Injectable Drugs Monographs v2

This procedure is adopted for PCH staff from:
Plymouth Community Healthcare CIC
Procedures for Administering Injectable

Drugs
Version No 2
Notice to staff using a paper copy of this guidance

The policies and procedures page of Intranet holds the most
recent version of this guidance. Staff must ensure they are
using the most recent guidance.
Author:
Advanced Specialist Clinical Pharmacist

Adults and Older People
Asset Number:
385
Page 1 of 201
Procedures for Administering Injectable Drugs

Date
Version
December 2013
Issue 9
Purpose
The purpose of this document is to inform Trust staff of the correct and safe methods of preparation
and administration of injectable drugs. It includes information on the use of infusion devices.
Who should read this document?
All staff working for or on behalf of Plymouth Hospitals NHS Trust who prepare and administer fluids
and drugs by injection or infusion.
Key messages
Staff working for or on behalf of Plymouth Hospitals NHS Trust who prepare and administer fluids and
drugs by injection or infusion must do so in accordance with these procedures.
Accountabilities
Production
Peter Gray, Pharmacist
Review and approval
Medicines Governance Committee
Ratification
Dissemination
Compliance
Page 2 of 201
Links to other policies and procedures

Pharmacy documents available on PHNT StaffNet
PHNT Medicines Management Policy
SOPs for preparing and administering intravenous medicines and fluids.
SOPs for the management of phlebitis, infiltraton, air embolism, speedshock and extravasation.
SOPs for the safe handling and administration of injectable cytotoxic drugs.
SOP for setting up and maintaining variable rate intravenous insulin infusions.
PHNT Vascular Access Documents:
Administration of Medication through a Central Venous Catheter (CVC)
Removal of a Central Line
PHNT Central Vascular Access Guidelines
PHNT Infection Control Documents:
Guidelines for the Management of Peripheral Intravenous Devices
Guidelines for the Management of Central Intravenous Catheters
Hand Hygeine Guidelines
Guidelines for Aseptic Technique
Safe Disposal of Sharps Policy
Other Documents:
Royal College Nursing Standards for Infusion Therapy, 2010
Department of Health High Impact Intervention Care Bundles for Central venous catheter care
Peripheral intravenous cannula care
Renal haemodialysis
Cleaning and decontamination
Blood Cultures
The Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and
related guidance (published 14 Dec 2010),
Page 3 of 201
Version History
Issue 6 November 2010
Issue 7 December 2011
Appendix 1: protocol added for non-medical staff to assess a patient and administer IM
adrenaline without a prescription to an adult or child with anaphylaxisis.
Alteplase monograph(for acute myocardial infarction):Concurrent use of IV heparin clarified.
Enoxaparin no longer needs monitoring of platelet count at Day 4-7 & Day 10-14.
Botulinum toxin: vial sharing in clinincs/day-case has been risk-assessed and sanctioned by
the Medicines Governance Committee. Stipulations in the monograph must be followed.
Ergocalciferol Injection: New monograph providing advice on using green B.Braun syringe.
DigiFab replaces Digibind which is now discontinued. Do not give DigiFab via a filter.
Ferinject: Added to the Formulary. New monograph inserted.
Filgrastim (Zarzio): Added to the Formulary. New monograph inserted.
Folinic acid monograph re-inserted.
Instructions for preparing and giving 3g IV ceftazidime and 1g vials of Fosfocina
(Fosfomycin) added to the respective monographs.
Glucose 10% with Actrapid to treat hyperkalaemia: Need to use 29 gauge Magellan 12.7mm
Insulin Safety Syringe to penetrate the rubber port on the bag of glucose.
Insuman and Apidra insulin monographs inserted.
Intravenous Iron preparations: All monographs amended to include instruction to observe
closely for signs of hypersensitivity during and for at least 30 minutes after each injection or
infusion.
Venofer (Iron Sorbitol): Test dose no longer recommended.
Ketamine for post-op analgesia: Rate reduced to 1-2ml/hour (100-200mcg/kg/hr).
Metoclopramide IV bolus is now recommended over at least 3 minutes.
Ondansetron: Due to the risk of QT-interval lengthening and subsequent Torsade-dePointes, 8mg dose must be infused over 15 minutes in patients aged 65 and older, and 16
mg dose (by infusion only) is only allowed for patients younger than 75.
Piperacillin/Tazobactam: Slow IV bolus is no longer recommended or licensed. Infuse this
over 30 minutes to achieve optimal MICs.
Epoprostenol: Monograph now makes reference to the ICU protocol.
Additional route (subcutaneous injection) added for alemtuzumab post kidney
transplantation.
CSM Black Triangle status has been removed from a number of injectable medications.
Last Approval
Due for Review
December 2013
December 2014
PHNT is committed to creating a fully inclusive and accessible service.

Making equality and diversity an integral part of the business will enable us to enhance the services we
deliver and better meet the needs of patients and staff.
We will treat people with dignity and respect, actively promote equality and diversity, and eliminate all
forms of discrimination regardless of (but not limited to) age, disability, gender reassignment, race,
religion or belief, sex, sexual orientation, marriage/civil partnership and pregnancy/ maternity. Larger text,
Braille and Audio versions can be made available upon request.
An electronic version of this document is available on PHNT StaffNet > Departments > Clinical
support Services > Pharmacy > Injectable Medicines > Procedures for Administration of Injectable
Drugs
Alternatively copy the link into your internet browser:
http://StaffNet.plymouth.nhs.uk/Portals/1/Documents/Department%20Documents/Surgery/Critical%
20Care/Monographs%20for%20IV%20Drug%20Administration%20Version%208%202012%20Jun
e%202013.pdf
Page 4 of 201
Contents
Section
1.1
1.2
Appendix 1
A1.1
A1.2
A1.3
A1.4
A1.5
A1.6
A1.7
A1.8
A1.9
A1.10
A1.11
A1.12
A1.13
A1.14
A1.15
A1.16
Appendix 2
A2.1
A2.2
A2.3
A2.4
Appendix 3
A3.1
A3.2
Appendix 4
A4.1
A4.2
A4.3
1.1
Injectable Drug Monographs

Chart of Injectable Drug Compatibilities
PHNT Analgesic ladder
PHNT Protocol for administering IV morphine to adults in Acute Care Areas
PHNT Protocol for administering IV morphine to adults in the Emergency Dept.
Management of Anaphylaxis
Protocol for administering intramuscular adrenaline 1:1000 (1mg/ml) for treating
anaphylaxis, when there is no prescription available
Legislation
Persons who can be treated under this protocol
Anaphylaxis
Assessing the patient
Explanation of treatment to the patient
Patient consent
Exclusions from treatment under this protocol
Contra-indications to administration of adrenaline to treat anaphylaxis
Immediate treatment
Source of adrenaline
Dosage of adrenaline
Adverse Effects
Follow up
Documentation
References
Anaphylaxis algorithm
Choice of Infusion device
Introduction
Additional Information
References
Copy of PHNT Policy for maintenance of patency, flushing and locking of
intravascular lines catheters or devices
Introduction
Policy
Document accountability, responsibility and dissemination
Accountability
Overall Responsibility for These Policies and Guidelines
Dissemination and Implementation
Page
7
184
185
186
187
188
189
189
190
190
191
191
191
191
191
191
192
192
192
192
192
193
194
194
196
196
197
197
199
199
199
Injectable Drug Monographs
All monographs contained in this section are the current versions as of the time of going to print and are
listed in alphabetical order according to generic name.
Detailed guidance for the administration of cytotoxic drugs is not given in the monographs, but should
be obtained from the appropriate ward or unit protocol.
Unlicensed use of medications
Where in the monographs the use of a drug is noted to be unlicensed, this either refers to the drug
formulation itself not having a UK product licence or where the indication, dosage, dilution or rate of
administration fall outside of the UK product licence.
Page 5 of 201
When an unlicensed medication is administered to a patient or a licensed medication is administered in

an unlicensed manner the prescribing doctor takes full responsibility for any adverse consequences.
Important notes
Intravenous fluids and drug solutions prepared in clinical areas must be changed every
24 hours unless otherwise specified in the drug monograph. This includes infusions such
as Patient Controlled Analgesia (PCA) and sliding-scale insulin.
Unless described in the drug monograph as Multidose all injectable products, including
bags of sodium chloride 0.9% and 5% glucose must be treated as single use only and
disposed of immediately after use.
Any infusion containing drug(s) or potassium or any other additive must be administered
using an infusion pump.
Dosiflows or other gravity-fed administration sets must only be used for administering
crystalloid infusions (eg. Sodium chloride infusion or glucose infusion) containing no
potassium or other additives.
For patients on a sliding-scale insulin infusion and glucose infusion, the glucose must
be infused using a volumetric pump.
Always read the label on the ampoule, syringe or box. Do not rely on familiar colours or shapes
of packaging to correctly identify medication.
Always label an IV container or syringe containing drug or added electrolytes for infusion with a
completed IV Additive Label.
All syringes containing drawn-up medication or flushing solution must be labelled with name of
medicine or flushing solution and the dose/strength, unless the risk of doing so (eg
contaminating a sterile field) is perceived by the individual practitioner to outweigh the risk of
mis-identifying un-labelled syringe(s). The individual practitioner is then responsible for ensuring
that any un-labelled syringes are not mis-identified. Labels for this purpose (Code QC31) can
be ordered from Pharmacy.
Drug solutions that have been drawn up or prepared in clinical areas must be administered
immediately after preparation or drawing up.
All the intravenous medications listed in the Section 4 monographs may be given via a
peripheral cannula or a central venous cannula, unless the monograph specifically says that a
particular drug or drug concentration must only be given via a central venous cannula.
If you require information on intravenous compatibilities; contact Pharmacy Drug Information on

Ext. 39976.
Groups of staff allowed to administer injectable medications which are referred to in the
monographs:
Group 1
o
Registered and Provisionally Registered Medical Practitioners. It is recommended that IV

drugs are checked by a second person either another medical practitioner or a registered
healthcare professional before administration.
Group 2
Page 6 of 201
Registered Nurses, Midwives and Operating Department Practitioners (ODPs) who have
undertaken the Plymouth Hospitals NHS Trust IV drug administration training (or satisfy the
criteria for new employees from outside the Trust), and have been assessed as competent.
Group 2 can administer to adult patients only. Another Registered healthcare professional
should check all aspects of the administration with this Nurse or Midwife. Cytotoxic IV
drugs are NOT to be administered by this group.
Exceptions are methotrexate are cyclophosphamide, which can be administered by this
group if the practitioner has previous experience of administering parenteral cytotoxics.
Group 3
o
Nurses who qualify for Group 2, working in identified specialist areas, and have undertaken
additional training and assessment to administer cytotoxic IV drugs.
Group 4
o
o
A Registered Sick Children's Nurse (RSCN) or Registered Nurse (Part 15 - Child Branch)
working in the paediatric field who qualifies for inclusion in Group 2.
The exception is for staff who work regularly in the Emergency Department, Intensive Care
Unit, Theatres, Maternity and Neonatal Intensive Care Unit, who can administer Group 2
drugs to paediatric patients, providing they are familiar with the drug and the calculation (if
any) required.
Group 5
o
Nurses who qualify for Group 4 and have undertaken additional training and assessment to
administer cytotoxic drugs.
Group 6
Named Individual Radiographers/Sonographers who have completed and passed an
accredited training programme in the administration of IV drugs may administer named
contrast media, Hyoscine Butylbromide, Sodium Chloride 0.9% and Glucagon via the IV
route according to the departments authorised and signed patient group direction.
Group 7
o
Named and authorised technical, scientific and delegated medical staff of the department of
Nuclear Medicine who have the appropriate training required by IR(ME)R 2000 to
administer radiopharmaceuticals and who have completed an accredited course in IV drug
administration or equivalent. Such individuals may administer named drugs and
radiopharmaceuticals by IV route according to the departments authorised and signed
patient group direction (PGD).
All Registered healthcare professionals must be assessed as competent in the methods

required for administration as advised in section 4 monographs. If they have not been
assessed as competent with the administration method, e.g. using a central line, or aseptic
non-touch technique they must not proceed.
All training and assessment of competency to administer intravenous medication should

include training and assessment of aseptic non-touch technique and administration via
central vascular access devices. For more information or training please contact the
Learning and Development Facilitator.
Abbreviations used in the drug monographs
o
(C)
(I)
IV
IM
SC
N/S
G
Continuous
Intermittent
Intravenous
Intramuscular
Subcutaneous
Sodium Chloride 0.9%
Glucose 5%
Page 7 of 201
G/S
H
Hep/S
W
Glucose 4% and sodium chloride 0.18%. Other combinations of glucose and sodium
chloride may not be compatible with the drugs listed in Section 4 contact Pharmacy for
advice on ext.39976.
Compound sodium lactate (Hartmanns)
Heparin 10 units in 1ml sodium chloride - heparinised sodium chloride (e.g. Hepsal)
Water for Injection (preservative free)
Page 8 of 201
DRUG
METHOD
Abatacept
(Orencia)
WHO MAY ADMINISTER OVER

GIVE
(I) IV infusion via a Groups Infuse all doses over 30
minutes
pump.
1 and 2
Infuse via a nonpyrogenic low
protein binding
filter (0.2-1.2
microns)
Abciximab
Initial IV bolus
Groups
1 minute
1 and 2
(C) IV infusion via Groups

pump immediately 1 and 2
following initial IV
bolus.
Acetazolamide IV bolus
Groups
1 and 2
4ml/hour for 12 hours

(50ml syringe driver) or
19ml/hour for 12 hours
(250ml infusion bag)
Suggested maximum
100-500mg/minute
INSTRUCTION FOR DILUTION AND

SUITABLE DILUENT
Reconstitute each 250mg vial with
10ml W using the silicone-free syringe
provided. Direct the stream of W down
the inside wall of the glass vial.
Minimise foam formation by rotating the
vial slowly with gentle swirling to
dissolve the powder. Do not shake.
After dissolution, vent the vial with a
needle to dissipate any foam that may
be present. Remove a volume of N/S
from a 100ml bag N/S equal to the
volume of reconstituted vials. Slowly
add the reconstituted solution from
each vial to the infusion bag using the
same silcone-free syringe. Gently mix.
Inject 5ml of air into the vial before
withdrawing the solution. Use the 20ml
syringe to draw up sufficient volume for
both the bolus and 12-hour infusion.
Connect the 0.2 or 0.22 micron filter
and connector provided. Draw the
volumes necessary for the bolus dose
and infusion into two separate syringes
through the connector.
See Filter Pack for nomogram. Either
dilute the volume drawn up for infusion
with N/S or G to make 50ml or add the
drawn up volume to 250ml of N/S or G.
Reconstitute each 500mg with at least
5ml W.
COMMENTS
Monitor blood pressure (increase in
BP is common), pulse and
temperature. Monitor for allergic
reactions (rare) and rash (common).
Check LFTs (ALT and AST
commonly raised).
If any serious allergic or
anaphylactic reaction occurs
discontinue the infusion immediately
and initiate appropriate therapy.
Do not mix with any other drug
solutions.
0.375mmol sodium per 250mg vial
Flush with N/S.
For stabilisation of unstable angina,
bolus dose followed by the infusion
is started up to 24 hours prior to PCI
and concluded 12 hours after PCI.
For other patients bolus is given 1060 minutes prior to PCI followed by
the infusion for 12 hours.
Do not shake unused vials.
Flush: N/S or G.
Do not infuse with any other drugs.
Flush with N/S or G.

Extravasation may cause tissue
damage.
Intravenous fluids and drug solutions must be changed every 24 hours unless otherwise specified in the drug monograph.
Unless described in the monograph as Multidose, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines http://nww.swretrieval.nhs.uk/DI_ALL.htm - for drug monographs click on
Intravenous Drug Administration Guide), current BNF For children (www.bnfc.org) or the Neonatal Formulary.
For more detailed information refer to the current BNF (www.bnf.org ). For full details of the licensed indications, dosage, contraindications and side effects refer to
www.medicines.org.uk
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 9, December 2013
DRUG
METHOD
WHO MAY
GIVE
Acetylcysteine
(C) IV infusion
Infusion pump
is required.
Groups 1
and 2
(C) IV infusion
via central line
Infusion pump
is required.
Groups 1
and 2
ADMINISTER OVER

SUITABLE DILUENT
Treatment of paracetamol overdosage:
three consecutive infusions as detailed in
the table below (For treating children
<40kg follow the instructions on the next
2 pages).
On ICU or HDU acetylcysteine may be
infused in smaller volumes of G or
undiluted if necessary (unlicensed - see
page 1) via a central IV line. However the
hourly infusion rate (ml/hour) will be
different to the figure in the table below.
COMMENTS
A change in colour of solutions of
acetylcysteine to light purple is
insignificant.
Flush with G or N/S.
Sodium content 12.78mmol/10ml
.
Adult Dosage Table for Treating Paracetamol Overdose

Regimen
Infusion Fluid
Duration of
Infusion
Drug Dose
Patients weight
(kg)1
First Infusion
200ml G (or 200ml N/S if G is unsuitable)
1 hour
Grams of
acetylcysteine
to prescribe
150mg/kg
Volume (ml)2 of
acetylcysteine to
add to 200ml fluid
Infusion rate
(ml/hour)
Second Infusion
4 hours
Grams of
acetylcysteine to
prescribe
50mg/kg
Volume (ml)2 of
acetylcysteine to
add to 500ml fluid
Infusion
rate
(ml/hour)
Third Infusion
16 hours
Grams of
acetylcysteine
to prescribe
40 - 49
6.8
34
234
2.4
12
128
4.6
50 - 59
8.4
42
242
2.8
14
129
5.6
60 - 69
9.8
49
249
3.4
17
129
6.6
70 79
11.4
57
257
3.8
19
130
7.6
80 89
12.8
64
264
4.4
22
131
8.6
90 99
14.4
72
272
4.8
24
131
9.6
100 109
15.8
79
279
5.4
27
132
10.6
110
16.6
83
283
5.6
28
132
11
1
Dose calculations are based on the weight in the middle of each band. If the patient weighs less than 40kg use the paediatric dosage table.
2
Ampoule volume has been rounded up to the nearest whole number.
100mg/kg
Volume (ml)2 of
acetylcysteine to
add to 1000ml fluid
Infusion
rate
(ml/hour)
23
28
33
38
43
48
53
55
64
64
65
65
65
66
66
66
10
Acetylcysteine for treating paracetamol overdose in Children

Children are treated with the same doses and regimen as adults. However, the quantity of intravenous fluid used has been modified to take into account age and weight,
as fluid overload is a potential danger. Doses should be administered sequentially using an appropriate infusion pump.
Preparation and administration of paediatric infusions
Weigh the child to determine the correct weight band.
Read off the table (on the next page) the total infusion volume required for each dose according to the weight of the child and make up the solutions according to the
directions below.
First Infusion
Prepare the appropriate volume for the weight of the child.
Prepare a 50 mg/mL solution by diluting acetylcysteine (200 mg/mL) with glucose 5% (preferred) or sodium chloride 0.9% as follows:
Weight 1-14kg
add 10mls of acetylcysteine to 30ml of diluent
Weight 15-24kg
Weight 25-39kg
The dose is infused over 1 hour at the infusion rate stated in the table (equiv to 3ml/kg/hour).
Second Infusion
Prepare the appropriate volume for the weight of the child.
Prepare a 6.25 mg/mL solution by diluting acetylcysteine (200 mg/mL) with glucose 5% (preferred) or sodium chloride 0.9% as follows:
Weight 1-9kg
add 8mls of acetylcysteine 200mg/ml to a 250ml bag
Weight 10-19kg
Weight 20-39kg
The dose is infused over 4 hours at the infusion rate stated in the table (equiv to 2ml/kg/hour).
Third Infusion
Use the solution prepared under second infusion above.
The dose is infused over 16 hours at the infusion rate stated in the table (equiv to 1ml/kg/hour).
For example for a child weighing 12 kg, the first infusion would be 38 mL infused at 38 mL/h over 1 hour,the second infusion would be 100 mL infused at 25 mL/h over 4
hours and the third infusion is 208 mL infused at 13 mL/h over 16 hours.
11
Weigh the child and prepare the infusion as instructed on the previous page.
Paediatric Dosage Table for Treating Paracetamol Overdose

Regimen
Infusion
Infusion rate
Patients weight1
(kg)
First Infusion
50mg/ml for 1 hour
3ml/kg/hour
Dose of
Total infusion
Infusion rate
acetylcysteine
volume
(ml/hour)
to prescribe
(ml)
3
6
9
12
15
18
21
24
3
6
9
12
15
18
21
24
Second Infusion
6.25mg/ml for 4 hours
2ml/kg/hour
Dose of
Total infusion
Infusion rate
acetylcysteine
volume
(ml/hour)
to prescribe
(ml)
1
2
3
4
5
6
7
8
9
150mg
300mg
450mg
600mg
750mg
900mg
1.05g
1.2g
50mg
100mg
150mg
200mg
250mg
300mg
350mg
400mg
1.35g
27
27
450mg
10-14
15-19
20-24
25-29
30-34
35-39
1.9g
2.65g
3.4g
4.15g
4.9g
5.65g
38
53
68
83
98
113
38
53
68
83
98
113
625mg
875mg
1.125g
1.375g
1.625g
1.875g
8
16
24
32
40
48
56
64
Third Infusion
6.25mg/ml for 16 hours
1ml/kg/hour
Dose of
Total infusion
Infusion rate
acetylcysteine
volume
(ml/hour)
to prescribe
(ml)
2
4
6
8
10
12
14
16
100mg
200mg
300mg
400mg
500mg
600mg
700mg
800mg
16
32
48
64
80
96
112
128
1
2
3
4
5
6
7
8
72
18
900mg
144
100
140
180
220
260
300
25
35
45
55
65
75
1.3g
1.8g
2.3g
2.8g
3.3g
3.8g
208
288
368
448
528
608
13
18
23
28
33
38
Dose calculations based on the weight in the middle of each band. If the patient weighs more than 40kg use the adult dosage table. Figures have been rounded up to
the nearest whole number.
12
DRUG
METHOD
Aciclovir
(Ready-diluted
brands)
(I) IV infusion
Infusion pump
is required.
Aciclovir
(Powder for
reconstitution)
(I) IV infusion
Infusion pump
is required.
Actrapid
Adenosine
See Insulin Section page

IV bolus
Group 1
(I) IV infusion
for cardiac
stress testing
Infusion pump
is required.
WHO MAY
GIVE
ADMINISTER OVER INSTRUCTION FOR DILUTION AND

SUITABLE DILUENT
Dilute
each 250-500mg in a 100ml bag
1 hour
Groups
N/S,
G/S
or H. For doses between
1,2,3,4 and 5
500mg and 1000mg use two 100ml bags
or one 250ml bag. The concentration
should not exceed 5mg/ml. Shake the
prepared infusion well before use.
1 hour
Groups
1,2,3,4 and 5
2 seconds
6 minutes
Group 1
and Group 7
COMMENTS
Flush with N/S, G/S or H.

Sodium content approx
1mmol/250mg.
Discard infusion if any visible
turbidity or crystallisation appears.
Reconstitute each 250mg with 10ml of W damage. Patient should be
adequately hydrated.
or N/S to produce a solution containing
25mg/ml. Dilute further with N/S, G/S or
H to a concentration not exceeding
5mg/ml. For fluid restricted patients the
reconstituted solution may be infused
without further dilution via a central IV
line.
Can be diluted with N/S if necessary.
If given into an IV line, inject as

proximally as possible and follow
with a rapid N/S flush. Cardiac
monitoring and resuscitation
equipment should be available for
immediate use. Sodium content
0.154mmol/3mg.
Administer in accordance with the
Nuclear Medicine Department
protocol.
13
DRUG
METHOD
WHO MAY
GIVE
ADMINISTER OVER
Adrenaline
(Epinephrine)
(I) IV infusion
Infusion pump is
required.
.
Groups 1
and 2
Adjust rate according

to response.
Emergency use in
CPR: IV bolus
Group 1
1 - 2 seconds
Emergency use in
anaphylaxis
IM Injection using
1:1,000 injection
Groups 1
and 2
Refer to the Marsden Manual for

guidance on IM injection.
Emergency use in
anaphylaxis
IV route is only
used in an acute
hospital setting by
an experienced
practitioner for a
patient with
immediately lifethreatening
profound shock.
Specialist use only:

Adults: 0.5ml of dilute
Only
1:10,000 adrenaline IV
anaesthetists
over 1 minute with
and senior
continuous ECG
clinicians
monitoring, pulse
working in
oximety and frequent
intensive care,
blood pressure
theatre or the
measurements.
Emergency
Repeat dose as
Department.
necessary according
to response
Use 1:10,000 injection or dilute

0.5ml of 1:1,000 adrenaline to
5ml with N/S or G to make a
1:10,000 solution.
Group 1
INSTRUCTION FOR DILUTION

AND SUITABLE DILUENT
Usual local practice is to use
1:10,000 adrenaline in a 50ml
syringe (5mg in 50ml).
Adrenaline may be diluted with
N/S, G, G10%, G/S or H.
COMMENTS
Protect infusion from light.
If G used as diluent pH must be below
5.5 (pH of G stocked in this Trust is
between 4-4.2). Infuse through a large
vein if possible. (I) IV infusion requires
continuous blood pressure monitoring.
Replace giving set - do not flush.
damage.
Note that 1mg ampoules are only
licensed for IM or SC use. However,
they are suitable for preparing an IV
infusion.
Use 1:10,000 (1mg in 10ml)

prefilled syringe.
Refer to the algorithm for the
management of suspected lifethreatening anaphylaxis on page 193.
IM is the usual route.
If a patient is suffering an anaphylactic
reaction, there is no prescription for
adrenaline and there is no doctor
immediately available to prescribe
adrenaline, IM adrenaline can be given
by a non-medical member of staff who
has the skills to assess a patient and
give IM injections. They should do this
in accordance with the protocol in
Appendix 1 (page 189)
14
DRUG
METHOD
WHO MAY
GIVE
ADMINISTER INSTRUCTION FOR DILUTION

OVER
Undiluted
No
greater
Group 1:
junior doctors than
trained in the 5mg/minute.
Maximum dose
technique
and with UK is 1mg/kg
ALS
accreditation,
or a
consultant
cardiologist
Ajmaline
(Unlicensedsee page 4)
For diagnosis
of Brugada
Syndrome
Slow IV
bolus
Alcohol
See Ethanol monograph
SC Injection Groups 1
in to the
and 2
deltoid
or
Post kidney
transplantation anterior
abdominal
(unlicensed
wall.
product see
page 4)
(I) IV infusion Groups 1
via an
and 2
infusion
pump
Alemtuzumab
1-2 minutes
2 hours
Alemtuzumab is prepared only by

Pharmacy. Contact the Renal
Pharmacist on Bleep 0728 or the
Pharmacy Screening Room on
ext.32278 (send prescription
chart to Pharmacy). Out of office
hours, bleep the on-call
pharmacist through Switchboard.
For SC injection, Pharmacy will
supply a 30mg in 1ml pre-filled
syringe.
For IV infusion, Pharmacy will
supply 30mg in 100ml N/S.
COMMENTS
For detailed instructions it is essential to
read the Ajmaline Protocol (Copies on
Torcross and Bickleigh wards)
Patient to be nil-by-mouth for at least 4 hours
before the test.
Continuous 12-lead ECG monitoring required
during administration. Cardiac rhythm
monitoring required for 4 hours following
administration.
Check the blood pressure at 5 minute
intervals during administration and for 10
minutes afterwards.
Give the following pre-medication 30-60
minutes prior to giving alemtuzumab:
Methylprednisolone 500mg IV prior to first
dose, 250mg IV prior to second dose.
Chlorphenamine 10mg IV and paracetamol
1g PO prior to first and second dose.
Additional information relating to IV
infusion of alemtuzumab:
Protect IV infusion from light: Cover with
infusion bag with the plastic bag supplied
from Pharmacy. No need to cover the line.
During and after administration monitor for
urticaria, rash, hypotension, nausea, rigors
and fever. Serious but rare reactions include:
respiratory distress, bronchospasm,
syncope, MI and cardiac arrest.
15
DRUG
METHOD
Alemtuzumab
for treating MS
(unlicensed
product see
page 4)
WHO MAY ADMINISTER

GIVE
OVER
(I) IV
Groups See
infusion via 1 and 2
administration
an infusion
schedule
pump
below.

Alemtuzumab is prepared only by
Pharmacy (Tel. 31083).
Dilution supplied is 12mg in
100ml N/S
Premedication prior to alemtuzumab for treating Multiple Sclerosis

(Allow 30 minutes for oral paracetamol to take effect).
Paracetamol 1gram PO
Chlorphenamine 10mg IV
Methylprednisolone 1gram IV daily for the first 3 days immediately prior to
administartion of alemtuzumab
1st Course of alemtuzumab:
Alemtuzumab 12mg IV daily for 5 consecutive days
2nd Course of alemtuzumab (Given 12 and 24 months after the 1st course)
Alemtuzumab 12mg IV daily for 3 consecutive days
COMMENTS
Premedication: see administration schedule below.
Protect the infusion from light: Cover with infusion bag with the
plastic bag supplied from Pharmacy. No need to cover the line.
During the infusion monitor for urticaria, rash, hypotension,
nausea, rigors and fever. Serious but rare reactions include:
respiratory distress, bronchospasm, syncope, MI and cardiac
arrest. Refer to the full Alemtuzumab Prescribing
Guidelines held on the Planned Investigation Unit (PIU).
The guidelines are also available on Plymouth Healthnet
under Clinical Guidelines.
Administration Schedule for premedication (treating Multiple Sclerosis)

Day 1 3:
Administer 1g methylprednisolone IV over 1 hour
Administer chlorphenamine 10mg IV and paracetamol 1gram PO
Administer alemtuzumab 12mg in 100ml N/S over 4 hours
Day 4 (1st course only):
Day 5 (1st course only):
16
DRUG
Alfacalcidol
Alfentanil
METHOD
WHO MAY
GIVE
INSTRUCTION FOR DILUTION AND COMMENTS

SUITABLE DILUENT
IV bolus
Shake the ampoule for a minimum of 5 For patients undergoing haemodialysis
Groups 1
seconds before use. Give undiluted.
the injection should be given into the
and 2
return line from the haemodialysis
machine at the end of dialysis.
Monitor serum calcium regularly during
treatment.
Staff prescribing, administering and/or screening prescriptions for opioid medications should be familiar with the PHNT Policy for
Reducing Errors with Opioid Medicines in Adults (Network Drive :Groups (G) > Trust Documents > Documents > Medicines Management
folder). The PHNT Analgesic Ladder and equivalent dosages of different opioids can be found on page 185.
Flush : N/S, G or H
Can be diluted with N/S, G or H.
IV bolus
Groups 1 Approximately
Anaesthesia : Adequate plasma levels
30 seconds in
using the
and 2
will only be achieved rapidly if the
spontaneously
500 microgram/ml
infusion (0.5-1 micrograms/kg/minute) is
breathing
injection
preceded by a loading dose of 50-100
patients.
micrograms/kg given as a bolus or fast
Ampoules of Alfentanil 5mg/ml are 5000 micrograms/ml and must be diluted as below
infusion over 10 minutes.
before administration by infusion.
(C) or (I) IV infusion
with assisted
ventilation. Infusion
pump is required.
Groups 1
and 2
Dilute with N/S, G or H to a usual

concentration of 0.5mg/ml.
Occasionally concentrations of 1mg/ml
or more have been used.
SC injection
Groups

guidance on SC injection.
1,2,3,4 and 5
(C) SC infusion via Groups
syringe driver for
1,2,3,4 and 5
use in palliative care
ADMINISTER
OVER
Approximately
30 seconds
Follow the PHNT Care of the Dying

Pathway in Advance Kidney Disease and
the PHNT Syringe Driver Policy.
Dilute with W when 2 or more drugs are
For combinations of 2 or 3 drugs in the
being mixed in the same syringe.
same syringe refer to the compatibility
W or N/S may be used when the
charts in the pump kit or contact
syringe only contains this drug.
Pharmacy on ext. 39976 for advice.
Alfentanil is unlicensed by the SC route
and for use in palliative care (See page
4).
17
DRUG
METHOD
Alglucosidase
alfa
(Mycozyme)
(I) IV infusion Groups

Infusion
1,2 and 3
pump is
required.
WHO MAY
GIVE
ADMINISTER OVER

SUITABLE DILUENT
Remove the required number of vials
Initial rate of
from the fridge and allow them to reach
1mg/kg/hour.
room temperature (may take about 30
Gradually increased
by 2mg/kg/hour every minutes). Reconstitute each 50mg vial
30 minutes if there are with 10.3ml W. Add the W by slow dropwise addition down the side of the vial
no reactions to the
and not directly in to the powder. Tilt
infusion, until a
and roll each vial gently. Do not invert,
maximum rate of
swirl or shake the vials. The
7mg/kg/hour is
reconstituted volume is 10.5ml
reached.
containing 5mg of enzyme/ml, and
appears as a clear colourless to pale
yellow solution which may contain
particles in the form of thin white
strands or translucent fibres. If on
immediate inspection foreign particles
other than those described above are
observed, or if the solution is
discoloured, do not use.
Dilute the drawn up dose of
alglucosidase alfa with N/S to a final
alglucosidase alfa concentration of
0.5mg/ml to 4mg/ml (Remove the same
volume of N/S from the bag first).
Remove airspace from within the bag.
Mix with gentle massage on inversion of
the bag. Do not shake or agitate the
bag. Infuse the solution via a 0.2micron
low protein-binding in-line filter.
COMMENTS
Suitable filters include PALL 0.22 micron,
Braun Sterifix 0.2 micron, Technopharm
codan 0.2 micron filters. These filters
should be ordered through ORACLE.
Instructions for dosing and administration
of alglucosidase alfa will usually be
included in the patients treatment plan
(Recommended dosage for Pompe
Disease is 20mg/kg once every 2 weeks)
During the infusion monitor for allergic
reactions, monitor blood pressure, pulse,
temperature, respiratory rate and for
difficulty in breathing.
18
DRUG
METHOD

GIVE

SUITABLE DILUENT
Alprostadil
(Prostin VR)
(C) IV infusion
Groups
1 and 2
Dilute 150micrograms/kg weight of

baby to a final volume of 50ml with G,
N/S or G10%.
(Note that after dilution with G10% the
product is unlicensed. See page 1)
Infusion pump is
required.
Alprostadil
(Caverject)
Intracavernosal Group 1
injection
(See comments)
Initial rate:
5 nanograms/kg/minute
= 0.1ml/hour of the
prepared dilution.
COMMENTS
If using a burette avoid direct

contact of the undiluted injection
with the wall of the plastic
burette. If this happens the
appearance of the burette chamber
may change and a hazy solution
may develop requiring the solution
to be discarded and the burette to
be changed.
Monitor arterial blood pressure,
heart rate, SaO2 pO2 pH and
respiratory rate
Fit the 22 gauge needle to the syringe. Using a half inch, 27 to 30 gauge
needle is generally recommended.
Inject the 1ml of diluent into the vial,
The intracavernosal injection must
and shake to dissolve the powder
be done with aseptic technique.
entirely. Withdraw slightly more than
the required dose of Caverject solution, The site of injection is usually along
the dorsolateral aspect of the
remove the 22 gauge needle, and fit
the 30 gauge needle. Adjust volume to proximal third of the penis. Visible
veins should be avoided. Both the
the required dose for injection.
side of the penis that is injected
and the site of injection must be
alternated. Prior to the injection, the
injection site must be cleansed with
an alcohol swab.
19
DRUG
METHOD
WHO MAY
GIVE
ADMINISTER
OVER

SUITABLE DILUENT
COMMENTS
If a special pre-programmed alteplase pump is unavailable then refer to the guidance on pages 19 and 20.
ECG and haemodynamic
Initial IV bolus
Reconstitute two 50mg vials each with
Accelerated
Groups
monitoring required. Sodium
dose then (I) IV
regimen
initiated
the
50ml
of
W
provided
using
the
transfer
1 and 2
content nil.
infusion
within
6
hours
of
needles
supplied.
Agitate
gently
until
the
Acute myocardial
Flush with N/S.
contents
of
the
vials
have
dissolved.
Do
symptom
onset
using
the
infarction (AMI)
not shake.
administer over:
special preWhen treating AMI, alteplase is
programmed
90 minutes
When using the special pre-programmed given together with IV heparin. The
alteplase pump
Initiated between 6 alteplase pump, draw up the contents of IV heparin regimen is 5,000unit
(Available in the
and 12 hours after both vials (100ml) into a 100ml syringe. bolus followed by a continuous IV
Emergency
infusion for at least 48 hours, using
symptom onset
Dept. and on
the standard PHNT IV heparin
administer over:
Torcross ward).
prescription form.
3 hours
Alteplase and heparin infusions are
not compatible. They should be
infused through separate IV
catheters. If IV access is a problem,
the infusion of heparin can be
commenced once the alteplase
infusion has finished.
ECG and haemodynamic
Alteplase (TPA)
Reconstitute two 50mg vials each with
Initial IV bolus
Group 1 1 2 minutes
to treat:
the 50ml of W provided using the transfer monitoring required. Sodium
dose
needles supplied. Agitate gently until the content nil.
Followed by (I) IV Groups
2 hours
contents of the vials have dissolved. Do Flush with N/S.
infusion
1 and 2
Pulmonary
not shake.
Alteplase and heparin infusions are
using
the
embolism
special preDraw up the 10mg (10ml) bolus in a 10ml not compatible. They should be
infused through separate IV
programmed
syringe for the doctor to inject over 1-2
catheters.
alteplase pump
minutes.
(Available in the
When using the special pre-programmed
Emergency
alteplase pump, draw up the remainder
Dept. and on
of the total dose into a 100ml syringe.
Torcross ward)
Alteplase (TPA)
to treat:
20
Alteplase to treat Acute Myocardial Infarction within 6 hours of symptom onset (Accelerated Regimen)
Suggested method when a pre-programmed alteplase pump is not available: Reconstitute two 50mg vials each with 25ml of the W provided using the
transfer needles provided to make a 2mg/ml solution. Draw up the 50ml (100mg) of solution into a 50ml syringe. Then using a syringe pump set the
infusion rate as follows:
Bolus of 15mg over 2 minutes for patients of all weights (Set the pump at 225ml/hour for 2 minutes) then:
Patient
weight
Further doses and infusion rates
65kg
50mg over 30 minutes. Set the pump at 50ml/hour for 30 minutes
then
35mg over 60 minutes. Set the pump at 17.5ml/hour for 60 minutes
64kg
then
62kg
46.5mg over 30 minutes. Set the pump at 46.5ml/hour for 30 minutes
then
60kg
then
58kg
then
56kg
then
54kg
then
52kg
then
50kg
then
48kg
then
46kg
then
21
Alteplase to treat Acute Myocardial Infarction between 6 and 12 hours after onset of symptoms
transfer needles provided to make a 2mg/ml solution. Draw up the 50ml (100mg) of solution into a 50ml syringe. Then using a syringe pump set the
infusion rate as follows:
Bolus of 10mg over 2 minutes for patients of all weights.: set the pump at 150ml/hour for 2 minutes, then:
50mg over 1 hour for patients 40kg: set the pump at 25ml/hour for 1 hour, then:
Patient weight
Dose and infusion rate
65kg
40mg over 2 hours. Set the pump at 10ml/hour for 2 hours
60 - 64kg
30mg over 2 hours. Set the pump at 7.5ml/hour for 2 hours
53.4 -63.9kg
20mg over 2 hours. Set the pump at 5ml/hour for 2 hours
46.7 53.3kg
40 46.6kg
No additional alteplase
Alteplase to treat Pulmonary Embolism
transfer needles provided to make a 2mg/ml solution.
Draw up the Bolus of 10mg (5ml) in a 5 ml or 10ml syringe for the doctor to inject over 1 -2 minutes
Then draw up the remainder of the total dose in a 50ml syringe. Then using a syringe pump set the infusion rate as follows:
Patient weight Dose and infusion rate
65kg
< 65kg
For patients less than 65kg the total prescribed dose (including bolus dose) should not exceed 1.5mg/kg.
Following the bolus dose of 10mg, the infusion rate = Total prescribed dose (mg) Bolus dose (10mg) ml/hour for 2 hours
4
22
DRUG
METHOD
WHO MAY ADMINISTER

GIVE
OVER

SUITABLE DILUENT
COMMENTS
Total dose is 900 micrograms/kg (Maximum dose 90mg). 10% of this dose (90micrograms/kg) given as a bolus over 2 minutes
IV bolus
It is essential to follow the detailed
Group 1 1 2 minutes Reconstitute one or two 50mg vials
each with 50ml of the W provided to
instructions in the PHNT Acute Ischaemic
make
1mg/ml
solution.
For
the
bolus
Stroke Protocol (Copy in the Emergency
Acute Ischaemic
dose,
draw
up
10%
of
the
total
dose
Department).
Stroke
(see table below) and inject using a
Unless the patient or companion knows their
10ml syringe.
recent weight, estimate to the nearest 5kg. Take
(I) IV infusion Groups 1 hour
From the solution above, draw up the 2 initial blood pressure readings at 15 minute
remainder of total dose (see table
intervals. Record in both arms initially to exclude
1 and 2
below) into one or two 50ml syringes.
aortic dissection.
Alteplase
to treat
Use 1 x 50mg vial
Use 2 x 50mg vials
Weight(Kg)
Weight (Imperial)
Total dose
900micrograms/kg
(Maximum 90mg)
Bolus dose (ml)

Inject over 1 -2
minutes
Infusion dose
infused over 1 hour
45
7st 1lb
40
36
50
7st 12lb
45
4.5
40.5
55
8st 9lb
49
4.9
44.1
60
9st 6lb
54
5.4
48.6
65
10st 3lb
58
5.8
52.2
70
11st 0lb
63
6.3
56.7
75
11st 11lb
67
6.7
60.3
80
12st 8lb
72
7.2
64.8
85
13st 5lb
76
7.6
68.4
90
14st 2lb
81
8.1
72.9
95
14st 13lb
85
8.5
76.5
100
15st 10lb
90
81
23
DRUG
METHOD
WHO MAY
GIVE
ADMINISTER
OVER
Alteplase (Low-Dose)
to treat acute venous
thrombosis (subclavian or
ilio-femoral deep vein
thrombosis)
(C) IV Infusion
2.5ml/hour
Groups
1,2,3,4 and 5
This will deliver
0.5mg alteplase
per hour

SUITABLE DILUENT
Reconstitute 1 x 10mg alteplase with
the 10ml of W provided.
Further dilute the 10mg of
reconstituted alteplase to 50ml with
N/S.
This indication for alteplase

is unlicensed see page 4
The minimum stable concentration

is 0.2mg/ml. Each prepared
infusion is stable upto 8 hours at
room temperature. Prepare a fresh
syringe and change the infusion
promptly, every 8 hours. After 8
hours, 30ml of solution will remain
in the used syringe which must be
discarded.
Follow the Low-Dose Alteplase
Protocol.
Amikacin
IM injection
Groups
1,2,3,4 and 5
Slow IV bolus
2 3 minutes
Groups
(For large once
1,2,3,4 and 5
daily doses see (I)
IV infusion below)
Undiluted
(I) IV infusion
30 60 minutes
Groups
1,2,3,4 and 5
For once daily
doses of 15mg/kg
or greater. Infusion
pump is required
A common dilution for adults is with

100ml of N/S or G.
Irrigation
Do not dilute. Refer to the Marsden

Manual for guidance on IM injection.
Groups
1,2,3,4 and 5
For most infections the

intramuscular route is preferred, but
the IV route may be used for life
threatening infection or when IM
injection is not feasible.
Once diluted for infusion use
immediately.
Patient should be well hydrated
during amikacin therapy.
Dilute the required dose with N/S to a Sterile irrigation of amikacin may be
concentration of 2.5mg/ml.
used in abscess cavities, the
pleural space, peritoneum or in the
cerebral ventricles.
24
DRUG
METHOD
WHO MAY
GIVE
Aminophylline (I) IV infusion Groups 1,

(initial loading 2 3 and 7
dose) Infusion
pump is
required.
(I) or (C) IV
infusion (after
loading dose).
Infusion pump
is required.
Groups
ADMINISTER OVER
Minimum 20 minutes.

