different Trusts in the country and is co-ordinated by the Pharmacy department at Charing Cross hospital. It was originally designed to help Pharmacists produce their own local IV drug administration guide and is fully referenced.
3.2. The ‘IV Guide’ is now available electronically and because it provides additional information to supplement the IV table in use in the Trust it has been added to the Trust Intranet ‘PHARMACY’ site.
The ‘IV Guide’ can be accessed as follows:-
Hammersmith Site:
Open Source on the Trust Intranet:
Select in order:
A-Z Departments
Pharmacy
IV Guide
Select ‘nurses’ version or ‘pharmacists’ version as appropriate
From the welcome to Medusa screen, select IV Guide tab from the top right hand corner, then select drug by name.
St Mary's Site:
Open Source on the Trust Intranet:
Select in order
Library
IV Guide
Select ‘nurses’ version or ‘pharmacists’ version as appropriate
From the welcome to Medusa screen, select IV Guide tab from the top right hand corner, then select drug by name.
3.3. If you have any problems accessing the ’IV Guide’ please contact Gill Bullock in the Pharmacy at Charing Cross hospital, or Medicines Information at St Mary's Hospital on extension 1203