IV drug preparation Open heart

IV Drug Preparation &
Administration Tips
:‫اإلكلينيكية‬ ‫الصيدلة‬ ‫وحدة‬ ‫مدير‬‫األول‬ ‫الصيدلي‬:
‫د‬‫سمير‬ ‫/ريهام‬‫الحي‬ ‫عبد‬ ‫د/محمد‬
JANUARY 26, 2016
Prepared by:
Mohammed Adel B.Sc., PharmD
Clinical Pharmacist
‫مدير‬:‫المستشفى‬
‫د‬‫رشاد‬ ‫/محمد‬

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Prepared by: Mohammed Adel B.Sc, PharmD
Index
 Inotropes:
oAdrenaline ……………………………..Page 2
oNoradrenaline…………………………Page 3
oDopamine……………………………….Page 4
oDobutamine (Dobutrex®)………..Page 5
oMilrinone (Primacor®)……………..page 5
 Antibiotics
oImipenem/Cilastatin (Tienam®)……Page 7
o Levofloxacin (TAvanic®)……………….Page 8
oCiprofloxacin (Cipro®)……….………….Page 8
oPenicillin G (Parenteral/Aqueous)..Page 8
oAmpicillin/Sulbactam (Unasy®)…….Page 9
oCeftriaxone………………………………..Page 10
oVancomycin……………………………….Page 12

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Index
Other IV Agents
oPotassium Chloride…..……………….Page 13
oCalcium gluconate………………….…Page 14
oMagnesium sulfate.……………….…..Page 16
oAminophylline.…………………………..Page 17
oAmiodarone (Cordarone®)………….Page 18
oRegular Insulin……………………………Page 19
oMorphine.………………………………….Page 21
oMidazolam (Dormicum®)……………Page 21
oProtamine………………………………….Page 21
oTranexamic acid (Kapron®)…………Page 22
oEthamsylate (Dicynone®)…………..Page 22
oPhenytoin (Ipanotine®)………………Page 22
oRantidine (Zantac®)……………………Page 24

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Inotropes:
1.Adrenaline:
 Preparation for Administration
 Dilution in dextrose containing solutions
(provides protection against significant loss of
potency by oxidation) and dilution in NS alone is
not recommended, dilution in NS has been
reported to be physically compatible (Trissel
2014).
 Usual Infusion Concentrations: Adult
 IV infusion: 1 mg in 250 mL (concentration:
4 mcg/mL) or 4 mg in 250 mL (concentration:
16 mcg/mL) of D5W or NS; 1 mg in 1,000 mL
(concentration: 1 mcg/mL) in D5W or D5NS
 Administration: IV
 When administering as a continuous infusion,
central line administration is preferred. IV infusions
require an infusion pump. If central line not available,
as a temporary measure, may administer through a
large vein. Avoid use of ankle veins (due to potential
for gangrene), leg veins in elderly patients, or leg
veins in those suffering from occlusive vascular
diseases (eg, diabetic endarteritis, Buerger’s disease,
arteriosclerosis, and atherosclerosis).
 Vesicant; ensure proper needle or catheter
placement prior to and during infusion; avoid
extravasation.
 Extravasation management: If extravasation
occurs, stop infusion immediately and Disconnect

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(leave cannula/needle in place); gently aspirate
extravasated solution (do NOT flush the line);
remove needle/cannula; elevate extremity.
Initiate phentolamine (or alternative antidote).
Apply dry warm compresses (Hurst 2004).
o Phentolamine: Dilute 5 to 10 mg in 10 to 15
mL NS and administer into extravasation
site as soon as possible after extravasation
(Peberdy 2010).
o Alternatives to phentolamine:
 Nitroglycerin topical 2% ointment
(based on limited case reports in
neonates/infants): Apply 4 mm/kg as a
thin ribbon to the affected areas; may
repeat after 8 hours if needed (Wong
1992) or apply a 1-inch strip on the
affected site (Denkler 1989).
 Terbutaline (based on limited case
reports): Infiltrate extravasation area
using a solution of terbutaline 1 mg
diluted to 10 mL in NS (large
extravasation site; administration
volume varied from 3 to 10 mL) or 1
mg diluted in 1 mL NS (small/distal
volume varied from 0.5 to 1 mL) (Stier
1999).
Do not administer sodium bicarbonate (or any
alkaline solution) through an IV line containing
norepinephrine;

