IV Medication Principles Flashcards
Central lines are required for administration of…
- highly concentrated drugs (e.g., potassium chloride > 20 mEq/100 mL)
- long-term antibiotics (e.g., to treat osteomyelitis)
- toxic drugs that would cause severe phlebitis or tissue damage (e.g., chemotherapy, especially with vesicants) if given peripherally
- drugs with a pH or osmolality that is not close to blood pH or osmolality (e.g., parenteral nutrition)
advantage of PICC line to a direct central line
It is simpler to insert a peripherally inserted central catheter (PICC) line than a direct central line.
- can be inserted at the bedside & a quick X-ray will confirm that the tip reached the right location
Vesicants are preferentially administered through a central line because the line is less likely to become dislodged from the vein. Vesicants include…
- vasopressors (e.g., dopamine, norepinephrine)
- anthracyclines (e.g., doxorubicin)
- vinca alkaloids (e.g., vincristine, vinblastine)
- digoxin, foscarnet, nafcillin, mannitol, mitomycin
- promethazine
risk of promethazine
Promethazine can cause severe tissue injury!
- Some hospitals have removed it from formulary due to this risk
- IM is preferred, but this also has a risk for tissue injury; intra-arterial or SC routes should not be used.
- Do NOT give to children < 2 years
- If using IV -> dilute the drug, limit the dose, & monitor patient
types of incompatibilities
Chemical incompatibility causes drug degradation or toxicity due to a hydrolysis, oxidation, or decomposition reaction.
Physical incompatibilities occur between a drug & one of the following:
- the container (e.g., polyvinyl chloride containers)
- the diluent (solution)
- another drug
What can leach from PVC containers into the solution?
The majority of polyvinyl chloride (PVC) containers use diethylhexyl phthalate (DEHP) as a “plasticizer” to make the plastic bag more flexible
- DEHP can leach from the container into the solution
- DEHP is toxic & can harm the liver and testes
Drugs with leaching/adsorption/absorption issues with PVC containers (remember acronym)
Leach Absorbs To Take In Nutrients (or LATIN)
- Lorazepam
- Amiodarone
- Tacrolimus
- Taxanes*
- Insulin
- Nitroglycerin
*Exception: paclitaxel-albumin bound (Abraxane) can be placed into PVC
Others: carmustine, cyclosporine, ixabepilone, sufentanil, temsirolimus
When drugs are diluted in solution for IV administration, they are commonly placed into a small volume (e.g., 100 mL or less) IV bag that contains ______________ or 0.9% ______________.
5% dextrose (D5W) or 0.9% sodium chloride (normal saline, NS)
Drugs that should be placed in saline (NO dextrose) remember acronym
A DIAbetic Can’t Eat Pie
- Ampicillin
- Daptomycin (Cubicin)
- Infliximab (Remicade)
- Ampicillin/Sulbactam (Unasyn)
- Caspofungin (Cancidas)
- Ertapenem (Invanz)
- Phenytoin (Dilantin)
Others: abatacept, azacitidine, belimumab, bevacizumab, idarucizumab, iron sucrose, ferric gluconate, natalizumab, trastuzumab
Drugs that should be placed in dextrose (NO saline) remember acronym
Outrageous Bakers Avoid Salt
- Oxaliplatin
- Bactrim (SMX/TMP)
- Amphotericin B (all)
- Synercid (Quinupristin/Dalfopristin)
Others: carfilzomib, mycophenolate, pentamidine
Ceftriaxone cannot be mixed with…
any calcium-containing solutions due to risk of precipitates
- Lactated Ringer’s contains calcium & cannot be mixed with ceftriaxone, including Y-site admin!
- This combo must be avoided in all age groups (but neonates have highest risk for lethal effects)
What two electrolytes can form a deadly precipitate in IV fluids?
Calcium & phosphate can form a deadly precipitate in IV fluids
- When calcium & phosphate are both put into parenteral nutrition, methods must be used to reduce the risk of a precipitate
primary resources for drug-drug incompatibility (mixing at the Y-site, mixing drugs in the same container, etc.)
