Critical care drug monographs - Wirral University … · Web viewCritical care guidelines – version 2d Principal Author: Debbie Hughes Update approved by Medicine DMT CG ... d)

Clinical guidelines

Critical care guidelines

Contents:

ACETYLCYSTEINE 3

ADRENALINE (EPINEPHRINE) 5

ALFENTANIL (INTRAVENOUS) 7

AMINOPHYLLINE (INTRAVENOUS) 8

AMIODARONE (INTRAVENOUS) 10

ARGATROBAN (INTRAVENOUS) 13

ATENOLOL (INTRAVENOUS) 15

ATRACURIUM (INTRAVENOUS) 17

CLARITHROMYCIN (INTRAVENOUS) 19

CLONIDINE (INTRAVENOUS) 20

CO-AMOXICLAV (INTRAVENOUS) 22

CO-TRIMOXAZOLE 23

DANAPAROID 25

DOBUTAMINE (INTRAVENOUS) 27

DOXAPRAM (INTRAVENOUS) 29

ENOXIMONE (INTRAVENOUS) 31

EPOPROSTENOL (INTRAVENOUS) 33

ERYTHROMYCIN (AS A PROKINETIC) 35

ESMOLOL (INTRAVENOUS) 37

ETHANOL (INTRAVENOUS) 39

FENTANYL (INTRAVENOUS) 41

FLUMAZENIL (INTRAVENOUS) 42

FOMEPIZOLE (INTRAVENOUS) 44

FUROSEMIDE (INTRAVENOUS) 46

GLYCERYL TRINITRATE (INTRAVENOUS) 48

HEPARIN (UNFRACTIONATED; INTRAVENOUS) 50Critical care guidelines – version 2d Principal Author: Debbie HughesUpdate approved by Medicine DMT CG November 2016 Review: May 2018

Page 1 of 106Published: 8th December 2016

HYDRALAZINE (INTRAVENOUS) 51

INSULINS 53

ISOPRENALINE (INTRAVENOUS) 54

KETAMINE (INTRAVENOUS) 55

LABETALOL (INTRAVENOUS) 57

LIDOCAINE (INTRAVENOUS) 59

MAGNESIUM (INTRAVENOUS) 62

MEROPENEM (INTRAVENOUS) 64

METARAMINOL (INTRAVENOUS) 66

MIDAZOLAM (INTRAVENOUS) 69

MORPHINE (INTRAVENOUS) 71

NALOXONE (INTRAVENOUS) 73

NEOSTIGMINE (INTRAVENOUS) 75

NICARDIPINE (INTRAVENOUS) 77

NIMODIPINE (INTRAVENOUS AND ORAL) 79

NORADRENALINE (INTRAVENOUS) 81

OXYCODONE INTRAVENOUS 82

PANTOPRAZOLE (CONTINUOUS INTRAVENOUS INFUSION) 84

PHENYLEPHRINE (INTRAVENOUS) 86

PHENYTOIN (ORAL OR INTRAVENOUS) 88

PROPOFOL (INTRAVENOUS) 90

REMIFENTANIL (INTRAVENOUS) 93

SALBUTAMOL (INTRAVENOUS) 95

SODIUM CHLORIDE 5% (INTRAVENOUS) 97

SUGAMMADEX INTRAVENOUS 98

PIPERACILLIN AND TAZOBACTAM (INTRAVENOUS) 100

TERLIPRESSIN (INTRAVENOUS) 102

VANCOMYCIN (INTRAVENOUS) 104

VASOPRESSIN (INTRAVENOUS) 106

Critical care guidelines – version 2d Principal Author: Debbie HughesUpdate approved by Medicine DMT CG November 2016 Review: May 2018


For full information on treatment side effects, cautions and contraindications, see electronic British National Formulary (www.bnf.org) or the relevant summary of product characteristics (www.medicines.org.uk).

[Back to top]CRITICAL CARE CLINICAL GUIDELINE

ACETYLCYSTEINEThis guideline is summary, full details are available from the SPC www.emc.medicines.org.uk

1. Indicationa) Prevention of contrast-induced nephropathy in high risk adult patients. Risk factors include:

Chronic kidney disease Sepsis Diabetes mellitus Age over 75 years Heart failure — NYHA level III or IV Hypotension Intra-arterial injection (angiography) Concurrent nephrotoxic medicines e.g: ACE inhibitors, angiotensin-II receptor

blockers, diuretics, metformin, NSAIDs, aminoglycosides, vancomycin.

Nephrotoxic drugs should be stopped where possible the day before the procedure and patients should be well hydrated.

For further information see Contrast induced nephropathy – prevention in patients undergoing CT, X-ray and fluoroscopy procedures

b) As a mucolytic

c) Paracetamol overdose in adult patients

d) Acute hepatic failure in adult patients (usually on the recommendation of a gastroenterologist)

2. Presentation2,000mg/10ml ampoules (200mg/ml), 600mg tablets

3. Dosea) Prevention of contrast-induced nephropathyOral (preferred route of administration if able to have enteral medication) — 600mg BD for four doses starting 12 hours before the contrast injection. NOTE: acetylcysteine injection may be administered enterally via a naso-gastric tube or mixed with squash or orange juice and given orally to disguise the bitter taste.

Intravenous — 1g on the day before the procedure and 1g on the day of the procedure.Do not delay the scan to give acetylcysteine, if the scan is booked as an emergency then give just one dose of 1g of acetylcysteine.

b) As a mucolytic



http://www.whnt.nhs.uk/document_uploads/Intranet-Pharmacy/Contrast-induced%20nephropathy%20-%20prevention%20in%20patients%20undergoing%20CT,%20x-ray%20and%20fluoroscopy.pdf

http://www.whnt.nhs.uk/document_uploads/Intranet-Pharmacy/Contrast-induced%20nephropathy%20-%20prevention%20in%20patients%20undergoing%20CT,%20x-ray%20and%20fluoroscopy.pdf

http://www.medicines.org.uk/

http://www.bnf.org/

3 to 5ml of undiluted acetylcysteine injection via a nebuliser TDS to QDS.

c) Following a paracetamol overdose, follow the paracetamol overdose care pathway.

d) In acute hepatic failure an acetylcysteine infusion may be started at a dose of 100mg/kg for 16 hours continuing the infusion until there is improvement in INR and/or LFTs.

4. AdministrationStandard Infusion Recommended by manufacturer

Drug Volume Fluid Duration of Infusion

Central or Peripheral

1g Up to 500ml

Glucose 5% or sodium chloride 0.9% 30 minutes to 1 hour

Minimum Volume (for fluid restricted patients)Drug Volume Fluid Duration of

InfusionMaximum Rate

Central preferred

1g Up to 100ml

Glucose 5% 30 minutes to 1 hour

400ml/hr (ie, 100ml over 15 minutes)

5. Side EffectsAnaphylactoid reactions including nausea, vomiting, injection site reactions, flushing, itching, rashes, angioedema, bronchospasm, hypotension, rarely tachycardia and hypertension. If this reaction occurs, stop the infusion and administer antihistaminines and/or corticosteroids as necessary.

Rarely coughing, puffy eyes, chest pain, sweating, raised temperature, acidosis, generalised seizure.

6. ContraindicationsCaution in patients with asthma or a history of bronchospasm

7. Y site compatibilityCompatible with:Adrenaline, alfentanil, aminophylline, amiodarone (if both are diluted in glucose 5%), atracurium, compound sodium lactate (Hartmann’s solution), dobutamine, fentanyl, heparin, insulin, midazolam, morphine and noradrenaline.

8. Notes Adequate hydration, usually with sodium chloride 0.9% or sodium bicarbonate 1.26%,

prior to contrast may also reduce the incidence of contrast-induced nephropathy.

9. Referenceswww.ukcpa.org.uk accessed 10/12/2010www.emc.medicines.org.uk accessed 17/04/2012Ashley C and Currie A. The Renal Drug Handbook (third edition) 2009.Medicines Q&As Which injections can be given enterally? UKMI June 2011.http://medusa.wales.nhs.uk Medusa medicines guide accessed 13/11/14



http://medusa.wales.nhs.uk/

http://www.emc.medicines.org.uk/

http://www.ukcpa.org.uk/


ADRENALINE (EPINEPHRINE)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationAnaphylaxis in adult patientsAdvanced cardiac life support in adult patientsCardiovascular support in severe sepsis in adult patients (outside product license)Reversal of airway obstruction in inflammatory disorders in adult patients (outside product license)

2. Presentation1 in 1,000 amps (1mg/ml) licensed for intramuscular use only

1 in 10,000 amps (100micrograms/ml)

3. Dosea. Acute allergy and anaphylactic shock

500micrograms (0.5ml of 1 in 1000 amp) by intramuscular injection, repeated every 5 minutes if necessary.

b. Advanced cardiac life support1mg (10ml of 1 in 10,000 amp) intravenously repeated every 3 to 5 minutes if necessary.

c. Reversal of airway obstruction in inflammatory disorders (unlicensed)Nebulised 1 in 1000. Max 5mg (5ml of 1 in 1000) repeated after 30 minutes if necessary. The effect should last for 2-3 hours.

d. Cardiovascular support in severe sepsis (unlicensed)Dose is adjusted to BP and cardiac output

4. Administration of intravenous infusion (outside product license)Route Drug Volume Fluid Concentration Usual RateCentral 8mg

(8ml of 1:1000 injection)

Up to 100ml

Glucose 5% 80microgram/ml 0 to 20ml/hr

Use 1:1000 adrenaline amps (i.e. 1mg/ml)

5. Common Side Effects Anaphylaxis, possibly with severe bronchospasm Hyperglycaemia, hypokalaemia, metabolic acidosis (raised lactate) Anxiety, headache, dizziness, tremors In patients with Parkinsonian Syndrome, adrenaline increases rigidity and tremor. Severe hypertension which has been associated with subarachnoid

haemorrhage,hemiplegia and pulmonary oedema Tachycardia, ECG changes (decrease in T-wave amplitude), cardiac arrhythmias

including potentially fatal ventricular arrhythmias, especially in patients with organic heart disease or those receiving other drugs that sensitise the heart to arrhythmias.

Chest pain/angina may occur.



Coldness of extremities may occur even with small doses of adrenaline. Nausea, vomiting, urinary retention, sweating, weakness. Repeated injections of adrenaline can cause necrosis as a result of vascular

constriction at the injection site. Tissue necrosis may also occur in the extremities, kidneys and liver.

6. ContraindicationsHypersensitivity to adrenaline, sodium metabisulphite or any of the other ingredients.Adrenaline 1 in 1000 should not be used in fingers, toes, ears, nose or genitalia owing to the risk of ischaemic tissue necrosis.

7. Y site compatibilityCompatible with:Alfentanil, amiodarone, atracurium, clonidine, compound sodium lactate (Hartmann’s), dobutamine, fentanyl, furosemide, glucose 4% and sodium chloride 0.18%, heparin, insulin, midazolam, morphine sulphate, noradrenaline, potassium chloride, vasopressin, vecuronium.

8. Notes Half life 2-3 minutes. pH 2.5-3.6 Adrenaline infusion may be made up in sodium chloride 0.9% but glucose 5% is advised

to aid compatibility with other inotropes/vasopressors. Adrenaline is a potent agonist at both alpha and beta adrenoceptors, although the effect

on beta adrenoceptors is more marked, particularly at lower doses. Continuous monitoring of blood pressure and ECG are essential. Blood glucose should

also be checked regularly. Beta blockers and alpha blockers will antagonise the effects of adrenaline. Tricyclic antidepressants may potentiate the effect of adrenaline, increasing the risk of

development of hypertension and cardiac arrhythmias. Although monoamine oxidase (MAO) is one of the enzymes responsible for adrenaline

metabolism, MAO inhibitors do not markedly potentiate the effects of adrenaline. The hypokalaemic effect of adrenaline may be potentiated by other drugs that cause

potassium loss, including corticosteroids, potassium-depleting diuretics, aminophylline and theophylline.

Adrenaline induced hyperglycaemia may lead to loss of blood-sugar control in diabetic patients treated with insulin or oral hypoglycaemic agents.

Adrenaline injection contains sodium metabisulphite, which can cause allergic-type reactions, including anaphylaxis and life-threatening or less severe asthmatic episodes, in certain susceptible individuals.

9. Referenceswww.ukcpa.org.uk accessed 9/11/11www.emc.medicines.org.uk accessed 9/11/11www.medicinescomplete.com accessed 9/11/11http://medusa.wales.nhs.uk Medusa medicines guide accessed 13/11/14BNF edition 61 March 2011




http://www.medicinescomplete.com/




ALFENTANIL (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationSedation, analgesia and suppression of respiratory activity in mechanically ventilated adult patients. It will aid compliance with mechanical ventilation, improve tolerance of the endotracheal tube and provide analgesia during painful procedures.

2. Presentation5mg/ml ampoules – this is a high strength opioid.

3. DoseInitial infusion rate 2mg/hour or 30mcg/kg/hour based on ideal body weight.Maintenance infusion typically between 0.5mg to 10mg per hour (in practice, doses above 2.5mg per hour are rarely used)Bolus doses of 0.5mg to 1mg may be given prior to painful procedures.4. AdministrationStandard Infusion Recommended by manufacturerRoute Drug Volume Fluid Concentration Initial

rateMaximum rate


25mg Up to 50ml Sodium Chloride 0.9% or Glucose 5%

0.5mg/ml 4ml/hour* 5ml/hour*

*rates based on a 70kg adult. Following initiation at 4ml/hour the rate may be decreased to a maintenance rate between 1 and 5ml/hour.5. Common side effectsNausea, vomiting, skeletal muscle rigidity, respiration depression, respiratory arrest, bradycardia, asystole, arrhythmias and hypotension.6. ContraindicationsKnown hypersensitivity to alfentanilConcurrent administration with a monoamine oxidase inhibitor (or within 2 weeks of stopping) due to risk of severe hypertension.7. Y site compatibilityCompatible with:Aminophylline, atracurium, clonidine, dobutamine, furosemide. heparin, insulin, midazolam, propofol, remifentanil.Amiodarone (in both made up in glucose 5%).8. Notes Maximum licensed duration is 4 days. Clearance of alfentanil may be reduced in severe hepatic impairment. The metabolism of alfentanil may be inhibited by cytochrome P450 3A4 inhibitors such

as fluconazole, erythromycin, diltiazem and cimetidine. Terminal half life: 90 to 111 minutes.9. Referenceswww.ukcpa.org.uk accessed 17/02/12www.emc.medicines.org.uk accessed 17/02/12www.medicinescomplete.com accessed 17/02/12http://medusa.wales.nhs.uk Medusa medicines guide accessed 13/11/14BNF edition 61 March 2011








AMINOPHYLLINE (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationBronchospasm in adult patients

2. Presentation250mg/10ml Injection

3. Dose Loading Dose 5mg/kg. Given in 100ml sodium chloride 0.9% over 20 minutes. DO NOT give the loading dose if patient usually takes oral theophylline/aminophylline. Maintenance dose 0.5mg/kg/hour Lower maintenance dose 0.3mg/kg/hour may be needed in elderly patients


Drug Volume Fluid Concentration Rate for 70kg patient


500mg Up to 500ml

Sodium Chloride 0.9% or Glucose 5%

1mg/ml 35ml/hour

Minimum Volume, unlicensed (for fluid restricted patients)Drug Volume Fluid Concentration Rate for 70kg

patientCentral 1000mg Up to

250mlSodium Chloride 0.9% or Glucose 5%

4mg/ml 8.8ml/hour

5. Common Side Effects Insomnia, confusion, tremor, delirium Tachycardia, palpitations, arrhythmias, hypotension Nausea, vomiting, abdominal pain, gastrointestinal bleeding Headache, rash, pruritis. Convulsions (especially if given too fast) Hypokalaemia (especially if also on salbutamol). Hyperventilation

6. ContraindicationsHypersensitivity or allergy to ethylenediamine, theophylline, caffeine or theobromine.Acute porphyria



7. Y site compatibilityCompatible with:Clonidine, fentanyl, furosemide, heparin, labetalol, potassium, propofol, sodium bicarbonate.

8. Notes Theophylline levels should be checked daily for patients on an aminophylline infusion, therapeutic range 10-20mg/L. Clearance is reduced in congestive heart failure, chronic obstructive pulmonary disease, renal or hepatic impairment and chronic alcoholism. Higher doses may be needed in chronic smokers The following conditions may be exacerbated by aminophylline: hypertension, peptic ulcer, hyperthyroidism, hepatic impairment and epilepsy. Erythromycin, ciprofloxacin, cimetidine and propranolol increase serum theophylline concentrations (may need lower dose). Phenytoin, phenobarbitone, carbamazepine and rifampicin decrease theophylline serum concentrations (may need higher dose). For further advice on interactions and monitoring please contact pharmacy.

9. Referenceswww.ukcpa.org.uk accessed 23/8/11www.emc.medicines.org.uk accessed 23/8/11http://medusa.wales.nhs.uk Medusa medicines guide accessed 13/11/14www.medicinescomplete.com accessed 23/8/11








AMIODARONE (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationAll types of tachyarrhythmias in adult patients including: supraventricular, nodal and ventricular tachycardias; atrial flutter and fibrillation; ventricular fibrillation.

2. Presentation150mg in 3ml ampoules

3. DoseLoading dose: 300mg over 30 minutesMaintenance infusion: Initial 900mg over 24 hours, this may be reduced to 600mg depending on clinical response

The maximum dose in 24 hours is 1200mg.

4. AdministrationCentral administration is recommended, continuous administration via a peripheral line may result in injection site reactions.

Standard Infusion Recommended by manufacturerDrug Volume Fluid Concentration Rate

Peripheralor Central

300mg Up to 250ml

Glucose 5% 1.2mg/ml 500ml/hour

Peripheralor Central

600mg Up to 500ml


Peripheral or Central

900mg Up to 500ml


Do not over-dilute. Solutions containing less than 300mg amiodarone in 500mL (i.e. less than 0.6mg/mL) are unstable and should not be used.

Minimum Volume, unlicensed. (for fluid restricted patients)Drug Volume Fluid Concentration Rate

Central 300mg Up to 50ml

Glucose 5% 6mg/ml 100ml/hour


Glucose 5% 12mg/ml 2.1ml/hour


Glucose 5% 18mg/ml 2.1ml/hour

Due to the low pH of amiodarone, concentrations exceeding amiodarone 2mg/mL should always be administered via a central venous catheter.

5. Common Side Effects Bradycardia Angioedema QT prolongation Benign intracranial hypertension Interstitial pneumonitis



Bronchospasm/apnoea Severe hepatocellular insufficiency Hypotension Hyperthyroidism Flushing Injection site reactions Acute liver dysfunction including raised transaminases and jaundice. Amiodarone has a low proarrhythmic effect. It is important to try and differentiate a

lack of efficacy from a proarrhythmic effect.

6. Contraindications

Sinus bradycardia and sino-atrial heart block (in patients with severe conduction disturbances e.g. high grade AV block, bifascicular or trifascicular block or sinus node disease, amiodarone should be used only in conjunction with a pacemaker)

Evidence or history of thyroid dysfunction. Severe respiratory failure, circulatory collapse, or severe arterial hypotension Known hypersensitivity to iodine or to amiodarone, or to any of the excipients. (One

ampoule contains approximately 56mg iodine).

7. Drug interactionsThere are many drug interactions associated with amiodarone. Please contact pharmacy for a complete list.Amiodarone can increase plasma levels of warfarin, digoxin, flecainide, ciclosporin, tacrolimus, statins and phenytoin. Avoid prescribing amiodarone with other drugs which prolong QT interval e.g. arrhythmic drugs e.g. quinidine, procainamide, disopyramide, sotalol, bretylium, erythromycin, co-trimoxazole, pentamidine, chlorpromazine, thioridazine, fluphenazine, pimozide, haloperidol, amisulpiride and sertindole, lithium and tricyclic anti-depressants, certain antihistamines e.g. terfenadine, astemizole, mizolastine, anti-malarials e.g. quinine, mefloquine, chloroquine, halofantrine and the antibiotic moxifloxacin.

8. Y site compatibilityIf all infusions made in Glucose 5%, then compatible with:Acetylcysteine, adrenaline, alfentanil, atracurium, calcium gluconate, clarithromycin, dobutamine, fentanyl, insulin, labetalol, midazolam, morphine, noradrenaline, potassium chloride, vancomycin.

9. NotesIntravenous to oral conversionAmiodarone tablets should be initiated at the usual loading dose of 200mg TDS. Oral therapy should be initiated concomitantly with the intravenous infusion which should then be phased out gradually (suggested over 24 hours).

Continuous blood pressure and ECG monitoring should be carried out during infusion of amiodarone. There should be facilities present for cardiac monitoring, defibrillation, and cardiac pacing. Elderly patients may be more susceptible to bradycardia and conduction defects with amiodarone.

10. Referenceswww.ukcpa.org.uk accessed 26/9/11www.emc.medicines.org.uk accessed 21/9/11www.medicinescomplete.com accessed 13/11/14






http://medusa.wales.nhs.uk Medusa medicines guide accessed 13/11/14




CRITICAL CARE CLINICAL GUIDELINE

ARGATROBAN (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationAnticoagulation in adult patients with confirmed/suspected Heparin-induced thrombocytopenia (HIT) including for haemofiltration. Approved at WUTH only in patients with CKD4/5.

For guidance on management of HIT see Heparin-induced thrombocytopenia (HIT): Diagnosis and management .

2. PresentationArgatroban 250mg in 2.5mL concentrated solution. Must be diluted prior to administration. Refer to the manufacturer’s information and Injectable Medicines Guide (Medusa) for further information on dilution.Pre prepared 30mg/30mL syringes are available from pharmacy aseptics.

