1

This procedure is adopted for LSW staff from:

Livewell Southwest

Procedures for Administering Injectable

Drugs
Version No 4.3
Review: May 2017

Notice to staff using a paper copy of this guidance

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

Author: Chief Pharmacist / Clinical Pharmacist

Asset Number: 385

 1

Procedures for Administering Injectable Drugs

Date Version
May 2016 Issue 11.4
Purpose
The purpose of this document is to inform Trust staff of the correct and safe methods of preparation
and administration of injectable drugs. It includes information on the use of infusion devices.
Who should read this document?
All staff working for or on behalf of Plymouth Hospitals NHS Trust who prepare and administer fluids
and drugs by injection or infusion.
Key messages
Staff working for or on behalf of Plymouth Hospitals NHS Trust who prepare and administer fluids and
drugs by injection or infusion must do so in accordance with these procedures.
Accountabilities
Production Peter Gray, Pharmacist
Review and approval Medicines Utilisation and Assurance Committee
Ratification Medicines Utilisation and Assurance Committee
Dissemination Peter Gray, Pharmacist
Compliance Medicines Utilisation and Assurance Committee

Links to other policies and procedures

Pharmacy documents available on PHNT StaffNet
 PHNT Medicines Management Policy
 SOPs for preparing and administering intravenous medicines and fluids.
 SOPs for the management of phlebitis, infiltraton, air embolism, speedshock and extravasation.
 SOPs for the safe handling and administration of injectable cytotoxic drugs.
 SOP for setting up and maintaining variable rate intravenous insulin infusions.
PHNT Vascular Access Documents:
 Administration of Medication through a Central Venous Catheter (CVC)
 Removal of a Central Line
 PHNT Central Vascular Access Guidelines

PHNT Infection Control Documents:

 Guidelines for the Management of Peripheral Intravenous Devices
 Guidelines for the Management of Central Intravenous Catheters
 Hand Hygeine Guidelines
 Guidelines for Aseptic Technique
 Safe Disposal of Sharps Policy
Other Documents:
 Royal College Nursing Standards for Infusion Therapy, 2010
 Department of Health High Impact Intervention Care Bundles for-
 1

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

Issue 11.3 (April 2016)

 Monograph for Intravenous Zanamivir added.

Issue 11.4 (May 2016)

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

 PHNT is committed to creating a fully inclusive and accessible service.

 Making equality and diversity an integral part of the business will enable us to enhance the services we deliver and
better meet the needs of patients and staff.
 We will treat people with dignity and respect, actively promote equality and diversity, and eliminate all forms of
discrimination regardless of (but not limited to) age, disability, gender reassignment, race, religion or belief, sex,
sexual orientation, marriage/civil partnership and pregnancy/ maternity. Larger text, Braille and Audio versions can
be made available upon request.

An electronic version of this document is available on PHNT StaffNet > Departments > Pharmacy > Injectable Medicines
 1
> “Procedures for Administration of Injectable Drug
Contents

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

1 Intravenous Drug Calculations

Coverting Between Units

Rounding up or down decimals

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

Calculation of the volume of drug to draw up

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

What you want

_____________ X Volume in the ampoule
What you’ve got

 Note that the units of “What you want” – i.e. the prescribed dose, and “What you’ve got” – i.e the
amount in the ampoule must be the same.
 You may need to convert the units so that both are mg or both are micrograms for example.
 1

Example
Your patient has been prescribed gentamicin 350mg IV once daily. Gentamicin ampoules are 80mg in
2ml.

What you want (350mg)

____________________ X Volume (2ml amps)
What you’ve got (80mg)
= 8.75ml which you’ll round up to 8.8ml

Concentration, Volume and Amount

The Concentration Triangle: Example

 Your patient has a low serum magnesium
and has been prescribed IV magnesium
sulphate 2g.
 What’s the minimum volume this should be
Amount
given in?
 You read the magnesium monograph in the
injectable drugs folder and it says “maximum
concentration of 200mg/ml”
Concentration Volume  2g = 2,000mg magnesium

Amount (2,000mg) Minimum vol.

 Concentration = Amount _______________________ = 10 (ml)
Volume Concentration (200mg/ml)
 Volume = Amount
Concentration

 Amount = Concentration x volume

Infusion Rate, Volume and Time

The Infusion Rate Triangle: Example

 You have drawn up 8.8ml of gentamicin
injection (350mg).
 As per the injectable drugs folder you dilute
this with 100ml saline to make 108.8ml
solution, for infusion over 30 minutes.
Volume
Volume (108.8ml)
________________ =Rate (3.626666ml/minute)
Time (30 minutes)
Rate Time
You have to set your pump in ml/hour. There are
60 minutes in an hour so multiply
3.6266666ml/minute by 60 to get 217.6ml/hour.
 Rate = Volume You may have to round this figure to 218ml/hour
Time to set your pump.
 Volume given = Rate x time
 Time taken for infusion = Volume P.S. If the infusion time is in hours then you don’t
Rate need to multiply the answer by 60. Also notice
that the decimal was only rounded at the final
answer.
 1

Displacement Values

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

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

Calculating a Drip Rate

 Any fluid containing potassium, magnesium Example

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

Round 41.66 up to 42 drops/minute

Volume (ml) x 20
______________ = drip rate (drops/minute)
Time (hours) x 60

N.B. 20= drops/ml in a standard giving set.

(Change to 60drops/ml for a paediatric giving
set). 60= number of minutes in an hour.
 1

2.1 Injectable Drug Monographs

All monographs contained in this section are the current versions as of the time of going to print and are
listed in alphabetical order according to generic name.

Detailed guidance for the administration of cytotoxic drugs is not given in the monographs, but should
be obtained from the appropriate ward or unit protocol.

Unlicensed use of medications

Where in the monographs the use of a drug is noted to be unlicensed, this either refers to the drug
formulation itself not having a UK product licence or where the indication, dosage, dilution or rate of
administration fall outside of the UK product licence.

When an unlicensed medication is administered to a patient or a licensed medication is administered in

an unlicensed manner the prescribing doctor takes full responsibility for any adverse consequences.

Important notes

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24
hours unless otherwise specified in the drug monograph. This includes infusions such as
Patient Controlled Analgesia (PCA) and sliding-scale insulin.

 Unless described in the drug monograph as “Multidose” all injectable products, including bags
of sodium chloride 0.9% and 5% glucose must be treated as single use only and disposed of
immediately after use.

 Any infusion containing drug(s) or potassium or any other additive must be administered using
an infusion pump.

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

 For patients on a variable-rate insulin infusion and glucose infusion, the glucose must be
infused using a volumetric pump.

 Always read the label on the ampoule, syringe or box. Do not rely on familiar colours or shapes
of packaging to correctly identify medication.

 Always label an IV container or syringe containing fluid to which a drug or electrolyte has been
added with a completed “Additive Label”.

 All syringes containing drawn-up medication or flushing solution must be labelled with name of
medicine or flushing solution and the dose/strength, unless the risk of doing so (eg
contaminating a sterile field) is perceived by the individual practitioner to outweigh the risk of
mis-identifying un-labelled syringe(s). The individual practitioner is then responsible for ensuring
that any un-labelled syringes are not mis-identified. Labels for this purpose (Code QC31) can
be ordered from Pharmacy.

 Drug solutions that have been drawn up or prepared in clinical areas must be administered
immediately after preparation or drawing up.

 All the intravenous medications listed in the Section 4 monographs may be given via a
peripheral cannula or a central venous cannula, unless the monograph specifically says that a
particular drug or drug concentration must only be given via a central venous cannula.
 1
 If you require information on intravenous compatibilities; contact Pharmacy Drug Information on
Ext. 39976.

  Groups of staff allowed to administer injectable medications which are referred to in the
monographs:

Group 1

o Registered and Provisionally Registered Medical Practitioners. It is recommended that IV drugs

are checked by a second person either another medical practitioner or a registered
healthcare professional before administration.

Group 2
o Registered Nurses, Midwives and Operating Department Practitioners (ODP’s) who have
undertaken the Plymouth Hospitals NHS Trust IV drug administration training (or satisfy the
criteria for new employees from outside the Trust), and have been assessed as competent.
Group 2 can administer to adult patients only. Another Registered healthcare professional
should check all aspects of the administration with this Nurse or Midwife. Cytotoxic IV drugs
are NOT to be administered by this group.
o Exceptions are methotrexate and cyclophosphamide, which can be administered by this group if
the practitioner has previous experience of administering parenteral cytotoxics.

Group 3

o Nurses who qualify for Group 2, working in identified specialist areas, and have undertaken
additional training and assessment to administer cytotoxic IV drugs.

Group 4

o A Registered Sick Children's Nurse (RSCN) or Registered Nurse (Part 15 - Child Branch)
working in the paediatric field who qualifies for inclusion in Group 2.
o The exception is for staff who work regularly in the Emergency Department, Intensive Care Unit,
Theatres, Maternity and Neonatal Intensive Care Unit, who can administer Group 2 drugs to
paediatric patients, providing they are familiar with the drug and the calculation (if any) required.

Group 5

o Nurses who qualify for Group 4 and have undertaken additional training and assessment to
administer cytotoxic drugs.

Group 6

o Named Individual Radiographers/Sonographers who have completed and passed an accredited

training programme in the administration of IV drugs may administer named contrast media,
Hyoscine Butylbromide, Sodium Chloride 0.9% and Glucagon via the IV route according to the
department’s authorised and signed patient group direction.
Group 7

o Named and authorised technical, scientific and delegated medical staff of the department of
Nuclear Medicine who have the appropriate training required by IR(ME)R 2000 to administer
radiopharmaceuticals and who have completed an accredited course in IV drug administration
or equivalent. Such individuals may administer named drugs and radiopharmaceuticals by IV
route according to the department’s authorised and signed patient group direction (PGD).

o All Registered healthcare professionals must be assessed as competent in the methods

required for administration as advised in section 4 monographs. If they have not been assessed
as competent with the administration method, e.g. using a central line, or aseptic non-touch
technique they must not proceed.
 1
o All training and assessment of competency to administer intravenous medication should include
training and assessment of aseptic non-touch technique and administration via central vascular
access devices. For more information or training please contact the Learning and
Development Facilitator.

Group 8

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

Abbreviations used in the drug monographs

(C) Continuous
(I) Intermittent
IV Intravenous
IM Intramuscular
SC Subcutaneous
N/S Sodium Chloride 0.9%
G Glucose 5%
G/S Glucose 4% and sodium chloride 0.18%. Other combinations of glucose and sodium
chloride may not be compatible with the drugs listed in Section 4 – contact Pharmacy for
advice on ext.39976.
H Compound sodium lactate (Hartmann’s)
Hep/S Heparin 10 units in 1ml sodium chloride - heparinised sodium chloride (e.g. Hepsal)
W Water for Injection (preservative free)
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE SUITABLE DILUENT
Abatacept (I) IV infusion via a  Groups Infuse all doses over 30 Reconstitute each 250mg vial with Monitor blood pressure (increase in
(Orencia®) pump. 1 and 2 minutes 10ml W using the silicone-free syringe BP is common), pulse and
provided. Direct the stream of W down temperature. Monitor for allergic
Infuse via a non- the inside wall of the glass vial. reactions (rare) and rash (common).
pyrogenic low Minimise foam formation by rotating the Check LFTs (ALT and AST
protein binding vial slowly with gentle swirling to commonly raised).
filter (0.2-1.2 dissolve the powder. Do not shake. If any serious allergic or
microns) After dissolution, vent the vial with a anaphylactic reaction occurs
needle to dissipate any foam that may discontinue the infusion immediately
be present. Remove a volume of N/S and initiate appropriate therapy.
from a 100ml bag N/S equal to the Do not mix with any other drug
volume of reconstituted vials. Slowly solutions.
add the reconstituted solution from 0.375mmol sodium per 250mg vial
each vial to the infusion bag using the Flush with N/S.
same silcone-free syringe. Gently mix.
Abciximab Initial IV bolus  Groups 1 minute Inject 5ml of air into the vial before For stabilisation of unstable angina,
1 and 2 withdrawing the solution. Use the 20ml bolus dose followed by the infusion
syringe to draw up sufficient volume for is started up to 24 hours prior to PCI
both the bolus and 12-hour infusion. and concluded 12 hours after PCI.
Connect the 0.2 or 0.22 micron filter For other patients bolus is given 10-
and connector provided. Draw the 60 minutes prior to PCI followed by
volumes necessary for the bolus dose the infusion for 12 hours.
and infusion into two separate syringes Do not shake unused vials.
through the connector. Flush: N/S or G.
(C) IV infusion via  Groups 4ml/hour for 12 hours See Filter Pack for nomogram. Either Do not infuse with any other drugs.
pump immediately 1 and 2 (50ml syringe driver) or dilute the volume drawn up for infusion
following initial IV 19ml/hour for 12 hours with N/S or G to make 50ml or add the
bolus. (250ml infusion bag) drawn up volume to 250ml of N/S or G.
Acetazolamide IV bolus  Groups Suggested maximum Reconstitute each 500mg with at least Flush with N/S or G.
1 and 2 100-500mg/minute 5ml W. Extravasation may cause tissue
damage.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 11
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE SUITABLE DILUENT
Acetylcysteine (C) IV infusion  Groups 1 Treatment of paracetamol A change in colour of solutions of
Infusion pump and 2 overdosage: three consecutive acetylcysteine to light purple is
is required. infusions as detailed in the table insignificant.
below (For treating children <40kg Flush with G or N/S.
follow the instructions on the next 2 Sodium content 12.78mmol/10ml
pages). .
(C) IV infusion  Groups 1 On ICU or HDU acetylcysteine may be
via central line and 2 infused in smaller volumes of G or
Infusion pump undiluted if necessary (unlicensed - see
is required. page 7) via a central IV line. However the
hourly infusion rate (ml/hour) will be
different to the figure in the table below.

Adult Dosage Table for Treating Paracetamol Overdose

Regimen First Infusion Second Infusion Third Infusion
Infusion Fluid 200ml G (or 200ml N/S if G is unsuitable) 500ml G (or 500ml N/S if G is unsuitable) 1000ml G (or 1000ml N/S if G is unsuitable)
Duration of 1 hour 4 hours 16 hours
Infusion
Drug Dose 150mg/kg 50mg/kg 100mg/kg
2 2 2
Patient’s weight Grams of Volume (ml) of Infusion rate Grams of Volume (ml) of Infusion Grams of Volume (ml) of Infusion
1
(kg) acetylcysteine acetylcysteine to (ml/hour) acetylcysteine to acetylcysteine to rate acetylcysteine acetylcysteine to rate
to prescribe add to 200ml fluid prescribe add to 500ml fluid (ml/hour) to prescribe add to 1000ml fluid (ml/hour)
40 - 49 6.8 34 234 2.4 12 128 4.6 23 64
50 - 59 8.4 42 242 2.8 14 129 5.6 28 64
60 - 69 9.8 49 249 3.4 17 129 6.6 33 65
70 – 79 11.4 57 257 3.8 19 130 7.6 38 65
80 – 89 12.8 64 264 4.4 22 131 8.6 43 65
90 – 99 14.4 72 272 4.8 24 131 9.6 48 66
100 – 109 15.8 79 279 5.4 27 132 10.6 53 66
≥ 110 16.6 83 283 5.6 28 132 11 55 66

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 12
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE SUITABLE DILUENT
1
Dose calculations are based on the weight in the middle of each band. If the patient weighs less than 40kg use the paediatric dosage table.
2
Ampoule volume has been rounded up to the nearest whole number.

Acetylcysteine for treating paracetamol overdose in Children

Children are treated with the same doses and regimen as adults. However, the quantity of intravenous fluid used has been modified to take into account age and weight,
as fluid overload is a potential danger. Doses should be administered sequentially using an appropriate infusion pump.

Preparation and administration of paediatric infusions

 Weigh the child to determine the correct weight band.
 Read off the table (on the next page) the total infusion volume required for each dose according to the weight of the child and make up the solutions according to the
directions below.

First Infusion
 Prepare the appropriate volume for the weight of the child.
 Prepare a 50 mg/mL solution by diluting acetylcysteine (200 mg/mL) with glucose 5% (preferred) or sodium chloride 0.9% as follows:
Weight 1-14kg add 10mls of acetylcysteine to 30ml of diluent
Weight 15-24kg add 20mls of acetylcysteine to 60ml of diluent
Weight 25-39kg add 30mls of acetylcysteine to 90ml of diluent
 The dose is infused over 1 hour at the infusion rate stated in the table (equiv to 3ml/kg/hour).

Second Infusion
 Prepare the appropriate volume for the weight of the child.
 Prepare a 6.25 mg/mL solution by diluting acetylcysteine (200 mg/mL) with glucose 5% (preferred) or sodium chloride 0.9% as follows:
Weight 1-9kg add 8mls of acetylcysteine 200mg/ml to a 250ml bag
Weight 10-19kg add 16mls of acetylcysteine 200mg/ml to a 500ml bag
Weight 20-39kg add 32mls of acetylcysteine 200mg/ml to a 1000ml bag
 The dose is infused over 4 hours at the infusion rate stated in the table (equiv to 2ml/kg/hour).

Third Infusion
 Use the solution prepared under second infusion above.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 13
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
 The dose is infused over 16 hours at the infusion rate stated in the table (equiv to 1ml/kg/hour).

For example for a child weighing 12 kg, the first infusion would be 38 mL infused at 38 mL/h over 1 hour,the second infusion would be 100 mL infused at 25 mL/h over 4
hours and the third infusion is 208 mL infused at 13 mL/h over 16 hours.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 14
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
 Weigh the child and prepare the infusion as instructed on the previous page.
Paediatric Dosage Table for Treating Paracetamol Overdose
Regimen First Infusion Second Infusion Third Infusion
Infusion 50mg/ml for 1 hour 6.25mg/ml for 4 hours 6.25mg/ml for 16 hours
Infusion rate 3ml/kg/hour 2ml/kg/hour 1ml/kg/hour
1
Patient’s weight Dose of Total infusion Infusion rate Dose of Total infusion Infusion rate Dose of Total infusion Infusion rate
(kg) acetylcysteine volume (ml/hour) acetylcysteine volume (ml/hour) acetylcysteine volume (ml/hour)
to prescribe (ml) to prescribe (ml) to prescribe (ml)
1 150mg 3 3 50mg 8 2 100mg 16 1
2 300mg 6 6 100mg 16 4 200mg 32 2
3 450mg 9 9 150mg 24 6 300mg 48 3
4 600mg 12 12 200mg 32 8 400mg 64 4
5 750mg 15 15 250mg 40 10 500mg 80 5
6 900mg 18 18 300mg 48 12 600mg 96 6
7 1.05g 21 21 350mg 56 14 700mg 112 7
8 1.2g 24 24 400mg 64 16 800mg 128 8
9 1.35g 27 27 450mg 72 18 900mg 144 9
10-14 1.9g 38 38 625mg 100 25 1.3g 208 13
15-19 2.65g 53 53 875mg 140 35 1.8g 288 18
20-24 3.4g 68 68 1.125g 180 45 2.3g 368 23
25-29 4.15g 83 83 1.375g 220 55 2.8g 448 28
30-34 4.9g 98 98 1.625g 260 65 3.3g 528 33
35-39 5.65g 113 113 1.875g 300 75 3.8g 608 38
1
Dose calculations based on the weight in the middle of each band. If the patient weighs more than 40kg use the adult dosage table. Figures have been rounded up to
the nearest whole number.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 15
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE SUITABLE DILUENT
Aciclovir (I) IV infusion  Groups 1 hour Dilute each 250-500mg in a 100ml bag Flush with N/S, G/S or H.
(Ready-diluted Infusion pump 1,2,3,4 and 5 N/S, G/S or H. For doses between Sodium content approx
brands) is required. 500mg and 1000mg use two 100ml bags 1mmol/250mg.
or one 250ml bag. The concentration Discard infusion if any visible
should not exceed 5mg/ml. Shake the turbidity or crystallisation appears.
prepared infusion well before use. Extravasation may cause tissue
Aciclovir (I) IV infusion  Groups 1 hour Reconstitute each 250mg with 10ml of W damage. Patient should be
or N/S to produce a solution containing adequately hydrated.
(Powder for Infusion pump 1,2,3,4 and 5
reconstitution) is required. 25mg/ml. Dilute further with N/S, G/S or
H to a concentration not exceeding
5mg/ml. For fluid restricted patients the
reconstituted solution may be infused
without further dilution via a central IV
line.
Actrapid® See Insulin Section page
Adenosine IV bolus  Group 1 2 seconds Can be diluted with N/S if necessary. If given into an IV line, inject as
proximally as possible and follow
with a rapid N/S flush. Cardiac
monitoring and resuscitation
equipment should be available for
immediate use. Sodium content
0.154mmol/3mg.
(I) IV infusion  Group 1 6 minutes Administer in accordance with the
for cardiac and Group 7 Nuclear Medicine Department
stress testing protocol.
Infusion pump
is required.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 16
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Adrenaline (C) IV infusion  Groups 1 Adjust rate according Usual local practice on General Protect infusion from light.
(Epinephrine) Infusion pump is and 2 to response. ICU is to use 1:10,000 adrenaline If G used as diluent pH must be below
required. in a 50ml syringe (5mg in 50ml). 5.5 (pH of G stocked in this Trust is
. between 4-4.2). Infuse through a large
Usual dilution on Torrington ICU vein if possible. (I) IV infusion requires
is 2mg diluted to 50ml with G. continuous blood pressure monitoring.
Replace giving set - do not flush.
Extravasation may cause tissue
damage.
Note that 1mg ampoules are only
licensed for IM or SC use. However,
they are suitable for preparing an IV
infusion.
Emergency use in  Group 1 1 - 2 seconds Use 1:10,000 (1mg in 10ml)
CPR: IV bolus prefilled syringe.
Emergency use in  All groups Refer to the Marsden Manual for Refer to the algorithm for the
anaphylaxis guidance on IM injection. management of suspected life-
IM Injection using threatening anaphylaxis on page 206.
1:1,000 injection IM is the usual route.
Emergency use in  Group 1 Specialist use only: Use 1:10,000 injection or dilute
anaphylaxis – Only
Adults: 0.5ml of dilute 0.5ml of 1:1,000 adrenaline to If a patient is suffering an anaphylactic
IV route is only 1:10,000 adrenaline IV 5ml with N/S or G to make a reaction, there is no prescription for
anaesthetists
used in an acute over 1 minute with 1:10,000 solution. adrenaline and there is no doctor
and senior
hospital setting by continuous ECG immediately available to prescribe
clinicians
an experienced monitoring, pulse adrenaline, IM adrenaline can be given
working in
practitioner for a oximety and frequent by a non-medical member of staff who
intensive care,
has the skills to assess a patient and
patient with theatre or the blood pressure
immediately life- measurements. give IM injections. They should do this
Emergency
threatening Repeat dose as in accordance with the protocol in
Department.
profound shock. necessary according Appendix 1 (page 202)
to response

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 17
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Ajmaline Slow IV bolus  Group 1: No greater Undiluted For detailed instructions it is essential to read the
(Unlicensed- junior doctors than Ajmaline Protocol (Copies on Torcross and Bickleigh
see page 7) trained in the 5mg/minute. wards)
For diagnosis technique and Maximum Patient to be nil-by-mouth for at least 4 hours before the
of Brugada with UK ALS dose is test.
Syndrome accreditation, 1mg/kg Continuous 12-lead ECG monitoring required during
or a consultant administration. Cardiac rhythm monitoring required for 4
cardiologist hours following administration.
Check the blood pressure at 5 minute intervals during
administration and for 10 minutes afterwards.
Alcohol See Ethanol monograph
Alemtuzumab Post kidney  Groups 1 1-2 minutes For SC injection draw up 1ml Give the following pre-medication 30-60 minutes prior
30mg vials transplant and 2 (30mg) from the vial into a to giving alemtuzumab:
SC Injection in syringe. Chlorphenamine 10mg IV and paracetamol 1g PO prior to
▼ This product
is being to the deltoid each dose. Post Kidney transplant also give
intensively or anterior methylprednisolone 500mg IV prior to first dose, 250mg IV
monitored by abdominal prior to second dose.
the CHM and wall. During and after administration monitor for urticaria, rash,
MHRA. Please hypotension, nausea, rigors and fever. Serious but rare
report all Haemopoietic  Groups 1 4 hours Draw up 30mg in 1ml using a reactions include: respiratory distress, bronchospasm,
suspected stem cell and 2 closed-system device and syncope, MI and cardiac arrest.
reactions transplant further dilute with 100ml N/S.
Women who are pregnant or trying to become
(including non- (I) IV infusion pregnant should not prepare or administer
serious ones) via an infusion alemtuzumab.
using a Yellow pump
Although the packaging states “Concentrate for solution
Card from the for infusion”, this product can be given by subcutaneous
BNF injection. For IV infusion, alemtuzumab can be diluted in
100ml G instead of N/S if there is a need to do this.
Note that 30mg/ml alemtuzumab is an unlicensed
product (see page 7).