SUITABLE DILUENT
Dilute further with 100ml N/S, G, G/S or
H. However, the loading dose can be
diluted to a smaller volume e.g. 50ml or
given undiluted (25mg/ml) if necessary.
COMMENTS
Flush with N/S, G or G/S.
Do not give loading dose if
patient previously taking
theophylline.
Remove 20ml from a 500ml bag of N/S, Do not infuse aminophylline down
the same central line lumen or
G, G/S or H then add 500mg (20ml)
1,2,3,4 and 5
peripheral line as salbutamol.
aminophylline
to
make
a
concentration
of
0.5-0.7mg/kg/hour for
1mg/ml.
adults and children aged
Take blood to check theophylline
12 years and older.
Can be diluted to higher concentrations levels 4-6 hours after commencing
0.3mg/kg/hour for the
than 1mg/ml or given undiluted
the aminophylline infusion.
elderly.
(25mg/ml) through a central line, but take
care with the calculation and prescription
1mg/kg/hour for children of the infusion rate.
aged under 12 years.
Usual starting rates:
To avoid excessive
dosage in obese
patients, the dose
should be calculated
on ideal body weight.
Adjust the rate
according to plasma
theophylline levels.
25
DRUG
METHOD
Amiodarone
(C) or (I) IV
infusion.
Infusion pump
is required.
WHO MAY
GIVE
ADMINISTER
OVER
Groups 1,2 5mg/kg loading
dose (usually
and 3
300mg) over 20
minutes - 2 hours.
This may be
followed by repeat
infusion up to 1.2g
per 24 hours.
Adjust rate
according to
response
IV bolus
Group 1
Emergency use

SUITABLE DILUENT
Recommended dilution: 5mg/kg loading
dose (Usually 300mg) diluted in 250ml
G. Repeat infusion (usually 900mg over
next 23 hours) diluted in 500ml G.
Where a lower volume is needed the
dose (e.g. 300mg, 900mg or 600mg)
may be diluted in 50, 100 or 250ml G.
Stability is concentration dependent - do
not over dilute. Do NOT add 300mg to
more than 500ml G or 600mg to more
than 1 litre G.
Dilute each 150-300mg with 10-20ml G.

During Advanced
Life Support for
Pre-filled syringe contains 300mg ready
VF/VT give as a
diluted in 10ml G.
fast bolus.
Otherwise give over
a minimum of 3
minutes. Do not
repeat dose for at
least 15 minutes.
COMMENTS
Cardiac monitoring required.
Flush with G.
Repeated or continuous infusion
via peripheral veins may lead to
local discomfort and inflammation.
Infusion concentrations greater
than 2mg amiodarone per ml must
be infused via a central venous
catheter.
When repeated or continuous
infusion of any concentration is
anticipated, administration via a
central venous catheter is
recommended.
Sodium content nil.
As soon as an adequate response
has been obtained, oral therapy
should be initiated concomitantly at
the usual loading dose (i.e. 200mg
three times a day). Intravenous
amiodarone should then be phased
out gradually.
26
DRUG
METHOD
Amoxicillin
IV bolus
(Usual method)
WHO MAY
GIVE
ADMINISTER
OVER
Inject
doses up to 1g
Groups
over
3
- 4 minutes.
1,2,3,4 and 5
Inject 2g doses
slowly over 6 - 8
minutes or give by
infusion (see below).
(I) IV infusion.
Infusion pump is
required.
IM Injection
Amphotericin
(Fungizone )
For AMBISOME
see next page
30 - 60 minutes
Groups
1,2,3,4 and 5
2-4 hours.
(I) IV infusion
Groups
Infusion pump is 1,2,3,4 and 5 Up to 6 hours if
required.
poorly tolerated.

SUITABLE DILUENT
Reconstitute each 500mg with 10ml W.
Displacement 0.4ml/500mg. Add 9.6ml W
to 500mg to produce 50mg/ml.
COMMENTS
Flush with N/S.
Use infusion within 90 minutes of
preparation.
Reconstitute as above then dilute with N/S Sodium content: 1.65mmol/500mg

or G to 100ml. Alternatively each 500mg
amoxicillin may first be reconstituted with
5ml of the diluent (N/S or G).
(Avoid Intrathecal administration)
For Amoxil brand only : If pain is
Reconstitute a 500mg vial with 2.5ml W
experienced on IM injection,
and shake vigorously (Final volume is
lidocaine 1% or procaine 0.5%
2.9ml). Reconstitute a 250mg vial with
injection may be used instead of W
1.5ml W and shake vigorously (Final
to reconstitute the vial.
volume is 1.7ml). Refer to the Marsden
A test dose must be given at start
Displacement is negligible. Add 10ml
of each new course of treatment;
diluent for 50mg in 10ml.
Reconstitute vial with 10ml W, then dilute Infuse the first 1mg of the first
dose required with 50 times as much G to infusion over 20-30 minutes and
observe for signs of anaphylactic
produce a maximum concentration of
reaction for at least a further 30
100micrograms/1ml. Add 1ml of buffer
minutes. If no reaction then give the
solution supplied by Pharmacy to each
remainder of the first infusion.
500ml G before adding amphotericin.
Flush with G before and after
administration.
Concentrations up to a maximum of
500micrograms/1ml can be given using a Protect infusion from light.
central line (unlicensed use - see page 1). May cause thrombophlebitis;
change infusion site frequently.
Sodium content 0.25mmol/50mg.
27
DRUG
METHOD
WHO MAY ADMINISTER

GIVE
OVER

COMMENTS
Liposomal
Amphotericin
(AmBisome )
(I) IV infusion
Infusion pump
is required.
Groups
Add 12ml W (2-8oC), shake

vigorously for at least 15
seconds. Resulting amphotericin
concentration 4mg/1ml.
Dilute dose required with
between 1 and 19 parts by
volume G, using 5 micron filter
provided, to give a final
concentration of 200micrograms2mg/1ml.
Infusion to be prepared by
Pharmacy. Telephone Ext.
31083. Doctor to prescribe dose
in 250 500ml N/S.
Administration of a test dose is advisable before a

new course: Give 1mg of prepared infusion over
10 minutes, stop infusion and observe patient for
30 minutes.
Protect infusion from direct sunlight. Flush before
and after administration with G.
Do not infuse with any other drugs or infusion
fluids.
Sodium content less than 0.5mmol/vial.
30-60 minutes
1,2,3,4 and
5
For Fungizone
See previous page
Anti-thymocyte
(I) IV infusion
immunoglobulin
into a large
rabbit (ATG rabbit) vein. Infusion
pump is
required.
Anidulafungin
(I) IV infusion
Infusion pump
This product is
is required.
being intensively
monitored by the
CHM and MHRA.
Please report all
suspected
reactions (including
non-serious ones)
using a Yellow
Card from the BNF
Groups 8-12 hours

1,2,3,4 and
5
Groups Infuse the
1,2,3,4 and 200mg dose
over at least 3
5
hours.
Infuse the
100mg dose
over at least
1 hours.
Reconstitute each 100mg vial

with 30ml WFI. Reconstitution
can take up to 5 minutes.
For the 200mg dose, remove
50ml from a 250ml bag of N/S or
G, then add 60ml (2 x 100mg in
30ml) of reconstituted solution
(Final volume 260ml).
For the 100mg dose, add the
30ml of reconstituted solution to a
100ml bag of N/S or G (final
volume 130ml).
A test dose is usually given. Give an IV

antihistamine 1 hour before.
Flush with N/S.
Do not infuse with any other drugs or infusion
fluids.
If the un-reconstituted vials are accidentally left
out of the fridge, as long as the period at room
temperature does not exceed 96 hours, they can
be returned to the fridge and are ok to use.
Flush with N/S.
28
DRUG
METHOD
WHO MAY ADMINISTER

GIVE
OVER
Aprotinin
IV bolus (initial
loading dose)
Group 1 Maximum rate Provided ready diluted.
(I) IV infusion
Infusion pump
is required.
Groups
1 and 2
This drug is
unlicensed see
page 4
10ml/minute
20-50ml/hour

COMMENTS
Flush with N/S.
Initial 1ml (10,000 KIU) should always be given at
least 10 minutes prior to treatment to test for
possible allergic and anaphylactic reactions.
Sodium content 7.7mmol/50ml.
Do not infuse with any other drugs including
heparin.
Patient must be in the supine position during the
administration of aprotinin.
29
DRUG
METHOD
Argatroban

GIVE
(I) IV infusion Groups Initial infusion rate in patients
via infusion
without hepatic impairment is
1 and 2
pump.
2micrograms/kg/minute.

Add the 250mg in 2.5ml from the
vial to a 250ml bag of N/S or G.
Mix the solution for 1 minute by
repeated inversion of the
prepared infusion. There may be
For critically ill or hepatically
impaired patients the initial infusion some brief haziness of the
solution that clears upon mixing.
rate is 0.5micrograms/kg/minute.
See tables at foot of monograph
for setting the initial infusion rate
COMMENTS
Obtain a baseline APTT. The target
APTT is 1.5-3.0 times the baseline
value, but not more than 100 seconds.
Check the APTT 2 hours after starting
the infusion or after a change of rate,
and at least once a day thereafter (For
critically ill or hepatically impaired
patients, check the APTT 4 hours after
starting infusion or changing the rate).
The maximum rate is

10micrograms/kg/minute
APTT (s)
Standard dosing schedule

Initial Infusion Rate 2 micrograms/kg/minute
Infusion Rate change
Next APTT
Critically Ill/Hepatically impaired patients

Initial infusion rate 0.5 micrograms/kg/minute
Infusion Rate change
Next APTT
< 1.5 times baseline
Increase by 0.5 mcg/kg/min.
2 hours
Increase by 0.1 mcg/kg/min.
1.5-3.0 times baseline (not

exceeding 100 s)
No change
2 hours; after 2 consecutive No change

APTT's within target range,
Check at least once per day
> 3.0 times baseline or > 100 s
Stop infusion until the APTT

is 1.5-3.0 times baseline;
Resume at half of the
previous infusion rate.
2 hours
Body weight (kg)

50
60
70
80
90
2micrograms/kg/min
Infusion rate (ml/hour)
6
7
8
10
11
0.5micrograms/kg/min
1.5
1.8
2.1
2.4
2.7
4 hours
4 hours; after 2 consecutive
APTT's within target range,
Check at least once per day
Stop infusion until the APTT is 4 hours

1.5-3.0 times baseline;
Resume at half of the previous
infusion rate.
Body weight (kg)

100
110
120
130
140
2micrograms/kg/min
12
13
14
16
17
0.5micrograms/kg/min
3
3.3
3.6
3.9
4.2
30
DRUG
METHOD
Argipressin See vasopressin

Atenolol
IV bolus
(I) Infusion
Infusion pump is
required.
Atosiban
(C) IV infusion. Infusion

pump is required.
ADMINISTER
OVER

COMMENTS
Groups 1 and 2
Maximum rate
1mg/minute
20 minutes
Can be diluted with N/S or G to any

convenient volume e.g.10ml.
Dilute with N/S or G to a suggested
volume of 50ml or 100ml.
Severe bradycardia and hypotension

may occur; monitor heart rate and
blood pressure. Can cause
conduction defects; monitor ECG.
Infusing quickly increases incidence of
side effects.
Sodium content : approximately 1.31.8mmol/5mg
Total duration of treatment should not
exceed 48 hours. The total dose given
should preferably not exceed 330mg.
Groups 1 and 2
Step 1: IV bolus loading Groups 1 and 2

dose using 7.5mg/ml
Solution For Injection
Step 2:
(I) IV loading infusion.
Infusion pump is
required.
Step 2:
(I) IV infusion Infusion
pump is required.
Atracurium IV bolus
WHO MAY GIVE
0.9ml (6.75mg)
over 1 minute
immediately
followed by Step 2
24ml (18mg)/hour Withdraw 10ml from a 100ml bag of
for 3 hours
N/S or G. Replace it with 10ml of
followed by Step 3 Atosiban 7.5mg/ml Concentrate
Solution for Infusion from two 5ml
8ml (6mg)/hour for vials to obtain a concentration of
75mg in 100ml
up to 45 hours
Group 1 must only

be given by doctors
proficient in advanced
airway management.
Also see comments.
300-600
Groups
micrograms/kg/
1 and 2
hour
Can be diluted with H, G, G/S or

N/S.
The vials and infusions should be

inspected visually for particulate
matter and discolouration prior to
administration.
Do not mix with any other drug
solutions.
A 0.5mg/ml dilution is stable for 4
hours in H, 8 hours in G or G/S and
24 hours in N/S. Flush with N/S.
If the patient is ventilated IV bolus can
be administered by Group 2 staff.
Incompatibilities include: propofol.
31
DRUG
METHOD
Atropine
IV bolus
SC injection
IM Injection
Augmentin
Azathioprine
WHO MAY
GIVE
ADMINISTER OVER INSTRUCTION FOR DILUTION

See
comments
If
necessary atropine injection can
Groups 1 & 2
be diluted with N/S.
Groups
guidance
on SC injection.
1 and 2
Groups
guidance
on IM injection.
1 and 2
See Co-amoxiclav
30-60 minutes
(I) IV infusion
Group 1 or
(preferred
Group 2 who
method
have previous
wherever
experience of
possible).
administering
Infusion pump intravenous
is required.
cytotoxics. Or a
Group 3 nurse.
Usually 3-5 minutes.
IV bolus
Group 1 or
Minimum 1 minute.
through tubing Group 2 who
of a fast flowing have previous
N/S or G drip.
experience of
administering
intravenous
cytotoxics. Or a
Group 3 nurse.
Azathioprine injection is
reconstituted and diluted only by
Pharmacy (Tel. 31083).
Handle the prepared injection or
infusion as for cytotoxic drugs (See
Appendix 3).
COMMENTS
Give rapidly since slow IV
administration may cause paradoxical
slowing of the heart. ECG monitoring
required. Flush with N/S.
IV incompatibilities include bromides,
iodides, noradrenaline, metaraminol
and sodium bicarbonate.
Premedication: IV immediately before
induction. IM or SC 30-60 minutes
before induction.
Control of muscarinic side effects of
neostimine: IV bolus.
Flush the IV bolus with at least 50ml
N/S, G or G/S since very irritant.
damage.
Sodium content 0.2mmol/vial.
32
DRUG
METHOD
WHO MAY
GIVE
Aztreonam
IV bolus
Groups
ADMINISTER
OVER
3-5 minutes

SUITABLE DILUENT
Reconstitute vial contents with 6 - 10ml
W and shake well.
Displacement 0.8ml/1g. Add 9.2ml to 1g
vial for 100mg/ml
20-60 minutes
Reconstitute each 1 gram with at least

3ml W and shake well .Then dilute each
1 gram with at least 50ml N/S, G or H.
1,2,3,4 and 5
Groups
(I) IV infusion
Infusion pump is
required.
1,2,3,4 and 5
IM injection
Groups
1,2,3,4 and 5
Baclofen
(C) Intrathecal
infusion or
Intrathecal bolus
Group 1 or
Group 2*
Reconstitute a 1gram vial with at least

3ml W or N/S and shake well.
Prepare and administer in accordance

with the Pain Management Centre
procedures.
COMMENTS
Development of slight pink colour on
standing does not affect potency.
Sodium content nil.
Give by deep injection into a large

muscle mass such as the upper
quadrant of the gluteus maximus or
the lateral part of the thigh. For doses
higher than 1g, or for septicaemia,
meninigitis, localised parenchymal
abcess, peritonitis or other severe
systemic or life-threatening infections,
use the IV route as above.
* Restricted to those persons who are
trained and competent to administer
medication via the intrathecal route.
For regular intravenous benzylpenicillin see next page

Do not inject this formulation
Deep IM injection Groups
Benzathine
Shake the vial to loosen the powder
benzylpenicillin
inside. Reconstitute the vial contents with intravenously.
1,2,3,4 and 5
the 8ml of W provided in the unlabelled
(Extencillin)
ampoule.
2.4 megaunit vial
(Unlicensed
product see
page 4)

33
DRUG
METHOD
Benzylpenicillin
IV bolus
(Usual method)
(Regular
benzylpenicillin
600mg and
1200mg vials)
ADMINISTER
OVER
3-5 minutes.
Groups
1,2,3,4 and 5 Maximum rate for
doses exceeding
1.2g:
300mg/minute.

SUITABLE DILUENT
Reconstitute each 600mg with 3.6-10ml
W or N/S.
Displacement 0.4ml/600mg. Add 3.6ml
of W or N/S for 600mg in 4ml.
Groups
Reconstitute each 600mg with 10ml N/S

or W .Can be further diluted if necessary
with N/S or G (Suggested volume
100ml).

1 mega unit = 600mg.
Reconstitute each 600mg vial with 1.6ml

to 2ml W. Refer to the Marsden Manual
for guidance on IM injection.
Doses greater than 1.2g should be

given by the IV route.
Preferred method: Groups

20-30 minutes
1,2,3,4 and 5
(I) IV infusion.
Infusion pump is
required.
Reconstitute 10mg vial with 2.5ml of the

W supplied in the accompanying
ampoule. Reconstitute 20mg vial with
5ml of the W supplied in the
accompanying ampoule. Then dilute
each 10mg to a volume of 25ml or
greater with N/S or G. To avoid foaming
mix by gently inverting do not shake.
Use immediately and complete

administration within 4 hours of
reconstitution.
Do not mix or infuse with other drugs
in the same lumen or IV line.
Anaphylactic reactions can occur
rarely
Groups
Reconstitute 10mg vial with 2.5ml of the

W supplied in the accompanying
ampoule. Reconstitute 20mg vial with
5ml of the W supplied in the
accompanying ampoule.
(I) IV infusion.
Infusion pump is
required.
IM Injection
Basiliximab
IV bolus
WHO MAY
GIVE
1,2,3,4 and 5
Groups
1,2,3,4 and 5
1,2,3,4 and 5
30-60 minutes
COMMENTS
Administration faster than the
recommended rate may cause
seizures and CNS toxicity.
Incompatibilities include: gentamicin.
34
DRUG
METHOD
(I) IV
Infusion
using an
Only prescribe
after consultation infusion
with a Consultant pump
Haematologist
Beriplex P/N
Available on
request from the
Blood Bank
WHO MAY ADMINISTER

GIVE
OVER
Groups Each 500 IU in 20ml
1,2,3,4 and W over 10-15
minutes
5
So set the infusion
pump rate at
80-120ml/hour

Follow the nine steps illustrated
below and continued on the next
page for reconstituting the vials.
Using the transfer device provided,
reconstitute each 250 IU vial with the
10ml of W provided.
Using the transfer device provided,
reconstitute each 500 IU vial with the
20ml W provided.
The concentration is 25 IU/ml.
Do not further dilute the
reconstituted solution.
COMMENTS
The Consultant Haematologist will advise on the
dosage to be given, and the monitoring to be
performed.
Do not administer down the same lumen or catheter
as other drugs and fluids. May be flushed with N/S.
Take care that no blood enters the syringe filled
with product, as there is a risk that the blood could
coagulate in the syringe and fibrin clots would
therefore be administered to the patient.
Store Beriplex P/N in the fridge. Use reconstituted
Beriplex within 8 hours
Instructions for reconstituting Beriplex P/N

1. Open the Mix2Vial package by
3. Carefully remove the package from the Mix2Vial set. Make
sure that you only pull up the package and not the Mix2Vial
peeling away the lid.
set.
3
2. Place the diluent vial on an even,
clean surface and hold the vial tight.
Take the Mix2Vial together with the
package and push the blue end straight
down through the diluent stopper.
4. Place the product vial on an even and firm surface. Invert

the diluent vial with the Mix2Vial set attached and push the
transparent adapter straight down through the product vial
stopper. The diluent will automatically flow into the product
vial.
4
Instructions continued on the next page
35
Instructions for reconstituting Beriplex P/N continued

5. With one hand hold the product-side of the
8. While keeping the syringe plunger pressed, invert the
Mix2Vial set, hold the diluent-side with the other
system upside down and draw the concentrate into the
hand and unscrew the set into two pieces.
syringe by pulling the plunger back slowly.
Discard the diluent vial with the blue part attached
5
6. Gently swirl the product vial until the substance is
fully dissolved. Do not shake.
9. Now that the concentrate has been transferred into the

syringe, firmly hold on to the barrel of the syringe (keeping
the syringe plunger facing down) and disconnect the
Mix2Vial set from the syringe.
9
7. Draw air into an empty, sterile syringe. While the
product vial is upright, connect the syringe to the
Mix2Vial's Luer Lock fitting. Inject air into the
product vial.
36
DRUG
METHOD
Bivalirudin
Rapid Initial IV
bolus Patients
undergoing PCI,
including primary
PCI : 0.75 mg/kg

GIVE
Groups Suggestion:
1,2,3,4 and 2 seconds
5
Patients with
unstable
angina/non-ST
segment elevated
myocardial
infarction: 0.1 mg/kg
(C) IV infusion
immediately
following the IV
bolus
Groups
Patients undergoing PCI,

1,2,3,4 and including primary PCI :
1.75mg/kg/hour = 0.35ml/kg/hour
5
of the 5mg/ml infusion during the
procedure and for up to 4 hours
post PCI if necessary. Then
0.25mg/kg/hour = 0.05ml/kg/hour
for 4- 12 hours if necessary.

Add 5 ml W to one vial of 250mg
bivalirudin and swirl gently until
completely dissolved and the
solution is clear. Withdraw 5 ml
from the vial, and further dilute to
50 ml with G or N/S to give a final
bivalirudin concentration of 5
mg/ml. Mix thoroughly. The
reconstituted/diluted solution will be
a clear to slightly opalescent,
colourless to slightly yellow
solution.
COMMENTS
Incompatible with alteplase,
amiodarone, amphotericin B,
chlorpromazine, diazepam,
prochlorperazine, reteplase,
streptokinase and vancomycin.
Activated Clotting Time (ACT)
values 5 minutes after
bivalirudin bolus average 365
+/- 100 seconds. If the 5-minute
ACT is less than 225 seconds,
a second bolus dose of 0.3
mg/kg should be administered.
Once the ACT value is greater
than 225 seconds, no further
monitoring is required provided
the 1.75 mg/kg infusion dose is
properly administered.
Patients with unstable

angina/non-ST segment elevated
myocardial infarction:
0.25 mg/kg/hour = 0.05ml/kg/hour
of the 5mg/ml infusion for up to
72 hours.
37
DRUG
METHOD
Botulinum toxin IM injection into

(Dysport)
specific muscles
to treat spasticity
WHO MAY
GIVE
ADMINISTER
OVER
Group 1

SUITABLE DILUENT
Reconstitute the 500unit vial with 1ml of
W to make a 500unit/ml solution.
Reconstitute the 300unit vial with 0.6ml
of W to make a 500unit/ml solution.
Bumetanide
SC injection into
specific facial
sites to treat
blepharospam
and hemifacial
spasm.
Group 1
IV bolus
Groups 1
and 2
Suggestion: 1
minute
Give undiluted.
(I) IV infusion.
Infusion pump is
required.
Groups 1
and 2
30-60 minutes
IM Injection
Groups 1
and 2
Dilute 2 5mg with 500ml of G, N/S or

G/S. Alternatively dilute to 1mg/10ml
with G, N/S or G/S (unlicensed dilutionsee page 1)

COMMENTS
Sharing a vials of botulinum between
patients in a day-case/clinic setting
(i.e. not in-patient on ward or in
theatre) has been risk assessed and
sanctioned by the PHNT Medicines
Governance Committee so long as the
following practice is strictly adhered
to:
Between patients the reconstituted
vial is kept in the fridge.
A separate drawing-up needle is
used for each patient.
Any reconstituted botulinum
remaining in the vial(s) at the end
of the session must be discarded.
The maximum time the product
may be stored at 2-80C following
reconstitution is 8 hours.
Flush with N/S.
Leave a gap of 20 minutes between
repeat bolus doses.
Protect infusion from light and discard
if cloudiness develops.
38
DRUG
METHOD
Bupivacaine
(epidural)
Adults:
0.167%
(with or without
Fentanyl)
Paediatric:
0.125%
Bupivacaine
Infusion for
local infiltration
0.167%
0.125%
0.0625%
Buprenorphine
WHO MAY
ADMINISTER
COMMENTS
GIVE
OVER
All epidural administration sets and epidural catheters must be labelled Epidural when in use (NPSA/2007/21)
Pre-made bags are supplied from *Staff administering and monitoring
Epidural infusion via Groups
Adult patients:
epidural infusions must have received
Pharmacy.
a McKinley epidural
Epidurals:
1and 2*
training from the Acute Care Team
pump, using a yellow
Protocol A PCEA
and demonstrated their competency at
coloured line which
or B CEA. Modified
administering and monitoring epidural
must be labelled
epidural protocols
infusions. Follow the PHNT Epidural
Epidural
are very rarely
Protocols.
prescribed by
Additional clinician boluses may be
Anaesthetists
administered by Pain Nurses if
required as per epidural protocol.
For specialist use: Groups
Refer to Acute Care Pre-made bags are supplied from Refer to the PHNT protocol for
local infiltration at
Team Guidelines
Pharmacy.
Continuous Local Anaesthetic
1and 2
other sites i.e. near
Infusions.
nerves, wound,
joint, body cavity
(e.g. interpleural,
paravertebral) Via a
dedicated, grey
McKinley 595 pump,
using a grey coloured
line which must be
labelled with the
route.
IV bolus
3-5 minutes
Can be diluted with N/S or G.
Flush with N/S.
Groups 1
Sodium content nil.
and 2
IM Injection
Groups 1
and 2
39
DRUG
METHOD
WHO MAY
GIVE
Caffeine and
sodium
benzoate
For treating low
CSF pressure
headache
(I) IV infusion
Groups 1
Calcitonin
SC injection
Groups
IM injection
1,2,3,4 and 5
Groups
1,2,3,4 and 5
and 2
For hypercalcaemia
of malignancy
IV injection*
Groups
1,2,3,4 and 5
(I) IV infusion for

Groups
severe or emergency 1,2,3,4 and 5
cases of
hypercalcaemia of
malignancy only.
ADMINISTER
OVER
1-2 hours

Dilute 500mg caffeine sodium
benzoate in 1 litre of N/S.

Suggestion: 1-2
minutes
At least 6 hours
Dilute 10units/kg in 500ml N/S.
COMMENTS
Record a resting ECG before
administration. Monitor for possible
side effects: tachycardia, cardiac
arrythythmias, extra-systoles,
restlessness, agitation, nausea,
diuresis, hypoglycaemia, and
hyperglycaemia.
Note that caffeine and sodium
benzoate injection is unlicensed (See
page 1
Allow the ampoule or vial to reach
room temperature before SC or IM
injection.
When in use the 400unit in 2ml
multidose vial can be stored at room
temperature. Record date of first use.
Discard the remaining contents of the
400unit in 2ml multidose vial 1 month
after first use.
Ampoules of calcitonin are for single
use only.
May be given by IV injection for
hypercalcaemia of malignancy after
previous rehydration.* Do not use the
calcitonin from the multiple dose
400unit in 2ml vial for bolus injection
(As it contains phenol).
Some adsorption of calcitonin to the
plastic of the infusion set will occur so
monitor the patients response to
treatment.
40
DRUG
METHOD
Calcium
chloride
WHO MAY ADMINISTER

GIVE
OVER
IV bolus
Maximum
adult
Groups
Emergency use
rates:
1 and 2
1ml of 14.7%/minute
or for severe acute
1-1.5ml of
hypocalcaemia
10%/minute
1ml of 13.4%/minute
(I) or (C) IV
Groups Adults: Maximum
infusion. Infusion
rate 1mmol/minute.
1 and 2
pump is required.
INSTRUCTION FOR DILUTION AND SUITABLE

DILUENT
If 10% Calcium Chloride Minijets are not available then
in cardiac arrest give 6.8ml of 14.7% calcium chloride
undiluted which is 6.8mmol Ca2+ (equivalent to a 10%
Calcium Chloride Minijet)
May be diluted with N/S, G or G/S to any suitable

volume. However, concentrations greater than 10ml of
14.7% calcium chloride in each 100ml diluent will be
irritant to peripheral veins and should ideally be given
via a central IV line.
Calcium
folinate
See Folinic Acid
Calcium
gluconate
IV bolus
Groups
Emergency use or 1 and 2
for severe acute
hypocalcaemia
Adults: Each 10ml

ampoule preferably
over 5 minutes,
minimum 3 minutes.
If 10% Calcium Chloride Minijets are not available then

in cardiac arrest give 30ml of 10% calcium gluconate
undiluted which is 6.6mmol Ca2+ (approximately
equivalent to a 10% Calcium Chloride Minijet)
(I) or (C) infusion

Groups
using plastic
1 and 2
ampoules of
calcium gluconate
Adults: Maximum
rate by infusion
200mg (0.44mmol
Calcium)/minute
May be diluted with N/S, G or G/S to any suitable

volume e.g. 100ml, 250ml, 500ml or 1 litre. However,
concentrations greater than 10ml of 10% calcium
gluconate in each 100ml diluent will be irritant to
peripheral veins and should ideally be given via a
central IV line.
COMMENTS
Very irritant; always administer
slowly. Extravasation may
cause tissue irritation and
necrosis. Flush with N/S.
Calcium chloride 10% contains
6.8mmol calcium/10ml.
Calcium chloride 13.4%
contains 9.12mmol
calcium/10ml.
Calcium chloride 14.7%
contains 10mmol calcium/10ml.
Flush with N/S.

Calcium gluconate 10%
contains 2.2mmol calcium in
10ml.
Irritant; extravasation may
cause tissue irritation and
necrosis.
In severe acute hypocalcaemia or hypocalcaemic tetany, an initial slow intravenous injection of 1020 ml of calcium gluconate injection 10% (use the plastic
ampoules) should be given, with plasma-calcium and ECG monitoring (risk of arrhythmias if given too rapidly), and either repeated as required or, if only
temporary improvement, followed by a continuous intravenous infusion to prevent recurrence. For infusion, dilute 100 ml of calcium gluconate 10%(Use the
plastic ampoules) in 1 litre of glucose 5% or sodium chloride 0.9% (remove 100ml from the bag first) and give at an initial rate of 50 ml/hour adjusted according
to response.
Calcium gluconate injection in glass ampoules or vials is now contra-indicated for use as repeated or prolonged treatment, including as an IV infusion, in
children younger than 18 years and in patients with renal impairment. This is to limit exposure of patients to aluminium which is leached from the glass by the
calcium gluconate solution. (MHRA Drug Safety Update, August 2010).
41
DRUG
METHOD
Campath
See Alemtuzumab
Caspofungin
(I) IV infusion.
Infusion pump is
required.
Cefotaxime
Only to be
prescribed when
ceftriaxone is
contra-indicated
due to the risk of
precipitation with
calcium
containing fluids
and TPN.
IV bolus preferred Groups

3-5 minutes
method.
1,2,3,4 and 5
Cefoxitine
(Unlicensed
product see
page 4)
WHO MAY
GIVE
1 hour
Groups
1,2,3,4 and 5
20-60 minutes
Groups
1,2,3,4 and 5
Groups
1,2,3,4 and 5
IV bolus preferred Groups
3-5 minutes
method
1,2,3,4 and 5
(I) IV infusion via
infusion pump
IM Injection
IM Injection
Groups
1,2,3,4 and 5
(C) IV infusion via Groups

infusion pump
1,2,3,4 and 5
ADMINISTER
OVER

DILUENT
COMMENTS
Allow the vial to warm to room temperature.

Reconstitute each 50mg and 70mg vial with 10.5ml
W. For the 50mg dose withdraw 10ml from the
reconstituted 50mg vial. For the 70mg dose
withdraw 10ml from the reconstituted 70mg vial. For
reduced dose in moderate hepatic impairment
(35mg) withdraw 7ml from the reconstituted 50mg
vial. Further dilute with 250ml N/S or H.
If the patient is fluid restricted

the 50mg and 35mg doses may
be diluted in 100ml N/S or H.
Flush with N/S.
Do not infuse caspofungin with
any other drug solutions or
infusions containing glucose.
Phebitis is commonly reported.
Sodium content 2.09mmol/1g.
Reconstitute 500mg with 2ml, 1g with 4ml and 2g

with 10ml W.
Displacement 0.2ml for 500mg vial. Add 1.8ml of W
for 500mg in 2ml.
Displacement 0.5ml for 1g vial. Add 3.5ml W for 1g
in 4ml.
Displacement 1.2ml for 2g vial. Add 8.8ml W for 2g
in 10ml.
Reconstitute as above then dilute 1-2g with 40100ml N/S, G, G/S or H.
Reconstitute as for IV bolus. For paediatric doses
apply the same displacement values.
Reconstitute the 2g vial with 10ml or 20ml W, N/S,
G or G10%. Displacement is 1ml for the 2g vial.
Shake to dissolve and let stand until clear.
Reconstitute the 2g vial with 4ml W. Displacement is
1ml for the 2g vial. Shake to dissolve and let stand
until clear.
Reconstitute each 2g vial with 10ml W. Shake to
dissolve and let stand until clear. Further dilute with
a suitable volume (eg. 500ml or 250ml) of N/S, G,
G10% or H.
Refer to the Marsden Manual

for guidance on IM injection.
Incompatible with
aminoglycosides eg.gentamicin,
tobramycin and amikacin.
Inject into a large muscle mass,
eg. gluteus maximus.
Diluted solutions for IV infusion
must be discarded 12 hours
after preparation.
42
DRUG
METHOD
Cefradine
Ceftazidime
Ceftriaxone
WHO MAY
GIVE
SUITABLE DILUENT
Cefradine injection is no longer commercially available.
Reconstitute 500mg vial with 5ml, 1g
IV bolus
3-5 minutes
Groups
vials with 10ml and 2g vial with 10ml
1,2,3,4 and 5
N/S or G. Carbon dioxide is released;
A 3g dose (1x1g
+1x2g vials) may be see package insert.
given by slow IV
bolus.
(I) IV infusion.
Maximum 30 minutes Reconstitute 2g vial with 50ml of N/S
Groups
Infusion pump
or G.
1,2,3,4 and 5
is required.
For 3g dose, also reconstitute a 1g
vial with10ml N/S. Dilute the
reconstituted 1g and 2g vials further
to 75ml with N/S.
IM Injection
Reconstitute 250mg with 1ml, 500mg
Groups
with
1.5ml and 1g with 3ml N/S or W.
1,2,3,4 and 5
carbon dioxide is released, see
package insert.
IV bolus
2-4
minutes
Reconstitute
250mg vial with 5ml W
Groups
and
1g
vial
with
10ml. Displacement
1,2,3,4 and 5
values vary between brands and are
not consistent refer to the package
insert or SPC for the particular brand
and vial size being used.
(I) IV infusion
At
least
30
minutes
Reconstitute 2g vial with 40ml G, G
Groups
(doses of 2g
10%,
or N/S.
1,2,3,4 and 5
and above) via
infusion pump
IM Injection
Reconstitute 250mg with 1ml, 1g with
Groups
3.5ml
and 2g with 7ml of 1%
1,2,3,4 and 5
lidocaine injection. Refer to the
Marsden Manual for guidance on IM
injection.
COMMENTS

Displacement values vary between brands,
and are not consistent. Refer to the SPC or
package insert for the brand and vial size
being used.
Doses exceeding 1g should be given IV see

above. When IM injection causes pain
Lidocaine 1% injection may be used to
reconstitute the vial instead of N/S or W.
Do not give with TPN or fluids containing
calcium, even by different infusion lines
(Cefotaxime is a suitable alternative for
these patients).
Sodium content: 3.6mmol/1g
Flush with N/S or G
For infants and children up to 12 years, doses
of 50mg/kg or over should be given by slow IV
infusion over at least 30 minutes. (For
neonates the dose is given over 60 minutes).
Give by deep IM injection. Doses greater than
1g should be divided and injected at more
than one site.
43
DRUG
METHOD
Cefuroxime
WHO MAY
ADMINISTER
GIVE
OVER
IV bolus
3-5 minutes
Groups
(Usual method) 1,2,3,4 and 5
(I) IV infusion.
Infusion pump
is required.
IM Injection
Maximum 30
Groups
1,2,3,4 and 5 minutes
(I) IV infusion
Infusion pump
is required.
At least 10
Groups

SUITABLE DILUENT
Reconstitute 250mg with at least 2ml,
750mg with at least 6ml and 1.5g with at
least 15ml W. Shake gently to produce an
opaque suspension.
Reconstitute as above then dilute to
50 - 100ml with N/S or G.
COMMENTS
Sodium content: 1.8mmol/750mg
Cefuroxime can be added to an infusion bag of
metronidazole.
Displacement values vary between brands and are
not consistent refer to the package insert or SPC
for the particular brand and vial size being used.
Groups
1,2,3,4 and 5
Reconstitute 250mg with 1ml W and 750mg

with 3ml W. Shake gently to produce an
opaque suspension. Refer to the Marsden
Cernevit and Decan (see page 47) are added daily, Monday to Friday, by Pharmacy to TPN. The TPN bags held as stock on Penrose Ward do not contain
vitamins or trace elements. If TPN is commenced for a Penrose patient when Pharmacy is closed, Penrose staff should confirm whether the duty ICU consultant
wants Cernevit and Decan given separately to the patient (Do not add Cernevit and Decan to the TPN bag on the ward).
Slow IV bolus Groups
Dosage for adults and children aged over 11
Cernevit
At least 10
Reconstitute the vial with 5ml of W, N/S or
years: 1 vial of 5ml per day.
minutes
G.
1,2,3,4 and 5
(Water and
Mix gently to dissolve the powder forming a Cernevit does not contain Vitamin K.
fat-soluble
yellow-orange coloured solution.
Cernevit may be administered via any type of
vitamins)
Either give undiluted or dilute further with a
intravenous cannula (including peripheral).
small volume of N/S or G.
Do not mix with any other drug solutions.
Reconstitute the vial with 5ml of W, N/S or

G.
Mix gently to dissolve the powder forming a
yellow-orange coloured solution, then dilute
further with N/S or G (e.g. up to 50ml).
44
DRUG
METHOD
WHO MAY
GIVE

Chloramphenicol IV bolus
At least 1 minute
Groups
sodium succinate (Usual method) 1,2,3,4 and 5
(I) IV infusion.
Infusion pump
is required.
Give slowly over 15

Groups
1,2,3,4 and 5 to 30 minutes
Clomethiazole
Discontinued product
Chloroquine
(C) IV infusion.
Group 1
Infusion pump is
required.
Reconstitute with W, N/S or G. See

package insert. Suggested maximum
concentration 100mg/1ml.
Displacement 0.8ml/1g vial. Add
9.2ml diluent to 1g vial for 1g in 10ml
(100mg in 1ml).
COMMENTS
Flush with N/S.
Sodium content 2.98/1g
In order to ensure rapid attainment of high
blood levels, chloramphenicol succinate is
best administered by IV injection. Where this
is not possible, however, IM injection may be
used, although it should be borne in mind that
absorption may be slow and unpredictable.
Reconstitute as above then dilute

with N/S or G (suggested volume
100ml).
Initially 10mg/kg of
Dilute with N/S to a suitable volume
Chloroquine base
e.g. 50ml.
over 8 hours then
5mg of base/kg for 3
more 8-hour
infusions
Oral therapy is started as soon as possible to

complete the course.
Flush with N/S.
45
DRUG
METHOD
WHO MAY
GIVE
ADMINISTER
OVER
Chlorphenamine
IV bolus
Groups
Minimum 1 minute May be diluted with N/S to a

convenient volume e.g. 10ml.
1,2,3,4 and 5
Chlorpromazine
IM injection
Groups
1,2,3,4
and 5
(Use the IV route
if a rapid effect is
required)

Groups
1,2,3,4 and 5

Groups
1,2,3,4 and 5
Groups
1,2,3,4 and 5

Dilute 25-50mg with 500ml-1 litre
N/S.
SC injection
(Use the IV route
if a rapid effect is
required)
Deep IM
injection
(I) IV infusion via
an infusion pump
to treat hiccups
when IM
injection fails.
IV bolus
(This method is
unlicensed see
page 1).

Groups
1,2,3,4 and 5
Slowly
(Suggestion: 12
hours)
Adults: Maximum
1mg/minute.
COMMENTS
Flush with N/S (IV)
Extra care should be taken when preparing the
injection for children under 1 year due to the
small volumes that are required. Dilution of
chlorphenamine injection with N/S should
facilitate preparation. For example, diluting
0.2ml chlorphenamine injection to 2ml with
N/S produces a solution containing
chlorphenamine 1mg/ml. The diluted product
should be used immediately.
IM injection can be repeated at 6 to 8 hour
intervals if required. Substitute with oral
chlorpromazine as soon as possible.
Very irritant; avoid IV administration if
possible. Do not administer via the SC
route.
Dilute to a maximum concentration of

Flush with N/S (IV).
1mg/1ml with N/S.
Hypotension can occur, especially with rapid
administration: Keep the patient supine and
monitor the blood pressure during and for 30
minutes after IM or IV administration.
46
DRUG
METHOD
Ciclosporin
Ciprofloxacin
Not for general
use. Refer to Trust
Policy for Control
of Infection.
WHO MAY
GIVE
ADMINISTER
OVER

COMMENTS
(I) IV infusion.
Groups
Infusion pump is 1,2,3,4 and 5
required.
2-6 hours
Dilute to a concentration of each

50mg in 20-100ml of N/S or G.
(I) IV infusion.
Groups
required.
Infusion into a
large vein will
reduce venous
irritation (low pH)
Adults: 200mg over

30 minutes, 400mg
over 60 minutes.
For children, infuse
the dose over 60
minutes.
Provided suitably diluted.
Use infusion within 6 hours of

preparation because the solution
contains polyethoxylated castor oil
which causes phthalate leaching from
PVC containers and tubing.
Observe patient continuously for the
first 30 minutes and at frequent
intervals thereafter (Risk of
anaphylactic reactions, acute
respiratory distress, blood pressure
changes).
Flush with N/S.
Flush with N/S.
47
DRUG
METHOD
Clarithromycin
Clindamycin
WHO MAY
ADMINISTER OVER
GIVE
(I) IV infusion via a
60 minutes
Groups
large peripheral vein (or 1,2,3,4 and 5
central vein). Infusion
pump is required.
(I) IV infusion
300mg over at least
groups
Maximum 1.2g. Infusion 1,2,3,4 and 5 10 minutes, 600mg
pump is required.
over at least 20
minutes, 900mg over
at least 30 minutes,
1.2g over at least 40
minutes.
Rate not to exceed
(C) IV infusion
Groups
Doses above 1.2g
1,2,3,4 and 5 30mg/minute.
Infusion pump is
required.
IM injection
Groups
1,2,3,4 and 5

Reconstitute 500mg vial with 10ml W
and shake to dissolve the contents.
Further dilute to a concentration of
2mg/ml with N/S, G or H (Adult dose
of 500mg = 10ml of reconstituted
solution in 250ml N/S, G or H).
COMMENTS
Do not give by IV bolus (can cause

cardiac arrythmias). Do not give by IM
injection.
The reconstituted vial contains 500mg
in 10ml (although the final volume in
the vial will be 10.4ml).
Use infusion within 6 hours of
preparation.
Flush with N/S or G. Sodium content:
Less than 0.5mmol/500mg
For fluid restricted patients 500mg
Incompatible with aminophylline,
cefuroxime, furosemide, heparin,
clarithromycin, reconstituted as
phenytoin, flucloxacillin and
above, may be diluted in 100ml of
N/S and infused over 60 minutes via ceftazidime.
Monitor infusion site for signs of
a central IV line (This dilution is
inflammation, tenderness, phlebitis and
unlicensed).
pain.
Dilute to a maximum concentration of Flush with N/S.
Sodium content: Nil.
18mg/ml with N/S or G.
Typically:
For doses of 300mg, 600mg or
900mg, dilute in 50ml or 100ml N/S
or G.
Dilute 1200mg in 100ml N/S or G.
Dilute to a maximum concentration of Continuous intravenous infusion may
begin with a single rapid infusion of the
18mg/ml with N/S or G.
first dose (generally over 30minutes),
followed by a continuous infusion of
0.75 to 1.25mg/minute.
Single IM injections of greater than
600mg are not recommended.
48

GIVE
DRUG
METHOD
Clonazepam
IV bolus
Groups
In to a large vein 1,2,3,4 and
in the antecubital 5
fossa.
Emergency use
Adults: Maximum rate

0.25 - 0.5mg/minute
Infants & children:
50microgram/kg
(maximum 1mg) over at
least 2 minutes
(I) IV infusion.
Groups Adjust rate according to
Infusion pump is 1,2,3,4 and response.
required.
5
Neonates and children 1
month to 18 years:
10 60
micrograms/Kg/hour =
0.83 5ml/kg/hour of
the 12microgram/ml
dilution.

COMMENTS
Immediately before use dilute

each 1mg in 1ml with 1ml W
(diluent supplied), to produce a
1mg in 2ml solution.
Resuscitation equipment must be readily

available.
EEG, respiratory function and blood pressure
should be monitored.
Flush with N/S, G or G10%.
Sodium content: Nil
If using a PVC bag and/or a PVC line begin
the infusion immediately and infuse over a
period no longer than 2 hours.
Alternatively dilute to 12 micrograms/ml with
N/S in a 50ml Terumo or BD syringe using a
PVC-free extension set. The following are
available to be ordered from NHS Supplies:
Codan PVC-free extension set 71.4001, order
code FKA064
Alaris G30302M line, order code FKA058
Using this method the solution will be stable
for 12 hours.
Dilute up to 3mg in 250ml of N/S,

G, G10% or G/S(2.5%/0.45%).
On Neonatal ICU dilute to a
maximum concentration of
300micrograms in 25ml or
600micrograms in 50ml (12
micrograms/ml) with G10%. In
fluid restricted infants
concentrations up to
100micrograms/ml have been
used.
49
DRUG
METHOD

GIVE

COMMENTS
Clonidine
IV bolus
Groups
Can be diluted with N/S or G to

any suitable volume.
Flush with N/S.