3. Dose Argatroban is administered as a continuous IV infusion. Standard dose 2micrograms/kg/minute Reduced dose of 0.5micrograms/kg/minute in critical illness (i.e. organ system failure) and

decompensated liver function (i.e. synthetic functions impaired). MAXIMUM DOSE 10 microgram/kg/minute Therapeutic effect is monitored using APTT. A baseline APTT should be checked before

starting the infusion. Aim for APTT 50 to 100 seconds.4. Administration

Bolus dose may be administered prior to haemodialysis or haemofiltration. This should only be considered in patients having the standard dose and should NOT be administered to critically ill patients with organ system failure. The intravenous bolus dose is 250microgram/kg. Note it may take 1 to 3 hours for full anticoagulant effect without a bolus dose.Weight 50 - 59 60-69 70-79 80-89 90-99 100-

109110-119

120-129

Bolus dose (mL)

12.5 15 17.5 20 22.5 25 27.5 30

Initial Rate (mL/hour) using a pre prepared 30mg in 30ml syringePatient Weight (kg) Standard Infusion Reduced Dose in Critical Illness

or Hepatic Impairment50 - 59 6 1.560 - 69 7 1.870 - 79 8 2.180 - 89 10 2.490 - 99 11 2.7

100 - 109 12 3.0110 - 119 13 3.3120 - 129 14 3.6

Monitoring

Check APTT every 2 hours until two consecutive APTT readings

are within target range 50-100seconds.

Then check APTT daily.

Check APTT every 4 hours until two consecutive APTT readings are

within target range of 50-100seconds.

Then check APTT daily



Dose AdjustmentAPTT Patient

Weight (kg)Standard Infusion

Reduced Dose in Critical Illness or Hepatic Impairment

Maximum rate mL/hour

Less than 50

Increase infusion rate (mL/hour)50 - 59 +1.5 +0.3 3060 - 69 +1.8 +0.35 3670 - 79 +2.1 +0.4 4280 - 89 +2.4 +0.45 4890 - 99 +2.7 +0.55 54

100 - 109 +3.0 +0.6 60110 - 119 +3.3 +0.65 66120 - 129 +3.6 +0.7 72

50-100 No change to infusion rate

More than 100

Stop infusion until the APTT is 1.5-3.0 times baseline; Resume at half of the previous infusion rate

5. Common Side EffectsAnaemia, thrombocytopenia, coagulopathy, hyponatraemia, hypoglycaemia, dizziness, headache, CVA, speech disorder, visual disturbance, AF, tachycardia, myocardial infarction, arrhythmias, hypotension, hypertension, DVT, PE, haemorrhage, thrombophlebitis, vomiting, constipation, malaena, hepatic failure, jaundice, rash, sweating, alopecia, myalgia, pyrexia, peripheral oedema.

6. ContraindicationsPatients with uncontrolled bleeding. Hypersensitivity to argatroban or to any of the excipients. Severe hepatic impairment.

7. Y site compatibilityCompatible with: dobutamine, fentanyl, furosemide, glucose 5%, GTN, Hartmann’s, hydrocortisone, midazolam, morphine, noradrenaline, phenylephrine, sodium chloride 0.9% and vasopressin.

8. Notes Argatroban is a direct thrombin inhibitor In patients with active bleeding stop the argatroban infusion, anticoagulation parameters

should return to baseline within 2 to 4 hours (longer in hepatic impairment). No specific antidote to argatroban is available. Argatroban is not cleared by haemofiltration.

1 ml of argatroban solution contains 400 mg ethanol (50% by volume) For conversion from argatroban to warfarin please check the SPC. Argatroban should be used with extreme caution in disease states and other circumstances

in which there is an increased risk of haemorrhage, e.g. severe hypertension, major surgery.

Concomitant use with antiplatelet agents, thrombolytics, and other anticoagulants may increase the risk of bleeding.

Steady state levels are attained within 1 to 3 hours. Argatroban is 54% bound in human serum proteins The apparent terminal elimination half life is 52 minutes. No dosage adjustment is needed in renal impairment or in elderly patients.

9. Referenceswww.emc.medicines.org.uk accessed 28/1/14www.medicinescomplete.com accessed 13/11/14BNF edition 66 September 2013http://medusa.wales.nhs.uk Medusa medicines guide accessed 13/11/14





ATENOLOL (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationLicensed indication: Arrhythmias and early intervention treatment for acute MI in adult patients.

Off label indication: hypertension, angina in adult patients.

2. Presentation500microgram/ml injection (5mg in 10ml).

3. DoseArrhythmias: 2.5mg repeated at 5 minute intervals to a maximum of 10mg.

Or infusion 150micrograms/kg over 20 minutes, repeated every 12 hours.

Early intervention (within 12 hours) post MI: 5mg stat

NOTE: due to the low bioavailability of oral atenolol, intravenous and oral doses of atenolol are NOT interchangeable. The intravenous dose should be approximately one tenth of the oral dose.

4. Administration

Maximum rate 1mg/minuteGive stat doses as a slow intravenous injection, e.g. 5mg give undiluted over 5 minutes.

Standard Infusion Recommended by manufacturerFor infusion, make up dose in a 50ml or 100ml bag and infuse over 20 minutes.

Drug Volume Fluid RateCentral or Peripheral

10mg Up to 50ml or 100ml


50ml bag at 150ml/hour

100ml bag at 300mg/hour

5. Common Side EffectsBradycardia, hypotension, sleep disturbance, confusion, nightmares, rash, thrombocytopenia, dizziness, headache, dry eyes, cold extremities, postural hypotension, bronchospasm, gastro intestinal disturbances, elevated transaminases, hepatic impairment, hypersensitivity reactions.

6. ContraindicationsAsthma, uncontrolled heart failure, bradycardia, hypotension, sick sinus syndrome, second- or third-degree AV block, cardiogenic shock, metabolic acidosis, severe peripheral arterial disease, phaeochromocytoma (except in combination with alpha blockers), known hypersensitivity to atenolol or any excipients.



7. Y site compatibilityNo data available. Must be given via a dedicated lumen.

8. Notes Excessive bradycardia may be treated with intravenous atropine 600micrograms,

repeated if necessary. See Toxbase for further information in glucagon use in massive overdose.

Avoid abrupt withdrawal, may result in rebound tachycardia. Caution in diabetes, COPD, myasthenia gravis and hypoglycaemia. Avoid concomitant use with verapamil. Blood pressure and heart rate should be monitored during and after the administration

of intravenous atenolol. Dose reduction may be necessary in elderly patients or patients with renal impairment. NOTE: due to the low bioavailability of oral atenolol, intravenous and oral doses of

atenolol are NOT interchangeable. The intravenous dose should be approximately one tenth of the oral dose.

9. Referenceswww.emc.medicines.org.uk accessed 16/7/12www.medicinescomplete.com accessed 14/11/14http://medusa.wales.nhs.uk Medusa medicines guide accessed 13/11/14BNF edition 63 March 2012







ATRACURIUM (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationNon depolarising neuromuscular blocking agent, used to relax skeletal muscle to allow intubation, aid mechanical ventilation or prevent shivering during therapeutic cooling in adult patients.

2. Presentation100mg in 10ml ampoules250mg in 25ml ampoules

3. DoseAtracurium paralyses the respiratory muscles as well as other skeletal muscles but has no effect on consciousness, it must only be administered with adequate general anaesthesia or with heavily sedated patients and with facilities for mechanical ventilation.

0.3 to 0.6 mg/kg (Ideal Body Weight) will provide adequate relaxation for about 15 to 35 minutes. The dose should be adjusted according to response.

Endotracheal intubation: 0.5 to 0.6mg/kg.

Continuous infusion in critical care:Optional bolus dose of 0.3 to 0.6 mg/kg followed byContinuous infusion: 11 to 13 microgram/kg/min. Although doses in the range 4.5microgram/kg/min to 29.5 microgram/kg/min are required in some patients.

Infusion rate in ml/hour based on a 10mg/ml atracurium infusionDose microgram/kg/minute

Weight in kg50 60 70 80 90 100

11 3.3 4.0 4.6 5.3 5.9 6.612 3.6 4.3 5.0 5.8 6.5 7.213 3.9 4.7 5.5 6.2 7.0 7.8


Drug Volume Fluid ConcentrationCentral or Peripheral

500mg 50ml Undiluted 10mg/ml

Atracurium should not routinely be diluted for administration. The expiry of diluted solutions is 8 hours.

5. Common Side EffectsAtracurium may lead to histamine release so should be used with caution in patients with a history of sensitivity to histamine. The histamine release may lead to bronchospasm in patients with allergy or asthma.

Tachycardia, mild transient hypotension, flushing, wheezing, bronchospasm, urticaria, myopathy, muscle weakness, anaphylactoid or anaphylactic reactions.



6. ContraindicationsHypersensitivity to atracurium, cisatracurium or benzenesulfonic acid or any excipients.

7. Y-site compatibilityCompatible with:Alfentanil, amiodarone, clarithromycin, clonidine, compound sodium lactate (hartmann’s), co-trimoxazole, dobutamine, esmolol, fentanyl, glucose 4% and sodium chloride 0.18%, glucose 5%, GTN, hydrocortisone, insulin, labetalol, midazolam, morphine, potassium chloride, sodium chloride 0.9%, vancomycin,

8. Notes There is no need to reduce the dose of atracurium in renal or hepatic impairment. The rate of spontaneous recovery from neuromuscular block after infusion of atracurium

in ICU patients is independent of the duration of administration. Spontaneous recovery from the end of full block occurs in about 35 minutes. Half life 20 to 30minutes. Elimination is by Hofmann elimination which is independent of

renal and hepatic function. pH is 3.2 to 3.7. Certain medications may prolong the duration of action of atracurium, including:

antibiotics: aminoglycosides: polymyxins, spectinomycin, tetracyclines, lincomycin, clindamycin and vancomycin; antiarrhythmics: lidocaine, procainamide and quinidine; beta-blockers, calcium channel blockers, diuretics: furosemide , thiazide diuretics; acetazolamide; magnesium sulphate; ketamine; lithium; dantrolene.

Atracurium should not be used concomitantly with a depolarising muscle relaxant such as suxamethonium.

Atracurium must be stored in a refrigerator between 2 and 8oC. An undiluted infusion prepared on the ward in a 50ml syringe has an expiry of 24 hours at room temperature.









CLARITHROMYCIN (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationFormulary choice for community acquired pneumonia (to cover atypical bacteria) in adult patients.

2. Presentation500mg vial

3. Dose500mg twice daily. No dose reduction required for renal impairment.4. AdministrationReconstitute each 500ml vial with 10ml water for injections.

Standard Infusion (recommended by manufacturer)Route Drug Volume Fluid Maximum RateCentral or Peripheral

500mg Up to 250ml


250ml/hr

Minimum Volume (for fluid restricted patients)Route Drug Volume Fluid Maximum RateCentral 500mg Up to

100mlSodium Chloride 0.9% orGlucose 5%

100ml/hr

5. Common Side EffectsNausea, diarrhoea, vomiting, injection site inflammation, allergic reaction including angioedema and anaphylaxis, dizziness, insomnia, anxiety, confusion, hallucinations, hypoglycaemia, hepatic dysfunction, renal dysfunction, convulsions and QT prolongation.6. Contraindications

Hypersensitivity to clarithromycin. Concomitant administration with ergot derivatives. Concomitant administration with certain drugs which prolong QT interval such as

cisapride, pimozide and terfenadine. 7. Y site compatibilityCompatible with:Amiodarone (if both in glucose 5%), atracurium, ciprofloxacin, compound sodium lactate (Hartmann’s), dobutamine, insulin, metronidazole, potassium chloride, vancomycin.

8. Notes Clarithromycin inhibits liver enzymes and can increase levels of drugs such as: aminophylline, ciclosporin, digoxin, phenytoin, tacrolimus, warfarin. Simvastatin should be omitted during therapy with clarithromycin. A urine sample should be sent to the microbiology laboratories to check for legionella and pneumococcal antigen.

9. Referenceswww.ukcpa.org.uk accessed 20/4/11www.emc.medicines.org.uk accessed 20/4/11www.medicinescomplete.com accessed 20/4/11http://medusa.wales.nhs.uk Medusa medicines guide accessed 13/11/14









CLONIDINE (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationSedation and analgesia in adult patientsClonidine is a centrally acting antihypertensive agent. It is an α2-agonist producing sedation and analgesia with minimal effect on respiratory function. Clonidine is of value when opioid or benzodiazepine requirements are increasing. Clonidine may be used to treat patients withdrawing from drugs or alcohol, note it has no effect on convulsions so should not be used as sole therapy for alcohol withdrawal.Continuous infusion of clonidine for sedation is an unlicensed method of administration.

2. Presentation150 microgram /mL injection

3. DoseIntermittent infusionDoses of 50 to 400micrograms TDS or QDS have been used

Continuous InfusionDoses in the range of 1 to 2 microgram/kg/hour are typically used. Doses up to 4 microgram /kg /hour have been used in exceptional circumstances. Use ideal body weight.

Doses should normally start at around 2 microgram/kg/hour for an hour as a loading dose, the rate is then titrated to sedative effect.

4. AdministrationRoute Drug Volume Fluid Concentration Initial

Rate*Usual Maximum Rate*


750 microgram (5 x 150 microgram amps)

Up to 50ml


15 microgram /ml 9ml/hour and review after one hour

9ml/hour(See notes above)

*Infusion rates are based on a 70kg patient.Use a lower starting rate if blood pressure is compromised.

5. Common Side Effects Hypotension and bradycardia (especially after prolonged administration >7-10 days),

may potentiate, or cause sinus bradycardia and AV block. Hyperglycaemia Acute colonic pseudo-obstruction has been reported at high doses Constipation, ileus, nausea, vomiting and headache Rash, itching Rarely fluid retention and abnormal LFTs. Dry mucous membranes




Known hypersensitivity to the active ingredient or other components of the product

Severe bradyarrhythmia resulting from either sick sinus syndrome or AV block of 2nd or 3rd degree.

Clonidine should only be used with caution in patients with depression, with Raynaud's disease or other peripheral vascular occlusive disease. As with other antihypertensive drugs, treatment in patients with heart failure should be carefully monitored.

7. Y site compatibilityCompatible with:Alfentanil, aminophylline, atracurium, fentanyl, heparin, insulin, magnesium, midazolam, morphine and potassium chloride, remifentanil. Amiodarone and dobutamine if clonidine made up with glucose 5%.

8. NotesTolerance /tachyphylaxis occurs within 7 days of starting therapy Withdrawal of clonidine should be gradual due to risk of rebound hypertension,

tachycardia and agitation. Advise reduce over several days if on infusion over 2 days. pH 5-7 The blood pressure lowering effect of clonidine may be exacerbated by other

hypotensive agents including other sedative drugs, diuretics, vasodilators. 30 to 40% protein bound t½ 10 to 20 hours - mean 13 hours (extended to up to 41 hours in severe renal

impairment) 60% renally excreted as unchanged drug. The remaining 40% is metabolised by

oxidation to metabolite, p-hydroxyclonidine, which is pharmacologically inactive. Clearance is reduced in renal impairment Should not be administered concomitantly with methylphenidate, cases of severe

adverse effects including sudden death have been reported. Drugs with α2- adrenoceptor antagonist properties such as Mirtazepine may reduce the

effectiveness of clonidine. High intravenous doses of clonidine may increase the arrhythmogenic effect/QT

prolongation of haloperidol. Clonidine can aid mild/moderate symptoms of alcohol withdrawal although has no effect

on convulsions so should not be used as sole therapy.

9. Referenceswww.ukcpa.org.uk accessedwww.emc.medicines.org.uk accessed 31/10/11www.medicinescomplete.com accessed 31/10/11http://medusa.wales.nhs.uk Medusa medicines guide accessed 13/11/14 Hall, JE et al. Sedative, analgesic and cognitive effects of clonidine infusions in humans.

2001. British Journal of Anaesthesia 86 (1) 5-11. Rubine AS et al. Impact of clonidine administration on delirium and related respiratory

weaning after surgical correction of acute type-A aortic dissection: results of a pilot study. 2010. Interactive cardiovascular and thoracic surgery.10 58-62.

Kamibayashi T et al. Clinical uses of α2-adrenergic agonists. 2000. Anesthesiology 93 (5) 1345-1349.

Clonidine guideline for critical care. Guys and St Thomas’ NHS Foundation Trust. 2004.




CO-AMOXICLAV (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationTreatment of bacterial infection in adult patients (including community-acquired pneumonia). See the trust antibiotic formulary for further details.

2. Presentation1.2g injection (comprising 1000mg amoxicillin and 200mg clavulanic acid).

3. Dose1.2g every 8 hoursReduce dose to 1.2g 12 hourly if creatinine clearance less than 30ml/minute.4. AdministrationStandard Infusion Recommended by ManufacturerPreferred administration on wards (e.g. for discharge prescribing onElectronic prescribing system)Route Drug Volume Fluid Infusion time RateCentral or Peripheral

1.2g Up to 100ml

Sodium Chloride 0.9%

30 minutes 200ml/hour

Or reconstitute 1.2g vial with 20ml water for injection and bolus over 3 to 5 minutes.Minimum Volume, unlicensed (for fluid restricted patients)Preferred administration on critical careRoute Drug Volume Fluid Infusion time RateCentral or Peripheral

1.2g Up to 20ml

Water for Injections

4 hours 5ml/hour

5. Common side effectsNausea, vomiting, anaphylactic reactions, rash (discontinue treatment), deranged LFTs, cholestatic jaundice, dizziness, convulsions (most commonly associated with use of high doses in renal impairment).6. ContraindicationsHypersensitivity to amoxicillin or clavulanic acid or to any of the excipients. Severe hypersensitivity (eg, anaphylactic reaction, severe skin reaction) to any other type of beta-lactam antibacterial agent (eg, penicillins or cephalosporins).History of co-amoxiclav- or penicillin-associated jaundice or hepatic dysfunction.7. Notes Co-amoxiclav should not be given with disulfiram. Co-amoxiclav may lead to increased toxicity with methotrexate Co-amoxiclav may raise digoxin levels. Co-amoxiclav may lead to a raised INR in patients also taking warfarin. Co-amoxiclav is not effective against MRSA or ESBL infections.8. Referenceswww.emc.medicines.org.uk accessed 17/02/12http://medusa.wales.nhs.uk Medusa medicines guide accessed 13/11/14BNF edition 61 March 2011Roberts J et al. Better outcomes through continuous infusion of tim-dependent antibiotics to critically ill patients. Current opinion in critical care. 2008. 14: 390-396.






CO-TRIMOXAZOLEThis guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationTreatment or prophylaxis of PCP pneumonia in adult patients. Treatment of Stenotrophomonas maltophilia infection only on recommendation of microbiology in adult patients.

2. Presentation480mg in 5ml ampoules. Each ampoule contains 80mg of trimethoprim and 400mg of sulfamethoxazole.

Note also available as 480mg or 960mg tablets and a 480mg/5ml suspension. Co-trimoxazole is well absorbed enterally.

3. DosePCP prophylaxis: 480mg every 12 hours on Monday, Wednesday and Friday or 960mg once a day on Monday, Wednesday and Friday.

PCP treatment 120mg/kg per day, given in 2 to 4 divided doses. Advise rounding the dose to the nearest whole ampoule for ease of administration. For example in a 70kg patient, total daily dose in 8400mg. Suggest giving 2880mg 8 hourly (i.e. 6 whole 480mg ampoules 8 hourly).

Treatment of Stenotrophomonas maltophilia infection: 60 to 120mg/kg per day, given in 2 to 4 divided doses.

Renal impairment: If creatinine clearance is less than 30ml/minute give the normal dose for up to 3 days but give in 2 divided doses. Contact pharmacy for dosing advice beyond 3 days.

4. Administration

Standard infusion recommended by manufacturerDilute each 480mg ampoule with 125ml of sodium chloride 0.9% or glucose 5%. Administer infusion over 60 to 90 minutes.

Drug Volume Fluid Rate


960mg Up to 250mlSodium Chloride 0.9% or Glucose 5%

250ml/hour1440mg Up to 500ml 500ml/hour1920mg Up to 500ml 500ml/hour2400mg Up to 1000ml 1000ml/hour2880mg Up to 1000ml 1000ml/hour



Infusion recommended by manufacturer for fluid restricted patientsDilute each 480mg ampoule with 75ml of glucose 5%. Administer infusion over 60 minutes.At high concentrations there is a risk of precipitation so must complete infusion within 1 hour.

Drug Volume Fluid Rate


960mg Up to 150mlGlucose 5%

160ml/hour1440mg Up to 225ml 240ml/hour1920mg Up to 300ml 320ml/hour2400mg Up to 375ml 400ml/hour2880mg Up to 450ml 480ml/hour

Minimum volume (unlicensed) — for fluid restricted patientsThis is the recommended administration for critical care patients with a central line.

Drug Fluid Concentration RateCentral Total dose None. Give undiluted 480mg/5ml Give over 1.5 hours

5. Common side effectsSevere reactions, including fatalities, have occurred. Including: skin reactions — co-trimoxazole should be discontinued immediately with first appearance of skin rash — hepatic and blood disorders, regular LFTs and FBC are needed especially during prolonged treatment; aplastic anaemia and hypersensitivity of the respiratory tract. If signs of bone marrow depression develop, treat with 5 to 10mg daily of calcium folinate.

Hyperkalaemia (especially in patients with renal impairment). Caution is needed if co-administered with other drugs known to cause hyperkalaemia.Hyponatraemia, nausea, fever.Local pain and inflammation at injection site.

6. ContraindicationsKnown hypersensitivity to trimethoprim, sulphonamides or any other ingredients in the injection or tablet. Severe hepatic failure or marked liver parenchymal damage, jaundice. Serious haematological disorders and porphyria. Must not be given concomitantly with clozapine.

7. Y site compatibilityCompatible with:Aciclovir, atracurium, glucose 4% and sodium chloride 0.18%, heparin, labetalol, magnesium, morphine.

8. Notes Co-trimoxazole may increase the INR in patients taking warfarin. Co-trimoxazole may increase phenytoin levels, advise close monitoring of levels.









DANAPAROIDThis guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationVTE prophylaxis in adult patients with a history of HIT (unlicensed indication).