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Stable in dextran 6% in dextrose, dextran 6% in
NS, D5LR, D51/4NS, D51/2NS, D5NS, D5R,
D2.5W, D5W, D10W, D10NS, LR, NS, Ringer's
injection.
2. Noradrenaline
Dilute with D5W, D5NS, or NS; dilution in NS is
not recommended by the manufacturer; however,
stability in NS has been demonstrated (Tremblay,
2008).
IV infusion: 4 mg in 250 mL (concentration:
16 mcg/mL) or 8 mg in 250 mL (concentration:
32 mcg/mL) of D5W or NS
 Administer as a continuous infusion with the
use of an infusion pump. Dilute prior to use.
Administration via central line recommended (may
cause severe ischemic necrosis if extravasated).
 Do not administer sodium bicarbonate (or
any alkaline solution) through an IV line
containing norepinephrine; inactivation of
norepinephrine may occur.
extravasation.
occurs, stop infusion immediately and disconnect

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Initiate phentolamine (or alternative) antidote.
Apply dry warm compresses (Hurst, 2004).
o Phentolamine: Dilute 5 to 10 mg in 10 to 15
mL NS and administer into extravasation
site as soon as possible after extravasation
(Peberdy 2010).
o Alternatives to phentolamine:
 Nitroglycerin topical 2% ointment
(based on limited case reports in
neonates/infants): Apply 4 mm/kg as a
thin ribbon to the affected areas; may
repeat after 8 hours if needed (Wong
1992) or apply a 1-inch strip on the
affected site (Denkler 1989).
 Terbutaline (based on limited case
reports): Infiltrate extravasation area
using a solution of terbutaline 1 mg
diluted to 10 mL in NS (large
volume varied from 3 to 10 mL) or 1
mg diluted in 1 mL NS (small/distal
volume varied from 0.5 to 1 mL) (Stier
1999).

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3.Dopamine
1600 mcg/mL) or 800 mg in 250 mL
(concentration: 3200 mcg/mL) of D5W or NS
 Administer as a continuous infusion with the use
of an infusion pump. Administer into large vein
to prevent the possibility of extravasation
(central line administration); monitor
continuously for free flow; use infusion device to
control rate of flow; when discontinuing the
infusion, gradually decrease the dose of
dopamine (sudden discontinuation may cause
hypotension). Vials (concentrated solution)
must be diluted prior to use.
extravasation.
Initiate phentolamine (or alternative) antidote.
Apply dry warm compresses (Hurst 2004).
 Stable in D5LR, D51/2NS, D5NS, D5W, D10W, LR,
1/2NS, NS, mannitol 20%;
 Incompatible with sodium bicarbonate 5%

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4.Dobutamine
 Usual Infusion Concentrations: Adult.
500 mcg/mL), 500 mg in 250 mL (concentration:
2000 mcg/mL), or 1000 mg in 250 mL
(concentration: 4000 mcg/mL) of D5W or NS
 Administration: Always administer via infusion device; administer into
large vein.
 Stable in D5LR, D51/2NS, D5NS, D5W, D10W, LR,
1/2NS, NS, mannitol 20%;
 Incompatible with sodium bicarbonate 5%
5.Milrinone
 Loading dose (optional): May administer undiluted;
diluting to a rounded total volume of 10 or 20 mL may
simplify the visualization of the injection rate.
 Maintenance dose: For a final concentration of 0.2
mg/mL: Dilute 1 mg/mL (20 mL) with 80 mL diluent
(final volume: 100 mL) of 1/2NS, NS or D5W. May
also dilute 1 mg/mL (10 mL) with 40 mL diluent
(final volume: 50 mL)
 20 mg in 100 mL (total volume) (concentration:
200 mcg/mL) of D5W

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 Administration:
 Administer loading dose (optional) undiluted slowly
over 10 minutes. Infuse maintenance dose via
continuous infusion pump.
 Stable in D5W, LR, 1/2NS, NS
‫ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬‫ــــــــ‬
Antibiotics:
6.Imipenem/Cilastatin (Tienam®)
 IV: Prior to use, dilute dose into 100-250 mL of
D5W, D10W, Mannitol 5%, Mannitol 10% or
NS. Imipenem is inactivated at acidic or alkaline
pH. Final concentration should not exceed 5
mg/mL.
 Do not administer IV push. Infuse doses ≤500
mg over 20-30 minutes; infuse doses ≥750 mg
over 40-60 minutes.
 Administration: Injectable Detail
 Vial contents must be transferred to 100 mL of
infusion solution. If nausea and/or vomiting
occur during administration, decrease the rate
of IV infusion. Do not mix with or physically add
to other antibiotics; however, may administer
concomitantly
 Variable stability in D5W, D5LR, D51/4NS,
D51/2NS, D5NS, D10W, mannitol 2.5%, mannitol
5%, mannitol 10%, NS, TPN.

