Procedures for Administering Injectable Drugs

222 Pages·2016·3.81 MB·English

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This procedure is adopted for LSW staff from:

Livewell Southwest

Procedures for Administering Injectable

Drugs

Version No 4.3

Review: May 2017

Notice to staff using a paper copy of this guidance

The policies and procedures page of LSW intranet holds the most
recent version of this document and staff must ensure that they are
using the most recent guidance.

Author: Chief Pharmacist / Clinical Pharmacist

Asset Number: 385
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Procedures for Administering Injectable Drugs

Date Version
May 2016 Issue 11.4
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 Utilisation and Assurance Committee
Ratification Medicines Utilisation and Assurance Committee
Dissemination Peter Gray, Pharmacist
Compliance Medicines Utilisation and Assurance Committee

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-
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Version History
Issue 11.2 (March 2016)
 The amendment to the phenytoin monograph, to make dilution in saline the preferred method, has
been superceded by the amendments in Issue 11.4.

Issue 11.3 (April 2016)
 Monograph for Intravenous Zanamivir added.

Issue 11.4 (May 2016)
 New Monographs for the following medications added: bevacizumab, cetuximab, pertuzumab,
ramucirumab and panitumumab, prepared on the ward using a closed-system device.
 Monographs for ipilimumab, nivolumab, and ofatumumab amended to allow preparation on the
ward using a closed-system device.
 Belatacept – new monograph inserted.
 Belimumab – new monograph inserted.
 Tocilizumab – new monograph inserted.
 Trastuzumab – new monograph inserted
 In line with the Joint British Diabetes Society guideline for managing diabetic ketoacidosis, and to
cover existing practice on Torrington ICU, the following statement has been added to the
Potassium Chloride monograph: “In adults, the rate of administration may be increased to
40mmol/hour in the initial management of diabetic ketoacidosis, and if necessary in Cardiothoracic
ICU, so long as the patient’s ECG is monitored and resuscitation equipment is available.”
 Use of oxycodone for Patient Controlled Analgesia (PCA) now included in this monograph.
 The phenytoin monograph has been amended following a critical incident: the infusion rate for
children has been removed, and the instructions “For children, refer to the Paediatric Injection
Administration Guide” and “This method, (undiluted infusion) may only be used for adults” have
been added.
 “Where dexamethasone ampoules/vials are labelled for IV, IM, intraarticular, intrabusal or
intralesional use, they are suitable (but unlicensed) for subcutaneous administration” has been
added to the dexamethasone monograph.
 Group 8 (Assistant Practitioners) has been added to the groups of staff allowed to administer
selected injectable medicines.
 Added instruction for Savene® (Dexrazoxane) administration: A chemotherapy closed system
bag spike should be used with a line adaptor to ensure the safe administration of Savene®. The
air inlet port on the bag spike should be opened to allow free flow of Savene®. An air inlet needle
should not be used in case of leakage during administration.
 Rituximab IV infusion monograph amended to reflect additional use to treat lymphoma or
leukaemia.
 Monograph for cisatracurium added as atracurium is intermittently on a manufacturer’s delay.
 Remifentanil monograph amended to include the Standard Derriford Hospital Protocol for
Remifentanil sedation in ICU.
 Protocol for administering iloprost now included in the monograph.
 Dexamethasone 1mg is now to be routinely added to each 50ml of ketamine solution for post-
operative subcutaneous infusion to reduce tissue irritation.
Last Approval Due for Review
December 2015 (Updated May 2016) (Extended) May 2017