Treatment of thromboembolic disorders in adult patients who require urgent parenteral anticoagulation because of the development, or history, of heparin-induced thrombocytopenia (HIT).

2. Presentation750 units in 0.6ml ampoules

3. DoseVTE prophylaxis: 750units, by SC injection, twice daily

Full anticoagulant dose (for treatment of thromboembolic disorders in patients with HIT):Loading dose, using actual body weight:Under 55kg 1250 units intravenous bolus55 to 90kg 2500 units intravenous bolusOver 90kg 3750 units intravenous bolus

Maintenance infusion:400 units/hour for 2 hours, then 300 units/hour for 2 hours, then continue infusion at 200 units/hour for maximum (licensed) duration of 5 days.


Drug Volume Fluid Concentration RateCentral or Peripheral

3000 units

Made up to 30ml


100 units/ml 4ml/hour for 2 hours, 3ml/hour for 2 hours and then 2ml/hour ongoing.

Licensed for maximum of 5 days treatment

5. Common Side EffectsRashesThrombocytopenia including HITInjection site reactionsHaemorrhage

6. Contraindications• Severe haemorrhagic diathesis• Haemorrhagic stroke in the acute phase • Uncontrollable active bleeding state • Severe uncontrolled hypertension • Active gastroduodenal ulcer• Diabetic retinopathy • Acute bacterial endocarditis • A positive HIT screen in the presence of danaparoid



• Hypersensitivity to sulphite• Hypersensitivity to the active substance or to any of the excipients

7. Y site compatibilityGlucose 4% and sodium chloride 0.18%.

8. Notes

Danaparoid should be used with caution in renal impairment, it should only be used in severe renal failure if there is no alternative anticoagulant available. The half life of danaparoid may be prolonged in renal failure.

Antibody-induced thrombocytopenia and thrombosis may occur during treatment with danaparoid. Monitor platelets during therapy with danaparoid and discontinue if thrombocytopenia develops.

Danaparoid contains sodium sulphite, this can result in bronchospasm in some hypersensitive patients with asthma.

In the event of serious bleeding, stop the danaparoid infusion. Contact haematology for advice, consider transfusion of fresh frozen plasma. Danaparoid is only partially reversed by protamine and this should not be used in the event of a bleed. The effects of danaparoid on anti-Xa activity cannot be antagonized with any known agent at this time.

Steady-state levels of plasma anti-Xa activity are usually reached within 4 to 5 days of dosing.

In general monitoring of plasma anti-Xa activity is not necessary. However, in patients suffering from renal insufficiency and/or patients weighing over 90kg, monitoring is recommended.

The expected plasma anti-Xa levels are 0.5 to 0.7 units/ml 5 to 10 minutes after the bolus, not higher than 1unit/ml during the adjustment phase of maintenance infusion and 0.5 to 0.8 units/ml during the maintenance infusion.

Anti-Xa levels are processed at the Royal Liverpool Hospital every day, the telephone number for the clinical chemistry laboratory is 706 4320. Anti-Xa levels should be sent in citrate bottles (blue top). The therapeutic range used by the Royal Liverpool Hospital is 0.4 to 0.8 units/ml.

9. Referenceswww.emc.medicines.org.uk accessed 25/6/12www.medicinescomplete.com accessed 25/6/12http://medusa.wales.nhs.uk Medusa medicines guide accessed 13/11/14BNF edition 63 March 2012







DOBUTAMINE (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationDobutamine is indicated for adult patients who require a positive inotropic support in the treatment of cardiac decompensation due to depressed contractility

2. Presentation250mg in 20ml ampoules

3. Dose2.5 to 10 micrograms/kg/minute. Doses up to 40micrograms/kg/minute may be needed.

4. AdministrationStandard Infusion Recommended by manufacturerRoute Drug Volume Fluid Concentration Initial

RateMaximum Rate*

Central 500mg Up to 100ml **

Glucose 5% 5mg/ml 2ml/hour Usual maximum: 10ml/hour

Absolute maximum:30ml/hour

*Rates are based on a 70kg patient.**Remove 40ml from a 100ml Glucose 5% and then add 500mg dobutamine (i.e. 40ml of 250mg in 20ml injection).

Route Drug Volume Fluid Concentration Initial Rate

Maximum Rate*

Peripheral 500mg Up to 500ml

Glucose 5%

1mg/ml 10ml/hour Usual maximum: 50ml/hour

Absolute maximum:150ml/hour

5. Common Side Effects Tachycardia Hypertension Hypotension Myocardial ischaemia Angina pectoris Hypokalaemia ST segment elevation on ECG Arrhythmias including ventricular tachycardia or fibrillation



Myoclonus (in patients with severe renal impairment)

Dobutamine contains sodium metabisulphite, which may cause allergic-type reactions, including anaphylactic symptoms and severe bronchospasm in susceptible people (particularly asthmatic patients).

Precipitous decreases in blood pressure have occasionally been observed with dobutamine therapy. Decreasing the dose or discontinuing the infusion usually results in rapid return of blood pressure to base-line values, but rarely reversibility may not be immediate.

6. ContraindicationsHypersensitivity to dobutamine, sodium metabisulphite or any of the other ingredients. Phaeochromocytoma

7. Y site compatibilityCompatible with: Acetylcysteine, amiodarone, atracurium, fentanyl, glucose 4% and sodium chloride

0.18%, Glyceryl Trinitrate, Hartmanns (compound sodium lactate), morphine, noradrenaline, propofol, vasopressin

Clonidine if both infusions made up in glucose 5%. Furosemide if both solutions made up in sodium chloride 0.9%.

8. Notes Dobutamine may be prepared in sodium chloride 0.9% but glucose 5% is the preferred

diluent if running alongside other inotropes/vasopressors. The rate of dobutamine should be reduced gradually. Drug interactions:

Halogenated anaesthetics: risk of ventricular arrhythmias Entacapone: may enhance the effect of dobutamine. Betablockers: will reverse the beta1 agonist properties of dobutamine. In therapeutic doses, dobutamine has mild alpha1- and beta2-agonist properties. Concurrent administration of a non-selective beta-blocker such as propranolol can result in elevated blood pressure, due to alpha-mediated vasoconstriction, and reflex bradycardia. Beta-blockers that also have alpha-blocking effects, such as carvedilol, may cause hypotension during concomitant use of dobutamine due to vasodilation caused by beta2 predominance.

Tolerance may develop after 72 hours of continuous dobutamine infusion and higher doses may be required to maintain the same effect.

Continuous blood pressure and heart rate monitoring is required whilst on dobutamine. Half life approximately 2 minutes. Due to low pH, central administration is preferred. The solution may appear slightly pink in colour due to oxidation, this does not lead to a

significant reduction in efficacy.









DOXAPRAM (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationAcute respiratory failure in adult patientsStimulation of ventilation following anaesthesia in adult patients

2. Presentation1g in 500ml Glucose 5% ready made infusion bag100mg in 5ml ampoules

3. DoseUse the 1g/500mL (in glucose 5%) ready made infusion and give IV as follows: From 0 to15mins: 4mg/min (120mL/hour) From 15 to 30mins: 3mg/min (90mL/hour) From 30 to 60mins: 2mg/min (60mL/hour) From 60mins (until condition improves or stabilises): 1.5mg/min (45mL/hour)

4. AdministrationStandard Infusion Recommended by manufacturerRoute Drug Volume Fluid Concentration RateCentral or Peripheral

1g Up to 500ml

Glucose 5% 2mg/ml 120ml/hour for 15 minutes then90ml/hour for 15 minutes then60ml/hour for 30 minutes then45ml/hour to continue

5. Common Side Effects Pyrexia, sweating, flushing Headache, dizziness Hyperactivity, confusion, hallucinations Muscle spasticity, clonus, convulsions Hypertension – discontinue doxapram if sudden or severe hypertension develops. Arrhythmias, sinus tachycardia, bradycardia and extrasystoles Chest pain or chest tightness Dyspnoea, cough, bronchospasm Nausea and vomiting

6. ContraindicationsHypersensitivity to any of the ingredients in the product Severe hypertension Status asthmaticus Coronary artery disease Epilepsy and other convulsive disorders Cerebral oedema Cerebrovascular accident Hyperthyroidism



Physical obstruction of the respiratory tract, or conditions resulting in restriction of chest wall, muscles of respiration or alveolar expansion.Doxapram should not be used in conjunction with mechanical ventilation.

7. Y site compatibilityCompatible with:Fentanyl, gentamicin, heparin, insulin, metoclopramide, metronidazole, ranitidine, vancomycin

8. Notes pH 3.5-5 Concurrent use of aminophylline and doxapram may be associated with agitation,

muscle fasciculation and hyperactivity. The effect of doxapram may be enhanced following administration of a monoamine

oxidase inhibitor, use combination with great caution. Doxapram may potentiate the effects of sympathomimetic agents. Half life around 3.4 hours. An adequate airway and oxygenation should be established before administering

doxapram. Take care to prevent vomiting and aspiration. Monitoring of blood pressure, heart rate and deep tendon reflexes is recommended to

prevent overdosage. Arterial blood gases should be monitored prior to and at 30 minute intervals during

administration of doxapram to guard against the development of respiratory acidosis. Doxapram should be given concurrently with oxygen. Doxapram should be discontinued if arterial carbon dioxide tension increases, oxygen

tension decreases, or mechanical ventilation is initiated. An adequate airway is essential and airway protection should be considered since

Doxapram may stimulate vomiting In patients with bronchoconstriction doxapram should always be used in conjunction

with beta adrenoceptor bronchodilator drugs.









ENOXIMONE (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationCardiogenic shock in adult patients

2. Presentation100mg/20ml ampoules

3. DoseLoading dose: 90microgams/kg/minute, administered over 10 to 30 minutesMaintenance dose: 5-20micrograms/kg/minute

Total dose in 24 hours should not exceed 24mg/kg

The loading dose is not normally recommended due to the risk of life-threatening hypotension.Loading Dose Weight (kg) 40 50 60 70 80 90 100Rate ml/hrUsing a 2.5mg/ml concentration at 90micrograms/kg/min

86.4 108 129.6 151.2 172.8 194.4

216

Maintenance Dose in ml/hour based on a 2.5mg/ml solutionDose micrograms/kg/min

40 50 60 70 80 90 100

5 4.8 6 7.2 8.4 9.6 10.8 127.5 7.2 9 10.8 12.6 14.4 16.2 1810 9.6 12 14.4 16.8 19.2 21.6 2412.5 12 15 18 21 24 27 3015 14.4 18 21.6 25.2 28.8 32.4 3617.5 16.8 21 25.2 29.4 33.6 37.8 4220 19.2 24 28.8 33.6 38.4 43.2 48

4. AdministrationStandard Infusion Recommended by manufacturerRoute Drug Volume Fluid ConcentrationCentral 500mg Up to

200mlSodium Chloride 0.9% 2.5ml/ml

Remove 150ml from a 250ml bag of sodium chloride 0.9%, then add 500mg (100ml of 100mg/20ml injection) enoximone.

5. Common Side EffectsEctopic beats HypotensionVentricular tachycardia HeadacheSupraventricular arrhythmias InsomniaNausea and vomiting DiarrhoeaOliguria FeverUrinary retention Upper and lower limb pain



6. ContraindicationsHeart failure associated with hypertrophic cardiomyopathyStenotic or obstructive valvular disease or other outlet obstruction

7. Y site compatibilityEnoximone must be administered via a dedicated lumen.

8. Notes pH 12, must be administered via a central line. Enoximone is unstable in solution and crystals may form at concentrations less than

2.5mg/ml. Administration in glucose leads to precipitation. Dose reduction may be required in hepatic and renal impairment, no further

information available. Loading dose can cause significant hypotension from vasodilation.

9. Referenceswww.ukcpa.org.uk accessed 27/10/11BNF edition 62 September 2011http://medusa.wales.nhs.uk Medusa medicines guide accessed 13/11/14






EPOPROSTENOL (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationAnticoagulation of haemofiltration circuits in adult patients on consultant request.Usually reserved for patients at high risk of bleeding (e.g. low platelets) where heparin is contraindicated and who have failed on haemofiltration without anticoagulation.

2. Presentation500microgram vial, brand name Flolan®

Epoprostenol is a Payment-by-Results-excluded drug and patient details must be recorded by pharmacy in order to receive payment from the CCG Therefore only one vial is kept on ITU in order to start treatment in an emergency; subsequent vials must be ordered from pharmacy.

3. DoseCommence epoprostenol 15 to 30 minutes prior to commencing haemofiltration. Start the infusion at 1nanogram/kg/minute and increase by 1nanogram/kg/minute every 5 to 10 minutes up to a maximum of 4nanograms/kg/minute. Monitor blood pressure closely.

Doses up to 5nanograms/kg/minute may occasionally be needed but, at this dose, cardiovascular side effects are more prominent so the dose may not be tolerated.

Infusion Rates (ml/hour) for a 2 microgram/ml solutionDose

(nanograms/kg/min)

Patient Weight (kg)30 40 50 60 70 80 90 100

1 0.9 1.2 1.5 1.8 2.1 2.4 2.7 32 1.8 2.4 3 3.6 4.2 4.8 5.4 63 2.7 3.6 4.5 5.4 6.3 7.2 8.1 94 3.6 4.8 6 7.2 8.4 9.6 10.8 125 4.5 6 7.5 9 10.5 12 13.5 15

4. AdministrationReconstitution:1. Use only the Glycine buffer diluent provided for reconstitution. 2. Withdraw approximately 10 ml of the Glycine buffer diluent into a sterile syringe, inject the contents of the syringe into the Epoprostenol vial and Solvent for Solution for Infusion and shake gently until the powder has dissolved. 3. Draw up the resulting solution into the syringe, re-inject it into the remaining volume of the Glycine buffer diluent solution and mix thoroughly. 4. Withdraw 50ml from a 250ml bag of sodium chloride 0.9%5. The epoprostenol solution must be filtered before use. Draw up the reconstituted product into a large syringe and then attach the sterile filter provided to the syringe. Inject the concentrated solution directly into the 200ml bag of NaCl 0.9% using firm but not



excessive pressure; the typical time taken for filtration of 50 ml of concentrated solution is 70 seconds. Mix well.

The filter unit must be used once only and then discarded.

The reconstituted infusion bag must be used within 12 hours if stored at room temperature, i.e. each syringe connected to the machine must be replaced after 12 hours.

The 250ml bag may be stored in the fridge for 24 hours.

Standard Infusion Recommended by manufacturerDrug Volume Fluid Concentration


500microgram reconstituted in 50ml

Up to 250ml

Sodium Chloride 0.9% 2micrograms/ml

5. Common Side EffectsHypotension, tachycardia, bradycardia, flushing, sweating, abdominal pain, hyperglycaemia.

6. ContraindicationsKnown hypersensitivity to epoprostenol or excipients.Congestive heart failure arising from severe left ventricular dysfunction. Patients who develop pulmonary oedema during dose-ranging.

Caution in patients at high risk of bleeding.

7. Y site compatibilityNo information available, epoprostenol must be administered via a dedicated lumen.

8. Notes pH or reconstituted solution 10.5 Epoprostenol must never be given by a bolus injection. Do not flush a line containing epoprostenol. Blood pressure and heart rate must be monitored during infusion of epoprostenol. Concomittant use with NSAIDs or anti-platelet drugs may increase the risk of bleeding. The half life is expected to be less than 6 minutes. Therefore any cardiac side effects

should diminish after 30 minutes.

9. Referenceswww.ukcpa.org.uk accessed 03/09/12www.emc.medicines.org.uk accessed 03/09/12http://medusa.wales.nhs.uk Medusa medicines guide accessed 13/11/14BNF edition 63 March 2012







ERYTHROMYCIN (AS A PROKINETIC)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationSecond-line prokinetic in adult patients (unlicensed indication).Consider adding to metoclopramide if aspirates remain high.

2. Presentation250mg/5ml syrup250mg tablets1g Injection

3. Dose250mg BD (PO,NG,IV). Advise for maximum duration 72 hours.

4. AdministrationFirst line — give via enteral route.

Second line — consider intravenous administration if enteral route has no effect after 24 to 48 hours or if enteral administration is impractical.

Standard infusion recommended by manufacturer. Infuse over 30 to 60 minutes.Drug Volume Fluid Concentration Rate


250mg Up to 100ml

Sodium Chloride 0.9% 2.5mg/ml 100ml/hour or 200ml/hour

Minimum Volume (for fluid restricted patients)Drug Volume Fluid Concentration Initial Rate


250mg Up to 50ml

Sodium Chloride 0.9% 5mg/ml 50ml/hour or 100ml/hour

5. Common side effectsProlonged QTc interval, palpitations, cardiac rhythm disorders.Nausea, diarrhoea, pseudomembranous colitis, cholestatic hepatitis, jaundice, hepatic dysfunction, hepatomegaly, hepatic failure.Confusion, seizures, hallucinations.Urticaria, pruritis, rashes.

6. ContraindicationsKnown hypersensitivity to erythromycin. Erythromycin is contraindicated in patients taking astemizole, terfenadine, cisapride or pimozide. Erythromycin is contraindicated with ergotamine and dihydroergotamine.Known previous or current MRSA or Clostridium difficile infection.



7. Y site compatibilityCompatible with:Aciclovir, aminophylline, compound sodium lactate (Hartmann’s), heparin, labetalol, magnesium, midazolam, morphine.

8. Notes The use of erythromycin could theoretically lead to development of macrolide

resistance. Therefore use if recommended only if first-line treatment (metoclopramide) fails and for a short duration only (max 72 hours).

Erythromycin may aggravate weakness in patients with myasthenia gravis. Rhabdomyolysis has been reported in patients taking erythromycin who are also taking

statins, particularly simvastatin. Simvastatin should be withheld during treatment with erythromycin.

Erythromycin is a cytochrome P450 enzyme inhibitor and therefore may lead to raised levels of other medicines metabolised by cytochrome P450 enzymes. These drugs include: alfentanil, carbamazepine, ciclosporin, digoxin, fluconazole, phenytoin, tacrolimus, theophylline and valproate.

The prokinetic dose is lower than the antibiotic dose but drug interactions may still occur and caution is advised. Contact pharmacy for further advice. Advise against concomitant use with simvastatin or amiodarone.

All prescriptions should be endorsed ‘prokinetic’.









ESMOLOL (INTRAVENOUS)This guideline is a summary, full details are available from the references listed below

1. IndicationLicensed indications:Hypertension and tachycardia in the perioperative period in adult patientsShort term treatment of supraventricular arrhythmias in adult patients

Off label indications:Treatment of hypertension and tachycardia in patients who are nil by mouth

2. Presentation100mg/10ml ampoule (10mg/ml)2500mg/250ml infusion bag (10mg/ml)

3. Dose

Supraventricular arrhythmias:Loading dose 500micrograms/kg given over 1 minuteMaintenance Infusion 50micrograms/kg/minute.Review after 4 minutes, if necessary repeat loading dose and increase infusion to 100micrograms/kg/minute. The loading dose may be repeated up to 3 times and the infusion rate may be increased to a maximum of 200micrograms/kg/minute.When transferring a patient to another antiarrhythmic drug, the infusion rate of esmolol hydrochloride is reduced by 50% thirty minutes after starting the alternative drug, and may be stopped one hour after the second dose of that drug.

Post operative hypertension and tachycardia:During anaesthesia: Loading dose 80mg over 15 to 30 seconds.Maintenance infusion 150micrograms/kg/minute up to max 300micrograms/kg/minute.

On waking from anaesthesia:Loading dose 500micrograms/kg/minute for 4 minutesMaintenance infusion up to 300micrograms/kg/minute.

Loading dose table – for 500microgram/kg doseWeight (kg) Dose (mg) Volume of

infusion (10mg/ml)

50 25 2.560 30 370 35 3.580 40 490 45 4.5100 50 5



Maintenance Infusion table – Infusion rate in ml/hour of 10mg/ml infusionDose (microgram/kg/minute)

Weight 50kg

Weight 60kg

Weight 70kg

Weight 80kg

Weight 90kg

Weight 100kg

50 15 18 21 24 27 30100 30 36 42 48 54 60150 45 54 63 72 81 90200 60 72 84 96 108 120250 75 90 105 120 135 150300 90 108 126 144 162 180


Drug Volume Concentration RateCentral 2500mg 250ml 10mg/ml See table above. Start at low rate and

titrate to BP and HRIf central access is unavailable it may be given via a large peripheral vein but the central route is preferred due to its potential to cause venous irritation.

5. Common Side EffectsBradycardia, hypotension, bronchospasm, hypersensitivity reactions, thrombophlebitis and infusion site reactions.

6. ContraindicationsAsthma, uncontrolled heart failure, bradycardia, hypotension, sick sinus syndrome, second or third degree AV block, cardiogenic shock, metabolic acidosis, severe peripheral arterial disease, phaeochromocytoma (except in combination with alpha blockers), known hypersensitivity to atenolol or any excipients.

7. Y site compatibilityCompatible with:Alfentanil, aminophylline, amiodarone, atracurium, compound sodium lactate (Hartmann’s), co-trimoxazole, fentanyl, glucose 4% and sodium chloride 0.18%, GTN, heparin, hydrocortisone, insulin, labetalol, magnesium, metronidazole, midazolam, morphine, noradrenaline, phenytoin, potassium chloride, propofol, sodium chloride 0.9%, glucose 5%, vancomycin.

8. Notes Use with caution in renal impairment. Licensed only in adults over 18 years. pH 4.5 to 5.5, give via large vein or central line if possible. Monitor BP and HR during infusion, reduce dose if HR falls below 55bpm. Elimination half life is approximately 9 minutes.

9. Referenceswww.ukcpa.org.uk accessed 17/7/12www.medicinescomplete.com accessed 17/7/12http://medusa.wales.nhs.uk Medusa medicines guide accessed 13/11/14BNF edition 63 March 2012







ETHANOL (INTRAVENOUS)This guideline is a summary, full details are available from www.toxbase.org

1. IndicationEthylene glycol (antifreeze) or methanol poisoning (Unlicensed) in adult patients

2. Presentation90% ethanol (alcohol) in 20ml ampoules

3. DoseLoading dose: 10ml/kg of 10% ethanol, given IV over 30 minutes. Dose based on actual body weight.

Maintenance dose: Continue with maintenance infusion according to chart below.