(C) IV infusion is unlicensed (See page 4).
Monitor for bradycardia and hypotension.
Withdraw gradually to avoid rebound
tachycardia, hypertension, agitation and
sweating.
Very little compatibility data infuse through a
dedicated lumen or line. May be infused via a
peripheral or central IV line.
1 and 2
(C) IV infusion
Groups
for sedation/
1 and 2
withdrawal from
sedation in
critical care
areas only.
Infusion pump is
required.
(C) Intrathecal
Group 1
infusion or
or Group 2*
Intrathecal bolus
Give slowly preferably

over 10-15 minutes to
avoid transient pressor
effect.
Usual rate: 0.5 - 1

Dilute 750 micrograms to 50ml
micrograms/kg/hour.
with N/S or G.
Rates up to 2
microgram/kg/hour have
been used.
Prepare and administer in

accordance with the Pain
Management Centre procedures
* Restricted to those persons who are trained

and competent to administer medication via
the intrathecal route.
50
DRUG
METHOD
WHO MAY
GIVE
ADMINISTER
OVER

Co-amoxiclav
IV bolus
Usual method.
Groups
3-4 minutes
Reconstitute 1.2g vial with 20ml

W and 600mg vial with 10ml W.
For doses requiring part of a vial
Displacement values:
Bowmed/Actavis brand:
0.4ml for the 600mg vial and
0.7ml for the 1.2g vial.
Augmentin and Wockhardt
brands:
0.5ml for the 600mg vial and
0.9ml for the 1.2g vial.
(I) IV infusion.
Infusion pump is
required.
Colistimethate
(Colistin)
(Colomycin )
(I) IV infusion.
Infusion pump is
required.
1,2,3,4 and 5
Groups
1,2,3,4 and 5
Groups
1,2,3,4 and 5
Patients with a
Groups
Totally Implantable 1,2,3,4 and 5
Venous Access
Device (TIVAD)
may tolerate a
slow IV bolus of up
to 2 million units
30-40 minutes
30 minutes
COMMENTS
Flush with N/S.

Complete infusion within 4 hours of
reconstitution.
Sodium content 2.7mmol/1.2g.
Potassium content 1mmol/1.2g.
For bolus injection use within 20 minutes of
reconstitution.
Do not dilute Co-amoxiclav with G.
Not suitable for IM injection.
Example: How to give 900mg
Using a 20ml syringe, reconstitute a 1.2g vial
Reconstitute as above then dilute with 15ml WFI. Draw up the entire vial
contents into the syringe then draw up more
1.2g with 100ml N/S or 600mg
W to the 20ml mark. Mix the syringe contents.
with 50ml N/S.
Then administer 15ml (contains 900mg) and
discard 5ml.
Reconstitute all vial strengths

with 10ml W or N/S. Roll vial in
hand to dissolve. Do not shake to
avoid foam formation, then dilute
further with N/S to 50ml.
Via TIVAD only: Reconstitute all vial strengths
Minimum 5
with 10ml W or N/S. Roll vial in
minutes
hand to dissolve. Do not shake to
avoid foam formation.
Flush with N/S.

Sodium content: less than 0.5mmol per
500,000 unit and 1,000,000 unit vials
The powder for injection is also licensed for
use via a nebuliser. To nebulise dissolve
dose in 2-4ml of W or N/S. The output from
the nebuliser may be vented to the open air
or a filter may be fitted. Nebulisation should
take place in a well ventilated room.
51
DRUG
METHOD
WHO MAY
GIVE
Collagenase
Clostridium
histolyticum
This product is
being intensively
monitored by the CHM
and MHRA. Please
report all suspected
non-serious ones)
using a Yellow Card
from the BNF
0.58mg per
Group 1
injection into a
palpable
Dupuytren's cord
ADMINISTER
OVER

COMMENTS
Remove the vial from the fridge

and allow to stand at room
temperature for at least 15
minutes and no longer than 60
minutes. Reconstitute the vial
with the solvent supplied
according to the table below. Use
only the supplied solvent as it
contains calcium required to
activate the medication. Inject the
appropriate volume (see below)
of the solvent slowly into the
sides of the vial. Do not invert or
shake the solution. Slowly swirl to
ensure dissolution. The final
solution must be clear and
colourless.
Each vial is for single use only.

When injecting a cord affecting a
proximal interphalangeal joint of the fifth
finger, the needle insertion must not be
more than 2 to 3 mm in depth and not
more than 4 mm distal to the palmar
digital crease.
Volumes needed for reconstitution and administration of Collagenase Clostridium histolyticum

Joint to be treated
Solvent required for reconstitution
Sodium injected per joint:

Metacarpophalangeal joints: 0.9mg
Proximal interphalangeal joints: 0.7mg
Injection volume to deliver 0.58 mg dose*
Metacarpophalangeal joints
0.39ml
0.25ml
Proximal interphalangeal joints
0.31ml
0.20ml
* Note that injection volume for delivery of a 0.58 mg dose is less than the total volume of solvent used for reconstitution.
52
DRUG
METHOD
WHO MAY
GIVE
ADMINISTER OVER

COMMENTS
Co-trimoxazole
(I) IV infusion.
Infusion pump
is required.
Groups
The dilution of Septrin

brand for PJP
(Formerly known as
PCP) each 5ml with
75ml G should be
given over no longer
than 1 hour.
For patients with Pneumocystis

jirovecii (formerly known as
Pneumocystis carinii)
pneumonitis

Flush with N/S.
Monitor all infusions carefully for turbidity and
crystallization.
Commence the infusion within half an hour of
preparation.
High doses have been given undiluted via a
central line and syringe pump over 1.5 - 2
hours; not recommended by manufacturer.
Extravasation : may cause tissue damage.
1,2,3,4 and
5
Other dilutions should

be given over no
longer than 90
minutes, but this
should be balanced
against the patients
fluid requirements
Septrin brand: Dilute each 5ml

with at least 75ml G.
Other infections dilute each
480mg (5ml) with 125ml,
960mg (10ml) with 250ml,
1440mg (15ml) with 500ml or an
equivalent dilution with N/S, G or
G/S.
These infusions must be
administered within 6 hours
53
DRUG
METHOD
WHO MAY
GIVE
ADMINISTER OVER

COMMENTS
Cyclizine
IV bolus
Groups
3-5 minutes
Can be diluted with N/S or G if

necessary to a convenient
volume e.g. 5ml. If diluted with
N/S, visually check the dilution.
Discard if there is any
crystallization, precipitation or
haziness. Otherwise use
immediately.
Flush with 5 ml of N/S or G.

Sodium content nil.
1,2,3,4 and
5
IM Injection
Groups

1,2,3,4 and
5
(C) SC
Groups
infusion via 1,2,3,4 and
syringe driver 5
in palliative
care
(C) SC
Groups
injection for
1,2,3,4 and
use in
5
palliative care
Continuous over 24
hours
Dilute with W.

Follow the PHNT Care of The Dying Pathways

and the PHNT Syringe Driver Policy.
Cyclizine may precipitate if the concentration
in W exceeds 10mg/ml.
Precipitation occurs if mixed with N/S.
For combinations of 2 or 3 drugs in the same
syringe, refer to the Syringe Driver Drug
Compatibility chart provided in the pump kit.
Contact Pharmacy on ext. 39976 for further
compatibility advice if necessary.
Cyclizine is not licensed via the SC route (See
page 124).
Cyclophosphamide When cyclophosphamide is prescribed to treat conditions including multiple sclerosis, glomerular kidney disease or rheumatoid
arthritis, it may be administered by Group 2 practitioners who have previous experience of administering parenteral cytotoxics.
Read Appendix 3 for guidance on the handling of cytotoxic drugs. On the Planned Investigation Unit, refer to the Unit protocol.
54
METHOD
Danaparoid
IV loading dose
See comments
Groups
injected over 30
1,2,3,4 and 5
seconds followed by (C)
IV infusion to treat
thrombo-embolism in
patients with
Heparin- Induced
Thrombocytopenia
(HIT). Infusion pump is
required.
Dantrolene
IV bolus
WHO MAY
GIVE
ADMINISTER
OVER
DRUG
Group 1
Give rapidly

COMMENTS
Seek advice of Consultant Haematologist as

Dilute with N/S, G or G/S. The
the Consultant Haematologists have different
volume of diluent is not critical and
can be adjusted to the fluid needs of regimens for different indications.
the patient.
One suggested dilution: Draw up the
contents of six 750 unit ampoules
(6x750 units = 4500 units) into a
50ml syringe and dilute to 45ml with
N/S or G to make a 100unit/ml
dilution.
However, if the maintenance
infusion rate is less than 187
units/hour the above dilution will
waste danaparoid (expensive). In
this case draw up the contents of
three 750 unit ampoules (3x750units
= 2250 units) into a 50ml syringe
and dilute to 45ml with N/S or G to
make a 50unit/ml dilution.
Reconstitute 20mg with 60ml W.
Shake the vial until the solution is
clear.
Due to high pH (9.5) avoid extravasation.

Sodium content 2mmol/20mg vial.
Each 20mg vial also contains 3g mannitol.
Protect from light.
Incompatible: do not give with any other
drugs or infusion fluids including G and N/S.
55
DRUG
METHOD
WHO MAY
GIVE
ADMINISTER
OVER

SUITABLE DILUENT
COMMENTS
Daptomycin
May only be
initiated on the
advice of a
consultant
microbiologist
IV bolus
Groups
1,2,3,4 and 5
2 minutes
Reconstitute the 500mg vial with 10ml

N/S or the 350mg vial with 7ml N/S Do
not use W to reconstitute. Gently
rotate the vial to ensure complete
wetting of the product and then allow to
stand for 10 minutes. The vial should
then be gently rotated/swirled for a few
minutes as needed to obtain a clear
reconstituted solution. Vigorous
shaking/agitation should be avoided to
prevent foaming of the product. The
concentration of the reconstituted
solution is 50mg/ml (No displacement)
Contains negligible sodium (<0.05mmol/vial).

Treatment should be discontinued if the CPK
level reaches greater than 5 times upper limit
of normal in the presence of unexplained
muscle symptoms.
Store vial in a refrigerator at 2-8oC.
If clotting profiles are required during
treatment, samples should be taken pre-dose.
Compatible with: Aztreonam, ceftazidime,
ceftriaxone, dopamine, fluconazole,
gentamicin, heparin, levofloxacin, lidocaine.
Incompatible with Glucose solutions.
Flush with N/S.
30 minutes
Reconstitute and dissolve as above.

Further dilute to 50ml or 100ml N/S.

1,2,3,4 and 5
Cernevit (See page 35) and Decan are added daily, Monday to Friday, by Pharmacy to TPN. The TPN bags held as stock on Penrose Ward do not contain
vitamins or trace elements. If TPN is commenced for a Penrose patient when Pharmacy is closed, Penrose staff should confirm whether the duty ICU
consultant wants Cernevit and Decan given separately to the patient (Do not add Cernevit and Decan to the TPN bag on the ward).
Dosage for adults: 1 vial of 40ml per day.
Decan
Suggestion: 1
Via a peripheral IV cannula, 40ml
Infusion
Decan must be diluted to at least 250ml Contra-indicated in children, patients
1,2,3,4 and 5 hour
weighing less than 40kg and in patients with
(Trace
pump is
with N/S, or to at least 500ml with G.
pronounced cholestasis (serum bilirubin >
elements)
required.
Via a CVC or PICC line, 40ml Decan
140micromol/l).
may be diluted in a smaller volume of
N/S or G or given undiluted if
Do not mix with any other drug solutions.
necessary.
56
DRUG
METHOD
Desferrioxamine (I) or (C) IV

infusion.
Infusion
pump is
required.
SC infusion
using a
portable
ambulatory
pump
WHO MAY
GIVE

Groups
1,2,3,4 and 5
Treatment of acute
iron poisoning:
15mg/kg/hour,
reduced as soon as
the situation permits
(usually after 4-6
hours). Total IV dose
not to exceed
80mg/kg in any 24
hour period
Chronic iron
overload:
20 60mg/kg/day
Reconstitute each 500mg with 5ml W

and each 2g vial with 20ml W then
dilute with N/S, G or G/S. to any
suitable volume (e.g. 500ml, 1000ml
or 250ml).
Example for treating acute iron
poisoning: Reconstitute 5 x 2g vials
each with 20ml W, remove 100ml
from a 500ml bag of N/S and add the
contents from the 5 x 2g vials to the
bag then to produce 10g
desferrioxamine in 500ml(=20mg/ml).
The initial rate for will be
0.75ml/kg/hour (= 15mg/kg/hour).
Displacements: 0.4ml/500mg
Desferal vial, 0.3ml/500mg Hospira
vial and 1.5ml/2g vial (both brands).
Chronic iron
overload:
20 60mg/kg/day.
Infuse the dose over
8 to 24 hours
Suggestion: Reconstitute as above

then either dilute with N/S or give
without further dilution.
Groups
1,2,3,4 and 5
COMMENTS
Discard infusion if opalescent.
Flush with N/S.
May be infused into the blood line through
a Y adaptor located near to the venous
site of injection.
For use in children with chronic iron
overload follow the protocol on CYPOD
(Childrens and Young Persons Outpatient
Department).
Desferrioxamine is incompatible with
heparin solutions.
If giving by SC infusion, monitor for

irritation or discomfort at the site of
administration.
57
DRUG
METHOD
Desmopressin
SC injection
4micrograms in
1ml
IM injection
WHO MAY
GIVE

Groups
1,2,3,4 and 5

Groups

1,2,3,4 and 5
IV bolus
Groups
1,2,3,4 and 5

(Haemophilia 1,2,3,4 and 5
and Von
Willibrands).
Infusion
pump is
required.
Desmopressin
15micrograms
in 1ml
(OCTIM Brand)
For specialist
use in Birch
Outpatients or
Haematology
Outpatients
SC injection
Flush after IV bolus with N/S.

After repeated doses monitor for fluid
overload; restrict fluid intake and check body
weight regularly
Suggestion: 1 minute Undiluted

20 minutes
Groups
1and 2
(I) IV infusion Groups 1

and 2
Infusion
pump is
required.
COMMENTS
Dilute the dose to 50ml with N/S

but see comments.
Tachycardia, hypotension and facial flushing

may occur during infusion; monitor blood
pressure continuously during infusion.
For (I) IV infusion 100ml N/S can be used
(unlicensed) if necessary but the 20 minute
infusion time should be adhered to.
Do not mix with other fluids or drugs

20 minutes
Dilute the dose to 50ml with N/S

but see comments.
Tachycardia, hypotension and facial flushing

may occur during infusion; monitor blood
pressure continuously during infusion.
Do not mix with other fluids or drugs.
Restrict fluid intake and check body weight
regularly.
Continued monitoring of Factor VIII levels is
recommended.
58
DRUG
METHOD
WHO MAY
GIVE
Dexamethasone IV bolus or
Groups
sodium
(I) IV infusion.
1,2,3,4 and
phosphate
Infusion pump is 5
required.
IM injection
Groups
1,2,3,4, 5
Intra-articular
Group 1
Soft tissue
infiltration
(Intralesional)
Intrathecal
(Use Hospira
brand vials)
(Unlicensed
route)
Group 1
Group 1
or Group 2*
ADMINISTER
OVER

COMMENTS
Organon brand:
Give 4mg over 1
minute.
Give large doses
over several
minutes.
Hospira brand:
For a 4mg
dexamethasone
dose give 1.2ml
over 1 minute.
Give large doses
over several
minutes.
May be diluted with N/S, G or H to

any convenient volume.
Organon brand contains a quantity of

dexamethasone phosphate equivalent to
4mg/ml dexamethasone.

Administer in accordance with the

Pain Management Centre
procedures or current anaesthetic
practice.
Hospira brand contains a 8mg in 2ml of

dexamethasone phosphate equivalent to
6.6mg dexamethasone in 2ml (3.3mg/ml).
Flush IV doses with N/S.
Anaphylactic reactions can occur.
(For treatment of anaphylaxis see page 38).
The IV and IM routes of administration of
dexamethasone should only be used where
acute illness or life-threatening situations
exist. Oral therapy should be substituted as
soon as possible.
Note that absorption will be slower after IM
injection.
Prior to intra-articular injection, the joint fluid
should be examined to exclude a septic
process. Administer under strictly aseptic
conditions.
Licensed sites include: bursae, tendon
sheaths and ganglia.
*Restricted to those persons who are trained
and competent to administer medication via
the intrathecal route.
Use Hospira brand dexamethasone as it does
not contain glycerol or disodium edetate.
59
DRUG
METHOD
WHO MAY
GIVE
ADMINISTER
OVER

COMMENTS
Dexrazoxane
(Cardioxane)
(I) IV infusion
Groups
1,3 and 5
15 minutes
Pharmacy. Telephone Ext. 31083.
Dexrazoxane
(Savene)
(I) IV infusion
Groups
into a large vein 1,3 and 5
in extremity/area
other than the
one affected by
the extravasation
1 2 hours
Administer about 30 minutes before

anthracycline (e.g. doxorubicin or epirubicin)
administration.
Handle as for cytotoxics. Wear gloves and
safety glasses when handling See
Appendix 3. Avoid handling drug if pregnant.
Store the prepared infusion in the fridge and
use within 6 hours of pharmacy preparation.
The first infusion should be initiated as soon
as possible and within the first six hours after
the accident. Cooling procedures such as ice
packs should have been removed from the
area at least 15 min before the Savene
administration in order to allow sufficient
blood flow. Treatment Day 2 and Day 3
should start at the same hour (+/- 3 hours) as
on the first day.
Refer to the Guidelines for the administration
of Savene(dexrazoxzane) for the treatment of
extravasations caused by anthracyclines.
60
DRUG
METHOD
Diamorphine
Reducing Errors with Opioid Medicines in Adults (Network Drive :Groups (G) > Trust Documents > Documents > Medicines Management
folder). The PHNT Analgesic Ladder and equivalent dosages of different opioids can be found on page 185.
Observe respiratory rate (especially with IV
IV bolus
Maximum rate
Usually reconstitute 5mg, 10mg ,
Groups
bolus doses). Naloxone and resuscitation
1mg/minute
30mg
and
100mg
ampoules
with
1,2,3,4 and
equipment should be available.
1ml
W.
Use
a
minimum
of
2ml
W
to
5
For acute pain the IV dose will be a quarter to
reconstitute 500mg ampoule.
half of the corresponding IM dose. For elderly
and frail patients reduce the usual dose by
half. Flush with N/S or G. Sodium content nil.
IM injection
Reconstitute
as
above.
Refer
to
the
Groups
Marsden Manual for guidance on IM
1,2,3,4 and
injection.
5
SC injection
Reconstitute as above. Refer to the For use in palliative care follow the PHNT Care
Groups
of The Dying Pathways
Marsden Manual for guidance on
1,2,3,4 and
SC injection.
5
(C) SC infusion
via syringe
driver in
palliative care
Epidural or
spinal injection
WHO MAY
GIVE
Groups
1,2,3,4 and
5
Group 1
ADMINISTER
OVER

Continuous over 24 Reconstitute as above. Dilute further

hours
with W when 2 or more drugs are
being mixed in the same syringe.
W or N/S may be used where the
syringe only contains diamorphine.
Administer in accordance with

standard anaesthetic practice.
COMMENTS

In chronic pain, the total daily dosage of IM or
SC diamorphine is about one third of the
equivalent total daily dosage of oral
morphine.
All syringes containing solution for epidural
administration should be labelled For Epidural
Use Only (NPSA/2007/21)
61
DRUG
METHOD
Diamorphine 50
micrograms/ml
with
bupivacaine
0.167% epidural
infusion for
adults
All epidural administration sets and epidural catheters must be labelled Epidural when in use (NPSA/2007/21)
*Staff administering and monitoring epidural
Pre-made bags supplied by
Epidural
Background rate of
Groups
infusions must have received training from
Pharmacy.
infusion via
0
-10
ml/hour
with
1and 2*
the Acute Care Team and demonstrated their
McKinley
additional PatientWhen these are not available the competency at administering and monitoring
pump
Controlled Epidural
epidural infusions. Follow the Acute Care
anaesthetist may prepare the
Analgesia (PCEA) of
Team Protocols. Additional clinician boluses
infusion in theatre, with the bag
5ml boluses with a
labelled For Epidural Use Only. may be administered by Pain Nurses if
lock-out time of 30
required as per epidural protocol.
minutes, if prescribed.
IV bolus
Maximum
rate:
5mg
Do
not
dilute.
Flush with G (do not use N/S).
Groups
(1ml)
per
minute.
1,2,3,4 and 5
Use infusion within 6 hours. Diazepam is
(I) IV infusion. groups
Titrate dose to
Dilute 2-8ml with 100ml G or
adsorbed by plastic infusion equipment.
Infusion
response.
G10%,
to
produce
a
1,2,3,4 and 5
It can be injected into the infusion tubing
pump is
concentration between 100during an ongoing infusion of N/S, G or
required. .
400micrograms/1ml.
G10%.
Diazepam
emulsion
(Diazemuls)
(This is the
preferred
diazepam
formulation for
IV injection)
Diazepam
IV bolus
WHO MAY
GIVE
Groups
1,2,3,4 and 5
(C) or (I) IV
infusion.
Infusion
pump is
required.
Groups
1,2,3,4 and 5
IM injection
Groups
1,2,3,4 and 5
ADMINISTER OVER
Suggestion for adults:

Maximum rate 5mg
(1ml) per minute
Titrate dose to
response.

Undiluted
Dilute with N/S or G to a
concentration not exceeding
40mg in 500ml.

COMMENTS
Elderly or debilitated patients should be given

not more than half of the usual dose.
Flush with N/S or G. Give IV injections into a
large vein to reduce local reactions
(thrombophlebitis and thrombosis).
It is recommended that patients should
remain under medical supervision and in a
supine position for at least one hour after
administration. Resuscitation equipment
should be available. Use infusion within 6
hours. Diazepam is adsorbed by plastic
infusion equipment.
The IM route should only be used when IV or
oral administration is not possible.
62
DRUG
METHOD
WHO MAY
GIVE
Diclofenac
(C) or (I)
Infusion.
Do NOT give
as IV bolus.
Infusion
pump is
required.
Groups 1
IM injection
Dicobalt edetate IV bolus.
and 2
Groups 1
and 2
Group 1

Treatment of post-op First add 0.5ml of 8.4%, or 1ml of
4.2% sodium bicarbonate solution
pain:
to 100-500ml N/S or G with then
75mg over
30 minutes - 2hours. add the contents of one ampoule
Prevention of post-op (75mg diclofenac in 3ml).
pain:
25-50mg over
15 minutes - 1 hour
then (C) IV infusion at
5mg/hour.
Give undiluted.
Adults: Each 300mg
dose over 1 minute,
or in less severe
poisoning over 5
minutes.
Give undiluted.
COMMENTS
Only use if solution is clear. Once prepared,
use infusion immediately.
Maximum daily dosage is 150mg.
Parenteral administration should not exceed 2
days.
Sodium content: negligible.
By deep intragluteal injection into the outer
quadrant. If a second IM injection of
diclofenac is needed, it is advised that the
other buttock is used.
Each dose may be followed immediately with
50ml G 50%.
100% oxygen should be administered
concurrently with Dicobalt Edetate.
When the patient is fully conscious, it is
unlikely that the extent of poisoning warrants
the use of Dicobalt Edetate Injection.
63
DRUG
METHOD
DigiFab
(Digoxin
Immune Fab)
(I) IV infusion. Groups

Infusion
1,2,3,4 and 5
pump is
required.
Bolus only if Group 1
cardiac arrest
seems
imminent
Digoxin

Infusion
1,2,3,4 and 5
pump is
required.
Dihydroergotamine
WHO MAY
GIVE

30 minutes
Reconstitute each vial with 4 ml
W. Mix gently. The reconstituted
solution may be further diluted to
any convenient volume with N/S.
Reconstitute as above.
COMMENTS
Can rarely cause anaphylaxis, allergic or
febrile reactions.
Resuscitation equipment should be available.
Monitor blood pressure & body temperature.
Monitor ECG continuously during and for at
least 24 hours after Digibind.
Hypokalaemia can develop- sometimes
rapidly. Monitor serum potassium level
carefully during and after DigiFab.
ECG monitoring required. Flush with N/S.
Emergency Loading Dose depends on age,
lean body weight and renal function. Consider
giving a reduced dose if digoxin has been
taken within the last 2 weeks.
Note that 500micrograms of IV digoxin is
equivalent to 750micrograms of digoxin in
tablet form.
For plasma monitoring, take blood at least 6
hours after a dose.
Emergency Loading Adults: Dilute loading and

maintenance doses to 50-100ml
Dose of
with N/S.
500micrograms to
1mg infused over at
least 2 hours (see
comments)
Maintenance dose
(when patient unable
to take by mouth or
enteral feeding tube)
infused over 1 hour.
For the use of IV dihydroergotamine to treat migraine or cluster headache, follow a copy of the protocol from the Planned Investigation
Unit (PIU). The protocol may also be found on Plymouth Healthnet > Depts > Pharmacy. Note that dihydroergotamine injection is an
unlicensed product (see page 4).
64
DRUG
METHOD
Disopyramide
Regimen 1
Slow IV
bolus
WHO MAY ADMINISTER

GIVE
OVER
Groups Adults: 2mg/kg
(maximum 150mg)
1 and 2
over at least 5
minutes

Either give undiluted or dilute
further with any suitable volume of
N/S or G.
COMMENTS
ECG monitoring is necessary. Monitor for ventricular
arrythmias, widening of QRS complex and lengthening
of QT interval, hypotension, hypoglycaemia, myocardial
depression, AV block and antimuscarinic side effects.
Stop administration of disopyramide if width of QRScomplex or QT-interval increase by more than 25%, or
hypogylaemia occurs.
If cardioversion occurs during the injection, stop
injecting the remainder of the dose.
Disopyramide
Regimen 2
This regimen
should be used for
patients who are
unable to take
disopyramide by
mouth or who
have serious
arrhythmias being
treated in critical or
coronary care
areas.
Slow IV
loading
dose
Groups
1 and 2
(C) IV
Groups
maintenance 1 and 2
infusion
Adults: 2mg/kg
Either give undiluted or dilute
(maximum 150mg) further with any suitable volume of
over at least 5
N/S or G.
minutes
Adults:
0.4mg/kg/hour
Maximum
30mg/hour.
Maximum total
800mg in 24
hours.
Suggested dilution:
Remove 50ml from a 500ml bag of
N/S or G. Then add 500mg = 50ml
of disopyramide injection into the
bag to make a 1mg/ml dilution.
If cardioversion is achieved (usually within 10-15

minutes after the first injection) but the arrhythmia
recurs, a second dose of 2mg/kg (maximum 150mg)
may be given by slow IV injection over at least 5
minutes (maximum of 300mg in the first hour,
maximum of 800mg disopyramide by any route in 24
hours).
Flush slowly with N/S.
ECG monitoring is necessary. Monitor for ventricular
arrythmias, widening of QRS complex and lengthening
of QT interval, hypotension, hypoglycaemia, myocardial
depression, AV block and antimuscarinic side effects.
Stop administration of disopyramide if width of QRScomplex or QT-interval increase by more than 25%, or
hypogylaemia occurs.
65
DRUG
METHOD
WHO MAY
GIVE
Dobutamine
(C) IV infusion
Infusion pump is
required.
Groups 1
and 2
ADMINISTER
OVER
Adjust rate
according to
response.
Administration via
a central IV line is
recommended*
as solutions of
dobutamine have
a low pH.

SUITABLE DILUENT
Dilute 250mg to at least 50ml with N/S or
G (If no central IV access available see
below*)
COMMENTS
Do not flush - replace giving set.
Infusion may turn a harmless pink colour.
Haemodynamic monitoring required.
Sodium content: 0.046mmol/vial.
Concentrations of up to 10mg/1ml have

been used via a central IV line but this is An alternative dilution: For administration
via a central IV line draw up milligrams of
outside the manufacturer's
dobutamine equal to six times the patients
recommendations.
body weight in kilograms, and dilute to
100ml with N/S or G (or milligrams of
*In circumstances where a central
venous catheter is not available and the dobutamine equal to three times the
infusion is going to be run for more than patients body weight in kg in 50ml). The
a couple of hours, use a solution of 1mg infusion rate set in ml/hour will equal
micrograms/kg/minute.
in 1mL (250mg in 250ml N/S) and
administer via a large peripheral vein.
Pump rate (ml/hour) = Prescribed rate (mcg/kg/min) x weight(kg) x 60(minutes in an hour)

1000 x concentration(mg/ml)
Rate (mcg/kg/min)
(I) IV infusion
using infusion
pump for cardiac
stress testing.
Infusion pump is
required.
= Pump rate(ml/hour) x concentration(mg/ml) x 1000

60 x weight(kg)
Group 1 or See comments

Group 7
Calculate the required amount of

dobutamine and dilute to 50ml with N/S.
Infuse at 10mcg/kg/min for 4 minutes, then

20mcg/kg/min for 4 minutes, then
30mcg/kg/min for 4 minutes, then
40mcg/kg/min.
66
DRUG
METHOD
Dopamine
(C) IV infusion.
Infusion pump is and 2
required.
WHO MAY
GIVE
Groups 1

For administration via a central IV ECG monitoring usually required. Do not

flush - replace giving set.
line draw up milligrams of
For peripheral administration use a dilute
dopamine equal to six times the
patients body weight in kilograms, solution and a large vein. Use a central
venous line for concentrations over
Administration
and dilute to 100ml with N/S, G,
1.6mg/ml.
via a central IV
G10%, G/S or H (or milligrams of
line is preferred
dopamine equal to three times the Extravasation causes local vasoconstriction;
as solutions of
patients body weight in kg in 50ml). irrigate affected area with 5-10mg
dobutamine
The infusion rate set in ml/hour will phentolamine in 10-15ml N/S.
have a low pH.
equal micrograms/kg/minute.
Alternatively for administration via
If no central IV
a central IV line dilute 200mg
access is
dopamine to 50ml with N/S, G,
available the
G10%, G/S or H and infuse at the
maximum
calculated rate.
concentration for
For administration via a peripheral
infusion through
IV line add 400mg dopamine to
a peripheral vein
250ml N/S and infuse at calculated
is 1.6mg/ml.
rate.
Pump rate (ml/hour) = Prescribed rate (mcg/kg/min) x weight(kg) x 60(minutes in an hour)
1000 x concentration(mg/ml)
Rate dependent on
indication and
response.
Rate (mcg/kg/min)
Dopexamine
COMMENTS
(C) IV infusion.
Groups 1
required.
= Pump rate(ml/hour) x concentration(mg/ml) x 1000

60 x weight(kg)
Adjust rate according Dilute with N/S, G, G/S or H to a

to response.
maximum concentration of 4mg/ml
via a central IV line or a maximum
concentration of 1mg/ml via a large
peripheral vein.
Infuse via a central vein or a large peripheral

vein.
Monitor BP, heart rate, ECG, urine flow and
where possible cardiac output.
Infusion may turn a harmless pink colour.
67
DRUG
METHOD
WHO MAY
GIVE
ADMINISTER OVER
Doxapram
IV bolus
Group 1
Minimum 30 seconds
Eculizumab
This product is
being intensively
monitored by the
CHM and MHRA.
Please report all
suspected
reactions
(including nonserious ones)
using a Yellow
Card from the BNF
Edrophonium
(C) IV
Groups
infusion.
1,2,3,4 and 5
Infusion pump
is required.
Adults: 1.5 4mg/minute

= 45 120ml/hour using
the 1g in 500ml infusion,
increasing the rate
gradually.
(I) IV infusion. Groups 1

Infusion pump and 2
is required.
25 45 minutes
IV bolus
Group 1
For example, to give

900mg in 180ml N/S over
30 minutes, set the
infusion pump at
360ml/hour.
To give 1200mg in 240ml
over 30 minutes, set the
pump at 480ml/hour.
INSTRUCTION FOR
DILUTION AND SUITABLE
DILUENT
Ampoule can be diluted with
N/S, G or G10%.
Adults: Dilute 1g doxapram in
500ml G.
COMMENTS
Can be diluted with W, but

maintenance of stability
cannot be guaranteed.
Have atropine available to counteract

possible severe cholinergic reactions. In
case of cholinergic crisis resuscitation
equipment should be available.

IV bolus dose may be repeated at one hour
intervals if necessary.
Monitoring of blood pressure, heart rate and
deep tendon reflexes is recommended to
prevent overdosage.
Check arterial blood gases (ABGs)
frequently (every 30 minutes suggested)
after starting infusion. If no improvement
increase infusion rate in suggested
increments of up to 1 mg/min (to a maximum
of 4 mg/min)
Patients should be monitored for one hour
following infusion. If an adverse event occurs
Pharmacy. Telephone Ext.
during the administration of eculizumab, the
31083.
infusion may be slowed or stopped at the
Doctor to prescribe each dose medical teams discretion. If the infusion is
slowed, the total infusion time must not
as an infusion in N/S at a
exceed two hours in adults and adolescents
concentration of 5mg/ml, eg.
prescribe 900mg eculizumab (aged 12 years to under18 years) and four
hours in children aged less than 12 years.
in 180ml N/S
Prescribe 1200mg eculizumab Flush with N/S.
Sodium content: 5mmol/300mg eculizumab.
in 240ml N/S.
68
DRUG
METHOD
WHO MAY
GIVE
Enoxaparin
Pre-filled
syringes
SC injection
For dose banding
and guidance on
choice of syringe
strength(s) and
volumes to inject
see the table below
ADMINISTER INSTRUCTION FOR DILUTION AND

OVER
SUITABLE DILUENT
Groups
guidance
on SC injection.
1,2,3,4 and 5
COMMENTS
Do not press the plunger before injecting to
expel the air bubble. Hold the syringe so
that the needle is pointing downwards
(vertically at a 900 angle). Insert the full
length of the needle into the skin fold.
To avoid bruising, do not rub the
injection site after giving the injection.
Enoxaparin VTE Dosing Guidance

Weight
(kg)
40 49
50 59
60 74
75 89
90 99
100 109
110 120
121 150
Treatment Dose
Continue for at least 5 days AND until two consecuive INRs >2.0
Separate protocol applies to pregnant women
GFR > 30ml/minute (1.5mg/kg)

60mg Daily
80mg Daily
100mg Daily
120mg Daily
Prophylactic Dose
GFR < 30ml/minute (1mg/kg)

40mg Daily
GFR > 30ml/minute

20mg Daily
GFR < 30ml/minute
60mg Daily
80mg Daily
40mg Daily
20mg Daily
40mg TWICE Daily
40mg Daily
150mg Daily
100mg Daily
180mg Daily
120mg Daily
Contact Consultant Haematologist
For patients over 150kg or complex cases, advice may be obtained from a Consultant Haematologist.
For patients requiring treatment doses who are morbidly obese (BMI> 35mg/m2), pregnant, or have significant renal impairment (eGFR <30ml/minute)
monitor anti-Xa levels. Take the first anti-Xa level 3 hours after the 3rd dose and state time dose was administered and time of level take on blood form.
Thereafter, repeat level if patients condition changes or advised by Haematology.
For ACS patients, use fondaparinux unless patients eGFR < 30ml/minute, then use enoxaparin 1mg/kg daily as above.
69
DRUG
Enoximone
Ephedrine
METHOD WHO MAY

GIVE
(C) or (I) Groups
IV
1 and 2
infusion
via a
pump.
IV bolus
Epoprostenol (C) IV
infusion
via a
pump.
Group 1
ADMINISTER OVER
Initial rate: 90 micrograms/
kg/minute for 10-30 minutes until the
required haemodynamic response is
achieved (This is 2.16ml/kg/hour
using an infusion of 2.5mg/ml) then
Maintenance rate:
5-20 micrograms/kg/minute.
(This is 0.12ml/kg/hour to
0.48ml/kg/hour using an infusion of
2.5mg/ml)
3-5 minutes

Dilute with an equal volume of W or
N/S (i.e. dilute to a concentration of
2.5mg/ml).
Must be diluted prior to

administration with N/S (suggested
dilution: 3mg in 1ml).
Withdraw about 10ml of the diluent
Groups See package insert.
For
use
during
CVVH
on
ICU,
refer
to
provided, inject into the vial of
1,2,3,4 and
the
critical
care
protocol
for
epoprostenol and shake gently to
5
epoprostenol.
dissolve the powder. Then draw up
the reconstituted epoprostenol and
re-inject via the filter into the
remainder of the diluent Mix well.
This is the Concentrated solution
(10micrograms/ml).
For use during CVVH on ICU, patient
is initially acclimatized with systemic
IV infusion of 2microgram/ml
epoprostenol for 2 hours (10ml of
Concentrated solution diluted
further to 50ml with N/S).
COMMENTS
Flush with N/S.
Extravasation will cause tissue
damage.
Do not administer unless diluted
product is a clear yellow solution.
Monitor blood pressure, heart rate,
ECG and CVP.
Incompatible: do not infuse with any
other drugs including G and
furosemide.
Flush with N/S.
Cardiac and blood pressure

monitoring required until dose is
titrated.
Do not stop infusion for more than a
few minutes. Replace giving set; do
not flush.
On the Derriford Hospital Critical Care
Unit the prepared solution is used for
up to 24 hours. This is unlicensed but
cost-saving. A drop in blood pressure
is possible when renewing an infusion
thats been made up longer than 12
hours.
Sodium content 2.5mmol/reconstituted
vial.
Incompatible: do not infuse with any
other drugs including G and G/S.
70
DRUG
METHOD
Ergocalciferol
300,000unit
injection
IM Injection
Ertapenem
(I) IV infusion Groups 30 minutes

via pump
1,2,3,4 and
5
May only be
initiated on the
advice of a
consultant
microbiologist
Erythromycin
(I) IV infusion Groups 20-60 minutes

via pump
1,2,3,4 and
5
(C) IV
infusion via
pump
(I) IV infusion
via a central
line using a
pump
WHO MAY ADMINISTER

GIVE
OVER
Groups
1,2,3,4 and
5
Groups
1,2,3,4 and
5
Groups Minimum 60
1,2,3,4and minutes
5

Reconstitute the contents of the 1g

vial with 10ml W or N/S to give a
solution of approximately 100mg/ml.
Shake well to dissolve. Dilute further
with N/S to a final concentration of
20mg/ml or less (e.g.1g in 100ml
N/S).
Reconstitute each 1g with 20ml W to
produce 50mg/1ml then further dilute
to a maximum concentration of
5mg/ml with N/S, G or G/S.
If G or G/S are used add 5ml sodium
bicarbonate 8.4%/litre as a buffer.
Displacement is allowed for. Addition
of 20ml W to 1g vial gives 1g in 20ml
(50mg in 1ml).
Reconstitute as above then dilute as
above to a concentration of 1mg/ml
to 5mg/ml (1mg/ml is recommended).
Reconstitute as above then dilute 1g
to 100ml with N/S.
COMMENTS
The product packaging states Only glass syringes
should be used, as the solution is very difficult to
expel from ordinary plastic syringes. However, glass
syringes are not available. The injection is easier to
expel from green B.Braun 3ml syringes which are
available from Pharmacy. One of these syringes
should be supplied with each dispensed ampoule.
Within Pharmacy, further supplies are available in
T/Services.
Use the infusion within 6 hours of preparation.
The product information suggests using a 50ml bottle
or bag of N/S but these are not stocked in this Trust.
Sodium content: 6mmol/1g
Extravasation is hazardous.
IV infusion may cause thrombophlebitis, particularly
concentrations exceeding 5mg/1ml.
Flush with N/S.
Sodium content nil.
125mg erythromycin used as prokinetic for GI tract
(Unlicensed use - see page 1) should be diluted in
25ml N/S and given over 5 minutes.
Prepare a fresh infusion every 8 hours.
In addition to the above points, this is an unlicensed

use for use in fluid restricted patients. Cardiac
monitoring necessary.
71
DRUG
METHOD
WHO MAY
GIVE
ADMINISTER
OVER
Follow the
dosage titration
flow chart in
the package
insert.

Vials containing 100mg esmolol
in 10ml (10mg/ml) are used
without further dilution.
COMMENTS
Treatment of supraventricular tachycardia: After

(I) IV infusion via an
Groups
achieving adequate control of heart rate introduce
infusion pump. Preferably 1 and 2
alternative oral agent and gradually reduce esmolol
administer via a central
infusion rate - see package insert for instructions.
line to avoid potential
Monitor the blood pressure frequently. Caution: Flushing
venous irritation as the
the line will administer a bolus dose. However 5ml N/S
preparation has a low pH.
has been used as a flush following loading doses, given
If this is not possible, use
at the same slow rate as the loading dose.
a large peripheral vein
10mg/ml IV infusion of esmolol for supraventricular tachycardia or post-operative tachycardia and/or hypertension
Elapsed Time
Loading dose given before each titration step to produce rapid Maintenance Infusion
(Minutes)
onset of action, infused over 1 minute (pump setting)
(pump setting)
Esmolol
01
15
56
6 10
10 11
11 15
15 16
16 20
20 - 21
21 25
25 26
26 - 30
500micrograms/kg
(=3ml/kg/hour)
500micrograms/kg
(=3ml/kg/hour)
*500micrograms/kg
(=3ml/kg/hour)
*500micrograms/kg
(=3ml/kg/hour)
*500micrograms/kg
(=3ml/kg/hour)
*500micrograms/kg
(=3ml/kg/hour)
(=0.3ml/kg/hour)
(=0.6ml/kg/hour)
*150micrograms/kg/minute
(=0.9ml/kg/hour
(=1.2ml/kg/hour)
(=1.5ml/kg/hour)
(=1.8ml/kg/hour)
*As the desired heart rate or endpoint (eg. Lowered blood pressure) is approached, omit the loading dose and reduce the incremental increases in infusion rate to
25micrograms/kg/minute (0.075ml/kg/hour to 0.15ml/kg/hour). The interval between titration steps may be increased from 5 to 10 minutes.
Once the desired clinical endpoint is reached continue the maintenance infusion at that rate.
10mg/ml IV infusion of esmolol for intra-operative immediate control of tachycardia and/or hypertension
80 mg (approximately 1 mg/kg) bolus dose over 15 to 30 seconds followed by a 150 mcg/kg/min infusion (0.9ml/kg/hour), if necessary. Adjust the infusion rate as
required up to 300 mcg/kg/min (1.8ml/kg/hour) to maintain desired heart rate and/or blood pressure.
72
DRUG
METHOD
Esomeprazole
IV bolus
Groups At least 3 minutes

1,2,3,4 and
5
(I) IV infusion Groups 10 30 minutes
via infusion
1,2,3,4 and
pump
5
IV Loading
Esomeprazole
For the specialist dose of
80mg
treatment of
endoscopically
controlled bleeding
peptic ulceration.
(C) IV
infusion via
infusion
pump
Ethanol (Alcohol) (C) IV
infusion via
infusion
(Unlicensed
productsee page pump
.
4)

GIVE

COMMENTS
Reconstitute 40mg vial with 5ml

N/S.
The reconstituted solution is clear and

colourless to very slightly yellow.
Revert to omeprazole capsules orally as soon
Reconstitute as above then further as possible. Alternatively revert to dispersible
lansoprazole Fastabs via PEG/NG/NJ as soon
dilute up to 100ml with N/S.
as possible.
Use infusion in N/S within 12 hours.
Groups 80mg in 100ml N/S over For each 40mg vial, withdraw 5ml of Use infusion in N/S within 12 hours.
N/S from a 100ml bag and use to
reconstitute the vial. Then inject the
5
reconstituted esomeprazole into the * The Gastroenterologists have agreed to a 70hour treatment (rather than 72 hours). A prebag. Do not add more than 80mg
printed prescription is available.
esomeprazole to 100ml of diluent.
After
loading
dose,
infuse
Reconstitute
and
dilute
each
40mg
Groups
1,2,3,4 and at 8mg/hour for 70 hours* vial as above.
(This is 10ml//hour with
5
each 80mg in 100ml N/S)
Dilute to 5 or 10% with G.
For
ethylene glycol or
Groups
10% solutions of ethanol are hyperosmolar and
methanol
overdose:
1,2,3,4 and
irritant to veins and are best given by central
For
a
5%
solution:
5
Remove 56ml from a litre bag of 5% venous catheter.
Refer to the Toxbase
Some references recommend discontinuing
Website for details of the glucose. Then add 56ml of 90%
gradually over 24-48 hours to avoid a possible
ethanol injection into the bag.
infusion rates.
major secondary withdrawal reaction.
For ethylene glycol overdose adjust infusion
For a 10% solution:
rate to achieve blood ethanol conc. of 1- 1.5g/L.
Remove 111ml from a litre bag of
Monitor blood glucose level.
5% glucose. Then add 111ml of
90% ethanol injection into the bag. Always refer to the Toxbase website for more
detailed instructions in the case of ethylene
glycol or methanol overdose.
73
DRUG
METHOD
WHO MAY
GIVE
ADMINISTER OVER
Etomidate
IV bolus
Group 1
30 60 seconds
Fentanyl
Reducing Errors with Opioid Medicines in Adults (Network Drive :Groups (G) > Trust Documents > Documents > Medicines
Management folder). The PHNT Analgesic Ladder and equivalent dosages of different opioids can be found on page 185.
IV bolus
Monitor the patient in accordance with the
Groups 1 Follow the algorithm Dilute 200 micrograms fentanyl to
(Theatre
from Recovery 2
10ml with N/S
algorithm from Recovery 2.
and 2
Recovery)
IV bolus
Can be diluted with N/S, G, G/S or For sedation in conscious adult patients follow
Groups 1
H.
the Sedation Guidelines on Plymouth Healthnet
and 2
(under Clinical Guidelines).
All healthcare practitioners involved directly or
participating in sedation techniques must have
the necessary knowledge, skills and
competences required.
Flush with N/S.
Patient
1000 micrograms fentanyl (20ml of PCA: 20 microgram (1ml) bolus, 5 minute lock Groups
Controlled 1,2,3,4 and 5
injection) diluted to 50ml with N/S. out period. Follow the Acute Pain/Care Service
Analgesia
Protocols.
(PCA)
(I) or (C) IV Groups 1
infusion.
and 2
Infusion
pump is
required.