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 18
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Alemtuzumab (I) IV  Groups 4 hours Withdraw 1.2 ml (12mg) of Premedication: see administration schedule below.
12mg vials infusion via 1 and 2 solution from the vial into a During the infusion monitor for urticaria, rash, hypotension,
For Multiple an infusion syringe. Inject into 100ml N/S. nausea, rigors and fever. Serious but rare reactions include:
Sclerosis pump The bag should be inverted respiratory distress, bronchospasm, syncope, MI and cardiac
gently to mix the solution. arrest. Refer to the full Alemtuzumab Prescribing Guidelines
▼ This product is
being intensively held on the Planned Investigation Unit (PIU). The guidelines
monitored by the are also available on Plymouth Healthnet under Clinical
CHM and MHRA. Guidelines.
Please report all Women who are pregnant or trying to become pregnant
suspected should not prepare or administer alemtuzumab.
reactions
(including non- Alemtuzumab can be diluted in 100ml G instead of N/S if there
serious ones) is a need to do this.
using a Yellow
Card from the BNF
Premedication prior to alemtuzumab for treating Multiple Sclerosis
(Allow 30 minutes for oral paracetamol to take effect).
 Paracetamol 1gram PO
 Chlorphenamine 10mg IV
 Methylprednisolone IV – see below

1st Course of alemtuzumab:

Alemtuzumab 12mg IV daily for 5 consecutive days – each dose immediately preceded by 500mg IV methylprednisolone over 30 minutes
2nd Course of alemtuzumab (Given 12 and 24 months after the 1st course)
Alemtuzumab 12mg IV daily for 3 consecutive days – each dose immediately preceded by 1g IV methylprednisolone over 1hour

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 19
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Alfacalcidol IV bolus  Groups 1 Approximately Shake the ampoule for a minimum
For patients undergoing haemodialysis the
and 2 30 seconds of 5 seconds before use. Give
injection should be given into the return line
undiluted. from the haemodialysis machine at the end of
dialysis.
Monitor serum calcium regularly during
treatment.
Alfentanil Staff prescribing, administering and/or screening prescriptions for opioid medications should be familiar with the PHNT Policy for
Reducing Errors with Opioid Medicines in Adults using the following link:
[Link]
sing%20Errors%20with%20Opioid%20Medicines%20in%[Link]?timestamp=1443106367868
IV bolus  Groups 1 Approximately Can be diluted with N/S, G or H. Flush : N/S, G or H
using the and 2 30 seconds in Anaesthesia: Adequate plasma levels will
500 microgram/ml spontaneously only be achieved rapidly if the infusion (0.5-1
injection breathing micrograms/kg/minute) is preceded by a
patients. loading dose of 50-100 micrograms/kg given
Ampoules of Alfentanil 5mg/ml are 5000 micrograms/ml and must be diluted as as a bolus or fast infusion over 10 minutes.
below before administration by infusion.
(C) or (I) IV infusion  Groups 1 Dilute with N/S, G or H to a usual
with assisted and 2 concentration of 0.5mg/ml.
ventilation. Infusion Occasionally concentrations of
pump is required. 1mg/ml or more have been used.
SC injection  Groups Refer to the Marsden Manual for Follow the PHNT Care of the Dying Pathway
1,2,3,4 and 5 guidance on SC injection. in Advance Kidney Disease and the PHNT
Syringe Driver Policy.
(C) SC infusion via  Groups Dilute with W when 2 or more
For combinations of 2 or 3 drugs in the same
syringe driver for 1,2,3,4 and 5 drugs are being mixed in the same
syringe refer to the compatibility charts in the
use in palliative care syringe.
pump kit or contact Pharmacy on ext. 39976
W or N/S may be used when the for advice. Alfentanil is unlicensed by the SC
syringe only contains this drug.
route and for use in palliative care (See page
7).

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 20
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE SUITABLE DILUENT
Alglucosidase (I) IV infusion  Groups Initial rate of Remove the required number of vials Suitable filters include PALL 0.22 micron,
alfa Infusion 1,2 and 3 1mg/kg/hour. from the fridge and allow them to reach Braun Sterifix 0.2 micron, Technopharm
(Mycozyme®) pump is Gradually increased room temperature (may take about 30 codan 0.2 micron filters. These filters
required. by 2mg/kg/hour every minutes). Reconstitute each 50mg vial should be ordered through ORACLE.
30 minutes if there are with 10.3ml W. Add the W by slow drop-
no reactions to the wise addition down the side of the vial Instructions for dosing and administration
infusion, until a and not directly in to the powder. Tilt of alglucosidase alfa will usually be
maximum rate of and roll each vial gently. Do not invert, included in the patient’s treatment plan
7mg/kg/hour is swirl or shake the vials. The (Recommended dosage for Pompe
reached. reconstituted volume is 10.5ml Disease is 20mg/kg once every 2 weeks)
containing 5mg of enzyme/ml, and
appears as a clear colourless to pale During the infusion monitor for allergic
yellow solution which may contain reactions, monitor blood pressure, pulse,
particles in the form of thin white temperature, respiratory rate and for
strands or translucent fibres. If on difficulty in breathing.
immediate inspection foreign particles
other than those described above are
observed, or if the solution is
discoloured, do not use.
Dilute the drawn up dose of
alglucosidase alfa with N/S to a final
alglucosidase alfa concentration of
0.5mg/ml to 4mg/ml (Remove the same
volume of N/S from the bag first).
Remove airspace from within the bag.
Mix with gentle massage on inversion of
the bag. Do not shake or agitate the
bag. Infuse the solution via a 0.2micron
low protein-binding in-line filter.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 21
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE SUITABLE DILUENT
Alprostadil (C) IV infusion  Groups Initial rate: Dilute 150micrograms/kg weight of If using a burette avoid direct
(Prostin VR®) 1 and 2 5 nanograms/kg/minute baby to a final volume of 50ml with G, contact of the undiluted injection
= 0.1ml/hour of the N/S or G10%. with the wall of the plastic
Infusion pump is
prepared dilution. (Note that after dilution with G10% the burette. If this happens the
required.
product is unlicensed. See page 7) appearance of the burette chamber
may change and a hazy solution
may develop requiring the solution
to be discarded and the burette to
be changed.
Monitor arterial blood pressure,
heart rate, SaO2 pO2 pH and
respiratory rate
Alprostadil Intracavernosal  Group 1 Fit the 22 gauge needle to the syringe. Using a half inch, 27 to 30 gauge
(Caverject®) injection Inject the 1ml of diluent into the vial, needle is generally recommended.
(See comments) and shake to dissolve the powder The intracavernosal injection must
entirely. Withdraw slightly more than be done with aseptic technique.
the required dose of Caverject solution, The site of injection is usually along
remove the 22 gauge needle, and fit the dorsolateral aspect of the
the 30 gauge needle. Adjust volume to proximal third of the penis. Visible
the required dose for injection. veins should be avoided. Both the
side of the penis that is injected
and the site of injection must be
alternated. Prior to the injection, the
injection site must be cleansed with
an alcohol swab.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 22
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE OVER SUITABLE DILUENT
Alteplase (TPA) If a special pre-programmed alteplase pump is unavailable then refer to the guidance on pages 24 and 25.
to treat: Initial IV bolus  Groups Accelerated Reconstitute two 50mg vials each with ECG and haemodynamic
dose then (I) IV 1 and 2 regimen initiated the 50ml of W provided using the transfer monitoring required. Sodium
Acute myocardial infusion within 6 hours of needles supplied. Agitate gently until the content nil.
infarction (AMI) using the symptom onset contents of the vials have dissolved. Do Flush with N/S.
special pre- administer over: not shake. When treating AMI, alteplase is
programmed 90 minutes When using the special pre-programmed given together with IV heparin. The
alteplase pump Initiated between 6 alteplase pump, draw up the contents of IV heparin regimen is 5,000unit
(Available in the and 12 hours after both vials (100ml) into a 100ml syringe. bolus followed by a continuous IV
Emergency symptom onset infusion for at least 48 hours, using
Dept. and on administer over: the standard PHNT IV heparin
Torcross ward). prescription form.
3 hours
Alteplase and heparin infusions are
not compatible. They should be
infused through separate IV
catheters. If IV access is a problem,
the infusion of heparin can be
commenced once the alteplase
infusion has finished.
Alteplase (TPA) Initial IV bolus  Group 1 1 – 2 minutes Reconstitute two 50mg vials each with ECG and haemodynamic
to treat: dose the 50ml of W provided using the transfer monitoring required. Sodium
Followed by (I) IV  Groups 2 hours needles supplied. Agitate gently until the content nil.
Pulmonary infusion 1 and 2 contents of the vials have dissolved. Do Flush with N/S.
embolism using the not shake. Alteplase and heparin infusions are
special pre- Draw up the 10mg (10ml) bolus in a 10ml not compatible. They should be
programmed syringe for the doctor to inject over 1-2 infused through separate IV
alteplase pump minutes. catheters.
(Available in the When using the special pre-programmed
Emergency alteplase pump, draw up the remainder
Dept. and on of the total dose into a 100ml syringe.
Torcross ward)

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 23
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
 Alteplase to treat Acute Myocardial Infarction within 6 hours of symptom onset (Accelerated Regimen)

Suggested method when a pre-programmed alteplase pump is not available: Reconstitute two 50mg vials each with 25ml of the W provided using the
transfer needles provided to make a 2mg/ml solution. Draw up the 50ml (100mg) of solution into a 50ml syringe. Then using a syringe pump set the
infusion rate as follows:

Bolus of 15mg over 2 minutes for patients of all weights (Set the pump at 225ml/hour for 2 minutes) then:

Patient Further doses and infusion rates

weight
≥ 65kg 50mg over 30 minutes. Set the pump at 50ml/hour for 30 minutes then 35mg over 60 minutes. Set the pump at 17.5ml/hour for 60 minutes

64kg 48mg over 30 minutes. Set the pump at 48ml/hour for 30 minutes then 32mg over 60 minutes. Set the pump at 16ml/hour for 60 minutes
62kg 46.5mg over 30 minutes. Set the pump at 46.5ml/hour for 30 minutes then 31mg over 60 minutes. Set the pump at 15.5ml/hour for 60 minutes
60kg 45mg over 30 minutes. Set the pump at 45ml/hour for 30 minutes then 30mg over 60 minutes. Set the pump at 15ml/hour for 60 minutes
58kg 43.5mg over 30 minutes. Set the pump at 43.5ml/hour for 30 minutes then 29mg over 60 minutes. Set the pump at 14.5ml/hour for 60 minutes
56kg 42mg over 30 minutes. Set the pump at 42ml/hour for 30 minutes then 28mg over 60 minutes. Set the pump at 14ml/hour for 60 minutes
54kg 40.5mg over 30 minutes. Set the pump at 40.5ml/hour for 30 minutes then 27mg over 60 minutes. Set the pump at 13.5ml/hour for 60 minutes
52kg 39mg over 30 minutes. Set the pump at 39ml/hour for 30 minutes then 26mg over 60 minutes. Set the pump at 13ml/hour for 60 minutes
50kg 37.5mg over 30 minutes. Set the pump at 37.5ml/hour for 30 minutes then 25mg over 60 minutes. Set the pump at 12.5ml/hour for 60 minutes
48kg 36mg over 30 minutes. Set the pump at 36ml/hour for 30 minutes then 24mg over 60 minutes. Set the pump at 12ml/hour for 60 minutes
46kg 34.5mg over 30 minutes. Set the pump at 34.5ml/hour for 30 minutes then 23mg over 60 minutes. Set the pump at 11.5ml/hour for 60 minutes

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 24
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
 Alteplase to treat Acute Myocardial Infarction between 6 and 12 hours after onset of symptoms

Suggested method when a pre-programmed alteplase pump is not available: Reconstitute two 50mg vials each with 25ml of the W provided using the
transfer needles provided to make a 2mg/ml solution. Draw up the 50ml (100mg) of solution into a 50ml syringe. Then using a syringe pump set the
infusion rate as follows:
Bolus of 10mg over 2 minutes for patients of all weights.: set the pump at 150ml/hour for 2 minutes, then:
50mg over 1 hour for patients ≥ 40kg: set the pump at 25ml/hour for 1 hour, then:

Patient weight Dose and infusion rate

≥ 65kg 40mg over 2 hours. Set the pump at 10ml/hour for 2 hours
60 - 64kg 30mg over 2 hours. Set the pump at 7.5ml/hour for 2 hours
53.4 -63.9kg 20mg over 2 hours. Set the pump at 5ml/hour for 2 hours
46.7 – 53.3kg 10mg over 2 hours. Set the pump at 2.5ml/hour for 2 hours
40 – 46.6kg No additional alteplase

Alteplase to treat Pulmonary Embolism

Suggested method when a pre-programmed alteplase pump is not available: Reconstitute two 50mg vials each with 25ml of the W provided using the
transfer needles provided to make a 2mg/ml solution.
Draw up the Bolus of 10mg (5ml) in a 5 ml or 10ml syringe for the doctor to inject over 1 -2 minutes
Then draw up the remainder of the total dose in a 50ml syringe. Then using a syringe pump set the infusion rate as follows:
Patient weight Dose and infusion rate
≥ 65kg 90mg over 2 hours. Set the pump at 22.5ml/hour for 2 hours
< 65kg For patients less than 65kg the total prescribed dose (including bolus dose) should not exceed 1.5mg/kg.

Following the bolus dose of 10mg, the infusion rate = Total prescribed dose (mg) – Bolus dose (10mg) ml/hour for 2 hours
4

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 25
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE OVER SUITABLE DILUENT
Alteplase Total dose is 900 micrograms/kg (Maximum dose 90mg). 10% of this dose (90micrograms/kg) given as a bolus over 2 minutes
to treat IV bolus  Group 1 1 – 2 minutes Reconstitute one or two 50mg vials It is essential to follow the detailed
each with 50ml of the W provided to instructions in the PHNT Acute Ischaemic
Acute Ischaemic make 1mg/ml solution. For the bolus Stroke Protocol (Copy in the Emergency
Stroke dose, draw up 10% of the total dose Department).
(see table below) and inject using a Unless the patient or companion knows their
10ml syringe. recent weight, estimate to the nearest 5kg. Take
(I) IV infusion  Groups 1 hour From the solution above, draw up the 2 initial blood pressure readings at 15 minute
1 and 2 remainder of total dose (see table intervals. Record in both arms initially to exclude
below) into one or two 50ml syringes. aortic dissection.
Weight(Kg) Weight (Imperial) Total dose Bolus dose (ml) Infusion dose
900micrograms/kg Inject over 1 -2 infused over 1 hour
(Maximum 90mg) minutes
45 7st 1lb 40 4 36
Use 1 x 50mg vial 50 7st 12lb 45 4.5 40.5
55 8st 9lb 49 4.9 44.1
60 9st 6lb 54 5.4 48.6
65 10st 3lb 58 5.8 52.2
70 11st 0lb 63 6.3 56.7
75 11st 11lb 67 6.7 60.3
Use 2 x 50mg vials
80 12st 8lb 72 7.2 64.8
85 13st 5lb 76 7.6 68.4
90 14st 2lb 81 8.1 72.9
95 14st 13lb 85 8.5 76.5
≥100 15st 10lb 90 9 81

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 26
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Alteplase (Low-Dose) (C) IV Infusion  Groups 2.5ml/hour Reconstitute 1 x 10mg alteplase The minimum stable concentration is
to treat acute venous 1,2,3,4 and with the 10ml of W provided. 0.2mg/ml. Each prepared infusion is stable
thrombosis (subclavian 5 Further dilute the 10mg of upto 8 hours at room temperature.
This will deliver
or ilio-femoral deep vein reconstituted alteplase to 50ml Prepare a fresh syringe and change the
0.5mg alteplase
thrombosis) with N/S. infusion promptly, every 8 hours. After 8
per hour
hours, 30ml of solution will remain in the
This indication for used syringe which must be discarded.
alteplase is unlicensed –
see page 7 Follow the Low-Dose Alteplase Protocol. A
copy is kept on Torcross ward.
Alternatively, a copy has been uploaded
onto:
StaffNet> Document Library> Clinical
Guidelines> Prescribing Regimens
Amikacin IM injection  Groups Do not dilute. Refer to the For most infections the intramuscular
1,2,3,4 and Marsden Manual for guidance on route is preferred, but the IV route may be
5 IM injection. used for life threatening infection or when
IM injection is not feasible.
Slow IV bolus  Groups 2 – 3 minutes Undiluted
(For large once daily Once diluted for infusion use immediately.
1,2,3,4 and
doses see (I) IV 5 Patient should be well hydrated during
infusion below) amikacin therapy.

(I) IV infusion  Groups 30 minutes A common dilution for adults is

For once daily doses 1,2,3,4 and with 100ml of N/S or G.
of 15mg/kg or greater. 5
Infusion pump is
required
Irrigation  Groups Dilute the required dose with N/S Sterile irrigation of amikacin may be used
1,2,3,4 and to a concentration of 2.5mg/ml. in abscess cavities, the pleural space,
5 peritoneum or in the cerebral ventricles.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 27
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE SUITABLE DILUENT
Aminophylline (I) IV infusion  Groups 1, Minimum 20 minutes. Dilute further with 100ml N/S, G, G/S or Flush with N/S, G or G/S.
(initial loading 2 3 and 7 H. However, the loading dose can be Do not give loading dose if
dose) Infusion diluted to a smaller volume e.g. 50ml or patient previously taking
pump is given undiluted (25mg/ml) if necessary. theophylline.
required.

(I) or (C) IV  Groups Usual starting rates:Remove 20ml from a 500ml bag of N/S, Do not infuse aminophylline down
infusion (after 1,2,3,4 and 5 G, G/S or H then add 500mg (20ml) the same central line lumen or
loading dose). aminophylline to make a concentration of peripheral line as salbutamol.
0.5-0.7mg/kg/hour for
Infusion pump adults and children aged 1mg/ml.
is required. 12 years and older. Take blood to check theophylline
Can be diluted to higher concentrations levels 4-6 hours after commencing
0.3mg/kg/hour for the
than 1mg/ml or given undiluted the aminophylline infusion.
elderly.
(25mg/ml) through a central line, but take
care with the calculation and prescription
1mg/kg/hour for children of the infusion rate.
aged under 12 years.

To avoid excessive
dosage in obese
patients, the dose
should be calculated
on ideal body weight.

Adjust the rate

according to plasma
theophylline levels.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 28
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE OVER SUITABLE DILUENT
Amiodarone (C) or (I) IV  Groups 1,2 5mg/kg loading Recommended dilution: 5mg/kg loading Cardiac monitoring required.
infusion. and 3 dose (usually dose (Usually 300mg) diluted in 100ml Flush with G.
Infusion pump 300mg) over 20 or 250ml G. Repeat infusion (usually Avoid peripheral administration
is required. minutes - 2 hours. 900mg over next 23 hours) diluted in unless absolutely necessary as
This may be 250ml or 500ml G. infusion via peripheral veins has
followed by repeat Where a lower volume is needed the lead to local discomfort and
infusion up to 1.2g dose (e.g. 300mg, 900mg or 600mg) inflammation.
per 24 hours. may be diluted in 50, 100 or 250ml G. Infusion concentrations greater
Adjust rate Stability is concentration dependent - do than 2mg amiodarone per ml must
according to not over dilute. Do NOT add 300mg to be infused via a central venous
response more than 500ml G or 600mg to more catheter.
than 1 litre G. When repeated or continuous
infusion of any concentration is
IV bolus  Group 1 During Advanced Dilute each 150-300mg with 10-20ml G. anticipated, administration via a
Emergency use Life Support for Pre-filled syringe contains 300mg ready central venous catheter is
VF/VT give as a diluted in 10ml G. recommended.
fast bolus. Sodium content nil.
Otherwise give over
a minimum of 3
minutes. Do not As soon as an adequate response
repeat dose for at has been obtained, oral therapy
least 15 minutes. should be initiated concomitantly at
the usual loading dose (i.e. 200mg
three times a day). Intravenous
amiodarone should then be phased
out gradually.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 29
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE OVER SUITABLE DILUENT
Amoxicillin is a penicillin – Check patient’s allergy status before administration
Amoxicillin IV bolus  Groups Inject doses up to Reconstitute each 500mg with 10ml W. Flush with N/S.
(Usual method) 1,2,3,4 and 5 1g over 3 - 4 Displacement 0.4ml/500mg. Add 9.6ml W MRHA Safety Alert 2015: Do not use
minutes. to 500mg to produce 50mg/ml. Wockhardt brand amoxicillin for
Inject 2g doses infants and neonates below one year
slowly over 6 - 8 old due to reports of extravasation &
minutes or give by injection site reactions. Other brands
infusion (see eg. Bowmed and GSK are safe to use
below). in this age group.
(I) IV infusion 30 - 60 minutes Reconstitute as above then dilute with N/S Use infusion within 90 minutes of
via infusion or G to 100ml. Alternatively each 500mg preparation.
pump amoxicillin may first be reconstituted with Sodium content: 1.65mmol/500mg
10ml of the diluent (N/S or G). (Avoid Intrathecal administration)
IM Injection Reconstitute a 500mg vial with 2.5ml W and For Amoxil® brand only: If pain is
shake vigorously (Final volume is 2.9ml). experienced on IM injection, lidocaine
Reconstitute a 250mg vial with 1.5ml W and 1% or procaine 0.5% injection may be
shake vigorously (Final volume is 1.7ml). used instead of W to reconstitute the
Refer to the Marsden Manual for guidance vial.
on IM injection.
Amphotericin (I) IV infusion  Groups 2-4 hours. Displacement is negligible. Add 10ml A test dose must be given at start of
(Fungizone® ) via infusion 1,2,3,4 and 5 Up to 6 hours if diluent for 50mg in 10ml. each new course of treatment; Infuse
pump poorly tolerated. Reconstitute vial with 10ml W, then dilute the first 1mg of the first infusion over
dose required with 50 times as much G to 20-30 minutes and observe for signs
produce a maximum concentration of of anaphylactic reaction for at least a
100micrograms/1ml. further 30 minutes. If no reaction then
give the remainder of the first infusion.
Concentrations up to a maximum of Flush with G before and after
500micrograms/1ml can be given using a administration.
central line (unlicensed use - see page 7). Protect infusion from light.
For AMBISOME
May cause thrombophlebitis; change
see next page
infusion site frequently.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 30
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE OVER SUITABLE DILUENT
Liposomal (I) IV infusion  Groups 30-60 minutes Add 12ml W (2-8oC), shake vigorously for at Administration of a test dose is advisable before
Amphotericin Infusion pump 1,2,3,4 and least 15 seconds. Resulting amphotericin a new course: Give 1mg of prepared infusion
(AmBisome ) is required. 5 concentration 4mg/1ml. over 10 minutes, stop infusion and observe
Dilute dose required with between 1 and 19 patient for 30 minutes.
parts by volume G, using 5 micron filter Protect infusion from direct sunlight. Flush before
provided, to give a final concentration of and after administration with G.
For Fungizone® 200micrograms-2mg/1ml. Do not infuse with any other drugs or infusion
See previous page fluids. Sodium content less than 0.5mmol/vial.
Anti-thymocyte (I) IV infusion  Groups At least 6 hours Doctor to prescribe dose in a volume of N/S A test dose is usually given. Give hydrocortisone
globulin rabbit into a large 1,2,3,4 and such that the concentration of the infusion is 100mg IV, chlorphenamine 10mg IV and
(ATG rabbit) vein. Infusion 5 0.5mg/ml. Infusion to be prepared by paracetamol 1g PO 30-60 minutes before the
pump is [Link] Ext.31083. ATG infusion.
required. Flush with N/S.
Do not infuse with any other drugs.
Anidulafungin (I) IV infusion  Groups Infuse theReconstitute each 100mg vial with 30ml WFI. Do not infuse with any other drugs or infusion
Infusion pump 1,2,3,4 and 200mg doseReconstitution can take up to 5 minutes. fluids.
is required. 5 over at least 3
For the 200mg dose, remove 50ml from a If the un-reconstituted vials are accidentally left
hours. 250ml bag of N/S or G, then add 60ml (2 x out of the fridge, as long as the period at room
100mg in 30ml) of reconstituted solution (Final temperature does not exceed 96 hours, they can
Infuse the volume 260ml). be returned to the fridge and are ok to use.
100mg dose For the 100mg dose, add the 30ml of
Flush with N/S.
over at least 1½ reconstituted solution to a 100ml bag of N/S or
hours. G (final volume 130ml).
Aprotinin IV bolus (initial  Group 1 Maximum rate Provided ready diluted. Flush with N/S.
loading dose) 10ml/minute Initial 1ml (10,000 KIU) should always be
This drug is (I) IV infusion  Groups 1 20-50ml/hour given at least 10 minutes prior to treatment to
unlicensed – see Infusion pump and 2 test for possible allergic and anaphylactic
page 7 is required. reactions.
Sodium content 7.7mmol/50ml.
Do not infuse with any other drugs including
heparin.
Patient must be in the supine position during the
administration of aprotinin.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 31
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Argatroban (I) IV infusion  Groups Initial infusion rate in patients Add the 250mg in 2.5ml from the Obtain a baseline APTT. The target
via infusion 1 and 2 without hepatic impairment is vial to a 250ml bag of N/S or G. APTT is 1.5-3.0 times the baseline
pump. 2micrograms/kg/minute. Mix the solution for 1 minute by value, but not more than 100 seconds.
repeated inversion of the Check the APTT 2 hours after starting
For critically ill or hepatically prepared infusion. There may be the infusion or after a change of rate,
impaired patients the initial infusion some brief haziness of the and at least once a day thereafter (For
rate is 0.5micrograms/kg/minute. solution that clears upon mixing. critically ill or hepatically impaired
See tables at foot of monograph patients, check the APTT 4 hours after
for setting the initial infusion rate starting infusion or changing the rate).