10% ethanol infusion

10% ethanol infusion for patients receiving dialysis

Standard maintenance dose (non-drinker)

1mL/kg/hr 2.5mL/kg/hr

Standard maintenance dose (average adult)

1.5mL/kg/hr 3mL/kg/hr

Standard maintenance dose (drinker)

2.3mL/kg/hr 4mL/kg/hr

Drinker defined as alcohol consumption above recommended level, or shown signs of dependence and alcoholism.

4. Administration

Standard Infusion Recommended by toxbase, unlicensedDrug Volume Fluid Concentration Initial Rate


111mL Up to 1000mL

Glucose 5% 10% 1mL/kg/hr

Eg. For a 70kg adult patient, non-drinker. The loading dose would be 700ml of 10% ethanol over 30 minutes, followed by 70mL per hour. Monitoring requirements applies.

To make a 10% ethanol solution; remove 111mL from a 1000mL bag of 5% glucose or 0.9% sodium chloride, then add 111 mL of ethanol 90%. Glucose is the preferred diluent. 10% ethanol solutions are hyperosmolar and irritant to the veins and are best given via a central venous catheter.

5. Common side effectsEffects of alcohol at higher concentrations may include; nausea, vomiting, headache,dizziness and tremor. Alcohol depresses medullary action causing lethargy, amnesia,hypothermia, hypoglycaemia (especially in children), stupor, coma, respiratorydepression, cardiomyopathy, hypotension or hypertension and cardiovascular collapse.



At low to moderate concentrations, alcohol acts as a stimulant depresses corticalfunction causing loss of judgement, emotional lability, muscle incoordination, visual impairment, slurred speech, ataxia, dysarthia and nystagmus.

6. ContraindicationsHypersensitivity to ethanol or to any of the excipients.

7. Y-site compatibilityNo information.

8. Notes The Oral route should be considered where this is available. Blood ethanol concentrations should be monitored every 1-2 hours initially until a

concentration of 1000-1500mg/L is reached and every 2-4 hours thereafter. Ethanol concentration should be repeated 1 hour after any change of rate.

Ethanol should be continued until either ethylene glycol or methanol concentration is undetectable or ethylene glycol or methanol concentration is less than 50 mg/L AND acidosis and signs of systemic toxicity have resolved.

Ethanol should be used with caution in the following situations:1. Patients with depressed conscious level2. Co-ingestion of other drugs that may cause CNS depression (e.g. opioids, sedatives,

antidepressants, anticonvulsants, antihistamines, hypnotics, muscle relaxants)3. Patients taking disulfiram or metronidazole - may cause hypotension and flushing, in

such patients fomepizole may be a better choice4. Hepatic disease5. Pregnancy- the use of alcohol is controversial. Please discuss individual cases with

the UK Teratology Information Service (UKTIS) on 0844 892 09096. Children - children are more susceptible to developing hypoglycaemia during treatment

with ethanol About 90% to 98% of alcohol is oxidised and the remainder is excreted unchanged by

the kidneys and the lungs and also in breast milk, saliva, sweat and other secretions Alcohol is also known to interact with the following medicines or group of medicines:

antihypertensive agents such as ACE inhibitors, adrenergic neurone blockers, betablockers, antidiabetic agents, alpha blockers, angiotensin II receptor antagonists, bromocriptine, calcium channel blockers, oral coagulants such as coumarins, phenindione, cycloserine, antifungal agents, hyoscine, diuretics, metronidazole, nabilone, and procarbazine. Please contact pharmacy for further information

May cause orthostatic hypotension in patients taking drugs with vasodilator action Ethanol has much greater affinity for alcohol dehydrogenase than ethylene glycol

or methanol, therefore competitively inhibits the metabolism

9. Referenceswww.medicinescomplete.com accessed 22/11/13http://medusa.wales.nhs.uk Medusa medicines guide accessed 13/11/14http://medusa.wales.nhs.uk/docs/SPCs/SPC_Absolute_alcohol_2008.pdf assessed 22/11/13http://www.toxbase.org accessed 22/11/13



http://www.toxbase.org/

http://medusa.wales.nhs.uk/docs/SPCs/SPC_Absolute_alcohol_2008.pdf%20assessed%2022/11/13

http://medusa.wales.nhs.uk/docs/SPCs/SPC_Absolute_alcohol_2008.pdf%20assessed%2022/11/13




FENTANYL (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationSedation and analgesia in adult patients

2. Presentation500micrograms in 10ml amps (50micrograms/ml)

3. Dose0.1micrograms/kg/minuteLower infusion rates 0.05-0.08micrograms/kg/minute are required to maintain spontaneous ventilation.


Drug Volume Fluid Concentration Usual dose rangeCentral or Peripheral

2500micrograms 50ml Undiluted 50micrograms/ml 0 to 5ml/hour

5. Side EffectsBradycardia, tachycardia, arrhythmias, hypotension, hypertension, bronchospasm, respiratory depression, nausea, muscle rigidity, agitation, confusion.

6. ContraindicationsKnown hypersensitivity to fentanylRespiratory depressionPatients following surgery on the biliary tract

7. CompatibilityCompatible with:Acetylcysteine, aminophylline, amiodarone, atracurium, clonidine, dobutamine, furosemide, GTN, heparin, labetalol, ketamine, metronidazole, midazolam, noradrenaline, pancuronium, potassium chloride, propofol, vecuronium.

8. Notes With continuous treatment fentanyl will accumulate so a dose reduction is likely to

be needed. Fluconazole and voriconazole reduce the metabolism of fentanyl so dose reduction

of fentanyl may be required. Half life is 3.7 hours

9. Referenceswww.ukcpa.org.uk accessed 15/7/11www.emc.medicines.org.uk accessed 15/7/11www.medicinescomplete.com accessed 15/7/11http://medusa.wales.nhs.uk/IVGuideDisplay.asp accessed 21/11/14



http://medusa.wales.nhs.uk/IVGuideDisplay.asp





FLUMAZENIL (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationReversal of the central effects of benzodiazepines, in order to restore spontaneous respiration in adult patients. For diagnosis and treatment of intoxication or overdose with only or predominantly benzodiazepines in adult patients.

2. Presentation500microgram in 5ml

3. DoseStat Doses200micrograms over 15 secondsIf the required level of consciousness is not obtained within 60 seconds, a further dose of 100micrograms can be injected and repeated at 60 second intervals, up to a maximum dose of 1mg. The usual dose required lies between 300 and 600 micrograms.

Infusion100 to 400micrograms per hour, adjusted according to response. Stop infusion every 6 hours to check whether re-sedation occurs.

4. AdministrationStandard Infusion Recommended by manufacturerRoute Drug Volume Fluid Concentration Initial Rate Maximum

RateCentral or Peripheral*

2000 microgram

Up to 500ml


4microgram/ml 25ml/hr 100ml/hr

*Advise administration via large vein due to extreme pH of flumazenil.

Minimum Volume, unlicensed. (for fluid restricted patients)Route Drug Volume Fluid Concentration Initial Rate Maximum

RateCentral 1000 microgram Up to

100mlSodium Chloride 0.9% or Glucose 5%

10microgram/ml 10ml/hr 40ml/hr

5. Common Side EffectsTransient increases in blood pressure and heart rate, flushing, anxiety, insomnia, vertigo, headache, agitation, tremor, dry mouth, hyperventilation, dyspnoea, cough, speech disorder, palpitations, chest pain, increased lacrimation, diplopia, nausea, sweating and shivering.Allergic reactions (including anaphylaxis).



Excessive (more than 1mg) and/or rapidly injected doses may induce anxiety, fear, agitation, dizziness, sweating, tachycardia and palpitationsConvulsions (in patients suffering epilepsy or severe hepatic insufficiency, mainly after long-term treatment with benzodiazepines or multiple medicinal product abuse).

6. Contraindications Hypersensitivity to flumazenil or to any of the excipients. Concomitant use of benzodiazepines for control of a potentially life-threatening

condition (e.g. control of intracranial pressure or status epilepticus). Mixed overdose with benzodiazepines and tricyclic and/or tetracyclic antidepressants

(the toxicity of the antidepressants can be masked by protective benzodiazepine effects).

Epilepsy (especially if on benzodiazepine treatment) Serious brain damage/unstable intracranial pressure Alcohol/drug dependency

7. Y site compatibilityCompatible with:Aminophylline, dobutamine, heparin.

8. Notes pH 3.5-4.5 The action of flumazenil is usually shorter than that of benzodiazepines and sedation

may recur. The patient should remain closely monitored until the effect of flumazenil has worn off.

Monitor ECG, pulse, oximetry, patient alertness and other vital signs such as heart rate, respiratory rate and blood pressure

In patients treated for long periods with benzodiazepines flumazenil can induce withdrawal symptoms. The symptoms are: tension, agitation, anxiety, confusion, hallucinations, tremor and convulsions. The dosage of flumazenil has to be titrated individually and the injection must be administered slowly.

Half life 40 to 80 minutes The half life is prolonged in patients with hepatic impairment. No dosage adjustment is needed in patients with renal impairment.

9. Referenceswww.emc.medicines.org.uk accessed 3/11/11www.medicinescomplete.com accessed 24/11/11http://medusa.wales.nhs.uk Medusa medicines guide accessed 21/11/14BNF edition 62 September 2011







FOMEPIZOLE (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationFomepizole is a competitive inhibitor of alcohol dehyrogenase used in the treatment of ethylene glycol (antifreeze) or methanol poisoning in adult patients. Treatment should be commenced within 1 hour of diagnosis or suspected diagnosis. Untreated ethylene glycol poisoning causes reduced conscious level, metabolic acidosis, oxalate crystalluria and acute renal failure.

2. ContraindicationsPatient’s with a documented allergy to fomepizole or other pyrazoles1,2.

3. CautionsNot to be administered undiluted or by bolus injection. Monitor patients for signs of allergic reaction.

Fomepizole reduces the rate of elimination of ethanol by approximately 40%1. Ethanol reduces the rate of elimination of fomepizole by approximately 50%1. Drugs that affect the P-450 system may alter blood levels of fomepizole1.

4. Dosing informationLoading dose: 15 mg/kg IV to a maximum bodyweight of 110kg.Maintenance doses: 10 mg/kg IV every 12 hours (starting at 12 hours after the loading dose is given) for a maximum of 4 doses; followed by 15 mg/kg IV every 12 hours thereafter1,2, to a maximum bodyweight of 110kg.

NOTE: for patients with body weight in excess of 110kg, then 110kg should be used to calculate the dose.

Fomepizole dosing during haemodialysis:A loading dose of 15 mg/kg is infused over 30 to 45 minutes, followed by 1 mg/kg/hour continuous infusion for the entire duration of the haemodialysis1,2.

5. Method of Administration Available as 100mg in 20ml ampoules.

All doses should be administered as slow intravenous infusion for 30 minutes. Dilute in at least 100 mL sodium chloride 0.9% or glucose 5%. Note due to large drug volume for each dose, advise removing between 250ml and 400ml of fluid from a 500ml infusion bag and then adding the drug.

6. Side effects Headache Nausea Dizziness Drowsiness Taste disturbance Abdominal pain



Fever Phlebitis Hypotension Eosinophilia Facial flushing Nystagmus

7. CompatibilityNo data available. Infuse via a dedicated line or lumen.

8. MonitoringMonitoring of fomepizole levels is not required.

9. DurationFomepizole should be continued until ethylene glycol or methanol concentration is undetectable or ethylene glycol or methanol concentration is less than 50 mg/L AND acidosis and signs of systemic toxicity have resolved1.

10. Notes

If fomepizole is unavailable then consider using ethanol.

11. References

1. Toxbase. Commissioned by the National Poisons Information Service and The Health Protection Agency. Date of text revision 12/2009. Available at www.toxbase.org. Accessed 02/06/11.

2. Summary of Product Characteristics. Antizol® (Fomepizole) Injection. Jazz Pharmaceuticals. Date of text revision 20/11/2006.



http://www.toxbase.org/


FUROSEMIDE (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationFurosemide is a loop diuretic used to treat oedema and fluid overload in adult patients.

2. Presentation50mg in 5ml InjectionAlso available as 20mg, 40mg, 500mg tablets and 40mg/5ml oral solution.

3. DoseOedema: 20 to 40mg daily po or ivResistant oedema: 80 to 120mg daily po or ivIn chronic renal failure, oral doses of 250mg to 500mg daily po or iv may be required.

Continuous intravenous infusion typically up to 10mg/hour.Rarely, intravenous stat dose of 250mg over 1 hour can be given.

4. Administration

Stat doses above 80mg should be infused at a rate no greater than 4mg/minute (or 2.5mg/minute in severe renal impairment).

Standard Infusion Recommended by manufacturerDrug Volume Fluid Concentration Typical

RateCentral or Peripheral

50mg Up to 50ml

Sodium Chloride 0.9% 1mg/ml Up to 10ml/hour

Minimum volume (unlicensed) — for fluid restricted patients or when giving high doses

Drug Volume Fluid ConcentrationCentral or Peripheral

250mg

or

500mg

25ml

or

50ml

Give undiluted 10mg/ml

5. Common side effectsPostural hypotension pancreatitis, hepatic encephalopathy, hyperglycaemia, electrolyte disturbance, metabolic alkalosis, blood disorders (including bone marrow suppression and thrombocytopenia), hyperuricaemia, hypersensitivity reactions.

6. ContraindicationsHypersensitivity to furosemide.Hypokalaemia, hyponatraemia.Hypovolaemia, dehydration.Severe hepatic encephalopathy.

7. Y-site compatibility



Furosemide 1mg/ml infusion:If all medicines administered in sodium chloride 0.9% then compatible with:Acetylcysteine, alfentanil, aminophylline, calcium gluconate, compound sodium lactate (Hartmann’s), digoxin, heparin, hydrocortisone, GTN, meropenem, midazolam, morphine, propofol 1%, sodium bicarbonate 8.4%.

Undiluted furosemide 10mg/ml is compatible with:Fentanyl, heparin, potassium chloride and meropenem.

Furosemide injection is incompatible with highly acidic solutions including glucose 5%.

8. Notes Furosemide causes dose-related diuresis. Peak effect occurs 30 minutes after an intravenous dose. Use with caution in patients at risk of hepatorenal syndrome. Rapid administration of high doses can cause tinnitus and deafness. For maximum efficacy, and to suppress counter regulation, a furosemide infusion is

preferred to multiple bolus doses. Use cautiously in patients on concomitant medication that causes hypokalaemia (eg,

salbutamol, hydrocortisone, aminophylline). Use with caution in patients who suffer from gout. Increased risk of ototoxicity if patient also prescribed gentamicin. Furosemide may increase levels of lithium; regular monitoring of lithium levels is

advised. Oral bioavailability is 60-70%, the effect lasts for up to 6 hours post dose. pH 8 to 9.3. Use with caution in anuria or in renal failure following overdose of hepatotoxic or

nephrotoxic drugs.

9. Referenceswww.ukcpa.org.uk accessed 24/02/12www.emc.medicines.org.uk accessed 24/02/12www.medicinescomplete.com accessed 24/02/12 http://medusa.wales.nhs.uk Medusa medicines guide accessed 21/11/14BNF edition 61 March 2011








GLYCERYL TRINITRATE (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationCongestive heart failure in adult patientsRefractory unstable angina pectoris in adult patientsHypertension in adult patients

2. Presentation50mg in 50ml infusion

3. DoseCongestive heart failure: 10-100 micrograms/minute

Refractory unstable angina pectoris. An initial infusion rate of 10 to 15 micrograms/minute is recommended; this may be increased cautiously in increments of 5 to 10 micrograms until either relief of angina is achieved, headache prevents further increase in dose, or the mean arterial pressure falls by more than 20 mm Hg.

Hypertension: The usual dose is 25 to 200 micrograms/minute. Doses up to 400microgram/minute have been required.


Drug Volume Concentration

Initial Rate Maximum Rate


50mg 50ml 1mg/ml 0.6ml/hour

(i.e. 10 microgram / minute)

Congestive heart failure 6ml/hour

Hypertension 12ml/hour(24ml/hour in exceptional circumstances)

Start at 0.6mL/hour. Titrate upwards in increments of 0.6mL/hour, every 30 minutes, according to blood pressure and chest pain.

5. Common Side Effects

Tachycardia Paradoxical bradycardiaHypotension Retrosternal discomfortDizziness NauseaDiaphoresis Abdominal painFlushing Restlessness


Known hypersensitivity to nitrates, severe anaemia, severe cerebral haemorrhage, head trauma, uncorrected hypovolaemia and hypotensive shock, arterial hypoxaemia and



angina caused by hypertrophic obstructive cardiomyopathy, constrictive pericarditis, pericardial tamponade, toxic pulmonary oedema. Concomitant use of sildenafil.

Glyceryl Trinitrate should be administered with caution and under continuous monitoring to patients with acute left-sided heart failure or acute myocardial infarction and only when the systolic blood pressure exceeds 90 mm Hg.

7. Y site compatibilityCompatible with:Aminophylline, amiodarone, atracurium, clonidine, fentanyl, furosemide, glucose 5%, heparin, insulin, labetalol, midazolam, morphine, propofol, sodium chloride 0.9%,

8. Notes Use of GTN and sildenafil is contraindicated due to a potentiation in hypotensive

effects which results in a potentially dangerous/fatally low blood pressure. Plasma half-life of glyceryl trinitrate is 1 to 4 minutes pH 3-6.5, advise administer infusion via central line or large peripheral cannula. Some brands of GTN contain propylene glycol which may cause lactic acidosis, avoid

use of continuous infusion for longer than 3 days. GTN infusion should be weaned gradually and not abruptly stopped.









HEPARIN (UNFRACTIONATED; INTRAVENOUS)

For information on dosing for unfractionated heparin, and how to monitor (and adjust) treatment, see the clinical guideline “Unfractionated heparin infusion — adult patients ” .



http://www.wuth.nhs.uk/media/1537557/Unfractionated-heparin-infusion-clinical-guideline-v5.pdf


HYDRALAZINE (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationSevere hypertension unresponsive to standard treatment in adult patients.

Hydralazine is a peripheral vasodilator. It’s precise mechanism of action is not known but it exerts it’s vasodilatory effect principally on the arterioles.

2. Presentation20mg ampoule

3. DoseAdult patients over 18 years.

Bolus dose: 5 to 10 mg by slow intravenous injection. This may be repeated if required after an interval of 20 to 30 minutes.

Continuous intravenous infusion:Initial rate of 200 to 300micrograms/minMaintenance flow rates must be determined individually and are usually within the range 50 to 150micrograms/min.

Hydralazine may start to accumulate in renal impairment (creatinine clearance less than 30ml/minute) or hepatic impairment, the rate may need to be reduced.

4. AdministrationThe contents of the 20mg ampoule should be reconstituted with 1 ml of water for injection.

Bolus dose further dilute the 20mg in 1ml reconstituted ampoule with 10 ml of Sodium Chloride 0.9% and administer by slow intravenous injection over at least 5 minutes, to avoid rapid reduction in blood pressure.

Standard Infusion Recommended by manufacturerDrug Volume Fluid Concentration Initial Rate

(ml/hour)Maintenance Rate (ml/hour)


20mg 500ml Sodium Chloride 0.9%

40 micrograms/ml (0.04mg/ml)

300 to 450 75 to 225

The maintenance rate should be titrated to the target blood pressure

Minimum Volume, unlicensed. (for fluid restricted patients)Drug Volume Fluid Concentration Initial Rate

(ml/hour)Maintenance Rate (ml/hour)


60mg 60ml Sodium Chloride 0.9%

1mg/ml 12 to 18 3 to 9



5. Common Side EffectsCommonly at the start of treatment: Tachycardia, palpitations, angina symptoms, flushing, headache, dizziness, nasal congestion and gastro-intestinal disturbances. However such effects generally subside later in the course of treatment.

Less common side effects include: peripheral neuritis, paraesthesia (reversed by administering pyridoxine), arthralgia, joint swelling, myalgia, rash, increased plasma creatinine, haematuria sometimes in association with glomerulonephritis, acute renal failure, urinary retention, diarrhoea, vomiting, jaundice, liver enlargement, abnormal LFTs, hepatitis, paralytic ileus, anaemia, leucopenia, neutropenia, thrombocytopenia, haemolytic anaemia, leucocytosis, lymphadenopathy, pancytopenia, splenomegaly, agranulocytosis, agitation, anorexia, anxiety, depression, hallucinations, Systemic Lupus Erythematosus (SLE)-like syndrome (sometimes resulting in a fatal outcome), hypersensitivity reactions such as pruritus, urticaria, vasculitis, eosinophilia, hepatitis, dyspnoea, pleural pain.

Hydralazine should be discontinued if rash, SLE syndrome or blood disorders develop.

6. Contraindications Known hypersensitivity to hydralazine or dihydralazine. Idiopathic systemic lupus erythematosus (SLE) and related diseases. Severe tachycardia and heart failure with a high cardiac output (e.g. in

thyrotoxicosis). Myocardial insufficiency due to mechanical obstruction (e.g. in the presence of

aortic or mitral stenosis or constructive pericarditis). Isolated right ventricular failure due to pulmonary hypertension (cor pulmonale). Dissecting aortic aneurysm.

7. Y site compatibilityCompatible with:Caspofungin, dobutamine, heparin, potassium chloride.

8. Notes Hydralazine produces a decrease in arterial blood pressure, effects which induce

reflux sympathetic cardiovascular responses. This may aggravate angina. The concomitant use of a beta-blocker will reduce these reflex effects and enhance the anti-hypertensive effect. Patients with confirmed coronary artery disease should be commenced on a betablocker prior to commencing hydralazine.