May be diluted with N/S or G.
COMMENTS
Pain can occur after injection into veins of the
dorsum of the hand. Use of larger veins
reduces pain on injection. Incompatible with
Hartmanns. Flush with N/S or G.
Can reduce serum cortisol levels during
induction so no longer kept in Main Theatres
74
DRUG
WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION

COMMENTS
GIVE
All epidural administration sets must be labelled Epidural when in use (not just the epidural catheter) NPSA/2007/21
Fentanyl
Pre-made bags supplied by
*Staff administering and monitoring epidural
2micrograms/ml Epidural
Groups Background rate of
Pharmacy.
infusions must have received training from the
7
15ml/hour
with
with bupivacaine infusion via
1and 2*
Acute Care Team and demonstrated their
McKinley pump
additional Patient0.1% epidural
competency at administering and monitoring
Controlled Epidural
infusion
epidural infusions. Follow the Acute Care Team
Analgesia (PCEA) of
Protocols. Additional clinician boluses may be
5ml boluses with a
administered by Pain Nurses if required as per
lock-out time of 30
epidural protocol.
minutes.
Ferric
Inspect
vials visually for sediment and damage
For doses of Groups Suggestion: 2
Either give undiluted or dilute with a
carboxymaltose 100-200mg:
before
use.
Use only those that are sedimentminutes
small volume N/S eg.10ml N/S
1 and 2
(Ferinject)
free.
IV bolus
(No more than 50ml of N/S).
The patient should be monitored closely for
signs of hypersensitivity during administration
This product is
For doses of Groups 5 minutes
For slow IV bolus, either give
and for 30 miutes after every dose of Ferinject
being intensively
201-500mg:
undiluted or dilute with a small
1 and 2
given.
monitored by the
volume N/S eg.10ml.
A single dose of Ferinject should not exceed
CHM and MHRA. Either slow IV
bolus or (I) IV
1000mg. Do not administer 1000mg more than
Please report all
infusion via
For IV infusion, dilute with no more once a week. If the total dose is greater than
suspected
pump
than 100ml N/S.
1000mg then it should be divided and given
reactions
For doses of Groups 15 minutes
Either give undiluted or dilute with over 2 weeks.
(including non501-1000mg: 1 and 2
N/S (No more than 250ml of N/S). Dilutions less than 2mg/ml are unstable.
serious ones)
(I) IV infusion
Do not mix with any other infusion or drug
using a Yellow
solutions, including glucose.
Card from the BNF via pump
Flush with N/S.
Each 50mg in 1ml of Ferinject contains
0.24mmol sodium.
METHOD
75
DRUG
METHOD
Ferumoxytol
IV Bolus
WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND

GIVE
OVER
SUITABLE DILUENT
Groups Maximum rate Do not dilute further.
1,2,3,4 and 1ml/second
(i.e. the
5
contents of
each 17ml vial
over at least 17
seconds).
This product is
being intensively
monitored by the
CHM and MHRA.
Please report all
suspected reactions
(including nonserious ones) using
a Yellow Card from
the BNF
Filgrastim
SC injection
Groups
(Zarzio)
Post chemotherapy, 1,2,3,4 and
Chronic neutopenia, 5
or HIV
Short IV infusion
Groups 30 minutes
Post chemotherapy 1,2,3,4 and
or for mobilisation of 5
PBPCs after bone
marrow transplant
Continuous SC or Groups Over 24 hours
IV infusion for
1,2,3,4 and
mobilisation of
5
PBPCs after bone
marrow transplant
Do not dilute further.

Refer to the Marsden Manual for guidance
on SC injection.
Dilute the required dose in 20ml G to produce
a final concentration of at least 1.5MU/mL
(15micrograms/mL; 300micrograms in 20ml).
COMMENTS
Follow the administration with a slow flush of
N/S to clear the line.
Monitor the patient for signs of hypotension
and hypersensitivity reactions for at least 30
minutes after giving the injection.
The maximum dose for a course of
treatment is 2 vials, but these must not be
given at the same time (The second
injection should be given 2 to 8 days after
the first injection).
Within its shelf-life and for the purpose of

ambulatory use, the patient may remove the
product from the refrigerator and store it at
room temperature (not above 25C) for one
single period of up to 72 hours. At the end of
this period, the product should not be put
back in the refrigerator and should be
disposed of.
Do not dilute to a concentration of less than

0.2MU/ml (2micrograms/ml).
Flush with G.
If a concentration of less than 1.5MU/ml
(15micrograms/ml; equivalent to less than
Zarzio is not compatible with saline
300micrograms in 20ml) is prepared in glucose
solutions.
5%, add human serum albumin to a final
concentration of 2mg/ml (e.g. in a final volume
of 20mL add 0.2ml 20% human serum
albumin). This is to reduce the amount of
filgrastim adsorbed on to the surface of the
administration set.
Do not shake the syringe before removing the
required dose.
76
DRUG
METHOD
Flebogamma
Flecainide
See Immunoglobulin Human Normal

IV bolus
Groups In an emergency or for
Adults:
rapid effect, give over at
1 and 2
2mg/kg
least 10 minutes. Minimum
Maximum
30 minutes for patients with
150mg
cardiac failure or ventricular
tachycardia.
(I) IV
Groups Adults: Loading dose over
infusion.
30 minutes as above
1 and 2
Infusion
followed by IV infusion at
pump is
1.5 mg/kg/hour for the first
required.
hour then 0.1-0.25
mg/kg/hour thereafter.
Using a 300mg in 50ml
dilution, this is
0.25ml/kg/hour for the first
hour then 0.017
0.042ml/kg/hour thereafter.

GIVE
INSTRUCTION FOR
DILUENT
COMMENTS
Can be diluted with G and given Flush with G.

as a mini-infusion (e.g. 50ml or Continuous ECG monitoring required for bolus
100ml of G).
doses.
It is recommended that the maximum duration
by infusion is 24 hours.
The maximum cumulative dose in the first 24
hours should not exceed 600mg.
Suggested dilution for
Switch to oral treatment as soon as possible.
maintenance infusion: Dilute
If infusion in N/S or H is necessary 150mg
300mg to 50ml with G.
flecainide must be diluted in at least 500ml.
77
DRUG
METHOD
WHO MAY
GIVE
Flucloxacillin
IV bolus
Usual method
Groups

Inject doses up to 1g
1,2,3,4 and 5 over 3-4 minutes
Inject 2g doses
slowly over 6-8
minutes or give by
infusion (see below).
Groups
(I) IV infusion.
Infusion pump
is required.
IM Injection
1,2,3,4 and 5
Intrapleural
Group 1
Intra-articular
Group 1
Groups
1,2,3,4 and 5
30-60 minutes
Reconstitute 250-500mg with 510ml and 1g with 15-20ml W. Can

be diluted with N/S or G.
Displacement volumes:
Bowmed/Actavis brand: 0.15mL for
250mg, 0.3mL for 500mg, 0.6mL
for 1g.
Wockhardt brand: 0.2mL for
250mg, 0.4mL for 500mg, 0.7mL
for 1g.
with N/S or G to 100ml.
COMMENTS
Flush with N/S.

For IV administration: The following drugs are

incompatible with flucloxacillin: amiodarone,
atropine sulphate, buprenorphine, calcium
gluconate, chlorpromazine hydrochloride,
ciprofloxacin, diazepam, dobutamine
hydrochloride, erythromycin lactobionate,
gentamicin sulphate, metoclopramide
hydrochloride, morphine sulphate, netilmicin
sulphate, ofloxacin, papaveretum, pethidine
Add 1.5ml of water for injections to hydrochloride, prochlorperazine edisylate,
250mg vial contents or 2ml of water promethazine hydrochloride, tobramycin and
verapamil hydrochloride.
for injections to 500mg vial
contents. Refer to the Marsden
Manual for guidance on IM
injection.
Dissolve 250mg in 5 to 10ml of
water for injections.
Dissolve 250 to 500mg in up to 5ml
of water for injections or 0.5%
lidocaine hydrochloride solution for
injection.
78
DRUG
METHOD
Fluconazole
(I) IV infusion.
Infusion pump
is required.
Flucytosine
(I) IV infusion.
Infusion pump
is required.
Groups
1,2,3,4 and 5
Flumazenil
IV bolus
Group 1
(I) IV infusion.
Infusion pump
is required.
Groups
1,2,3,4 and 5
Fluorescein
IV bolus
Folic acid
IV bolus
Group 1 or F
grade Group 2
with ENB346 or
relevant
ophthalmic
qualification
Groups
1,2,3,4 and 5
WHO MAY GIVE ADMINISTER

OVER
Provided ready diluted (2mg/ml).
10-20mg/minute.
Groups
Set
the
pump
at
1,2,3,4 and 5
300 600ml/hour
COMMENTS
Flush with N/S.

Fluconazole is well absorbed from the gut so
consider an early switch to oral/NG/PEG
treatment.
Sodium content 15mmol/200mg (100ml bottle).
20-40 minutes
Provided ready diluted.
Flush with N/S. Must be stored at 18oC to 25oC.
Can be administered concurrently Sodium content 34.5mmol/250ml.
Infusion must not be used as a multidose
with N/S, G or G/S.
container. Incompatible: do not infuse with any
other drugs except N/S, G, or G/S.
Minimum 15
Can be diluted with N/S or G to any Flush with N/S.
seconds
suitable volume.
Give (I) IV infusion if drowsiness recurs after
initial IV bolus.
100-400
Flumazenil infusion should be used within 3
micrograms/ hour
hours of preparation.
Incompatible: do not infuse with any other
drugs.
Test dose in 5ml N/S then 3-5ml of Follow the REI Fluorescein Angiograhy
10%-20% fluorescein injection
Guidelines
followed by N/S flush.
Suggestion: 1
minute
Can be diluted with N/S
Flush with N/S. Flush with N/S.
79
DRUG
METHOD
Folinic acid
IV bolus
(calcium folinate)
(I) infusion
Deep SC injection.
Alternate sites
For the treatment between the left &
right anterolateral
of Acute
and left & right
Coronary
posterolateral
Syndrome
abdominal wall.
Insert the whole
length of the needle
at right angles into
the skin.
Foscarnet
(I) IV infusion.
sodium
Initial loading dose.
Infusion pump is
required.
(C) IV infusion
Maintenance
therapy.
Infusion pump is
required.
Fondaparinux
WHO MAY
GIVE
ADMINISTER
OVER

SUITABLE DILUENT
COMMENTS
Groups
1,2,3,4 and
5
Groups
1,2,3,4 and
5
Groups
1,2,3,4 and
5
Minimum 3-5
minutes
Can be diluted with N/S.
Folinic acid (calcium folinate) 350mg contains

0.7mmol of calcium therefore administer
slowly.
Intravenous incompatibilities include:
droperidol, methotrexate, 5-fluorouracil and
foscarnet.
Groups
Maximum
Dilute with N/S or G.
rate of
160 mg/minute
To avoid the loss of fondaparinux
solution, do not expel the air bubble
from the pre-filled syringe before
injection.
Infusion to be prepared by Pharmacy.

Rate
Telephone Ext 31083.
determined
by
1,2,3,4 and
renal
function,
5
see data sheet.
Groups Minimum
1,2,3,4 and infusion time of
1 hour.
5
2.5mg once daily initiated as soon as possible

following diagnosis and continued for up to 8
days. The medical team can stop the
treatment once the patient has had no chest
pain for 48 hours.
For patients with ACS and an eGFR less than
30ml/minute, prescribe 1mg/kg enoxaparin
once daily instead.
Refer to the Marsden Manual for guidance on
SC injection.
Can be infused undiluted via a central line.
drugs.
Peripheral administration may lead to local
irritation and thrombophlebitis.
DO NOT administer by rapid intravenous
injection.
Wear gloves, gown and safety glasses when
handling. Avoid handling drug if pregnant.
80
DRUG
METHOD
Fosfomycin
(Fosfocina)

Infuse all doses over 1 Reconstitute the 4g vial with 20ml of W.
Infusion pump 1,2,3,4 and 5 hour
Reconstitute each 1g vial with 10ml W
is required.
(ampoule provided). Upon dissolving, the
vial will become slightly warm. To give a 4g
dose, remove 50ml G from a 250ml bag of
G. Then add 4g of reconstituted
fosfomycin into the bag containing 200ml
G. To give a 2g dose, add 2g reconstituted
fosfomycin to 100ml G.
Infuse all doses over Reconstitute the 2g bottle with 40ml to
Infusion pump 1,2,3,4 and 5 30 minutes
60ml W and begin infusion immediately.
is required.
Reconstitute the 3g and 5g bottles with
100ml W. Reconstitute the 8g vial with
200ml W. Begin the infusion immediately
after reconstitution. During reconstitution
the solution may get warm.
If necessary G or G10% may be used
instead of W to reconstitute the bottles
(volumes as for W). Do not further dilute.
N.B. This
brand is
unlicensed
WHO MAY
GIVE
ADMINISTER OVER

SUITABLE DILUENT
COMMENTS
Sodium content 14.35mmol/1g fosfomycin

Incompatible with the following drug
solutions: erythromycin, gentamicin and
rifampicin.
Flush with N/S.
Sodium content 14.5mmol/1g fosfomycin

Monitor serum electrolytes, in particular
serum sodium, potassium and creatinine.
Monitor patient for phlebitis at the infusion
site. Flush with N/S.
Safe to be given to patients with allergies to
any other commonly used antibiotics
including penicillins, cephalosporins,
levofloxacin, tetracyclines, trimethoprim and
erythromycin.
On storage the bottles should be protected
from light (Keep in original box)
Either dilute with N/S (a common dilution is Flush with N/S.
Furosemide
IV bolus
Adults: The rate
Groups
1mg/ml) or give undiluted.
Sodium content 0.14mmol/1ml for 20mg/2ml
1,2,3,4,5 and should not usually
and 50mg/5ml; 0.04mmol/1ml for
exceed 4mg/minute,
(C) or (I) IV
7
250mg/25ml. Rapid administration may
however single doses
infusion.
damage the hearing. Furosemide
of up to 80mg may be
Infusion pump
precipitates in glucose solutions.
given more quickly.
is required.
See Sodium Fusidate
Fusidic Acid
Gallamine
IV bolus
Flush with N/S.
Group 1
Gammanorm See Immunoglobulin Human Normal
Gammapex
Fosfomycin
(Infectofos)
81
DRUG
METHOD
Ganciclovir
(I) IV infusion.
Infusion pump is
required.
Gentamicin
IV bolus
WHO MAY GIVE ADMINISTER

OVER
Minimum
60
Group 1 or
minutes
Group 2
Groups
1,2,3,4 and 5
Refer to the
Plymouth
Healthnet Clinical
Guidelines/
Infection Control
for the use and
current dosage of
gentamicin,
teicoplanin and
vancomycin.
(I) IV infusion for

once-daily dosing
(>200mg). Infusion
pump is required.
Groups
1,2,3,4 and 5
Intraperitoneal
Groups 1 and
2
IM injection
Groups
1,2,3,4
and 5
Discuss further with a
Consultant
Microbiologist if
unable to give
gentamicin via the IV
route
Glargine insulin See Insulin Section page
3-5 minutes
(minimum 3
minutes)
30 minutes

Doctor to prescribe dose (see
comments) in 100ml N/S or G.
Either give undiluted or dilute with

N/S or G (usually 10-20ml).
Dilute with 50ml or 100ml N/S or G.
COMMENTS
To facilitate accurate measurement of the
dose, the prescribed dose in milligrams
(rounded up or down if necessary) divided
by 50 should have no more than one
decimal figure.
Wear gloves, gown and safety glasses when
handling. Avoid handling drug if pregnant.
Preferably infuse through a large vein. Flush
with N/S or G.
Administration by (I) IV infusion once a day
is current Trust policy, although this use is
outside of the manufacturers
recommendations. Flush with N/S.
Sodium content negligible
Incompatibilies include benzylpenicillin and
teicoplanin.
Follow the Renal Services Directorate
Peritoneal Dialysis Peritonitis Protocol
on IM injection.
82
DRUG
METHOD
WHO MAY
GIVE
Glucagon
SC Injection
Groups
1,2,3,4,5 and 6
IM Injection
Groups
1,2,3,4,5 and 6
IV bolus
Groups
(For diagnostic 1,2,3,4,5 and 6
testing)
IV bolus
(Loading
dose)
followed by (I)
IV infusion.
Infusion pump
is required.
Groups
1,2,3,4 and 5
ADMINISTER OVER

DILUENT
Reconstitute with diluent provided (1ml W) and
shake gently until the glucagon has dissolved and
the solution is clear. The resulting solution is
1mg/ml. Do not further dilute. Refer to the Marsden
Manual for guidance on SC injection.
Reconstitute as above. Refer to the Marsden
COMMENTS
Intravenous glucose must be given
if the patient fails to respond to
Glucagon within 10 minutes.
Intravenous glucose must be given
if the patient fails to respond to
Glucagon within 10 minutes.
Flush with N/S.
Reconstitute as above. However, for doses > 2mg

reconstitute each vial with 1ml G instead of the
diluent provided, to avoid administration of large
amounts of preservative.
Treatment of cardiogenic shock caused by beta-blocker poisoning
Loading dose of 2 -10mg For loading doses > 2mg reconstitute each vial with (I) IV infusion is an unlicensed use
(See page 1) to treat cardiogenic
1ml G instead of the diluent provided, to avoid
(Child: 50 150
shock from beta blocker poisoning.
administration of large amounts of preservative.
microgram/kg, max.
10mg) by slow IV bolus
Suggestion for the infusion for an adult:
over 3 5 minutes
Reconstitute 10 x 1mg vials, each with 1ml G (Do
followed by IV infusion not use the diluent provided as the patient will get a
of 50 micrograms/kg/hour: large dose of preservative).
Using syringe pump
Using 1mg/ml glucagon Draw up the reconstituted glucagon into a 50ml
for infusion:
syringe and either infuse undiluted (1mg/ml) or
50micrograms/kg/hour
dilute further with G.
= 0.05ml/kg/hour
Using a volumetric pump
Using a dilution of 10mg Draw up the reconstituted glucagon and dilute
further with G. (suggestion for an adult: 10mg
in 100ml for infusion:
glucagon diluted to a volume of 100ml with G. 10ml
50micrograms/kg/hour
G from the bag can be used to reconstitute the 10
= 0.5ml/kg/hour
vials of glucagon).
83
DRUG
METHOD
WHO MAY
GIVE
Glucose 5-10%
N.B All bags of
glucose are for
single use only.
IV bolus
Groups
1,2,3,4 and 5
(C) or (I) IV
infusion via
infusin
pump
Groups
(C) or (I) IV
infusion
Groups
1,2,3,4 and 5
Concentrations greater than 20% should be infused

through a central line to prevent venous irritation and
thrombophlebitis.
Groups
(PHNT Hypoglycaemia Guideline 2011)
Glucose 20-50%
Glucose 5% to treat Fast IV

severe
infusion
hypoglycaemia
ADMINISTER
OVER
1,2,3,4 and 5

COMMENTS
Glucose infusions can be diluted
G5% is iso-osmotic with blood and can be infused
with W if the concentration required through a peripheral line.
is unavailable.
If G10% is administered peripherally use a large vein
and preferably alter the injection site daily.
Fast IV infusion
1,2,3,4 and 5 200ml of 5%
glucose
or Glucose 10% to
treat severe
hypoglycaemia
Fast IV
Fast IV infusion
Groups
infusion via 1,2,3,4 and 5 100ml of 10%
a large vein
glucose
Glucose 50% to
treat severe
hypoglycaemia
IV bolus via Groups

20ml of 50%
a central
1,2,3,4 and 5 glucose over 1-2
vein.
minutes
20ml of 50% glucose over 1-2 minutes is very irritant

and potentially damaging to peripheral veins.
Glucose 10% to
(I) IV
500ml of 10%
Groups
treat hyperkalaemia infusion via 1,2,3,4 and 5 glucose over 30
a large vein
minutes
Add 10 units of Actrapid insulin into

the 500ml of 10% glucose using a
29 gauge Magellan 12.7mm
(1.3cm) Insulin Safety Syringe
available from Thrushel, Tavy or
ED (NHS order code: FTR1276)
For patients at risk

(I) IV
50ml of 50%
Groups
from heart failure or
infusion via 1,2,3,4 and 5 glucose over 15
fluid overload :
a large vein
minutes
Glucose 50% to
treat hyperkalaemia
Add 10 units of Actrapid insulin into Monitor U&Es every 2 hours until the serum
the 50ml of 50% glucose.
potassium is stable and less than 6mmol/L. Monitor
blood glucose every 30 minutes during the infusion of
glucose with Actrapid, and for 2 hours after the
infusion
Monitor U&Es every 2 hours until the serum

potassium is stable and less than 6mmol/L. Monitor
blood glucose every 30 minutes during the infusion of
glucose with Actrapid, and for 2 hours after the
infusion
84
DRUG
METHOD
Glucose 5%
Glyceryl trinitrate
ADMINISTER
OVER
(C) SC
Usual
rate is
Groups
infusion
500ml
over 8
1,2,3,4 and 5
hours
(21
drops
Only use
per
minute).
gravity-feed
Maximum rate is
administratio
500ml over 4
n sets.
hours (40 drops
Never use
per minute)
an infusion
pump for
SC
infusions.
(C) or (I) IV Groups 1 0.6 - 12 mg/hour
infusion via and 2
pump
Up to a maximum
of 24 mg/hour
depending on
indication.
Intracoronary in
Cardiac
Catheter
Labs.
WHO MAY
GIVE
Group 1

Maximum concentration of glucose
for SC infusion is 5%
Use the 50mg in 50ml ready-made

vials. If these are not available
dilute with G to 1mg/ml.
Can be diluted with N/S instead.
COMMENTS
Maximum of 2 litres of glucose 5% in 24 hours. The
needle and giving set should preferably be changed
every 72 hours. However, infusion sets can be left in
place for up to 5-7 days if there are no complications.
Refer to potassium chloride monograph for SC
potassium.
Due to the acidic pH of glucose 5%, monitor the
infusion site regularly for early signs of inflammation
and irritation.
Give via a syringe driver and either a polyethylenelined PVC extension set or a PVC-free extension.
The following extension sets are suitable and are
available to order from NHS Supplies:
Codan PVC-free extension set 71.4001, order code
FKA064.
Vygon PE-lined extension set 6222.151, order code
FSB147.
BMS PE-lined extension set 30-7200, order code
FSB646.
Other suitable sets include the Vygon 71100.15 PE
extension set and the Vygon 0832.211R PE-lined
extension set.
Do not flush - replacing giving set.
Monitor blood pressure and pulse during infusion.
Follow Cardiac Catheter Laboratory procedures.
85
DRUG
METHOD

COMMENTS
Groups 1 Rapid IV bolus

and 2
May be diluted with N/S or G if

needed.
IM injection
Groups 1
and 2

SC injection to
reduce
secretions in
palliative care
Groups

Glycopyrronium IV bolus
(Glycopyrrolate)
WHO MAY
GIVE
1,2,3,4 and
5
(C) SC infusion Groups

via syringe
1,2,3,4 and
driver to reduce 5
secretions in
palliative care
ADMINISTER
OVER
Continuous over
24 hours
Dilute with W when 2 or more

drugs are being mixed in the
same syringe.
syringe only contains
glycopyrromium.
Follow the PHNT Care of The Dying Pathways and the

PHNT Syringe Driver Policy.
For combinations of 2 or 3 drugs in the same syringe,
refer to the Syringe Driver Drug Compatibility chart
provided in the pump kit. Contact Pharmacy on ext.
39976 for further compatibility advice if necessary.
Glycopyrronium is not licensed via the SC route (See
page 124).
86
DRUG
METHOD
Glypressin
Gonadorelin
See Terlipressin.
IV bolus or SC Group 1
Injection (for
pituitary
function test)
IV bolus
Minimum 30 seconds
Groups
1,2,3,4 and 5
(I) IV infusion
5 minutes
(Adults).
Infusion pump
is required.
IM injection
Groups
1,2,3,4 and 5
Granisetron
Haloperidol
IV bolus
SC injection for
use in palliative
care
(C) SC infusion
via syringe
driver in
palliative care
WHO MAY
GIVE

Reconstitute HRF brand
100micrograms with 1ml diluent
provided.
COMMENTS
Refer to the Marsden Manual for guidance on SC

injection.
Dilute each 1mg with 5ml with N/S. Flush with N/S.
Dilute each 3mg with 20-50ml N/S, Sodium content 1.17mmol/3mg vial,
H, G or G/S.
0.15mmol/1mg vial.
Oral treatment should succeed IM administration

as soon as practicable. Oral bioavailability is
about 60% of that from the IM route so
adjustment of the dosage may be necessary.
1-2 minutes, longer if Do not dilute to give by IV route.
Flush with N/S.
Groups
Note that haloperidol injection is no longer
1,2,3,4 and 5 possible. Maximum
5mg/minute.
licensed by the IV route in the UK. This is not due
to any new safety concerns about IV haloperidol.
The manufacturer has only taken this action to
standardise the license across all global markets.
Follow the PHNT Care of The Dying Pathways and
Groups
1,2,3,4 and 5
Continuous over 24
Dilute with W when 2 or more drugs syringe, refer to the Syringe Driver Drug
Groups
are being mixed in the same
1,2,3,4 and 5 hours
syringe.
Haloperidol is not licensed by the SC route (See
syringe only contains haloperidol.
page 4).
87
DRUG
METHOD
WHO MAY
GIVE
Heparin
IV bolus
loading dose
followed by (C)
below.
3 5 minutes
Groups
1,2,3,4 and 5
(C) IV infusion
Immediately
following the
loading dose.
Infusion pump
is required.
Initial infusion rate 15

Groups
1,2,3,4 and 5 units/kg/hour =
0.015ml/kg/hour of
1,000 unit/ml infusion.
SC injection
Groups
1,2,3,4 and 5
Groups 1
and 2
Intraperitoneal
ADMINISTER OVER

5,000 units = 5ml of 1,000 unit/ml
solution with no further dilution.
(Or 10,000 units = 10ml of 1,000
unit/ml solution with no further
dilution for severe pulmonary
embolism see prescription).
Take a 20ml ampoule containing
20,000 units of heparin. Draw up
the 20ml into a 50ml syringe.
COMMENTS
Use of a PVC-free or PE-lined extension set will

avoid adsorption of heparin to the line. The
following extension sets are suitable and are
available to order from NHS Supplies:
Do not dilute this any further

Codan PVC-free extension set 71.4001, order
code FKA064.
Vygon PE-lined extension set 6222.151, order
code FSB147.
BMS PE-lined extension set 30-7200, order
code FSB646.
Other suitable sets include the Vygon 71100.15
PE extension set and the Vygon 0832.211R
PE-lined extension set.
Prepare a fresh infusion every 24 hours.
Alter rate according to

APTTR (Check before
commencing heparin
therapy, then 4-6 hours
after commencing the
infusion, 4-6 hours after
every infusion rate
change, and at least
once daily thereafter.
1,000 units per litre of dialysis fluid
Follow the PHNT Renal Services Directorate

Procedures
Heparin may only be used for locking or flushing IV lines, cannulae or devices in accordance with PHNT policy see Appendix 5, page 215
Hizentra
Humalog
Humalog Mix
Humulin

See Insulin Section
88
DRUG
METHOD
WHO MAY
ADMINISTER
GIVE
OVER
Groups
1,2,3,4 and 5
Hyaluronidase With S/C infusion of fluid

(Hypodermoclysis)
Either give 1,500iu by S/C
injection into the site before
the infusion is set up, or
iniect 1,500iu into the tubing
of the infusion set about
2cm back from the needle
at the start of the infusion.
With S/C and I/M
Groups
injections
1,2,3,4 and 5
INSTRUCTION FOR DILUTION COMMENTS

Reconstitute 1,500iu of
1,500iu hyaluronidase is sufficient for the
hyaluronidase with 1ml of N/S
administration of 500-1000ml of most fluids.
or W.
Compatible fluids include: N/S, G,
G/S(4%/0.18%), G/S(2.5%/0.45%).
1,500iu to be dissolved directly

in the solution to be injected.
Compatible when mixed with: morphine,

diamorphine, hydrmorphone, chlorpromazine,
metoclopramide, dexamethasone and very low
concentrations of adrenaline.
Incompatible with: heparin, moderate to high
concentrations of adrenaline, furosemide,
phenytoin and benzodiazepines.
With local anaesthetics
Group 1
(Other
Groups
only in
accordance
with specific
PGDs)
Groups
1,2,3,4 and 5
Extravastion where
dispersal rather than
localisation is indicated.
Administer by S/C infiltration
Haematoma
Groups
By S/C infiltration
1,2,3,4 and 5
1,500iu mixed with the quantity

of local anaesthetic solution to
be used.
In ophthalmology 15iu
hyaluronidase per ml is the
recommended concentration.
Reconstitute 1,500 iu of
or W.
Follow the PHNT protocol for managing

extravasation See Section 2.8.6
Reconstitute 1,500 iu of
or W.
89
DRUG
METHOD
Hydralazine
Slow IV
bolus
(C) IV
infusion via
an infusion
pump
WHO MAY
GIVE
ADMINISTER OVER

SUITABLE DILUENT
Over
at
least
5
minutes
to
avoid
over-rapid
Reconstitute
with 1ml W then dilute
Groups
reduction
in
blood
pressure.
with
10ml
with
N/S.
1,2,3,4 and 5
Groups
Adults:
1,2,3,4 and 5 Initial rate of 200-300micrograms/minute
Usual maintenance rate of
50-150micrograms/minute
Adjust rate according to patient's blood
pressure response and tolerance.

20mg with 500ml of N/S to give 40
micrograms/ml.
COMMENTS
Flush with N/S.
If necessary, a repeat
injection can be given after
an interval of 20-30
minutes.
Sodium content nil.
Monitor heart rate and
blood pressure.
Incompatible with glucose
solutions.
However, for fluid restricted patients

60mg hydralazine may be diluted to
60ml with N/S to make a
1000microgram/ml solution, and
infused via a central IV line. (This
dilution is unlicensed).
Pump rate (ml/hour) =Prescribed rate(micrograms/minute) x 60(minutes in an hour)

Concentration of the infusion(micrograms/ml)
Hydrocortisone
sodium
succinate
Groups
IV bolus
(Usual
method)
(C) or (I) IV
infusion via
an infusion
pump
Manufacturer recommends injection over

1,2,3,4 and 5 1 - 10 minutes
IM injection
Groups
1,2,3,4 and 5
Groups
1,2,3,4 and 5
Reconstitute each 100mg with not

more than 2ml W and shake before
drawing up.
Reconstitute as above then dilute to
100-1000ml with N/S or G (maximum
concentration of 1mg/1ml).

Sodium content
0.5mmol/100mg.
Reconstitute as for IV bolus. Refer to

the Marsden Manual for guidance on
IM injection.
The preferred method for

initial emergency use is IV
injection.
90
DRUG
METHOD
WHO MAY
GIVE
Hyoscine
butylbromide
(Buscopan)
Slow IV bolus
Groups
1,2,3,4,5 and
6
IM injection
Groups
ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS

OVER
SUITABLE DILUENT
3-5 minutes
Can be diluted with G or N/S.
Give slowly as in rare cases it has caused a marked
drop in blood pressure or even shock.
1,2,3,4,5 and
6
(C) SC infusion
Groups
via syringe driver 1,2,3,4 and 5
in palliative care
Hyoscine
hydrobromide
IM injection as
premedication
SC injection as
premedication
IV bolus as
premedication
(For acute use)
SC injection for
use in palliative
care
(C) SC infusion
via syringe driver
in palliative care
Continuous
Dilute with W when 2 or more drugs
over 24 hours are being mixed in the same syringe.
Groups
1,2,3,4 and 5
Groups
1,2,3,4 and 5
Groups
1,2,3,4 and 5
Groups
1,2,3,4 and 5
Groups
1,2,3,4 and 5

Hyoscine butylbromide is not licensed via the SC route
(See page 124).

3-5 minutes
Continuous
over 24 hours are being mixed in the same syringe.

Hyoscine hydrobromide is not licensed for use in
palliative care (See page 124).
91
DRUG
METHOD
WHO MAY
GIVE
SUITABLE DILUENT
Ibandronic acid For prevention of skeletal events in patients with breast cancer and bone metastases:
(Ibandronate)
(I) IV infusion
Groups 1 At least 15 minutes. Add the dose to 100ml N/S or G.
Infusion pump and 2
If GFR<50ml/minute
is required.
then infuse dose over If GFR<50ml/minute then add the
1 hour.
reduced dose to 500ml N/S or G.
COMMENTS
Do not mix with calcium containing
solutions.
Extravasation can lead to tissue damage.
Treatment of tumour-induced hypercalcaemia:

(I) IV infusion
Infusion pump
is required.
Groups 1
2 hours
Add the dose to 500ml N/S (or G).
and 2
Treatment of post-menopausal osteoporosis:

IV bolus using
the prefilled
syringes
Ibuprofen
(Pedea)
(I) IV infusion
Infusion pump
is required.
Groups 1
15-30 seconds
The contents of the prefilled syringes may

be injected into an existing IV line through
which N/S or G is running.
and 2
Groups 1
and 2
15 minutes
Patient should be adequately rehydrated

with N/S prior to treatment for tumourinduced hypercalcaemia.
Preferably do not dilute further. If

necessary, the injection volume may be
adjusted with either N/S or G.
A course of therapy is defined as three

intravenous injections of Pedea given at 24hour intervals. The first injection should be
given after the first 6 hours of life.
1st injection:10 mg/kg, 2nd and 3rd injections:
5 mg/kg.
If anuria or manifest oliguria occurs after the
first or second dose, the next dose should
be withheld until urine output returns to
normal levels.
If the ductus arteriosus does not close 48
hours after the last injection or if it re-opens,
a second course of 3 doses may be given.
92
DRUG
METHOD
WHO MAY
GIVE
Iloprost
(I) IV infusion
via a syringe
pump.
Preferred
method.
Infusion pump
is required.
Groups 1
and 2

SUITABLE DILUENT
6 hour infusion
Dilute 50 micrograms(0.5ml) to 25ml
(once each day).
with N/S or G. For patients who require
more than 50 micrograms during the 6
hour infusion dilute 100
micrograms(1ml) to 50ml with N/S or
G.
(I) IV infusion.
Infusion pump
is required.
Immunoglobulin
human normal
(FlebogammaDIF)
50mg/ml = 5%
Supplied by Pharmacy
(I) IV infusion.
Infusion pump
is required.
Groups
Initially 0.6
1,2,3,4 and 5 1.2ml/kg/hour for 30
minutes. If well
tolerated, the rate
may be gradually
increased to a
maximum of
6ml/kg/hour
COMMENTS
Obtain written administration instructions
from Pharmacy or from Braunton Ward.
Iloprost injection is not licensed in the UK
(See page 124).
Dilute 50 micrograms(0.5ml) to 250ml

with N/S or G. For patients who require
more than 50 micrograms during the 6
hour infusion dilute 100
micrograms(1ml) to 500ml with N/S or
G.
If side effects occur reduce rate or interrupt
infusion until symptoms subside then
restart at lower tolerated infusion rate.
Have adrenaline available in case of
anaphylactoid reactions.
Monitor vital signs and observe patient
during infusion and for 20 minutes
afterwards (for 1 hour after the first
infusion, or after the first infusion after a
long interval in treatment eg. Several
weeks).
Do not infuse with other drugs or fluids.
93
DRUG
METHOD
Immunoglobulin
human normal
(FlebogammaDIF)
100mg/ml = 10%

Infusion
1,2,3,4 and 5
pump is
required.
WHO MAY
GIVE
ADMINISTER OVER
Initially 0.6ml/kg/hour for
30 minutes. If tolerated,
advance to 1.2ml/kg/hour
for the second 30 minutes.
Again, if tolerated,
advance to 2.4ml/kg/hour
for the third 30 minutes. It
the patient tolerates the
infusion well, additional
increments of
1.2ml/kg/hour may be
made at 30 minute
intervals up to a maximum
of 4.8ml/kg/hour.

COMMENTS
weeks).
94
DRUG
METHOD
WHO MAY
GIVE
Immunoglobulin
Human Normal
(Gammanorm)
16.5%=165mg/ml
Subcutaneous
infusion via
syringe driver for
home treatment.
Groups
ADMINISTER OVER

Provided ready diluted
Instruct the patient in the use of a syringe
driver, infusion techniques, the keeping of
a treatment diary and measures to be
taken in case of severe adverse events.
When large doses are given, it is
advisable to administer them in divided
doses at different sites.
afterwards.
Sodium content: 100mg/40ml
Initial infusion rate:

1,2,3,4 and 5 10ml/hour per syringe
driver. The infusion
Also
administered rate may be gradually
by patient or increased by 1ml/hour
per syringe driver
If Gammanorm is patients
every three to four
guardian.
accidentally
weeks. The maximum
administered into a
dose administered has
blood vessel, the
been 40 ml/hour using
patient could
two syringe drivers
develop shock.
simultaneously.
IM Injection-Only
Groups
in exceptional
1,2,3,4 and 5
cases where
subcutaneous
administration is
not possible
95
DRUG
METHOD
Immunoglobulin
human normal
(Gammaplex)
50mg/ml = 5%
(I) IV infusion.
Infusion pump is
required.
This product is
being intensively
monitored by the CHM
and MHRA. Please
non-serious ones)
using a Yellow Card
from the BNF
WHO MAY
GIVE
ADMINISTER OVER

Infuse
at
an
initial
rate
Groups
of
0.6
1.2
ml/kg/hour
1,2,3,4 and 5
for 15 minutes. If well
tolerated, the rate of
administration may be
increased to
2.4ml/kg/hour for 15
minutes, then to
3.6ml/kg/hour for 15
minutes, followed by a
weeks).
maximum of
4.8ml/kg/hour for the
remainder of the
infusion.
96
DRUG

Subcutaneous
Instruct the patient or carer in the use of a
Immunoglobulin
The
recommended
Groups
infusion via syringe 1,2,3,4 and 5 initial infusion rate
syringe driver, infusion techniques, the
human normal
driver for home
keeping of a treatment diary and
depends
on
individual
(Hizentra)
Also
treatment. Suitable administered needs of the patient
measures to be taken in case of severe
200mg/ml = 20%
sites of
adverse events.
and
should
not
exceed
by patient or
15
ml/hour/site.
If
wellSupplied by Pharmacy administration
patients
include the
tolerated, the infusion
carer.
abdomen, thigh,
rate can then
This product is
upper arm and
gradually be increased
being intensively
monitored by the CHM lateral hip.
to 25 ml/hour/site.
and MHRA. Please
If Hizentra is
Up to 4 infusion sites
accidentally
can be used
non-serious ones)
administered into a
simultaneously,
using a Yellow Card
blood vessel,
provided that the
long interval in treatment eg. several
from the BNF
patients could
maximum infusion rate
weeks).
for all sites combined
develop shock.
does not exceed 50
ml/hour. Injection sites
Hizentra is essentially sodium-free.
should be at least 5cm
apart.
METHOD
WHO MAY
GIVE
ADMINISTER OVER
97
DRUG
METHOD
Immunoglobulin
human normal
(Kiovig)
10%=100mg/ml
(I) IV infusion via

pump.
WHO MAY
GIVE
ADMINISTER OVER

Initially
0.5ml/kg/hour
Groups
for
30
minutes.
If
well
1,2,3,4 and 5
tolerated, the rate may
be gradually increased
to a maximum of
6ml/kg/hour
long interval in treatment eg. several
weeks).
98
DRUG
METHOD
Immunoglobulin
human normal
(Octagam)
5%=50mg/ml
WHO MAY
GIVE
ADMINISTER OVER

(I) IV
Initially 1ml/kg/hour for Provided ready diluted.
Groups
infusion via 1,2,3,4 and 5 30 minutes, If well
infusion until symptoms subside then restart at
pump.
lower tolerated infusion rate.
administration may
Monitor vital signs and observe patient during
to a maximum of 5
infusion and for 20 minutes afterwards (for 1 hour
ml/kg/hour.
after the first infusion, or after the first infusion
after a long interval in treatment eg. several
weeks).
(I) IV
Initially 0.6ml/kg/hour Provided ready diluted.
Groups
infusion until symptoms subside then restart at
infusion via 1,2,3,4 and 5 for 30 minutes. If well
lower tolerated infusion rate.
pump.
administration may
to a maximum of
7.2ml/kg/hour.
weeks).
99
DRUG
METHOD
Immunoglobulin
human normal
(Privigen)
10%=100mg/ml
(I) IV
infusion.
Infusion
pump is
required.
WHO MAY
GIVE
ADMINISTER OVER

Initially
0.3ml/kg/hour.
Groups
If
well
tolerated,
the
1,2,3,4 and 5
rate may be gradually However, if dilution prior to
infusion is required Privagen
increased to
100mg/ml may be diluted with
4.8ml/kg/hour.
an equal volume of G to make a after a long interval in treatment eg. Several
In patients with
weeks).
50mg/ml solution.
Primary
In all patients, IV immunoglobulin administration
Immunodeficiency who
requires:
have tolerated
4.8ml/kg/hour well, the
adequate hydration prior to the initiation of the
rate may be further
infusion of IV immunoglobulin.
increased gradually to
monitoring of urine output
7.2ml/kg/hour
monitoring of serum creatinine levels
avoidance of concomitant use of loop
diuretics.
In case of adverse reaction, either the rate of
administration must be reduced or the infusion
stopped.
Privigen is essentially sodium-free.
100
DRUG
METHOD
Immunoglobulin
Human Normal
(Subcuvia)
16%=160mg/ml

The recommended
initial
rate
is
10
1,2,3,4 and 5
ml/hour per syringe
Also
administered driver.
by patient or The infusion speed
can be increased by 1
patients
ml/hour per syringe
guardian.
driver every
subsequent infusion.
The recommended
maximum speed is 20
If Subcuvia is
ml/hour.
accidentally
More than one pump
administered into a
can be used
blood vessel,
simultaneously.
patients could
develop
anaphylactic shock
or thromboembolic
events.
Instruct the patient in the use of a syringe driver,

infusion techniques, the keeping of a treatment
diary and measures to be taken in case of severe
adverse events.
The infusion site should be changed every
5-15ml.
weeks).
IM Injection Groups
Only in exceptional 1,2,3,4 and 5
cases where
subcutaneous
administration is
not possible.
In exceptional cases where IM administration is

necessary, cumulative monthly dose should be
divided up into weekly or bi-weekly applications,
in order to keep the injected volume low. To
further minimize the discomfort for the patient,
each single dosage may need to be injected at
different anatomic sites.
Supplied by
Pharmacy
Subcutaneous
infusion via
syringe driver for
home treatment,
preferentially
administered into
the abdominal
wall, thigh and/or
buttocks.
WHO MAY
GIVE
ADMINISTER OVER

Groups
101
DRUG

Instruct the patient in the use of a syringe driver,
Immunoglobulin Subcutaneous
Initially the infusion
Groups
infusion techniques, the keeping of a treatment
Human Normal infusion via
1,2,3,4 and 5 rate should be no
diary and measures to be taken in case of severe
syringe driver for
more than 10ml/hour
(Subgam)
Also
adverse events.
16%=160mg/ml home treatment.
administered for each syringe
by patient or driver. If well tolerated
it
can
be
increased
at
Supplied by
patients
If Subgam is
after the first infusion).
weekly
intervals
by
Pharmacy
guardian.
accidentally
2ml/hour
per
syringe
administered into a
driver to a maximum
blood vessel,
of 20ml/hour. The
patients could
administration can be
develop shock.
performed at two or
more different sites
simultaneously to
reduce infusion time.
IM InjectionProvided ready diluted
In exceptional cases where IM administration is
Groups
Only in exceptional 1,2,3,4 and 5
necessary, cumulative monthly dose should be
cases where
divided up into weekly or bi-weekly applications,
subcutaneous
in order to keep the injected volume low. To
administration is
further minimize the discomfort for the patient,
not possible.
each single dosage may need to be injected at
different anatomic sites.
METHOD
WHO MAY
GIVE
ADMINISTER OVER
102
DRUG
METHOD
Immunoglobulin (I) IV infusion via

Human Normal pump.
(Vigam)
Infuse via an IV
5%=50mg/ml
infusion set fitted
with a 15 micron
Supplied by
filter
Pharmacy
Indometacin
(I) IV infusion
(Indocid PDA)
Single use vials
Infliximab
(I) IV infusion.
Infusion pump is
required.
WHO MAY
GIVE
Groups
1,2,3,4 and
5

Initially:
0.6 1.2ml/kg/hour
for 30 minutes.
Increase gradually
up to 2.4ml/kg/hour
(Maximum of
180ml/hour).
COMMENTS
If side effects occur, reduce rate or interrupt infusion.