The maximum rate is

10micrograms/kg/minute
Standard dosing schedule Critically Ill/Hepatically impaired patients
Initial Infusion Rate 2 micrograms/kg/minute Initial infusion rate 0.5 micrograms/kg/minute
APTT (s) Infusion Rate change Next APTT Infusion Rate change Next APTT
< 1.5 times baseline Increase by 0.5 mcg/kg/min. 2 hours Increase by 0.1 mcg/kg/min. 4 hours
1.5-3.0 times baseline (not No change 2 hours; after 2 consecutive No change 4 hours; after 2 consecutive
exceeding 100 s) APTT's within target range, APTT's within target range,
Check at least once per day Check at least once per day
> 3.0 times baseline or > 100 s Stop infusion until the APTT 2 hours Stop infusion until the APTT is 4 hours
is 1.5-3.0 times baseline; 1.5-3.0 times baseline;
Resume at half of the Resume at half of the previous
previous infusion rate. infusion rate.

2micrograms/kg/min 0.5micrograms/kg/min 2micrograms/kg/min 0.5micrograms/kg/min

Body weight (kg) Infusion rate (ml/hour) Infusion rate (ml/hour) Body weight (kg) Infusion rate (ml/hour) Infusion rate (ml/hour)
50 6 1.5 100 12 3
60 7 1.8 110 13 3.3
70 8 2.1 120 14 3.6
80 10 2.4 130 16 3.9
90 11 2.7 140 17 4.2
 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 32
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 33
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE OVER SUITABLE DILUENT

Argipressin See vasopressin

Artesunate IV bolus  Groups 1 1-2 minutes Reconstitute each 60mg vial with 1ml of the The reconstituted artesunate solution should
and 2 supplied sodium bicarbonate solvent from the always be used immediately, and discarded if
This drug is ampoule. Shake the vial for several minutes to not used within one hour.
unlicensed – see mix well until the powder is completely
page 7 dissolved and the solution is clear. Dilute Do not use water for injection for
further with 5ml of N/S or G to make 60mg in reconstitution of the artesunate powder or
6ml (10mg/ml) solution. Shake to mix well, for dilution of the resulting solution prior to
ensuring that the resulting solution is still clear. injection.
If the solution appears cloudy or a precipitate
is present, it should be discarded. Dosage: 2.4mg of artesunate / kg body weight,
IM Injection  Groups 1 Reconstitute each 60mg vial with 1ml of the by IV or IM injection, at 0, 12 and 24 hours, then
and 2 supplied sodium bicarbonate solvent from the once daily until oral treatment can be
ampoule. Shake the vial for several minutes to substituted.
mix well until the powder is completely Dosage adjustment is not considered necessary
dissolved and the solution is clear. Dilute in patients with hepatic or renal impairment.
further with 2ml of N/S or G to make 60mg in
3ml (20mg/ml) solution. Shake to mix well, The anterior thigh is usually the preferred site
ensuring that the resulting solution is still clear. for intramuscular injection. If the total volume of
If the solution appears cloudy or a precipitate solution to be injected intramuscularly is large, it
is present, it should be discarded. may be preferable to divide the volume and
inject it at several sites, e.g. both thighs.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 34
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY GIVE ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
OVER AND SUITABLE DILUENT
Atenolol IV bolus  Groups 1 and 2 Maximum rate Can be diluted with N/S or G to any Severe bradycardia and hypotension
1mg/minute convenient volume e.g.10ml. may occur; monitor heart rate and
(I) Infusion  Groups 1 and 2 20 minutes Dilute with N/S or G to a suggested blood pressure. Can cause
Infusion pump is volume of 50ml or 100ml. conduction defects; monitor ECG.
required. Infusing quickly increases incidence of
side effects.
Flush with N/S or G.
Sodium content : approximately 1.3-
1.8mmol/5mg
ATG See Anti-Thymocyte Globulin Rabbit (ATG rabbit)
Atosiban Step 1: IV bolus loading  Groups 1 and 2 0.9ml (6.75mg) Total duration of treatment should not
dose using 7.5mg/ml over 1 minute exceed 48 hours. The total dose given
Solution For Injection immediately should preferably not exceed 330mg.
followed by Step 2
Step 2: 24ml (18mg)/hour Withdraw 10ml from a 100ml bag of The vials and infusions should be
(I) IV loading infusion. for 3 hours N/S or G. Replace it with 10ml of inspected visually for particulate
Infusion pump is followed by Step 3 Atosiban 7.5mg/ml Concentrate matter and discolouration prior to
required. Solution for Infusion from two 5ml administration.
Step 2: 8ml (6mg)/hour for vials to obtain a concentration of
(I) IV infusion Infusion up to 45 hours 75mg in 100ml Do not mix with any other drug
pump is required. solutions.
Atracurium IV bolus  Group 1 – must only Can be diluted with H, G, G/S or A 0.5mg/ml dilution is stable for 4
be given by doctors N/S. hours in H, 8 hours in G or G/S and
proficient in advanced 24 hours in N/S. Flush with N/S.
airway management. If the patient is ventilated IV bolus can
Also see comments. be administered by Group 2 staff.
(C) IV infusion. Infusion  Groups 300-600 Incompatibilities include: propofol.
pump is required. 1 and 2 micrograms/kg/
hour

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 35
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Atropine IV bolus  Groups 1, 2 See comments If necessary atropine injection can Give rapidly since slow IV
and 8 be diluted with N/S. administration may cause paradoxical
SC injection  Groups Refer to the Marsden Manual for slowing of the heart. ECG monitoring
1 and 2 guidance on SC injection. required. Flush with N/S.
IV incompatibilities include bromides,
IM Injection  Groups Refer to the Marsden Manual for
iodides, noradrenaline, metaraminol
1 and 2 guidance on IM injection.
and sodium bicarbonate.
Premedication: IV immediately before
induction. IM or SC 30-60 minutes
before induction.
Control of muscarinic side effects of
neostimine: IV bolus.

Augmentin See Co-amoxiclav

Azathioprine (I) IV infusion  Group 1 or 30-60 minutes Azathioprine injection is Flush the IV bolus with at least 50ml
(preferred Group 2 who reconstituted and diluted only by N/S, G or G/S since very irritant.
method have previous Pharmacy (Tel. 31083). Extravasation may cause tissue
wherever experience of Handle the prepared injection or damage.
possible). administering infusion as for cytotoxic drugs (See Sodium content 0.2mmol/vial.
Infusion pump intravenous Appendix 3). Do not infuse with any other drugs.
is required. cytotoxics. Or a
Group 3 nurse.
IV bolus  Group 1 or Usually 3-5 minutes.
through tubing Group 2 who Minimum 1 minute.
of a fast flowing have previous
N/S or G drip. experience of
administering
intravenous
cytotoxics. Or a
Group 3 nurse.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 36
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE OVER SUITABLE DILUENT
Aztreonam IV bolus  Groups 3-5 minutes Reconstitute vial contents with 6 - 10ml W Development of slight pink colour on
1,2,3,4 and 5 and shake well. standing does not affect potency.
Displacement 0.8ml/1g. Add 9.2ml to 1g vial Flush with N/S or G.
for 100mg/ml Sodium content nil.
(I) IV infusion  Groups 20-60 minutes Reconstitute each 1 gram with at least 3ml
Infusion pump is 1,2,3,4 and 5 W and shake well .Then dilute each 1 gram
required. with at least 50ml N/S, G or H.
IM injection  Groups Reconstitute a 1gram vial with at least 3ml Give by deep injection into a large
1,2,3,4 and 5 W or N/S and shake well. muscle mass such as the upper
Refer to the Marsden Manual for guidance quadrant of the gluteus maximus or
on IM injection. the lateral part of the thigh. For doses
higher than 1g, or for septicaemia,
meninigitis, localised parenchymal
abcess, peritonitis or other severe
systemic or life-threatening infections,
use the IV route as above.
Baclofen (C) Intrathecal  Group 1 or Prepare and administer in accordance with * Restricted to those persons who are
infusion or Group 2* the Pain Management Centre procedures. trained and competent to administer
Intrathecal bolus medication via the intrathecal route.
Basiliximab Preferred method:  Groups 20-30 minutes Reconstitute 10mg vial with 2.5ml of the W Use immediately and complete
(I) IV infusion. 1,2,3,4 and 5 supplied in the accompanying ampoule. administration within 4 hours of
Infusion pump is Reconstitute 20mg vial with 5ml of the W reconstitution.
required. supplied in the accompanying ampoule. Do not mix or infuse with other drugs
Then dilute each 10mg to a volume of 25ml in the same lumen or IV line.
or greater with N/S or G. To avoid foaming Anaphylactic reactions can occur
mix by gently inverting – do not shake. rarely
IV bolus  Groups Reconstitute 10mg vial with 2.5ml of the W Flush with N/S or G.
1,2,3,4 and 5 supplied in the accompanying ampoule.
Reconstitute 20mg vial with 5ml of the W
supplied in the accompanying ampoule.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 37
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE OVER SUITABLE DILUENT
Belatacept (I) IV infusion  Groups 30 minutes via Reconstitute each vial with 10.5ml W or N/S Flush the line after the infusion with
via infusion 1,2,3,4 and 5 a 0.2-1.2 micron using the silicone-free syringe provided with the N/S.
pump in-line filter vials. Direct the stream of fluid to the glass wall To allow for slight loss in the form of
of the vial and not into the powder. To minimize foam, the vial contains a small excess
foam formation, gently swirl and invert the vial of powder such that you will be able to
for at least 30 seconds or until the powder is extract 250mg in 10ml (The
completely dissolved. Do not shake. Draw up the reconstituted solution is 25mg/ml).
prescribed dose, using the same disposable
syringe used for reconstitution of the powder,
and dilute further with N/S or G so that the final
concentration of Belatacept is between 2mg/ml
and 10mg/ml. Gently mix the infusion.
Belimumab (I) IV infusion  Groups 1 hour Allow 10-15 minutes for the vial to warm to room Protect the reconstituted solution from
▼ This product is via infusion 1,2,3,4 and 5 temperature. sunlight.
being intensively pump Reconstitute the 120mg vial of belimumab with Belimumab is incompatible with 5%
monitored by the 1.5ml of W. Reconstitute the 400mg vial of glucose solution.
CHM and MHRA. belimumab with 4.8ml of W. This will make a Patients should remain under clinical
Please report all concentration of 80mg/ml belimumab for both supervision for a prolonged period of
suspected vial sizes. time (for several hours), following at
reactions During reconstitution, direct the stream of W least the first 2 infusions, taking into
(including non- toward the side of the vial to minimize foaming. account the possibility of a late onset
serious ones) Gently swirl the vial for 60 seconds. Allow the hypersensitivity reaction (eg.
using a Yellow vial to sit at room temperature during anaphylaxis, bradycardia,
Card from the reconstitution, gently swirling the vial for 60 hypotension, angioedema, dyspnoea).
BNF seconds every 5 minutes until the powder is Other delayed-onset reactions can
dissolved. Do not shake. Reconstitution is include: rash, nausea, fatigue,
typically complete within 10 to 15 minutes after myalgia, headache, and facial
the water has been added, but it may take up to oedema.
30 minutes. Flush with N/S.
Dilute the prescribed dose to 250ml with N/S
(First remove a volume of N/S from the bag
equal to the volume of belimumab being diluted).
Gently invert the bag to mix the solution.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 38
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE OVER SUITABLE DILUENT
▼ This is a penicillin – Check patient’s allergy status before administration ▼
Benzylpenicillin IV bolus  Groups 3-5 minutes. Reconstitute each 600mg with 3.6-10ml W or Administration faster than the
(Usual 1,2,3,4 and 5 Maximum rate N/S. recommended rate may cause
(Regular method) for doses Displacement 0.4ml/600mg. Add 3.6ml of W or seizures and CNS toxicity.
benzylpenicillin exceeding 1.2g: N/S for 600mg in 4ml. Incompatibilities include: gentamicin.
600mg and 300mg/minute. Flush with N/S or G.
1200mg vials) (I) IV infusion.  Groups 30-60 minutes Reconstitute each 600mg with 10ml N/S or W Sodium content 1.68mmol/600mg.
Infusion pump 1,2,3,4 and 5 .Can be further diluted if necessary with N/S or 1 mega unit = 600mg.
is required. G (Suggested volume 100ml). Doses greater than 1.2g should be
IM Injection  Groups Reconstitute each 600mg vial with 1.6ml to 2ml given by the IV route.
1,2,3,4 and 5 W. Refer to the Marsden Manual for guidance on
IM injection.
For regular intravenous benzylpenicillin see above
Benzathine Deep IM  Groups Shake the vial to loosen the powder inside. Do not inject this formulation
benzylpenicillin injection 1,2,3,4 and 5 Reconstitute the vial contents with the 8ml of W intravenously.
(Extencillin®) provided in the unlabelled ampoule.
2.4 megaunit vial Refer to the Marsden Manual for guidance on IM
(Unlicensed injection.
product –see p4)

DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS

GIVE OVER AND SUITABLE DILUENT
 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 39
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Beriplex P/N® (I) IV  Groups Each 500 IU in 20ml Follow the nine steps illustrated The Consultant Haematologist will advise on the
Infusion 1,2,3,4 and W over 10-15 below and continued on the next dosage to be given, and the monitoring to be
Only prescribe using an 5 minutes page for reconstituting the vials. performed.
after consultation infusion Using the transfer device provided, Do not administer down the same lumen or catheter
with a Consultant pump So set the infusion reconstitute each 250 IU vial with the as other drugs and fluids. May be flushed with N/S.
Haematologist pump rate at 10ml of W provided.
80-120ml/hour Using the transfer device provided, Take care that no blood enters the syringe filled
Available on reconstitute each 500 IU vial with the with product, as there is a risk that the blood could
request from the 20ml W provided. coagulate in the syringe and fibrin clots would
Blood Bank The concentration is 25 IU/ml. therefore be administered to the patient.
Do not further dilute the
reconstituted solution.
Store Beriplex P/N® in the fridge. Use reconstituted
Beriplex® within 8 hours
Instructions for reconstituting Beriplex P/N®
1. Open the Mix2Vial package by 3. Carefully remove the package from the Mix2Vial set. Make
peeling away the lid. sure that you only pull up the package and not the Mix2Vial
set.

1 3
2. Place the diluent vial on an even, 4. Place the product vial on an even and firm surface. Invert
clean surface and hold the vial tight. the diluent vial with the Mix2Vial set attached and push the
Take the Mix2Vial together with the transparent adapter straight down through the product vial
package and push the blue end straight stopper. The diluent will automatically flow into the product
down through the diluent stopper. vial.

2 4
Instructions continued on the next page

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 40
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
 Instructions for reconstituting Beriplex P/N® continued
5. With one hand hold the 6 6. Gently swirl the product vial
product-side of the Mix2Vial set, until the substance is fully
hold the diluent-side with the other dissolved. Do not shake.
hand and unscrew the set into two
pieces.

Discard the diluent vial with the

5 blue part attached

7 7. Draw air into an empty, sterile 8 8. While keeping the syringe 9 9. Now that the
syringe. While the product vial is plunger pressed, invert the concentrate has
upright, connect the syringe to the system upside down and draw the been transferred
Mix2Vial's Luer Lock fitting. Inject concentrate into the syringe by into the syringe,
air into the product vial. pulling the plunger back slowly. firmly hold on to
the barrel of the
syringe (keeping
the syringe plunger
facing down) and
disconnect the
8 Mix2Vial set from
the syringe.
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Bevacizumab (I) IV Infusion  Groups Initial dose should be infused A closed-system device must be Do not infuse bevacizumab
using an infusion 1,2,3,4 and 5 over 90 minutes. If the first used to prepare bevacizumab. through th same line or lumen as
pump. infusion is well tolerated, the Draw up the prescribed dose and any other drugs or glucose.
second infusion may be dilute with N/S so that the final
administered over 60 minutes. If concentration is within the range of
the 60-minute infusion is well 1.4 mg/ml to 16.5 mg/ml. Usually the
tolerated, all subsequent prescribed dose diluted with N/S to
infusions may be administered a total volume of 100 ml is within
over 30 minutes. these limits – but check.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 41
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Bivalirudin Rapid Initial IV  Groups Suggestion: Add 5 ml W to one vial of 250mg Incompatible with alteplase,
bolus Patients 1,2,3,4 and 2 seconds bivalirudin and swirl gently until amiodarone, amphotericin B,
undergoing PCI, 5 completely dissolved and the chlorpromazine, diazepam,
including primary solution is clear. Withdraw 5 ml prochlorperazine, reteplase,
PCI : 0.75 mg/kg from the vial, and further dilute to streptokinase and vancomycin.
50 ml with G or N/S to give a final
bivalirudin concentration of 5
Patients with
unstable mg/ml. Mix thoroughly. The Activated Clotting Time (ACT)
angina/non-ST reconstituted/diluted solution will be values 5 minutes after
segment elevated a clear to slightly opalescent, bivalirudin bolus average 365
myocardial colourless to slightly yellow +/- 100 seconds. If the 5-minute
infarction: 0.1 solution. ACT is less than 225 seconds,
mg/kg a second bolus dose of 0.3
mg/kg should be administered.
(C) IV infusion  Groups Patients undergoing PCI, Once the ACT value is greater
immediately 1,2,3,4 and including primary PCI : than 225 seconds, no further
following the IV 5 1.75mg/kg/hour = 0.35ml/kg/hour monitoring is required provided
bolus of the 5mg/ml infusion during the the 1.75 mg/kg infusion dose is
procedure and for up to 4 hours properly administered.
post PCI if necessary. Then
0.25mg/kg/hour = 0.05ml/kg/hour
for 4- 12 hours if necessary.