Hydralazine can result in sodium and fluid retention, producing oedema and reduced urinary volume. These effects can be prevented by concomitant administration of a diuretic.

Prolonged treatment with hydralazine may provoke a systemic lupus erythematosus (SLE)-like syndrome. First symptoms are likely to be similar to rheumatoid arthritis (arthralgia, sometimes associated with fever, anaemia, leucopenia, thrombocytopenia and rash) and are reversible after withdrawal of the drug.

Monitor blood pressure and heart rate pH 3.5 to 4.2 once reconstituted

9. Referenceswww.ukcpa.org.uk accessed 17/1/13www.emc.medicines.org.uk accessed 17/1/13www.medicinescomplete.com accessed 21/11/14http://medusa.wales.nhs.uk Medusa medicines guide accessed 21/11/14BNF edition 64 September 2012








INSULINS

For information on how to monitor patients’ blood glucose levels and maintain control, see the clinical guideline “Blood glucose control in critical care”.



http://www.wuth.nhs.uk/media/1165584/Blood-glucose-control-in-critical-care-clinical-guideline-v3.pdf


ISOPRENALINE (INTRAVENOUS)[Back to top]1. IndicationThis medicine is unlicensed. It is used for bradycardia as a bridging therapy before pacing in adult patients.

2. PresentationAmpoules containing 2mg isoprenaline

3. Dose for adult patientsIV infusion: Give at a rate of 0.5-20micrograms per minute using a syringe pump, adjusted according to response.

4. AdministrationStandard Infusion Recommended by Manufacturer

Drug Volume Fluid Concentration Initial Rate Maximum Rate


2mg Up to 500ml

Glucose 5% 4microgram/ml 7.5ml/hour 300ml/hour

Adjust dose according to response

Minimum Volume, unlicensed. (for fluid restricted patients)Drug Volume Fluid Concentration Initial Rate Maximum

RateCentral 2mg Up to

50mlGlucose 5% 40micrograms/ml 0.75ml/hour 30ml/hour

Adjust dose according to response

5. Common Side EffectsTachycardia, cardiac arrhythmias, palpitations, hypotension, tremor, headache, sweating and facial flushing.

6. ContraindicationsTachycardia. Caution in ischaemic heart disease, arrhythmias.

7. Y site compatibilityCompatible with:Adrenaline, amiodarone, atracurium, dobutamine, heparin, magnesium sulphate, morphine, propofol, potassium chloride.

8. Notes Discard the injection if it is pinkish or darker than slightly yellow or contains a

precipitate Half life quoted as one to several minutes.

9. Referenceswww.ukcpa.org.uk accessed 11/2/13www.medicinescomplete.com accessed 21/11/14http://medusa.wales.nhs.uk Medusa medicines guide accessed 21/11/14BNF edition 66 September 2013




KETAMINE (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationLicensed indications include: anaesthesia in adult patients (especially for asthmatic patients) Unlicensed indications include: severe bronchospasm unresponsive to standard treatment for intubated adult patients, pain management (including neuropathic pain) for adult patients.

2. Presentation200mg/20ml Injection (10mg/ml) recommended strength to use on critical care.500mg/10ml vial (50mg/ml) to be used only if concentrated infusion/high dose required. 50mg/ml may be infused undiluted via a central line.Also available as a 10mg/ml oral solution. A high strength 100mg/mL vial is available but is not routinely stocked by WUTH.

3. DosePain management 0.1 to 0.5mg/kg over 20 minutes as a loading dose (5 to 15mg usually sufficient), followed by an infusion of 0.1mg/kg/hour. Doses up to 0.3mg/kg/hour may be used.Larger doses may be given for painful procedures such as dressing changes, for example 10mg intravenous bolus dose every 5 minutes. Bronchospasm Intravenous loading dose 0.5 to 1mg/kg over 2 to 4 minutes followed by an infusion 0.5 to 2 mg/kg/hour. Doses up to 3mg/kg/hour have been used. Beneficial effects are usually seen within 30 minutes to several hours.Infusions are usually given with concurrent midazolam to avoid emergence reactions, suggested dose at least 1mg/hour. For stat doses of ketamine give 0.5mg midazolam stat.

4. AdministrationStandard Infusion Recommended by manufacturerRoute Drug Volume Fluid Concentration Rate*Central or Peripheral

200mg Up to 200ml

Sodium Chloride 0.9%orGlucose 5%

1mg/ml Pain: 7ml/hour

Bronchospasm:Loading dose: 35 to 70ml over two to four minutes

Maintenance dose: 35 to 140ml/hour.

*Rates based on a 70kg patient

Minimum volume (unlicensed) — for fluid-restricted patientsRoute Drug Volume Fluid Concentration Rate*Central or Peripheral

400mg 40ml Undiluted 10mg/ml Pain: 0.7ml/hour

Bronchospasm:Loading dose: 3.5 to 7ml over two to four minutes

Maintenance dose: 3.5 to 14ml/hour

*Rates based on a 70kg patient



5. Common side effectsHypertension and tachycardia are common but ketamine may also cause hypotension and bradycardia. Arrhythmias, anaphylaxis, laryngospasm, increased intraocular pressure, obstructive airway disorder, apnoea, rash, salivary hypersecretion, nausea, vomiting. haemorrhagic cystitis. Rarely may cause respiratory depression.

Hallucination, abnormal dreams, nightmare, confusion, agitation, abnormal behaviour, nystagmus, hypertonia, tonic-clonic movements, delirium, flashback, dysphoria, insomnia, disorientation. These symptoms can occur as emergence reactions when the ketamine infusion is stopped. The incidence of these reactions may be reduced by minimising verbal and tactile stimulation of the patient and concurrent use of midazolam. If the patient experiences significant hallucination the infusion should be discontinued and small doses of benzodiazepine should be considered (eg, diazepam 2 to 5mg orally) for one or two doses.

6. ContraindicationsEclampsia or pre-eclampsia, severe coronary or myocardial disease, cerebrovascular accident or cerebral trauma. Patients in whom hypertension could pose a serious threat. Hypersensitivity to ketamine or any excipients. Raised cerebrospinal fluid pressure.

7. Y-site compatibilityCompatible with: clonidine, fentanyl, morphine, propofol.

8. Notes pH: 3.5 to 5.5. Half-life: 2 to 3 hours. Ketamine is considered to be a controlled drug at WUTH. Ketamine is available as a 100mg/ml concentration. This concentration must be diluted

before use and should be avoided as it is likely to lead to hyponatraemia. Only one strength of ketamine should be stocked to reduce the risk of selection/administration errors. The 100mg/ml ampoules are not kept at WUTH and should not be used.

Ketamine produces bronchodilation by stimulating the release of catecholamines, it may also have a direct bronchodilator effect.

Ketamine should be used with caution in patients with known chronic high alcohol consumption.

Hepatic impairment may lead to a prolonged duration of action, dose reduction should be considered.

Use with caution in patients with a history of psychiatric illness (especially schizophrenia) or with a history of seizures.

Patients with hyperthyroidism or those being treated with levothyroxine are at higher risk of hypertension with ketamine.

Ketamine may potentiate the neuromuscular blocking effects of atracurium. When ketamine and theophylline are given concurrently seizure threshold may be

significantly reduced. Ketamine has an opioid-sparing effect when used for pain management.9. Referenceswww.ukcpa.org.uk accessed 28/03/12www.emc.medicines.org.uk accessed 28/03/12www.medicinescomplete.com accessed 28/03/12http://medusa.wales.nhs.uk Medusa medicines guide accessed 26/11/14Rosario C, Cousins D. What strategies can be adopted to make the use of ketamine safer? The Pharmaceutical Journal 2010;284:613.Macintyre P. Acute pain management a practical guide third edition. 2007. Elsevier Ltd.Martin R. Alternative and experimental agents for the treatment of asthma. Jan 2012. www.uptodate.com (accessed on 15/03/12)Tietze K. Pain control in the critically ill adult. Jun 2011. www.uptodate.com (accessed on 15/03/12)



http://www.uptodate.com/

http://www.uptodate.com/






LABETALOL (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationHypertension in adult patients

2. Presentation100mg/20ml Injection (5mg/ml). Brand Name Trandate®

3. DoseInfusion: 15mg/hour increased to maximum 120mg/hour.




500mg Up to 500ml


1mg/ml 15ml/hour 120ml/hour

Minimum Volume (for fluid restricted patients)Drug Volume Fluid Concentration Initial Rate Maximum

RateCentral or Peripheral

300mg 60ml Undiluted 5mg/ml 3ml/hour 24ml/hour

Ideally administer via a central line especially for prolonged infusions due to risk of venous irritation.

5. Side EffectsPostural hypotension TirednessWeakness HeadacheRashes Scalp tinglingNausea VomitingLiver damage – cases of severe hepatocellular damage. Discontinue labetalol if laboratory evidence of damage or jaundice. Do not restart.

6. ContraindicationsBronchospasm Uncontrolled heart failureBradycardia HypotensionSick sinus syndrome Second or third degree AV blockCardiogenic shock Metabolic acidosisSevere peripheral artery diseasePhaeochromocytoma (only use in combination with alpha-blockers)



7. CompatibilityCompatible with:Adrenaline Magnesium sulphateAlfentanil MidazolamAminophylline MorphineAmiodarone NoradrenalineAtracurium Potassium chlorideClonidine PropofolHartmann’s VancomycinDobutamine VecuroniumFentanylGlucose 4% and NaCl 0.18%Glyceryl trinitrate

8. NotesThe half life is approximately 4 hours. About 50% of labetalol in blood is protein bound.

9. Referenceswww.ukcpa.org.uk accessed 15/5/09www.emc.medicines.org.uk accessed 15/5/09BNF edition 57 March 2009www.medicinescomplete.org.uk accessed 15/5/09http://medusa.wales.nhs.uk Medusa medicines guide accessed 26/11/14



http://www.medicinescomplete.org.uk/




LIDOCAINE (INTRAVENOUS)This guideline is summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationPost operative analgesia in adult patients

2. PresentationLidocaine 1% ampoules (10mL) preservative free (will state on box for intravenous use)(Previously called lignocaine). Lidocaine 1% ampoules contain 10mg/ml lidocaine.

3. DoseLoading dose 1.5mg/kg (use ideal body weight)Maintenance dose up to 2mg/kg/hour (use ideal body weight). Typical starting dose 1mg/kg/hour and increase every 8 hours (to allow levels to stabilise) in increments of 0.25 to 0.5mg/kg/hour.

Maximum duration 48 hours.

[Some trials have used up to 3mg/kg/hour. Another common dose is 2mg/minute as a continuous infusion. Note the dose for arrhythmias in adults is 20-50 micrograms/kg/minute (1-3 mg/minute in an average 70 kg adult i.e. 210mg/hour)]

4. AdministrationLoading dose – administer at a rate of 25 to 50mg per minute

Standard Infusion Recommended by manufacturer

Use 0.5% infusion (5mg/ml)Drug Volume Fluid Concentration Starting

RateMaximum Rate


250mL of 1%

(2500mg)

Up to 500ml Glucose 5% 5mg/mL (or 0.5%) 12ml/hour 24mL/hour*

Remove 250ml from a 500ml bag of glucose 5% and then add 250ml of lidocaine 1% (i.e. 25 x 10mL ampoules)*rate based on a 60kg patient

Due to low pH administer via central line where possible.

Minimum Volume, unlicensed. (for fluid restricted patients)Drug Volume Fluid Concentration Starting

RateMaximum Rate


200mL of 1%

(2000mg)

Up to 250ml Glucose 5% 8mg/mL (or 0.8%) 7.5ml/hour 15mL/hour*

Remove 200ml from a 250ml bag of glucose 5% and then add 200ml of lidocaine 1% (i.e. 20 x 10mL ampoules)*rate based on a 60kg patient



5. Common Side EffectsHypersensitivity reactions including rash, urticaria and angioedema.

Neurological signs of systemic toxicity include dizziness or light-headedness, nervousness, tremor, circumoral paraesthesia, tongue numbness, drowsiness, convulsions, coma. Nervous system reactions may be excitatory and or depressant. Signs of CNS stimulation may be brief, or may not occur at all, so that the first signs of toxicity may be confusion and drowsiness, followed by coma and respiratory failure. Blurred vision, diplopia and transient amaurosis may be signs of lidocaine toxicity. Cardiovascular reactions are depressant and may manifest as hypotension, bradycardia, myocardial depression, cardiac arrhythmias and possibly cardiac arrest or circulatory collapse. Respiratory side effects include: dyspnoea, bronchospasm, respiratory depression and respiratory arrest.

If the patient shows any signs of severe toxicity (e.g. hypotension, bradycardia, seizures, change in conscious level) the lidocaine infusion should be stopped immediately and the consultant informed. Serum lidocaine levels should be monitored if toxicity is suspected.


Known hypersensitivity to lidocaine or other anaesthetics of the amide type.

• Sino-atrial disorders • All grades of atrioventricular block • Severe myocardial depression • Porphyria (use with caution in local anaesthesia) • Complete heart block • Hypovolaemia

7. Y site compatibilityCompatible with:Amiodarone, ciprofloxacin, clarithromycin, dobutamine, dopamine, heparin, labetalol, morphine, potassium chloride, remifentanil.

8. Notes Must have continuous blood pressure and ECG monitoring. pH 4 to 6 Consider monitoring lidocaine levels especially if high dose and long duration, some

trials demonstrated high levels. Therapeutic drug level for lidocaine for pain control is 6-12 micromol/L.

Lidocaine infusion may lead to a reduction in opioid requirement. Lidocaine is a local anaesthetic of the amide type It has a rapid onset of action (about one minute following intravenous injection and

fifteen minutes following intramuscular injection) and rapidly spreads through the surrounding tissues. The effect lasts about ten to twenty minutes and about sixty to ninety minutes following intravenous and intramuscular injection respectively

Lidocaine should be used with caution in patients with epilepsy, myasthenia gravis, cardiac conduction disturbances, congestive heart failure, bradycardia, severe shock, impaired respiratory function or impaired renal function with a creatinine clearance of less than 10mL/minute.

Lidocaine is metabolised in the liver and it should be used with caution in patients with impaired hepatic function.

Hypokalaemia, hypoxia and disorders of acid-base balance should be corrected before treatment with intravenous lidocaine begins.



Avoid using lidocaine infusion if patient receiving any other local anaesthetic by any route.

Medicines which may increase levels of lidocaine: amiodarone, citalopram, clarithromycin, fluconazole, fluoxetine,

The clearance of Lidocaine may be reduced by beta-adrenoceptor blocking agents (e.g. propranolol) and by cimetidine, requiring a reduction in the dosage of lidocaine. Increase in serum levels of lidocaine may also occur with anti-viral agents (e.g. amprenavir, atazanavir, darunavir, lopinavir).

There may be an increased risk of ventricular arrhythmia in patients treated concurrently with antipsychotics which prolong or may prolong the QT interval (e.g. pimozide, sertindole, olanzapine, quetiapine, zotepine), or 5HT3 antagonists (e.g. tropisetron, dolasetron).

Inhibition of CYP1A2 by fluvoxamine considerably reduces elimination of lidocaine and increases the risk of lidocaine toxicity. Concomitant use of both fluvoxamine and a CYP3A4 inhibitor such as erythromycin can further increase lidocaine concentrations. Because lidocaine possesses a narrow therapeutic window, doses of lidocaine may need to be adjusted accordingly. Conversely, reduced serum lidocaine concentrations may result from drugs that may stimulate the hepatic metabolism of lidocaine (e.g. phenytoin, oral HRT).

9. Referenceswww.emc.medicines.org.uk accessed 10/7/15www.medicinescomplete.com accessed 10/7/15http://medusa.wales.nhs.uk Medusa medicines guide accessed 10/7/15BNF online accessed 10/7/15Vigneault L et al. Perioperative intravenous lidocaine infusion for postoperative pain control: a meta-analysis of randomized controlled trials. Canadian Journal of Anaesthesia. 2011. 58 22-37.McCarthy G et al. Impact of Intravenous Lidocaine Infusion on Postoperative Analgesia and Recovery from Surgery. A systematic review of Randomized Controlled Trials. Drugs 2010; 70 (9): 1149-1163The Ottawa Hospitals Guideline: Intravenous or subcutaneous lidocaine for pain management. 2010.







MAGNESIUM (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationLicensed indication: hypomagnesaemia in adult patientsUnlicensed indication: severe asthma

2. PresentationMagnesium sulphate 2mmol/mL (50%) ampoules

3. Dosea) Hypomagnesaemia

20 mmol of magnesium

Patients with severe hypomagnesaemia may have a deficit of 0.5-1 mmol/kg. To correct this deficit up to 160mmol of magnesium may be needed over 5 days.

b) Severe asthma

8mmol of magnesium (equivalent to 2g)

4. AdministrationMaximum rate of administration 0.6mmol/minute for hypomagnesaemia.

1. HypomagnesaemiaDrug Volume Fluid Concentration Usual

RateMaximum Rate


20mmol

(10mL of 50%)

Up to 100mL


0.2mmol/mL (5%)

50mL/hr 180mL/hr

Central 20mmol

(10mL of 50%)

10mL* N/A 2mmol/mL (50%)

5mL/hr 18mL/hr

*Minimum volume, unlicensed. (for fluid restricted patients). Administration over 2 hours may increase uptake of magnesium.

2. AsthmaDrug Volume Fluid Concentration Rate

Central 8mmol

(4mL of 50%)

Up to 100mL


0.08mmol/mL 300mL/hr



5. Common Side EffectsHypersensitivity reactions. Hypocalcaemia. Hypermagnesaemia characterised by flushing, thirst, hypotension, drowsiness, nausea, vomiting, confusion, slurred speech, double vision, loss of tendon reflexes due to neuromuscular blockade, muscle weakness, respiratory depression, electrolyte/fluid abnormalities (hypophosphatemia, hyperosmolar dehydration), ECG changes (prolonged PR, QRS and QT intervals), bradycardia, cardiac arrhythmias, coma and cardiac arrest. There is a risk of respiratory depression if magnesium sulphate is administered concomitantly with high doses of barbiturates, opioids or hypnotics.

6. ContraindicationsHypersensitivity to magnesium and it’s salts Magnesium sulphate is contraindicated in patients with heart block, myocardial damage or severely impaired renal function.

7. Y site compatibilityCompatible with: aciclovir, amikacin, clonidine, erythromycin, esmolol, fentanyl, gentamicin, GTN, heparin, insulin (soluble), labetalol, metronidazole, milrinone, morphine sulphate, potassium chloride, propofol, remifentanil and vancomycin.

Also fluids: glucose 10%, sodium lactate infusion, compound sodium lactate (Hartmann's), sodium chloride 0.45% and glucose and sodium chloride combinations.

8. Notes Normal magnesium reference levels are 0.7 -1.0 mmol/L Magnesium sulphate must be used with caution in patients suspected of or known

to have renal impairment. Magnesium sulphate should not be used in hepatic coma if there is a risk of renal

failure. Parenteral magnesium salts should be used with caution in patients with

myasthenia gravis. Hypomagnesaemia often leads to hypocalcaemia, hypokalaemia and

hyponatraemia. Magnesium is not well absorbed from the GI tract and can act as an osmotic

laxative. Options to maintain magnesium in mild hypomagnesaemia include magnesium citrate tablets (6.2mmol) 150mg via the oral route once in the morning or magnesium aspartate (10mmol) 6.5g sachet via NG/PEG tube once daily. Both preparations are unlicensed.

Up to 50% of an I.V. dose may be eliminated in the urine, slower administration may improve retention.

9. Referenceswww.ukcpa.org.uk accessed 26/11/14www.emc.medicines.org.uk accessed 22/05/13www.medicinescomplete.com accessed 22/05/13http://medusa.wales.nhs.uk Medusa medicines guide accessed 26/11/14BNF edition 65 March 2013UpToDate Magnesium Sulphate Drug Information. Accessed 6/2/14




MEROPENEM (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationLower respiratory-tract, urinary-tract, intra-abdominal, skin infections, and septicaemia where ESBL infection known or suspected or on advice from microbiology, in adult patients.

2. Presentation1g ampoules, powder for reconstitution.

3. Dose1g three times daily.Increase to 2g three times daily in severe infection including meningitis.

Renal Impairment:In severe infection give full dose for at least the first 24 hours of therapy.

CrCl less than 25ml/min 1g twice dailyCrCl less than 10ml/min 1g once dailyDuring haemofiltration 1g twice daily

4. AdministrationStandard Infusion Recommended by manufacturerPreferred administration on wards

Drug Volume Fluid Infusion time Infusion rateCentral or Peripheral

1g Up to 100ml



Or reconstitute 1g vial with 20ml water for injection and bolus over 3-5 minutes.

Minimum Volume (for fluid restricted patients)Preferred administration on critical care

Drug Volume Fluid Infusion time Infusion rate


1g Up to 20ml

Water for Injection

4 hours 5ml/hour

5. Side Effects Seizures Eosinophilia, thrombocytopenia, leucopenia, neutropenia Hypersensitivity reactions: angioedema, anaphylaxis, rash, pruritis Diarrhoea, vomiting, nausea, abdominal pain Hepatic toxicity: raised transaminases, alkaline phosphatase, lactate dehydrogenase

and bilirubin. Hepatic function should be closely monitored during treatment. Toxic epidermal necrolysis, Stevens Johnson syndrome, erythema multiforme Blood creatinine increased, blood urea increased



Inflammation, pain at injection site

6. ContraindicationsHypersensitivity to the active substance or to any of the excipients. Hypersensitivity to any other carbapenem antibacterial agent. Severe hypersensitivity (e.g. anaphylactic reaction, severe skin reaction) to any other type of beta-lactam antibacterial agent (e.g. penicillins or cephalosporins), unless on advice on critical care consultant or consultant microbiologist. Note 99% of patients with a positive skin prick test to penicillin will tolerate a carbapenem1.

7. CompatibilityCompatible with:Aminophylline, caspofungin, dexamethasone, digoxin, fluconazole, furosemide, heparin, insulin, linezolid, magnesium, metoclopramide, morphine, potassium chloride, vancomycin.