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7.Levofloxacin (Tavanic®)
 Solution for injection: Single-use vials must be further
diluted in compatible solution to a final concentration of 5
mg/mL prior to infusion.
 Infuse 250-500 mg IV solution over 60 minutes; infuse 750
mg IV solution over 90 minutes. Too rapid of infusion can
lead to hypotension. Avoid administration through an
intravenous line with a solution containing multivalent
cations (eg, magnesium, calcium). Maintain adequate
hydration of patient to prevent crystalluria or cylindruria.
 Stable in D5LR, D5NS, D51/2NS with 20 mEq/L
KCl, D5W, NS, Plasma-Lyte® 56 in 5% dextrose,
sodium lactate (M/6); incompatible with
mannitol 20%, sodium bicarbonate 5%.
8.Ciprofloxacin (Cipro®)
 Injection, vial: May be diluted with NS, D5W, SWFI, D10W,
D51/4NS, D51/2NS, LR.
 Administer by slow IV infusion over 60 minutes into a large
vein (reduces risk of venous irritation).
 Stable in D51/4NS, D51/2NS, D5W, D10W, LR, NS, SWFI;

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9. Penicillin G (Parenteral/Aqueous)
 Intermittent IV: 5 million unit vial: Add 8.2 mL for a final
concentration of 500,000 units/mL; add 3.2 mL for a final
concentration of 1,000,000 units/mL. Dilute further to
50,000-145,000 units/mL prior to infusion.
 Continuous IV infusion: 20 million unit vial: Add 11.5 mL
for a final concentration of 1,000,000 units/mL. Dilute
further in 1-2 L of infusion solution and administer over a
24-hour period.
 Administration IV: Usually administered by intermittent infusion.
In some centers, large doses may be administered by continuous
IV infusion. Note: The 20 million unit dosage form may be
administered by continuous IV infusion only.
 Intermittent IV: May be dissolved in small
amounts of SWFI, NS, D5W and administered
peripherally as a 50,000-100,000 unit/mL
solution. In fluid-restricted patients, 146,000
units/mL in SW results in a maximum
recommended osmolality for peripheral infusion.
Infuse over 15-30 minutes.
 Continuous IV infusion: Determine the volume
of fluid and rate of its administration required by
the patient in a 24-hour period. Add the
appropriate daily dosage of penicillin to this fluid.
For example, if the daily dose is 10 million units
and 2 L of fluid/day is required, add 5 million
units to 1 L and adjust the rate of flow so the liter
will be infused over 12 hours (83 mL/hour).

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Repeat steps (5 million units/L at 83 mL/hour) for
the remaining 12 hours.
 Penicillin G potassium: Stable in dextran 6% in
dextrose, dextran 6% in NS, D5LR, D51/4NS,
D51/2NS, D5NS, D5W, D10W, LR, 1/2NS, NS,
hetastarch 6%; incompatible with dextran 70 6%
in dextrose, dextran 40 10% in dextrose;
variable stability in fat emulsion 10%, peritoneal
dialysis solutions.
 Penicillin G sodium: Stable in dextran 40 10%;
incompatible with fat emulsion 10%; variable
stability in D5W, NS, peritoneal dialysis solution.
10. Ampicillin/Sulbactam (Unasyn®)
 Direct IV administration and IV infusion:
Reconstitute with sterile water for injection
(SWFI). Sodium chloride 0.9% (NS) is the diluent
of choice for IV infusion use.
 Administer around-the-clock to promote less
variation in peak and trough serum levels.
Administer by slow injection over 10 to 15
minutes or as an IV infusion over 15 to 30
minutes. Ampicillin and gentamicin should not be
mixed in the same IV tubing.
 Some penicillins (eg, ampicillin, carbenicillin,
ticarcillin, and piperacillin) have been shown to
inactivate aminoglycosides in vitro. This has been
observed to a greater extent with tobramycin and