Have adrenaline available in case of anaphylactoid
reactions.
Monitor vital signs and observe patient during infusion
and for 20 minutes afterwards (for 1 hour after the first
infusion, or after the first infusion after a long interval
in treatment eg. several weeks).
Careful consideration needed before giving to diabetic
patients (contains sucrose). Flush with G or N/S.
Do not reconstitute with glucose solutions.
Either reconstitute the 1mg of
Groups 1 20 30 minutes
powder with 1ml of N/S or W to If anuria or marked oliguria (urinary output
and 2
<0.6ml/kg/hour) is evident at the time of the scheduled
produce a concentration of
second or third dose, further doses must not be given
100micrograms in 0.1ml, or
reconstitute the 1mg of powder until laboratory studies indicate that renal function has
with 2ml N/S or W to produce a returned to normal.
concentration of 50micrograms If the ductus reopens, a second course of treatment
may be given.
in 0.1ml. Do not further dilute.
Observe patients for at least 1-2 hours after the
Reconstitute each 100mg vial
Groups Not less than 2
with 10ml W to make a 10mg/ml infusion for anaphylactic reactions.
1,2,3,4 and hours.
solution. Direct the stream of W Equipment and medication to treat anaphylaxis must
(Infusion rate not
5
to the glass wall of the vial and be immediately available.
more than
Use an infusion set with an in-line sterile non2ml/minute for 250ml gently swirl the solution. Avoid
pyrogenic, low protein-binding filter (pore size 1.2
vigorous agitation and do not
infusion).
micrometre or less). PIU (Planned Investigation Unit)
In carefully selected shake as foaming is common.
Allow the reconstituted solution use these filters routinely to administer infliximab and
patients who have
will know where to obtain them.
to stand for 5 minutes. First
tolerated three 2remove from a 250ml bag of N/S The displacement value is insignificant.
hour infusions,
subsequent infusions a volume equal to the volume of
infliximab being added then add
may be given over
not less than 1 hour. in the required dose of
infliximab. Mix gently.
103
Insulin Section
Important notes for all insulins
When prescribing and administering insulin refer to the patients Insulin Passport to confirm the brand of insulin and type of injection device.
Only use Insulin syringes to draw up insulin. Do not use intravenous syringes to draw up or measure insulin (Even for IV sliding scale infusion).
Subcutaneous administration should be in the upper arms, thighs, buttocks, or abdomen.
When administered subcutaneously, care should be taken when injecting to ensure that a blood vessel has not been entered (inject into a lifted skin-fold).
Keep the needle under the skin for at least 6 seconds to ensure that the entire dose is injected. After injection, the site of injection should not be massaged.
Patients must be educated to use the proper injection techniques.
Before first use store all insulin products in the refrigerator (2 80C). Do not freeze.
If the package insert is missing, refer to the SPC on www.medicines.org.uk for instructions on how to use the various devices.
Patients own insulin pens containing insulin do not need to be kept in a fridge when they are in current use.
DRUG
METHOD
WHO MAY
COMMENTS
GIVE
(C) IV infusion Groups
Insulin neutral
In accordance with
Inspect product before use: Actrapid Follow the appropriate PHNT protocols/pre-printed
Infusion pump 1,2,3,4 and 5 the sliding-scale
(e.g. Human
and Humulin S injection should be
prescriptions for the control of blood glucose:
is required.
instructions.
clear and colourless.
Peri-operative/Fasting/Unstable Adults
Actrapid,
Adult patients with an acute MI
Humulin S)
Dilute with N/S to 1unit/1ml.
Multidose Vial
Hyperglycaemic Emergencies in diabetic
adults
See the guidelines for setting up
Critical Care Unit insulin protocol
and maintaining I.V Sliding Scale
Loss of drug into bag, plastic syringe or giving set
Insulin Infusion in Section 8.
may occur. If an infusion bag is used ensure
insulin is not injected into dead space of injection
port.
Compatible with IV glucose infusion/injection and
N/S or G containing potassium chloride for
infusion.
SC Injection
Inspect product before use: Actrapid Refer to the Marsden Manual for guidance on SC
Groups
and Humulin S injection should be
injection.
1,2,3,4 and 5
clear and colourless.
Actrapid: Discard vial 6 weeks after first use
Humulin S: Discard vial 4 weeks after first use
Record the date of first use on the vial.
104
DRUG
METHOD
ADMINISTRATION
COMMENTS
Humalog (Insulin
Lispro)
Humalog Mix 25
Humalog Mix 50
SC Injection
by Groups
1,2,3,4 and 5

Give Humalog very close to mealtimes.

Give Humalog Mix (25 or 50) shortly before meals. When necessary, Humalog Mix
(25 or 50) can be given soon after meals.
Humalog should not be mixed with insulin produced by other manufacturers or with
animal insulin preparations.
Expiry after cartridge insertion, or after first use (vial and prefilled pen): 28 days.
After cartridge insertion or first use (pre-filled pen) store below 30C. Do not
refrigerate. The pen with the inserted cartridge and the pre-filled pen should not be
stored with the needle attached.
Humulin I
(Isophane)
Humulin M3
SC Injection
by Groups
1,2,3,4 and 5

Insuman Basal
SC Injection
Insuman Comb 15 by Groups
Insuman Comb 25 1,2,3,4 and 5
Insuman Rapid

Vials containing Humulin I or the Humulin M3 formulations should be rotated several

times in the palms of the hands before use to completely resuspend the insulin, until
it appears uniformly cloudy or milky. Cartridges and pre-filled pens containing
Humulin I and Humulin M3 formulations should be rolled in the palms of the hands
ten times and inverted 180 ten times immediately before use to resuspend the
insulin until it appears uniformly cloudy or milky. If not, repeat the above procedure
until contents are mixed. Cartridges contain a small glass bead to assist mixing. Do
not shake vigorously
Expiry after insertion of the cartridge in the pen or first use of a vial: 28 days.
Do not use beyond this period. When in use, the cartridges and vials should be
stored below 30C.
The cartridge or pen in-use or carried as a spare may be stored for a maximum of 4
weeks not above 25C and away from direct heat or direct light.
The pen containing a cartridge in-use or the solostar pen in-use must not be stored
in the refrigerator.
The pen cap must be put back on the pen after each injection in order to protect from
light. Before use, keep a new cartridge (in the pen) or the new solostar pen at room
temperature for 1 to 2 hours.
Apidra
(Insuline glulisine)

SC Injection
by Groups
1,2,3,4 and 5
As for Insuman preparations above.
105
DRUG
METHOD
Lantus
SC Injection
(Insulin Glargine) by Groups
1,2,3,4 and 5
Levemir
(Insulin Detemir)
SC Injection
by Groups
1,2,3,4 and 5
NovoMix 30
SC Injection
by Groups
1,2,3,4 and 5
Novorapid
(Insulin Aspart)
ADMINISTRATION
COMMENTS
Inspect the cartridge, pen or vial

before use. It must only be used if the
solution is clear, colourless, with no
solid particles visible, and if it is of
water-like consistency
Inspect the Levemir injection: it must
not be used if it does not appear clear
and colourless.
If the Lantus has been in the refrigerator, it should ideally be taken out 1 to 2 hours
before injection to allow it to warm up as cold insulin is more painful to inject.
After first use, Lantus may be kept for a maximum of 4 weeks at a temperature
below 25C. Record the date of first use on the vial.
Shelf life after first opening: A maximum of 6 weeks when stored below 30C.
Each Penfill cartridge, Flexpen or Innolet must only be used for a single patient.

Allow the NovoMix30 to warm up to room temperature (Makes mixing easier).

Alternate rolling the pen 10 times horizontally in your palm with tilting to get the glass
ball to roll from one end to the other several times until the suspension of insulin
appears uniformly white and cloudy.
When stored at room temperature (less than 300C) the expiry date of a vial, Penfill or
Flexpen is 4 weeks from the date of first use.
Each Penfill cartridge or Flexpen must only be used for a single patient
Inspect product before use: Novorapid NovoRapid should generally be given immediately before a meal. When necessary
NovoRapid can be given soon after a meal.
injection should be clear and
When stored at room temperature (less than 300C) the expiry date of a vial, Penfill or
colourless.
Flexpen is 4 weeks form the date of first use.
Each Penfill cartridge or Flexpen must only be used for a single patient.
106
DRUG
METHOD
Intralipid 20%
IV bolus and IV
infusion
For the
treatment of
cardiac arrest
due to toxic
intravenous
concentrations
of local
anaesthetic
WHO MAY
GIVE
Group 1
ADMINISTER OVER

SUITABLE DILUENT
Follow the Association of Anaesthetists of GB and Ireland guidelines. The
Intralipid is located on the crash trolleys in Theatre, along with a laminated
copy of the guideline.
1. Give IV bolus of 1.5ml/kg over 1 minute and start IV infusion at
15ml/kg/hour.
2. After 5 minutes give a maximum of two repeat IV boluses of 1.5ml/kg if:
adequate circulation has not been restored or
an adequate circulation deteriorates.
Leave 5 minutes between boluses.
A maximum of three boluses can be given (including the initial bolus).
COMMENTS
Continue CPR throughout

treatment with Intralipid.
Recovery from local
anaesthetic induced cardiac
arrest may take more than 1
hour.
Propofol is not a suitable
substitute for Intralipid.
Lidocaine should not be used
as an anti-arrythmic therapy.
3. Continue the infusion at the same rate, but double the rate to
30ml/kg/hour at any time after 5 minutes if:
cardiovascular stability has not been restored or
an adequate circulation deteriorates.
4. Continue the infusion until stable and adequate circulation restored or the
maximum cumulative dose of Intralipid has been given.
Do not exceed a maximum cumulative dose of Intralipid of 12ml/kg
107
DRUG
METHOD
WHO MAY
GIVE
ADMINISTER OVER
Iron dextran
(Cosmofer)
First test dose

before
administration of
Cosmofer to all
new patients
Groups
Test dose (25mg = 0.5ml) over 12 minutes. Monitor the patient

closely. If no adverse reactions
occur after 60 minutes give the
remainder of the very first dose as
below.
Each ml
contains
50mg Iron(III)
1,2,3,4 and
5
Slow IV bolus
Preferred method: Groups
1,2,3,4 and
(I) IV infusion.
Infusion pump is 5
required.
Hospital Use
Only:Total Dose
IV Infusion.
Infusion pump is
required.
Groups
1,2,3,4 and
5
IV bolus
Groups
(or injection into 1,2,3,4 and
the venous limb 5
of the dialyser
during
haemodialysis)
Infuse the first 25mg over 15

minutes before each subsequent
infusion. If no adverse effects
during this time infuse the
remaining solution at maximum
rate of 100ml/30 minutes.
Infuse the first 25mg of the
infusion over 15 minutes. If no
adverse effects during this time
infuse the remaining solution over
4 6 hours. The rate of infusion
may be increased progressively
to 135-180ml/hour.
Administer the first 25mg over 1-2
minutes before each subsequent
slow bolus. Wait 15 minutes and
monitor for adverse effects. If no
adverse effects give remainder of
each dose at 10mg/minute
(0.2ml/minute)

Consult the Haematology Cosmofer
protocol.
Monitor patient closely in case of
anaphylaxis.
Resuscitation equipment should be
available.
Stop the infusion or injection immediately if
Dilute 100-200mg iron (2 4ml) any signs of hypersensitivity or intolerance
occur.
in 100ml of N/S or G.
Observe the patient closely for signs of
hypersensitivity during Cosmofer
administration and for at least 1 hour after IV
administration (Especially after Total Dose
For Total Dose Infusion add the Infusion to monitor for delayed
hypersensitivity-like reactions).
required dose (determined by
the dosage table or calculation Do not infuse with any other drugs or fluids.
Flush with N/S.
in the product leaflet) to 500ml
N/S or G.
Cosmofer may alternatively be given by
deep IM injection refer to the SPC for
Dose of 100-200mg iron (2-4ml) further instructions (www.medicines.org.uk)
Do not give Cosmofer to patients with a
preferably diluted in 10-20ml
history of asthma, allergic eczema or other
N/S or G.
atopic allergy by the IV route (For these
patients IM is the preferred route for
Cosmofer).
For use on the Planned Investigation
Unit, follow the PIU Cosmofer Pathway.
108
DRUG
METHOD
Iron sucrose
(Venofer)
IV bolus
Groups
(or injection into 1,2,3,4 and
the venous limb 5
of the dialyser
during
haemodialysis )
Each ml
contains 20mg
Iron
(I) IV infusion.
Infusion pump
is required.
WHO MAY
GIVE
Groups
1,2,3,4 and
5
Groups
1,2,3,4 and
5
ADMINISTER OVER

COMMENTS
1ml/minute (5ml
ampoule over 5
minutes).
Undiluted
Do not give Venofer by IM injection.

The patient should be monitored closely for
signs of hypersensitivity during administration
and for 30 minutes after every dose of Venofer
given. If hypersensitivity reactions or signs of
intolerance occur during administration, the
treatment must be stopped immediately
Resuscitation equipment should be available.
Do not infuse with any other drugs or fluids.
Extravasation may cause tissue damage.
Maximum 10ml (200mg)

per injection.
100mg over at least 15
minutes
Dilute each 5ml ampoule to a

maximum of 100ml with N/S.
Two 5ml ampoules should not be

diluted to more than 200ml with
N/S
Give slowly. Suggestion: Recommended to administer
3-5 minutes
undiluted but can be further diluted
with W if needed.
200mg over at least 30
minutes
Isoniazid
IV bolus
Isophane
insulin
Isophane insulin should be prescribed by brand. See Insulin Section page
109
DRUG
METHOD
WHO MAY
GIVE
Isoprenaline
(C) or (I) IV
Groups
infusion.
1,2,3,4 and 5
Infusion pump
is required.
Preferably
administer via a
central venous
catheter to
avoid potential
venous irritation
as the
preparation has
a low pH
ADMINISTER OVER

COMMENTS
For severe
bradycardia: Dose
range 0.5 10
micrograms/minute
Adjust rate according
to response
ECG monitoring required.

Via a central IV line (or large
peripheral vein if central access is
not available) dilute 2mg or
2.25mg isoprenaline sulphate
(depending on the brand of
ampoule available) in 500ml G.
In fluid restricted patients 2mg or
2.25mg isoprenaline sulphate
(depending on the brand of
ampoule available) may be diluted
to 50ml with G and given via a
central line.
Pump rate (ml/hour) =Prescribed rate(micrograms/minute) x 60(minutes in an hour)

Infusion using 2mg isoprenaline sulphate in 500ml G: 0.5 10micrograms/minute = 7.5 150ml/hour
Infusion using 2.25mg isoprenaline sulphate in 500ml G: 0.5 10micrograms/minute = 6.7 133ml/hour
If patient is fluid restricted then via a central line:
Infusion using 2mg isoprenaline sulphate in 50ml G: 0.5 10micrograms/minute = 0.75 15ml/hour
Infusion using 2.25mg isoprenaline sulphate in 50ml G: 0.5 10micrograms/minute = 0.67 13.3ml/hour
IV bolus
Group 1
Using the 100microgram in 2ml

ampoule, dilute 2ml
(100micrograms) to 5ml with N/S
or G.
110

GIVE
DRUG
METHOD
Isosorbide
dinitrate
(Isoket)
(C) or (I) IV Groups 1 Usually 2-12mg/hour. Up

Provided ready-diluted 25mg of
infusion via and 2
to 20mg/hour if needed.
isosorbide dinitrate in 50ml.
pump
This equates to 4 -24
ml/hour (Max 40ml/hour) of
0.05% (25mg in 50ml)
solution.
Intracoronary
Group 1 1mg bolus given prior to

balloon inflation

COMMENTS
Use a plastic syringe with a PVC-free or PE-lined
extension set. The following extension sets are suitable
and are available to order from NHS Supplies:
Codan PVC-free extension set 71.4001, order code

FKA064.
Vygon PE-lined extension set 6222.151, order code
FSB147.
BMS PE-lined extension set 30-7200, order code
FSB646.
Other suitable sets include the Vygon 71100.15 PE
extension set and the Vygon 0832.211R PE-lined
extension set.
Flush with N/S or G. Monitor blood pressure and pulse
during infusion.
Manufacturer recommends
Further doses may be given, not exceeding 5mg within a
dilution to 0.5mg/ml with N/S or G. 30 minute period.
111
DRUG
METHOD

GIVE

COMMENTS
Itraconazole
(I) IV
infusion.
Infusion
pump is
required.
Groups
Following the package insert

instructions remove the outer
wrap from the 50ml bag of N/S
provided. Inject 250mg
itraconazole (25ml) into the bag in
a slow single action (up to 60
seconds) and agitate gently.(The
bag now contains 250mg in
75ml). Close the infusion set
clamp then push the pin of an
infusion set into the flexible port of
the infusion bag. Then prime the
infusion set in the usual manner.
Connect the infusion set to the
two-way stop cock of the
extension line and open the
clamp to allow all the air to be
expelled from the infusion set and
extension line.
To avoid incompatibility problems, after infusing the

itraconazole flush the extension line with 15-20ml N/S at
the two-way stop cock, just before the 0.2 micron in-line
filter as directed in the package insert instructions.
Do not infuse any other drug solutions together with
itraconazole down the same line/lumen.
Protect prepared infusion from direct sunlight.
Do not administer if the solution is a milky white colour that
does not disappear after gentle mixing.
Administer 60 ml (200mg)
1,2,3,4 and over 1 hour
5
Stop the infusion when
60ml (200mg) has been
administered
(About 15ml will remain in
the bag and infusion set to
be discarded)
112
DRUG
METHOD
WHO MAY GIVE
ADMINISTER OVER
Ketamine
Induction &
maintenance of
anaesthesia
IV bolus
Group 1
Minimum 60 seconds
Low dose as
premedication prior
to invasive or
painful procedures
IV bolus
(C) IV infusion.
Infusion pump is
required.
Groups 1 and 2
3-5 minutes
Induction &
maintenance of
anaesthesia
IM Injection
Post-operative
(C) IV Infusion.
Use a locked
infusion pump
designated for
ketamine.
Kidney
perfusion
solution
(Soltran)
Group 1

50mg/ml is the recommended
maximum concentration.
Flush IV bolus with N/S or G.
50mg/ml is the recommended

maximum concentration.
Can be diluted to 1mg/1ml with G

or N/S or infused as 10mg/ml or
50mg/ml (undiluted product).
Can be given by
Group 2 staff to a
ventilated patient in
level 3 critical care.
COMMENTS

available.
Monitor cardiac and respiratory functions.
Ketamine is chemically incompatible with
barbiturates and diazepam because of
precipitate formation. Therefore, these
should not be mixed in the same syringe
or infusion fluid.
Group 1

1 2ml/hour via antiOnly to be

siphon/reflux line.
prescribed by an
anaesthetist or the Titrate to response.
Acute Care Team.
Group 2 staff can
administer.
Draw up 0.1ml/kg of ketamine

50mg/ml injection. Dilute this to
50ml with N/S.
Monitor the patient in accordance with the

PHNT Acute Pain protocols.
Do not further dilute.
Not for Intravenous Infusion
Kidney perfusion via Group 1 or

kidney transplant
Group 2 trained in
catheter
the use of the
LifePort system
Chill to 4oC then

rapidly perfuse kidney
with 8 litres, followed
by slower perfusion of
75-100ml/minute
Follow the operating instructions for the

LifePort system.
113
METHOD
Kiovig
Labetalol

IV bolus
50mg bolus over at
Groups 1
least 1 minute.
and 2
Lower doses are used
during anaesthesia.
(C) or (I) IV
Usual
maximum rate
Dilute to 1mg/1ml with G or G/S.
Groups
infusion.
120mg/hour
Suggested volume 200ml.
1,2,3,4 and 5
Infusion pump
is required.
For patients in critical care areas who
are fluid restricted undiluted labetolol
injection (5mg/ml) may be given by IV
infusion via a central IV line -this method
is unlicensed (See page 4)
30 minutes
Using the 19G needle provided,
Infusion pump 1,2,3,4 and 5
reconstitute with the 1.05ml W provided
is required.
and agitate gently to ensure complete
dissolution (do not shake vigorously).
Dilute with N/S or G up to 50ml/vial for
Granocyte-13 or up to 100ml/vial for
Granocyte-34.
SC Injection
Reconstitute as above using the 19G
Groups
needle. Keep the19G needle and the
1,2,3,4 and 5
syringe attached to the vial and
withdraw the required volume of
reconstituted solution from the vial.
Replace the needle used for
reconstitution and fit the syringe with the
26G needle provided for subcutaneous
injection.
Lantus
Lenograstim
WHO MAY
GIVE
ADMINISTER OVER
DRUG

SUITABLE DILUENT
COMMENTS
IV bolus can be repeated every 5

minutes to a maximum dose of 200mg.
ECG and blood pressure monitoring
required.
The patient should remain supine for at
least 3 hours after administration.
Flush with G.
Flush with N/S.

114
DRUG
METHOD
Leucovorin
calcium
Levemir
Levetiracetam
See Folinic Acid
WHO MAY
GIVE
ADMINISTER OVER

COMMENTS

Give all doses over 15 Dilute all doses with 100ml N/S or IV and oral dosage (dose and frequency) are
Infusion pump 1,2,3,4 and 5 minutes
G.
the same. No adjustment is needed when
is required.
switching between these routes.
Sodium content: 1.5g dose contains 25mmol
sodium.
The SPC states that there is no experience with
administration of IV levetiracetam for longer
than 4 days.
Levobupivacaine Epidural
Administer
in
accordance
with
All syringes containing solution for epidural
Group 1
injection
standard anaesthetic practice
administration should be labelled For Epidural
Local Infiltration
Use Only (NPSA/2007/21)
Intrathecal
injection
Peripheral
nerve block
Peribulbar
block
Levofloxacin
250mg over at least 30 Provided ready diluted.
Infusion pump 1,2,3,4 and 5 minutes. 500mg over
Sodium content : 15.4mmol/100ml bottle.
is required.
at least 60 minutes.
Rarely, profound hypotension may occur during
infusion. If this happens halt the infusion
immediately.
Levofloxacin is well absorbed from the GI tract
so consider an early switch to the oral route.
The bag should only be removed from the
outer covering at the time of infusion as the
shelf life reduces to 7 days once this outer
covering is removed.
115
DRUG
METHOD
Levomepromazine IV bolus
WHO MAY ADMINISTER

OVER
GIVE

COMMENTS
Groups 1 3-5 minutes
Dilute with at least an equal

volume of N/S before
administration.
Protect infusion from light. Discard injection if

pink or yellow colouration occurs.
Flush with N/S.
Postural hypotension can occur, particularly in
patients over 50; monitor blood pressure.
Sodium content: 0.037mmol/1ml
Follow the PHNT Care of The Dying Pathways.
and 2
SC injection for use Groups

in palliative care
1,2,3,4 and
5
(C) SC infusion via Groups Continuous over 24
syringe driver in
1,2,3,4 and hours
palliative care
5

same syringe.

116
DRUG
METHOD
Lidocaine
(Lignocaine)
WHO MAY GIVE ADMINISTER OVER INSTRUCTION FOR DILUTION

Slow IV bolus Groups 1 and 2 3 minutes
2
Dilute with N/S or G. Usual
Loading Dose Groups 1 and Infusion for adults:
concentration of 1mg/ml or
(Slow IV bolus 2
4mg/minute for 30
2mg/ml but concentrations up to
as above)
minutes then
8mg/ml have been used in fluid
followed by (C)
2mg/minute for 2
restricted patients.
or (I) IV
hours than
infusion.
1mg/minute.
Infusion pump
is required.
Anaesthesia:
Infiltration
Regional IV
Nerve blocks
Linezolid
(I) IV infusion.
Infusion pump
is required.
Group 1
(Other Groups
only in
accordance with
specific PGDs)
Groups 1 and
2
COMMENTS
Flush with N/S.
50mg bolus dose for patients who have
gross circulatory impairment or low body
weight.
Use reduced dosage for patients with CCF,
hepatic failure and cardiac surgery.
If an IV infusion is not immediately
commenced, the slow bolus may be
repeated once or twice at intervals of at
least 10 minutes.
1gram Lidocaine in 500ml G (2mg/ml)
ready-made infusion available from
Pharmacy.
Administer in accordance with

standard anaesthetic practice
30 to 120 minutes

Linezolid is a reversible non-selective
inhibitor of Monoamine Oxidase (MAOI)
With the new FreeFlex bag
and may theoretically enhance increases
containing linezolid, the spike of
in blood pressure produced by
the giving set should be pushed
into the blue port, after twisting off sympathomimetics (e.g. dopamine,
the cap marked with a down-ward noradrenaline, adrenaline). Theoretically it
may cause serotonin syndrome with
pointing arrow. The white port is
serotonin re-uptake inhibitors e.g. SSRIs
not intended to be used.
(fluoxetine etc).
Sodium content 5mmol/600mg.
117
DRUG
METHOD
WHO MAY
GIVE
Liothyronine
20micrograms
Slow IV bolus
Groups
1,2,3,4 and 5
Lorazepam
IV bolus
Usual
Groups
(Preferred route) 1,2,3,4 and 5 maximum rate
2mg/minute
except in
control of status
epilepticus
where rapid
injection is
required.
IM injection
Groups
(Give IV to treat 1,2,3,4 and 5
status
epilepticus)
IV bolus
Suggestion: 2
Groups
1,2,3,4 and 5 3 minutes
(DL)-Lysine acetyl
salicylate
(Aspegic)
(product see
page 4)
MabCampath
ADMINISTER
OVER
3-5 minutes

COMMENTS
SUITABLE DILUENT
Reconstitute the 20microgram vial with 1 to
Flush with N/S.
2ml W and shake gently until the powder has Sodium content 1.49mmol/1g.
dissolved.
Displacement 0.2ml/20micrograms.
(For example, to give 10micrograms,
reconstitute with 1ml W which expands to
1.2ml. Then withdraw 0.6ml = 10micrograms)
Can be diluted 1:1 with N/S or W.
For IM administration the injection must be

Absorption from an IM injection is too slow
diluted 1:1 with N/S or W. Refer to the
for a rapid effect, and no more rapid than
Marsden Manual for guidance on IM injection. oral administration.
Immediately before use, reconstitute the

Do not mix with other injectable products in
contents of each 500mg vial with the 5ml of
the same line.
W provided to make a 100mg/5ml solution.
(I) infusion
Suggestion: 30 Reconstitute as above then dilute the dose
Minimum interval between doses is 4 hours.
Groups
(500mg or 1g) with N/S or G suggested
volume 100ml.
Deep IM
Reconstitute as above. Refer to the Marsden
Groups
injection
1,2,3,4 and 5
See Alemtuzumab
118
DRUG
METHOD

GIVE
Magnesium sulphate
(I) IV
infusion.
Infusion
pump is
required.
Groups
2g (8mmol Mg2+)
magnesium sulphate=
20ml of 10%(1g in 10ml)
injection or
4ml of 50%(5g in 10ml)
injection.
4g (16mmol Mg2+)
magnesium sulphate=
40ml of 10%(1g in 10ml)
injection or
8ml of 50%(5g in 10ml)
injection.
5g (20mmol Mg2+)
magnesium sulphate=
50ml of 10%(1g in 10ml)
injection or
10ml of 50%(5g in 10ml)
injection.

10% (1g in 10ml) magnesium

Arrythmias: 2g (8mmol
2+
sulphate injection may be given
)
over
10-15
minutes
Mg
1,2,3,4 and
repeated once if necessary. undiluted.
5
Dilute 50% (5g in 10ml)
magnesium sulphate injection to
Treatment of
a maximum concentration of
hypomagnesaemia:
200mg/1ml with N/S or G (e.g. 2g
2g (8mmol Mg2+) over a
minimum of 30 minutes or (4ml of 50% injection) diluted to
at least 10ml).
5g (20mmol Mg2+) over a
minimum of 1 hour
For patients requiring rehydration
Prevention of Re-Feeding or larger volumes of fluid, the
magnesium replacement dose
Syndrome:
0.2mmol/kg (0.05g/kg) over may be diluted with 500ml or 1L
of N/S or G.
a minimum of 1 hour
Treatment of seizures and Loading dose: Draw up 4g (8ml
of 50% magnesium sulphate
and prevention of
recurrence in Eclampsia: injection). Dilute to 20ml in a
4g loading dose over 5-15 50ml syringe with N/S. Mix well.
minutes.
Maintenance infusion:
1g/hour. Using 5g in 50ml
dilution set pump at
10ml/hour.
Maintenance infusion: Draw up

5g (10ml of 50% magnesium
sulphate injection). Dilute to 50ml
in a 50ml syringe with N/S. Mix
well.
COMMENTS
Flush with N/S.
Monitor blood pressure and pulse. Also monitor
for signs of Mg overdose which include
weakness, nausea, drowsiness & slurred
speech.
Continue the infusion for at least 24 hours after

the seizure or delivery, whichever is later. If
seizure recurs, increase the infusion rate to 1.52g/hour or give an additional IV bolus of 2g over
5 minutes (Dilute 4ml of 50% magnesium
sulphate injection to 10ml with N/S).
Monitor the patellar reflex and oxygen saturation
levels hourly during administration of
magnesium sulphate (including overnight) to
exclude signs of toxicity.
119
DRUG
METHOD

GIVE
Magnesium
sulphate
(Continued
from previous
page)
IM Injection,
only if IV
access is not
possible or
impractical
Groups
1,2,3,4 and
5
SC infusion,
Groups
only if no other 1,2,3,4 and
route is
5
possible or
practical
Mannitol
(I) IV infusion.
Infusion pump
is required.
Groups
Reduction of intracranial
1,2,3,4 and pressure:
0.25g -0.5g/kg over 30-60
5
minutes.
Can be repeated as necessary.
Urgent reduction of intra-ocular
pressure before eye surgery:
Up to 500ml of 20% mannitol
given by slow IV infusion until the
intra-ocular pressure has been
satisfactorily reduced.

SUITABLE DILUENT
For adults, administer the dose using
50% (1g in 2ml) injection undiluted, or
dilute to 25% (1g in 4ml) with N/S.
For children a maximum
recommended concentration for IM
injection is 20% (200mg/ml) eg. For a
500mg dose, dilute 1ml of 50%
magnesium sulphate injection to 2.5ml
with N/S.
Keep the concentration as low as
possible, preferably not greatly
exceeding the isotonic concentration of
6.3% w/v in Water For Injections (6.3g
=25.2mmol in 100ml Water For
Injections). Discuss and check
dose/concentration/route with a
Pharmacist.
500ml of ready-to-use 10% (50g in
500ml) mannitol is routinely stocked.
(If using 20% mannitol, infuse through
an administration set incorporating a
filter*).
COMMENTS
IM injection of magnesium sulphate is painful.
on IM injection.
There is little published data to support

administration of magnesium sulphate by the
S/C route. There are isolated case reports of
between 2 and 4mmol magnesium sulphate
added to 500ml - 1 litre of N/S being tolerated
by S/C infusion. Administration via the S/C
route is not licensed in the UK (See page
124).
Flush with N/S
Infusion may crystallise at low temperatures;
redissolve by warming.
Extravasation causes inflammation and
thrombophlebitis.
20% mannitol should preferably be
administered via a central IV line or at least
through a large peripheral vein due to its high
osmolarity.
*Suitable filters to administer mannitol are
PALL 0.22 micron,
codan 0.2 micron filters. These filters should
be ordered via ORACLE.
120
DRUG
METHOD
Meropenem IV bolus for doses

up to 1g
Mesna
(I) IV infusion.
Infusion via pump
(I) IV infusion when
ifosfamide or
cyclophosphamide
are given as an (I)
infusion over 1-2
hours or as IV
bolus, or
cyclophosphamide
has been given
orally
(C) IV infusion

GIVE
Groups 5 minutes
1,2,3,4 and
5
Groups
15-30 minutes
1,2,3,4, 5
Groups
15-30 minutes
1,2,3,4 and
5
Groups Typically, for the duration of

1,2,3,4 and a (C) infusion of ifosfamide,
and then for a further 12
5
hours afterwards.
Example shown for 2 hour infusion of cyclophosphamide:

IV mesna over
15-30 minutes
2 hr
Cyclophos
infusion
0
2
IV mesna over
15-30 minutes

Reconstitute each 250mg
meropenem with 5ml W. This
provides an approximate
concentration of 50mg/ml.
Reconstitute and dilute to 50200ml using N/S or G.
Dilute the required dose of mesna
(Usually 20% of the dose of
cyclophosphamide or ifosfamide)
to 50ml or 100ml with N/S.
Dilute with N/S or G to any

convenient volume
IV mesna over
15-30 minutes
IV mesna over
15-30 minutes
10

Sodium content: 4mmol/gram.
The preferred method for administering doses
greater than 1g is intermittent IV infusion.
When protection against urothelial toxicity is
required, three doses of mesna are typically given
with each dose of cyclophospamide or ifosfamide.
The first dose of mesna is usually IV and given just
prior to the dose/infusion of cyclophosphamide or
ifosfamide. Intravenous second and third doses are
given at 4 hours and 8 hours (after the end of an
infusion). Alternatively, the second and third doses
of mesna can be given orally, in which case each
oral dose is 40% of the dose of cyclophosphamide
or ifosfamide given, given at 2 hours and 6 hours
(after the end of an infusion), using mesna injection
by the oral route.
On occasions Pharmacy Technical Services add the
required dose of Mesna into the bag containing
ifosfamide.
Oral mesna
(40% of the cyclophos. dose)
Oral mesna
(40% of the cyclophos. dose)
2 hr
Cyclophos
infusion
OR
4
Hours
COMMENTS
4
Hours
10
121
DRUG
METHOD
WHO MAY
GIVE
Metaraminol
IV bolus
Emergency use
only.
IV bolus
Groups 1
For use in
haematology and
oncology refer to
chemotherapy
protocols

Undiluted.
and 2
Groups 1
and 2
(C) IV infusion. Groups 1

required.
Methotrexate
ADMINISTER OVER
0.5 1ml over a few

Dilute 10mg in 1ml with 19ml of
seconds via a large
N/S to make 10mg in 20ml.
peripheral vein or a central
vein.
Adjust rate according to
response.
COMMENTS
Bolus dose: 0.5 5mg (0.05 0.5ml)
Sodium content : 0.087mmol/ml.
Follow each bolus dose with a 20ml flush of
N/S. The bolus dose of 0.5 1ml of the
prepared dilution may be repeated every 1 5
minutes as indicated by the mean arterial
pressure (MAP) and patient response.
Metaraminol injection from Torbay
Manufacturing Unit is unlicensed (See page
4).
Dilute 15-100mg in 500ml N/S or

G.
The volume may be varied
depending on the rate of
administration and the patient's
fluid needs.
When methotrexate is prescribed to treat conditions including multiple sclerosis, glomerular kidney disease, severe psoriasis or rheumatoid
arthritis, it may be administered by Group 1 or 2 practitioners who have previous experience of administering parenteral cytotoxics. Read
Appendix 3 for guidance on the handling of cytotoxic drugs. Explicitly inform the patient of the once a week dosing schedule for ongoing therapy
and determine a fixed weekday as the day of injection. This should be stated on the prescription.
IV bolus
Group 1 or 2
Consider folic acid supplementation.
injection (Not for
Refer to the SPC for Metoject on
children or
www.medicines.org.uk for details of the
adolescents)
recommended monitoring to detect signs of
SC bolus
Group 1 or 2
Refer to the Marsden Manual for toxicity (Mouth and throat examinations, full
blood counts, liver function tests, renal
injection
IM injection
Group 1 or 2
Refer to the Marsden Manual for function etc). Refer to specific protocols as
appropriate:
IM methotrexate for ectopic pregnancy (EPU
and Monkswell).
122
DRUG
METHOD
WHO MAY
GIVE
ADMINISTER
OVER

(I) IV infusion.
Infusion pump is
To treat hypotension required. .
refractory to fluids
(C) IV infusion.
and vasopressors in Infusion pump is
septic shock
required.
Groups
1 and 2
15 60 minutes
Dilute to a suggested
concentration of 1mg/ml with G.
Methyl-prednisolone IV bolus (doses

up to 250mg)
sodium succinate
Groups
Methylene Blue
(Solu-Medrone)
1,2,3,4 and 5
(I) IV infusion
Groups
(doses over
1,2,3,4 and 5
250mg) via pump
IM injection
Groups
1,2,3,4 and 5
Methyl-prednisolone IM injection
acetate
Intra-articular
(Depo-Medrone)
Peri-articular
Intrabursal
Intralesional
Into tendon
sheaths
Groups
1 and 2
Groups
1,2,3,4 and 5
Group 1
COMMENTS
Dose to treat hypotension in septic shock

refractory to fluids and vasopressors is
1-2mg/kg over 15-60 minutes. May be repeated
as required, alternatively after 2 hours set up a
0.25-2 mg/kg/hour
Dilute to a suggested
continuous infusion.
concentration of 1mg/ml with G.
Do not infuse down the same lumen/line as any
other drugs.
Do not dilute with N/S.
Extravasation can cause tissue damage.
The use of methylene blue to treat hypotension
in septic shock is unlicensed (See page 4)
Give slowly minimum Reconstitute with diluent provided. Flush with N/S, G or G/S.
5 minutes.
Sodium content: 2mmol/g.
Minimum 30 minutes Reconstitute as above then dilute For Acute Spinal Cord Injury refer to protocol
with G, N/S or G/S to any suitable on Pencarrow.
volume (e.g. 50-250ml).
Reconstitute with diluent provided.
Inject deeply into the gluteal
Refer to the Marsden Manual for guidance on
muscle.
IM injection.
Prior to intra-articular injection the joint fluid
should be examined to exclude a septic
process. Administer under strictly aseptic
conditions.
Do not give via the intrathecal route
(potentially neurotoxic) or the IV route.
123
DRUG
METHOD
WHO MAY
GIVE
ADMINISTER OVER

COMMENTS
Metoclopramide
10mg in 2ml
Slow IV bolus
Groups
1,2,3,4 and 5
At least 3 minutes
Give undiluted.

Sodium content 10mg/2ml = 0.26mmol.
Groups
1,2,3,4 and 5
SC injection for Groups
use in palliative 1,2,3,4 and 5
care
for us in
1,2,3,4 and 5
palliative care
IM injection
Metoprolol
IV bolus
Groups
1,2,3,4 and 5
Metronidazole
(I) IV infusion.
Infusion pump
is required.
Groups
1,2,3,4 and 5

Continuous over 24
hours

same syringe.
Give undiluted
Cardiac arrhythmias:
1-2 mg/minute
During anaesthesia:
2-4mg injected slowly
Further injections of 2mg
up to a maximum overall
dose of 10mg may be
given
Adults:
300ml/hour (5ml/minute)
will deliver the 100ml
infusion over 20 minutes.
Follow the PHNT Care of The Dying

Pathways.
Follow the PHNT Care of The Dying
Pathways and the PHNT Syringe Driver
Policy. For combinations of 2 or 3 drugs in
the same syringe refer to the compatibility
charts in the pump kit or contact Pharmacy
on ext. 39976 for advice.
If an infusion containing metoclopramide
becomes discoloured it should be discarded.
Early intervention post MI:
5mg every 2 minutes up to a maximum of
15mg total as determined by blood pressure
and heart rate.
Monitor blood pressure, heart rate and ECG.
Flush with N/S, G or G/S. Cefuroxime can be
mixed into an infusion of metronidazole.
Sodium content: 13.5mmol/500mg infusion.
124
DRUG

GIVE
IV bolus for sedation Groups Administer over at least 30 seconds an
Midazolam
in conscious adult
1,2,3,4 and initial dose of midazolam guided by:
(Monograph patients
Age
5
continues on
Weight
the next
Other medications
page)
Medical history and co-existing
disease
Planned procedure
Assess the level of sedation after 2-5
minutes and repeat as necessary
(minimum of 2 minutes between
subsequent doses).
During the procedure, additional doses
may be given.
IV bolus for induction Groups Induction of anaesthesia and loading
of anaesthesia
1,2,3,4 and dose for ICU sedation for adults: Each
increment over 20-30 seconds allowing
5
2 minutes between successive
increments.
(I) or (C) IV infusion Groups 1
following initial
and 2
loading dose via
infusion pump
METHOD

Dilution not recommended.
Dilution not recommended.
COMMENTS
For sedation in conscious adult
patients follow the Sedation
Policy on Plymouth Healthnet
(under Clinical Guidelines).
All healthcare practitioners
involved directly or participating
in sedation techniques must
have the necessary knowledge,
skills and competences required
Flush with N/S.
Respiratory depression and
arrest have occurred when doses
were given too rapidly.
Naloxone, Flumazenil and
resuscitation equipment must be
immediately available.
Dilute with N/S, G or G/S.

Usual dilution is 50mg in 50ml.
(Pharmacy stocks 50mg in 50ml
vials).
125
DRUG
METHOD
Midazolam
(Continued)
Slow IV bolus for

Carotid Artery
Rupture
SC injection for
terminal restlessness
and agitation
(C) SC infusion via
syringe driver for
terminal restlessness
and agitation

GIVE
Groups 1 2.5 5mg over 1-2 minutes repeated at
2 minute intervals if sedation is not
and 2
adequate.
Groups
1,2,3,4 and
5
Groups Continuous over 24 hours
1,2,3,4 and
5

Use the 5mg in 5ml pre-filled
syringe prepared by Pharmacy and
kept in the patients bedside locker.
If a pre-filled syringe is not available
use a 5mg in 5ml ampoule.
COMMENTS
For the Management of Carotid
Artery Rupture (Carotid Blow
Out) follow the specific additional
guideline on Lynher ward.
Follow the PHNT Care of The

Dying Pathways and the PHNT
Syringe Driver Policy. For
Dilute with W when 2 or more drugs combinations of 2 or 3 drugs in
the same syringe, refer to the
Syringe Driver Drug
syringe.
Compatibility chart provided in
the pump kit. Contact Pharmacy
on ext. 39976 for further
126
DRUG
METHOD
WHO MAY GIVE
Milrinone
(I) or (C) IV
infusion.
Infusion pump
is required.
Groups 1 and 2
Milrinone 10mg in 50ml G dilution

eGFR >50ml/minute
Maintenance infusion rate: Infusion pump rate
Titrate from 0.375 to 0.750 ml/kg/hour
micrograms/kg/minute
0.375
0.11
0.400
0.12
0.500
0.15
0.600
0.18
0.700
0.21
0.750
0.22
Mivacurium
IV bolus
Group 1 must
only be given by
doctors proficient in
advanced airway
management
(C) IV infusion. Groups 1 and 2
Infusion pump
is required.
ADMINISTER OVER
INSTRUCTION FOR
COMMENTS
DILUENT
Monitor blood pressure, heart rate, ECG,
Loading dose (50microgram/Kg) Dilute to 200 microgram/ml
fluid balance and renal function.
with N/S or G (e.g. 10mg
over 10 minutes followed by
Do not mix with other drugs.
ampoule diluted to 50ml).
infusion at 0.375-0.75
microgram/kg/minute according
to haemodynamic response (For However solutions of different Using a 200microgram/ml dilution the
recommended maintenance infusion rate
concentrations may be used
help setting the infusion pump
according to the patients fluid is 0.11-0.22ml/kg/hour.
rate see table below).
requirements.
For patients with renal impairment (eGFR < 50ml/minute) using Milrinone 10mg in 50ml G dilution
eGFR
ml/minute/1.73m2
5
10
20
30
40
50
Initial maintenance infusion rate

micrograms/kg/minute (titrate
according to haemodynamic response).
0.20
0.23
0.28
0.33
0.38
0.43
Doses up to 150micrograms/kg
over 5-15 seconds.
Higher doses over 30 seconds.
See comments
8-10 micrograms/kg/
minute
Initial Infusion pump rate

ml/kg/hour (titrate according to
haemodynamic response).
0.06
0.07
0.08
0.10
0.11
0.13
Can be administered undiluted Give IV bolus over 60 seconds to patients

or diluted to 500 micrograms with cardiovascular disease, those with
in 1ml with N/S, G, G/S or H. increased sensitivity to histamine (eg.
asthmatics) and those who may be
unusually sensitive to falls in arterial blood
pressure (eg. those with cardiovascular
disease).
Monitor blood pressure.
Flush with N/S.
127
DRUG
METHOD
Morphine
WHO MAY
ADMINISTER OVER
COMMENTS
GIVE
Staff prescribing, administering and/or screening prescriptions for opioid medications should be familiar with the PHNT Policy for Reducing
Errors with Opioid Medicines in Adults (Network Drive :Groups (G) > Trust Documents > Documents > Medicines Management folder). The
PHNT Analgesic Ladder and equivalent dosages of different opioids can be found on page 185.
IV bolus
Groups 1 Follow the algorithm from Dilute 10mg morphine to 10ml
(Theatre Recovery) and 2
Recovery 2
with N/S
Sodium content negligible.
IV bolus
(Acute Care Areas)
Groups 1
and 2
IV bolus
(Emergency
Department)
Groups 1
and 2
(C) or (I) IV infusion

in Critical Care areas
via infusion pump.
Patient Controlled
Analgesia (PCA)
Groups 1
IM injection
SC injection
Follow the IV Morphine

Protocol for Adults in
Acute Areas (Copy on
page 186)
Follow the IV Morphine
Protocol for Adults in the
Emergency Department
(Copy on page 187)
and 2
Groups
1,2,3,4 and 5
Groups
See comments
Dilute 10mg morphine to 10ml

with N/S
For monitoring required when IV morphine is
given in the Emergency Department, see the
protocol on page 187.
Vials of ready-diluted morphine
50mg in 50ml N/S are available
from Pharmacy).
Vials of ready-diluted morphine
50mg in 50ml N/S are available
from Pharmacy).
1,2,3,4 and 5

Groups
1,2,3,4 and 5

Monitor blood pressure, heart rate,

respiratory rate. Have naloxone and
resuscitation equipment available.
Adult PCA: Usual bolus dose 1mg. Usual
lock-out period is 5 minutes. Refer to Acute
Pain/Care Service Protocols. Background
morphine infusion may only be prescribed by
a member of the Acute Pain/Care Team.
Nurse-led Controlled Analgesia via the PCA
pump is available seek advice from the
Acute Pain/care Team.
SC injection not suitable for oedematous

patients
128
DRUG
METHOD
Morphine 40mg
in 1ml
preservative-free
(Unlicensed)
Mycophenolate
(C) Intrathecal
Group 1 or
infusion or
Group 2*
Intrathecal bolus
(I) IV infusion
WHO MAY
GIVE
Groups
1,2,3,4 and 5
Mycozyme
ADMINISTER OVER

COMMENTS
SUITABLE DILUENT
Prepare and administer in accordance with * Restricted to those persons who are
trained and competent to administer
the Pain Management Centre protocols.
medication via the intrathecal route.
2 hours.
Infusion to be prepared by Pharmacy.