8. Notes No dosage adjustment is needed in hepatic impairment or elderly patients. The concomitant use of meropenem and valproic acid/sodium valproate is not

recommended due to reports of a significant drop (60-100%) in valproate levels in 2 days.

Meropenem is likely to cause a rise in INR in patients taking warfarin. Similar to other beta-lactam antibacterial agents, the time that meropenem

concentrations exceed the MIC (T>MIC) has been shown to best correlate with efficacy. Meropenem should not be administered via a line with compound sodium lactate

(Hartmann’s solution) running.

9. References1. Up-to-date and literature search conducted on 23-8-10 by Clinical Librarian WUTH.www.emc.medicines.org.uk accessed 08/11/11BNF edition 61 March 2011www.medicinescomplete.com accessed 23/11/11http://medusa.wales.nhs.uk Medusa medicines guide accessed 26/11/14






METARAMINOL (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationAcute hypotension in adult patients (unlicensed).

2. Presentation10mg in 1ml ampoules.

3. DoseIn an emergency, 500micrograms to 5mg by intravenous bolus.

Normally used as a temporary measure before insertion of a central line. Infusions should only be continued beyond 24 hours by consultant request.

4. AdministrationStandard infusion recommended by manufacturer

Drug Volume Fluid Concentration Initial Rate

Maximum Rate


20mg Up to 500ml


40microgram/ml 10ml/hour 250ml/hour

Titrate rate to blood pressure. Central line preferred to avoid risk of venous irritation due to low pH.

Minimum volume (unlicensed) — this concentration should be used whenever possible in critical care.


Central or peripheral

20mg Up to 40ml


0.5mg/ml 1ml/hour 20ml/hour.

Titrate rate to blood pressure. Central line preferred to avoid risk of venous irritation due to low pH.

5. Common side effectsHypertension, bradycardia, arrhythmias, thrombophlebitis, headache, dyspnoea, hypersensitivity reactions. Tissue necrosis may occur following extravasation.

Metaraminol injection contains sodium metabisulphite, which can cause hypersensitivity reactions, circulatory collapse and depression of the central nervous system in susceptible individuals, particularly in patients with asthma.

6. ContraindicationsHypertension. Known hypersensitivity to metaraminol or excipients.

7. Y-site compatibilityCompatible with:Amiodarone, dobutamine, potassium chloride, sodium bicarbonate.





8. Notes pH 3.2 to 4.2 Ideally, metaraminol should be infused via a central line due to potential irritation from

its low pH. However, anecdotally, and as a temporary measure prior to insertion of a central line, it may be infused peripherally.

Metaraminol has a longer duration of action than noradrenaline so an excessive vasopressor response may result in prolonged hypertension.

Metaraminol is a sympathomimetic with direct and indirect effects on adrenergic receptors. It has alpha-and beta-adrenergic activity, the former being predominant. Metaraminol acts as a positive inotrope and a peripheral vasocontrictor, leading to increased cardiac output, peripheral resistance and, consequently, blood pressure.

9. Referenceswww.medicinescomplete.com accessed 22/3/12http://medusa.wales.nhs.uk Medusa medicines guide accessed 27/11/14www.ukcpa.org.uk accessed 22/03/12







MIDAZOLAM (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationSedation, agitation in adult patients

For further information, refer to Midazolam for conscious sedation guidelines

2. Presentation50mg in 50ml infusion5mg/5ml ampoules10mg in 2ml ampoules (CD strength)

3. Dose

IV sedation during minor procedures (conscious sedation)o 2mg by IV injection over 30 seconds. o If after 3 to 5 minutes sedation is not adequate incremental doses of 0.5 to

1mg of midazolam may be giveno In elderly patients start with 1 mg

Sedation in intensive care in ventilated patientso 3-200microgram/kg/hr (Start with lower end of range)o If used in conjunction with opioids start with 10 microgram/kg/hr

Weight (kg) Maximum Infusion Rate (ml/hr) of 1mg/ml solution

40 850 1060 1270 1480 1690 18100 20

4. AdministrationStandard Infusion Recommended by manufacturerRoute Drug Volume Fluid ConcentrationCentral or Peripheral

50mg 50ml Undiluted 1mg/ml

5. Common Side Effects Hypotension Bradycardia Respiratory depression, apnoea and respiratory arrest Confusion, hallucinations and delirium Short term memory impairment. Pain on injection Thrombophlebitis



http://www.whnt.nhs.uk/document_uploads/Intranet-Pharmacy/Midazolam%20for%20conscious%20sedation%20-%20clinical%20guideline,%20v2.pdf

Anterograde amnesia Agitation, aggression Involuntary movements (including tonic/clonic convulsions and muscle tremor) Constipation, nausea, dry mouthIncreased plasma levels of midazolam in patients on erythromycin, diltiazem, ketoconazole & itraconazole

6. ContraindicationsKnown hypersensitivity to benzodiazepines or to any excipient of the product.

7. Y site compatibilityCompatible with:Alfentanil, amiodarone, atracurium, clonidine, compound sodium lactate (Hartmann’s), digoxin, fentanyl, fluconazole, gentamicin, glucose 5%, glyceryl trinitrate, heparin, insulin, labetalol, linezolid, metronidazole, morphine, potassium chloride, propofol, remifentanil, sodium chloride 0.9%, vancomycin, vecuronium.

8. Notes pH 2.9-3.7 administer via central line or large peripheral cannula where possible. When midazolam is used in long-term sedation in ICU physical dependence may

develop. The risk of dependence increases with dose and duration of treatment; it is also greater in patients with a medical history of alcohol and/or drug abuse

Gradual reduction is needed after prolonged IV infusion. Withdrawal symptoms may occur: headaches, muscle pain, anxiety, tension, restlessness, confusion, irritability, rebound insomnia, mood changes, hallucinations and convulsions.

Midazolam 1 mg/ml contains 3.47 mg sodium per ml. Midazolam is metabolized by CYP3A4. Drugs which inhibit CYP3A4 so may increase levels of midazolam:

1. Fluconazole and voriconazole2. Erythromycin and clarithromycin3. Verapamil and diltiazem

Drugs which induce CYP3A4 and may reduce levels of midazolam:1. Rifampicin2. Carbamazepine and phenytoin

Half life in healthy volunteers 1.5-2.5 hours. The half life may be prolonged by 6 times in critically ill patients. Midazolam will accumulate in patients with renal impairment. All strengths of midazolam must be ordered in the CD book but only the 10mg/2ml

strength needs to be stored in the CD cupboard. Flumazenil must always be available on the ward when midazolam is administered for

conscious sedation.





MORPHINE (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationAnalgesia and sedation in adult patients

2. Presentation10mg/ml Injection (CD)60mg/ml Injection (CD)

3. DoseSevere pain: 2.5 to 10mg intravenously.In some situation a continuous infusion may be needed (at a dose of 1 to 5mg/hour). Start at 1mg/hour and titrate until pain is controlled.

Sedation: usually 1 to 5mg/hour although higher doses may be needed.

4. Administration

Bolus injection: Dilute 10mg morphine to 10ml with sodium chloride 0.9% or Glucose 5%. Slow bolus over 3 to 5 minutes.

Standard Infusion Recommended by manufacturerDrug Volume Fluid Concentration Initial Rate Maximum Rate


60mg 60ml Sodium Chloride 0.9% or Glucose 5%

1mg/ml 1ml/hour Titrate to pain, conscious level and respiratory rate.

5. Common Side EffectsNausea, vomiting, constipation, skeletal muscle rigidity, bronchospasm, respiratory depression, respiratory arrest, bradycardia, hypotension, asystole, tachycardia, arrhythmias, rash, urticaria, drowsiness and hallucinations.

6. Contraindications and cautionsHypersensitivity to the active substance or to any of the excipients. Respiratory depression, obstructive airways disease, raised intracranial pressure, coma, convulsive disorders, acute alcoholism, renal failure, ureteral stenosis, pancreatitis, liver failure, gall-bladder dysfunction, ileus, inflammatory bowel disease, hypotension with hypovolaemia, prostatic hypertrophy, myxoedema, pheochromocytoma, concurrent administration of monoamine oxidase inhibitors or within two weeks of discontinuation of their use.

7. Y-site compatibilityCompatible with:Acetylcysteine, alfentanil, aminophylline, amiodarone, atracurium, calcium chloride, clonidine, digoxin, erythromycin, esmolol, fentanyl, fluconazole, glyceryl trinitrate, hydrocortisone, insulin, labetalol, magnesium sulphate, methylprednisolone, metronidazole, midazolam, potassium, propofol, remifentanil, salbutamol, vancomycin, vecuronium.



8. Notes Morphine is a controlled drug. Morphine can produce drug dependence and therefore has the potential for being

abused. Upon repeated administration of morphine, psychological and physical dependence may occur and tolerance may develop. However, when doses of morphine are carefully titrated against pain, clinically significant respiratory depression, addiction, rapid tolerance and euphoria rarely develop.

Drug interactions: morphine may enhance the effects of skeletal muscle relaxants, additive effects if combined with other CNS depressants; morphine reduces the efficacy of diuretics.

The effects of morphine may be reversed by naloxone 400micrograms given intravenously (repeated as necessary), see naloxone guideline for further information.

35% morphine is bound to plasma proteins 60% morphine excreted in urine at 24 hours, half life much extended in renal

impairment. Rapid injection may increase the frequency of side effects. The NPSA have highlighted the potential risk of administration of high doses of

morphine (30mg or more) to patients who have not previously received opiates. Conversion to oral morphine: multiply total dose of intravenous morphine by 2 to give

the total oral dose in 24 hours. Note oral dose usually split for BD administration with Zomorph®. E.g. morphine infusion 2.5mg/hour, gives 60mg in 24 hours. Therefore need 120mg of oral morphine in 24 hours so prescribe Zomorph® 60mg BD.

Morphine should be used with caution in patients with renal failure as it may accumulate.

Morphine ampoules should be diluted before administration due to low pH.

9. Referenceswww.ukcpa.org.uk accessed 12/7/12www.emc.medicines.org.uk accessed 12/7/12http://medusa.wales.nhs.uk accessed 27/11/14BNF edition 63 March 2012







NALOXONE (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationReversal of CNS or respiratory depression caused by natural or synthetic opioids in adult patients.

2. Presentation400 microgram/ml ampoules.

3. DoseComplete or partial reversal of opioid: 100micrograms to 200micrograms given as an intravenous bolus over 3 to 5 minutes. This dose may be repeated every 2 minutes until a satisfactory level of respiration and consciousness is achieved.

Higher doses may be needed in suspected overdose, starting dose suggested 400micrograms but doses up to 2mg may be needed. The dose can be repeated every 2 minutes. If a dose of 10mg has been given with no beneficial response then opioid toxicity is unlikely to be the cause of respiratory depression or unconsciousness.

Adults - IV Infusion: Dose and rate of administration should be titrated according to patient’s response to IV bolus and reaction to IV infusion. Usual starting dose is 60% of initial resuscitative intravenous injection infused over 1 hour, then adjusted according to respiratory rate and level of consciousness.

For example: A patient with some response to a 400microgram dose, who required an additional 400micrograms which then achieved satisfactory ventilation for 15 mins. Total dose received 800micrograms, so start infusion at 480micrograms per hour.

4. AdministrationIV injection: Naloxone may be diluted to a convenient volume with water for injections. It is then administered as a slow bolus over 3 to 5 minutes.

Standard infusion recommended by manufacturerDrug Volume Fluid Concentration Initial Rate*


2mg Up to 500ml


4micrograms/ml 120ml/hour

*Rate based on a patient requiring an initial resuscitative dose of 800micrograms.Adjust according to respiratory rate and level of consciousness.

Minimum volume (unlicensed) — for fluid restricted patientsDrug Volume Fluid Concentration Initial Rate*


10mg Up to 50ml


200micrograms/ml 2.4ml/hour

*Rate based on a patient requiring an initial resuscitative dose of 800micrograms.Adjust according to respiratory rate and level of consciousness.



5. Common side effectsNausea and vomiting.Hypertension, tachycardia, cardiac arrhythmias and pulmonary oedema have been reported after postoperative use of naloxone, generally in patients with pre-existing heart disease undergoing cardiac surgery.Tremor, seizures, hyperventilation, hypotension, dyspnoea, cardiac arrest.Opioid withdrawal symptoms are common in opioid-dependant patients.Return of pain.

6. ContraindicationsHypersensitivity to naloxone or any excipients.

7. Y-site compatibilityCompatible with:Heparin and propofol.

8. Notes Naloxone will reverse analgesia as well as respiratory depression, plus will increase a

patient’s level of consciousness. It is possible to titrate the dose of naloxone to avoid completely reversing analgesia. Consider the use of non opioid analgesia to support patient’s analgesic needs.

Use with caution in patients taking high doses of opioids or who are physically dependent on opioids. Use of naloxone to rapidly reverse the opioid can cause an acute withdrawal syndrome, symptoms may include: hypertension, cardiac arrhythmias, pulmonary oedema and cardiac arrest.

pH range 3 to 6.5 depending on the brand. Naloxone is likely to cause extravasation leading to tissue damage due to its low pH.

Precaution should be taken to avoid extravasation. Ideally, naloxone should be given through a central line and patients receiving repeated doses of hazardous drugs peripherally should have the cannula re-sited at regular intervals

May be injected intramuscularly if the intravenous route is not available. Use of the intramuscular route can lead to tissue damage.

The duration of action for naloxone varies between about 45 minutes and 4 hours. The duration of action of most opioids is likely to be longer than naloxone and therefore close monitoring of the patient is required after administering naloxone.

Naloxone should be used with caution in the elderly or those taking cardiotoxic drugs because they are more at risk of ventricular tachycardia and fibrillation arrhythmias.

Naloxone may not completely reverse buprenorphine (a partial opioid agonist). No dosage adjustment is needed in renal or hepatic impairment.

9. Referenceswww.emc.medicines.org.uk accessed 26/3/12www.medicinescomplete.com accessed 28/03/12http://medusa.wales.nhs.uk Medusa medicines guide accessed 27/11/14BNF edition 62 September 2011






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NEOSTIGMINE (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

10. IndicationMyasthenia Gravis – when unable to take enteral pyridostigmine

Acute colonic pseudo-obstruction in adults (unlicensed indication if given intravenously)

11. Presentation2.5mg ampoules neostigmine. Ensure the preparation with neostigmine alone is used (i.e. NOT the preparation with neostigmine and glycopyrronium).

12. DoseMyasthenia Gravis

Converting usual dose of pyridostigmine to parenteral preparation: 60mg pyridostigmine is approximately equivalent to 0.5mg intravenous neostigmine or 1mg of subcutaneous neostigmine.

Initiating therapy: 0.5mg intravenous (unlicensed) or 1mg subcutaneous neostigmine QDS.

Acute colonic pseudo-obstruction

Seek Consultant surgical opinion before prescribing intravenous neostigmine. It is essential to exclude colonic obstruction or complications of acute colonic pseudo-obstruction.

Option 1 (preferred): 2mg intravenously over 3 to 5 minutes, repeat after 3 hours if no clinical effect. Maximum of 3 doses (i.e. 6mg in 24 hours).

Option 2: start in increments of 0.5mg to maximum 2.5mg intravenously. Consider this option if the patient is deemed to be at high risk of side effects.

Option 3: Intravenous infusion of neostigmine 0.4mg/hour to 0.8mg/hour to a maximum cumulative dose of 10mg. This may be considered in cases where no clinical benefit from 2mg bolus doses was seen.

13. AdministrationMust have continuous ECG monitoring during and after administration of intravenous neostigmine. For administration on Critical care or in theatres only.Glycopyrronium must be available to treat bradycardia.Intravenous bolus of up to 2.5mg or continuous infusion 0.4 to 0.8mg/hour.Infusion for maximum 24 hours.



5mg Up to 50mL


0.1mg/mL 4mL/hour

For maximum 24 hours

8mL/hour

For maximum 12 hours

14. Common Side Effects



Adverse effects of Neostigmine are chiefly those of exaggerated response to parasympathetic stimulation.

Lacrimation, bradycardia, decreased cardiac conduction, cardiac arrest, hypotension, increased bronchial secretion, bronchospasm, nausea, vomiting, diarrhoea, abdominal cramps, salivary hypersecretion, involuntary defecation, hyperhidrosis, muscle spasms, urinary incontinence,

15. ContraindicationsHypersensitivity to neostigmine or to any of the excipients. Mechanical obstruction of gastrointestinal or urinary tracts, peritonitis or doubtful bowel viability. Neostigmine should not be used in conjunction with depolarising muscle relaxants such as suxamethonium as neuromuscular blockade may be potentiated.

16. Y site compatibilityCompatible with:Glycopyrronium, heparin, potassium chloride.

17. Notes Half life 80 minutes Neostigmine is available as two intravenous preparation: neostigmine 2.5mg injection

and neostigmine with glycopyrronium. For pseudo-obstruction the neostigmine injection must be used (i.e. WITHOUT glycopyrronium).

Tablets not stocked by WUTH pharmacy, they are poorly absorbed, lack efficacy and this route is not recommended for these indications. The oral dose is: 15mg to 30mg stat.

Neostigmine inhibits cholinesterase activity and prolongs and intensifies the muscarinic and nicotinic effects of acetylcholine. The anticholinesterase actions of Neostigmine are reversible.

Neostigmine should be used with extreme caution in patients with asthma, bradycardia, cardiac arrhythmia or recent coronary occlusion, epilepsy, vagotonia, hyperthyroidism, peptic ulceration or parkinsonism.

Administration of anticholinesterase agents to patients with intestinal anastomoses may produce rupture of the anastomosis or leakage of intestinal contents.

Neostigmine injection contains approximately 3.54 mg sodium per ml. 0.5 mg intravenously neostigmine = 1mg intramuscularly or subcutaneously

neostigmine = 15 mg neostigmine orally. The maximum daily dose of subcutaneous neostigmine is 20mg (i.e equivalent to 10mg

total daily dose of intravenous neostigmine). In patients who have received opioids consider giving enteral naloxone to reverse

enteral constipating effects.

18. Referenceswww.emc.medicines.org.uk accessed 24/7/15www.medicinescomplete.com accessed 24/7/15 (Martindale)http://medusa.wales.nhs.uk Medusa medicines guide accessed 24/7/15UpToDate Neostigmine for acute pseudo obstruction accessed 24/7/15Ponec RJ et al. Neostigmine for the treatment of acute colonic pseudo-obstruction. NEJM. 1999. 341 (3) 137-141.Jain A and Vargas. Advances and Challenges in the Management of Acute Colonic Pseudo-Obstruction (Ogilvie Syndrome). Clin Colon Rectal Surg. 2012. 25(1) 37–45. Valle, RGL and Godoy FL. Neostigmine for acute colonic pseudo-obstruction: A meta-analysis. Annals of Medicine and Surgery 2014. 3 60-64.




NICARDIPINE (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationHypertension in adults

2. Presentation10mg/10mL ampoule

3. DoseInitial dose: Treatment should start with the continuous administration of nicardipine at a rate of 3-5 mg/h for 15 minutes. Rates can be increased by increments of 0.5 or 1 mg every 15 minutes. The infusion rate should not exceed 15 mg/hr.

May need lower doses e.g. 1mg/hr in the elderlyMaintenance dose: When the target pressure is reached, the dose should be reduced progressively, usually to between 2 and 4 mg/h, to maintain the therapeutic efficacy.


Drug Volume Fluid Concentration

Initial Rate

Maximum Rate


100mg Up to 500mL

Glucose 5% 0.2mg/mL 15mL/hour 75mL/hour

Consider reducing the initial rate to 5mL/hour in the elderly or patients with hepatic or renal impairment.

Minimum Volume. (for fluid restricted patients)Drug Volume Fluid Concentration Initial Rate Maximum

RateCentral 50mg 50mL Undiluted 1mg/mL 3mL/hour 15mL/hourConsider reducing the initial rate to 1mL/hour in the elderly or patients with hepatic or renal impairment.

5. Common Side EffectsHeadache, dizziness, tacchycardia, lower limb oedema, angina, pulmonary oedema, nausea, vomiting, paralytic ileus, increased hepatic enzymes, erythema, flushing.

6. Contraindications Known hypersensitivity to nicardipine or to any of the excipients Severe aortic stenosis Compensatory hypertension, i.e. in case of an arteriovenous shunt or aortic

coarctation Unstable angina Within 8 days after myocardial infarction

Patients with rare hereditary problems of fructose intolerance.

7. Y site compatibilityCritical care guidelines – version 2d Principal Author: Debbie HughesUpdate approved by Medicine DMT CG November 2016 Review: May 2018


Compatible with:Aminophylline, calcium gluconate, clindamycin, esmolol, fentanyl, labetalol, linezolid, magnesium, midazolam, morphine, potassium, vancomycin.

8. Notes Nicardipine is licensed for use in pregnancy Nicardipine should be used cautiously in patients with congestive heart failure or

pulmonary oedema, particularly when administered in combination with beta-blockers, as worsening of cardiac insufficiency may occur.

Concommitant use of nicardipine and magnesium may increase the risk of pulmonary oedema or excessive decrease in blood pressure.

High doses of nicardipine may worsen portal vein hypertension in patients with liver cirrhosis.

Infusion site reactions can occur, particularly with prolonged duration of administration via peripheral veins.

Calcium channel inhibitors should not be administered with dantrolene as there have been cases of ventricular arrhythmias in animal studies.

Nicardipine is metabolized in the liver by cytochrome P450 3A4. Agents known to induce CYP 3A4 such as carbamazepine, phenobarbital, phenytoin, fosphenytoin, primidone and rifampicin may decrease the plasma concentrations of nicardipine. Agents known to inhibit CYP 3A4 such as cimetidine, itraconazole and grapefruit juice may increase the plasma concentrations of nicardipine.

Nicardipine may increase levels of cyclosporine, tacrolimus or sirolimus. Blood levels should be monitored.