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gentamicin, while amikacin has shown greater
stability against inactivation. Concurrent Y-site
administration should be avoided.
 Intermittent IV infusion: Solutions made in NS
are stable up to 72 hours when refrigerated
whereas dextrose solutions (same concentration)
are stable for only 4 hours
11.Ceftriaxone
 IV infusion: Infusion is prepared in two stages:
Initial reconstitution of powder, followed by
dilution to final infusion solution.
 Vials: Reconstitute powder with appropriate IV
diluent (including SWFI, D5W, D10W, NS) to
create an initial solution of ~100 mg/mL.
Recommended volume to add:
 250 mg vial: 2.4 mL
 500 mg vial: 4.8 mL
 1 g vial: 9.6 mL
 2 g vial: 19.2 mL
 Note: After reconstitution of powder, further
dilution into a volume of compatible solution (eg,
50-100 mL of D5W or NS) is recommended.
 Piggyback bottle: Reconstitute powder with
appropriate IV diluent (D5W or NS) to create a
resulting solution of ~100 mg/mL. Recommended
initial volume to add:
 1 g bottle:10 mL
 2 g bottle: 20 mL

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 Note: After reconstitution, to prepare the final
infusion solution, further dilution to 50 mL or 100
mL volumes with the appropriate IV diluent
(including D5W or NS) is recommended.
 Do not coadminister with calcium-containing
solutions. Infuse as an intermittent infusion over
30 minutes. IV push administration over 1 to 4
minutes has been reported in children ≥12 years,
adolescents, and adults (concentration: 100
mg/mL), primarily in patients outside the hospital
setting (Baumgartner 1983; Garrelts 1988; Poole
1999), although a 2 g dose administered IV push
over 5 minutes resulted in tachycardia,
restlessness, diaphoresis, and palpitations in one
patient (Lossos 1994). IV push administration in
young infants may also have been a contributing
factor in risk of cardiopulmonary events occurring
from interactions between ceftriaxone and
calcium (Bradley 2009).
 Stable in D5W with KCl 10 mEq, D51/4NS with
KCl 20 mEq, D51/2NS, D5W, D10W, NS,
mannitol 5%, mannitol 10%, sodium bicarbonate
5%, bacteriostatic water, sterile water for
injection

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12. Vancomycin
 Injection: Reconstitute 500 mg vial with 10 mL
SWFI, 750 mg vial with 15 mL SWFI, 1 g vial with
20 mL SWFI, 5 g vial with 100 mL SWFI (final
concentration: 500 mg/10 mL), and 10 g vial with
95 mL SWFI (final concentration: 1 g/10 mL). The
reconstituted solution must be further diluted with
at least 100 or 200 mL of a compatible diluent
per 500 mg of vancomycin prior to parenteral
administration.
 Administer vancomycin with a final
concentration not to exceed 5 mg/mL by IV
intermittent infusion over at least 60 minutes
(recommended infusion period of ≥30 minutes for
every 500 mg administered). Not for IM
administration.
 Red man syndrome may occur if the infusion is
too rapid. It is not an allergic reaction, but may
be characterized by hypotension and/or a
maculopapular rash appearing on the face, neck,
trunk, and/or upper extremities. If this should
occur, slow the infusion rate to over 11/2 to 2
hours and increase the dilution volume.
Reactions are often treated with antihistamines
and steroids.
 Irritant; ensure proper needle or catheter
placement prior to and during infusion. Avoid
extravasation.

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remove needle/cannula; elevate extremity. Apply
dry cold compresses (Hurst, 2004).
 Stable in D5NS, D5W, D10W, LR, NS
Other IV Agents:
13.Potassium Chloride
 Parenteral: Potassium must be diluted prior to
parenteral administration. The concentration of
infusion may be dependent on patient condition
and specific institution policy. Some clinicians
recommend that the maximum concentration for
peripheral infusion is 10 mEq/100 mL and 20-40
mEq/100 mL for central infusions.
 Potassium must be diluted prior to parenteral
administration. Do not administer IV push. In
general, the dose, concentration of infusion and
rate of administration may be dependent on
patient condition and specific institution policy.
Some clinicians recommend that the maximum
concentration for peripheral infusion is 10
mEq/100 mL and maximum rate of administration
for peripheral infusion is 10 mEq/hour (Kraft,
2005). ECG monitoring is recommended for