Patients with unstable

angina/non-ST segment elevated
myocardial infarction:
0.25 mg/kg/hour = 0.05ml/kg/hour
of the 5mg/ml infusion for up to
72 hours.
Blinatumomab (C) IV infusion via  Groups Duration of infusion may vary Infusion to be prepared by
pump 1 and 2 Pharmacy. Telephone ext. 31083

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 42
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE OVER SUITABLE DILUENT
Botulinum toxin IM injection into specific  Group 1 Reconstitute the 500unit vial with 1ml of Sharing a vials of botulinum between
(Dysport®) muscles to treat W to make a 500unit/ml solution. patients in a day-case/clinic setting
spasticity (i.e. not in-patient on ward or in
theatre) has been risk assessed and
Reconstitute the 300unit vial with 0.6ml
sanctioned by the PHNT Medicines
of W to make a 500unit/ml solution.
Governance Committee so long as the
SC injection into specific  Group 1 Reconstitute the 500unit vial with 2.5ml following practice is strictly adhered
facial sites to treat of W to make a 200unit/ml solution. to:
blepharospam and  Between patients the reconstituted
hemifacial spasm. Reconstitute the 300unit vial with 1.5ml vial is kept in the fridge.
of W to make a 200unit/ml solution.  A separate drawing-up needle is
used for each patient.
Note that Dysport and Botox brands are NOT interchangable due to different unit potencies. Botox brand
has only been approved locally for the indications stated below.  Any reconstituted botulinum
remaining in the vial(s) at the end
Botulinum toxin 31-39 x 0.1ml (5unit)  Group 1 Reconstitute a 200 unit vial of Botox® of the session must be discarded.
(Botox® 200 unit injections into specific with 4ml of N/S and mix gently.  The maximum time Dysport® may
vials) head and neck muscles be stored at 2-80C following
to treat chronic reconstitution is 8 hours.
migraine  The maximum time Botox® may
Botulinum toxin 30 x 1ml (6.7unit)  Group 1 Reconstitute a 200 unit vial of Botox® be stored at 2-80C following
(Botox® 200 unit injections into the with 6ml of N/S and mix gently. reconstitution is 24 hours.
vials) detrusor muscle to treat Draw 2ml from the vial into each of three
neurogenic detrusor 10ml syringes. Then complete the
overactivity reconstitution by adding 8ml N/S into
each of the 10ml syringes, and mix
gently. This will result in three 10ml
syringes, each containing about 67 units
of reconstituted Botox®
Botulinum toxin 20 x 0.5ml (5unit)  Group 1 Reconstitute a 100 unit vial of Botox®
(Botox® 100 unit injections into the with 10ml of N/S and mix gently
vials) detrusor muscle to treat
overactive bladder

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 43
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Bumetanide IV bolus  Groups 1 Suggestion: 1 Give undiluted. Flush with N/S.
and 2 minute Leave a gap of 20 minutes between
repeat bolus doses.
(I) IV infusion. Infusion  Groups 1 Dilute 2 – 5mg with 500ml of G,
30-60 minutes Protect infusion from light and discard
pump is required. and 2 N/S or G/S. Alternatively dilute to if cloudiness develops.
1mg/10ml with G, N/S or G/S Sodium content 0.007mmol/1ml.
(unlicensed dilution- see page 7)
IM Injection  Groups 1 Refer to the Marsden Manual for
and 2 guidance on IM injection.
Bupivacaine All epidural administration sets and epidural catheters must be labelled “Epidural” when in use (NPSA/2007/21)
(epidural) Epidural infusion via a  Groups Adult patients: Pre-made bags are supplied from *Staff administering and monitoring
Adults: McKinley epidural 1and 2* Epidurals: Pharmacy. epidural infusions must have received
0.167% pump, using a yellow Protocol “A” PCEA training from the Acute Care Team
coloured line which or “B” CEA. Modified and demonstrated their competency at
(with or without must be labelled epidural protocols administering and monitoring epidural
Fentanyl) “Epidural” are very rarely infusions. Follow the PHNT Epidural
Paediatric: prescribed by Protocols.
0.125% Anaesthetists Additional clinician boluses may be
administered by Pain Nurses if
required as per epidural protocol.
Bupivacaine For specialist use:  Groups Refer to Acute Care Pre-made bags are supplied from Refer to the PHNT protocol for
Infusion for local infiltration at 1and 2 Team Guidelines Pharmacy. Continuous Local Anaesthetic
local infiltration other sites i.e. near Infusions.
0.167% nerves, wound, joint,
0.125% body cavity (e.g.
0.0625% interpleural,
paravertebral) Via a
dedicated, grey
McKinley 595 pump,
using a grey coloured
line which must be
labelled with the route

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 44
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Buprenorphine IV bolus  Groups 1 3-5 minutes Can be diluted with N/S or G. Flush with N/S.
and 2 Sodium content nil.
IM Injection Refer to the Marsden Manual for
guidance on IM injection.
Caffeine and (I) IV infusion  Groups 1 1-2 hours Dilute 500mg caffeine sodium Record a resting ECG before administration.
sodium and 2 benzoate in 1 litre of N/S. Monitor for possible side effects:
benzoate tachycardia, cardiac arrythythmias, extra-
For treating low systoles, restlessness, agitation, nausea,
CSF pressure diuresis, hypoglycaemia, and
headache hyperglycaemia.
Note that caffeine and sodium benzoate
injection is unlicensed – see page 7.
Calcitonin SC injection  Groups Refer to the Marsden Manual for Allow the ampoule or vial to reach room
1,2,3,4 and 5 guidance on SC injection. temperature before SC or IM injection.
IM injection  Groups Refer to the Marsden Manual for When in use the 400unit in 2ml multidose
1,2,3,4 and 5 guidance on IM injection. vial can be stored at room temperature.
Record date of first use.
Discard the remaining contents of the
400unit in 2ml multidose vial 1 month after
first use.
Ampoules of calcitonin are for single use
only.
For hypercalcaemia  Groups Suggestion: 1- May be given by IV injection for
of malignancy 1,2,3,4 and 5 2 minutes hypercalcaemia of malignancy after previous
IV injection* rehydration.* Do not use the calcitonin from
the multiple dose 400unit in 2ml vial for
bolus injection (As it contains phenol).
(I) IV infusion for  Groups At least 6 hours Dilute 10units/kg in 500ml N/S. Some adsorption of calcitonin to the plastic
severe or emergency 1,2,3,4 and 5 of the infusion set will occur so monitor the
cases of patient’s response to treatment.
hypercalcaemia of
malignancy only.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 45
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND SUITABLE COMMENTS
GIVE DILUENT
Calcium Rapid IV bolus  Groups 1-2 seconds If 10% Calcium Chloride Minijets are not available In the presence of spontaneous
chloride during CPR for 1 and 2 then in cardiac arrest give 6.8ml of 14.7% calcium circulation, calcium must be
Cardiac Arrest chloride undiluted which is 6.8mmol Ca2+ (equivalent given slowly.
to a 10% Calcium Chloride Minijet)
IV bolus  Groups Maximum adult rates: Very irritant; always administer
Emergency use 1 and 2 1ml of 14.7%/minute slowly. Extravasation may
or for severe acute 1-1.5ml of 10%/minute cause tissue irritation and
hypocalcaemia 1ml of 13.4%/minute necrosis. Flush with N/S.
Calcium chloride 10% contains
(I) or (C) IV  Groups Adults: Maximum rate May be diluted with N/S, G or G/S to any suitable
6.8mmol calcium/10ml.
infusion. Infusion 1 and 2 1mmol/minute. volume. However, concentrations greater than 10ml of
Calcium chloride 13.4%
pump is required. 14.7% calcium chloride in each 100ml diluent will be
contains 9.12mmol
irritant to peripheral veins and should ideally be given
calcium/10ml.
via a central IV line.
Calcium chloride 14.7%
contains 10mmol calcium/10ml.
Calcium IV bolus  Groups Adults: Each 10ml If 10% Calcium Chloride Minijets are not available Flush with N/S.
gluconate Emergency use or 1 and 2 ampoule preferably then in cardiac arrest give 30ml of 10% calcium Calcium gluconate 10%
for severe acute over 5 minutes, gluconate undiluted which is 6.6mmol Ca2+ contains 2.2mmol calcium in
hypocalcaemia minimum 3 minutes. (approximately equivalent to a 10% Calcium Chloride 10ml.
Minijet) Irritant; extravasation may
(I) or (C) infusion  Groups Adults: Maximum rate May be diluted with N/S, G or G/S to any suitable cause tissue irritation and
using plastic 1 and 2 by infusion 200mg volume e.g. 100ml, 250ml, 500ml or 1 litre. However, necrosis.
ampoules of (0.44mmol concentrations greater than 10ml of 10% calcium
calcium gluconate Calcium)/minute gluconate in each 100ml diluent will be irritant to
peripheral veins and should ideally be given via a
central IV line.
In severe acute hypocalcaemia or hypocalcaemic tetany, an initial slow intravenous injection of 10–20 ml of calcium gluconate injection 10% (use the plastic ampoules)
should be given, with plasma-calcium and ECG monitoring (risk of arrhythmias if given too rapidly), and either repeated as required or, if only temporary improvement, followed
by a continuous intravenous infusion to prevent recurrence. For infusion, dilute 100 ml of calcium gluconate 10%(Use the plastic ampoules) in 1 litre of glucose 5% or sodium
chloride 0.9% (remove 100ml from the bag first) and give at an initial rate of 50 ml/hour adjusted according to response.
Calcium gluconate injection in glass ampoules or vials is now contra-indicated for use as repeated or prolonged treatment, including as an IV infusion, in children younger than
18 years and in patients with renal impairment. This is to limit exposure of patients to aluminium which is leached from the glass by the calcium gluconate solution. (MHRA Drug
Safety Update, August 2010).

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 46
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND SUITABLE COMMENTS
GIVE OVER DILUENT
‘Campath’ See Alemtuzumab
Caspofungin (I) IV infusion.  Groups 1 hour Allow the vial to warm to room temperature. If the patient is fluid restricted
Infusion pump is 1,2,3,4 and 5 Reconstitute each 50mg and 70mg vial with 10.5ml the 50mg and 35mg doses may
required. W. For the 50mg dose withdraw 10ml from the be diluted in 100ml N/S or H.
reconstituted 50mg vial. For the 70mg dose Flush with N/S.
withdraw 10ml from the reconstituted 70mg vial. For Do not infuse caspofungin with
reduced dose in moderate hepatic impairment any other drug solutions or
(35mg) withdraw 7ml from the reconstituted 50mg infusions containing glucose.
vial. Further dilute with 250ml N/S or H.
Phebitis is commonly reported.
Cefotaxime IV bolus preferred  Groups 3-5 minutes Reconstitute 500mg with 2ml, 1g with 4ml and 2g Flush with N/S, G or G/S.
Only to be method. 1,2,3,4 and 5 with 10ml W. Sodium content 2.09mmol/1g.
prescribed when Displacement 0.2ml for 500mg vial. Add 1.8ml of W
ceftriaxone is for 500mg in 2ml.
contra-indicated Displacement 0.5ml for 1g vial. Add 3.5ml W for 1g
due to the risk of in 4ml.
precipitation with Displacement 1.2ml for 2g vial. Add 8.8ml W for 2g
calcium in 10ml.
containing fluids (I) IV infusion via  Groups 20-60 minutes Reconstitute as above then dilute 1-2g with 40-
and TPN. infusion pump 1,2,3,4 and 5 100ml N/S, G, G/S or H.
IM Injection  Groups Reconstitute as for IV bolus. For paediatric doses Refer to the Marsden Manual
1,2,3,4 and 5 apply the same displacement values. for guidance on IM injection.
Cefoxitine IV bolus preferred  Groups 3-5 minutes Reconstitute the 2g vial with 10ml or 20ml W, N/S, Incompatible with
method 1,2,3,4 and 5 G or G10%. Displacement is 1ml for the 2g vial. aminoglycosides [Link],
Shake to dissolve and let stand until clear. tobramycin and amikacin.
(Unlicensed
product – see IM Injection  Groups Reconstitute the 2g vial with 4ml W. Displacement is Inject into a large muscle mass,
page 7) 1,2,3,4 and 5 1ml for the 2g vial. Shake to dissolve and let stand eg. gluteus maximus.
until clear.
(C) IV infusion via  Groups Reconstitute each 2g vial with 10ml W. Shake to Diluted solutions for IV infusion
infusion pump 1,2,3,4 and 5 dissolve and let stand until clear. Further dilute with must be discarded 12 hours
a suitable volume (eg. 500ml or 250ml) of N/S, G, after preparation.
G10% or H.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 47
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE SUITABLE DILUENT
Cefradine Cefradine injection is no longer commercially available.
Ceftazidime IV bolus  Groups 3-5 minutes Reconstitute 500mg vial with 5ml, 1g Flush with N/S, G or G/S.
1,2,3,4 and 5 vials with 10ml and 2g vial with 10ml Sodium content 2.3mmol/1g.
A 3g dose (1x1g N/S or G. Carbon dioxide is released; Displacement values vary between brands,
+1x2g vials) may be see package insert. and are not consistent. Refer to the SPC or
given by slow IV package insert for the brand and vial size
bolus. being used.
(I) IV infusion.  Groups Maximum 30 minutes Reconstitute 2g vial with 50ml of N/S
Infusion pump 1,2,3,4 and 5 or G.
is required. For 3g dose, also reconstitute a 1g
vial with10ml N/S. Dilute the
reconstituted 1g and 2g vials further
to 75ml with N/S.
IM Injection  Groups Reconstitute 250mg with 1ml, 500mg Doses exceeding 1g should be given IV – see
1,2,3,4 and 5 with 1.5ml and 1g with 3ml N/S or W. above. When IM injection causes pain
carbon dioxide is released, see Lidocaine 1% injection may be used to
package insert. reconstitute the vial instead of N/S or W.
Ceftriaxone IV bolus  Groups 2-4 minutes Reconstitute 250mg vial with 5ml W Do not give with TPN or fluids containing
1,2,3,4 and 5 and 1g vial with 10ml. Displacement calcium, even by different infusion lines
values vary between brands and are (Cefotaxime is a suitable alternative for
not consistent – refer to the package these patients).
insert or SPC for the particular brand Sodium content: 3.6mmol/1g
and vial size being used. Flush with N/S or G
(I) IV infusion  Groups At least 30 minutes Reconstitute 2g vial with 40ml G, G For infants and children up to 12 years, doses
(doses of 2g 1,2,3,4 and 5 10%, or N/S. of 50mg/kg or over should be given by slow IV
and above) via infusion over at least 30 minutes. (For
infusion pump neonates the dose is given over 60 minutes).
IM Injection  Groups Reconstitute 250mg with 1ml, 1g with Give by deep IM injection. Doses greater than
1,2,3,4 and 5 3.5ml and 2g with 7ml of 1% 1g should be divided and injected at more
lidocaine injection. Refer to the than one site.
Marsden Manual for guidance on IM
injection.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 48
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE SUITABLE DILUENT
Cefuroxime IV bolus  Groups 3-5 minutes Reconstitute 250mg with at least 2ml, 750mg Flush with N/S, G or G/S.
(Usual 1,2,3,4 and with at least 6ml and 1.5g with at least 15ml W. Sodium content: 1.8mmol/750mg
method) 5 Shake gently to produce an opaque Cefuroxime can be added to an infusion bag
suspension. of metronidazole.
(I) IV infusion  Groups Maximum 30 minutes Reconstitute as above then dilute to Displacement values vary between brands
via pump. 1,2,3,4 and 50 - 100ml with N/S or G. and are not consistent – refer to the package
5 insert or SPC for the particular brand and vial
size being used.
IM Injection  Groups Reconstitute 250mg with 1ml W and 750mg
1,2,3,4 and with 3ml W. Shake gently to produce an opaque
5 suspension. Refer to the Marsden Manual for
guidance on IM injection.
Cernevit Slow IV  Groups At least 10 minutes Reconstitute the vial with 5ml of W, N/S or G. Dosage for adults and children aged over
bolus 1,2,3,4 and Mix gently to dissolve the powder forming a 11 years: 1 vial of 5ml per day.
(Water and 5 yellow-orange coloured solution. Cernevit does not contain Vitamin K.
fat-soluble Either give undiluted or dilute further with a Cernevit may be administered via any type of
vitamins) small volume of N/S or G. intravenous cannula (including peripheral).
Do not mix with any other drug solutions.
(I) IV infusion  Groups At least 10 minutes Reconstitute the vial with 5ml of W, N/S or G.
Infusion 1,2,3,4 and Mix gently to dissolve the powder forming a
pump is 5 yellow-orange coloured solution, then dilute
required. further with N/S or G (e.g. up to 50ml).

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 49
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Cetuximab (I) IV infusion  Groups Infuse doses of A closed-system device must Prior to the first infusion, patients must receive
Infusion 1,2,3,4 and 400mg/m2 or be used to prepare premedication with an antihistamine and a corticosteroid
pump is 500mg/ m2 over 2 cetuximab. at least 1 hour prior to administration of cetuximab. This
required. hours. premedication is recommended prior to all subsequent
Give undiluted in an EVA bag infusions.
Infuse doses of (EVA bag supplied by Close monitoring is required during the infusion and for
250mg/m2 over 1 Pharmacy). at least 1 hour after the end of the infusion. Availability of
hour. resuscitation equipment must be ensured.
Severe infusion-related reactions, including anaphylactic
reactions, may commonly occur, despite premedication.
Fever, chills, dizziness, dyspnoea, bronchospasm,
urticaria or skin reactions are also very common,
particularly with the first infusion.
Do not infuse cetuximab through th same line or lumen
as any other drugs or glucose.

Flush with N/S.

Chloramphenicol IV bolus  Groups Reconstitute with W, N/S or G.
At least 1 minute Flush with N/S.
sodium succinate (Usual 1,2,3,4 and See package insert. Suggested Sodium content 2.98/1g
method) 5 maximum concentration In order to ensure rapid attainment of high blood levels,
100mg/1ml. chloramphenicol succinate is best administered by IV
Displacement 0.8ml/1g vial. Add injection. Where this is not possible, however, IM
9.2ml diluent to 1g vial for 1g in injection may be used, although it should be borne in
10ml (100mg in 1ml). mind that absorption may be slow and unpredictable.
(I) IV  Groups Give slowly over 15 Reconstitute as above then
infusion. 1,2,3,4 and to 30 minutes dilute with N/S or G (suggested
Infusion 5 volume 100ml).
pump is
required.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 50
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Chloroquine (C) IV infusion.  Groups 2 Initially 10mg/kg of Dilute with N/S to a suitable volume Oral therapy is started as soon as possible to
Infusion pump is and 2 Chloroquine base e.g. 50ml. complete the course.
required. over 8 hours then Flush with N/S.
5mg of base/kg for
3 more 8-hour
infusions
Chlorphenamine IV bolus  Groups Minimum 1 minute May be diluted with N/S to a Flush with N/S (IV)
1,2,3,4, 5 & 8 convenient volume e.g. 10ml. Extra care should be taken when preparing the
injection for children under 1 year due to the
IM injection  Groups Refer to the Marsden Manual for
guidance on IM injection. small volumes that are required. Dilution of
(Use the IV route 1,2,3,4 and 5
chlorphenamine injection with N/S should
if a rapid effect is facilitate preparation. For example, diluting
required)
0.2ml chlorphenamine injection to 2ml with
SC injection  Groups Refer to the Marsden Manual for N/S produces a solution containing
(Use the IV route 1,2,3,4 and 5 guidance on SC injection. chlorphenamine 1mg/ml. The diluted product
if a rapid effect is should be used immediately.
required)
Chlorpromazine Deep IM  Groups Refer to the Marsden Manual for IM injection can be repeated at 6 to 8 hour
injection 1,2,3,4 and 5 guidance on IM injection. intervals if required. Substitute with oral
(I) IV infusion via  Groups Slowly Dilute 25-50mg with 500ml-1 litre chlorpromazine as soon as possible.
an infusion pump 1,2,3,4 and 5 (Suggestion: 12 N/S. Very irritant; avoid IV administration if
to treat hiccups hours) possible. Do not administer via the SC
when IM route.
injection fails.
IV bolus  Groups Adults: Maximum Dilute to a maximum concentration of Flush with N/S (IV).
(This method is 1mg/minute. 1mg/1ml with N/S. Sodium content 0.2mmol/2ml.
1,2,3,4 and 5
unlicensed – see Hypotension can occur, especially with rapid
page 7). administration: Keep the patient supine and
monitor the blood pressure during and for 30
minutes after IM or IV administration.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 51
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Ciclosporin (I) IV infusion. Infusion  Groups 2-6 hours Dilute to a concentration of 0.5 - Use a PE/PVC (Polyethylene-lined)
pump is required. 1,2,3,4 and 2.5mg/ml of N/S or G. extension set when prepared in a
5 Do not use a standard PVC 50ml syringe.
infusion bag. Observe patient continuously for the
Either prepare the infusion in a first 30 minutes and at frequent
50ml syringe, or in a PVC-free intervals thereafter (Risk of
polyolefil bag of N/S (available anaphylactic reactions, acute
from pharmacy in 50ml, 250ml respiratory distress, blood pressure
and 500ml sizes). changes).
Flush with N/S.
Do not infuse down the same line as
any other drug solutions.
Cidofovir (I) IV infusion. Infusion  Groups 1 hour Infusion to be prepared by To facilitate accurate measurement
pump is required. 1,2,3,4 and Pharmacy. Telephone Ext. of the dose, the prescribed dose in
5 31083. Doctor to prescribe milligrams (rounded up or down if
dose (see comments) in 100ml necessary) divided by 75 should
N/S. have no more than one decimal
figure.
Wear gloves, gown and safety
glasses when handling. Avoid
handling drug if pregnant or trying to
become pregnant. Do not infuse with
any other drugs. Flush with N/S.
 Give 2g probenecid PO 3 hours pre-cidofovir infusion, 1g PO 2 hours after cidofovir infusion and 1g PO 8 hours after cidofovir infusion.
Probenecid can cause nausea so if possible the patient should eat some food before each dose. Alternatively, administer antiemetics as
required.
 Infuse 1 Litre N/S IV over 1 hour immediately before the cidofovir infusion. An additional 1 Litre of N/S may be infused IV over 2 hours after this
Ciprofloxacin (I) IV infusion. Infusion  Groups Adults: 200mg over 30 Provided suitably diluted. Flush with N/S.
Not for general pump is required. 1,2,3,4 and minutes, 400mg over Sodium content 15.4mmol/100ml.
use. Refer to Trust Infusion into a large 5 60 minutes.
Policy for Control vein will reduce venous For children, infuse the
of Infection. irritation (low pH) dose over 60 minutes.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 52
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY GIVE ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS
OVER SUITABLE DILUENT
Cisatracurium IV bolus  Group 1 – must Can be given undiluted, or diluted further Flush with N/S.
only be given by with N/S or G. If the patient is ventilated IV bolus can be
doctors proficient administered by Group 2 staff.
in advanced (The lowest recommended concentration Cisatracurium is incompatible with
airway is 0.1mg/ml) propofol and Hartmann’s.
management.
Also see
comments.
(C) IV infusion.  Groups
Infusion pump is 1 and 2
required.
Clarithromycin (I) IV infusion via a  Groups 1,2,3,4 60 minutes Reconstitute 500mg vial with 10ml W and Do not give by IV bolus (can cause
large peripheral and 5 shake to dissolve the contents. Further cardiac arrythmias). Do not give by IM
vein (or central dilute to a concentration of 2mg/ml with injection.
vein). Infusion N/S, G or H (Adult dose of 500mg = 10ml The reconstituted vial contains 500mg in
pump is required. of reconstituted solution in 250ml N/S, G 10ml (although the final volume in the vial
or H). will be 10.4ml).
Use infusion within 6 hours of preparation.
Flush with N/S or G. Sodium content: Less
than 0.5mmol/500mg
For fluid restricted patients 500mg Incompatible with aminophylline,
clarithromycin, reconstituted as above, cefuroxime, furosemide, heparin,
may be diluted in 100ml of N/S and phenytoin, flucloxacillin and ceftazidime.
infused over 60 minutes via a central IV Monitor infusion site for signs of
line (This dilution is unlicensed – see page inflammation, tenderness, phlebitis and
7). pain.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 53
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Clindamycin I) IV infusion  groups 300mg over at least 10 Dilute to a maximum concentration Flush with N/S.
Maximum 1.2g. 1,2,3,4 and minutes, 600mg over of 18mg/ml with N/S or G. Sodium content: Nil.
Infusion pump is 5 at least 20 minutes, Typically:
required 900mg over at least 30 For doses of 300mg, 600mg or
minutes, 1.2g over at 900mg, dilute in 50ml or 100ml
least 40 minutes. N/S or G.
Dilute 1200mg in 100ml N/S or G.
(C) IV infusion  groups Rate not to exceed Dilute to a maximum concentration Continuous intravenous infusion may begin with
via pump for 1,2,3,4 and 30mg/minute. of 18mg/ml with N/S or G. a single rapid infusion of the first dose (generally
doses above 5 over 30minutes), followed by a continuous
1.2g infusion of 0.75 to 1.25mg/minute.
IM injection  groups Refer to the Marsden Manual for Single IM injections of greater than 600mg are
1,2,3,4 & 5 guidance on IM injection. not recommended.
Clonazepam IV bolus  Groups Adults: Maximum rate Immediately before use dilute each Resuscitation equipment must be readily
In to a large vein 1,2,3,4 and 0.25 - 0.5mg/minute 1mg in 1ml with 1ml W (diluent available.
in the antecubital 5 Infants & children: supplied), to produce a 1mg in 2ml EEG, respiratory function and blood pressure
fossa. 50microgram/kg solution. should be monitored.
Emergency use (maximum 1mg) over Flush with N/S, G or G10%.
at least 2 minutes Sodium content: Nil
(I) IV infusion.  Groups Adjust rate according Dilute up to 3mg in 250ml of N/S, If using a PVC bag and/or a PVC line begin the
Infusion pump is 1,2,3,4 and to response. G, G10% or G/S(2.5%/0.45%). infusion immediately and infuse over a period no
required. 5 Neonates and children On Neonatal ICU dilute to a longer than 2 hours.
1 month to 18 years: maximum concentration of Alternatively dilute to 12 micrograms/ml with N/S
300micrograms in 25ml or in a 50ml Terumo or BD syringe using a PVC-
10 – 60
600micrograms in 50ml (12 free extension set. The following are available to
micrograms/Kg/hour =
0.83 – 5ml/kg/hour of micrograms/ml) with G10%. In fluid be ordered from NHS Supplies:
the 12microgram/ml restricted infants concentrations up Codan PVC-free extension set 71.4001, order
to 100micrograms/ml have been code FKA064
dilution.
used. Alaris G30302M line, order code FKA058
Using this method the solution will be stable for
12 hours.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 54
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Clonidine IV bolus  Groups Give slowly preferably Can be diluted with N/S or G to Flush with N/S.
1 and 2 over 10-15 minutes to any suitable volume. Sodium content 0.15mmol/1ml.
avoid transient pressor (C) IV infusion is unlicensed (See page 7).
effect. Monitor for bradycardia and hypotension.
(C) IV infusion  Groups Usual rate: 0.5 - 1 Dilute 750 micrograms to 50ml Withdraw gradually to avoid rebound
for sedation/ 1 and 2 micrograms/kg/hour. with N/S or G. tachycardia, hypertension, agitation and
withdrawal from Rates up to 2 sweating.
sedation in microgram/kg/hour have Very little compatibility data – infuse through a
critical care been used. dedicated lumen or line. May be infused via a
areas only. peripheral or central IV line.
Infusion pump is
required.
(C) Intrathecal  Group 1 Prepare and administer in * Restricted to those persons who are trained
infusion or or Group 2* accordance with the Pain and competent to administer medication via
Intrathecal bolus Management Centre procedures the intrathecal route.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 55
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Co-amoxiclav contains a penicillin – Check patient’s allergy status before administration
Co-amoxiclav IV bolus  Groups 3-4 minutes Reconstitute 1.2g vial with 20ml Flush with N/S.
Usual method. 1,2,3,4 and 5 W and 600mg vial with 10ml W. Complete infusion within 4 hours of
For doses requiring part of a vial reconstitution.
Displacement values: Sodium content 2.7mmol/1.2g.
Bowmed/Actavis brand: Potassium content 1mmol/1.2g.
0.4ml for the 600mg vial and For bolus injection use within 20 minutes of
0.7ml for the 1.2g vial. reconstitution.
Augmentin® and Wockhardt Do not dilute Co-amoxiclav with G.
brands: Not suitable for IM injection.
0.5ml for the 600mg vial and Example: How to give 900mg
0.9ml for the 1.2g vial. Using a 20ml syringe, reconstitute a 1.2g vial
(I) IV infusion.  Groups 30-40 minutes Reconstitute as above then dilute with 15ml WFI. Draw up the entire vial
Infusion pump is 1,2,3,4 and 5 1.2g with 100ml N/S or 600mg contents into the syringe then draw up more
required. with 50ml N/S. W to the 20ml mark. Mix the syringe contents.
Then administer 15ml (contains 900mg) and
discard 5ml.
Colistimethate (I) IV infusion.  Groups 30 minutes Reconstitute all vial strengths Flush with N/S.
(Colistin) Infusion pump is 1,2,3,4 and 5 with 10ml W or N/S. Roll vial in Do not infuse with any other drugs.
(Colomycin ®) required. hand to dissolve. Do not shake to Sodium content: less than 0.5mmol per
avoid foam formation, then dilute 500,000 unit and 1,000,000 unit vials
further with N/S to 50ml.
Patients with a  Groups Via TIVAD only: Reconstitute all vial strengths The powder for injection is also licensed for
Totally Implantable 1,2,3,4 and 5 Minimum 5 with 10ml W or N/S. Roll vial in use via a nebuliser. To nebulise dissolve
Venous Access minutes hand to dissolve. Do not shake to dose in 2-4ml of W or N/S. The output from
Device (TIVAD) avoid foam formation. the nebuliser may be vented to the open air
may tolerate a or a filter may be fitted. Nebulisation should
slow IV bolus of up take place in a well ventilated room.
to 2 million units