Avoid direct contact of the drug solution
Telephone Ext. 31083. Doctor to prescribe with skin or mucous membranes. If such
dose in 100ml G.
contact occurs, wash thoroughly with
soap and water.
Commence the infusion immediately after
preparation.
See Alglucosidase alfa
129
DRUG
METHOD
Naloxone IV bolus for:

Reversal of opiate
induced respiratory
depression in adults
prescribed opiates as
part of their
palliative, chronic
pain or peri-operative
care
IV bolus followed by
(C) infusion to treat
PCA or epidural
opiate-induced
pruritis
IV boluses to treat
Acute opiate
overdose/poisoning
IV infusion to treat
Acute opiate
overdose/poisoning
IM Injection only if IV
administration is not
possible
SC injection only if IV
administration is not
possible

GIVE
Groups Adults: Bolus dose of 100 micrograms may be
1,2,3,4 and repeated at intervals of not less than 2 minutes
to achieve desired response.
5
Groups
40microgram IV bolus (=0.1ml of 400mg/ml

1,2,3,4 and injection) followed by 200micrograms infused
over 6 8 hours.
5
Groups 1 400 micrograms 2000 micrograms (2mg)

Dilute to a concentration of
100micrograms/ml with N/S. If
repeated bolus doses are
insufficient a continuous infusion
may be required using an infusion
pump Dilute 2mg naloxone with
500ml N/S or G (Resulting
concentration 4micrograms/ml).
Starting rate is 60% of the initial IV
bolus infused over 1 hour then
titrate to response.
For the infusion, dilute
200micrograms in 1 litre N/S
infused over 6 8 hours.
over 2-3 minutes. If no response then repeat

every 2-3 minutes to a maximum of 10mg
(then review the diagnosis).Further doses may
be required if respiratory function deteriorates.
Dilute 10mg in 50ml N/S or G.
Groups 1 Initially the rate may be set at 60% of initial
resuscitive
IV
bolus
infused
over
1
hour,
then
and 2
adjusted according to respiratory rate and
level of consciousness.
Groups Refer to the Marsden Manual for guidance on
1,2,3,4 and IM injection.
5
Groups Refer to the Marsden Manual for guidance on
1,2,3,4 and SC injection.
5
and 2
COMMENTS
Use infusions within 12 hours.
Monitor for possible
hypotension, hypertension,
ventricular tachycardia and
fibrillation and withdrawal
syndrome.
Note that 4mg in 20ml is an
unlicensed dilution (see page
1).
When using a continuous
infusion to treat opiate induced
respiratory depression in
adults prescribed opiates as
part of their palliative, chronic
pain or peri-operative care do
not suddenly stop the infusion.
Once the patient is stabilised
and it is deemed appropriate,
the naloxone infusion should
be titrated down rather than
just turned off. Close
monitoring is essential at this
stage for the possibility of
opioid toxicity recurring again
especially when it is due to
long acting opioids.
130
DRUG
METHOD
Natalizumab
(Tysabri)
This product is being
intensively monitored
by the CHM and
MHRA. Please report
all suspected reactions
(including non-serious
ones) using a Yellow
Card from the BNF
Neostigmine
WHO MAY
GIVE
Infusion
pump is
required.
IV bolus
Groups
Groups
1 and 2
SC Injection
Groups
IM injection
1 and 2
Groups
1 and 2

SUITABLE DILUENT
COMMENTS
Observe the patient during the infusion and

for 1 hour after the completion of the infusion
for signs and symptoms of hypersensitivity
reactions.
Do not administer as a bolus injection.
Equipment and medication to treat
anaphylaxis must be immediately available.
Discontinue administration of natalizumab
and initiate appropriate therapy at the first
symptoms or signs of hypersensitivity.
Flush with N/S. Protect from light.
Minimum 3-5
Have atropine or glycopyrollate available to
minutes.
counteract possible cholinergic reactions.
However, for
For use in Critical Care for acute colonic
reversal of
pseudo-obstruction, follow the Critical Care
neuromuscular
Bowel Management Protocol (Use for this
block, administer
indication is unlicensed -see page 1).
over 1 minute.
Start at 0.4mg/hour Dilute 5mg neostigmine to 50ml with N/S to Use atropine or glycopyrronium if necessary
make a concentration of 0.1mg/ml.
to treat bradycardia, and for patients with
(4ml/hour). If no
spinal cord lesions.
response after 8
Follow the Critical Care Bowel Management
hours increase to
Protocol (Use for this indication is unlicensed
0.8mg/hour
- see page 1). The only confirmed Y-Site
(8ml/hour)
compatibilities are with heparin,
hydrocortisone and potassium chloride.
When treating Myaesthenia Gravis,
Refer to the
500micrograms of neostigmine metilsulfate
Marsden Manual
by intravenous injection is equivalent in
for guidance on IM
effect to about 1 to 1.5mg of neostigmine
or SC injection.
metilsulfate by intramuscular or
subcutaneous injection, and to about 60mg
of oral pyridostigmine
Approximately 1
1,2,3,4 and 5 hour
1 and 2
(I) or (C) IV
infusion to
treat severe
constipation
in Critical
Care
ADMINISTER
OVER
Check that the solution is clear and free of

particles. Draw up 15 ml from the vial and
add to 100ml N/S. Gently invert the bag to
mix completely. Do not shake. Visually
inspect the diluted product for particles or
discolouration prior to administration.
Flush the line with N/S when the infusion
has finished.
Do not mix with any other drugs or
diluents.
Give undiluted.
131
DRUG
METHOD
Nimodipine

via a central
1 and 2
IV line.
Infusion
pump is
required.
Nitroprusside
Noradrenaline
(Norepinephrine) base
1mg/1ml
See Sodium Nitroprusside

(C) or (I) IV
Groups
infusion via a 1 and 2
central IV
line. Infusion
pump is
required.
(=Noradrenaline
tartrate 2mg/ml)
WHO MAY
GIVE
ADMINISTER INSTRUCTION FOR DILUTION AND

OVER
SUITABLE DILUENT
500micrograms Provided ready diluted (10mg in 50ml).
-2mg/ hour
=2.5
10ml/hour
Adjust rate
according to
response.
Single Strength
4ml (4mg noradrenaline base) diluted to
50ml with G (or G/S) = 80micrograms/ml.
Double strength
50ml with G (or G/S) = 160micrograms/ml.
Quadruple Strength
50ml with G (or G/S)= 320micrograms/ml.
COMMENTS
Draw up solution into 50ml syringe and
use the polyethylene line provided in the
box. Administer via a central catheter
through a Y-piece connector into an
infusion of N/S, G, H, Dextran 40, human
albumin 5% or mannitol 10% running at
40ml/hour.
Protect infusion from direct sunlight.
Incompatible with PVC
Infuse via a central venous catheter. Loss
of potency occurs if diluent is N/S. Discard
infusion if brown colour develops.
Flush with G or N/S.
Protect infusion from direct sunlight.
Haemodynamic monitoring required.
Rate (micrograms/kg/minute) = Pump rate (ml/hour) x concentration (micrograms/ml)

Patients weight (kg) x 60
Pump rate (ml/hour) =Prescribed rate(micrograms/kg/minute) x 60(minutes in an hour) x Patients weight (kg)
Novomix 30 Insulin
Novorapid Insulin
Octagam
See Insulin Section, page 103

132
DRUG
METHOD
WHO MAY
GIVE
Octreotide
SC injection
Groups 1
Octreotide
Depot
(Sandostatin
LAR)
IM injection by
Groups 1
and 2
ADMINISTER
OVER

COMMENTS
Subcutaneous injection is preferred method of

administration.
and 2
IV bolus
Dilute each 1ml octreotide injection ECG monitoring necessary with IV injection (Not
Groups 1 3-5 minutes
with SC injection). Flush after IV injection with N/S.
with a minimum of 1ml and a
and 2
It is not recommended to use G to dilute octreotide
maximum of 9ml of N/S.
(except for treatment of variceal bleeding below).
The rubber caps of the Multidose vials should
not be punctured more than 10 times.
(C) SC infusion via Groups
Continuous over Dilute with W when 2 or more drugs Follow the PHNT Care of The Dying Pathways and
syringe driver in
1,2,3,4 and 5 24 hours
palliative care.
syringe.
syringe refer to the compatibility charts in the pump
(Unlicensed see
kit or contact Pharmacy on ext. 39976 for advice.
page 1)
Instructions for IM injection of Sandostatin LAR for deep intragluteal injection only
1. Remove the cap from vial containing Sandostatin LAR. Ensure that the powder is settled at the bottom of the vial by lightly tapping the vial.
Remove the cap from the vehicle syringe. Attach one of the supplied needles to the vehicle syringe.
2. Insert needle through centre of rubber stopper of the Sandostatin LAR vial.
3. Without disturbing the Sandostatin LAR powder, gently inject the vehicle into the vial by running the vehicle down the inside wall of the
vial. Do not inject the vehicle directly into the powder. Withdraw any excess air present in the vial.
4. Do not disturb the vial until the vehicle has wetted the Sandostatin LAR powder for suspension. Once complete wetting (approximately 2-5
minutes) has occurred, the vial should be moderately swirled until a uniform suspension is achieved. Do not vigorously shake the vial.
5. Immediately draw 2ml of air into the syringe and re-insert the needle through the rubber stopper. Inject the 2ml of air into the vial and then,
with the bevel down and the vial tipped at approximately 45 degree angle, slowly draw the entire contents of the vial containing the
suspension into the syringe. Immediately change the needle (supplied).
6. Gently invert the syringe as needed to maintain a uniform suspension. Eliminate air from syringe and disinfect the injection site. Insert
needle into right or left gluteus and draw back to ensure that no blood vessel has been penetrated. Immediately inject IM by deep
intragluteal injection.
7. Sandostatin LAR must be given only by intragluteal injection, never IV If a blood vessel has been penetrated, select another injection site.
133
DRUG
METHOD
WHO MAY ADMINISTER

GIVE
OVER
Omalizumab
SC injection in the
deltoid region of the
arm. Alternatively, the
injections can be
administered in the
thigh if there is any
reason precluding
administration in the
deltoid region.
(I) IV infusion. Infusion
pump is required.
Groups 1
Omeprazole
Omeprazole
For the specialist
treatment of
endoscopically
controlled bleeding
peptic ulceration
IV Loading dose of
80mg
(C) IV infusion.
Infusion pump is
required.

SUITABLE DILUENT
Available in pre-filled syringes.
COMMENTS
and 2
Group
1,2 and 3
20-30 minutes
Reconstitute each 40mg with

Flush with N/S.
approximately 5ml N/S or G. Dilute each Sodium content 0.1mmol/40mg vial.
40mg to 100ml with N/S or G.
Revert to omeprazole capsules orally or
omeprazole dispersible tablets via
PEG/NG/NJ as soon as possible.
Use infusion in N/S within 12 hours, 3
hours if in G. Incompatible: do not infuse
with any other drugs.
Groups 80mg in 100ml For each 40mg vial, withdraw 5ml of
Omeprazole infusion must not be infused
N/S from a 100ml bag and use to
1,2,3,4 and N/S over 30
through the same venflon or line lumen as
minutes
reconstitute the vial. Then inject the
5
reconstituted omeprazole into the bag. any other drug solution.
Each bag is for single use only and must
Do not add more than 80mg
be used immediately after preparation.
omeprazole to 100ml of diluent.
Reconstitute and dilute each 40mg vial
Groups After loading
1,2,3,4 and dose, infuse at as above.
8mg/hour for
* The Gastroenterologists have agreed to
5
70 hours*
a 70-hour treatment (rather than 72
(This is
hours). A pre-printed prescription is
10ml//hour with
available.
each 80mg in
100ml N/S)
134
DRUG
METHOD
Ondansetron IV bolus only for:

4mg dose in
any adult
patient.
8mg dose in
patients
younger than
65 years.
(I) IV infusion via
infusion pump is
required for:
8mg doses in
patients aged
65 and older.
16mg doses
(only allowed
for patients
younger than
75 years).
(C) IV infusion.
Infusion pump is
required.
IM injection
WHO MAY
GIVE
ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS

SUITABLE DILUENT
3-5
minutes
Either
give undiluted or dilute to any
Flush with N/S.
Groups
convenient
volume
of
N/S
or
G.
1,2,3,4 and 5
As recommended in MHRA Drug Safety
Update July 2013 to prevent lengthening of
the QT-interval and possible Torsade De
Pointes.
8mg doses for patients aged 65 or older
should be given by IV infusion over 15
minutes.
15 minutes
Dilute with 50ml to 100ml N/S or G
Groups
8mg is the maximum dose for patients

1,2,3,4 and 5
aged 75 or older.
All 16mg doses should be given by IV
infusion over 15 minures.
Repeat doses should be given at least 4
hours apart.
Ondansetron should be avoided in
patients with congenital long QT
syndrome.
Caution must be used if administering
ondansetron to patients with risk factors
1mg/hour
Groups
for QT interval prolongation or cardiac
1,2,3,4 and 5
arrhythmias. These include: electrolyte
abnormalities; use of other medicines that
Groups
prolong QT interval (including cytotoxic
1,2,3,4 and 5
drugs) or that may lead to electrolyte
abnormalities; congestive heart failure;
bradyarrhythmias; or use of medicines
that lower heart rate .
Hypokalaemia and hypomagnesaemia

should be corrected before ondansetron
administration.
135
DRUG
METHOD
Oxytocin
Optiray 300
Orencia
WHO MAY
GIVE

SUITABLE DILUENT
(C) infusion.
Dilute 3 units of oxytocin (3 units =
Groups 1 Increase the rate
every 30 minutes
0.6ml of the 5 units/ml injection) to
required.
until contractions are 50ml with N/S.
satisfactory (4 5/10)
Using the 3 unit in 50ml dilution:
Time from start of infusion
Infusion rate
Infusion rate
(Minutes)
(milliunits/minute)
(ml/hour
0
1
1
30
2
2
60
4
4
90
8
8
120
12
12
150
16
16
180
20
20
Only increase the rate beyond this point following review and at the discretion of the specialist
registrar or consultant.
210
24
24
240
28
28
270
32
32
Do not dilute.
Group 1 or 50ml from prefilled
syringe
Group 6
COMMENTS
For detailed instructions it is essential
to read the PHNT Guidelines for
Augmentation of Labour
Continuous electronic fetal monitoring
during administration is required.
Stop the infusion during a prolonged
deceleration or definite fetal distress (if
CTG is abnormal perform FBS first).
Do not infuse through the same line as
blood or plasma.
Monitor for possible anaphylaxis or other

allergic reactions. Resuscitation
equipment must be immediately available.
Flush catheter frequently
See Abatacept
136
DRUG
WHO MAY
ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE
SUITABLE DILUENT
Oxycodone
SC bolus
Follow the PHNT Care of the Dying
Groups
Pathway in Advance Kidney Disease and
1,2,3,4 and 5
24 hours
via syringe driver 1,2,3,4 and 5
are being mixed in the same syringe. For combinations of 2 or 3 drugs in the
same syringe refer to the compatibility
for use in
charts in the pump kit or contact
palliative care.
Pharmacy on ext. 39976 for advice.
Pabrinex IV high (I) IV infusion
30
minutes
The
contents
of
the
pair(s)
of
Groups 1
Mild allergic reactions are warning signs
potency injection
(Preferred
ampoules
should
be
diluted
with
50
to
and 2
method).
100ml N/S or G. (Up to 3 pairs of 5ml that further doses may cause anaphylactic
shock
Infusion pump is
ampoules can be diluted with 50required.
100ml N/S or G).
IV bolus
Mix contents of one 5ml Ampoule
Facilities for treating anaphylaxis must be
Groups 1 10 minutes
No.1
and
one
5ml
Ampoule
No.2
available.
and 2
(Maximum volume 10ml) in a single
syringe immediately before use.
Pabrinex IM high IM injection
The contents of one ampoule number Do not give the IM formulation via the IV
Groups 1
route.
potency injection
1 and one ampoule number 2 of
and 2
Pabrinex Intramuscular High Potency Refer to the Marsden Manual for
(total 7ml) are drawn up into a
Mild allergic reactions are warning signs
syringe to mix them just before use,
that further doses may cause anaphylactic
then injected slowly high into the
shock.
gluteal muscle, 5cm below the iliac
Facilities for treating anaphylaxis must be
crest.
available.
METHOD
137
DRUG
METHOD
Pamidronate
Pancuronium
WHO MAY
GIVE
ADMINISTER OVER

SUITABLE DILUENT
For some brands the vials contain solution
that requires further dilution.
COMMENTS
(I) IV infusion.
Maximum 1mg/minute.
Groups
required.
A dose of 90 mg should
For vials that contain powder needing
normally be
reconstitution before further dilution:
administered as a 2reconstitute each 15mg vial with 5ml W.
hour infusion.
Reconstitute each 30mg and 90mg vial
with 10ml W.
In renally impaired
patients the maximum
Further dilution is necessary:
recommended rate is
Dilute 30mg to at least 125ml with N/S
20mg/hour.
Flush with N/S. Sodium content

0.11mmol/15mg.
Monitor serum electrolytes, calcium and
phosphate.
Aredia and Medac brands state that
they should not be given if eGFR<30
unless the hypercalcaemia is lifethreatening and the benefit outweighs the
risk.
In order to minimise local reactions at the
infusion site, the cannula should be
inserted carefully into a relatively large
vein.
IV bolus
Groups 1
preferably via a and 2
central IV line or
through tubing of
flowing N/S or G
drip.
138
DRUG
WHO MAY
COMMENTS
GIVE
Pantoprazole
Pantoprazole is non-formulary and should only be used if both intravenous omeprazole & esomeprazole are unavailable
IV bolus
2 minutes
Reconstitute 40mg vial with 10ml The reconstituted solution is clear and
Groups
N/S.
yellowish.
1,2,3,4 and 5
15 minutes
Reconstitute as above then further Revert to omeprazole capsules orally as
soon as possible. Alternatively revert to
dilute with 100ml with N/S or G.
dispersible lansoprazole Fastabs via
is required.
PEG/NG/NJ as soon as possible.
(C) infusion is
unlicensed (See page
4) and is for specialist
drugs.
use after endoscopic (C) IV infusion. Groups
Reconstitute each 40mg vial with *The loading dose is 2 x 40mg doses, each
After loading dose*,
treatment of bleeding Infusion pump 1,2,3,4 and 5 infuse at 8mg/hour
diluted in a 100ml bag of N/S and infused
10ml N/S and dilute up to 100ml
peptic ulceration.
over 15 minutes each, one after the other.
with N/S or G.
is required.
for 72 hours
(This is 20ml//hour
(Do not add the contents of more
with each 40mg in
than one vial to larger bags of
100ml)
N/S)
Paracetamol
Intravenous paracetamol must only be used when a patient cannot take any medicines by mouth and paracetamol cannot be given via an
enteral feeding tube. Peri-operative patients able to take sips of water can take paracetamol orally with a little water.
15 minutes
Provided ready-diluted
Can be flushed with N/S.
Each bottle is for single use only.
is required.
Do not administer parecoxib together with
Reconstitute 40mg vial with 2ml
Parecoxib
IV bolus
Rapid bolus directly
Groups
1,2,3,4 and 5 into a vein or into an N/S (can be reconstituted with 2ml opioids in the same syringe.
Do not reconstitute with Hartmanns as this
G instead of N/S if necessary).
existing line through
which N/S, G or H is Dissolve the powder with a gentle will cause precipitation.
swirling motion.
running.
Deep IM
Reconstitute as above. Refer to
Groups
injection
the Marsden Manual for guidance
1,2,3,4 and 5
on IM injection.
METHOD
139
DRUG
ADMINISTER
COMMENTS
OVER
Parenteral nutrition (C) IV infusion. Infusion
Adults: Each bag
Groups
See
back of Pharmacy TPN order
(TPN)
pump is required.
should
run
over
no
1,2,3,4 and 5
form for required monitoring of
longer than 24
electrolytes, and LFTs etc.
hours
1. TPN must be ordered by 12 noon on the day it is required. Ensure that biochemistry results are available before the TPN is
prescribed. It is advised to Red Spot the samples to speed the results.
2. All patients (except those on Penrose or Pencarrow) should be referred to the Nutrition Support Team (NST). If you wish to contact
or refer a patient to the NST contact Dr Stephen Lewis Consultant Gastroenterologist on bleep 89756, Dr Andrew Latchford
Consultant Gastroenterologist on bleep 89149, Nutrition Nurse Specialist bleep 89755 or 89760, Dietitian on Ext 52266 or
Pharmacy Technical Services on Ext 53429.
3. For patients on ICU please follow the ICU TPN protocol.
4. The protocol for connecting TPN bags and monitoring should be followed with meticulous attention.
5. TPN should not be commenced out-of-hours on weekdays (Between 5pm and 9am). On a Saturday, Sunday or Bank Holiday TPN
is only available after discussion with the on-call Gastroenterologist. Once the on-call Gastroenterologist has agreed on the
commencement of TPN, then he will contact the on-call pharmacist for a supply. This applies to all wards other than Penrose and
Pencarrow (TPN bags are no longer available from the Pharmacy Night Cupboard).
Pentamidine
(I) IV infusion with patient Groups
Minimum 1 hour
Pharmacy must prepare this.
Flush with N/S or G. Sodium content
(Pentamidine
supine, via an infusion
Contact
Ext.
31083
nil.
1,2,3,4 and 5
isethionate)
pump,
Blood pressure must be closely
for the treatment of
monitored. To reduce the risk of
Pneumocystis jirovecii
severe, sudden hypotension, patient
(formerly known as
should be supine. Do not infuse with
Pneumocystis carinii)
any other drugs.
pneumonia, or
Trypanosomiasis
METHOD
WHO MAY
GIVE
IM injection for the

treatment of
Leishmaniasis or
Trypanosomiasis
Groups 1
and 2

140
DRUG
METHOD
WHO MAY
GIVE
Pethidine
IM injection
Groups
Slow IV bolus
SC injection
1,2,3,4 and 5
Groups
1,2,3,4 and 5
Groups
1,2,3,4 and 5
Groups
1,2,3,4 and 5

2 - 5 minutes
For status epilepticus Dilute to 10 times its own volume
in adults: 10mg/kg at with W.
a rate of no more
than 100mg/minute.
Maximum dose 1g.
Phenobarbitone
IV bolus
Phentolamine
mesylate
IV bolus
To treat hypertensive
episodes due to
phaeochromocytoma
Group 1
May be diluted with N/S if

required.
Rapid IV bolus or IM
injection for
Group 1

Diagnosis of
phaeochromocytoma Rogitine blocking test
(C) IV infusion
Group 1
0.2-2mg per minute

titrating the dose to
the desired blood
pressure response
Dilute with a suitable volume of

N/S or G.
COMMENTS
Flush after IV bolus with N/S or G
Monitor blood pressure, heart rate
and respiratory rate. Have naloxone
and resuscitation equipment
available.
Sodium content nil.
Flush with N/S.
The injection is highly alkaline and
may produce local tissue damage.
damage. Monitor sedation score,
respiratory rate, heart rate and blood
pressure.
Monitor blood pressure and ECG.
Protect from light.
Use with care in asthmatics: monitor
for hypersensitivity reactions.
Refer to the translation of the
package insert for details of how to
perform the test and the monitoring
required.
Note that IV infusion of phentolamine

is unlicensed.
141
DRUG
METHOD
Phenylephrine
Phenytoin
sodium

IV bolus
100-500micrograms slowly Dilute to 1mg in 1ml with N/S.
Group 1
over 3-5 minutes, repeated
if necessary after at least
15 minutes.
Add 10mg to 500ml of N/S or G.
(I) IV infusion.
Groups 1 Adults: Maximum initial
rate 180micrograms/
required.
minute reduced according
to response to 30 60
micrograms/minute
IM injection
Groups 1
and 2
SC injection
Groups 1
guidance
on SC injection.
and 2
Slow IV bolus or Groups
Adults: Maximum
Give undiluted.
(I) IV infusion into 1,2,3,4 and 5 50mg/minute.
a large vein. A
pump is required
for infusion.
(I) IV infusion
through a large
vein. Infusion
pump is
required.
WHO MAY
GIVE
ADMINISTER OVER
COMMENTS
Flush IV bolus with N/S or G.
Extravasation may cause tissue damage.
Monitor blood pressure and heart rate.
When an IV infusion is discontinued,
slow the infusion rate gradually; do not
stop it abruptly

essential. Monitor for possible respiratory
depression. Flush with N/S before and
after administration of each injection or
infusion to avoid venous irritation.
An in-line 0.22-0.5 micron filter
Adults: Maximum
Groups
should be used to administer
Incompatible: Do not infuse with any other
1,2,3,4 and 5 50mg/minute.
phenytoin injection diluted in N/S. If drugs.
Children: up to
1mg/kg/minute. Maximum a suitable in-line filter is not
available then give as undiluted
50mg/minute.
available.
injection via a syringe driver as
Suitable filters to administer phenytoin
above. If a suitable filter is available diluted in N/S include PALL 0.22 micron,
After dilution: Use
dilute in 50-100ml N/S to a final
immediately, complete
concentration not exceeding
infusion within 1 hour.
codan 0.2 micron filters. These filters
10mg/1ml. Do not use if solution is
should be ordered through ORACLE.
hazy or contains precipitate.
142
DRUG
METHOD
Phosphate
Polyfusor

COMMENTS
SUITABLE DILUENT
Dosage: Serum phosphate 0.5-0.7mmol/L
Provided ready-diluted. Do not
(I)infusion via
Infuse over 6 12
Groups
infuse 1 - 2ml/kg. Serum phosphate <0.5mmol/L
further dilute.
peripheral or
1,2,3,4 and 5 hours.
infuse 2 5ml/kg. Maximum dose 500ml per
central IV line.
Maximum rate:
infusion. Infusion can be repeated if necessary.
Infusion pump is
150ml/hour
required.
To treat Re-feeding Syndrome, 500ml (50mmol
phosphate) is typically infused over 12 hours.
Incompatible with
This dose may be repeated depending on serum
other solutions
phosphate levels.
containing calcium
Consider reduced dosage in the elderly or
or magnesium,
patients with impaired renal function. Monitor
Hartmanns
serum electrolytes including phosphate and
solution, Ringers
calcium (frequently in renal impairment). Monitor
solution,
renal function, ECG and fluid balance.
ciprofloxacin,
Pain and phlebitis may occur at the infusion site.
dobutamine and
TPN
Sodium content 162mmol/L
Potassium content 19mmol/L
Phosphate content 100mmol/L
Flush with N/S.
Phytomenadione IV bolus
(Konakion MM
vitamin K)
10mg in 1ml
WHO MAY
GIVE
Groups
Over at least 30
May be given undiluted.
seconds,
usually
3-5
1,2,3,4 and 5
Alternatively, draw up the required
minutes per 10mg.
dose from the ampoule then dilute
further with a small volume (eg.
10-20ml) of G.
Do not dilute the 10mg in 1ml with
G and take the fraction of the
diluted injection corresponding to
the required dose, as the MM
formulation does not distribute
evenly in the diluent.
Product has been reformulated without

polyethoxylated castor oil, however there is still a
risk of anaphylaxis with rapid IV administration.
Protect infusion and giving set from light.
Flush with G.
The contents of the 10mg in 1ml ampoules can
be given by mouth, but this use is unlicensed
(See page 4)
Do not administer via the IM route.
143
DRUG
METHOD
Phytomenadione
(Konakion MM
Paediatric
vitamin K)
2mg in 0.2ml
IV bolus.
Groups
The dose may be 1,2 and 4
injected into the
lower part of an
infusion set
containing 5%
dextrose or 0.9%
sodium chloride
running at
0.7ml/minute
IM injection
WHO MAY
GIVE
Groups
1,2 and 4

SUITABLE DILUENT
Do not further dilute.
COMMENTS
Product has been reformulated without
polyethoxylated castor oil, however there is
still a risk of anaphylaxis with rapid IV
administration.
Flush with G.
The contents of the 2mg in 0.2ml ampoules
are also licensed to be given by mouth.
For neonatal use following the protocols Further neonatal information can be found
on NICU
in the Neonatal Formulary 6th Edition.
Konakion MM Paediatric must be
administered by IV injection when used as
an antidote to anticoagulant drugs such as
warfarin & phenindione, as IM injections
may result in significant bleeding in these
patients.
144
DRUG
METHOD
Piperacillin/
Tazobactam
(I) IV infusion.
Groups
required.
Slow IV bolus of
this medication
is no longer
recommended
or licensed.
Pitressin
WHO MAY
GIVE
ADMINISTER
OVER
30 minutes

SUITABLE DILUENT
Reconstitute each 2.25g with 10ml and
each 4.5g with 20ml of W, or N/S.
Swirl until dissolved. When swirled
constantly reconstitution should occur
within 10 minutes.
Displacement ranges 1.5 1.7ml per
2.25g.
Dilute further to at least 50ml with N/S
or G (adding to a 100ml bag is ok).
In paediatrics, the maximum
concentration for infusion is 90mg/ml.
COMMENTS
Flush with N/S.
Sodium content: 4.7 - 5.58mmol/2.25g vial
and 9.4 11.2mmol/4.5g vial.
Incompatible with all aminoglycosides.
Do not mix with or give through the same
line at the same time as gentamicin,
amikacin, tobramycin etc. If only one line
available separate the doses and flush well
with N/S before and after each dose.
Do not give through the same line as
Hartmanns
See vasopressin
145

SUITABLE DILUENT
COMMENTS
Potassium chloride (C) IV infusion.

Adults: Maximum
Groups
Infusion pump is 1,2,3,4 and 5 rate 20mmol
ready prepared
required.
infusion bags
potassium/hour.
containing
20mmol/L
or 40mmol/L
potassium in N/S, G
or G/S.
Can be kept as stock
by all wards and
departments.
Ready-made bags
containing
80mmol/litre are also
available
If a concentration of potassium other

than 20, 40 or 80mmol/litre is
prescribed contact the ICU pharmacist
or the on-call pharmacist.
Potassium chloride (I) IV infusion.

Groups 1
15% injection
May only be stocked required.
by Critical Care
areas
Critical care areas only may give

undiluted 2mmol/ml potassium
injection via a central line with ECG
monitoring, or dilute to the required
concentration with N/S, G , G/S or H
with thorough mixing.
Pain or phlebitis may occur during

peripheral administration of solutions
containing 30mmol or more
potassium/litre. Solutions containing more
than 40mmol/litre potassium should ideally
be given via a central line. However, in
cases of serious hypokalaemia with no
central access up to 80mmol/litre
potassium may be tolerated peripherally if
given via a large vein (e.g. femoral vein).
Extravasation will cause tissue damage.
ECG monitoring essential and
resuscitation equipment must be available
when administering more than 20mmol
potassium/hour to adults.
Administration of IV potassium at a rate
exceeding 40mmol/hour poses a serious
risk of asystole.
Flush with N/S.
For instructions on the use of potassium
chloride injection during cardiopulmonary
bypass refer to the Blood Cardioplegia
Management section of the Clinical
Perfusion policy.
DRUG
METHOD
WHO MAY
GIVE
ADMINISTER
OVER
Adults: Usual
maximum rate
20mmol
potassium/hour.
Children:
Usual maximum
rate
0.2mmol/kg/hour
146
DRUG
METHOD
Potassium chloride
ready prepared
infusion bags
containing
20mmol/L
potassium in N/S, G
or G/S.
(C) SC infusion
Adults: maximum
Groups
rate 20mmol
1,2,3,4
and
5
Only use gravitypotassium/hour.
feed
administration
sets. Never use
an infusion
pump for SC
infusions.
Potassium chloride Intra-cardiac for

15% injection
feticide
WHO MAY
GIVE
Group 1
ADMINISTER
OVER

SUITABLE DILUENT
COMMENTS
Use the ready-made infusion bags

containing 20mmol/L potassium
chloride available from Pharmacy.
There is anecdotal evidence that up to

40mmol/L potassium can be given by SC
infusion. However, SC potassium infusion
can cause ulceration and the risk is greater
at 40mmol/L than at 20mmol/L.
Monitor the infusion site regularly for early
signs of irritation and inflammation.
To be administered in accordance with

procedures for feticide on the Early
Pregnancy Unit or the Emergency
Gynaecology Unit.
A single ampoule may be ordered as a

Controlled Drug by these Units. Records of
receipt and administration are as for
Controlled Drugs.
147
DRUG
METHOD
Potassium
phosphate
(Dipotassium
hydrogen
phosphate)
injection
(I) infusion.
required.
*May only be
stocked by Critical
Care areas.
Privigen
Prochlorperazine
Procyclidine
WHO MAY
GIVE
Groups 1
It is suggested that
general wards ask
the doctor to
prescribe a dose of
Phosphate
Polyfusor instead
(See page 182)
See Immunglobulin Human Normal
Deep IM injection Groups 1
and 2
IV bolus
Groups 1 Maximum rate
6.25mg/minute
and 2
IV bolus
Groups 1
and 2
ADMINISTER
OVER
Adult patients on a
critical care unit:
Usual maximum
rate 20mmol
potassium/hour
(30mmol phosphate
over 3 hours)
Suggestion: over 3
minutes

SUITABLE DILUENT
Critical care areas only may give
undiluted potassium phosphate
injection via a central line with ECG
monitoring. For administration via a
peripheral line dilute with N/S, G or G/S
to a usual maximum concentration of
40mmol potassium/litre.

Dilute 1 part with 5 parts N/S before
administration.
COMMENTS
Flush with N/S
Up to 0.3 0.6mmol/kg/day of phosphate
may be required during the treatment of
Refeeding Syndrome.
Dipotassium phosphate 17.42 % injection
contains 1mmol phosphate/ml and 2 mmol
potassium/ml.
Flush IV bolus with N/S.

Prochlorperazine is unlicensed (See page
4) by the IV route.
IV administration can cause hypotension
and venous irritation.
Dilution is not recommended.
148
DRUG
METHOD
WHO MAY
GIVE
Propofol
IV bolus
Groups 1
ADMINISTER OVER
and 2*
(C) IV infusion. Groups 1

and 2
Propranolol
IV bolus
Emergency
use.
Group 1
Dependent on
indication.
Adults: 1mg over 1

minute. May be
repeated at 2-minute
intervals until desired
response observed or
until maximum dose*

SUITABLE DILUENT
Do not dilute. Can be administered
through tubing (close to the injection
site) of infusions of N/S, G or G/S.
COMMENTS
Monitor ECG and blood pressure. Also

monitor for airway obstruction and oxygen
saturation. Resuscitation equipment should
be available.
*Boluses of propofol may only be given by
Group 2 nurses to ventilated patients in
level 3 critical care.
Administer immediately after preparation of
Infuse undiluted or dilute with G to a
concentration of not less than 2mg/1ml. the syringe or infusion.
Anaesthetics Directorate policy: Administer
B.Braun Propfol-Lipuro can be diluted propofol within 30 minutes of drawing up
into syringe.
with G, N/S or G/S to a concentration
Use propofol diluted with G, N/S or G/S
of not less than 2mg/1ml.
within 6 hours of preparation.
When using B.Braun (Propofol Lipuro),
Generics UK and Fresenius kabi brands of
propofol in bottles for infusion, the bottle
and line should be changed at least every
12 hours.
If diluted in a PVC bag withdraw a
To reduce pain on injection 20ml 1%
volume of infusion fluid and replace it
propofol may be mixed with up to 1ml of 1%
with an equal volume of propofol 1%.
lignocaine immediately before use.
Flush with N/S.
Flush with N/S. Sodium content nil.
If IV used as temporary substitute for oral
propranolol 1mg IV = 10mg orally.
*Maximum dose of 10mg in conscious
patients or 5mg in patients under
anaesthesia.
149
DRUG
METHOD
Protamine
sulphate
WHO MAY
GIVE

Reversal of IV heparin
Slow
injection
over
Can
be diluted with N/S.
Groups
infusion
10
minutes.
1,2,3,4 and 5
Maximum rate
IV bolus
5mg/minute
Dilute to a suitable volume with
Reversal of SC heparin: Groups
Slow IV injection
N/S or G.
Dose: 1mg protamine per 1,2,3,4 and 5 (maximum rate
5mg/minute)
100 units heparin. Give
followed by infusion
25-50mg of this dose by
of the remainder of
slow IV bolus followed by
the calculated
(C) IV infusion of the
protamine dose over
remainder of the
8-16 hours
calculated protamine
dose via an Infusion
pump.
Partial (60% maximum) Groups
Maximum rate
reversal of enoxaparin 1,2,3,4 and 5 5mg/minute
Within the first 8 hours
after enoxaparin
administration: 1mg
protamine per 1mg
enoxaparin (maximum
dose 50mg protamine) by
slow IV bolus
Can be diluted with N/S.
COMMENTS
Flush with N/S.
Monitor APTT coagulation tests.
Too rapid administration of
protamine sulphate may cause
severe hypotension and
anaphylactoid reactions. Facilities
for resuscitation and treatment of
shock should be available.
Decisions regarding the necessity

and dose of subsequent protamine
injections should be based on
clinical response rather than
measurement of anti Xa or anti XIIa
results. The physician should also
consider that the amount of
enoxaparin in the body drops to
50% after 8 hours and 33% or less
after 12 hours. The dose of
protamine should be adjusted
depending on the length of time
since enoxaparin was administered.
150
DRUG
METHOD
WHO MAY
GIVE
ADMINISTER OVER
Protirelin
IV bolus
Group 1
Suggestion: Over 30-60

seconds
Quinine
dihydrochloride
(I) IV infusion.
Infusion pump
is required.
Groups
4 hours
Ranitidine
IV bolus
Groups
1,2,3,4 and 5
(I) IV infusion.
Infusion pump
is required.
Groups
1,2,3,4 and 5
(C) IV infusion
following initial
IV bolus.
Infusion pump
is required.
Groups
IM injection
Groups
1 and 2
1,2,3,4 and 5
1,2,3,4 and 5

Do not dilute.
COMMENTS
Diagnostic test.
Flush with N/S

Quinine may cause hypoglycaemia.
Therapy should be changed to oral
See comments for
as soon as possible.
alternative possible
Sodium content: negligible.
administration of loading
Usual loading dose is 20mg/kg (upto
dose on ICU.
a maximum of 1.4g) quinine
dihydrochloride over 4 hours. On ICU
the loading dose can alternatively be
given as 7mg/kg quinine
dihydrochloride infused over 30
minutes followed immediately by
10mg/kg over 4 hours.
Adults: at least 2 minutes*
May be diluted further with G or
N/S
(20ml
for
example)
Children: at least 3 minutes*
*A slower bolus over 5 minutes is
2 hours at 25mg/hour
Add 50mg ranitidine to 100ml N/S
recommended by some references
or G.
because of the risk of causing
bradycardia on administration.
125-250 micrograms/
Dilute 150mg ranitidine to 250ml
kg/hour
with N/S or G.
Dilute required dose in 250ml or
500ml N/S or G.
However, in fluid restricted
patients a maximum dilution of
30mg/ml may be infused via a
central IV line,

151
DRUG
METHOD
WHO MAY
GIVE
Group 1 30 minutes
and Group 2
(I) IV infusion
Remifentanil
IV bolus infusion Groups 1

at induction of
and 2
anaesthesia.
(C) IV infusion
during
maintenance of
anaesthesia or
for sedation of
ventilated
patients in
intensive care.
Infusion pump is
required.
COMMENTS
Refer to Group Protocols/PGDs within
the Department of Nuclear Medicine.
and Group 7
Rasburicase

Group 1
RadioPharmaceuticals
ADMINISTER OVER
If not using preprogrammed syringe

pump see table on the
next page
Rasburicase infusion is prepared

in Pharmacy. Tel. ext. 31083.
The prescribed dose will be diluted
to 50ml with N/S.
Infuse through a different line to that used

for chemotherapy agents. If this is not
possible, flush between the chemotherapy
agents and rasburicase with N/S.
Rasburicase is not cytotoxic.
Rasburicase is not compatible with
glucose solutions.
Reconstitute to a concentration of
1mg/ml with N/S, G, W or 0.45%
saline. Further dilute to a
concentration of 20-250
micrograms/ml with N/S, G or
0.45% saline.
(20 -25 micrograms/ml is
recommended for paediatric
patients aged 1 year and over).
For TCI (Target Controlled
Infusion) the recommended dilution
is 20-50 micrograms/ml. However,
100 microgram/ml (eg 5mg in
50ml) is often used for TCI and for
sedation of ventilated ICU patients.
IV bolus infusion not necessary if

intubation is to occur more than 8-10
minutes after commencing remifentanil
infusion.
IV bolus infusion is not recommended for
induction in cardiac anaesthesia .Instead
intubate at least 5 minutes after start of
infusion. Bolus infusions are not
recommended when infusing remifentanil
for ICU sedation.
Monitor cardiovascular and respiratory
functions.
Resuscitation equipment must be
available.
Do not flush line. Sodium content: Nil.
152
REMIFENTANIL INFUSION RATES

Anaesthesia in adults
Anaesthesia in children
including cardiac anaesthesia
1 12 years of age
Bolus infusion Continuous
Continuous
Bolus infusion
1 microgram/kg infusion 0.05 1.3
0.5 1 microgram/kg infusion 0.025 2
microgram/kg/minute over at least 30 microgram/kg/minute
over at least 30
(rate dependent on
(rate dependent on
seconds.
seconds.
choice of general
choice of general
anaesthetic(s))
anaesthetic(s))
Set pump at:
Set
pump
at:
Set pump at:
Set pump at::
Concentration:
100 micrograms/ml 0.6 1.2 ml/kg/hour 0.015 1.2
1.2 ml/kg/hour for 0.03 0.78
ml/kg/hour
30 seconds
ml/kg/hour
(eg. 5mg in 50ml) for 30 seconds
60 micrograms/ml 1 2 ml/kg/hour for 0.025 2 ml/kg/hour 2 ml/kg/hour for 0.05 1.3 ml/kg/hour
30 seconds
(eg. 3mg in 50ml) 30 seconds
50 micrograms/ml 1.2 2.4 ml/kg/hour 0.03 2.4 ml/kg/hour 2.4 ml/kg/hour for 0.06
for 30 seconds
30 seconds
1.56ml/kg/hour
40 micrograms/ml 1.5 3 ml/kg/hour for 0.0375 3
3 ml/kg/hour for 0.075 1.95
30 minutes
ml/kg/hour
30 minutes
ml/kg/hour
25 micrograms/ml 2.4 4.8 ml/kg hour 0.06 4.8 ml/kg/hour 4.8 ml/kg hour for 0.12 3.12
for 30 seconds
30 seconds
ml/kg/hour
20 micrograms/ml 3 6 ml/kg/hour for 0.075 6 ml/kg/hour 6 ml/kg/hour for 0.15 3.9
30 seconds
30 seconds
ml/kg/hour
Sedation in Intensive Care

Starting rate 0.1 0.15 micrograms/kg/minute
adjusting by 0.025 micrograms/kg/minute at
intervals of at least 5 minutes
Set pump at:

0.06 0.09 ml/kg/hour. Adjust by 0.015 ml/kg/hour
0.15 0.225 ml/kg/hour. Adjust by 0.0375
ml/kg/hour
0.3 0.45 ml/kg/hour. Adjust by 0.075ml/kg/hour
153
DRUG
METHOD
Rifampicin
(I) IV infusion. Groups 1,2,3,4

Infusion
and 5
pump is
required.
Rituximab
The monograph for rituximab is on the next page.