Nicardipine may increase the plasma levels of digoxin, levels should be monitored. Nicardipine is a second generation slow calcium channel inhibitor, and belongs to

the phenyl-dihydropyridine group Nicardipine is highly protein bound. A risk of precipitation exists with products presenting a pH in solution greater than 6

(for example, bicarbonate solution, Ringer's solution, diazepam, furosemide, thiopental).

Blood pressure should be monitored continuously during treatment with intravenous nicardipine.

Nicardipine should be administered via an electronic syringe driver or a volumetic pump.

9. Referenceswww.emc.medicines.org.uk accessed 22/10/14www.medicinescomplete.com accessed 23/10/14






NIMODIPINE (INTRAVENOUS AND ORAL)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationPrevention and treatment of neurological deficits following aneurysmal subarrachnoid haemorrhage (not indicated for traumatic subarrachnoid haemorrhage) in adult patients.

2. Presentation10mg in 50ml vials (0.02%)30mg tablets

3. DoseIntravenous: 1mg (5ml) per hour (or up to 500micrograms [2.5ml] per hour if weight less than 70kg), increased to 2mg (10ml) per hour after 2 hours if blood pressure stable. Continue for at least 5 days, maximum 14 days.

Oral: 60mg every 4 hours for 21 days (tablets may be crushed and administered via a naso-gastric tube)


Drug Volume Fluid Concentration Initial Rate Maintenance Rate


10mg 50ml Give undiluted

0.2mg/ml 5ml/hour for 2 hours

2.5ml/hour if bodyweight under 70kg

10ml/hour

Nimodipine infusion should be co-administered with an infusion of sodium chloride 0.9%, compound sodium lactate or glucose 5% running at 40ml/hour via the same line. This applies when given centrally or peripherally.

The manufacturers advise administration via a central line, but it may be administered peripherally if central access is unavailable (unlicensed).

5. Common side effectsHypotension (especially in patients with hepatic impairment), tachycardia, bradycardia, flushing, feeling of warmth, thrombocytopenia, hypersensitivity reactions, headache.

6. ContraindicationsKnown hypersensitivity to Nimodipine or any of the excipients. Avoid within one month of a myocardial infarction or an episode of unstable angina.

7. Y-site compatibilityNo information available. Nimodipine and the fluid it is co-administered with must be infused via a dedicated line.



8. Notes Nimodipine tablets and injection should not be given at the same time. Use with caution in patients with raised intracerebral pressure. Use with caution in hypotensive patients. Nimodipine is metabolised via the cytochrome P450 3A4 liver enzymes and therefore

inhibitors of these enzymes (such as erythromycin and ketoconazole) may increase the levels of nimodipine.

Nimodipine infusion contains 23.7% ethanol. Therefore extravasation is likely to cause tissue damage.

Concurrent administration of fluoxetine may increase levels of nimodipine. Oral bioavailability of nimodipine is 5 to 15%. The manufacturer advises that the solution should be protected from direct sunlight.

However the solution does not need to be covered whilst it is administered as long as it is only exposed to artificial light/diffuse daylight and not direct sunlight.

Nimodipine reacts with PVC and so should be administered in polyethylene or polypropylene syringes and giving sets. All syringes at WUTH are PVC free. A PVC free giving set is including in the nimodipine box.

9. Referenceswww.emc.medicines.org.uk accessed 23/02/12www.medicinescomplete.com accessed http://medusa.wales.nhs.uk Medusa medicines guide accessed 27/11/14BNF edition 61 March 2011







NORADRENALINE (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationAcute hypotension in adult patients

2. PresentationAlso called norepinephrine. Note 16mg noradrenaline acid tartrate is equivalent to 8mg noradrenaline base. All doses are as noradrenaline base.

8mg in 8ml ampoules8mg and 16mg in 100ml Glucose 5% pre made infusion bag

3. DoseWeight based dosing from clinical trials range from 0.01 to 3 micrograms/kg/minute. 4. AdministrationStandard infusion concentration recommended by the Intensive Care Society. Start with single strength infusion and convert to double strength if requiring high infusion rate.


CENTRAL intravenous line only

8mg Up to 100ml

Glucose 5%

80mcg/ml‘Single’ strength

3 to 5ml/hour or as advised by doctor

Titrate to target blood pressure

CENTRAL intravenous line only

16mg Up to 100ml

Glucose 5%

160mcg/ml‘Double’ strength

Convert from single strength rate

Titrate to target blood pressure

5. Side EffectsHypertension, headache, peripheral ischaemia, bradycardia, arrhythmias, extravasation may lead to tissue necrosis, decreased urine output, respiratory difficulty, metabolic acidosis, tremor, hypokalaemia, hyperglycaemia.If extravasation occurs infiltrate the area with phentolamine 5mg made up in 15ml NaCl 0.9%

6. ContraindicationsHypertension Hypotension due to hypovolaemiaCaution if patient on MAOI (prolonged hypertension) or inhaled anaesthetics (cardiac arrhythmias)7. CompatibilityCompatible with: Adrenaline, amiodarone, dobutamine, vasopressin8. Notes The infusion rate should be titrated up or down gradually and should never be bolused. Invasive haemodynamic monitoring should be used during administration. Single infusion pumps only should be used for noradrenaline and the pump should be

labelled ‘for inotropes only’. Noradrenaline should not run alongside drugs which may be bolused.9. Referenceswww.emc.medicines.org.uk accessed 30/3/11www.medicinescomplete.com accessed 30/3/11UpToDate – Norepinephrine. Accessed 17/04/12.http://medusa.wales.nhs.uk Medusa medicines guide accessed 27/11/14







OXYCODONE INTRAVENOUSThis guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

19. IndicationPain and sedationOxycodone has analgesic, anxiolytic, antitussive and sedative properties.

20. PresentationAvailable as 10mg in 1ml and 20mg in 2ml ampoules

21. DoseSevere pain 1mg to 5mg intravenous bolus repeated every 4 hours as necessary (doses up to 10mg may be needed)

Palliative care (opioid naïve)Dyspnoea: Use lower doses such as 1.25mg subcutaneously Pain: 2.5mg to 5mg subcutaneously 4 hourly PRN

In patients established on opioids use equivalent dose see notes below.




50mg 50ml Sodium Chloride 0.9% or Glucose 5%

1mg/mL 1 to 2mL/hr 5mL/hr*

*Note there is no maximum dose, titrate to effect. Avoid starting high dose infusion in an opioid naïve patient especially if not ventilated.

23. Common Side EffectsAnxiety, confusion, hallucinations, mood changes, agitation, somnolence, dizziness, amnesia, tremor, twitching, epileptic seizures, withdrawal syndrome, hypotension, syncope, dyspnoea, bronchospasm, rhinitis, epistaxis, respiratory depression, constipation, nausea, vomiting, abdominal pain, ileus, stomatitis, biliary spasm, gastrointestinal disorders, rash, sweating, chest pain, allergic reaction, anaphylactic reaction, drug dependence.


Oxycodone injection is contraindicated in patients with known hypersensitivity to oxycodone or any of the other constituents. Also contraindicated in respiratory depression, head injury, paralytic ileus, acute abdomen, chronic obstructive airways disease, cor pulmonale, chronic bronchial asthma, hypercarbia; moderate to severe hepatic impairment, severe renal impairment (creatinine clearance <10 ml/min); chronic constipation, concurrent administration of monoamine oxidase inhibitors or within 2 weeks of discontinuation of their use, pregnancy, lactation.



25. Y site compatibilityCompatible with:Hyoscine butylbromide, hyoscine hydrobromide, dexamethasone, haloperidol, midazolam, metoclopramide, levomepromazine (in a subcutaneous syringe driver).

Note there is limited information available about intravenous compatibility with oxycodone, it CANNOT run alongside Propofol.

26. Notes Oxycodone is a Kappa opioid receptor agonist Oxycodone is approximately twice as potent as morphine, therefore 5mg morphine is

approximately equivalent to 2.5mg oxycodone. There is no conversion available to convert from intravenous fentanyl to oxycodone, but

an approximate guide is 100mcg fentanyl is equivalent to 7.5mg oxycodone 1mg alfentanil is approximately equivalent to 7.5mg oxycodone. 2 mg of oral oxycodone is equivalent to 1 mg of parenteral oxycodone Biological Half-life is 2 to 4 hours It is hepatically metabolised by cytochrome P450, and does have active metabolites

(Oxymorphone – hepatically glucuronidated) Oxycodone may be used in patients with acute kidney injury Consider starting laxatives and/or antiemetics when starting oxycodone. Approximately 45% is bound to plasma proteins Oxycodone effects may be reversed with naloxone:Lower Dose Reversal RegimeTo reverse non-life threatening opioid toxicity without fully reversing analgesiaNaloxone 100 microgram, intravenous bolus. May be repeated at 2-3 minute intervals until opioid toxicity symptoms resolved. Dose can be repeated at 1-2 hourly intervals if needed Higher Dose Reversal RegimeTo reverses life threatening opioid toxicityNaloxone 400 microgram, intravenous bolus. Then if required 800 micrograms for up to 2 doses at 1 minute intervals. If no response increase to 2 mg for 1 dose (4 mg dose may be required in seriously poisoned patient). Review diagnosis if no further response. Give further doses if respiratory function deteriorates.

27. Referenceswww.emc.medicines.org.uk accessed 14/4/16www.medicinescomplete.com accessed 14/4/16http://medusa.wales.nhs.uk Medusa medicines guide accessed 14/4/16BNF edition April 2016




PANTOPRAZOLE (CONTINUOUS INTRAVENOUS INFUSION)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationNon-variceal upper GI bleed confirmed by endoscopy in adult patients (unlicensed indication).

2. Presentation40mg vial

3. Dose80mg, stat, followed by 8mg/hour for 72 hours.This is also known as the ‘Hong Kong’ regimen.4. Administration80mg in 100ml sodium chloride 0.9% over 15 minutesFollowed by continuous infusion:Standard Infusion Recommended by manufacturer

Drug Volume Fluid RateCentral or Peripheral

80mg Up to 250ml

Sodium Chloride 0.9% 25ml/hour for 72 hours

Minimum volume (unlicensed) — for fluid restricted patientsDrug Volume Fluid Rate


80mg Up to 100ml

Sodium Chloride 0.9% 10ml/hour for 72 hours

5. Common Side EffectsNausea, diarrhoea, constipation, vomiting, deranged LFTs, itching, rash, rarely blood dyscrasias, candidiasis of the oesophagus.

6. ContraindicationsHypersensitivity to pantoprazole, substituted benzimidazoles, or to any of the excipients.

7. Y-site compatibilityCompatible with:Aminophylline, compound sodium lactate (Hartmann’s), furosemide, GTN, insulin and morphine.

8. Notes Pantoprazole is likely to increase the incidence of nosocomial pneumonia and

Clostridium difficile infection. Increasing the pH of the stomach may have an adverse effect on the absorption of

medicines which have a gastric pH-dependent bioavailability. May lead to an increase in INR in patients on warfarin. There is no need for dosage adjustment in hepatic and renal failure.







http://medusa.wales.nhs.uk Medusa medicines guide accessed 27/11/14BNF edition 61 March 2011





PHENYLEPHRINE (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationHypotension due to circulatory failure or drug-induced hypotension in adult patients.

2. Presentation10mg/ml ampoules1mg/10ml (100microgram/ml) ampoules (unlicensed)

3. Dose100 to 500micrograms by slow intravenous injection every 5 minutes. The 10mg/ml strength must be diluted to 100micrograms/ml or less with sodium chloride 0.9% or glucose 5%. The 100microgram/ml ampoules can be administered undiluted.Intravenous infusion: Initially up to 180micrograms/minute. Then reduce to 30 to 60micrograms/minute, according to response. May be administered intramuscularly — dose: 2 to 5mg, initially, followed by 1 to 10mg as needed (titrated to blood pressure). Avoid this route where possible due to risk of tissue necrosis.

Normally administered peripherally as a temporary measure before the insertion of a central line. Infusions should only be continued beyond 24 hours by consultant request.




10mg Up to 500ml


20micrograms/ml 10ml/hour 180ml/hour

Using the 10mg/ml ampoules.

Minimum volume — for fluid restricted patients (unlicensed)Using 10mg/ml ampoules

Drug Volume Fluid Concentration Initial Rate

Maximum Rate


10mg in 1ml

100ml Sodium Chloride 0.9% or Glucose 5%

100micrograms/ml 2ml/hour 36ml/hour

Using 1mg/10ml ampoules Drug Volume Fluid Concentration Initial

RateMaximum Rate


5mg 50ml Undiluted 100micrograms/ml 2ml/hour 36ml/hour



5. Common side effectsMay precipitate angina.Extravasation may lead to tissue necrosis.Headache, vomiting, tachycardia, bradycardia, cardiac arrhythmias, flushing, urinary retention, mydriasis, dyspnoea, sweating, hypersalivation. Paraesthesia in the extremities.

6. ContraindicationsSevere hypertension.Treatment with a monoamine oxidase inhibitor in the last 14 days. Known hypersensitivity to phenylephrine or any excipients.Hyperthyroidism.

7. Y site compatibilityCompatible with:Amiodarone (if both in glucose), caspofungin, dobutamine, dobutamine, haloperidol, micafungin, potassium chloride, vasopressin.

8. Notes pH 4.5 to 6.5 Increased risk of arrhythmias if administered to patients on cardiac glycosides or

tricyclic antidepressants. Phenylephrine is a sympathomimetic agent acting on adrenergic receptors. It has

predominantly alpha-adrenergic activity and, at usual doses, does not have significant stimulating effects on the central nervous system. It produces peripheral vasoconstriction and increased blood pressure. It also causes reflex bradycardia.

Phenylephrine has a longer duration of action than noradrenaline, so an excessive vasopressor response may result in a prolonged period of hypertension.

Intravenous bolus injections are effective for approximately 20 minutes. Do not stop infusion abruptly.









PHENYTOIN (ORAL OR INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationStatus epilepticus and epilepsy in adult patients.

2. Presentation250mg/5ml amps100mg capsules30mg/5ml syrup

3. DoseLoading dose20mg/kg. Advise max dose of 1800mg. Use adjusted body weight.

Maintenance doseUsually 300mg to 400mg once daily unless very low body weight.

Prescribe 100mg three or four times a day if intravenousPrescribe 300mg or 400mg nocte if oralPrescribe 270mg or 360mg nocte if NG and using syrup 30mg/5ml

Route of administration, note that NG feed must be stopped 2 hours before and after an enteral dose, despite this absorption may still be significantly reduced.

4. Intravenous administrationStandard Infusion Recommended by manufacturerRoute Drug Volume Fluid Maximum RateCentral or Peripheral

Loading dose or maintenance dose

Up to 100ml


MUST use a 0.22 or 0.5 micron inline filter

Loading dose maximum rate 50mg/min

Maintenance dose give over 30 minutes

Note - ECG and BP monitoring is essential during loading dose.

Minimum Volume, unlicensed (for fluid restricted patients)Drug Fluid Maximum Rate

Central Loading dose or maintenance dose

Give undiluted Loading dose maximum rate 50mg/min

Maintenance dose give 100mg over 3 to 5 minutes.

Loading doses of intravenous phenytoin can cause significant hypotension, arrhythmias, respiratory and circulatory depression. Advise administering undiluted phenytoin over at least 1 hour in patients requiring inotropic support. There is no requirement for a filter when using undiluted phenytoin.



5. Common Side Effects Severe cardiotoxic reactions and fatalities have been reported, most commonly in

gravely ill patients or the elderly. Nausea, vomiting, constipation, nystagmus, ataxia, slurred speech, decreased

coordination and mental confusion, dizziness, insomnia, transient nervousness, motor twitchings, toxic hepatitis, liver damage, pulmonary fibrosis and headaches. Gingival hyperplasia is common with long-term therapy.

Rarely dyskinesias, including chorea, dystonia, tremor and asterixis. Blood dyscrasias including: thrombocytopaenia, leucopaenia, agranulocytosis, and pancytopaenia with or without bone marrow suppression. Macrocytosis and megaloblastic anaemia can occur but usually respond to folic acid therapy.

Soft tissue irritation and inflammation can occur at the site of the injection with and without extravasation. This may vary from slight tenderness to extensive necrosis, sloughing and in rare instances has led to amputation.

The most common rash with phenytoin is a measles-like rash, seen more commonly in children and young adults. Serious rashes which may be fatal can develop including: bullous, exfoliative or purpuric dermatitis, lupus erythematosus, Stevens-Johnson syndrome and toxic epidermal necrolysis. Phenytoin should be discontinued if a skin rash appears.

6. ContraindicationsPatients with a known hypersensitivity to phenytoin or other hydantoins e.g. fosphenytoin.Patients with sinus bradycardia, sino-atrial block, second and third degree AV block or Adams-Stokes syndrome. Intra-arterial administration must be avoided in view of the high pH of the preparation.

7. Y site compatibilityPhenytoin should be administered via a dedicated lumen and not mixed with any other fluid or medication.

8. Notes The plasma half-life is normally from 10 to 15 hours Avoid subcutaneous or intramuscular injection. Phenytoin should not be abruptly withdrawn unless patient suffers an adverse drug

reaction. Due to the non linear kinetics of phenytoin maintenance doses should be adjusted in

small increments e.g. max 50mg. The usual therapeutic range is 10 to 20mg/L although levels up to 25mg/L may be

needed in resistant cases. Levels should ideally be checked pre dose but may also be at least 2 hours post dose. Check post loading dose to confirm within therapeutic range.

Phenytoin is highly protein bound. Note protein binding may be altered in renal impairment.

Levels must be corrected for low albumin, please contact pharmacy. Raised levels may produce: encephalopathy, confusional, nystagmus, ataxia, tremor,

hyperflexia, lethargy, slurred speech, nausea and vomiting and hypotension. Phenytoin interacts with many medicines, please contact pharmacy for more detailed

information.9. Referenceswww.emc.medicines.org.uk accessed 23/11/11www.medicinescomplete.com accessed 23/11/1http://medusa.wales.nhs.uk Medusa medicines guide accessed 28/11/14BNF edition 61 March 2011







PROPOFOL (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationSedation of ventilated patients over 16 years of age in the intensive care unit.

2. PresentationPropofol 1% ampoules 20ml (10mg/ml)Propofol 1% bottles 100ml (10mg/ml)

Propofol 2% bottles 50ml (20mg/ml)

3. Dose0.3 – 4mg/kg/hour

4. AdministrationPropofol should be initiated using 1% ampoules made up in a 50ml syringe. Propofol is administered undiluted. If high infusion rates are required then the 100ml bottles may be used or the patient may be converted to propofol 2%.

Start infusion at a low rate and titrate to the level of sedation required. Regular sedation scoring should be performed and a daily sedation break is recommended.

The maximum infusion rates based on patients’ weight are listed below:

Weight (kg) Maximum rate of infusion (mL/hour) for

Use propofol 1% wherever possible

Propofol 2% is rarely needed, it should only be initiated when higher infusion volumes are required.

Propofol 1% Propofol 2%

50 20 1055 22 1160 24 1265 26 1370 28 1475 30 1580 32 1685 34 1790 36 1895 38 19100 40 20

5. Common side effectsHypotension, bradycardia, arrhythmias, pulmonary oedema, hyperkalaemia, metabolic acidosis, involuntary movements, sexual disinhibition, euphoric mood, nausea, headache, hepatomegaly, pancreatitis, rhabdomyolysis, apnoea, discolouration of urine after prolonged infusion, pain at injection site. Tissue necrosis may rarely occur following extravasation.





6. ContraindicationsKnown hypersensitivity to propofol or any of the excipients.Patients under 16 years.Known hypersensitivity to soya or peanut.

7. Y-site compatibilityCompatible with:Alfentanil, aminophylline, compound sodium lactate (Hartmann’s), esmolol, fentanyl, furosemide, glucose 4% and sodium chloride 0.18%, glucose 5%, heparin, hydrocortisone, insulin, ketamine, labetalol, magnesium, mannitol, midazolam, morphine, potassium chloride, remifentanil, sodium bicarbonate, sodium chloride 0.9%, thiopental, vancomycin.

Care should be taken when selecting infusions to run alongside propofol if there is a high chance of having to give bolus doses of propofol — this may result in a potential bolus of the concurrently administered infusion.

8. Notes The manufacturer advises measuring blood lipid concentrations in patients at risk of fat overload. This includes patients on high infusion rates and patients on propofol for longer than 3 days. 1ml of propofol 1% contains approximately 0.1g of fat. Propofol has no analgesic properties. Clearance of propofol may be reduced if cardiac output is reduced. ‘Propofol infusion syndrome’ may develop in some high risk patients, for example: neurological injury, sepsis, high dose vasoconstrictors/steroids/inotropes/propofol. It usually follows prolonged periods of receiving high-dose propofol (ie, above 4mg/kg/hour). Symptoms include metabolic acidosis, rhabdomyolysis, hyperkalaemia, hepatomegaly, renal failure, hyperlipidaemia, cardiac arrhythmia and cardiac failure usually unresponsive to inotropic treatment. Propofol supports bacterial growth and contains no antimicrobial agents. The syringes must be drawn up using aseptic technique. A single infusion of propofol should not exceed 12 hours. Both the syringe and the giving set should be replaced after 12 hours.









REMIFENTANIL (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationAnalgesia and sedation for mechanically ventilated Intensive Care patients over 18 years of age.

2. Presentation5mg vial – controlled drug

3. DoseAnalgesia and sedation in ventilated ITU patients, initially 0.1 to 0.15 micrograms/kg/min. Adjusted according to response in steps of 0.025micrograms/kg/min allowing at least 5 minutes between dosage adjustments. If 0.2 micrograms/kg/min does not produce adequate sedation add another sedative.

Additional analgesia during stimulating or painful procedures in ventilated ITU patients, maintain infusion at 0.1micrograms/kg/min for at least 5 minutes before procedure and adjust every 2-5 minutes according to requirements, usual range 0.25-0.75 micrograms/kg/min.

Doses should be based on ideal body weight.