 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 > Pharmacy > Injectable Medicines
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> “Procedures for Administration of Injectable Drug
Contents
Section Page
1 Intravenous Drug Calculations 5
2.1 Injectable Drug Monographs 10
2.2 Chart of Injectable Drug Compatibilities 195
2.4 PHNT Protocol for subcutaneous morphine for acute apin in adults 196
2.5 PHNT Protocol for administering IV morphine to adults in Acute Care Areas 197
2.6 PHNT Protocol for administering IV morphine to adults in the Emergency Dept. 198
2.7 PHNT Protocol for subcutaneous ketamine infusion 199
Appendix 1 Protocol for administering intramuscular adrenaline 1:1000 (1mg/ml) for treating
anaphylaxis, when there is no prescription available
A1.1 Legislation 202
A1.2 Persons who can be treated under this protocol 202
A1.3 Anaphylaxis 203
A1.4 Assessing the patient 203
A1.5 Explanation of treatment to the patient 204
A1.6 Patient consent 205
A1.7 Exclusions from treatment under this protocol 205
A1.8 Contra-indications to administration of adrenaline to treat anaphylaxis 205
A1.9 Immediate treatment 205
A1.10 Source of adrenaline 205
A1.11 Dosage of adrenaline 205
A1.12 Adverse Effects 205
A1.13 Follow up 205
A1.14 Documentation 205
A1.15 References 205
A1.16 Anaphylaxis algorithm 206
Appendix 2 Choice of Infusion device
A2.1 Introduction 207
A2.2 Choice of Infusion device 207
A2.3 Additional Information 207
A2.4 References 207
Appendix 3 Copy of PHNT Policy for maintenance of patency, flushing and locking of
intravascular lines catheters or devices
A3.1 Introduction 210
A3.2 Policy 210
Appendix 4 Document accountability, responsibility and dissemination
A4.1 Accountability 212
A4.2 Overall Responsibility for These Policies and Guidelines 212
A4.3 Dissemination and Implementation 212
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1 Intravenous Drug Calculations

Coverting Between Units

Rounding up or down decimals

 Rounding up or down decimals too early in a calculation can make the final figure inacurate. Only
round up or down at the point where you have to measure a volume in a syringe or set a drip rate or
an infusion rate on a pump.
 If a decimal figure is 5 or above, then the preceding decimal figure is rounded up.
 If a decimal figure is less than 5, then the preceding decimal figure stays as it is (rounded down).
 Take for example 9.1506ml
Your syringe can only measure to one decimal figure so you’ll draw up 9.2ml (the 5 means you
round the 1 up to 2)

Calculation of the volume of drug to draw up

 The basic formula for the volume to draw up is:

What you want
_____________ X Volume in the ampoule
What you’ve got

 Note that the units of “What you want” – i.e. the prescribed dose, and “What you’ve got” – i.e the
amount in the ampoule must be the same.
 You may need to convert the units so that both are mg or both are micrograms for example.
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Example
Your patient has been prescribed gentamicin 350mg IV once daily. Gentamicin ampoules are 80mg in
2ml.

What you want (350mg)

____________________ X Volume (2ml amps)

What you’ve got (80mg)

= 8.75ml which you’ll round up to 8.8ml

Concentration, Volume and Amount

The Concentration Triangle: Example

 Your patient has a low serum magnesium

and has been prescribed IV magnesium

sulphate 2g.

 What’s the minimum volume this should be
Amount
given in?

 You read the magnesium monograph in the

injectable drugs folder and it says “maximum

concentration of 200mg/ml”

Concentration Volume  2g = 2,000mg magnesium

Amount (2,000mg) Minimum vol.

 Concentration = Amount _______________________ = 10 (ml)

Volume Concentration (200mg/ml)

 Volume = Amount

Concentration

 Amount = Concentration x volume

Infusion Rate, Volume and Time

The Infusion Rate Triangle:
Example
 You have drawn up 8.8ml of gentamicin
injection (350mg).
 As per the injectable drugs folder you dilute
this with 100ml saline to make 108.8ml
solution, for infusion over 30 minutes.
Volume

Volume (108.8ml)
________________ =Rate (3.626666ml/minute)
Time (30 minutes)
Rate Time