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 56
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Collagenase 0.58mg per  Group 1 Remove the vial from the fridge Each vial is for single use only.
Clostridium injection into a and allow to stand at room When injecting a cord affecting a
histolyticum palpable temperature for at least 15 proximal interphalangeal joint of the fifth
▼ This product is Dupuytren's cord minutes and no longer than 60 finger, the needle insertion must not be
being intensively minutes. Reconstitute the vial more than 2 to 3 mm in depth and not
monitored by the CHM with the solvent supplied more than 4 mm distal to the palmar
and MHRA. Please according to the table below. Use digital crease.
report all suspected only the supplied solvent as it
reactions (including contains calcium required to Sodium injected per joint:
non-serious ones) activate the medication. Inject the Metacarpophalangeal joints: 0.9mg
using a Yellow Card appropriate volume (see below) Proximal interphalangeal joints: 0.7mg
from the BNF of the solvent slowly into the
sides of the vial. Do not invert or
shake the solution. Slowly swirl to
ensure dissolution. The final
solution must be clear and
colourless.
Volumes needed for reconstitution and administration of Collagenase Clostridium histolyticum
Joint to be treated Solvent required for reconstitution Injection volume to deliver 0.58 mg dose*
Metacarpophalangeal joints 0.39ml 0.25ml
Proximal interphalangeal joints 0.31ml 0.20ml
* Note that injection volume for delivery of a 0.58 mg dose is less than the total volume of solvent used for reconstitution.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 57
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Co-trimoxazole (I) IV infusion.  Groups The dilution for PJP For patients with Pneumocystis
Do not infuse with any other drugs.
Infusion pump 1,2,3,4 and (Formerly known as jirovecii (formerly known asFlush with N/S.
is required. 5 PCP) – each 5ml with Pneumocystis carinii) Monitor all infusions carefully for turbidity and
75ml G – should be pneumonitis crystallization.
given over no longer
Dilute each 5ml with at least 75ml Commence the infusion within half an hour of
than 1 hour. preparation.
G.
For fluid-restricted patients:
Other dilutions should High doses have been given undiluted via a
Other infections dilute each
be given over no central line and syringe pump over 1.5 - 2
480mg (5ml) with 125ml,
longer than 90 hours (Unlicensed).
960mg (10ml) with 250ml,
minutes, but this
1440mg (15ml) with 500ml or an Sodium content 1.64mmol/480mg.
should be balanced
equivalent dilution with N/S, G or Extravasation: may cause tissue damage.
against the patient’s
G/S.
fluid requirements
These infusions must be
administered within 6 hours

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 58
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE OVER SUITABLE DILUENT
Cyclizine IV bolus  Groups 3-5 minutes Can be diluted with N/S or G if Flush with 5 ml of N/S or G.
1,2,3,4 and necessary to a convenient volume e.g. Sodium content nil.
5 5ml. If diluted with N/S, visually check
the dilution. Discard if there is any
crystallization, precipitation or
haziness. Otherwise use immediately.
IM Injection  Groups Refer to the Marsden Manual for
1,2,3,4 & 5 guidance on IM injection.
(C) SC  Groups Continuous over Dilute with W. Follow the PHNT Care of The Dying Pathways
infusion via 1,2,3,4 and 24 hours and the PHNT Syringe Driver Policy.
syringe driver 5 Cyclizine may precipitate if the concentration
in palliative in W exceeds 10mg/ml.
care Precipitation occurs if mixed with N/S.
For combinations of 2 or 3 drugs in the same
(C) SC  Groups Refer to the Marsden Manual for
injection for guidance on SC injection. syringe, refer to the Syringe Driver Drug
1,2,3,4 and
use in Compatibility chart provided in the pump kit.
5
palliative care Contact Pharmacy on ext. 39976 for further
compatibility advice if necessary.
Cyclizine is not licensed via the SC route (See
page 124).
Cyclophosphamide When cyclophosphamide is prescribed to treat conditions including multiple sclerosis, glomerular kidney disease or rheumatoid
arthritis, it may be administered by Group 2  practitioners who have previous experience of administering parenteral cytotoxics. On
the Planned Investigation Unit, refer to the Unit protocol.
Slow IV  Groups 3-5 minutes Pharmacy will supply pre-filled Wear gloves, gown and safety glasses when
bolus 1,2,3, 4 and syringes of 150mg, 200mg, 400mg or handling. Avoid handling drug if pregnant or
5 500mg to make up the prescribed trying to become pregnant.
dose. Flush with N/S.
(I) IV  Groups 30-60 minutes Infusion to be prepared by Pharmacy. Typically, doses of 1500mg or less are given
infusion. 1,2,3,4 and Telephone Ext. 31083. Typically the by slow IV bolus.
Infuse via 5 dose is diluted in 250ml or 500ml N/S.
pump

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 59
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Danaparoid IV loading dose  Groups See comments Dilute with N/S, G or G/S. The Seek advice of Consultant Haematologist as
injected over 30 1,2,3,4 and 5 volume of diluent is not critical and the Consultant Haematologists have different
seconds followed by (C) can be adjusted to the fluid needs of regimens for different indications.
IV infusion to treat the patient.
thrombo-embolism in One suggested dilution: Draw up the Although the Orgaran® packing states “For
patients with contents of six 750 unit ampoules subcutaneous administration”, this product is
Heparin- Induced (6x750 units = 4500 units) into a also licensed for intravenous infusion.
Thrombocytopenia 50ml syringe and dilute to 45ml with
(HIT). Infusion pump is N/S or G to make a 100unit/ml
required. dilution.
However, if the maintenance
infusion rate is less than 187
units/hour the above dilution will
waste danaparoid (expensive). In
this case draw up the contents of
three 750 unit ampoules (3x750units
= 2250 units) into a 50ml syringe
and dilute to 45ml with N/S or G to
make a 50unit/ml dilution.
SC Injection  Groups Refer to the Marsden Manual for
1,2,3,4 and 5 guidance on SC injection.
Dantrolene IV bolus  Group 1 Give rapidly Reconstitute 20mg with 60ml W. Due to high pH (9.5) avoid extravasation.
Shake the vial until the solution is Sodium content 2mmol/20mg vial.
clear. Each 20mg vial also contains 3g mannitol.
Protect from light.
Incompatible: do not give with any other
drugs or infusion fluids including G and N/S.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 60
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE OVER SUITABLE DILUENT
Daptomycin IV bolus  Groups 2 minutes Reconstitute the 500mg vial with 10ml Contains negligible sodium (<0.05mmol/vial).
May only be 1,2,3,4 and 5 N/S or the 350mg vial with 7ml N/S Do Treatment should be discontinued if the CPK
initiated on the not use W to reconstitute. Gently level reaches greater than 5 times upper limit
advice of a rotate the vial to ensure complete of normal in the presence of unexplained
consultant wetting of the product and then allow to muscle symptoms.
microbiologist stand for 10 minutes. The vial should Store vial in a refrigerator at 2-8oC.
then be gently rotated/swirled for a few If clotting profiles are required during
minutes as needed to obtain a clear treatment, samples should be taken pre-dose.
reconstituted solution. Vigorous Compatible with: Aztreonam, ceftazidime,
shaking/agitation should be avoided to ceftriaxone, dopamine, fluconazole,
prevent foaming of the product. The gentamicin, heparin, levofloxacin, lidocaine.
concentration of the reconstituted Incompatible with Glucose solutions.
solution is 50mg/ml (No displacement)
Flush with N/S.
(I) IV infusion  Groups 30 minutes Reconstitute and dissolve as above.
1,2,3,4 and 5 Further dilute to 50ml or 100ml N/S.
Decan (I) IV infusion  Groups Suggestion: 1 Via a peripheral IV cannula, 40ml Dosage for adults: 1 vial of 40ml per day.
Infusion 1,2,3,4 and 5 hour Decan must be diluted to at least 250ml Contra-indicated in children, patients
(Trace pump is with N/S, or to at least 500ml with G. weighing less than 40kg and in patients with
elements) required. Via a CVC or PICC line, 40ml Decan pronounced cholestasis (serum bilirubin >
may be diluted in a smaller volume of 140micromol/l).
N/S or G or given undiluted if
necessary. Do not mix with any other drug solutions.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 61
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE SUITABLE DILUENT
Defibrotide (I) IV  Groups 2 hours Dilute the dose (6.25mg/kg) with N/S or Monitor for side effects: bleeding,
▼ This product is being infusion via 1,2,3,4 G to a final concentration in the range of vomiting and hypotension are all
intensively monitored a pump and 5 4mg/ml to 20mg/ml. The total final common.
by the CHM and volume of infusion should be suitable Flush with N/S.
MHRA. Please report for the patient’s weight.
all suspected reactions Remove a volume of the N/S or G from The prepared infusion will be stable if
(including non-serious the infusion bag equal to the total stored in a fridge for upto 24 hours
ones) using a Yellow volume of defibrotide solution to be before use.
Card from the BNF added. Then add the defibrotide in to
the bag and mix gently.
Desferrioxamine (I) or (C) IV  Groups Treatment of acute Reconstitute each 500mg with 5ml W Discard infusion if opalescent.
infusion. 1,2,3,4 iron poisoning: and each 2g vial with 20ml W then Flush with N/S.
Infusion and 5 15mg/kg/hour, dilute with N/S, G or G/S. to any May be infused into the blood line
pump is reduced as soon as suitable volume (e.g. 500ml, 1000ml or through a “Y” adaptor located near to
required. the situation permits 250ml). the venous site of injection.
(usually after 4-6 Example for treating acute iron For use in children with chronic iron
hours). Total IV dose poisoning: Reconstitute 5 x 2g vials overload follow the protocol on CYPOD
not to exceed each with 20ml W, remove 100ml from (Childrens’ and Young Persons
80mg/kg in any 24 a 500ml bag of N/S and add the Outpatient Department).
hour period contents from the 5 x 2g vials to the bag
Chronic iron then to produce 10g desferrioxamine in
overload: 500ml(=20mg/ml). The initial rate for will Desferrioxamine is incompatible with
be 0.75ml/kg/hour (= 15mg/kg/hour). heparin solutions.
20 – 60mg/kg/day
Displacements: 0.4ml/500mg Desferal®
vial, 0.3ml/500mg Hospira vial and
1.5ml/2g vial (both brands).
SC infusion  Groups Chronic iron Suggestion: Reconstitute as above then
using a 1,2,3,4 overload: either dilute with N/S or give without
If giving by SC infusion, monitor for
portable and 5 20 – 60mg/kg/day. further dilution.
irritation or discomfort at the site of
ambulatory Infuse the dose over administration.
pump 8 to 24 hours

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 62
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Desmopressin SC injection  Groups Refer to the Marsden Manual for Flush after IV bolus with N/S.
4micrograms in 1,2,3,4 and 5 guidance on SC injection. After repeated doses monitor for fluid
1ml overload; restrict fluid intake and check body
IM injection  Groups Refer to the Marsden Manual for
weight regularly
1,2,3,4 and 5 guidance on IM injection.
IV bolus  Groups Suggestion: 1 minute Undiluted
1,2,3,4 and 5
(I) IV infusion  Groups 20 minutes Dilute the dose to 50ml with N/S Tachycardia, hypotension and facial flushing
(Haemophilia 1,2,3,4 and 5 but see comments. may occur during infusion; monitor blood
and Von pressure continuously during infusion.
Willibrands). For (I) IV infusion 100ml N/S can be used
Infusion (unlicensed) if necessary but the 20 minute
pump is infusion time should be adhered to.
required. Do not mix with other fluids or drugs
Desmopressin SC injection  Groups Refer to the Marsden Manual for
15micrograms 1and 2 guidance on SC injection.
in 1ml
(I) IV infusion  Groups 1 20 minutes Dilute the dose to 50ml with N/S Tachycardia, hypotension and facial flushing
(OCTIM Brand) but see comments. may occur during infusion; monitor blood
Infusion and 2
For specialist pump is pressure continuously during infusion.
use in required. Do not mix with other fluids or drugs.
Haematology
Restrict fluid intake and check body weight
patients
regularly.
Continued monitoring of Factor VIII levels is
recommended.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 63
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Dexamethasone IV bolus or  Groups Give doses of May be diluted with N/S, G or H Hospira and Hameln brands contain 4mg in 1ml of
sodium (I) IV infusion 1,2,3,4,5 & 4mg or less over to any convenient volume. dexamethasone phosphate equivalent to 3.3mg
phosphate via infusion 8 1 minute. dexamethasone in 1ml. For a 4mg dose of
pump Give large doses dexamethasone give 1.2ml over 1 minute.
over several Flush IV doses with N/S.
minutes. Anaphylactic reactions can occur.
IM injection  Groups Refer to the Marsden Manual Aspen Pharma brand contains a quantity of
1,2,3,4, 5 for guidance on IM injection. dexamethasone phosphate equivalent to 3.8mg/ml
dexamethasone.
Intra-articular  Group 1 Prior to intra-articular injection, the joint fluid should
be examined to exclude a septic process. Administer
under strictly aseptic conditions.
Soft tissue  Group 1 Licensed sites include: bursae, tendon sheaths and
infiltration ganglia.
(Intralesional)
Nerve Root  Group 1 *Restricted to those persons who are trained and
Administer in accordance with
Blocks or or Group 2* competent to administer medication via the
the Pain Management Centre
Intrathecal use procedures or current intrathecal route.
(Use Hospira Use Hospira 3.3mgin 1ml dexamethasone as it does
neurosurgical practice.
3.3mg in 1ml not contain sulphites or disodium edetate which are
vials) potentially neurotoxic.
SC injection for  Groups Refer to the Marsden Manual Follow the PHNT Care of The Dying Pathways and the
use in palliative 1,2,3,4 & 5 for guidance on SC injection. PHNT Syringe Driver Policy.
care For combinations of 2 or 3 drugs in the same syringe,
(C) SC infusion  Groups Continuous over Dilute with W when 2 or more refer to the Syringe Driver Drug Compatibility chart
via syringe driver 1,2,3,4 & 5 24 hours drugs are being mixed in the provided in the pump kit. Contact Pharmacy on ext.
in palliative care same syringe. 39976 for further compatibility advice if necessary.
W or N/S may be used when the [Link] dexamethasone ampoules/vials are
syringe only contains this drug. labelled for IV, IM, intraarticular, intrabusal or
intralesional use, they are suitable (but unlicensed)
for subcutaneous administration.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 64
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Dexrazoxane (I) IV infusion  Groups 15 minutes Infusion to be prepared by Administer about 30 minutes before
(Cardioxane®) 1,3 and 5 Pharmacy. Telephone Ext. anthracycline (e.g. doxorubicin or epirubicin)
31083. administration.
Handle as for cytotoxics. Wear gloves, gown
and safety glasses when handling. Avoid
handling drug if pregnant.
Store the prepared infusion in the fridge and
use within 6 hours of pharmacy preparation.
Dexrazoxane (I) IV infusion  Groups 1 – 2 hours Infusion to be prepared by The first infusion should be initiated as soon
(Savene®) into a large vein in 1,3 and 5 Pharmacy. Telephone Ext. as possible and within the first six hours after
extremity/area other than 31083. the accident. Cooling procedures such as ice
the one affected by the packs should have been removed from the
extravasation area at least 15 min before the Savene
administration in order to allow sufficient
A chemotherapy closed blood flow. Treatment Day 2 and Day 3
system bag spike should should start at the same hour (+/- 3 hours) as
be used with a line on the first day.
adaptor to ensure the Refer to the Guidelines for the administration
safe administration of of Savene(dexrazoxzane) for the treatment of
Savene®. The air inlet extravasations caused by anthracyclines.
port on the bag spike Handle as for cytotoxics. Wear gloves, gown
should be opened to and safety glasses when handling. Avoid
allow free flow of handling drug if pregnant.
Savene®. An air inlet Store the prepared infusion in the fridge and
needle should not be use within 4 hours of pharmacy preparation.
used in case of leakage
during administration.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 65
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Diamorphine Staff prescribing, administering and/or screening prescriptions for opioid medications should be familiar with the PHNT Policy for
Reducing Errors with Opioid Medicines in Adults using the following link:
[Link]
osing%20Errors%20with%20Opioid%20Medicines%20in%[Link]?timestamp=1443106367868
IV bolus  Groups Maximum rate Usually reconstitute 5mg, 10mg , Observe respiratory rate (especially with IV
1,2,3,4 and 5 1mg/minute 30mg and 100mg ampoules with bolus doses). Naloxone and resuscitation
1ml W. Use a minimum of 2ml W to equipment should be available.
reconstitute 500mg ampoule. For acute pain the IV dose will be a quarter to
Can be diluted with N/S or G. half of the corresponding IM dose. For elderly
and frail patients reduce the usual dose by
half. Flush with N/S or G. Sodium content nil.
IM injection  Groups Reconstitute as above. Refer to the
1,2,3,4 and 5 Marsden Manual for guidance on IM
injection.
SC injection  Groups Reconstitute as above. Refer to the For use in palliative care follow the PHNT Care
1,2,3,4 and 5 Marsden Manual for guidance on of The Dying Pathways
SC injection.
(C) SC  Groups Continuous over 24 Reconstitute as above. Dilute further Follow the PHNT Care of The Dying Pathways
infusion via 1,2,3,4 and 5 hours with W when 2 or more drugs are and the PHNT Syringe Driver Policy.
syringe driver being mixed in the same syringe. For combinations of 2 or 3 drugs in the same
in palliative W or N/S may be used where the syringe, refer to the Syringe Driver Drug
care syringe only contains diamorphine. Compatibility chart provided in the pump kit.
Contact Pharmacy on ext. 39976 for further
compatibility advice if necessary.
In chronic pain, the total daily dosage of IM or
SC diamorphine is about one third of the
equivalent total daily dosage of oral
morphine.
Epidural or  Group 1 Administer in accordance with All syringes containing solution for epidural
spinal injection standard anaesthetic practice. administration should be labelled “For Epidural
Use Only” (NPSA/2007/21)