- ASHP Injectable Drug Information
- Trissel’s 2 Clinical Pharmaceutics Database
- King Guide to Parenteral Admixtures
- The drug’s package insert
The majority of drugs in which filters are necessary use a ___________.
0.22 micron filter
What filter size is used for parenteral nutrition to catch calcium-phosphate particulates & injectable lipid emulsions?
1.2 micron
Common drugs with filter requirements (remember acronym)
my GAL Is PAT who has a MaP
- Golimumab
- Amphotericin B (lipid formulations)*
- Lipids-1.2 micron
- Isavuconazonium
- Phenytoin**
- Amiodarone
- Taxanes (cabazitaxel & paclitaxel)
- Mannitol 20% (& higher concs)
- Parenteral nutrition-1.2 micron
*Larger pore size filter required; prepare using a 5-micron filter
**Phenytoin requires a filter when administered by continuous infusion; a filter is not required for IV push
Others: abatacept, albumin (select products), infliximab
medications that cannot be refrigerated (remember acronym)
Dear Sweet Pharmacist, Freezing Makes Me Edgy!
- Dexmedetomidine*
- Sulfamethoxazole/Trimethprim
- Phenytoin: crystallizes
- Furosemide: crystallizes
- Metronizaole
- Moxifloxacin
- Enoxaparin
*Optional: diluted dexmedetomidine & furosemide can be kept cold
Others: acetaminophen, acyclovir (crystallizes), deferoxamine (precipitates), levetiracetam, pentamidine (crystallizes), valproate
Medications that need to be protected from light during administration (think of acronym)
Protect Every Necessary Med from Daylight
- Phytonadione (vitamin K)
- Epoprostenol
- Nitroprusside
- Micafungin
- Doxycycline
Others: Amphotericin B, Deoxycholate, Anthracyclines, Dacarbazine (if extravasates, protect exposed tissues from light), Pentamidine
Agitation destroys some drugs, including hormones & other proteins. Drugs that are easily destroyed/damaged should not be shaken during compounding or transport, & cannot be transported via pneumatic tube systems!
Examples include:
- Protein/blood products, such as albumin, immune globulins, monoclonal antibodies, & insulins (note: some manufacturers allow insulin to be transported via pneumatic tube one time)
- Products that foam, such as alteplase, etanercept (Enbrel), rasburicase, quinupristin/dalfopristin (Synercid), or caspofungin (should only be swirled when reconstituting -> do not shake; wait for foam to dissolve)
- Vaccines that have been reconstituted, such as varicella zoster virus vaccine
- Emulsions such as propofol & injectable lipid emulsion
Chlorpromazine should not be used if what color?
Darker than slight yellow
- slight yellow: potency
Dacarbazine should not be used if what color?
Pink
Oxidation turns dobutamine what color? Is potency lost?
Oxidation turns the solution slightly pink, but potency is not lost.
Dopamine should not be used if what color?
Darker than slight yellow
- slight yellow: potency retained, okay to use
Epinephrine should not be used if what color?
Pink, then brown
Isoproterenol should not be used if what color?
Pink or darker
- damaged by air, light, heat
Morphine should not be used if…
dark
Nitroprusside should not be used if what color?
Orange -> brown -> blue
- Blue indicates nearly complete dissociation to cyanide!
Norepinephrine should not be used if what color?
Pink or darker
Tigecycline should not be used if what color?
Green/black
- normal color: yellow/orange
What color is anthracyclines (e.g. doxorubicin)?
Red (discolors sweat & urine)
What color is rifampin?
Red (discolors saliva, urine, sweat, & tears)
What color is mitoxantrone?
Blue (discolors skin, eyes, & urine)
What color is methotrexate?
Yellow
What color is multivitamins for infusion (MVI)?
Yellow
What color is tigecycline?
Yellow/orange
- discolors teeth (if used during teeth development)
*think orange like a TIGEr (TIGEcycline)
What color is IV iron, various?
Brown (discolors urine)
