Contents
Third edition editorial board
Contributors
Acknowledgements
Preface
Section A
1 Introduction
2 Overview
2.1 Organisation of information in the Guide
2.2 Sources of information and disclaimer
3 UCLH policies
3.1 Responsibilities of professional staff at UCLH
3.2 Preparation of injectable medicines on wards, clinics and departments at UCLH
4 An overview of intravenous therapy
4.1 When is intravenous therapy appropriate?
4.2 Drug factors that influence the choice of route
4.3 Disadvantages of intravenous administration
4.4 Routes of intravenous administration
5 Factors affecting patency of intravenous sites
5.1 Factors increasing failure of intravenous sites
5.2 Factors decreasing failure of intravenous sites
5.3 Occlusion of central venous catheters
6 Methods of intravenous administration
6.1 Intravenous bolus
6.2 Intermittent intravenous infusion
6.3 Continuous intravenous infusion
6.4 Preparation and administration of intravenous medicines
6.5 Aseptic non-touch technique (ANTT)
7 Extravasation of injectables: overview and management advice
7.1 Patient factors affecting extravasation
7.2 Medicine factors affecting extravasation
7.3 Administration factors affecting extravasation
7.4 Overall risk for extravasation
7.5 Treatment of extravasation
8 Flushing cannulae, catheters and administration sets
8.1 Flushing between medicines
8.2 When not to flush
8.3 Flushing catheters and cannulae not in use
8.4 Flushing with heparin
9 Infusion pumps
9.1 Pumps used at UCLH
9.2 Volumetric pumps
9.3 Syringe pumps
9.4 Pumps for ambulatory use
9.5 Patient-controlled analgesia (PCA) pumps
9.6 Target-controlled anaesthesia (TCI or TIVA) pumps
10 Administration of injectables in primary care
10.1 Self-caring patients
11 Formulation and presentation of injectables
11.1 Medicines that require reconstitution
11.2 Preparations in solution requiring further dilution before use
11.3 Preparations available ‘ready to use’ without further dilution
11.4 Preparations available ‘ready to administer’
12 Pharmaceutical aspects of injectable administration
12.1 Displacement values
12.2 Sodium content
12.3 Drop size
12.4 Layering
12.5 Fluid restriction
13 Factors influencing medicine stability and compatibility of injectable medicines
13.1 Degradation
13.2 Precipitation
13.3 Binding of medicines to plastics
13.4 Destabilisation of parenteral emulsions
13.5 Leaching of plasticisers
13.6 Blood and blood products
14 Allergic reactions to injectables
14.1 Latex allergy
15 Compatibility of drugs in a syringe driver for subcutaneous use
16 Risk assessment of injectables and risk reduction
16.1 Risk assessment
16.2 Risk reduction
17 Useful resources
17.1 Websites
17.2 Further reading
Section B
User guide
Monographs in alphabetical order
Index of monographs
Users of the UCL Hospitals Injectable Medicines Administration Guide should be familiar with the terminology used in the monographs. A full explanation of the terms is found in the User Guide and Tutorial in Section B. For quick reference, the key abbreviations are listed here.
| Method of administration | Description |
| IV bolus | Intravenous bolus |
| (I) IV infusion | Intermittent intravenous infusion |
| (C) IV infusion | Continuous intravenous infusion |
| SC bolus | Subcutaneous bolus |
| (C) SC infusion | Continuous subcutaneous infusion |
| IM | Intramuscular injection |
| Diluent | Definition |
| NS | Sodium chloride 0.9% |
| W | Water for injections |
| G | Glucose 5% (dextrose monohydrate) |
| G10 | Glucose 10% |
| G20 | Glucose 20% |
| H | Compound sodium lactate |
| (Hartmann’s or lactated Ringer’s) | |
| GS | Glucose 4% and sodium chloride 0.18% |
| Infusion device | Description |
| Volumetric pump | A device which pumps fluid from a reservoir, such as an infusion bag or bottle, through an administration set at a preset rate |
| Syringe pump | A device which delivers fluid from a syringe into an administration set at a preset rate |
| Syringe driver | A portable device which delivers fluid from a syringe into an administration set at a preset rate |
| Term | Definition/Explanation |
| Reconstitute | Add fluid to a dry powder to produce a solution or suspension |
| Dissolve | Add fluid to a dry powder to give a solution |
| Diluent | The fluid used to either reconstitute a powder, or to further dilute a drug solution or suspension |
| Dilute to XmL fluid | Add fluid to the container so the final volume is X. For example, if the instruction says "dilute dopamine 200 mg/5 mL to 20 mL water", the user should take the dopamine and mix it with water so that the final volume is 20 mL. The final concentration is dopamine 200 mg/20 mL, or 10 mg/mL. |
| Dilute with XmL fluid | Add XmL to the container. For example, if the instruction says "dilute dopamine 200 mg/5 mL with 20 mL water" the user should take the dopamine and add 20 mL water, so that the final volume is 25 mL (20 mL from the water, 5 mL from the drug). The final concentration is dopamine 200 mg/25 mL, or 8 mg/mL |
Understanding the NPSA risk rating: a full explanation of the risk rating scale is provided in the User Guide. The number bar indicates the complexity of the adjacent preparation and administration method. It is colour coded to give a visual indication of the risk: low risk tasks are green, moderate risk tasks are amber, and high risk tasks are red. The user should take additional time to plan and prepare medicines with a high risk rating, ensuring local protocols are adhered to, and appropriate safety measures and patient monitoring are in place.
This edition first published 2010
© 1998, 2007, 2010 Pharmacy Department, University College London Hospitals
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Library of Congress Cataloging-in-Publication Data
UCL Hospitals injectable medicines administration guide/Pharmacy Department, University College London
Hospitals. – 3rd ed.
p.; cm.