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peripheral or central infusions >10 mEq/hour in
adults (Kraft, 2005). Concentrations and rates of
infusion may be greater with central line
administration. Concentrations of 20 to 40
mEq/100 mL at a maximum rate of 40 mEq/hour
via central line have been safely administered
(Hamill, 1991; Kruse, 1990).
 Vesicant/irritant (at concentrations >0.1
mEq/mL); ensure proper needle or catheter
placement prior to and during IV infusion. Avoid
extravasation.
(leave needle/cannula in place); gently aspirate
initiate hyaluronidase antidote; remove
needle/cannula; apply dry cold compresses
(Hurst, 2004); elevate extremity.
 Stable in D5LR, D51/4NS, D51/2NS, D5NS,
D5W, D10W, D20W, LR, 1/2NS, NS
14.Calcium gluconate
 IV: Observe the vial for the presence of
particulates. If particulates are observed, place
vial in a 60°C to 80°C water bath for 15 to 30
minutes (or until solution is clear); occasionally
shake to dissolve; cool to body/room temperature
before use. Do not use vial if particulates do not
dissolve. Note: Due to the potential presence of

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particulates, American Regent, Inc recommends
the use of a 5 micron filter when preparing
calcium gluconate-containing IV solutions
(Important Drug Administration Information,
American Regent, 2013); a similar
recommendation has not been noted by other
manufacturers. Usual concentrations: 1 g/100 mL
D5W or NS; 2 g/100 mL D5W or NS. Maximum
concentration in parenteral nutrition solutions is
variable depending upon concentration and
solubility (consult detailed reference).
 Administer slowly (~1.5 mL calcium gluconate
10% per minute; not to exceed 200 mg/minute
except in emergency situations) through a small
needle into a large vein in order to avoid too
rapid increases in the serum calcium and
extravasation. Note: Due to the potential
presence of particulates, American Regent, Inc
recommends the use of a 0.22 micron inline filter
for IV administration (1.2 micron filter if admixture
contains lipids) (Important Drug Administration
Information, American Regent, 2013); a similar
recommendation has not been noted by other
manufacturers. Not for IM administration.
extravasation.
extravasated solution (DO NOT flush the line);

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 Stable in D5LR, D51/4NS, D51/2NS, D5NS,
D5R, D5W, D10W, D20W, LR, NS;
incompatible in fat emulsion 10%
15. Magnesium sulfate
 IV: Dilute to a ≤20% solution for IV infusion.
 Must be diluted to a ≤20% solution for IV infusion and may
be administered IV push, IVPB, or continuous IV infusion.
When giving IV push, must dilute first and should
generally not be given any faster than 150 mg/minute;
may administer over 1 to 2 minutes in patients with
persistent pulseless VT or VF with known
hypomagnesemia (Dager, 2006). ACLS guidelines
recommend administration over 15 minutes in patients
with torsade de pointes (ACLS, 2010). In patients not in
cardiac arrest, hypotension and asystole may occur
with rapid administration. In patients with asthma (acute
severe exacerbation) (off-label use), may administer single
dose over 20 minutes to 60 minutes (GINA 2015; NAEPP
2007).
 Maximal rate of infusion: Up to 50% of an IV dose may be
eliminated in the urine, therefore, slower administration
may improve retention (maximum rate: 1 g/hour in
asymptomatic patients). For doses <6 g, infuse over 8 to
12 hours and for larger doses infuse over 24 hours if

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patient is asymptomatic. If patient is severely
symptomatic (or has conditions such as preeclampsia or
eclampsia) more aggressive therapy (≤4 g over 4 to 5
minutes) may be required; patients should be closely
monitored (Kraft, 2005).
 Stable in D5W, D10W, D51/4NS, D5NS, LR, NS, R;
incompatible with fat emulsion 10%.
16.Aminophylline
 IV infusion: 250 mg in 250 mL (concentration: 1
mg/mL) of D5W or NS
 IV: For IV administration only (IM use is not
recommended). Loading doses should be
administered IV over 30 minutes. Infusion rate
should not exceed 21 mg/hour (equivalent to
theophylline 17 mg/hour) in patients with cor
pulmonale, cardiac decompensation, liver
dysfunction, patients >60 years of age, or
patients taking medications which reduce
theophylline clearance.
 For reversal of adenosine-, dipyridamole-, or
regadenoson-induced adverse events during
nuclear cardiac stress testing, administer IV
undiluted over 30-60 seconds, repeat as
necessary. Since adenosine-induced side effects
are short lived after discontinuation of the
infusion, aminophylline administration is only very
rarely required.