Rapid IV
Group 1- must
bolus
only be given by
advanced airway
management. Also
see comments
300-600
(C) IV
Groups 1 and 2
micrograms/kg/hour
infusion.
Infusion
pump is
required.
Rocuronium
WHO MAY GIVE

SUITABLE DILUENT
Reconstitute with diluent provided (10ml) and
2-3 hours
shake vigorously for 30 seconds. Then dilute to
a concentration of 600mg in 500ml N/S, G or
G10%.
If patient is fluid restricted 600mg may be
diluted in 100ml G and given over 30 minutes.
No specific recommendations. Dilute to

appropriate volume with N/S, H or G.
COMMENTS
Flush with N/S.
Discard remaining infusion after 6
hours. Sodium content less than
0.5mmol/600mg.
Displacement volume for a
600mg vial is 0.48ml.
Do not infuse with any other
drugs.
Compatible with G/S and H.
If the patient is ventilated IV
bolus can be administered by
Group 2 staff.
154
DRUG
METHOD

GIVE
Read
and
print
off
the
full
guideline
from
the
Royal
College
of
Nursing:
Rituximab
http://www.rcn.org.uk/__data/assets/pdf_file/0008/262385/Rituximab_protocol.pdf
For treating
Although rituximab may be diluted
(I) IV
Groups 1 (Premedication is required see comments)
severe active
with N/S to a concentration between
infusion via and 2
Rheumatoid
First infusion on Day 1:
1mg/ml and 4mg/ml, the usual
an infusion
Arthritis in
50mg/hour (25ml/hour of 1g in 500ml dilution)
concentration is 2mg/ml.
pump
adults after
for the first 30 minutes then
failure of
100mg/hour (50ml/hour of 1g in 500ml dilution) So the usual dilution of a 1g dose is
treatment with
for the second 30 minutes,
1g in 500ml N/S.
a TNF inhibitor
then the rate can be increased by 50mg/hour
(25ml/hour of 1g in 500ml dilution) every 30
Rituximab infusion should be
minutes to a maximum rate of 400mg/hour
prepared by Pharmacy. Telephone
(200ml/hour of 1g in 500ml dilution) providing
Ext. 31083.
no adverse reactions occur.
(Premedication is required see comments)
Second infusion on Day 15:
100mg/hour (50ml/hour of 1g in 500ml dilution)
for the first 30 minutes then
200mg/hour (100ml/hour of 1g in 500ml
dilution) for the second 30 minutes,
then the rate can be increased by 100mg/hour
(50ml/hour of 1g in 500ml dilution) every 30
minutes to a maximum rate of 400mg/hour
(200ml/hour of 1g in 500ml dilution) providing
no adverse reactions occur.
COMMENTS
Premdication:
Dose of oral paracetamol 60
minutes before each rituximab
infusion (not if paracetamol
already given in the last 4 hours).
Chlorphenamine 10mg IV 60
infusion. Methylprednisolone
100mg in 100nl N/S infused over
30 minutes to be commenced 60
infusion.
Full resuscitation facilities must
be immediately available.
Monitoring:
1st hour blood pressure, pulse,
temperature and O2 sats every 15
minutes. Thereafter, every 30
minutes after increasing the
infusion rate, and throughout the
course of the infusion once
maximum rate is reached.
Possible reactions:
Low grade fever, BP drop of
<30mmHg from baseline: halve
the infusion rate.
Fever >38.50C, chills, mucosal
swelling, dyspnoea, BP drop of >
30mmHg from baseline: stop the
infusion and contact the doctor.
155
DRUG
METHOD
Romiplostim
(Nplate)
SC Injection by
1. Remove the plastic cap from

Romiplostim powder vial and clean
rubber stopper using the provided
alcohol swab.
5. Holding the pre-filled syringe of
2. Attach vial adapter to Romiplostim

vial by peeling off paper backing
from vial adapter, keeping the vial
adapter in its packaging. Keeping
the vial on the bench, push the vial
adapter down onto the centre of the
vial until it is firmly in place.
6. Keeping the vial on the bench,

attach the pre-filled syringe of water
for injections to vial adapter: hold the
outer edge of the vial adapter with
one hand and twist the syringe tip
clockwise onto the adapter with the
other hand until you feel a slight
resistance.
3. Remove and discard vial adapter

packaging.
7. Very slowly and gently expel all

water (0.72ml) into the 250
microgram powder vial. Water should
flow slowly onto powder. GENTLY
swirl the vial until all of the powder
has dissolved and the fluid in the vial
is clear and colourless. Do not shake
or agitate vial
4. Attach plunger rod to the prefilled syringe of water for

injections by twisting the plunger rod
clockwise onto the syringe plunger,
until you feel a slight resistance.
8. Visually inspect the reconstituted solution for particulate matter and/or

discoloration. The reconstituted solution should be clear and colourless and
should not be administered if particulate matter and/or discolouration are
observed. Make sure solution is fully dissolved before removing syringe.
Instructions continued on next page
Groups 1 and 2
Each vial is for
single use only.
Do not mix with
N/S or any drug
solutions
Refer to the
Marsden Manual
for guidance on
SC injection.
water for injections with one hand,

bend the tip of the white plastic cover
downward with your other hand. This
will break the seal of the white plastic
cover. Once the seal is broken, pull
cover off to separate the grey rubber
cap from the clear plastic syringe tip.
156
DRUG
METHOD (Continued from previous page)
Romiplostim
(Nplate)
SC Injection by
9. Remove the empty pre-filled

syringe from the vial adapter.
10. Remove 1 ml administration
syringe from package. Attach the
1 ml syringe to vial adapter of
reconstituted solution by twisting the
syringe tip onto the vial adapter until
you feel a slight resistance.
13. Twist off administration

syringe from vial adapter.
11. Turn assembled syringe-vial

unit upside down, so the vial of
reconstituted product is above the
syringe. Withdraw all of the
medicinal product solution into the
administration syringe.
14. Prepare injection site with a new

alcohol swab. Pull back on the
pink safety cover toward the
syringe and away from the needle.
Remove clear needle shield from
prepared needle by holding syringe
in one hand and carefully pulling
shield straight off with the other
hand.
12. Ensure the correct amount of

solution for the patient dose is in
the administration syringe by
expelling any excess solution back
into the vial.
15. Administer subcutaneous injection following local protocols and

good aseptic technique.
Groups 1 and 2
(Continued)
0.5ml of reconstituted solution

contains 250micrograms
Attach safety needle to the filled

administration syringe by twisting
needle clockwise into syringe Luer
lock tip.
16. After injecting, activate the

pink safety cover by pushing the
cover forward using the same hand
until you hear and/or feel it
click/lock.
17. Immediately discard syringe and needle into an approved Sharps

Container
157
DRUG
METHOD
Salbutamol
IV bolus

GIVE
Groups 3-5 minutes
1and 2
Groups 1
and 2
(C) IV infusion. Groups
Infusion pump 1,2,3,4 and
is required.
5
SC injection
(I) IV infusion
using syringe
pump.
Groups 1
and 2
(I) IV infusion.
Using
volumetric
pump.
Groups 1
and 2

Dilute 500micrograms in 1ml
salbutamol injection with 9ml W,
N/S or G to give a concentration of
50micrograms in 1ml.
Asthma: Dilute 5ml (5mg) of
Asthma:
Ventolin Solution for Infusion to
3-20 micrograms/minute
= 18 -120ml/hour of the 5mg in 500ml with G or N/S to make a
concentration of 10micrograms/ml
500ml dilution
Premature labour: Dilute 10ml
Premature Labour:
(10mg) of Ventolin Solution for
10 micrograms/minute
increasing the rate at 10 minute Infusion to 50ml with G or N/S to
intervals to maximum rate of 45 make a concentration of 200
micrograms/ml
micrograms/minute. Once
uterine contractions have
Premature Labour: Dilute 10ml
ceased the infusion rate should (10mg) of Ventolin Solution for
be maintained at the same level Infusion to 500ml with G or N/S to
for one hour and then reduced make a concentration of
by 50% decrements at six
20 micrograms/ml
hourly intervals
COMMENTS
ECG monitoring recommended.
Sodium content 0.15 mmol/ml.
If necessary in adult or paediatric
intensive care salbutamol 5mg/5ml IV
solution for infusion may be given
undiluted via a central IV line (this method
is unlicensed -see page 1) 3 20
micrograms/minute = 0.18 1.2ml/hour
using this dilution.
10 45micrograms/minute =
3 -13.5ml/hour of the 10mg in
50ml dilution.
10 45micrograms/minute =
30 135ml/hour of the 10mg in
500ml dilution.
158
DRUG
METHOD
WHO MAY
GIVE
Secretin
pentahydrochloride
(Secrelux)
IV bolus
Groups 1
(Secrelux is an
unlicensed productsee page 4)
Sodium benzoate
2g in 10ml
and 2
(I) IV infusion.
Groups 1
required.
Loading dose
(I) IV infusion
(Unlicensed product- Maintenance

see page 4)
(C) IV infusion
Groups 1
and 2
Groups 1
and 2
ADMINISTER OVER

Reconstitute each vial with the
For exocrine
pancreatic function test 10ml N/S provided making a
concentration of 10 Clinical
inject over 1 2
Units/ml. Draw up the prescribed
minutes
dose.
1 hour
Reconstitute each vial with the
10ml N/S provided making a
concentration of 10 Clinical
Units/ml. Draw up the prescribed
dose and infuse over 1 hour.
90 minutes
Draw up 250mg/kg = 1.25ml/kg
of injection and dilute in 5ml/kg of
10%G.
24 hours
Draw up 250mg/kg = 1.25ml/kg
of injection and dilute in 5ml/kg of
10%G.
COMMENTS
Can be given as infusion using a syringe
pump depending on how the test is run.
1 Clinical Unit/kg dose = 0.1ml/kg of
reconstituted secretin
2 Clinical Unit/kg dose = 0.2ml/kg of
reconstituted secretin.
Administer immediately after preparation.
Follow the BRHC guidelines for the
management of hyperammonaemia
http://nww.swretrieval.nhs.uk/DI_ALL.htm
Click on Clinical Guidelines then

Hyperammonaemia
159
DRUG
METHOD
Sodium bicarbonate
(C) IV infusion.
Groups
required.
Sodium chloride
N.B. All bags of
sodium chloride are
for single use only.
WHO MAY
GIVE

Ready prepared infusions are
available from pharmacy.
COMMENTS
Concentrations over 1.8% should be

given via a central line. Sodium content of
0.9% injection is 150mmol/1 litre.
IV bolus
Group 1
(C) or (I) IV
infusion.
Groups
1,2,3,4 and 5
Ready prepared infusions are

available from pharmacy.
IV bolus
Groups
Can be diluted with G, G/S or H.

Concentrations for IV infusion greater
than 1.4% should be given via a central IV
line
1,2,3,4,5,6
and 7
(C) SC infusion
Groups
Only use gravity- 1,2,3,4 and 5
feed
administration
sets. Never use
an infusion
pump for SC
infusions.
ADMINISTER OVER
Usual rate is 500ml

over 8 hours (21 drops
per minute). Maximum
rate is 500ml over 1
hour (167 drops per
minute)
Maximum concentration of sodium

chloride by subcutaneous infusion is
0.9%.
Usual maximum of 2 litres in 24 hours.
However, 3 litres may be given if
necessary over 24 hours using two SC
sites. The needle and giving set should
preferably be changed every 72 hours.
However, infusion sets can be left in place
for up to 5-7 days if there are no
complications. Refer to potassium
chloride monograph for SC potassium.
160
DRUG
METHOD
WHO MAY
GIVE
Sodium fusidate/
Fusidic acid
(I) IV infusion into Groups

a central venous 1,2,3,4 and 5
line (preferred
method). Infusion
pump is required
ADMINISTER OVER
2 hours
6 - 8 hours
(I) IV infusion into Groups

wide bore
1,2,3,4 and 5
peripheral vein.
Infusion pump is
required.
6 -8 hours

Displacement is negligible. Add
10ml buffered diluent for 500mg in
10ml (50mg in 1ml).
Reconstitute with 10ml buffered
diluent provided then dilute with
500ml N/S or G.
For fluid restricted patients
reconstitute as above then dilute
with 100ml N/S (unlicensed dilution
- see page 1)
Reconstitute and dilute with 500ml
as above. Alternatively for fluid
restricted patients dilute with 250ml
N/S or G (unlicensed dilution - see
page 1).
COMMENTS
G can be used as diluent but opalescence

may occur with more acidic samples
(infusion must be discarded).
Flush with N/S.
When reconstituted with 10ml buffer,
preparation contains 3.1mmol sodium and
1.1mmol phosphate.
Sodium fusidate is well absorbed from the
GI tract so consider an early switch to
tablets or mixture.
161
DRUG
METHOD
Sodium
nitroprusside
(C) IV infusion.
Infusion pump is 1 and 2
required.
(N.B Nitroprussiat
fides brand is
unlicensed see
page 4)

COMMENTS
GIVE
Increase rate slowly until Reconstitute 50mg with 2-3ml G (or Intra-arterial blood pressure monitoring
Groups
necessary.
Protect infusion and administration set
from light: Use the tin foil provided to wrap
the bag and administration set, or the line.
Use an amber syringe if giving by syringe
pump.
Discontinue infusion gradually over 15-30
Intensive care areas or Theatres
only may use a dilution of 1mg/ml minutes.
50mg in 50ml) in G via a central IV Discard infusion solution if it is highly
coloured.
line.
When using the Nitroprussiat fides
brand the prepared infusion should be
discarded after 4 hours.
Do not flush - replace giving set.
Using the 50mg in 50ml dilution for Intensive Care areas or Theatres:
Hypertensive crisis
0.5 8micrograms/kg/minute
= 0.03 0.48ml/kg/hour
Maintenance of blood pressure at 30-40% lower than pre- 20 400micrograms/minute
=1.2 24ml/hour
treatment diastolic
(Lower doses if treated with other
antihypertensives)
Controlled hypotension in surgery
Up to a maximum of
=Up to a maximum of 0.09ml/kg/hour
1.5micrograms/kg/minute
Heart failure
10 200micrograms/minute
=0.6 12ml/hour
desired effect occurs.
The maximum rate is
in order to avoid
excessive levels of
cyanide and thiocyanate
and to lessen the
possibility of a sudden
drop in blood pressure.
the 5ml G provided in the case of

the unlicensed Spanish
Nitroprussiat fides brand) then
further dilute with 500ml or 1000ml
of G.
162
DRUG
METHOD
Sodium
phenylbutyrate
2g in 10ml
Loading dose
(I) IV infusion
(Unlicensed
productsee page
4)
Maintenance
(C) IV infusion
WHO MAY
GIVE
Groups 1
ADMINISTER OVER

COMMENTS
About 90 minutes
Draw up 250mg/kg = 1.25ml/kg of

injection and dilute in 5ml/kg of
10%G.
Draw up 250mg/kg = 1.25ml/kg of
injection and dilute in 5ml/kg of
10%G.
Follow the BRHC guidelines for the

management of hyperammonaemia
and 2
Groups 1
and 2
24 hours
http://nww.swretrieval.nhs.uk/DI_ALL.htm
Click on Clinical Guidelines, then ALL

then Hyperammonaemia
For a ready-made phosphate infusion that can be given via a peripheral or central vein, see the monograph for Phosphate Polyfusor
Flush with N/S.
Via a peripheral vein dilute dose
(I) or (C) IV
Sodium
Adult patients on a
Groups
with a suggested volume of 500ml
infusion. Infusion 1,2,3,4 and 5 critical care unit:
Phosphate
Up to 0.3 0.6mmol/kg/day of phosphate
pump is required
(Disodium
Suggested maximum N/S or G.
may be required during the treatment of
Hydrogen
infusion rate of
Refeeding Syndrome.
Phosphate)
10mmol phosphate per Undiluted sodium phosphate
injection may be infused via a
hour (30mmol
Disodium hydrogen phosphate 21.49%
central IV line using a syringe
phosphate in 50ml
injection contains 6mmol phosphate in
pump.
over 3 hours).
10ml
It is suggested that
(30mmol phosphate in 50ml).
general wards infuse
the dose of phosphate
over 12 hours or ask
the doctor to prescribe
a dose of Phosphate
Polyfusor instead (See
page 182)
163
DRUG
METHOD
WHO MAY
GIVE
ADMINISTER OVER
Sodium valproate
IV bolus
Usual method
Groups

Sodium content 2.41mmol/400mg vial.
Usually continue the patients current oral
dosage as repeated slow bolus injections.
Alternatively continue total usual oral daily
dosage as a continuous IV infusion over
24 hours.
For patients not previously treated with
sodium valproate a slow bolus of 400
800mg depending on patients weight (up
to 10mg/kg) is given followed by
continuous infusion (Max. 2500mg per
day).
Myocardial Infarction: Streptase brand reconstitute all ECG and blood pressure monitoring
required.
sizes with 5ml N/S. Further
1.5 MU over 60
1 MU= 1,500,000 units
dilute 1.5 MU dose in 50minutes.
Flush with N/S.
Embolism/thrombosis 200mlN/S, G or H.
Duration of infusion: 72 hours for DVT or
Dilute other doses in any
250,000 units over 30
suitable volume of N/S or G e.g. 24 hours for PE or 24-72 hours for arterial
minutes followed by
thrombosis or 12 hours for central retinal
50-250ml.
100,000units/hour.
thrombosis.
Streptokinase
1,2,3,4 and 5
(C) IV infusion.
Infusion pump
is required.
(I) IV infusion.
Infusion pump
is required.
Groups
1,2,3,4 and 5
(C) or (I) IV
infusion.
Infusion pump
is required.
Groups 1,2
and 3
Groups
1,2,3,4 and 5

3 - 5 minutes.
Reconstitute with 4ml diluent
provided.
Due to the product displacement
this produces a solution of
95mg/ml.
Divide total infusion
Reconstitute as above then
volume by 24 to set the dilute with N/S, G or G/S to any
hourly rate on the pump suitable volume of at least 50ml
1 hour
Reconstitute as above then
dilute with N/S, G or G/S to any
suitable volume of at least 50ml
COMMENTS
164
DRUG
METHOD
WHO MAY
GIVE
Streptomycin
Deep IM
injection
Groups 1
and 2
(Unlicensed product
see page 4)
Change the
injection site
each time.
ADMINISTER OVER

Refer to the Marsden
A 1g dose is usually dissolved in In the treatment of tuberculosis the usual
dose for adults, and children 1month to
Manual for guidance on 2 -3ml W.
18 years is 15mg/kg up to a maximum of
IM injection.
1000mg, given daily or three times a
The displacement volume is
week. For the elderly and adults over 40
approximately 0.75ml
years of age or less than 50kg body
weight give 500mg-750mg once daily or
So if you dissolve the powder
with 3.25ml W the solution
750mg three times a week.
produced will be 250mg/ml
Monitor serum levels, particularly in
patients with renal impairment, and
adjust dosage accordingly.
One hour (peak) levels should be 15
40mg/litre and pre-dose (trough) levels
should be less than 5mg/litre (less than
1mg/litre in renal impairment or in those
over 50 years).
Subcuvia
Subgam
165
DRUG
METHOD
WHO MAY
GIVE
ADMINISTER OVER
Sugammadex
Rapid IV bolus Group 1
Rapid injection within

10 seconds
Approved use in this

Trust: Immediate
reversal of
neuromuscular block
by rocurronium when
intubation and
ventilation have failed.
It will also be effective
in a similar emergency
situation to reverse
vecuronium.

Adult dose for immediate
reversal of rocuronium block is
16mg/kg of undiluted 500mg in
5ml injection.
16mg/kg = 0.16ml/kg of the
500mg in 5ml injection
COMMENTS
If sugammadex is administered via the
same infusion line that is also used for
other medicinal products, flush before
and after sugammadex administration
with N/S.
However, sugammadex can be injected
into the intravenous line of a running
infusion with the following intravenous
solutions: N/S, G, H, and sodium chloride
0.45% and glucose 2.5%.
166
DRUG
METHOD
WHO MAY GIVE
ADMINISTER OVER
Sulphadiazine
(I) IV infusion.
Infusion pump
is required.
Groups 1,2,3,4 and

5
Minimum 30-60
minutes
IV bolus
Group - must only
Suxamethonium

Dilute dose with N/S to a
maximum concentration of
50mg/1ml. Preferably dilute
required dose to 500ml to 1 litre
to reduce risk of crystallisation in
the urine.
Ready diluted
COMMENTS
Flush with N/S.
Sodium content approximately 4mmol/1g.
To reduce the risk of crystallisation in the
urine a high fluid intake (2.5-3.5 litres in
24 hours) should be maintained with
urinary output of not less than half that
amount. In addition the urine should be
rendered alkaline.
be given by doctors
proficient in advanced
airway management.
(C) IV infusion. Groups 1 and 2
Infusion pump
is required.
Synacthen
2.5 - 4mg/minute
Infuse as a 1mg/ml to 2mg/ml

solution diluted in N/S or G.
Infusion not usually recommended due to

development of phase II neuromuscular
block and likelihood of exceeding
maximum dose.
See Tetracosactide.
167
DRUG
METHOD
(C) IV
infusion.
Give by mouth Infusion
pump is
or enteral
required.
feeding tube
routes if at all
possible.
Tacrolimus
WHO MAY ADMINISTER

GIVE
OVER
Groups Infuse daily
1,2,3,4 and dose in 48ml
over 24 hours
5
(Pump set at
2ml/hour)

Draw up the correct dose in a 1ml
syringe (See table below).
Transfer and dilute to 48ml with
N/S or G in a 50ml Terumo or BD
syringe. The final concentration
should be between 4 and 100
micrograms/ml. Infuse through a
PVC-free extension set (Codan
PVC-free extension set 71.4001
available via ORACLE, order
code FKA064 or Alaris G30302M
line via ORACLE order code
FKA058)
Oral to IV tacrolimus conversion chart

Total oral dose of
Approximately
Volume of tacrolimus
tacrolimus in 24 hours
equivalent IV dose
injection (5mg in 1ml) to
over 24 hours
draw up for further dilution
0.5mg
100micrograms
0.02ml
1mg
200micrograms
0.04ml
1.5mg
300micrograms
0.06ml
2mg
400micrograms
0.08ml
2.5mg
500micrograms
0.1ml
3mg
600micrograms
0.12ml
3.5mg
700micrograms
0.14ml
4mg
800micrograms
0.16ml
4.5mg
900micrograms
0.18ml
5mg
1mg
0.2ml
COMMENTS
Tacrolimus is adsorbed to PVC and must be infused though a
PVC-free or PE-lined extension set
The following extension sets are suitable and are available to
order from NHS Supplies:
Codan PVC-free extension set 71.4001, order code FKA064.

Vygon PE-lined extension set 6222.151, order code FSB147.
BMS PE-lined extension set 30-7200, order code FSB646.
Other suitable sets include the Vygon 71100.15 PE extension set
and the Vygon 0832.211R PE-lined extension set.
Where the need is immediate and a PVC-free extension set has
not been provided with the supply of IV tacrolimus a PVC-free
extension set can be obtained from Neonatal ICU.
Wear gloves when preparing the infusion
Not Y-site compatible with ganciclovir or aciclovir.
Oral to IV tacrolimus conversion chart (continued)
Total oral dose of
Approximately
Volume of tacrolimus
tacrolimus in 24 hours equivalent IV dose
injection (5mg in 1ml) to draw
over 24 hours
up for further dilution
5.5mg
1.1mg
0.22ml
6mg
1.2mg
0.24ml
6.5mg
1.3mg
0.26ml
7mg
1.4mg
0.28ml
7.5mg
1.5mg
0.3ml
8mg
1.6mg
0.32ml
8.5mg
1.7mg
0.34ml
9mg
1.8mg
0.36ml
9.5mg
1.9mg
0.38ml
10mg
2mg
0.4ml
168
DRUG
METHOD
Tazocin
Teicoplanin
Refer to the
Plymouth Healthnet
Clinical
Guidelines/Infection
Control for the use
and current dosage
of gentamicin,
teicoplanin and
vancomycin.
WHO MAY
GIVE
See Pipercillin/Tazobactam
IV bolus
Groups
Usual method
1,2,3,4 and 5
(I) IV infusion.
Infusion pump is
required.

SUITABLE DILUENT
COMMENTS
3 5 minutes for
all doses.
Slowly reconstitute each 200mg or 400mg

vial with the 3.2ml of W provided. Roll the
vial gently until the powder has
completely dissolved. Take care to avoid
formation of foam. If it does foam, leave
the vial to settle for 15 minutes until the
foam subsides. Reconstituted in this
manner you will be able to extract 200mg
in 3ml from the 200mg vial and 400mg in
3ml from the 400mg vial.
Flush with N/S.

Sodium content less than 0.5mmol/vial
(200mg and 400mg).
Incompatibile with aminoglycosides (eg.
gentamicin).
Teicoplanin solutions will precipitate when
they come into contact with gentamicin
flush the catheter well with N/S between
giving these two antibiotics.
30 minutes
Groups
1,2,3,4 and 5
IM injection of
Groups
doses up to 400mg 1,2,3,4 and 5
possible only when
IV access cannot
be established and
after discussion
with Microbiologist
ADMINISTER
OVER
Reconstitute as above then dilute the

required dose further with N/S, G, G/S or
H (e.g. 50ml or 100ml).
Reconstitute as above.

on IM injection.
169
DRUG
METHOD
WHO MAY
GIVE
Temocillin
Slow IV bolus
Groups
1,2,3,4 and 5
(I) IV infusion
Infusion pump is
required.
Groups
1,2,3,4 and 5
IM injection
Groups
1,2,3,4 and 5
ADMINISTER
OVER
3 4minutes

SUITABLE DILUENT
Reconstitute each 1g with 10ml W and
shake vigorously. The final volume is
10.7ml (i.e. displacement volume is 0.7ml)
30-40minutes
Reconstitute as above then add the dose

to 100ml N/S.
COMMENTS
Incompatible with aminoglycosides e.g.
gentamicin, tobramycin & amikacin if
administering down the same IV line, flush
with N/S between the temocillin and the
aminoglycoside.
Reconstitute each 1g with 2ml W and

shake vigorously. The final volume is
on IM injection.
2.7ml (i.e. displacement volume is 0.7ml).
If pain is experienced at the site of IM
injection each 1g can be reconstituted with
2ml of lidocaine 0.5% or 1% injection
instead of W.
170
DRUG
METHOD
WHO MAY
GIVE
Tenecteplase
IV bolus
Groups
ADMINISTER
OVER
About 10 seconds
1and 2
Follow the protocol for
the treatment of Acute
Myocardial Infarction
(See Plymouth
Healthnet Clinical
Guidelines)
INSTRUCTION FOR DILUTION AND SUITABLE DILUENT

1) Remove the flip-off cap from the vial.
2) Remove the tip-cap from the syringe. Then immediately screw the pre-filled
syringe onto the vial adapter and penetrate the vial stopper in the middle with the
spike of the vial adapter.
3) Add the water for injections into the vial by pushing the syringe plunger down
slowly to avoid foaming.
4) Reconstitute by swirling gently.
5) The reconstituted preparation results in a colourless to pale yellow, clear solution.
Only clear solution without particles should be used.
6) Directly before the solution will be administered, invert the vial with the syringe still
attached, so that the syringe is below the vial.
7) Transfer the appropriate volume of reconstituted solution of Metalyse into the
syringe, based on the patient's weight.
8) Disconnect the syringe from the vial adapter.
9) Alternatively the reconstitution can be performed with the included needle.
Do not inject into a line containing glucose. Compatible with N/S
Patient Weight Vial size to

pick
Reconstitute with Dose

the W provided
Volume to give
<60kg
40mg
8ml
30mg
6ml
>60kg to <70kg
40mg
8ml
35mg
7ml
>70kg to <80kg
40mg
8ml
40mg
8ml
>80kg to <90kg
50mg
10ml
45mg
9ml
>90kg
50mg
10ml
50mg
10ml
171
DRUG
METHOD
Terbutaline SC injection
WHO MAY
GIVE

Groups
1,2,3,4 and 5
IM injection
Groups
1,2,3,4 and 5
Slow IV bolus
Groups

Suggestion: 3 5
(C) IV infusion for

Adult dosage:
Groups
bronchodilation via 1,2,3,4 and 5 30 60ml/hour for 8
a volumetric pump
10 hours
(C) IV infusion for
Groups
premature labour
1,2,3,4 and 5
via syringe pump.
(Recommended
method to avoid fluid
overload)
SC and IM injection are usually preferable to slow IV

bolus, but if slow IV bolus is necessary monitor the
patients pulse.
Dilute 3 5ml (1.5 2.5mg) of
terbutaline injection in 500ml G, N/S
or G/S.
Dilute 10ml (5mg) of terbutaline

Initially 3ml/hour
(5microgram/minute) injection to 50ml with G.
for 20 minutes.
Titrate dosage in
increments of
1.5ml/hour
(2.5microgram/minut
e)
Dilute 10ml (5mg) of terbutaline

(C) IV infusion for
Initially 30ml/hour
Groups
premature labour
1,2,3,4 and 5 (5microgram/minute) injection to 500ml with G (remove
10ml G from the bag first).
via volumetric pump.
for 20 minutes.
Titrate dosage in
increments of
15ml/hour
(2.5microgram/minut
e)
SC infusion treating
brittle asthma
COMMENTS
Typical dose range:

Groups
1,2,3,4 and 5 5 15mg/24 hours
Can be infused undiluted or diluted

with N/S to the required volume.
Titrate the hourly rate with reference to suppression

of contractions, increase in pulse rate and changes
in blood pressure, which are limiting factors. These
parameters should be carefully monitored during
treatment. A maternal heart rate of more than 135
beats/min should be avoided. In order to minimise
the risk of hypotension associated with tocolytic
therapy, special care should be taken to avoid caval
compression by keeping the patient in the left or
right lateral positions throughout the infusion.
Infusion via a syringe pump is preferable to keep
the volume of fluid administered to a minimum and
to avoid maternal pulmonary oedema.
The recommended diluent in premature labour is G.
If it is necessary to use N/S monitor for maternal
pulmonary oedema.
SC infusion of terbutaline is unlicensed see page 1
172
DRUG
METHOD
Terlipressin
IV bolus
WHO MAY
GIVE

SUITABLE DILUENT
Suggestion: Each 1mg For Variquel brand:
Groups
Slowly add the entire contents of the
1,2,3,4 and 5 over 1 minute
solvent ampoule (5ml) to the powder
vial and roll the vial gently until the
powder is completely dissolved. The
powder should dissolve to form a
colourless solution within 10 seconds.
This may be further diluted to 10 ml
with N/S if required.
ForGlypressin brand:
Ready diluted (1mg in 8.5ml)
1.3micrograms/kg/hour
For Variquel brand:
Groups 1
=0.065ml/kg/hour
of
a
Reconstitute one 1mg vial as above
and 2
1mg in 50ml G dilution. and dilute the contents further to 50ml
with G.
(C) infusion in
Critical Care
areas only via
central IV line.
(Preceded by an
IV bolus of 0.5mg
or 1mg at the
discretion of the
consultant
intensivist)
Tetracosactide IV bolus
Groups
(Synacthen)
1,2,3,4 and 5
Terlipressin to
treat septic
shock in
critical care
areas only,
when
vasopressin is
unavailable
IM injection
ADMINISTER OVER
(Infusion rate may be

titrated to effect at the
discretion of the
consultant intensivist)
Suggestion: Give over Ready diluted.

30 to 60 seconds
Inject deep into the

1,2,3,4 and 5 deltoid muscle
Groups
ForGlypressin brand:
Dilute the contents of a 1mg ampoule
further to 50ml with G.
COMMENTS
Monitor blood pressure, serum sodium
and potassium and fluid balance. Flush
with N/S.
This is an unlicensed regimen (see page

1) to reduce noradrenaline requirements
in patients with septic shock based on
the following reference:
http://www.biomedcentral.com/content/pdf/cc799
0.pdf
N/S is not a suitable diluent for

terlipressin infusion.
The suggested expiry for terlipressin in G
infusion is 12 hours after preparation.
Flush with N/S.
Keep patient under observation for 30
minutes after the injection
hypersensitivity reactions are possible.
The Planned Investigation Unit (PIU) have
copies of the Short Synacthen test
protocol.

173
DRUG
METHOD
WHO MAY
GIVE
Thiopental
(Thiopentone)
IV bolus
Group 1
(C) infusion
Groups 1
via a central and 2*
IV line Pump
is required.
ADMINISTER OVER

SUITABLE DILUENT
Reconstitute 500mg vial with 20ml W Flush with N/S.
Anaesthesia
to produce a 2.5% (25mg/ml) solution. Check for haze or precipitation before
induction:
administering.
100 150mg over 10Extravasation causes local tissue necrosis
15 seconds Longer in
and severe pain. This can be relieved by
the elderly or
application of an ice pack and local injection
debilitated) repeated
of hydrocortisone.
after 1 minute if
necessary.
The reconstituted solution should be
Control of
discarded after 7 hours.
convulsions:
75 125mg over 3-5
minutes
Lowering raised
intracranial
pressure:
1.5 3mg/kg over 3-5
minutes. Repeat as
necessary.
For the management
of refractory
intracranial
hypertension or
Status Epilepticus,
refer to the
appropriate critical
care protocol.
(C) IV infusion is not a licensed method of

administration of thiopentone (See page
126)
Sodium content: 2.31mmol/500mg
Use the prepared solution within 7 hours.
In intensive care areas or Theatres
only, the 2.5% (25mg/ml) solution may For the management of refractory
intracranial hypertension or Status
be infused without further dilution
through a central line (local practice). Epilepticus, refer to the appropriate critical
care protocol.
*Group 2 nurses may only administer
prescribed additional boluses of thiopental to
ventilated patients in level 3 critical care.
Reconstitute three 500mg vials, each
with 20ml W, making an infusion of
1500mg in 60ml (2.5% solution).
174
DRUG
METHOD
Ticarcillin with
clavulanic acid
Tigecycline
See Timentin
WHO MAY
GIVE
ADMINISTER
OVER
(I) IV infusion
30 60 minutes
Groups
May only be initiated required.
on the advice of a
consultant
microbiologist
This product is
being intensively
monitored by the
CHM and MHRA.
Please report all
suspected reactions
(including nonserious ones) using a
Yellow Card from the
BNF.

SUITABLE DILUENT
COMMENTS
Reconstitute the powder in the vial with

5.3ml N/S or G to make a 10mg/ml
solution. Gently swirl to dissolve the
powder. Then withdraw 5ml (50mg)
from the vial and add to a 100ml bag of
N/S or G. For the 100mg dose
reconstitute two vials as above and add
10ml to a 100ml bag of N/S or G.

Tigecycline in N/S is compatible at a YSite with dobutamine, dopamine,
gentamicin, lidocaine,morphine,
potassium chloride, propofol, ranitidine
and Hartmanns
The solution should be inspected for the
presence of particulate matter or green
or black discolouration before use.
Tigecycline should be yellow/orange in
colour once reconstituted, if it is not, it
should be discarded.
175
DRUG
METHOD
Timentin
(I) IV infusion
Groups
required.
Tinzaparin
2,500units
3,500units
4,500units
Pre-filled syringes
Tinzaparin
40,000units in 2ml
Multidose vial
(Non-Formulary)
WHO MAY
GIVE
Injection into the

arterial limb of
the dialyser at
the start of
haemodialysis
Groups 1
and 2
SC injection
Groups
ADMINISTER
OVER
30-40 minutes

SUITABLE DILUENT
Reconstitute the 3.2g vial with 10ml W
to form a pale straw-coloured solution.
Heat is released when the powder
dissolves. Further dilute 3.2g with 100 150ml G.
COMMENTS
Incompatible with gentamicin and other
aminoglycosides.
Each 3.2g of Timentin contains
approximately 15.9mmol of sodium.
Do not administer Timentin by IV bolus
or IM injection.
Flush with N/S.
Displacement value: 2.2ml for 3.2g of

Timentin so reconstitute 3.2g vial with
7.8ml W to get 3.2g in 10ml.
Follow the PHNT guidelines for the use
No further dilution required.
of tinzaparin (sodium) for preventing
clotting in the haemodialysis circuit.
(Firstly, prime the circuit with 1 litre N/S).
1,2,3,4 and 5

Tinzaparin must not be administered by

intramuscular injection due to the risk of
haematoma. Do not administer
intravenously.
Discard the vial 14 days after first use.
Record the date of first use on the vial.
176
DRUG
METHOD
WHO MAY ADMINISTER

COMMENTS
GIVE
OVER
Withdraw 50ml from a 250ml bag of Intravenous infusion of unfractionated heparin (5,000unit IV
Tirofiban Loading dose Groups See below for
bolus followed by IV infusion at initial rate of 1,000units per
N/S or G and replace with 50ml of
followed by
1,2,3,4 and indicationhour: target APTTR approximately 2) should be
specific infusion Tirofiban solution to make a
(C) IV infusion 5
administered concurrently with Tirofiban and may be
concentration
of
50
micrograms/ml.
rates.
via Infusion
infused through the same catheter/Venflon as the Tirofiban.
Mix
well
before
use.
pump
For NSTE-ACS patients managed with an early invasive strategy and not
For patients diagnosed with NSTE-ACS and managed with an invasive
strategy undergoing angiography within 4 hours after the diagnosis,
planned to undergo angiography for at least 4 hours and up to 48 hours after
tirofiban is given IV initially by 25 microgram/kg bolus dose given over 3
diagnosis, tirofiban is given IV at an initial infusion rate of 0.4 microgram/kg/min
minutes initiated at the start of PCI followed by a continuous infusion of 0.15
for 30 minutes. At the end of the initial infusion, tirofiban is continued at a
maintenance infusion rate of 0.1 microgram/kg/min.
microgram/kg/min for 18-24 hours and up to 48 hours.
When administering the bolus dose, always pre-set the infusion pump with the
When administering the loading infusion, always pre-set the infusion pump with the
total bolus volume to be administered
total loading infusion volume to be administered.
Patient weight(kg)
Bolus (ml)
3 minute bolus
infusion rate (ml/hour)
Maintenance infusion rate

(ml/hour)
30 37
17
340
6
38 45
21
420
7
46 54
25
500
9
55 62
29
580
11
63 70
33
660
12
71 79
38
760
14
80 87
42
840
15
88 95
46
920
16
96 104
50
1000
18
105 112
54
1080
20
113 120
58
1160
21
121 128
62
1240
22
129 137
67
1340
24
138 145
71
1420
25
146 153
75
1500
27
In patients with an eGFR<30ml/min reduce the dosage by 50%
Patient weight(kg)
30 minute loading
infusion (ml)
30 minute loading infusion

rate (ml/hour)
Maintenance infusion
rate (ml/hour)
30 37
8
16
4
38 45
10
20
5
46 54
12
24
6
55 62
14
28
7
63 70
16
32
8
71 79
18
36
9
80 87
20
40
10
88 95
22
44
11
96 104
24
48
12
105 112
26
52
13
113 120
28
56
14
121 128
30
60
15
129 137
32
64
16
138 145
34
68
17
146 153
36
72
18
In patients with an eGFR<30ml/min reduce the dosage by 50%
177
DRUG
METHOD
WHO MAY
GIVE
Tobramycin
IV bolus
Groups
1,2,3,4 and 5
(I) IV infusion
Groups
for once daily
1,2,3,4 and 5
dosing in cystic
fibrosis
Infusion pump
is required.
IM injection
ADMINISTER
OVER
3 5 minutes

SUITABLE DILUENT
30 minutes
10mg/kg dose in Cystic Fibrosis diluted

to 50ml or 100ml with N/S or G.
Groups
1,2,3,4 and 5

COMMENTS
Flush with N/S.
N.B. Current recommended dose of
10mg/kg once daily in Cystic Fibrosis
patients exceeds the dose stated in the
package insert.
Maximum once daily dose in Cystic
Fibrosis is 660mg with trough levels
measured before the 2nd and 8th doses
(Target trough level <1mg/L. Modify dose
interval if trough level >2mg/L.
TPN
Tramadol
See Parenteral Nutrition

IV bolus
Slowly over 2 3
Undiluted
Maximum total IV/IM dose in 24 hours is
Groups
minutes
600mg
1,2,3,4 and 5
IV infusion is incompatible with diazepam,
(I) IV infusion
12 24mg/hour
Dilute 200mg tramadol in 500ml N/S, G
Groups
diclofenac, indometacin, midazolam and
(=30 60ml/hour) or H
1,2,3,4 and 5
piroxicam.
IM injection
Groups
1,2,3,4 and 5
Tranexamic acid
IV bolus
Groups
100mg/minute
1,2,3,4 and 5
(C) IV infusion. Groups
is required.
25-50mg/kg/24
hours
Tri-iodothyronine
See Liothyronine
Trimethoprim
Trimethoprim injection is a discontinued product
Can be diluted with any convenient

volume of N/S or G (e.g.. 20-50ml for a
bolus or more for an infusion) or given
undiluted.
178
DRUG
METHOD
WHO MAY
GIVE
Triptorelin
(Decapeptyl)
IM injection
Groups
Tysabri
See natalizumab
1,2,3,4 and 5
ADMINISTER
OVER

SUITABLE DILUENT
COMMENTS
Draw up the mannitol diluent provided This is a single-use vial

into the syringe provided using one of
the injection needles and inject in to
the vial containing the powder. Gently
swirl the vial until a uniform suspension
is formed, then draw the mixture back
into the syringe without inverting the
vial. The injection needle should then
be changed and the second needle
used to administer the injection. As the
product is a suspension, the injection
should be administered immediately
after reconstitution to prevent
sedimentation.
179
DRUG
METHOD
Urokinase
WHO MAY ADMINISTER

GIVE
OVER
Lock for unblocking Groups Retain in the
midlines and PICC 1and 2
line for 1-2
lines (Adults)
hours
(or longer)
Catheter lock for
unblocking
haemodialysis
CVC
(Adults)
Groups
1and 2
Inter-dialysis
infusion via the
haemodialysis
CVC
(Adults)
Groups
1and 2
Intraperitoneal
catheter lock for
unblocking the
catheter.
Groups
1and 2

SUITABLE DILUENT
Reconstitute one 10,000unit vial of
urokinase with 3ml of N/S. Instil 1.5ml
(5,000units) of the reconstituted solution into
each lumen of the catheter.
COMMENTS
If the lumen is completely blocked do not force

urokinase into the lumen.Refer to the full PHNT
guidelines:
http://www.plymouthhospitals.nhs.uk/ourservices/clinic
aldepartments/Pages/VascularAccessTeam.aspx
Reconstitute urokinase 25,000unit vial with N/S in a volume equal to the priming volume of both catheter lumen
plus an additional 0.2mls (e.g. A lumen = 1.7, V lumen = 1.9, therefore 1.7 + 1.9 + 0.2 = 3.8 ml of N/S).
Draw up solution into two syringes: one equal to arterial lumen volume + 0.1ml and one equal to venous
lumen + 0.1ml (e.g. A lumen syringe = 1.7 + 0.1 = 0.8 ml; V lumen syringe = 1.9 + 0.1 = 2ml)
All staff must be aware that any connection/disconnection to a haemodialysis CVC must be performed using
aseptic technique
o Flush each lumen with 10ml of N/S
o Inject 12,500unit urokinase into each lumen to the priming volume
o Positively lock the lumen and place the red obdurate, then wait for 30 minutes
o Aspirate 5mls from each lumen and flush with 10-20ml of N/S if flows have restored
Commence dialysis treatment
The decision to use an inter-dialysis infusion of urokinase must be agreed beforehand with one of the
Trust consultant nephrologists each time it is used, and after assessment of any increased bleeding risk.
Reconstitute two 100,000unit vials of urokinase each with 2ml N/S and add both vials to 100ml N/S
(200,000unit urokinase in 100ml N/S).
Draw up the urokinase solution into two 50ml luer-lock syringes.
Attach the 50ml syringes to the lumens of the dialysis CVC.
Using a syringe driver, infuse a 50ml syringe containing the urokinase solution (100,000iu in 50ml N/S) down
each lumen over 90 minutes (34ml/hour).
When the infusion is complete, flush each lumen with 1020ml N/S to establish blood-flow.
Commence haemodialysis.
Retain in
Dilute 12,500 international units with 5ml
Follow the Renal Services Directorate Peritoneal
catheter for 2
N/S.
Dialysis Protocols
hours
180
DRUG
METHOD
Vancomycin
(I) IV infusion
preferred
method.
Infusion pump
is required.
Refer to the
Plymouth Healthnet
Clinical
Guidelines/Infection
Control for the use
and current dosage
of gentamicin,
teicoplanin and
vancomycin.

GIVE
Groups Adults: 500mg over 1
1,2,3,4 and hour. Doses over
500mg maximum rate
5
10mg/minute.
(C) IV infusion. Groups 24 hours

Infusion pump 1,2,3,4 and
is required.
5
Example IV
calculations
Intrathecal
Injection
COMMENTS
Reconstitute 1g vial with 20ml W and

500mg vial with 10ml W.
Dilute 500mg with at least 100ml N/S or
G.
Dilute 750mg with at least 150ml N/S or
G.
Dilute 1g with at least 200ml N/S or G.
Dilute 1.5g with at least 300ml N/S or G.
Dilute 2g with at least 400ml N/S or G.