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 66
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Diamorphine 50 All epidural administration sets and epidural catheters must be labelled “Epidural” when in use (NPSA/2007/21)
micrograms/ml Epidural  Groups Background rate of Pre-made bags supplied by *Staff administering and monitoring epidural
with infusion via 1and 2* 0 -10 ml/hour with Pharmacy. infusions must have received training from
bupivacaine McKinley additional Patient- the Acute Care Team and demonstrated their
0.167% epidural pump Controlled Epidural When these are not available the competency at administering and monitoring
infusion for Analgesia (PCEA) of anaesthetist may prepare the epidural infusions. Follow the Acute Care
adults 5ml boluses with a infusion in theatre, with the bag Team Protocols. Additional clinician boluses
lock-out time of 30 labelled “For Epidural Use Only”. may be administered by Pain Nurses if
minutes, if prescribed. required as per epidural protocol.
Diazepam IV bolus  Groups Maximum rate: 5mg Do not dilute. Flush with G (do not use N/S).
emulsion 1,2,3,4 and 5 (1ml) per minute.
(Diazemuls) (I) IV infusion.  groups Titrate dose to Dilute 2-8ml with 100ml G or Use infusion within 6 hours. Diazepam is
(This is the Infusion adsorbed by plastic infusion equipment.
1,2,3,4 and 5 response. G10%, to produce a
preferred pump is concentration between 100- It can be injected into the infusion tubing
diazepam required. . 400micrograms/1ml. during an ongoing infusion of N/S, G or
formulation for G10%.
IV injection)
Diazepam IV bolus  Groups Suggestion for adults: Undiluted Elderly or debilitated patients should be given
1,2,3,4 and 5 Maximum rate 5mg not more than half of the usual dose.
(1ml) per minute Flush with N/S or G. Give IV injections into a
(C) or (I) IV  Groups Titrate dose to Dilute with N/S or G to a large vein to reduce local reactions
infusion. 1,2,3,4 and 5 response. concentration not exceeding (thrombophlebitis and thrombosis).
Infusion 40mg in 500ml. It is recommended that patients should
pump is remain under medical supervision and in a
required. supine position for at least one hour after
administration. Resuscitation equipment
should be available. Use infusion within 6
hours. Diazepam is adsorbed by plastic
infusion equipment.
IM injection  Groups Refer to the Marsden Manual for The IM route should only be used when IV or
1,2,3,4 and 5 guidance on IM injection. oral administration is not possible.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 67
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Diclofenac (C) or (I)  Groups 1 Treatment of post-op First add 0.5ml of 8.4%, or 1ml of Only use if solution is clear. Once prepared,
Infusion. and 2 pain: 4.2% sodium bicarbonate solution use infusion immediately.
Do NOT give 75mg over to 100-500ml N/S or G with then Maximum daily dosage is 150mg.
as IV bolus. 30 minutes - 2hours. add the contents of one ampoule Parenteral administration should not exceed 2
Infusion Prevention of post-op (75mg diclofenac in 3ml). days.
pump is pain: Flush with N/S or G.
required. 25-50mg over Sodium content: negligible.
15 minutes - 1 hour Do not infuse with any other drugs.
then (C) IV infusion at
5mg/hour.
IM injection  Groups 1 Give undiluted. By deep intragluteal injection into the outer
and 2 Refer to the Marsden Manual for quadrant. If a second IM injection of
guidance on IM injection. diclofenac is needed, it is advised that the
other buttock is used.
Dicobalt edetate IV bolus.  Group 1 Adults: Each 300mg Give undiluted. Each dose may be followed immediately with
dose over 1 minute, 50ml G 50%.
or in less severe 100% oxygen should be administered
poisoning over 5 concurrently with Dicobalt Edetate.
minutes. When the patient is fully conscious, it is
unlikely that the extent of poisoning warrants
the use of Dicobalt Edetate Injection.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 68
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
DigiFab ® (I) IV infusion.  Groups 30 minutes Reconstitute each vial with 4 ml Can rarely cause anaphylaxis, allergic or
(Digoxin Infusion pump 1,2,3,4 and W. Mix gently. The reconstituted febrile reactions.
Immune Fab) is required. 5 solution may be further diluted to Resuscitation equipment should be available.
any convenient volume with N/S. Monitor blood pressure & body temperature.
Bolus only if  Group 1 Reconstitute as above. Monitor ECG continuously during and for at
cardiac arrest least 24 hours after Digibind.
seems Hypokalaemia can develop- sometimes
imminent rapidly. Monitor serum potassium level
carefully during and after DigiFab.
Digoxin (I) IV infusion.  Groups Emergency Loading Adults: Dilute loading and ECG monitoring required. Flush with N/S.
Infusion pump 1,2,3,4 and Dose of 500micrograms to maintenance doses to 50-100ml Emergency Loading Dose depends on age,
is required. 5 1mg infused over at least 2 with N/S. lean body weight and renal function. Either
hours (see comments), or avoid giving an IV loading dose, or give a
alternatively give in divided reduced loading dose if digoxin has been
doses at intervals of 4-8 taken within the last 2 weeks.
hours, assessing clinical Note that 500micrograms of IV digoxin is
response before giving equivalent to 750micrograms of digoxin in
each additional dose, with tablet form.
each part-dose being For plasma monitoring, take blood at least 6
given over 20 minutes. hours after a dose.
Maintenance dose (when
patient unable to take by
mouth or enteral feeding
tube) infused over 1 hour.
Dihydro- For the use of IV dihydroergotamine to treat migraine or cluster headache, follow a copy of the protocol from the Planned Investigation Unit
ergotamine (PIU). The protocol may also be found on Plymouth Healthnet > Depts > Pharmacy. Note that dihydroergotamine injection is an unlicensed
product (see page 7).

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 69
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Disopyramide Slow IV  Groups Adults: 2mg/kg Either give undiluted or dilute ECG monitoring is necessary. Monitor for ventricular
Regimen 1 bolus 1 and 2 (maximum 150mg) further with any suitable volume of arrythmias, widening of QRS complex and lengthening
over at least 5 N/S or G. of QT interval, hypotension, hypoglycaemia, myocardial
minutes depression, AV block and antimuscarinic side effects.
Stop administration of disopyramide if width of QRS-
complex or QT-interval increase by more than 25%, or
hypogylaemia occurs.

If cardioversion occurs during the injection, stop

injecting the remainder of the dose.

If cardioversion is achieved (usually within 10-15

minutes after the first injection) but the arrhythmia
recurs, a second dose of 2mg/kg (maximum 150mg)
may be given by slow IV injection over at least 5
minutes (maximum of 300mg in the first hour,
maximum of 800mg disopyramide by any route in 24
hours).
Flush slowly with N/S.
Disopyramide Slow IV  Groups Adults: 2mg/kg Either give undiluted or dilute ECG monitoring is necessary. Monitor for ventricular
Regimen 2 loading 1 and 2 (maximum 150mg) further with any suitable volume of arrythmias, widening of QRS complex and lengthening
This regimen dose over at least 5 N/S or G. of QT interval, hypotension, hypoglycaemia, myocardial
should be used for minutes depression, AV block and antimuscarinic side effects.
patients who are Stop administration of disopyramide if width of QRS-
unable to take complex or QT-interval increase by more than 25%, or
disopyramide by (C) IV  Groups Adults: Suggested dilution: hypogylaemia occurs.
mouth or who maintenance 1 and 2 0.4mg/kg/hour Remove 50ml from a 500ml bag of
have serious infusion Maximum N/S or G. Then add 500mg = 50ml
arrhythmias being 30mg/hour. of disopyramide injection into the
treated in critical or Maximum total bag to make a 1mg/ml dilution.
coronary care 800mg in 24
areas. hours.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 70
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE OVER SUITABLE DILUENT
Dobutamine (C) IV infusion  Groups 1 Adjust rate Dilute 250mg to at least 50ml with N/S or Do not flush - replace giving set.
Infusion pump is and 2 according to G (If no central IV access available see Infusion may turn a harmless pink colour.
required. response. below*) Haemodynamic monitoring required.
Sodium content: 0.046mmol/vial.
Administration via Concentrations of up to 10mg/1ml have
a central IV line is been used via a central IV line but this is An alternative dilution: For administration
recommended* outside the manufacturer's via a central IV line draw up milligrams of
as solutions of recommendations. dobutamine equal to six times the patient’s
dobutamine have body weight in kilograms, and dilute to
a low pH. *In circumstances where a central 100ml with N/S or G (or milligrams of
venous catheter is not available and the dobutamine equal to three times the
infusion is going to be run for more than patient’s body weight in kg in 50ml). The
a couple of hours, use a solution of 1mg infusion rate set in ml/hour will equal
in 1mL (250mg in 250ml N/S) and micrograms/kg/minute.
administer via a large peripheral vein.

Pump rate (ml/hour) = Prescribed rate (mcg/kg/min) x weight(kg) x 60(minutes in an hour)

1000 x concentration(mg/ml)

Rate (mcg/kg/min) = Pump rate(ml/hour) x concentration(mg/ml) x 1000

60 x weight(kg)

(I) IV infusion  Group 1 or See comments Calculate the required amount of Infuse at 10mcg/kg/min for 4 minutes, then
using infusion Group 7 dobutamine and dilute to 50ml with N/S. 20mcg/kg/min for 4 minutes, then
pump for cardiac 30mcg/kg/min for 4 minutes, then
stress testing. 40mcg/kg/min.
Infusion pump is
required.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 71
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Dopamine (C) IV infusion.  Groups 1 For administration via a central IV ECG monitoring usually required. Do not
Rate dependent on
Infusion pump is and 2 indication and line draw up milligrams of flush - replace giving set.
required. response. dopamine equal to six times the For peripheral administration use a dilute
patient’s body weight in kilograms, solution and a large vein. Use a central
Administration and dilute to 100ml with N/S, G, venous line for concentrations over
via a central IV G10%, G/S or H (or milligrams of 1.6mg/ml.
line is preferred dopamine equal to three times the Extravasation causes local vasoconstriction;
as solutions of patient’s body weight in kg in 50ml). irrigate affected area with 5-10mg
dobutamine The infusion rate set in ml/hour will phentolamine in 10-15ml N/S.
have a low pH. equal micrograms/kg/minute. Sodium content 0.52mmol/200mg.
Alternatively for administration via
If no central IV a central IV line dilute 200mg
access is dopamine to 50ml with N/S, G,
available the G10%, G/S or H and infuse at the
maximum calculated rate.
concentration for For administration via a peripheral
infusion through IV line add 400mg dopamine to
a peripheral vein 250ml N/S and infuse at calculated
is 1.6mg/ml. rate.
Pump rate (ml/hour) = Prescribed rate (mcg/kg/min) x weight(kg) x 60(minutes in an hour)
1000 x concentration(mg/ml)

Rate (mcg/kg/min) = Pump rate(ml/hour) x concentration(mg/ml) x 1000

60 x weight(kg)

Dopexamine (C) IV infusion.  Groups 1 Adjust rate according Dilute with N/S, G, G/S or H to a Infuse via a central vein or a large peripheral
Infusion pump is and 2 to response. maximum concentration of 4mg/ml vein.
required. via a central IV line or a maximum Monitor BP, heart rate, ECG, urine flow and
concentration of 1mg/ml via a large where possible cardiac output.
peripheral vein. Infusion may turn a harmless pink colour.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 72
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR COMMENTS
GIVE DILUTION AND SUITABLE
DILUENT
Doxapram IV bolus  Group 1 Minimum 30 seconds Ampoule can be diluted with Flush with N/S or G.
N/S, G or G10%. IV bolus dose may be repeated at one hour
(C) IV  Groups Adults: 1.5 – 4mg/minute Adults: Dilute 1g doxapram in intervals if necessary.
infusion. 1,2,3,4 and 5 = 45 – 120ml/hour using 500ml G. Monitoring of blood pressure, heart rate and
Infusion pump the 1g in 500ml infusion, deep tendon reflexes is recommended to
is required. increasing the rate prevent overdosage.
gradually. Check arterial blood gases (ABGs)
frequently (every 30 minutes suggested)
after starting infusion. If no improvement
increase infusion rate in suggested
increments of up to 1 mg/min (to a maximum
of 4 mg/min)
Eculizumab (I) IV infusion.  Groups 1 25 – 45 minutes Infusion to be prepared by Patients should be monitored for one hour
Infusion pump and 2 Pharmacy. Telephone Ext. following infusion. If an adverse event occurs
is required. For example, to give 31083. during the administration of eculizumab, the
900mg in 180ml N/S over infusion may be slowed or stopped at the
30 minutes, set the Doctor to prescribe each dose medical team’s discretion. If the infusion is
infusion pump at as an infusion in N/S at a slowed, the total infusion time must not
360ml/hour. concentration of 5mg/ml, eg. exceed two hours in adults and adolescents
To give 1200mg in 240ml prescribe 900mg eculizumab (aged 12 years to under18 years) and four
over 30 minutes, set the in 180ml N/S hours in children aged less than 12 years.
pump at 480ml/hour. Prescribe 1200mg eculizumab Flush with N/S.
in 240ml N/S. Sodium content: 5mmol/300mg eculizumab.
Edrophonium IV bolus  Group 1 Can be diluted with W, but Have atropine available to counteract
maintenance of stability possible severe cholinergic reactions. In
cannot be guaranteed. case of cholinergic crisis resuscitation
equipment should be available.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 73
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE OVER SUITABLE DILUENT
Enoxaparin SC injection  Groups Refer to the Marsden Manual for Do not press the plunger before injecting to
Pre-filled For dose banding 1,2,3,4,5 and guidance on SC injection. expel the air bubble. Hold the syringe so
syringes and guidance on 8 that the needle is pointing downwards
choice of syringe (vertically at a 900 angle). Insert the full
strength(s) and length of the needle into the skin fold.
volumes to inject To avoid bruising, do not rub the
see the table below injection site after giving the injection.

Enoxaparin VTE Dosing Guidance

Treatment Dose
Weight Continue for at least 5 days AND until two consecuive INRs >2.0 Prophylactic Dose
(kg) Separate protocol applies to pregnant women
GFR > 30ml/minute (≈1.5mg/kg) GFR < 30ml/minute (≈1mg/kg) GFR > 30ml/minute GFR < 30ml/minute
40 – 49 60mg Daily 40mg Daily 20mg Daily
50 – 59 80mg Daily
60 – 74 100mg Daily 60mg Daily 40mg Daily 20mg Daily
75 – 89 120mg Daily 80mg Daily
90 – 99
100 – 109 150mg Daily 100mg Daily
110 – 120 180mg Daily 120mg Daily 40mg TWICE Daily 40mg Daily
121 – 150 Contact Consultant Haematologist
 For patients over 150kg or complex cases, advice may be obtained from a Consultant Haematologist.
 For patients requiring treatment doses who are morbidly obese (BMI> 35mg/m2), pregnant, or have significant renal impairment (eGFR <30ml/minute)
monitor anti-Xa levels. Take the first anti-Xa level 3 hours after the 3rd dose and state time dose was administered and time of level take on blood form.
Thereafter, repeat level if patient’s condition changes or advised by Haematology.
 For ACS patients, use fondaparinux unless patient’s eGFR < 30ml/minute, then use enoxaparin ≈1mg/kg daily as above.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 74
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Enoximone (C) or (I)  Groups Initial rate: 90 micrograms/ Dilute with an equal volume of W or Flush with N/S.
IV 1 and 2 kg/minute for 10-30 minutes until the N/S (i.e. dilute to a concentration of Extravasation will cause tissue
infusion required haemodynamic response is 2.5mg/ml). damage.
via a achieved (This is 2.16ml/kg/hour Do not administer unless diluted
pump. using an infusion of 2.5mg/ml) then product is a clear yellow solution.
Maintenance rate: Monitor blood pressure, heart rate,
5-20 micrograms/kg/minute. ECG and CVP.
(This is 0.12ml/kg/hour to Incompatible: do not infuse with any
0.48ml/kg/hour using an infusion of other drugs including G and
2.5mg/ml) furosemide.
Ephedrine IV bolus  Group 1 3-5 minutes Must be diluted prior to Flush with N/S.
administration with N/S (suggested
dilution: 3mg in 1ml).
Epoprostenol (C) IV  Groups See package insert. Withdraw about 10ml of the diluent Cardiac and blood pressure
infusion 1,2,3,4 and For use during CVVH on ICU, refer to provided, inject into the vial of monitoring required until dose is
via a 5 the critical care protocol for epoprostenol and shake gently to titrated.
pump. epoprostenol. dissolve the powder. Then draw up Do not stop infusion for more than a
the reconstituted epoprostenol and few minutes. Replace giving set; do
re-inject via the filter into the not flush.
remainder of the diluent Mix well. On the Derriford Hospital Critical Care
This is the “Concentrated solution” Unit the prepared solution is used for
(10micrograms/ml). up to 24 hours. This is unlicensed but
For use during CVVH on ICU, patient cost-saving. A drop in blood pressure
is initially acclimatized with systemic is possible when renewing an infusion
IV infusion of 2microgram/ml that’s been made up longer than 12
epoprostenol for 2 hours (10ml of hours.
“Concentrated solution” diluted Sodium content 2.5mmol/reconstituted
further to 50ml with N/S). vial.
Incompatible: do not infuse with any
other drugs including G and G/S.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 75
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Ergocalciferol IM Injection  Groups The product packaging states “Only glass syringes
300,000unit 1,2,3,4 and should be used”, as the solution is very difficult to
injection 5 expel from ordinary plastic syringes. However, glass
syringes are not available. The injection is easier to
expel from green [Link] 3ml syringes which are
available from Pharmacy. One of these syringes
should be supplied with each dispensed ampoule.
Within Pharmacy, further supplies are available in
T/Services.
Ertapenem (I) IV infusion  Groups 30 minutes Reconstitute the contents of the 1g Use the infusion within 6 hours of preparation.
via pump 1,2,3,4 and vial with 10ml W or N/S to give a The product information suggests using a 50ml bottle
May only be 5 solution of approximately 100mg/ml. or bag of N/S but these are not stocked in this Trust.
initiated on the Shake well to dissolve. Dilute further Sodium content: 6mmol/1g
advice of a with N/S to a final concentration of
consultant 20mg/ml or less (e.g.1g in 100ml
microbiologist N/S).
Erythromycin (I) IV infusion  Groups 20-60 minutes Reconstitute each 1g with 20ml W to Extravasation is hazardous.
via pump 1,2,3,4 and produce 50mg/1ml then further dilute IV infusion may cause thrombophlebitis, particularly
5 to a maximum concentration of concentrations exceeding 5mg/1ml.
5mg/ml with N/S, G or G/S. Flush with N/S. Sodium content nil.
If G or G/S are used add 5ml sodium 125mg erythromycin used as prokinetic for GI tract
bicarbonate 8.4%/litre as a buffer. (Unlicensed use - see page 7) should be diluted in
Displacement is allowed for. Addition 25ml N/S and given over 5 minutes.
of 20ml W to 1g vial gives 1g in 20ml Prepare a fresh infusion every 8 hours.
(50mg in 1ml).
(C) IV  Groups Reconstitute as above then dilute as
infusion via 1,2,3,4 and above to a concentration of 1mg/ml
pump 5 to 5mg/ml (1mg/ml is recommended).
(I) IV infusion  Groups Minimum 60 Reconstitute as above then dilute 1g In addition to the above points, this is an unlicensed
via a central 1,2,3,4and minutes to 100ml with N/S. use for use in fluid restricted patients. Cardiac
line using a 5 monitoring necessary.
pump

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 76
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Esmolol (I) IV infusion via an  Groups Follow the Vials containing 100mg esmolol
Treatment of supraventricular tachycardia: After
infusion pump. Preferably 1 and 2 dosage titration in 10ml (10mg/ml) are used
achieving adequate control of heart rate introduce
administer via a central flow chart in without further dilution.
alternative oral agent and gradually reduce esmolol
line to avoid potential the package infusion rate - see package insert for instructions.
venous irritation as the insert. Monitor the blood pressure frequently. Caution: Flushing
preparation has a low pH. the line will administer a bolus dose. However 5ml N/S
If this is not possible, use has been used as a flush following loading doses, given
a large peripheral vein at the same slow rate as the loading dose.
10mg/ml IV infusion of esmolol for supraventricular tachycardia or post-operative tachycardia and/or hypertension
Elapsed Time Loading dose given before each titration step to produce rapid Maintenance Infusion
(Minutes) onset of action, infused over 1 minute (pump setting) (pump setting)
0–1 500micrograms/kg (=3ml/kg/hour)
1–5 50micrograms/kg/minute (=0.3ml/kg/hour)
5–6 500micrograms/kg (=3ml/kg/hour)
6 – 10 100micrograms/kg/minute (=0.6ml/kg/hour)
10 – 11 *500micrograms/kg (=3ml/kg/hour)
11 – 15 *150micrograms/kg/minute (=0.9ml/kg/hour
15 – 16 *500micrograms/kg (=3ml/kg/hour)
16 – 20 *200micrograms/kg/minute (=1.2ml/kg/hour)
20 - 21 *500micrograms/kg (=3ml/kg/hour)
21 – 25 *250micrograms/kg/minute (=1.5ml/kg/hour)
25 – 26 *500micrograms/kg (=3ml/kg/hour)
26 - 30 *300micrograms/kg/minute (=1.8ml/kg/hour)
*As the desired heart rate or endpoint (eg. Lowered blood pressure) is approached, omit the loading dose and reduce the incremental increases in infusion rate to
25micrograms/kg/minute (0.075ml/kg/hour to 0.15ml/kg/hour). The interval between titration steps may be increased from 5 to 10 minutes.
Once the desired clinical endpoint is reached continue the maintenance infusion at that rate.
10mg/ml IV infusion of esmolol for intra-operative immediate control of tachycardia and/or hypertension
80 mg (approximately 1 mg/kg) bolus dose over 15 to 30 seconds followed by a 150 mcg/kg/min infusion (0.9ml/kg/hour), if necessary. Adjust the infusion rate as
required up to 300 mcg/kg/min (1.8ml/kg/hour) to maintain desired heart rate and/or blood pressure.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 77
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT