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extravasation.
extravasated solution (do NOTflush the line);
 Stable in dextran 6% in D5W, dextran 6% in NS,
D5LR, D5NS, D51/2NS, D51/4NS, D5W, D10W,
D20W, LR, 1/2NS, NS;
17.Amiodarone (Cordarone®)
1.8 mg/mL) of D5W or NS
 For infusions >1 hour, use concentrations ≤2
mg/mL unless a central venous catheter is
used;
 Use only volumetric infusion pump; use of drop
counting may lead to under dosage.
 Administer through an IV line located as centrally
as possible. For continuous infusions, an in-line
filter has been recommended during
administration to reduce the incidence of
phlebitis. During pulseless VT/VF,
administering undiluted is preferred (Dager
2006; Skrifvars 2004). The Handbook of

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Emergency Cardiovascular Care (Hazinski 2015)
and the ACLS guidelines do not make any
specific recommendations regarding dilution of
amiodarone in this setting.
 Adjust administration rate to urgency (give
more slowly when perfusing arrhythmia
present). Slow the infusion rate if
hypotension or bradycardia develops.
Infusions >2 hours must be administered in a
non-PVC container (eg, glass or polyolefin).
PVC tubing is recommended for administration
regardless of infusion duration.
 Incompatible with heparin; flush with saline
prior to and following infusion. Note: IV
administration at lower flow rates (potentially
associated with use in pediatrics) and higher
concentrations than recommended may result in
leaching of plasticizers (DEHP) from
intravenous tubing. DEHP may adversely affect
male reproductive tract development.
Alternative means of dosing and administration
(1 mg/kg aliquots) may need to be considered.
18.Regular Insulin
 For IV infusion:
o Humulin R: May be diluted in NS or D5W to
concentrations of 0.1-1 unit/mL.
o Novolin R: May be diluted in NS, D5W, or
D10W with 40 mEq/L potassium chloride at
concentrations of 0.05 to 1 unit/mL.

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 IV infusion: 100 units in 100 mL (concentration:
1 unit/mL) of NS
 Do not use if solution is viscous or cloudy; use
only if clear and colorless. May be administered
IV with close monitoring of blood glucose and
serum potassium; appropriate medical
supervision is required. Do not administer
mixtures of insulin formulations
intravenously. IV administration of U-500
regular insulin is not recommended.
 IV infusions: To minimize insulin adsorption to IV
tubing: Flush the IV tubing with a priming infusion
of 20 mL from the insulin infusion, whenever a new
IV tubing set is added to the insulin infusion
container (Jacobi 2012; Thompson 2012).
 Note: Also refer to institution-specific protocols
where appropriate.
 If insulin is required prior to the availability of the
insulin drip, regular insulin should be administered
by IV push injection.
 Because of insulin adsorption to IV tubing or
infusion bags, the actual amount of insulin being
administered via IV infusion could be substantially
less than the apparent amount. Therefore,
adjustment of the IV infusion rate should be
based on effect and not solely on the apparent
insulin dose. The apparent dose may be used as
a starting point for determining the subsequent
SubQ dosing regimen (Moghissi 2009); however,

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the transition to SubQ administration requires
continuous medical supervision, frequent
monitoring of blood glucose, and careful
adjustment of therapy. In addition, SubQ insulin
should be given 1 to 4 hours prior to the
discontinuation of IV insulin to prevent
hyperglycemia (Moghissi 2009).
 Stable in D5W and NS.
 Note: A universal sterile diluent, Sterile Diluent for
Humalog, Humulin N, Humulin R, Humulin 70/30,
and Humulin R U-500, is available from the
manufacturer for SubQ administration
19. Morphine
 IV infusion: 1 mg/mL
 When giving morphine IV push, it is best to first
dilute with sterile water or NS for a final
concentration of 1 to 2 mg/mL and then
administer slowly over 4 to 5 minutes.
 Stable in dextran 6% in dextrose, dextran 6% in
NS, D5LR, D51/4NS, D51/2NS, D5NS, D5W,
D10W, LR, 1/2NS, NS;
20.Midazolam (Dormicum®)
 IV infusion: concentration: 1 mg/mL of D5W or
NS