Other title: Injectable medicines administration guide
ISBN 978-1-4051-9192-0 (pbk.: alk. paper)
1. Injections–Handbooks, manuals, etc. 2. Drugs-Handbooks, manuals, etc. I. University College London Hospitals Foundation NHS Trust. Pharmacy Dept. II. Title: Injectable medicines administration guide. [DNLM: 1. Pharmaceutical Preparations–administration & dosage–Handbooks. 2. Injections, Intramuscular–methods–Handbooks. 3. Injections, Intravenous-methods–Handbooks. 4. Injections, Subcutaneous–methods–Handbooks. QV 735 U17 2010]
RM170.U26 2010
615’.6–dc22
2010003288
A catalogue record for this book is available from the British Library.
Third edition editorial board
Editor
Mr Kenneth Mole, MPharm, Dip Clin Pharm, MRPharmS
Sub-editors
Dr Robert Shulman, BSc, DHC, MRPharmS
Dr Anthony Grosso, BSc, MSc, PhD, MRPharmS
Dr Robert Urquhart, BPharm, PhD, MRPharmS
Mr Robin Offord, BPharm, MSc, MRPharmS
The UCL Hospitals Injectable Medicine Administration Guide, Third Edition, is produced by the UCLH Pharmacy Department on behalf of the Trust Use of Medicines Committee.
Contributors
Ms Fiona Maguire, BPharm, Dip Clin Pharm, MRPharmS
Mr Neil Tickner, MPharm, Dip Clin Pharm, MRPharmS
Mrs June Minton, BPharm, Dip Clin Pharm, MRPharmS
Ms Carolyn Gates, BPharm, MSc, MRPharmS
Mr Shahid Gani, MSc, MRPharmS
Ms Preet Panesar, BPharm, MRPharmS
Ms Emma Riches, Dip Clin Pharm, MRPharmS
Ms Kerstin von Both, MPharm, MSc, MRPharmS
Ms Hannah Wilton, MPharm, Dip Clin Pharm, MRPharmS
Mrs Shola Ajibodu, BSc, Dip Clin Pharm, MRPharmS
Ms Sheetal Sumaria, BSc, MRPharmS
Ms Evelyn Frank, MPharm, Dip Clin Pharm, MRPharmS
Mr Balram Malhotra, BSc (Hons), MSc, MRPharmS
Ms Rina Kundi, MRPharmS
Ms Aoife Sheilds, Dip Clin Pharm, MRPharmS
Mrs Ravijyot Saggu, MPharm, Dip Clin Pharm, MRPharmS
Acknowledgements
The UCL Hospitals Injectable Medicines Guide is the result of an extensive team effort, some members of which have changed since the book was published within UCL Hospitals. The editors would like to acknowledge the contribution of Sarla Drayan, Robert Shulman, Simon Badcott, Mark Harries and Denise Hoare for their extensive work on the first edition.
We offer our sincere thanks to the above contributors for their detailed feedback; their in-depth knowledge and attention to detail ensures the monographs are both authoritative and representative of current practice. Furthermore, the editors would like to thank the nurses of Ward T9 at University College Hospital for road testing some of the new monographs and for providing their frank and honest opinion of the content. Nursing feedback has allowed us to make this an altogether more user-friendly guide. We would also like to thank Mr Ronny Jahne for his constructive advice regarding the format of the new style monographs.
Furthermore, we acknowledge the UKCPA Critical Care Group for their Minimum Infusion Volume document (third edition). We would also like to recognise the contribution of the Pharmacy Department of Imperial College Healthcare Trust, Susan Keeling, and the pharmacists from the many different hospitals from around the UK who have contributed to the National Injectable Guide website. Information on the IV Guide site can be obtained from Gill Bullock (gbullock@hhnt.org) who is based in the pharmacy at Charing Cross Hospital.
Preface
The UCL Hospitals Injectable Medicines Administration Guide, Third Edition, is a fully revised and updated version of the previous editions published in 1997 and 2007. The general structure and format remain unchanged. The positive feedback we have received from nurses, pharmacists and doctors across the globe demonstrates that the Guide is a winning format. As computer-based systems are being introduced to manage all aspects of patient care, including patients’ medicines, an internet version of the Guide has been launched. In 2009 the UCLH Guide online went live (www.uclhguide.com) to meet the demand for up-to-date information in the digital age.
Healthcare is a rapidly evolving field, and in recent years patient safety has become an NHS priority. There is great interest in reducing the risk associated with injectable medicines, particularly since the publication of the National Patient Safety Agency alert Promoting Safer Use of Injectable Medicines. The injectable practices within the UCLH have been thoroughly scrutinised; every identifiable practice has been risk assessed and risk reduction strategies introduced. At UCLH we believe we are now working in a safer environment: we have rationalised the injectable products we use, expanded the range of ready-to-use injectables on our formulary, introduced guidelines to support those who prescribe, dispense and administer high-risk injectables and improved the training package for new staff who give injectables. Many of the risk reduction strategies have resulted in amendments to the monographs that form the core of this publication. Staff in the pharmacy department of UCLH are proud in the knowledge that their hard work is protecting patients through the safer use of injectable medicines, and we are happy to share the progress we have made through the Guide.
The opening chapters of the Guide have been revised to reflect recent changes in the use of injectables. Many concepts in the introductory chapters have been expanded to give the reader a more comprehensive overview of injectable therapy. Examples from current practice have been given so that readers can relate their own experiences to the text. A tutorial and example monograph has been added to make it easier for new users to get to grips with the Guide. This edition features over