Esomeprazole IV bolus  Groups At least 3 minutes Reconstitute 40mg vial with 5ml The reconstituted solution is clear and
1,2,3,4 and N/S. colourless to very slightly yellow.
5 Revert to omeprazole capsules orally as soon
(I) IV infusion  Groups 10 – 30 minutes Reconstitute as above then further as possible. Alternatively revert to dispersible
via infusion dilute up to 100ml with N/S. lansoprazole Fastabs via PEG/NG/NJ as soon
1,2,3,4 and
pump as possible.
5
Use infusion in N/S within 12 hours.
Do not infuse with any other drugs.
Esomeprazole IV Loading  Groups 80mg in 100ml N/S over For each 40mg vial, withdraw 5ml of Use infusion in N/S within 12 hours.
For the specialist dose of 1,2,3,4 and 30 minutes N/S from a 100ml bag and use to Do not infuse with any other drugs.
treatment of 80mg 5 reconstitute the vial. Then inject the
endoscopically reconstituted esomeprazole into the * The Gastroenterologists have agreed to a 70-
controlled bleeding bag. Do not add more than 80mg hour treatment (rather than 72 hours). A pre-
peptic ulceration. esomeprazole to 100ml of diluent. printed prescription is available.
(C) IV  Groups After loading dose, infuse Reconstitute and dilute each 40mg
infusion via 1,2,3,4 and at 8mg/hour for 70 hours* vial as above.
infusion 5 (This is 10ml//hour with
pump each 80mg in 100ml N/S)
Ethanol (Alcohol) (C) IV  Groups For ethylene glycol or Dilute to 5 or 10% with G. Flush with N/S or G.
infusion via 1,2,3,4 and methanol overdose: 10% solutions of ethanol are hyperosmolar and
(Unlicensed infusion 5 For a 5% solution: irritant to veins and are best given by central
product- see page pump Refer to the Toxbase Remove 56ml from a litre bag of 5% venous catheter.
7) . Website for details of the glucose. Then add 56ml of 90% Some references recommend discontinuing
infusion rates. ethanol injection into the bag. gradually over 24-48 hours to avoid a possible
major secondary withdrawal reaction.
For a 10% solution: For ethylene glycol overdose adjust infusion
Remove 111ml from a litre bag of rate to achieve blood ethanol conc. of 1- 1.5g/L.
5% glucose. Then add 111ml of Monitor blood glucose level.
90% ethanol injection into the bag. Always refer to the Toxbase website for more
detailed instructions in the case of ethylene
glycol or methanol overdose.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 78
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Etomidate IV bolus  Group 1 30 – 60 seconds May be diluted with N/S or G. Pain can occur after injection into veins of the
dorsum of the hand. Use of larger veins
reduces pain on injection. Incompatible with
Hartmann’s. Flush with N/S or G.
Can reduce serum cortisol levels during
induction so no longer kept in Main Theatres
Fentanyl Staff prescribing, administering and/or screening prescriptions for opioid medications should be familiar with the PHNT Policy for
Reducing Errors with Opioid Medicines in Adults using the following link:
[Link]
Dosing%20Errors%20with%20Opioid%20Medicines%20in%[Link]?timestamp=1443106367868
IV bolus  Groups 1 Follow the algorithm Dilute 200 micrograms fentanyl to Monitor the patient in accordance with the
(Theatre and 2 from Recovery 2 10ml with N/S algorithm from Recovery 2.
Recovery)
IV bolus  Groups 1 Can be diluted with N/S, G, G/S or For sedation in conscious adult patients follow
and 2 H. the Sedation Guidelines on Plymouth Healthnet
(under Clinical Guidelines).
All healthcare practitioners involved directly or
participating in sedation techniques must have
the necessary knowledge, skills and
competences required.
Flush with N/S.
Patient  Groups 1000 micrograms fentanyl (20ml of PCA: 20 microgram (1ml) bolus, 5 minute lock-
Controlled 1,2,3,4 and 5 injection) diluted to 50ml with N/S. out period. Follow the Acute Pain/Care Service
Analgesia Protocols.
(PCA)
(I) or (C) IV  Groups 1 Sodium content 0.3mmol/1ml.
infusion. and 2
Infusion
pump is
required.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 79
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Fentanyl All epidural administration sets must be labelled “Epidural” when in use (not just the epidural catheter) NPSA/2007/21
2micrograms/ml Epidural  Groups Background rate of Pre-made bags supplied by *Staff administering and monitoring epidural
with bupivacaine infusion via 1and 2* 7 – 15ml/hour with Pharmacy. infusions must have received training from the
0.1% epidural McKinley pump additional Patient- Acute Care Team and demonstrated their
infusion Controlled Epidural competency at administering and monitoring
Analgesia (PCEA) of epidural infusions. Follow the Acute Care Team
5ml boluses with a Protocols. Additional clinician boluses may be
lock-out time of 30 administered by Pain Nurses if required as per
minutes. epidural protocol.
Ferric For doses of  Groups Suggestion: 2 Either give undiluted or dilute with a Inspect vials visually for sediment and damage
carboxymaltose 100-200mg: 1,2 and 8 minutes small volume N/S eg.10ml N/S before use. Use only those that are sediment-
(Ferinject®) IV bolus (No more than 50ml of N/S). free.
The patient should be monitored closely for
▼ This product is signs of hypersensitivity during administration
being intensively For doses of  Groups 6 minutes For slow IV bolus, either give and for 30 minutes after every dose of
monitored by the 201-500mg: 1,2 amd 8 undiluted or dilute with a small Ferinject® given.
CHM and MHRA. Either slow IV volume N/S eg.10ml. A single dose of Ferinject® should not exceed
Please report all bolus or (I) IV 1000mg. Do not administer 1000mg more than
suspected infusion via For IV infusion, dilute with no more once a week. If the total dose is greater than
reactions pump than 100ml N/S. 1000mg then it should be divided and given
(including non- For doses of  Groups 15 minutes Either give undiluted or dilute with over 2 weeks.
serious ones) 501-1000mg: 1,2 and 8 N/S (No more than 250ml of N/S). Dilutions less than 2mg/ml are unstable.
using a Yellow (I) IV infusion Do not mix with any other infusion or drug
Card from the BNF via pump solutions, including glucose.
Flush with N/S.
Each 50mg in 1ml of Ferinject® contains
0.24mmol sodium.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 80
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE OVER SUITABLE DILUENT
Ferumoxytol IV Bolus  Groups Maximum rate Do not dilute further. Follow the administration with a slow flush of
1,2,3,4 and 1ml/second N/S to clear the line.
▼ This product is 5 (i.e. the Monitor the patient for signs of hypotension
being intensively contents of and hypersensitivity reactions for at least 30
monitored by the each 17ml vial minutes after giving the injection.
CHM and MHRA. over at least 17 The maximum dose for a course of
Please report all seconds). treatment is 2 vials, but these must not be
suspected reactions given at the same time (The second
(including non- injection should be given 2 to 8 days after
serious ones) using the first injection).
a Yellow Card from
the BNF
Filgrastim SC injection  Groups Do not dilute further. Within its shelf-life and for the purpose of
(Zarzio®) Post chemotherapy, 1,2,3,4,5 Refer to the Marsden Manual for guidance ambulatory use, the patient may remove the
Chronic neutopenia, and 8 on SC injection. product from the refrigerator and store it at
or HIV room temperature (not above 25°C) for one
Short IV infusion  Groups 30 minutes Dilute the required dose in 20ml G to produce single period of up to 72 hours. At the end of
Post chemotherapy 1,2,3,4,5 a final concentration of at least 1.5MU/mL this period, the product should not be put
or for mobilisation of and 8 (15micrograms/mL; 300micrograms in 20ml). back in the refrigerator and should be
PBPCs after bone disposed of.
marrow transplant Do not dilute to a concentration of less than
Continuous SC or  Groups Over 24 hours 0.2MU/ml (2micrograms/ml). Flush with G.
IV infusion for If a concentration of less than 1.5MU/ml
1,2,3,4, 5 (15micrograms/ml; equivalent to less than
mobilisation of and 8 Zarzio® is not compatible with saline
300micrograms in 20ml) is prepared in glucose
PBPCs after bone solutions.
5%, add human serum albumin to a final
marrow transplant concentration of 2mg/ml (e.g. in a final volume
of 20mL add 0.2ml 20% human serum
albumin). This is to reduce the amount of
filgrastim adsorbed on to the surface of the
administration set.
Do not shake the syringe before removing the
required dose.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 81
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR COMMENTS
GIVE DILUTION AND SUITABLE
DILUENT
Flebogamma® See Immunoglobulin Human Normal
Flecainide IV bolus  Groups In an emergency or for Can be diluted with G and given Flush with G.
Adults: 1 and 2 rapid effect, give over at as a mini-infusion (e.g. 50ml or Continuous ECG monitoring required for bolus
2mg/kg least 10 minutes. Minimum 100ml of G). doses.
Maximum 30 minutes for patients with It is recommended that the maximum duration
150mg cardiac failure or ventricular by infusion is 24 hours.
tachycardia. The maximum cumulative dose in the first 24
(I) IV  Groups Adults: Loading dose over Suggested dilution for hours should not exceed 600mg.
infusion. 1 and 2 30 minutes as above maintenance infusion: Dilute Switch to oral treatment as soon as possible.
Infusion followed by IV infusion at 300mg to 50ml with G. If infusion in N/S or H is necessary 150mg
pump is 1.5 mg/kg/hour for the first flecainide must be diluted in at least 500ml.
required. hour then 0.1-0.25
mg/kg/hour thereafter.
Using a 300mg in 50ml
dilution, this is
0.25ml/kg/hour for the first
hour then 0.017 –
0.042ml/kg/hour thereafter.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 82
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE SUITABLE DILUENT
Flucloxacillin is a penicillin – Check patient’s allergy status before administration
Flucloxacillin IV bolus  Groups Inject doses up to 1g Reconstitute 250-500mg with 5-10ml and Flush with N/S.
Usual method 1,2,3,4 and 5 over 3-4 minutes 1g with 15-20ml W. Can be diluted with Sodium content 0.57mmol/250mg.
N/S or G.
Inject 2g doses Displacement volumes: For IV administration: The following
slowly over 6-8 Bowmed/Actavis brand: 0.15mL for drugs are incompatible with
minutes or give by 250mg, 0.3mL for 500mg, 0.6mL for 1g. flucloxacillin: amiodarone, atropine
infusion (see below). Wockhardt brand: 0.2mL for 250mg, sulphate, buprenorphine, calcium
0.4mL for 500mg, 0.7mL for 1g. gluconate, chlorpromazine hydrochloride,
(I) IV infusion.  Groups 30-60 minutes Reconstitute as above then dilute with ciprofloxacin, diazepam, dobutamine
via pump 1,2,3,4 and 5 N/S or G to 100ml. hydrochloride, erythromycin lactobionate,
IM Injection  Groups Add 1.5ml of water for injections to 250mg gentamicin sulphate, metoclopramide
1,2,3,4 and 5 vial contents or 2ml of water for injections hydrochloride, morphine sulphate,
to 500mg vial contents. Refer to the netilmicin sulphate, ofloxacin,
Marsden Manual for guidance on IM papaveretum, pethidine hydrochloride,
injection. prochlorperazine edisylate, promethazine
Intrapleural  Group 1 Dissolve 250mg in 5 to 10ml of water for hydrochloride, tobramycin and verapamil
injections. hydrochloride.
Intra-articular  Group 1 Dissolve 250 to 500mg in up to 5ml of
water for injections or 0.5% lidocaine
hydrochloride solution for injection.
Fluconazole (I) IV infusion.  Groups 10-20mg/minute. Set Provided ready diluted (2mg/ml). Flush with N/S.
Infusion pump 1,2,3,4 and 5 the pump at 300 – Fluconazole is well absorbed from the
is required. 600ml/hour gut so consider an early switch to
oral/NG/PEG treatment. Sodium content
15mmol/200mg (100ml bottle).
Flucytosine (I) IV infusion.  Groups 20-40 minutes Provided ready diluted. Flush with N/S. Must be stored at 18oC
Infusion pump 1,2,3,4 and 5 Can be administered concurrently with to 25oC. Sodium content
is required. N/S, G or G/S. 34.5mmol/250ml. Infusion must not be
used as a multidose container.
Incompatible: do not infuse with any
other drugs except N/S, G, or G/S.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 83
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY GIVE ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
OVER AND SUITABLE DILUENT
Flumazenil IV bolus  Groups Minimum 15 Can be diluted with N/S or G to any Flush with N/S.
1,2,3,4,5 and 8 seconds suitable volume. Give (I) IV infusion if drowsiness recurs after
initial IV bolus.
(I) IV infusion.  Groups 100-400 Flumazenil infusion should be used within 3
Infusion pump 1,2,3,4 and 5 micrograms/ hour hours of preparation.
is required.
Incompatible: do not infuse with any other
drugs.
Fluorescein IV bolus  Group 1 or F Test dose in 5ml N/S then 3-5ml of Follow the REI Fluorescein Angiograhy
grade Group 2 10%-20% fluorescein injection Guidelines
with ENB346 or followed by N/S flush.
relevant
ophthalmic
qualification
Folic acid IV bolus  Groups Suggestion: 1 Can be diluted with N/S Flush with N/S. Flush with N/S.
1,2,3,4 and 5 minute
Folinic acid IV bolus  Groups Minimum 3-5 Can be diluted with N/S. Folinic acid (calcium folinate) 350mg contains
(calcium 1,2,3,4 and 5 minutes 0.7mmol of calcium therefore administer slowly.
folinate) (I) IV infusion  Groups Maximum Dilute with N/S or G. Intravenous incompatibilities include:
via infusion 1,2,3,4 and 5 rate of droperidol, methotrexate, 5-fluorouracil and
pump 160 mg/minute foscarnet.
Fomepizole (I) IV infusion  Groups All doses should Dilute each calculated dose of If the fomepizole injection has become solid in
via infusion 1,2,3,4 and 5 be infused over fomepizole injection with N/S or G the vial, the solution should be liquefied by
pump 30 minutes to a final volume of 250ml or 500ml running the vial under warm water or by holding
and mix well. in the hand (solidification does not affect
efficacy or stability of the product)
(Can be diluted with 100ml N/S or Continue treatment with fomepizole until the
G if patient is fluid restricted) plasma ethylene glycol or methanol
concentration is either undetectable or has
been reduced below 50mg/L and acidosis and
signs of systemic toxicity have resolved.
Refer to the Toxbase website for full details.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 84
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT

Fondaparinux Deep SC injection.  Groups To avoid the loss of fondaparinux 2.5mg once daily initiated as soon as possible
Alternate sites 1,2,3,4 and solution, do not expel the air following diagnosis and continued for up to 8 days.
For the treatment between the left & 5 bubble from the pre-filled syringe The medical team can stop the treatment once the
of Acute right anterolateral before injection. patient has had no chest pain for 48 hours.
Coronary and left & right For patients with ACS and an eGFR less than
Syndrome posterolateral 30ml/minute, prescribe 1mg/kg enoxaparin once
abdominal wall. daily instead.
Insert the whole
length of the needle Refer to the Marsden Manual for guidance on SC
at right angles into injection.
the skin.
Foscarnet (I) IV infusion.  Groups Minimum Infusion to be prepared by Can be infused undiluted via a central line.
sodium Initial loading dose. 1,2,3,4 and infusion time of Pharmacy. Telephone Ext 31083. Flush with N/S or G. Sodium content 15.6mmol/1g.
Infusion pump is 5 1 hour. Incompatible: do not infuse with any other
required. drugs. Peripheral administration may lead to local
(C) IV infusion  Groups irritation and thrombophlebitis.
Maintenance 1,2,3,4 and DO NOT administer by rapid intravenous injection.
therapy. 5 Wear gloves, gown and safety glasses when
Infusion pump is handling. Avoid handling drug if pregnant.
required.
Fosfomycin (I) IV infusion.  Groups 2g over at least Dissolve 2g fosfomycin (Fomicyt®) Do not infuse with any other drugs.
(Fomicyt®) Infusion pump is 1,2,3,4 and 15 minutes. in 50ml W, G or G10%. Dissolve Avoid inadvertent intra-arterial administration.
required 5 4g over at least 4g fosfomycin (Fomicty®) in 100ml 2g vial contains 27.8mmol sodium
30 minutes. W, G or G10%. Dissolve 8g 4g vial contains 55.6mmol sodium
8g over at least fosfomycin (Fomicyt®) in 200ml 8g vial contains 111.3mmol sodium
60 minutes. W, G or G10%. On dissolution the Flush with N/S.
solution becomes slightly warm.
Displacement values:
1ml for the 2g vial
2ml for the 4g vial
4ml for the 8g vial

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 85
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE SUITABLE DILUENT

Fosfomycin (I) IV infusion.  Groups Infuse all doses over 1 Reconstitute the 4g vial with 20ml of W. Sodium content 14.35mmol/1g fosfomycin
(Fosfocina®) Infusion pump 1,2,3,4 and 5 hour Reconstitute each 1g vial with 10ml W Incompatible with the following drug
is required. (ampoule provided). Upon dissolving, the solutions: erythromycin, gentamicin and
N.B. This vial will become slightly warm. To give a 4g rifampicin.
brand is dose, remove 50ml G from a 250ml bag of Flush with N/S.
unlicensed G. Then add 4g of reconstituted
fosfomycin into the bag containing 200ml
G. To give a 2g dose, add 2g reconstituted
fosfomycin to 100ml G.
Fosfomycin (I) IV infusion.  Groups Infuse all doses over Reconstitute the 2g bottle with 40ml to
Sodium content 14.5mmol/1g fosfomycin
(Infectofos®) Infusion pump 1,2,3,4 and 5 30 minutes 60ml W and begin infusion immediately.
Monitor serum electrolytes, in particular
is required. Reconstitute the 3g and 5g bottles with
serum sodium, potassium and creatinine.
100ml W. Reconstitute the 8g vial with
Monitor patient for phlebitis at the infusion
200ml W. Begin the infusion immediately
site. Flush with N/S.
after reconstitution. During reconstitution
Safe to be given to patients with allergies to
the solution may get warm. any other commonly used antibiotics
If necessary G or G10% may be used including penicillins, cephalosporins,
instead of W to reconstitute the bottles
levofloxacin, tetracyclines, trimethoprim and
(volumes as for W). Do not further dilute.
erythromycin.
On storage the bottles should be protected
from light (Keep in original box)
Furosemide IV bolus  Groups Adults: The rate Either dilute with N/S (a common dilution is Flush with N/S.
1,2,3,4,5 and should not usually 1mg/ml) or give undiluted. Sodium content 0.14mmol/1ml for 20mg/2ml
(C) or (I) IV 7 exceed 4mg/minute, and 50mg/5ml; 0.04mmol/1ml for
infusion. however single doses 250mg/25ml. Rapid administration may
Infusion pump of up to 80mg may be damage the hearing. Furosemide
is required. given more quickly. precipitates in glucose solutions.
Fusidic Acid See Sodium Fusidate
Gallamine IV bolus  Group 1 Flush with N/S.
Gammanorm® See Immunoglobulin Human Normal
Gammapex® See Immunoglobulin Human Normal

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 86
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY GIVE ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
OVER AND SUITABLE DILUENT
Ganciclovir (I) IV infusion.  Group 1 or Minimum 60 Infusion to be prepared by To facilitate accurate measurement of the
Infusion pump is Group 2 minutes Pharmacy. Telephone Ext. 31083. dose, the prescribed dose in milligrams
required. Doctor to prescribe dose (see (rounded up or down if necessary) divided
comments) in 100ml N/S or G. by 50 should have no more than one
decimal figure.
Wear gloves, gown and safety glasses when
handling. Avoid handling drug if pregnant or
trying to become pregnant. Do not infuse
with any other drugs. Preferably infuse
through a large vein. Flush with N/S or G.
Gentamicin IV bolus  Groups 3-5 minutes Either give undiluted or dilute with Administration by (I) IV infusion once a day
1,2,3,4 and 5 (minimum 3 N/S or G (usually 10-20ml). is current Trust policy, although this use is
Refer to the minutes) outside of the manufacturer’s
Plymouth (I) IV infusion for  Groups 30 minutes Dilute with 50ml or 100ml N/S or G. recommendations. Flush with N/S.
Healthnet Clinical once-daily dosing 1,2,3,4 and 5 Sodium content negligible
Guidelines/ (>200mg). Infusion Incompatibilies include benzylpenicillin and
Infection Control pump is required. teicoplanin.
for the use and Intraperitoneal  Groups 1 and Follow the Renal Services Directorate
current dosage of 2 Peritoneal Dialysis Peritonitis Protocol
gentamicin,
teicoplanin and IM injection  Groups Refer to the Marsden Manual for guidance
vancomycin. Discuss further with a 1,2,3,4 and 5 on IM injection.
Consultant
Microbiologist if
unable to give
gentamicin via the IV
route
Glargine insulin See Insulin Section page

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 87
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND SUITABLE COMMENTS
GIVE DILUENT
Glucagon SC Injection  Groups Reconstitute with diluent provided (1ml W) and Intravenous glucose must be given
1,2,3,4,5 and 6 shake gently until the glucagon has dissolved and if the patient fails to respond to
the solution is clear. The resulting solution is Glucagon within 10 minutes.
1mg/ml. Do not further dilute. Refer to the Marsden
Manual for guidance on SC injection.
IM Injection  Groups Reconstitute as above. Refer to the Marsden Intravenous glucose must be given
1,2,3,4,5 and 6 Manual for guidance on IM injection. if the patient fails to respond to
Glucagon within 10 minutes.
IV bolus  Groups Reconstitute as above. However, for doses > 2mg Flush with N/S.
(For diagnostic 1,2,3,4,5 and 6 reconstitute each vial with 1ml G instead of the
testing) diluent provided, to avoid administration of large
amounts of preservative.
Treatment of cardiogenic shock caused by beta-blocker poisoning
IV bolus  Groups Loading dose of 2 -10mg For loading doses > 2mg reconstitute each vial with (I) IV infusion is an unlicensed use
(Loading 1,2,3,4 and 5 (Child: 50 – 150 1ml G instead of the diluent provided, to avoid (See page 7) to treat cardiogenic
dose) microgram/kg, max. administration of large amounts of preservative. shock from beta blocker poisoning.
followed by (I) 10mg) by slow IV bolus Suggestion for the infusion for an adult:
IV infusion. over 3 – 5 minutes Reconstitute 10 x 1mg vials, each with 1ml G (Do
Infusion pump followed by IV infusion not use the diluent provided as the patient will get a
is required. of 50 micrograms/kg/hour: large dose of preservative).
Using syringe pump
Using 1mg/ml glucagon
Draw up the reconstituted glucagon into a 50ml
for infusion: syringe and either infuse undiluted (1mg/ml) or
50micrograms/kg/hour dilute further with G.
= 0.05ml/kg/hour
Using a volumetric pump
Using a dilution of 10mg Draw up the reconstituted glucagon and dilute
in 100ml for infusion: further with G. (suggestion for an adult: 10mg
glucagon diluted to a volume of 100ml with G. 10ml
50micrograms/kg/hour
G from the bag can be used to reconstitute the 10
= 0.5ml/kg/hour vials of glucagon).