In practice 1g in 100ml may be used in
fluid restricted patients; but the use of
such high concentrations may increase
the risk of infusion related events when
administered via a peripheral vein. Note
that the current recommended target
trough level is higher than that in the SPC
and is therefore unlicensed (See page 4).
500mg vancomycin (in 10ml W) added to a 100ml bag N/S = 110ml over 1 hour
750mg vancomycin (in 15ml W) added to a 250ml bag N/S = 265ml over 1 hours
1g vancomycin (in 20ml W) added to a 250ml bag N/S = 270ml over 2 hours
1.5g vancomycin (in 30ml W) added to a 500ml bag N/S = 530ml over 2 hours
2g vancomycin (in 40ml W) added to a 500ml bag N/S = 540ml over 3 hours (200 minutes)
Group 1
Intraperitoneal Groups 1
and 2

SUITABLE DILUENT
Set pump rate at :

110ml/hour
177ml/hour
135ml/hour
212ml/hour
162ml/hour
Refer to the Neurosurgical Antibiotic

Therapy Guidelines for Adults on
Plymouth Healthnet (Under Clinical
Guidelines)
Follow the Renal Services Directorate
Peritoneal Dialysis Peritonitis Protocol
181
DRUG
METHOD
Vasopressin
=Argipressin
(I) IV infusion. Groups 1

Infusion
and 2
pump is
required.
Administer
via a central
IV line.
For use in Critical

Care to reduce
noradrenaline
requirements in
patients with
refractory septic
shock.
Regent and Sandoz
brands must be kept
at room
temperature
WHO MAY
GIVE
ADMINISTER OVER

SUITABLE DILUENT
Dosage for use in

Dilute 20 units to 50ml with G.
critical care for
refractory septic shock:
0.62.4 units/hour
(= 1.5 -6ml/hour using
20 units/50ml dilution)
COMMENTS
Flush with G.
Note that Regent and Sandoz brand vials
are only labelled for IM and SC use.
However, they are also suitable for IV
use. Regent and Sandoz brands are
unlicensed in the UK (see page 1).
Note that Sandoz brand vials are
multidose 40units in 2ml. Part-used vials
should be stored at room temperature
and discarded 28 days after initial use.
(Unlicensed indication- see page 1).
Pitressin - keep in
the fridge
182
DRUG
METHOD
WHO MAY GIVE

SUITABLE DILUENT
COMMENTS
Vecuronium
IV bolus
Group 1 must
only be given by
advanced airway
management. Also
see Comments.
See Data Sheet
The 10mg vial can be reconstituted with

5ml W to produce 2mg/ml solution.
Alternatively reconstitute the 10mg vial
with 10ml W, G, N/S or H to produce a
1mg/ml solution. The reconstituted
solution can be given undiluted or
diluted further with N/S or G to a
maximum dilution of 4mg/100ml.

The reconstituted solution can be injected
or infused in to the line of a running
infusion of Hartmanns.
If the patient is ventilated IV bolus can be
administered by Group 2 staff.
Using a 2mg/ml dilution e.g. 100mg in 50ml
48 84micrograms/kg/hour
= 0.024 0.042ml/kg/hour
Using a 1mg/ml dilution e.g. 100mg in 100ml
48 84micrograms/kg/hour
= 0.048 0.084ml/kg/hour
(I) IV infusion. Groups 1 and 2

Infusion
pump is
required.
Bolus of 40-100
micrograms/kg
followed by 48 - 84
micrograms/kg/hour.
183
DRUG
METHOD
WHO MAY
GIVE
ADMINISTER OVER
Verapamil
IV bolus
Emergency use.
Group 1 or
2 minutes
(elderly patients
minimum 3 minutes)
Group 2
Vigam
Vitamins B and C
High Potency IV
injection
Vitamin K
Voriconazole
See Pabrinex
See phytomenadione
(I) IV infusion.
groups
required.
Over 1-2 hours.

Maximum rate
3mg/kg/hour.
Xiapex
See Collagenase Clostridium histolyticum
IV bolus
X-ray Contrast
According to X-ray
Groups
Medium,
Department protocol.
1 and 6
Non-ionic,
tri-iodinated
X-ray Contrast
IV bolus
According to X-ray
Groups
Medium,
Department protocol
1and 6
Gadolinium based.

Ready diluted.
COMMENTS
necessary.
Flush with N/S.
Sodium content 0.15mmol/ml.
Do not infuse concomitantly with other

Add 19ml W to each 200mg vial.
Resulting concentration is 200mg drug solutions through the same
in 20ml (Displacement 1ml/200mg lumen/Venflon.
vial). Dilute the required dose with
N/S, G, H or 0.45% saline to a final
concentration of 0.5 to 5mg/ml.
Do not dilute.
Do not dilute

equipment should be immediately
available.
equipment should be immediately
available.
184
DRUG
METHOD
WHO MAY
GIVE
ADMINISTER OVER
Zidovudine
(I) IV infusion
groups
1,2,3,4 and 5
1 hour
Zoledronic acid
(Aclasta 5mg in
100ml bags)
(I) IV infusion
groups
Zoledronic acid
(Zometa 4mg in
5ml vials)
(I) IV infusion
Infuse all doses over at Ready diluted.

least 15 minutes.
Set the pump rate at a
maximum of
400ml/hour
Infuse all doses over at Draw up the prescribed dose
(dependent on renal function see
least 15 minutes.
below) and add to 100ml N/S or G.
When diluted with
100ml N/S set the
pump rate at a
maximum of
400ml/hour
Dosing according to renal function
4mg dose
1,2,3,4 and 5
GFR > 60
groups
1,2,3,4 and 5

Dilute the prescribed dose to
2mg/ml or 4mg/ml with G see
comments for examples.
COMMENTS
Example: For a 63mg dose you would
draw up 6.3ml of zidovudine
injection(10mg/ml) and dilute to 31.5ml
with G in a 50ml syringe to make a final
concentration of 2mg/ml, and set the
pump rate at 31.5ml/hour.
Example for doses > 100mg:
For a 130mg dose, you would draw up
13ml zidovudine injection(10mg/ml) and
dilute to 32.5ml with G in a 50ml syringe
to make a final concentration of 4mg/ml,
and set the pump rate at 32.5ml/hour.
Do not give by IM injection.
Do not mix with magnesium or calcium
containing solutions such as Hartmanns.
Do not mix with magnesium or calcium

containing solutions such as Hartmanns.
For the treatment of tumour-induced
hypercalcaemia ensure the patient is well
hydrated before and after administration
of zoledronic acid.
Draw up 5ml from the vial
GFR 50 60
3.5mg dose
Draw up 4.4ml from the vial
GFR 40 49
3.3mg dose
GFR 30 -39
3mg dose
185
C C C
C
C
C
I
C C I
C I C I
C
C
C
C I C
C
C
C
C C C
C I
I C I I
C
C
C C C
C
C
C C C C
I
C
C
C C
C C
C
C C I
Pabrinex up to 3 pairs of ampoules in 50 or 100ml 5% glucose
Thiopentone 25mg/ml in water
Sodium nitroprusside up to 1mg/ml in 5% glucose (Central IV)
C
C
I
I
C
Sodium bicarbonate 1.26%
C C
C
C I
C I
C
Sodium bicarbonate 8.4% (Central IV)
I I
C C
Propofol 10ml/ml undiluted
I
I C I
C
I
C
I
C
C
C C C
C
I
I
I
Remifentanil upto 250micrograms/ml in 5% glucose
C C I
C
C I
C I
C C
I I
C C C
I
C
C
C C C
I I
C I
I I
C I
C I C
I
I
I
C
C C
C C
C
C
C
C
C
C C I
Potassium chloride 2mmol/ml undiluted (Central IV)
I
C C
C
C C
C C C
C C C C
C
Potassium phosphate 30mmol in 50m (Central IV)
C
I
C C
C
I C I
C
I
I
C
C C
C
C
Vecuronium 2mg/ml in water
C
C
Vancomycin up to 5mg/ml in 5% glucose
C C
C C I
C
C
I
Vasopressin 10 units in 50ml 5% glucose
I I I
C C
I C
C
C
C
C
C
I
I
C
I
C C
C
I C
C
C I C
C
C C C
C C C C I
C
C
I
I I I
C
C C
C
I
I
C C C
C
C C C
I
I C
I
I
C C C
Tirofiban 50micrograms/ml in 5% glucose
C
C
C
C C I
C
I
C C I
C
I
Sodium phosphate 30mmol in 50ml undiluted (Central IV)
C C C C
I
C C
C C C
C I C I
I
I
C
I
I
I
I
C
C C
I C
C I
C C
C C C
I
C
C C
C
C
C
C
C C C C
C
I
C
C
C
Phenytoin up to 10mg/ml in 0.9% saline using in-line filter
C I
C C
I C I
C I
C
I
I C
I
C I C
C I C
C
C C C C
C C C C
C
C C
I
I
I
C
C
C I C C
C
I
I
C
I C C C
C C C C C C
C
I I I I
C
I I I I
I
I C
C
C C
C I
C C C
C
C C C C
C
Morphine sulphate 50mg in 50ml (0.9% saline)
Noradrenaline up to 16mg in 50ml 5% glucose
C
C
C
C
Midazolam 1mg/ml or 2mg/ml in 0.9% saline
Milrinone 10mg in 50ml 5% glucose
C C
C C C
Sodium valproate
Methyl prednisolone in 0.9% saline
C
C
C
C
I
I
I C
C
Rifampicin, salbutamol
Metronidazole 500mg in 100ml 0.9% saline
C
I C
C C
C C I
I
I
C C C
C C C
C C
Flumazenil
Mannitol 10%
Linezolid 600mg in 300ml glucose (Ready diluted)
C
C
C C
C
Epoprostenol (Flolan)
Metaraminol in 0.9% saline
C I
I
C
C
C C
C C
I
C
I I C I
C
C
C
C
C
I
Enoximone, Ambisome
Magnesium sulphate 5g in 100ml 0.9% saline
C C
C
I
I
C
C
I
C
I
I
C C
(empty box) = no data available therefore this combination cannot be recommended
Do not infuse the following drugs together

with any other drug solutions down the same
central line lumen or venflon:
Levofloxacin 500mg in 100ml 0.9% saline
C
C
C
C
= Incompatible
Lidocaine 2mg/ml in 5% glucose
C
C
I
I
I
C C
C I
I
I C I
C C
C C
Isoprenaline sulphate 2.25mg in 50ml or 500ml 5% glucose
Heparin sodium 1,000 units/ml
C I
C I
Glyceryl trinitrate 50mg in 50ml 5% glucose
C I
Gentamicin up to 5mg/kg dose in 100ml saline
I
C
C
I
I C C
C C C C I
C
C
I
C
I
Fluconazole 2mg/ml (in 0.9% saline)
C
I
Glucose 10%
Esomeprazole 40mg in 100ml 0.9% saline
Erythromycin 125ml in 25ml 0.9% saline
Dobutamine 250mg in 50ml 5% glucose
Digoxin in 100ml 0.9% saline
Ceftriaxone 2g in 40ml 0.9% saline
Argatroban 1mg/ml in 0.9% saline
Co-trimoxazole (Septrin) 480mg/75ml 5% glucose
C
C
I
C C
C C
C C C
I I
I I I
C
Ketamine 10mg/ml or 50mg/ml in 0.9% saline
C
C C
C C
I C C
C I I
= Compatible but read the warnings above
Labetalol 1mg/ml in 5% glucose or 5mg/ml undiluted (Central IV)
C I
C
C
C C C C
C
C I I
C I
I C
I
I C
C
I I
Isosorbide dinitrate 25mg in 50ml 5% glucose
Insulin soluble 50 units in 50ml 0.9% saline
C
C C
I
C C
C C
C C C
C C
I
C I C I
C
I
or
Hartmann's
C C C
Furosemide 10mg/ml (Undiluted) or 1mg/ml in 0.9% saline
C
C
Fentanyl 50micrograms/ml (Undiluted)
C
C C
C
C C
I I
Esmolol 10mg/ml in 5% glucose
Dopexamine 50mg in 50ml 5% glucose
C I
C
I
I
C
I
C
I
C C C
C C C
C
Important warnings: The table below shows Y-site physical or visual (not chemical) compatibilities between drugs tested at specific concentrations
in specific diluents. The concentrations tested are often different to those used in practice on the ward which are
shown in the table below.
This table gives information for two-drug combinations only. The information cannot be extrapolated to three-drug combinations. While the
indications of compatibility in the table are consistent with the best currently available advice, there is no absolute guarantee of compatibility
where the concentrations in the literature differ significantly from those shown below. Pay careful attention to the diluent(s) quoted for particular
drugs in the table below.
Doxapram 2mg/ml in 5% glucose
I
I
I
C
Dopamine 200mg in 50ml 5% glucose (Central IV)
I
I
C I
I
I
Clindamycin up to 18mg/ml in 5% glucose
C
C
C
Atracurium 10mg/ml (Undiluted)
Aminophylline up to 25mg/ml in saline
I
C
Amiodarone in 5% glucose (Central IV)
Aciclovir up to 5mg/ml in 5% glucose
Updated by Derriford Pharmacy December 2012
Adrenaline 1:10,000 undiluted
Alteplase 100mg in 100ml Water

Alteplase 100mg in 100ml Water
Acetylcysteine in 5% glucose
Aciclovir up to 5mg/ml in 5% glucose
Adrenaline 1:10,000 undiluted (Central IV)
Aminophylline up to 25mg/ml in saline
Amiodarone in 5% glucose (Central IV)
Argatroban 1mg/ml in 0.9% saline
Atracurium 10mg/ml (Undiluted)
Ceftriaxone 2g in 40ml 0.9% saline
Clindamycin up to 18mg/ml in 5% glucose
Co-trimoxazole (Septrin) 480mg/75ml 5% glucose
Digoxin in 100ml 0.9% saline
Dobutamine 250mg in 50ml 5% glucose
Dopamine 200mg in 50ml 5% glucose (Central IV)
Dopexamine 50mg in 50ml 5% glucose
Doxapram 2mg/ml in 5% glucose
Erythromycin 125mg in 25ml 0.9% saline
Esmolol 10mg/ml in 5% glucose
Esomeprazole 40mg in 100ml 0.9% saline
Fentanyl 50micrograms/ml (Undiluted)
Fluconazole 2mg/ml (in 0.9% saline)
Furosemide 10mg/ml (undiluted) or 1mg/ml in 0.9% saline
Gentamicin up to 5mg/kg dose in 100ml saline
Glucose 10%
Glyceryl trinitrate 50mg in 50ml 5% glucose
Hartmann's
Heparin sodium 1,000 units/ml
Insulin soluble 50 units in 50ml 0.9% saline
Isoprenaline sulphate 2.25mg in 50ml or 500ml 5% glucose
Isosorbide dinitrate 25mg in 50ml 5% glucose
Ketamine 10mg/ml or 50mg/ml in 0.9% saline
Labetalol 1mg/ml in 5% glucose or 5mg/ml undiluted
Levofloxacin 500mg in 100ml 0.9% saline (Ready diluted)
Lidocaine 2mg/ml in 5% glucose
Linezolid 600mg in 300ml 5% glucose (Ready diluted)
Magnesium sulphate 5g in 100ml 0.9% saline
Mannitol 10%
Metaraminol in 0.9% saline
Methyl prednisolone in 0.9% saline
Metronidazole 500mg in 100ml 0.9% saline
Midazolam 1mg/ml or 2mg/ml in 0.9% saline
Milrinone 10mg in 50ml 5% glucose
Morphine sulphate 50mg in 50ml (0.9% saline)
Noradrenaline up to 16mg in 50ml 5% glucose
Pabrinex up to 3 pairs of ampoules in 50 or 100ml 5% glucose
Phenytoin up to 10mg/ml in 0.9% saline using in-line filter
Potassium chloride 2mmol/ml undiluted (Central IV)
Potassium phosphate 30mmol in 50ml (Central IV)
Propofol 10ml/ml undiluted
Remifentanil upto 250micrograms/ml in 5% glucose
Sodium bicarbonate 1.26%
Sodium bicarbonate 8.4% (Central IV)
Sodium nitroprusside up to 1mg/ml in 5% glucose
Sodium phosphate 30mmol in 50ml undiluted (Central IV)
Thiopentone 25mg/ml in water
Tirofiban 50micrograms/ml in 5% glucose
Vancomycin up to 5mg/ml in 5% glucose
Vasopressin 20 units in 50ml 5% glucose
Vecuronium 2mg/ml in water
Acetylcysteine in 5% glucose
186
Compatibilities of Injectable Drugs
187
Derriford Hospital Analgesic Ladder

for non-malignant acute pain
If pain unresolved:
Identify type of pain and
consider adjuvant medication
Alternative or parenteral
opioid
Contact Team for review
ACT Nurse Specialist 0195
Mild pain
Regular Paracetamol 1g qds

(maximum paracetamol
dosage 60mg/kg/day if weight
< 50kg.See drug chart for
further advice)
eGFR 30ml/min
Consider PRN NSAID unless
contraindicated (see drug chart
for further advice).
Caution if eGFR < 60ml/min
eGFR < 30ml/min
Avoid non-steroidal drugs.
Notes
Severe pain
Surgical Patients
Oramorph dose PRN 2hrly
Age (years)
Dose(mg)
18-59
20-30mg
60-69
10-20mg
70-89
5-10mg
>89
2.5-5mg
Oxynorm dose PRN 2hrly
Age (years)
Dose(mg)
18-59
10-15mg
60-69
5-10mg
70-89
2.5-5mg
>89
2.5mg
eGFR 30ml/min
As for moderate pain
Plus
Moderate pain
Regular Paracetamol 1g qds
(maximum paracetamol
dosage 60mg/kg/day if weight
< 50kg. See drug chart for
further advice)
Plus
Regular NSAID
unless contraindicated
e.g. eGFR < 30ml/min
Caution if eGFR <60ml/min
Plus
PRN intermediate opioid
(eg:Codeine 30-60mg qds,
Tramadol 50-100mg qds)
eGFR < 30ml/min
Avoid non-steroidal drugs.

Caution with tramadol and
codeine observe for opioid
toxicity
Surgical Patients
PRN Oramorph 20-30mg
2 hourly
(adjust by age - see notes)
Medical Patients
Regular Oramorph 5mg 4
hourly
Increase to 10mg 4 hourly if
necessary
>75 years old reduce to 2.5mg
4 hourly
Plus PRN Oramorph of the
same dose 4 hourly
eGFR < 30ml/min

SurgicalPatients:
Patients
Surgical
PRN Oramorph
Oxynorm 10-15mg
PRN
20-30mg
hourly (adjust
observe
22 hourly
by for
ageopioid
- see
toxicity
notes)
(adjust by age - see notes)
Medical Patients
Regular Oxynorm 2.5mg 4
hourly observe for opioid
toxicity
This guideline is to be used in conjunction

with the BNF and PHNT joint formulary.
Ensure a full pain history is taken from all
patients and regular analgesics are
prescribed.
Be aware of the dose equivalence of
opioids prescribed particular care is
needed with opioid patches.
Consider subcutaneous route rather than
repeated im injections.
Be aware of the influence of renal
impairment, age and opioid tolerance on
opioid prescribing. Refer to opioid
prescribing guidelines if unsure.
Opioid equivalence:
10mg oral morphine
5 mg Morphine SC/IM
3mg Morphine iv
5mg oral Oxycodone
50mg oral Tramadol
120mg oral Codeine
200mcg sublingual Buprenorphine
NB: Fentanyl patches are not to be used for
acute pain (consultant prescribing only)
Pain is the Fifth Vital Sign and must be assessed and recorded alongside other vital signs
All staff involved in the prescribing, dispensing and administration of controlled drugs must be familiar with the
characteristics of the drug
188
Emergency Department Adult Intravenous Morphine
189
Guideline
This guideline is to be used in conjunction with BNF & PHNT joint

formulary & Trust acute pain analgesic ladder.
No intravenous morphine to be given in minors.
Always take into account age, weight and co-morbidities use with extreme
caution in renal impairment. Give 1/2 or 1/3 of below doses in elderly and
frail.
Consider non-pharmacological methods of analgesia eg splintage, LA

blocks.
Actively seek out times and doses of prior (including pre-hospital) analgesia.
Patients with high pain scores should be asked if they require further pain
relief. Only prescribe if the patient says they do.
Seek senior advice for non-responsive pain.

Severe Pain = 8-10
Moderate Pain = 4-7
Mild Pain = 1-3
No Pain = 0
Prescribe multi-modal analgesia (paracetamol

+/-NSAIDs) to be given simultaneously.
Assess with pain score & consider IV

morphine for moderate or severe pain.
Prescribe IV morphine on STAT section

of the drug chart 0.1mg/kg titrated to
effect over 2-3 minutes but see above
Reassess at 20 minutes with

observations including RR, conscious
level & pain score
Repeat up to above dose as required but no

sooner than 20 mins
If a second dose is given in ED apply monitoring
minimum of pulse oximetry
Author: Dr Mark Rockett 2012
190
For more information please contact the Resuscitation Department on 52851
References
The Electronic Medicines Compendium 2012 published by Datapharm Communications Ltd

(http://www.medicines.org.uk/emc/)
The Injectable Medicines Guide produced by the network of UK hospital pharmacists,

published by the Pharmacy Dept. Charing Cross Hospital, London, and endorsed by the UK
Medicines Information service (http://medusa.wales.nhs.uk/)
The British National Formulary No.64 (September 2012) (http://bnf.org/bnf/bnf/current/)
The British National Formulary for Children (2012-2013) (http://bnfc.org/bnfc/bnfc/current/
UK Resuscitation Council Anaphylaxis Algorithm

(http://www.resus.org.uk/pages/anaalgo.pdf)
191
Appendix 1
Protocol for administering intramuscular adrenaline 1:1000 (1mg/ml) for treating
anaphylaxis, when there is no prescription available
Date
Version
September 2013
Purpose
To instruct staff on how to correctly identify when a person is suffering an anaphylactic reaction and to
treat the person correctly with intramuscular adrenaline, when there is no prescription for this medication
Scope of this document
Applies to all non-medical clinical staff working in any area with the skill and competence to assess a
patients condition and administer intramuscular medication.
Key Message
Non-medical clinical staff working for or on behalf of Plymouth Hospitals NHS Trust may legally
administer adrenaline injection to treat anaphylaxis without a prescription. They must do so in
accordance with this protocol.
Accountabilities
Production
Peter Gray, Senior Pharmacist
Review and approval
Ratification
Dissemination
Peter Gray, Senior Pharmacist
Links to other policies and procedures

Pharmacy Documents:
PHNT Medicines Management Policy
Procedures For Administering Injectable Medicines
Other Documents:
Emergency Treatment of Anaphylactic Reactions- Guidelines For Healthcare Providers: Working Group of
the Resuscitation Council (UK) 2008
Medicinal products for parenteral administration in an emergency. The Human Medicines Regulations
2012, Regulation 238, Schedule 19.
Version History
Version 1
1.1
October 2013
Last Approval
Due for Review
Version 1
October 2015
Adrenaline (1:1000) can legally be administered without a prescription for

the purpose of treating anaphylaxis
Medicines legislation restricts the administration of Prescription-Only injectable medicines.

Unless self administered, they may only be administered by in accordance with a prescription.
However, in the case of 1:1000 adrenaline there is an exemption to this restriction which means
in an emergency, a suitably trained person (eg. nurse or ODP) is permitted to administer it by
(intramuscular) injection for the purpose of treating anaphylaxis without a prescription or
instruction from a doctor.
1.2
Persons who can be treated under this protocol

Individuals displaying the signs and symptoms described below who are:
Hospital in-patients
Hospital out-patients attending out-patient or diagnostic departments
Visitors or members of staff
192
1.3
Anaphylaxis
Anaphylaxis is a severe, life-threatening, generalised or systemic hypersensitivity reaction. This

is characterised by rapidly developing life-threatening airway and/or breathing and/or circulation
problems usually associated with skin and mucosal changes.
Administration of intramuscular (IM) adrenaline should be considered for individuals who show
signs and symptoms of an anaphylactic reaction.
Anaphylaxis is likely when all of the following three criteria are met:
1.4
Sudden onset and rapid progression of symptoms.

Life-threatening airway and/or breathing and/or circulation problems.
Skin and/or mucosal changes (flushing, urticaria, angioedema).
Assessing the patient
The ABCDE approach to assess and treat a patient should be followed, as patients can have an
Airway, Breathing or Circulation Problem or any combination which is life threatening.
Airway
Airway swelling, e.g. throat and tongue
Hoarse voice, unable to speak
Stridor
Breathing
Shortness of breath
Wheeze
Confusion caused by hypoxia
Patient becoming tired
Cyanosis late sign
Respiratory arrest
Circulation
Signs of shock, pale, clammy
Increased pulse rate
Low blood pressure, feeling faint, collapse
Decreased conscious level or loss of consciousness
Cardiac arrest
The above Airway, Breathing and Circulation problems can all alter the patients neurological
status (Disability problems) because of decreased brain perfusion. There may be confusion,
agitation and loss of consciousness.
Patients can also have gastro-intestinal symptoms (abdominal pain, incontinence, vomiting)
Exposure
The patient must be exposed ensuring dignity to observe for skin and/or mucosal changes. This
is often the first feature present in over 80% of anaphylactic reactions.
They can be subtle or dramatic.

There may be just skin, just mucosal, or both skin and mucosa changes.
There may be erythema a patchy, or generalised, red rash.
There may be urticaria which can appear anywhere on the body. The weals may be pale,
pink or red, and may look like nettle stings. They can be different shapes and sizes and
are often surrounded by a red flare. They are usually itchy.
Angioedema is similar to urticaria but involves swelling of deeper tissues, most
commonly in the eyelids and lips, and sometimes in the mouth and throat.
193
1.5
Explanation of treatment to the patient
Prior to the administration of adrenaline the patient should receive an explanation that they are
having an allergic reaction and that IM adrenaline is going to be administered to relieve the
symptoms and help reverse the reaction.
1.6
Patient Consent
Prior to the administration of the drug, consent should be obtained either from the patient, parent,
guardian or person with parental responsibility. Verbal consent is acceptable in the emergency
scenario. This should be documented in the patients medical records once the patients
condition is stable.
If the patient, parent or guardian does not wish treatment to be given under this protocol they
should be advised of the potential risks.
If the patient is unable to give consent due to a life-threatening situation, or if parents or
guardians are not present, adrenaline should be administered where treatment is judged
to be in the best interests of the patient.
Exclusions from treatment under this protocol
1.7
None
1.8
Contra-indications to administration of adrenaline to treat anaphylaxis
There are no absolute contra-indications to the administration of adrenaline under this protocol.
1.9
Immediate Treatment Also refer to treatment algorithm on page 193
1.10
Reassure and explain the situation to the patient.

Assess airway and breathing and identify signs and symptoms of anaphylaxis (see 2.1).
Identify and discontinue trigger factors.
Call for help, e.g. 999, a doctor, 2222 Clinical Emergency Team.
Patients with airway or breathing problems may prefer to sit up as this will make
breathing easier.
Assess circulation (see Section 2). Laying the patient flat with or without leg elevation
may be helpful for patients with hypotension. If the patient feels faint, do not sit or stand
them up as this may cause cardiac arrest. NB. A sudden change to a more upright
position may be dangerous due to the effect on blood flow to the heart.
If the patient presents with signs of clinical shock and/or stridor, administer IM adrenaline
1:1000 as recommended, noting the time given and the response.
Continue to observe the patient supporting and maintaining a clear airway, observing
breathing.
Continuous assessment of the patient is important using the ABCDE approach.
Patients who are breathing and unconscious should be placed in the recovery position.
Pregnant patients should lie on their left side to prevent caval compression.
If the patient is not breathing or has no pulse, commence cardio pulmonary resuscitation
(CPR) using current guidelines.
Continue until:
o More qualified help arrives
o You become exhausted
o Patient shows signs of recovery
Source of Adrenaline
Use ampoules of adrenaline 1:1000 (1mg/1ml). If these are not available, use any pre-filled autoinjector (eg. Epipen or Anapen) that the patient may be carrying.
194
1.11 Dosage of Adrenaline
Dose for Adults: 500micrograms (0.5mL) of adrenaline 1:1000 (1mg/mL).
Dose for Infants and Children:
Age
Under 6 years
6 - 12 years
Over 12 years
Dose of
Adrenaline
150 micrograms IM
300 micrograms IM
500 micrograms IM
(300 micrograms IM if the
patient is small or pre-pubertal)
Volume of 1:1000
(1mg/mL) solution
0.15mL
0.3mL
0.5mL
(0.3mL)
Frequency
The dose stated above can be repeated once, as necessary after 5 minutes if there is no
improvement in the patients condition or on assessment of the patients blood pressure, pulse and
respiratory function.
1.12 Adverse Effects

Adverse effects are extremely rare with correct doses injected intramuscularly
1.13
Follow-Up
Hospital in-patients require close observation on the ward (or Theatre/Recovery). They may need
to be transferred to HDU depending on the severity of reaction and medical decision. Any
affected hospital out-patients, staff or visitors, patients in the community or those attending
clinics/health centres/lectures/training need to be transferred to the Emergency Department.
1.14
Documentation of all events and actions once the patient is stable
For patients, document all events and actions in the medical notes. For affected members of
staff, visitors or other persons, all events and actions must be documented on admission to the
Emergency Department. Details recorded should include:
Full details of the event

Time course of the reaction
Whether consent to treatment has been given
All drugs and treatments administered, including details of dose(s) given
Resuscitative measures
Patients response to treatment
Any previous adverse reactions
Signature and printed name of person administering treatment under this protocol
Date
Statement that adrenaline was administered to treat suspected anaphylaxis without a
prescription in accordance with the hospital protocol.
If the anaphylactic reaction is considered to be drug-induced, the medical practitioner should

consider completing a Yellow Card from the BNF and sending it to the MHRA or reporting
the reaction via the MHRA website at http://yellowcard.mhra.gov.uk
1.15 References
Emergency Treatment of Anaphylactic Reactions- Guidelines For Healthcare Providers:

Working Group of the Resuscitation Council (UK) 2008
Medicinal products for parenteral administration in an emergency. The Human Medicines
Regulations 2012, Regulation 238, Schedule 19.
195
1.16 Management of Anaphylaxis
196
Appendix 2
2.1
Introduction
All individuals that operate infusion devices within the remit of their role have a responsibility to
ensure that they are competent to operate the equipment in a safe and effective manner, seek
advice and training where necessary and complete relevant documentation with their assessor in
line with the Trusts Policy and Procedure document for the Training of Plymouth Hospitals NHS
Staff in the Use of Medical Devices.
It is the responsibility of the person administering the drug to select the appropriate infusion
pump for the therapy required. Alterations to the pump setting may only be made and recorded
by a person entitled to administer intravenous drugs. The volume of fluid administered must be
recorded on the fluid chart. All pumps must be checked 2 hourly throughout the infusion and
details of the infusion should be recorded on the relevant infusion chart.
Infusion Devices must always be operated and serviced in accordance with the Manufacturers
operating instructions and the MEMS Medical Equipment Users Guide. Every area should
maintain a library of user manuals for commonly used equipment, which may be kept in the Ward
Equipment File. Manuals for commonly used infusion devices can be found on the Medical
Devices Training webpage on TrustNet. The MEMS Medical Equipment Users Guide is available
on the Trust documents drive.
2.2
The choice of infusion device should be based upon the clinical application it is intended for, and
the safety features incorporated within the device. Infusion devices may be grouped into the
following categories:
a.
Volumetric pumps
Pump of choice for medium and high flow rates, and large volume infusions.
Pressure sensitivity of pump: Some pumps have selectable occlusion pressure alarm levels.
Selecting low levels will help to prevent excessive delivery pressures and possible vein
damage.
Some may allow for the addition of piggyback or secondary infusions.
The majority of volumetric pumps will perform satisfactorily at rates down to 5 ml/hr.
Although the controls can set rates below 1ml/hr, these pumps are not considered
appropriate for delivering drugs at such low rates.
Once the infusion has been connected to the patient, the vertical position of the device
should be altered as little as possible as an increase in height of the device above the
infusion site may result in a bolus of infusate being delivered to the patient.
Blood transfusions may be given through a Baxter Colleague Volumetric Pump safely if given
with correct blood giving set.
Most volumetric pumps also incorporate the following safety features:
o Automatic alarm and stopping of infusion following detection of air in line,
upstream/downstream occlusion, and reservoir/bag empty alert.
o Facility to pre-set volume to be infused (VTBI) and digital read out of total volume
infused.
o Automatic switch to keep vein open (KVO) rate towards end of infusion.
o Automatic battery operations in the case of mains supply failure.
PHNT has standardised on the Baxter Colleague pump as the volumetric pump of choice,
although others may still be in service in some areas.
197
b.
Syringe pumps
The preferred choice for lower volumes and low rate infusions.
Capable of delivering very low flow rates of < 1ml/hr.
Operated by driving a syringe plunger forward at a controlled rate to deliver the infusate to
the patient.
The syringe is located and clamped within the device, with the plunger attached to a moving
carriage.
Users should be aware that the flow delivered at the start of an infusion might be
considerably less than the rate set on the device. At low flow rates, the mechanical slack
must be taken up before the set rate is achieved. Mechanical slack can be eliminated by
operating the syringe pump to purge the line prior to connection to the patient.
Some pumps have a selectable occlusion pressure alarm levels. Selecting low levels will
help to prevent excessive delivery pressures and possible vein damage.
Additional features may include:
o In line pressure monitoring
o Syringe barrel clamp alarm
o Syringe plunger disengagement alarm
o Volume to be infused (VTBI) display
o Volume infused (VI) display
o Automatic keep vein open (KVO) rate facility
o Patient history log
o Drug name library
PHNT has standardised in the Alaris GH syringe pump of choice. Other syringe pumps may still
be available in some areas.
c.
Patient Controlled Analgesia pumps (IVPCA)
Used specifically for the patient to administer a prescribed intravenous dose of opioid as
required, by activating a demand button, which has a pre-set lockout interval.
PCA pumps (the Alaris IVAC PCAM) contains a memory log, to enable the clinician to
determine how frequently the patient has made a demand, and the total volume of drug
infused over a given time.
Monitoring of patients with PCA devices may only be performed by those individuals who
have received formalised training from the Department of Pain Management or those that
have already been deemed competent in the use of PCA.
d.
Ketamine Infusions
Ketamine is an anaesthetic agent with analgesic properties. A low dose Ketamine infusion
can provide safe and effective analgesia. It is usually used with IVPCA to improve pain relief
and reduce opioid side effects.
The Graseby 3300 pump must always be used for these infusions. This is a locked pump.
The responsibility of Ketamine infusions falls to the Acute Care Team / Anaesthetic team.
Ward areas should not be the key holder unless under specific instructions of the Pain Team.
In an emergency situation ward nurses should be aware of how to stop the infusion pump.
Specific guidelines / protocols are in place within the Trust on all Advanced Pain
Management Systems and must be followed. Please refer to the Acute Pain Resource
Manuals or on the Hospital Healthnet
198
e.
f.
2.3
2.4
Ambulatory pumps
Allows for the mobility of the patient due to the small nature of the device.
Preferred pump of choice for treatment in palliative care.
Ambulatory pumps may be powered by electricity or by other means.
The previously used Graseby MS26 has now been replaced, in this Trust, with the Mckinley
T34 ambulatory syringe pump. The T34 is calibrated in ml/hr in common with other types of
infusion device.
The Syringe Driver Infusion Chart should be used in conjunction with every infusion given
via an ambulatory syringe driver device.
Gravity feed
Gravity feed involves the control of infusion rate by means of the height of the infusion
reservoir being sufficiently greater than the infusion site to allow a slow flow of the infusate.
Control is further refined by use of a clamp on the infusion line.
Generally suited to the delivery of fluids containing no added drugs or drugs with no potential
for vaso-irritation or damage. This is due to the poor reliability of flow rate and pressure
sensing in the delivery system.
Provides a cheap and readily available delivery system.
Additional Information
Only luer-lock syringes should be used within syringe pumps/drivers, PCA pumps. This is a
standard instruction issued by all infusion device manufacturers, as there is a risk of the
pressure generated in the infusion line causing the line to come apart from the syringe.
Plymouth Hospital NHS Trust currently uses BD Plastipak syringes for this purpose.
Anti-syphon lines must be used on all syringe pump infusions in all areas.
Gravity lines may be used for administration of electrolytes and most antibiotics. If
considered necessary however, an infusion device may be used.
References
Medical Devices Agency (2000) Equipped to Care

CQC Essential Standards of Quality & Safety
Medicines and Healthcare products Regulatory Agency (2008) Devices in Practice
199
Appendix 3
Copy of the PHNT Policy for maintenance of patency, flushing and locking of
intravascular lines catheters or devices
3.1
Introduction
This appendix contains tables of instructions which have been copied from the PHNT Medicines
Management Policy. The full ratified copy of this policy can be found on Plymouth Healthnet
using the link:
http://nww.picts.nhs.uk/PHNetLive/Portals/57ad7180-c5e7-49f5-b282c6475cdb7ee7/prowsea_TRW.MMA.POL.265.6%20Medicines%20Management%20Policy.pdf
These tables were produced following review of current local practice and extensive local
consultation, and in response to the National Patient Safety Agency Rapid Response Alert No.2
(2008) Risks with Intravenous Heparin Flush Solutions.
3.2
Policy
All flushes (Bolus and infusions) and line/catheter locks must be prescribed.
Administration of all flushes and line/catheter locks must be recorded on the
prescription chart.
Always attempt to aspirate the heparin lock before use of the line. If unable to aspirate the
heparin from the line, discuss with the duty consultant whether the heparin may be flushed
into the patient.
Heparin must not be used in a patient with recognised or suspected HIT, or at risk of HIT
(Heparin-induced thrombocytopenia) without discussion with a Consultant Haematologist.
Type of intravascular line,

catheter or device
Short-term Peripheral Venous
Catheters
(Adults and children)
Cannula, venflon
Arterial Lines
Central Venous Lines
(Inpatient Adults)
Tunnelled lines eg. Hickman
or Broviac lines
PICCs and Midlines
Short-term CVCs
Long Lines
Short-term Central Venous
Catheters
(Children)
Maintenance of Patency, Flushing and Locking

Flush with 5 -10ml 0.9% sodium chloride
Maintain patency with an infusion of 0.9% sodium chloride.

Flush with 0.9% sodium chloride (at least 10ml for adult
patients) and lock with 0.9% sodium chloride (volume stated
on the line) using a positive pressure clamp technique.
All lines without a continuous infusion running should be

flushed with 0.9% sodium chloride 6-hourly. To avoid blood
flashing back into the lumen, positive pressure is applied
at the end of the flush.
Above table continued on the next page
200
Table continued from the previous page
Type of intravascular line,

catheter or device
Long-term Central Venous Lines
(Children)
Long Lines (Children)

Long Lines (Neonates)
Umbilical Arterial Catheters
(Neonates)
Vascaths
(In General and Cardiothoracic
Intensive Care)
Renal-type large bore lines

(On Adult Renal and
Haemodialysis Units, and in Adult
Haematology patients)
Dialysis lines
Vascaths
Ports
Totally implantable venous
access devices eg.
Portacaths
Central Lumen of Intra-aortic
Balloon Pump Catheter
Central Venous Lines

(Outpatient or Day Case Adults)
Tunnelled lines eg. Hickman
or Broviac lines
Line lock in patients receiving

TPN who have had a previous
line infection
Maintenance of Patency, Flushing and Locking
Hickman, Cook & Broviac Lines: Flush with 0.9%

sodium chloride and lock with 3ml of 10 units/ml
heparin.
Groshong Lines: Flush with 0.9% sodium chloride and
lock with 5ml sodium chloride 0.9%.
Use 10 units/ml heparin to flush and lock Long Lines in
children
Maintain patency with an infusion of 0.9% sodium chloride.
In the case of an extremely premature infant maintain
patency with an infusion of 0.45% sodium chloride.
Maintain patency with an infusion of 1unit/ml heparin,
prepared by diluting 10 units/ml heparin, according to the
Neonatal ICU protocol.
Lock the catheter with 1,000 units/ml heparin (volume as
stated on the catheter lumen). Before use, aspirate the
heparin from the catheter and flush with 10ml of 0.9%
sodium chloride. If unable to aspirate the heparin, discuss
with the duty consultant whether the heparin may be flushed
into the patient.
Flush the line with at least 10ml 0.9% sodium chloride then
lock the line/catheter with trisodium citrate 46.7% solution (If
no allergy). The locking volume will be stated on the
catheter. Before use, aspirate the trisodium citrate 46.7%
solution from the line/catheter. If this is not possible, the
trisodium citrate 46.7% solution may be slowly flushed into
the patient. Then flush with at least 10ml 0.9% sodium
chloride.
When in use with the needle in, flush with at least 10ml
0.9% sodium chloride. Lock the device with the appropriate
volume of 10 units/ml heparin. Before the needle is
removed, flush with at least 10ml 0.9% sodium chloride then
lock the device with the appropriate volume of
100 unit/ml heparin.
Use Heparin Sodium 2000 units/L in 0.9% Sodium Chloride
IV Infusion, 500mL bags, REF Baxter B0953, as a
continuous flush of the central lumen of the Intra-Aortic
Balloon Catheter, as per protocol.
Flush the line with at least 10ml 0.9% sodium chloride then
lock the line/catheter with trisodium citrate 46.7% solution (If
no allergy). The locking volume will be stated on the
catheter. Before use, aspirate the trisodium citrate 46.7%
solution from the line/catheter. If this is not possible, the
trisodium citrate 46.7% solution may be slowly flushed into
the patient. Then flush with at least 10ml 0.9% sodium
chloride.
Lock the line with the appropriate volume of Taurolock
(This contains taurolidine and sodium citrate).
201
Appendix 5
Document accountability, responsibility and dissemination
4.1
Accountability
Production
Review and approval
Dissemination
4.2
Overall responsibility for this document
The Director of Pharmacy has overall responsibility for the safe preparation and administration of
medicines in this Trust, and therefore has overall responsibility for this document.
4.3
Dissemination and Implementation
Following approval and ratification by the Medicines Governance Committee this eighth
edition of the injectable drug monographs with appendices will be rolled out across the Trust.
Publication of the eighth issue will be publicised in Vital signs and in the weekly staff news
brief. The new edition will be held in the Pharmacy Dept. Section of PHNT StaffNet.
Paper copies will be printed by the hospital Print Room, and together with electronic copies
for selected recipients, will be distributed according to a distribution list held in Pharmacy.

Injectable Drugs Monographs v2

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Injectable Drugs Monographs v2

Uploaded by

Copyright:

Available Formats

This procedure is adopted for PCH staff from:

Plymouth Community Healthcare CIC

Procedures for Administering Injectable

Notice to staff using a paper copy of this guidance

Advanced Specialist Clinical Pharmacist

Procedures for Administering Injectable Drugs

Peter Gray, Pharmacist

Review and approval

Medicines Governance Committee

Medicines Governance Committee

Peter Gray, Pharmacist

Medicines Governance Committee

Links to other policies and procedures

PHNT is committed to creating a fully inclusive and accessible service.

Injectable Drug Monographs

Injectable Drug Monographs

When an unlicensed medication is administered to a patient or a licensed medication is administered in

If you require information on intravenous compatibilities; contact Pharmacy Drug Information on

Registered and Provisionally Registered Medical Practitioners. It is recommended that IV

All Registered healthcare professionals must be assessed as competent in the methods

All training and assessment of competency to administer intravenous medication should

WHO MAY ADMINISTER OVER

(C) IV infusion via Groups

4ml/hour for 12 hours

INSTRUCTION FOR DILUTION AND

Flush with N/S or G.

INSTRUCTION FOR DILUTION AND

Adult Dosage Table for Treating Paracetamol Overdose

Acetylcysteine for treating paracetamol overdose in Children

Paediatric Dosage Table for Treating Paracetamol Overdose

See Insulin Section page

ADMINISTER OVER INSTRUCTION FOR DILUTION AND

Flush with N/S, G/S or H.

Can be diluted with N/S if necessary.

If given into an IV line, inject as

Adjust rate according

Refer to the Marsden Manual for

Specialist use only:

Use 1:10,000 injection or dilute

INSTRUCTION FOR DILUTION

Use 1:10,000 (1mg in 10ml)

ADMINISTER INSTRUCTION FOR DILUTION

See Ethanol monograph

Alemtuzumab is prepared only by

WHO MAY ADMINISTER

INSTRUCTION FOR DILUTION

Premedication prior to alemtuzumab for treating Multiple Sclerosis

Administration Schedule for premedication (treating Multiple Sclerosis)

INSTRUCTION FOR DILUTION AND COMMENTS

Dilute with N/S, G or H to a usual

Refer to the Marsden Manual for

Follow the PHNT Care of the Dying

(I) IV infusion Groups

INSTRUCTION FOR DILUTION AND

WHO MAY ADMINISTER OVER

INSTRUCTION FOR DILUTION AND

Dilute 150micrograms/kg weight of

If using a burette avoid direct

INSTRUCTION FOR DILUTION AND

Further doses and infusion rates

50mg over 30 minutes. Set the pump at 50ml/hour for 30 minutes

35mg over 60 minutes. Set the pump at 17.5ml/hour for 60 minutes

48mg over 30 minutes. Set the pump at 48ml/hour for 30 minutes

32mg over 60 minutes. Set the pump at 16ml/hour for 60 minutes