4. Administration

DO NOT BOLUS

REMIFENTANIL MUST BE ADMINISTERED VIA A DEDICATED LUMEN, to avoid accidental bolus administration when concurrent drug infused. When the infusion is stopped the line must be aspirated to ensure there is no residual remifentanil in the line which may be bolused in error.

Standard Infusion Recommended by manufacturerRoute Drug Volume Fluid ConcentrationCentral or Peripheral

5mg Up to 100ml


50 micrograms /ml

Infusion Rates (ml/hour) for a 50 microgram/ml SolutionInfusion Rate

(micrograms/kg/min)

Patient Weight (kg)30 40 50 60 70 80 90 100

0.05 1.8 2.4 3 3.6 4.2 4.8 5.4 60.075 2.7 3.6 4.5 5.4 6.3 7.2 8.1 90.1 3.6 4.8 6 7.2 8.4 9.6 10.8 120.15 5.4 7.2 9 10.8 12.6 14.4 16.2 180.2 7.2 9.6 12 14.4 16.8 19.2 21.6 24Suggest titrating dose upward in 25% to 100% increments and downward in 25% to 50% decrements, every 2 to 5 minutes to attain the desired response.



5. Common Side EffectsHypotension, bradycardia, skeletal muscle rigidity, pruritis, constipation, aches, nausea, vomiting, apnoea and respiratory depression.

Very rarely, allergic reactions including anaphylaxis have been reported in patients receiving remifentanil in conjunction with one or more anaesthetic agents. In common with other opioids, very rare cases of asystole, usually preceded by severe bradycardia, have been reported in patients receiving remifentanil in conjunction with other anaesthetic agents.Withdrawal symptoms may develop especially after abrupt cessation after prolonged administration. These symptoms include: shivering, agitation, tachycardia, hypertension. If these symptoms occur re-introduction and tapering of the infusion may be beneficial.

6. ContraindicationsKnown hypersensitivity to any component of the preparation and other fentanyl analogues. Contraindicated for use as the sole agent for induction of anaesthesia.As glycine is present in the formulation remifentanil is contra-indicated for epidural and intrathecal use.

7. Y site CompatibilityCompatible with:Aciclovir, aminophylline, calcium gluconate, ceftriaxone, ciprofloxacin, dexamethasone, digoxin, esmolol, fentanyl, GTN, heparin, hydrocortisone, magnesium sulphate, midazolam, morphine, potassium chloride, vancomycin.

8. Notes Remifentanil infusions SHOULD NOT be bolused as there is a high risk of respiratory

depression. Following extubation, the infusion rate should be reduced by 25% decrements in at least

10 minute intervals until the infusion is discontinued. During weaning from the ventilator the remifentanil infusion should not be increased and only down titration should occur, supplemented as required with alternative analgesics.

Following administration of the recommended doses of remifentanil, the effective biological half-life is 3 to10 minutes

There is no evidence that remifentanil is extracted during renal replacement therapy. Continuation of remifentanil infusion beyond 3 days is not recommended.









SALBUTAMOL (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationSevere bronchospasm in adult patients

2. Presentation5mg/5ml ampoules. Brand name Ventolin®

3. Dose3-20 micrograms/minuteStart at 5 micrograms/minuteAdjust according to clinical response and heart rate.

4. AdministrationStandard Infusion recommended by manufacturer

Drug Volume Fluid Concentrationmicrograms/ml

Initial Rate

Maximum Rate


5mg Up to 500ml

Glucose 5%ORSodium Chloride 0/9%

10 18ml/hr 120ml/hr

Minimum Volume for use in fluid restricted patients (outside product license)Drug Volume Fluid Concentration

micrograms/mlInitial Rate

Maximum Rate


5mg Up to 50ml

Glucose 5%ORSodium Chloride 0.9%

100 1.8ml/hr

12ml/hr

5. Side EffectsFine tremor HypokalaemiaHeadache PalpitationsTachycardia ArrhythmiasParadoxical bronchospasm UrticariaAngiodema HypotensionHyperglycaemia

6. ContraindicationsKnown hypersensitivity to salbutamol and ischaemic heart disease.

Caution in hyperthyroidism, hypertension, cardiovascular disease, arrhythmias and susceptibility to QT prolongation.



7. Y-site CompatibilityCompatible with:Morphine

8. Notes Salbutamol administered intravenously has a half-life of 4 to 6 hours and is cleared partly renally and partly by metabolism to the inactive 4'-0-sulphate (phenolic sulphate). Most of a dose of salbutamol given intravenously is excreted within 72 hours. Salbutamol is also available as a 500microgram injection, this is not licensed for continuous infusion. pH 3.5

9. Referenceswww.ukcpa.org.uk accessed 06/09/11www.emc.medicines.org.uk accessed 06/09/11BNF edition 61 March 2011www.medicinescomplete.org.uk accessed 06/09/11http://medusa.wales.nhs.uk Medusa medicines guide accessed 01/12/14




http://www.medicinescomplete.org.uk/




SODIUM CHLORIDE 5% (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationRaised intracranial pressure/cerebral oedema in adult patients.

Sodium chloride 5% is used as a second line agent. The first line agent to treat raised intracranial pressure/cerebral oedema is mannitol (0.5g/kg 20% mannitol over 15 minutes).

SODIUM CHLORIDE 5% SHOULD NOT BE USED TO CORRECT HYPONATRAEMIA. 1.8% sodium chloride may be used on consultant request — see Hyponatraemia management.

2. PresentationSodium chloride 5% polyfusor 500ml

3. Dose3ml/kg over 15 minutes.

This may be repeated if necessary. Serum sodium levels should be monitored regularly.

Ideally, administer via a central line but may be administered via a large peripheral vein if no central line is available.

4. Common side effectsHypernatraemia, local irritation at injection site.

5. ContraindicationsSerum osmolality over 360mosmol/L Serum sodium concentration over 170mmol/L

6. Y-site compatibilityNo data available for sodium chloride 5%. Administer via a dedicated lumen.

7. Notes Serum sodium concentration should not be raised by more than 12mmol/L in 24 hours. Rapid elevation in serum sodium levels can lead to central pontine myolinolysis, this is

most likely to occur following correction of severe hyponatraemia (serum sodium concentration less than 120mmol/L).

Doses administered are likely to be less than 500ml so care must be taken to ensure that the contents of the entire polyfusor are not administered.

Please note that treatment with sodium chloride 5% forms only a part of the medical management of raised intracerebral pressure or cerebral oedema.

8. Referenceshttp://medusa.wales.nhs.uk Medusa medicines guide accessed 01/12/14Management of raised ICP. Dr I Tweedie. WCNN. April 2007.Hypertonic saline search report. Victoria Treadway clinical librarian. October 2012.




http://www.whnt.nhs.uk/document_uploads/Intranet-Pharmacy/Hyponatraemia_clinical_guideline.pdf

http://www.whnt.nhs.uk/document_uploads/Intranet-Pharmacy/Hyponatraemia_clinical_guideline.pdf


SUGAMMADEX INTRAVENOUSThis guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

28. IndicationReversal of neuromuscular blockade induced by rocuronium or vecuronium in adults. At WUTH approved for use in emergency only and not for routine reversal.

For consideration as treatment adjunct for rocuronium anaphylaxis (unlicensed)

29. Presentation100mg/ml vials (2ml and 5ml vials)One box of 10 x 5ml ampoules are kept in main theatre recovery at APH, resus and in gynae theatre 4. One box of 10 x 2ml ampoules is kept at CGH on M1.

30. DoseAll doses should be based on ACTUAL body weight.

Immediate reversal of rocuronium-induced blockade: 16 mg/kg sugammadex is recommended. Administer as single rapid intravenous bolus injection

Administration of sugammadex should be considered in cases of rocuronium anaphylaxis.

There are no data to recommend the use of sugammadex for immediate reversal following vecuronium induced blockade.

Dose AdjustmentNo dosage adjustment is needed in renal impairment, hepatic impairment or in elderly patients. However there are no data to support the use of sugammadex in creatinine clearance less than 30ml/minute or in severe hepatic impairment.

31. Common Side EffectsHypersensitivity reactions including anaphylaxis, bronchospasm, unwanted awareness during anaesthesia, marked bradycardia and bradycardia with cardiac arrest have been observed within minutes after administration of sugammadex, recurrence of neuromuscular blockade, prolonged APTT.

32. ContraindicationsHypersensitivity to sugammadex or to any of the excipients.

33. Y site compatibilityCompatible with: sodium chloride 0.9%, glucose 5%, sodium chloride 0.45% and glucose 2.5%.

34. Notes Ventilatory support is mandatory for patients until adequate spontaneous respiration

is restored following reversal of neuromuscular blockade. Even if recovery from neuromuscular blockade is complete, other medicinal products could depress respiratory function and therefore ventilatory support might still be required.

In clinical trials recurrence of neuromuscular blockade was reported (mainly when sub-optimal doses were administered).



Sugammadex may prolong APTT and increase INR in patients taking warfarin, unfractionated heparin, low molecular weight heparins, rivaroxaban and dabigatran. In patients receiving routine post-operative prophylactic anticoagulation this pharmacodynamic interaction is not clinically relevant.

Sugammadex may increase the risk of bleeding in patients with hereditary vitamin K dependent clotting factor deficiencies, pre-existing coagulopathies, on coumarin derivates and at an INR above 3.5 and in patients using anticoagulants who receive a dose of 16 mg/kg sugammadex.

Theoretically rocuronium or vecuronium could be displaced from sugammadex following the administration of other medications. This may result in recurrence of neuromuscular blockade, necessitating ventilation. Patients should be carefully monitored for signs of recurrence of neuromuscular blockade (approximately up to 15 minutes) after parenteral administration of another medicinal product within a period of 7.5 hours after sugammadex administration. Toremifene and fusidic acid theoretically may lead to some displacement of vecuronium or rocuronium from the complex with sugammadex. These medicines may delay in the recovery of the T4/T1

ratio to 0.9. Sugammadex may lead to a decrease in progestogen and oestrogen exposure, this

theoretically could lead to a reductive in effectiveness of oral contraception. In adult anaesthetized patients with normal renal function the effective half-life of

sugammadex is about 2.5 hours. Using the recommended doses for routine reversal will result in a slightly faster

median time to recovery of the T4/T1 ratio to 0.9 of rocuronium when compared to vecuronium induced neuromuscular blockade.

Conditions associated with prolonged circulation time such as cardiovascular disease, old age or oedematous state (e.g., severe hepatic impairment) may be associated with longer recovery times.

Each ml sugammadex solution contains 9.7 mg sodium. The rubber stopper of the vial does not contain latex.

35. Referenceswww.emc.medicines.org.uk accessed 25/6/15http://medusa.wales.nhs.uk Medusa medicines guide accessed 25/6/15www.medicinescomplete.com BNF June 2015 accessed 25/6/15Takazawa T et al. Sugammadex and rocuronium-induced anaphylaxis. Journal of Anesthesia. April 2016, Volume 30, Issue 2, pp 290–297. McDonnell NJ et al. Sugammadex in the management of rocuronium-induced anaphylaxis.

1. Br.

J. Anaesth. (2011) 106 (2): 199-201.




PIPERACILLIN AND TAZOBACTAM (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationLower respiratory-tract, urinary-tract, intra-abdominal, skin infections, and septicaemia in adult patients

2. Presentation4.5g vial of powder for reconstitution.Brand name Tazocin®.

3. Dose4.5g every 8 hours4.5g every 6 hours in neutropenic sepsis in 4.5g every 12 hours in renal impairment (CRCL less than 20ml/min)

4. AdministrationStandard Infusion Recommended by ManufacturerPreferred administration on wards

Drug Volume Fluid Infusion time Infusion rateCentral or Peripheral

4.5g Up to 50ml



Minimum Volume (for fluid restricted patients) — unlicensedPreferred administration on critical care

Drug Volume Fluid Infusion time Infusion rate


4.5g Up to 20ml

Water for Injection

4 hours 5ml/hour

Or reconstitute 4.5g vial with 20ml water for injection and bolus over 3-5 minutes (unlicensed).

5. Common Side EffectsCandidal superinfection Hypersensitivity reactionLeucopenia HypotensionNeutropenia Raised liver enzymesJaundice Raised creatinine

6. ContraindicationsKnown hypersensitivity to piperacillin or any other penicillin.

7. Y-site CompatibilityCompatible with:Glucose 5% and sodium chloride 0.9%



8. Notes Each 4.5g vial contains 9.4mmol of sodium Piperacillin/tazobactam may prolong the duration of neuromuscular blockade with vecuronium Half life of piperacillin and tazobactam quoted between 0.7-1.2 hours Dose as normal in hepatic impairment. Incompatible with Hartmann’s (Sodium Lactate Compound).

9. Referenceswww.emc.medicines.org.uk accessed 06/09/11www.medicinescomplete.com accessed 07/09/11http://medusa.wales.nhs.uk Medusa medicines guide accessed 01/12/14Roberts J et al. Better outcomes through continuous infusion of tim-dependent antibiotics to critically ill patients. Current opinion in critical care. 2008. 14: 390-396.







TERLIPRESSIN (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationBleeding oesophageal varices in adult patientsHepatorenal syndrome (prevention and treatment) in adult patients. (unlicensed)As alternative to vasopressin to treat hypotension due to vasodilatory shock in adult patients (unlicensed)

2. Presentation1mg in 8.5ml ampoule (0.12mg/ml)

3. DoseBleeding oesophageal varices: 2mg iv bolus every 4 hours. Treatment should be maintained until bleeding has been controlled for 24 hours but to a maximum of 48 hours.

Reduce to 1mg every 4 hours after initial 2mg bolus in patients with bodyweight less than 50kg.

NICE guidance is to continue until definitive haemostasis has been achieved or for up to 5 days (unlicensed duration).

Hepatorenal syndrome: unlicensed indication 1mg every 6 hours. Trial for 5 to 7 days, stop if no improvement.

Vasodilatory shock: 0.25mg to 1mg four times daily. Start with low dose and titrate upwards if necessary. This is an alternative to addition of vasopressin. It is expected that noradrenaline is first line, vasopressin is added in second line and terlipressin would be third line instead of vasopressin.

4. AdministrationSlow intravenous bolus over 3 to 5 minutes.

Dose Volume1mg 8.5ml0.5mg 4.2ml0.25mg 2.1ml

5. Common Side EffectsCramps, diarrhoea, headache, tremor, sweating, injection site necrosis, transient blanching, increased arterial blood pressure, peripheral ischemia, cyanosis, ventricular and supra-ventricular arrhythmias including ‘Torsade de pointes’, bradycardia, tachycardia, signs of ischemia on the ECG, angina, myocardial ischaemia and infarction, bronchospasm and respiratory arrest.

6. Contraindications & cautions Hypersensitivity to terlipressin or any excipients. Pregnancy.



Terlipressin has antidiuretic and pressor activity it should be used with great caution in patients with hypertension, atherosclerosis, cardiac dysrhythmias or coronary insufficiency. Constant monitoring of blood pressure, serum sodium and potassium and fluid balance is essential.

7. Y-site compatibilityNo data available, terlipressin must be administered via a dedicated lumen.

8. Notes Terlipressin is a synthetic analogue of vasopressin, it may be regarded as a circulating

depot of vasopressin. Following intravenous injection, three glycyl moieties are enzymatically cleaved from the N-terminus to release lysine vasopressin.

The slowly released vasopressin reduces blood flow in the splanchnic circulation in a prolonged manner, thereby helping to control bleeding from ruptured oesophageal varices.

half-life of elimination is about 50 -70 minutes pH 3 to 4. Terlipressin is stored in a refrigerator.

9. Referenceswww.emc.medicines.org.uk accessed 01/12/14www.medicinescomplete.com accessed 11/10/12http://medusa.wales.nhs.uk Medusa medicines guide accessed 13/11/14BNF edition 63 March 2012NICE guidance upper gastro intestinal bleeding management. June 2012. NICE clinical guideline 141.WUTH guideline for acute gastrointestinal bleeding. Nov 2012.







VANCOMYCIN (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationVancomycin is a glycopeptide antibiotic which is bactericidal against many gram positive organisms including MRSA in adult patients.

2. Presentation500mg and 1g vialsAvailable as a pre-prepared infusion from pharmacy, 750mg or 1g in 250ml sodium chloride 0.9%, 1.5g or 2g in 500ml sodium chloride 0.9%.

3. Dose Rapid injection can lead to severe hypotension, shock and cardiac arrest.

A loading dose is given to ALL patients irrespective of renal function, the dose is dependent on the patients weight:Under 50kg 1.25g in 250ml sodium chloride 0.9% over 2 hours50-70kg 1.5g in 500ml sodium chloride 0.9% over 2.5 hoursOver 70kg 2g in 500ml sodium chloride 0.9% over 3.5 hours

The maintenance dose is based on the patient’s renal function, please contact pharmacy for advice.

Vancomycin may be given orally to treat severe clostridium difficile infection, the dose is 125mg to 500mg qds. This may be given either as capsules or the injection via a nasogastric tube. Serum concentrations do not need to be monitored for enteral vancomycin as it is not well absorbed from the gastrointestinal tract. Intravenous vancomycin CANNOT be used to treat Clostridium difficile infection.


Drug Volume Fluid Concentration Rate



3mg/ml 150ml/hour1g Up to 250ml 4mg/ml 125ml/hour1.25g Up to 250ml 5mg/ml 125ml/hour1.5g Up to 500ml 3mg/ml 200ml/hour2g Up to 500ml 4mg/ml 125ml/hour

Maximum rate of administration 10mg/minute.

Minimum Volume, unlicensed. (for fluid restricted patients)Drug Volume Fluid Concentration Maximum Rate

Central or peripheral via large vein.


7.5mg/ml 75ml/hour1g Up to 100ml 10mg/ml 60ml/hour1.25g Up to 150ml 8.3mg/ml 70ml/hour1.5g Up to 150ml 10mg/ml 60ml/hour2g Up to 200ml 10mg/ml 60ml/hour

For concentrations above 5mg/ml central administration is preferred.



5. Common Side Effects Anaphylactoid reactions may occur following or during infusion, including:

hypotension, wheezing, dyspnoea, urticaria or pruritus. Rapid infusion may cause flushing of the upper-body ('red-man syndrome'), pain, muscle spasm of the chest and back, hypotension and bradycardia. Vancomycin should be discontinued if a bullous rash develops. Nausea, chills and rashes may develop.

Nephrotoxicity, ototoxicity: hearing loss associated with intravenous vancomycin. Vertigo, dizziness and tinnitus have also been reported.

Haematological: neutropenia, usually starting one week or more after onset of intravenous therapy or after a total dose of more than 25g, this is usually reversible on discontinuing the drug. Thrombocytopenia and reversible agranulocytosis may be associated with vancomycin.

Injection site pain and thrombophlebitis are common and may be severe. This is more common with higher concentrations.

6. ContraindicationsKnown hypersensitivity to vancomycin or any excipients.

7. Y site compatibilityCompatible with:Aciclovir, atracurium, caspofungin, clarithromycin, compound sodium lactate (Hartmann’s), esmolol, fentanyl, fluconazole, insulin, labetalol, linezolid, magnesium, meropenem, midazolam, morphine, nicardipine, potassium.

Amiodarone (if both in glucose 5%).

8. Notes Serum concentrations of vancomycin must be checked for all patients on vancomycin. For patients on regular dosing of vancomycin a pre dose ‘trough’ level is checked about twice a week. The first level is checked immediately before the third of fourth dose. A pre dose level should be checked immediately before the dose (certainly within 30minutes of the time the dose is due), the dose should then be given without waiting for the result. The usual range aimed for is 10 to 15mg/L, in MRSA infections or patients who are critically ill the range is 15 to 20mg/L. For patients in acute renal failure levels are often checked daily and a 1g dose is given only when the level is less than 20mg/L. The exact timing of these levels is not critical, they can often be sent with the normal morning bloods. This method of monitoring is also used for patients on haemofiltration. Rapid injection can lead to severe hypotension, shock and cardiac arrest. The risk of ototoxicity and nephrotoxicity is greatest in patients with renal failure, the elderly and if the serum concentrations are elevated. Vancomycin should also be avoided in patients with previous hearing loss. The combination of vancomycin and gentamicin should be avoided where possible as there is a much higher risk of renal and ototoxicity. Concommitant administration of vancomycin and anaesthetic agents may increase the risk of erythema, histamine like flushing and anaphylactoid reactions.









VASOPRESSIN (INTRAVENOUS)This guideline is a summary, full details are available from the SPC www.emc.medicines.org.uk

1. IndicationHypotension due to vasodilatory shock (unlicensed indication) in adult patients

2. Presentation20 units in 1ml ampouleNote there are various products available, brand names include Argipressin® and Pitressin®. Note one brand is stored at room temperature and one brand in the fridge.

3. Dose0.01 to 0.04 units/minute



Central 20 units Up to 50ml

Glucose 5%

0.4units/ml 1.5ml/hour 6ml/hour

5. Common Side EffectsSigns of water intoxicationTremor, sweating, abdominal cramps, nausea, vomiting, urticaria, bronchial constriction. Anaphylaxis (cardiac arrest and/or shock) has been observed shortly after injection. Peripheral ischaemia and rarely gangrene have been reported.

6. ContraindicationsHypersensitivity or anaphylaxis to vasopressin or ingredientsHypertension

7. Y site compatibilityCompatible with:Adrenaline, amiodarone, dobutamine, fluconazole, heparin, insulin, noradrenaline.

8. Notes The maximum rate of 6ml/hour must NEVER be exceeded in living patients. Higher doses, up to 4 units per hour (i.e. 10ml/hour) may be used at the request of

a specialist nurse for organ donation for donor optimisation. Vasopressin may be administered in sodium chloride 0.9% but best to use glucose

if being administered alongside other inotropes/vasopressors. Use with caution in peripheral vascular disease, observe closely for signs of

ischaemia. pH 3.6 so extravasation likely to result in tissue damage. May be administered via a large peripheral line but ideally administer centrally.







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