You have to set your pump in ml/hour. There are

60 minutes in an hour so multiply

3.6266666ml/minute by 60 to get 217.6ml/hour.
 Rate = Volume
Time You may have to round this figure to 218ml/hour
to set your pump.
 Volume given = Rate x time

 Time taken for infusion = Volume
P.S. If the infusion time is in hours then you don’t
Rate
need to multiply the answer by 60. Also notice
that the decimal was only rounded at the final
answer.
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Displacement Values

 Some, but not all, powdered medications produce a slight expansion of the volume of diluent when
they dissolve. The volume by which the diluent expands is called the Displacement Value.
 When you administer the whole of the dose present in the vial, you draw up the total volume and
you don’t need to consider the displacement value.
 However, if part of the vial is prescribed for a paediatric patient or a patient in renal failure, you
should take any displacement value into account. There are a couple of ways of doing this – see
the example below.

Example
 A patient is prescribed Co-amoxiclav IV 600mg. The stock vial that you have is 1.2g (1200mg)-
Bowmed brand.
 The Injectable Drugs Folder says the displacement value is 0.7ml for this vial (i.e. on dissolution the
20ml expands to 20.7ml). After adding 20ml WFI you would need to withdraw 10.35ml containing
600mg, which cannot be accurately measured.
 Method 1: Using a 20ml syringe, reconstitute the vial contents with 15ml of WFI, draw the entire
contents up into the syringe and then draw up more WFI to the 20ml mark. Mix the syringe
contents then give 10ml (containing 600mg) and discard the other 10ml.
 Method 2: Reconstitute the 1.2g vial contents with 19.3ml WFI (This requires two syringes). The
volume in the vial will expand by 0.7ml to 20ml. Then you can draw up 10ml containing 600mg.

Calculating a Drip Rate

 Any fluid containing potassium, magnesium Example
or added drug should be administered using  You are asked to set up an infusion
an infusion pump. The only exception to this of 1 litre Normal Saline to run over
would be Hartmann’s solution without the next 8 hours, using a standard
additional potassium or drugs added. drip set.
 So only plain Normal Saline, 5% Glucose,  Using the formula:
Hartmann’s or Glucose-Saline can be
administered IV using Dosiflows or other
1000ml x 20 = 20,000 = 41.66
gravity-fed administration sets.
8hours x 60 480
You can use this drip-rate formula:

Round 41.66 up to 42 drops/minute
Volume (ml) x 20
______________ = drip rate (drops/minute)
Time (hours) x 60

N.B. 20= drops/ml in a standard giving set.
(Change to 60drops/ml for a paediatric giving
set). 60= number of minutes in an hour.
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2.1 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.

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 administration sets must only be used for administering crystalloid
infusions (eg. Sodium chloride infusion or glucose infusion) containing no potassium or other
additives. However, Hartmann’s (which contains 5mmol/L potassium as standard) may be
infused using a Dosiflow or other gravity administration set. Hartmann’s with extra potassium
added must be pumped.

 For patients on a variable-rate 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 fluid to which a drug or electrolyte has been
added with a completed “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.
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 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
o Registered Nurses, Midwives and Operating Department Practitioners (ODP’s) 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.
o Exceptions are methotrexate and 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 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.
o 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
o 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
department’s 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 department’s authorised and signed patient group direction (PGD).

o 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.
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o 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.

Group 8

o Assistant Practitioners working within PHNT who have received the necessary additional local
training on medicines provided by PHNT, and who have been assessed as competent to
administer selected oral and parenteral medications in accordance with the Assistant
Practitoner Drug Protocols.

Abbreviations used in the drug monographs

(C) Continuous
(I) Intermittent
IV Intravenous
IM Intramuscular
SC Subcutaneous
N/S Sodium Chloride 0.9%
G Glucose 5%
G/S 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.
H Compound sodium lactate (Hartmann’s)
Hep/S Heparin 10 units in 1ml sodium chloride - heparinised sodium chloride (e.g. Hepsal)
W Water for Injection (preservative free)