25 | P a g e
 Administer by slow IV injection over at least 2 to
5 minutes at a concentration of 1 to 5 mg/mL or
by IV infusion. For induction of anesthesia,
administer IV bolus over 5 to 30 seconds.
Continuous infusions should be administered via
an infusion pump.
 Stable in D5NS, D5W, NS; incompatible with
LR.
21.Protamine
 For IV use only. Administer slow IV Push (50
mg over 10 minutes). Rapid IV infusion causes
hypotension. Inject without further dilution over
1-3 minutes; maximum of 50 mg in any 10-
minute period.
 Stable in D5W, NS.
22. Tranexamic acid (kapron®)
 Tranexamic acid doses may be diluted in 50 to
250 mL of NS or D5W (Trissels 2015). According
to the manufacturer, tranexamic acid may be
mixed with most solutions for infusion such as
electrolyte solutions, carbohydrate solutions,
amino acid solutions, and dextran solutions.
 May be administered by direct IV injection at a
maximum rate of 100 mg/minute; use plastic
syringe only for IV push

26 | P a g e
 In general, tranexamic acid loading doses are
diluted in 50 to 250 mL of D5W or NS and are
administered over 5 to 30 minutes.
 Compatible with dextrose, saline, electrolyte,
amino acid, or dextran solutions, heparin;
 Incompatible with solutions containing penicillin.
23.Ethamsylate (Dicynone®)
 N/A
24.Phenytoin (Ipanotine®)
 Hazardous agent; use appropriate precautions
for handling and disposal.
 IV: May be further diluted in NS to a final
concentration (5-10 mg/mL); infusion must be
completed within 4 hours after preparation. Do
not refrigerate. Stable in NS
 Fosphenytoin may be considered for loading in
patients who are in status epilepticus,
hemodynamically unstable, or develop
hypotension/bradycardia with IV administration of
phenytoin. Although, phenytoin may be
administered by direct IV injection, it is
preferable that phenytoin be administered via
infusion pump either undiluted or diluted in
normal saline as an IV piggyback (IVPB) to
prevent exceeding the maximum infusion rate

27 | P a g e
(monitor closely for extravasation during
infusion). The maximum rate of IV administration
is 50 mg/minute in adults. Highly sensitive
patients (eg, elderly, patients with preexisting
cardiovascular conditions) should receive
phenytoin more slowly (eg, 20 mg/minute) (Meek
1999). An in-line 0.22 to 0.55 micron filter is
recommended for IVPB solutions due to the
potential for precipitation of the solution. Avoid
extravasation. Following IV administration, NS
should be injected through the same needle
or IV catheter to prevent irritation.
 Note: SubQ administration is not
recommended because of the possibility of local
tissue damage (due to high pH).
extravasation.
remove needle/cannula; elevate extremity. There
is conflicting information regarding an antidote;
some sources recommend not to use an antidote
(Montgomery 1999 [pediatric reference]), while
other sources recommend hyaluronidase.

28 | P a g e
25.Rantidine (Zantac®)
 Continuous infusion: Dilute in D5W or other
compatible IV solution; for Zollinger-Ellison
patients, dilute in D5W or other compatible IV
solution to a maximum concentration of 2.5
mg/mL.
 Intermittent bolus injection: Dilute in NS or other
compatible IV solution to a maximum
concentration of 2.5 mg/mL (20 mL).
 Intermittent infusion: Dilute in D5W or other
compatible IV solution to a maximum
concentration of 0.5 mg/mL (100 mL).
 IV infusion: 50 mg in 50 mL (concentration: 1
mg/mL) or 500 mg in 250 mL (concentration: 2
mg/mL) of D5W or NS
.Administration: IV
 IV must be diluted; may be administered
intermittent bolus, intermittent IV infusion, or
continuous IV infusion
 Intermittent bolus: Manufacturer recommends a
maximum rate of administration of 10 mg/minute
(infuse over at least 5 minutes); however, in adults
may also be administered at a maximum rate of
25 mg/minute (or over 2 minutes) if necessary
(Coursin 1988; Goelzer 1988; Smith 1987).
 Intermittent IV infusion: Administer over a
maximum rate of 2.5 to 3.5 mg/minute (infuse
over at least 15 to 20 minutes)

29 | P a g e
 Continuous IV infusion: Administer at a rate of
6.25 mg/hour; for Zollinger-Ellison patients,
administer at a rate of 1 mg/kg/hour (infusion rates
as high as 220 mg/hour have been used).
 Stable in D51/2NS, D5W, D10W, fat emulsion
10%, LR, NS, sodium bicarbonate 5%; for
injection, do not add other medications to
premixed bag;

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