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 88
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Glucose 5-10% IV bolus  Groups Glucose infusions can be diluted G5% is iso-osmotic with blood and can be infused
N.B All bags of 1,2,3,4 and with W if the concentration required through a peripheral line.
glucose are for 5 is unavailable.
single use only. If G10% is administered peripherally use a large vein
(C) or (I) IV  Groups and preferably alter the injection site daily.
infusion 1,2,3,4,5
and 8
Glucose 20-50% (C) or (I) IV  Groups Concentrations greater than 20% should be infused
infusion 1,2,3,4 and through a central line to prevent venous irritation and
5 thrombophlebitis.
or Glucose 10% to IV infusion  Groups 150-200ml 10% Refer to the PHNT Hypoglycaemia Guideline 2014
treat severe via infusion 1,2,3,4 and glucose over 15 for detailed guidance).
hypoglycaemia pump 5 minutes
Glucose 50% to IV bolus via  Groups 20ml of 50% 20ml of 50% glucose over 1-2 minutes is very irritant
treat severe a central 1,2,3,4 and glucose over 1-2 and potentially damaging to peripheral veins.
hypoglycaemia vein. 5 minutes
Glucose 10% to (I) IV infusion  Groups 500ml of 10% Add 10 units of Actrapid insulin into Monitor U&E’s every 2 hours until the serum
treat hyperkalaemia via a large 1,2,3,4 and glucose over 30 the 500ml of 10% glucose using a potassium is stable and less than 6mmol/L. Monitor
vein 5 minutes 29 gauge Magellan 12.7mm blood glucose every 30 minutes during the infusion of
(1.3cm) Insulin Safety Syringe glucose with Actrapid, and for 2 hours after the
available from Thrushel, Tavy or infusion
ED (NHS order code: FTR1276)
For patients at risk (I) IV infusion  Groups 50ml of 50% Add 10 units of Actrapid insulin into Monitor U&E’s every 2 hours until the serum
from heart failure or via a large 1,2,3,4 and glucose over 15 the 50ml of 50% glucose. potassium is stable and less than 6mmol/L. Monitor
fluid overload : vein 5 minutes blood glucose every 30 minutes during the infusion of
Glucose 50% to glucose with Actrapid, and for 2 hours after the
treat hyperkalaemia infusion

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 89
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Glucose 5% (C) SC  Groups Usual rate is Maximum concentration of glucose Maximum of 2 litres of glucose 5% in 24 hours. The
infusion 1,2,3,4 and 500ml over 8 for SC infusion is 5% needle and giving set should preferably be changed
Only use 5 hours (21 drops every 72 hours. However, infusion sets can be left in
gravity-feed per minute). place for up to 5-7 days if there are no complications.
administration Maximum rate is Refer to potassium chloride monograph for SC
sets. Never 500ml over 4 potassium.
use an hours (40 drops Due to the acidic pH of glucose 5%, monitor the
infusion per minute) infusion site regularly for early signs of inflammation
pump for SC and irritation.
infusions.
Glyceryl trinitrate (C) or (I) IV  Groups 1 0.6 - 12 mg/hour Use the 50mg in 50ml ready-made Give via a PVC-free or PE/PVC (PE –lined)
infusion via and 2 vials. If these are not available extension set.
pump Up to a maximum dilute with G to 1mg/ml. Do not flush - replacing giving set.
of 24 mg/hour Monitor blood pressure and pulse during infusion.
depending on Can be diluted with N/S instead.
indication.
Intra-coronary  Groups Follow Cardiac Catheter Laboratory procedures.
in Cardiac 1,2 and 8
Catheter Labs.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 90
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Glycopyrronium IV bolus  Groups 1 Rapid IV bolus May be diluted with N/S or G if Flush with N/S or G.
(Glycopyrrolate) and 2 needed.
IM injection  Groups 1 Refer to the Marsden Manual for
and 2 guidance on IM injection.
SC injection to  Groups Refer to the Marsden Manual for Follow the PHNT Care of The Dying Pathways and the
reduce 1,2,3,4 and guidance on SC injection. PHNT Syringe Driver Policy.
secretions in 5 For combinations of 2 or 3 drugs in the same syringe,
palliative care refer to the Syringe Driver Drug Compatibility chart
(C) SC infusion  Groups Continuous over Dilute with W when 2 or more provided in the pump kit. Contact Pharmacy on ext.
via syringe 24 hours drugs are being mixed in the 39976 for further compatibility advice if necessary.
1,2,3,4 and Glycopyrronium is not licensed via the SC route (See
driver to reduce 5 same syringe.
secretions in W or N/S may be used where the page 124).
palliative care syringe only contains
glycopyrromium.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 91
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Glypressin See Terlipressin.
Gonadorelin IV bolus or SC  Group 1 Reconstitute 100microgram vial Refer to the Marsden Manual for guidance on SC
Injection (for with 1ml W. injection.
pituitary
function test)
Granisetron IV bolus  Groups Minimum 30 seconds Dilute each 1mg with 5ml with N/S. Flush with N/S.
1,2,3,4,5 and
(I) IV infusion 8 5 minutes Dilute each 3mg with 20-50ml N/S, Sodium content 1.17mmol/3mg vial,
(Adults). H, G or G/S. 0.15mmol/1mg vial.
Infusion pump
is required.
Haloperidol IM injection  Groups Oral treatment should succeed IM administration
1,2,3,4 and 5 as soon as practicable. Oral bioavailability is
about 60% of that from the IM route so
adjustment of the dosage may be necessary.
IV bolus  Groups 1-2 minutes, longer if Do not dilute to give by IV route. Flush with N/S.
1,2,3,4 and 5 possible. Maximum Note that haloperidol injection is no longer
5mg/minute. licensed by the IV route in the UK. This is not due
to any new safety concerns about IV haloperidol.
The manufacturer has only taken this action to
standardise the license across all global markets.
SC injection for  Groups Refer to the Marsden Manual for Follow the PHNT Care of The Dying Pathways and
use in palliative 1,2,3,4 and 5 guidance on SC injection. the PHNT Syringe Driver Policy.
care For combinations of 2 or 3 drugs in the same
(C) SC infusion  Groups Continuous over 24 Dilute with W when 2 or more drugs syringe, refer to the Syringe Driver Drug
via syringe 1,2,3,4 and 5 hours are being mixed in the same Compatibility chart provided in the pump kit.
driver in syringe. Contact Pharmacy on ext. 39976 for further
palliative care W or N/S may be used where the compatibility advice if necessary.
syringe only contains haloperidol. Haloperidol is not licensed by the SC route (See
page 4).

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 92
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Heparin IV bolus  Groups 3 – 5 minutes 5,000 units = 5ml of 1,000 unit/ml
loading dose 1,2,3,4 and 5 solution with no further dilution.
followed by (C) (Or 10,000 units = 10ml of 1,000
below. unit/ml solution with no further
dilution for severe pulmonary
embolism – see prescription).
(C) IV infusion  Groups Initial infusion rate 15 Take a 20ml ampoule containing Use of a PVC-free or PE/PVC (PE-lined)
Immediately 1,2,3,4 and 5 units/kg/hour = 20,000 units of heparin. Draw up extension set will avoid adsorption of heparin to
following the 0.015ml/kg/hour of the 20ml into a 50ml syringe. the line. Prepare a fresh infusion every 24
loading dose. 1,000 unit/ml infusion. hours.
Infusion pump Do not dilute this any further
is required. Alter rate according to
APTTR (Check before
commencing heparin
therapy, then 4-6 hours
after commencing the
infusion, 4-6 hours after
every infusion rate
change, and at least
once daily thereafter.
SC injection  Groups Refer to the Marsden Manual for
1,2,3,4 and 5 guidance on SC injection.
Intraperitoneal  Groups 1 1,000 units per litre of dialysis fluid Follow the PHNT Renal Services Directorate
and 2 Procedures
Flushing or  Groups1, Heparin may only be used for locking or flushing IV lines, cannulae or devices in accordance with
locking IV 2, 4 and 8 PHNT policy – see Appendix 3, page 208
access device
Hizentra® See Immunoglobulin Human Normal
Humalog® See Insulin Section
Humalog Mix®
Humulin®

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 93
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Hyaluronidase With S/C infusion of fluid  Groups Reconstitute 1,500iu of 1,500iu hyaluronidase is sufficient for the
(Hypodermoclysis) 1,2,3,4 and 5 hyaluronidase with 1ml of N/S administration of 500-1000ml of most fluids.
Either give 1,500iu by S/C or W.
injection into the site before Compatible fluids include: N/S, G,
the infusion is set up, or G/S(4%/0.18%), G/S(2.5%/0.45%).
iniect 1,500iu into the tubing
of the infusion set about
2cm back from the needle
at the start of the infusion.
With S/C and I/M  Groups 1,500iu to be dissolved directly Compatible when mixed with: morphine,
injections 1,2,3,4 and 5 in the solution to be injected. diamorphine, hydrmorphone, chlorpromazine,
metoclopramide, dexamethasone and very low
concentrations of adrenaline.

Incompatible with: heparin, moderate to high

concentrations of adrenaline, furosemide,
phenytoin and benzodiazepines.
With local anaesthetics  Group 1 1,500iu mixed with the quantity
(Other of local anaesthetic solution to
Groups be used.
only in In ophthalmology 15iu
accordance hyaluronidase per ml is the
with specific recommended concentration.
PGDs)
Extravastion where  Groups Reconstitute 1,500 iu of Follow the PHNT protocol for managing
dispersal rather than 1,2,3,4 and 5 hyaluronidase with 1ml of N/S extravasation – See Section 2.8.6
localisation is indicated. or W.
Administer by S/C infiltration
Haematoma  Groups Reconstitute 1,500 iu of
By S/C infiltration 1,2,3,4 and 5 hyaluronidase with 1ml of N/S
or W.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 94
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE SUITABLE DILUENT
Hydralazine Slow IV  Groups Over at least 5 minutes to avoid over-rapid Reconstitute with 1ml W then dilute Flush with N/S.
bolus 1,2,3,4 and 5 reduction in blood pressure. with 10ml with N/S. If necessary, a repeat
injection can be given after
an interval of 20-30
minutes.
Sodium content nil.
(C) IV  Groups Adults: Reconstitute as above then dilute Monitor heart rate and
infusion via 1,2,3,4 and 5 Initial rate of 200-300micrograms/minute 20mg with 500ml of N/S to give 40 blood pressure.
an infusion micrograms/ml. Incompatible with glucose
pump Usual maintenance rate of solutions.
50-150micrograms/minute However, for fluid restricted patients
60mg hydralazine may be diluted to
Adjust rate according to patient's blood 60ml with N/S to make a
pressure response and tolerance. 1000microgram/ml solution, and
infused via a central IV line. (This
dilution is unlicensed).

Pump rate (ml/hour) =Prescribed rate(micrograms/minute) x 60(minutes in an hour)

Concentration of the infusion(micrograms/ml)

Hydrocortisone IV bolus  Groups Inject doses of 100mg – 500mg over Reconstitute each 100mg with not Flush with N/S or G.
sodium (Usual 1,2,3,4,5 and 1 - 10 minutes. Inject 50mg in 1ml dose more than 2ml W and shake before Sodium content
succinate method) 8 over at least 30 seconds. Inject 25mg in drawing up. 0.5mmol/100mg.
0.5ml over at least 15 seconds
(C) or (I) IV  Groups Reconstitute as above then dilute to
infusion via 1,2,3,4 and 5 100-1000ml with N/S or G (maximum
an infusion concentration of 1mg/1ml).
pump
IM injection  Groups Reconstitute as for IV bolus. Refer to The preferred method for
1,2,3,4 and 5 the Marsden Manual for guidance on initial emergency use is IV
IM injection. injection.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 95
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE OVER SUITABLE DILUENT
Hyoscine Slow IV bolus  Groups 3-5 minutes Can be diluted with G or N/S. Flush with N/S or G.
butylbromide 1,2,3,4,5 and Give “slowly” as in rare cases it has caused a marked
(Buscopan®) 6 drop in blood pressure or even shock.
IM injection  Groups Refer to the Marsden Manual for
1,2,3,4,5 and guidance on IM injection.
6
(C) SC infusion  Groups Continuous Dilute with W when 2 or more drugs Follow the PHNT Care of The Dying Pathways and the
via syringe driver 1,2,3,4 and 5 over 24 hours are being mixed in the same syringe. PHNT Syringe Driver Policy.
in palliative care W or N/S may be used when the For combinations of 2 or 3 drugs in the same syringe,
syringe only contains this drug. refer to the Syringe Driver Drug Compatibility chart
provided in the pump kit. Contact Pharmacy on ext.
39976 for further compatibility advice if necessary.
Hyoscine butylbromide is not licensed via the SC route
(See page 124).
Hyoscine IM injection as  Groups Refer to the Marsden Manual for
hydrobromide premedication 1,2,3,4 and 5 guidance on IM injection.
SC injection as  Groups Refer to the Marsden Manual for
premedication 1,2,3,4 and 5 guidance on SC injection.
IV bolus as  Groups 3-5 minutes
premedication 1,2,3,4 and 5
(For acute use)
SC injection for  Groups Refer to the Marsden Manual for Follow the PHNT Care of The Dying Pathways and the
use in palliative 1,2,3,4 and 5 guidance on SC injection. PHNT Syringe Driver Policy.
care For combinations of 2 or 3 drugs in the same syringe,
(C) SC infusion  Groups Continuous Dilute with W when 2 or more drugs refer to the Syringe Driver Drug Compatibility chart
via syringe driver 1,2,3,4 and 5 over 24 hours are being mixed in the same syringe. provided in the pump kit. Contact Pharmacy on ext.
in palliative care W or N/S may be used when the 39976 for further compatibility advice if necessary.
syringe only contains this drug. Hyoscine hydrobromide is not licensed for use in
palliative care (See page 124).

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 96
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE SUITABLE DILUENT
Ibandronic acid For prevention of skeletal events in patients with breast cancer and bone metastases: Do not mix with calcium containing
solutions.
(Ibandronate) (I) IV infusion  Groups At least 15 minutes. Add the dose to 100ml N/S or G.
Infusion pump 1,2 and 8 If GFR<50ml/minute Extravasation can lead to tissue damage.
is required. then infuse dose over If GFR<50ml/minute then add the
1 hour. reduced dose to 500ml N/S or G.
Treatment of tumour-induced hypercalcaemia:
(I) IV infusion  Groups 2 hours Add the dose to 500ml N/S (or G).
Infusion pump 1,2 and 8 Patient should be adequately rehydrated
is required. with N/S prior to treatment for tumour-
induced hypercalcaemia.
Treatment of post-menopausal osteoporosis:
IV bolus using  Groups 15-30 seconds The contents of the prefilled syringes may
the prefilled 1,2, and 8 be injected into an existing IV line through
syringes which N/S or G is running.
Ibuprofen (I) IV infusion  Groups 1 15 minutes Preferably do not dilute further. If A course of therapy is defined as three
(Pedea®) Infusion pump and 2 necessary, the injection volume may be intravenous injections of Pedea given at 24-
is required. adjusted with either N/S or G. hour intervals. The first injection should be
given after the first 6 hours of life.
1st injection:10 mg/kg, 2nd and 3rd injections:
5 mg/kg.
If anuria or manifest oliguria occurs after the
first or second dose, the next dose should
be withheld until urine output returns to
normal levels.
If the ductus arteriosus does not close 48
hours after the last injection or if it re-opens,
a second course of 3 doses may be given.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 97
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Iloprost (I) IV infusion  Groups 6 hour infusion Dilute 50 micrograms(0.5ml) to Monitor for side effects: nausea, vomiting, facial flushing, headache,
(Unlicensed via a syringe 1,2,3,4 and (once each 25ml with N/S or G. For patients abdominal cramps.
product – pump. 5 day) who require more than 50 Also closely monitor the blood pressure and pulse rate.
micrograms during the 6 hour Days 1, 2 and 3:
see page 7) Preferred
infusion dilute 100 Start the daily infusion at 1ml/hour for 30 minutes. Continue to
method.
micrograms(1ml) to 50ml with increase the rate by 1ml/hour every 30 minutes until the patient
N/S or G. experiences unacceptable side effects. Then reduce the rate by
1ml/hour – this is the optimal rate. For the majority of patients the
optimal rate will not exceed 5ml/hour. For patients who weigh less
than 75kg, the optimal rate seldom exceeds 4ml/hour.
Stop the infusion each day after 6 hours.
If significant hypotension, tachycardia, bradycardia or vomiting occurs,
stop the infusion until the situation returns to normal. Wait one hour
and then recommence the infusion at half the previous flow-rate.
Day 4 until the end of the treatment course:
Start the daily infusion at the optimal hourly rate established over days
1-3.
(I) IV infusion.  Groups 6 hour infusion Dilute 50 micrograms(0.5ml) to Monitor for side effects: nausea, vomiting, facial flushing, headache,
Infusion via 1,2,3,4 and (once each 250ml with N/S or G. For abdominal cramps.
pump 5 day) patients who require more than Also closely monitor the blood pressure and pulse rate.
50 micrograms during the 6 Days 1, 2 and 3:
hour infusion dilute 100 Start the daily infusion at 10ml/hour for 30 minutes. Continue to
micrograms(1ml) to 500ml with increase the rate by 10ml/hour every 30 minutes until the patient
N/S or G. experiences unacceptable side effects. Then reduce the rate by
10ml/hour – this is the optimal rate. For the majority of patients the
optimal rate will not exceed 50ml/hour. For patients who weigh less
than 75kg, the optimal rate seldom exceeds 40ml/hour.
Stop the infusion each day after 6 hours.
If significant hypotension, tachycardia, bradycardia or vomiting occurs,
stop the infusion until the situation returns to normal. Wait one hour
and then recommence the infusion at half the previous flow-rate.
Day 4 until the end of the treatment course:
Start the daily infusion at the optimal hourly rate established over days
1-3.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 98
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Immunoglobulin (I) IV infusion.  Groups Initially 0.6 – 1.2ml/kg/hour Provided ready diluted. If side effects occur reduce rate or interrupt
human normal Infusion 1,2,3,4 and 5 for 30 minutes. If well infusion until symptoms subside then
(FlebogammaDIF) pump is tolerated, the rate may be restart at lower tolerated infusion rate.
50mg/ml = 5% required. gradually increased to a Have adrenaline available in case of
maximum of 6ml/kg/hour anaphylactoid reactions.
Supplied by Pharmacy Monitor vital signs and observe patient
during infusion and for 20 minutes
afterwards (for 1 hour after the first
infusion, or after the first infusion after a
long interval in treatment eg. Several
weeks).
Do not infuse with other drugs or fluids.
Immunoglobulin (I) IV infusion.  Groups Initially 0.6ml/kg/hour for Provided ready diluted. If side effects occur reduce rate or interrupt
human normal Infusion 1,2,3,4 and 5 30 minutes. If tolerated, infusion until symptoms subside then
(FlebogammaDIF) pump is advance to 1.2ml/kg/hour restart at lower tolerated infusion rate.
100mg/ml = 10% required. for the second 30 minutes. Have adrenaline available in case of
Again, if tolerated, anaphylactoid reactions.
Supplied by Pharmacy advance to 2.4ml/kg/hour Monitor vital signs and observe patient
for the third 30 minutes. It during infusion and for 20 minutes
the patient tolerates the afterwards (for 1 hour after the first
infusion well, additional infusion, or after the first infusion after a
increments of long interval in treatment eg. Several
1.2ml/kg/hour may be weeks).
made at 30 minute Do not infuse with other drugs or fluids.
intervals up to a maximum
of 4.8ml/kg/hour.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 99
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Immunoglobulin Subcutaneous  Groups Initial infusion rate: Provided ready diluted Instruct the patient in the use of a syringe
Human Normal infusion via 1,2,3,4 and 5 10ml/hour per syringe driver, infusion techniques, the keeping of
(Gammanorm) syringe driver for Also driver. The infusion a treatment diary and measures to be
16.5%=165mg/ml home treatment. administered rate may be gradually taken in case of severe adverse events.
by patient or increased by 1ml/hour When large doses are given, it is
Supplied by Pharmacy If Gammanorm is patient’s per syringe driver advisable to administer them in divided
accidentally guardian. every three to four doses at different sites.
administered into a weeks. The maximum Monitor vital signs and observe patient
blood vessel, the dose administered has during infusion and for 20 minutes
patient could been 40 ml/hour using afterwards.
develop shock. two syringe drivers Sodium content: 100mg/40ml
simultaneously.
IM Injection-Only  Groups Provided ready diluted
in exceptional 1,2,3,4 and 5
cases where
subcutaneous
administration is
not possible

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 100
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Immunoglobulin (I) IV infusion.  Groups Infuse at an initial rate Provided ready diluted. If side effects occur reduce rate or interrupt
human normal Infusion pump is 1,2,3,4 and 5 of 0.6 - 1.2 ml/kg/hour infusion until symptoms subside then
(Gammaplex) required. for 15 minutes. If well restart at lower tolerated infusion rate.
50mg/ml = 5% tolerated, the rate of Have adrenaline available in case of
administration may be anaphylactoid reactions.
Supplied by Pharmacy increased to Monitor vital signs and observe patient
2.4ml/kg/hour for 15 during infusion and for 20 minutes
▼ This product is minutes, then to afterwards (for 1 hour after the first
being intensively 3.6ml/kg/hour for 15 infusion, or after the first infusion after a
monitored by the CHM minutes, followed by a long interval in treatment eg. Several
and MHRA. Please maximum of weeks).
report all suspected 4.8ml/kg/hour for the Do not infuse with other drugs or fluids.
reactions (including remainder of the
non-serious ones) infusion.
using a Yellow Card
from the BNF

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 101
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER
INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Immunoglobulin Subcutaneous  Groups The recommended Provided ready diluted Instruct the patient or carer in the use of a
human normal infusion via syringe 1,2,3,4 and 5 initial infusion rate syringe driver, infusion techniques, the
(Hizentra) driver for home Also depends on individual keeping of a treatment diary and
200mg/ml = 20% treatment. Suitable administered needs of the patient measures to be taken in case of severe
sites of by patient or and should not exceed adverse events.
Supplied by Pharmacy administration patient’s 15 ml/hour/site. If well-
include the carer. tolerated, the infusion If side effects occur reduce rate or interrupt
▼ This product is abdomen, thigh, rate can then infusion until symptoms subside then
being intensively upper arm and gradually be increased restart at lower tolerated infusion rate.
monitored by the CHM lateral hip. to 25 ml/hour/site. Have adrenaline available in case of
and MHRA. Please anaphylactoid reactions.
report all suspected If Hizentra is Up to 4 infusion sites Monitor vital signs and observe patient
reactions (including accidentally can be used during infusion and for 20 minutes
non-serious ones) administered into a simultaneously, afterwards (for 1 hour after the first
using a Yellow Card blood vessel, provided that the infusion, or after the first infusion after a
from the BNF patients could maximum infusion rate long interval in treatment eg. several
develop shock. for all sites combined weeks).
does not exceed 50 Do not infuse with other drugs or fluids.
ml/hour. Injection sites
should be at least 5cm Hizentra® is essentially sodium-free.
apart.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 102
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Immunoglobulin (I) IV infusion via  Groups Initially 0.5ml/kg/hour Provided ready diluted. If side effects occur reduce rate or interrupt
human normal pump. 1,2,3,4 and 5 for 30 minutes. If well infusion until symptoms subside then
(Kiovig) tolerated, the rate may restart at lower tolerated infusion rate.
10%=100mg/ml be gradually increased Have adrenaline available in case of
to a maximum of anaphylactoid reactions.
Supplied by Pharmacy 6ml/kg/hour Monitor vital signs and observe patient
during infusion and for 20 minutes
afterwards (for 1 hour after the first
infusion, or after the first infusion after a
long interval in treatment eg. several
weeks).
Do not infuse with other drugs or fluids.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 103
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Immunoglobulin (I) IV  Groups Initially 1ml/kg/hour for Provided ready diluted. If side effects occur reduce rate or interrupt
human normal infusion via 1,2,3,4 and 5 30 minutes, If well infusion until symptoms subside then restart at
(Octagam) pump. tolerated, the rate of lower tolerated infusion rate.
5%=50mg/ml administration may Have adrenaline available in case of
gradually be increased anaphylactoid reactions.
Supplied by Pharmacy to a maximum of 5 Monitor vital signs and observe patient during
ml/kg/hour. infusion and for 20 minutes afterwards (for 1 hour
after the first infusion, or after the first infusion
after a long interval in treatment eg. several
weeks).
Do not infuse with other drugs or fluids.
Immunoglobulin (I) IV  Groups Initially 0.6ml/kg/hour Provided ready diluted. If side effects occur reduce rate or interrupt
human normal infusion via 1,2,3,4 and 5 for 30 minutes. If well infusion until symptoms subside then restart at
(Octagam) pump. tolerated, the rate of lower tolerated infusion rate.
10%=100mg/ml administration may Have adrenaline available in case of
gradually be increased anaphylactoid reactions.
Supplied by Pharmacy to a maximum of Monitor vital signs and observe patient during
7.2ml/kg/hour. infusion and for 20 minutes afterwards (for 1 hour
after the first infusion, or after the first infusion
after a long interval in treatment eg. several
weeks).
Do not infuse with other drugs or fluids.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 104
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Immunoglobulin (I) IV  Groups Initially 0.3ml/kg/hour. Provided ready diluted. Have adrenaline available in case of
human normal infusion. 1,2,3,4 and 5 If well tolerated, the anaphylactoid reactions.
(Privigen) Infusion rate may be gradually However, if dilution prior to Monitor vital signs and observe patient during
10%=100mg/ml pump is increased to infusion is required Privagen® infusion and for 20 minutes afterwards (for 1 hour
required. 4.8ml/kg/hour. 100mg/ml may be diluted with after the first infusion, or after the first infusion
Supplied by Pharmacy In patients with an equal volume of G to make a after a long interval in treatment eg. Several
Primary 50mg/ml solution. weeks).
Immunodeficiency who In all patients, IV immunoglobulin administration
have tolerated requires:
4.8ml/kg/hour well, the  adequate hydration prior to the initiation of the
rate may be further infusion of IV immunoglobulin.
increased gradually to  monitoring of urine output
7.2ml/kg/hour  monitoring of serum creatinine levels
 avoidance of concomitant use of loop
diuretics.
In case of adverse reaction, either the rate of
administration must be reduced or the infusion
stopped.

Privigen® is essentially sodium-free.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 105
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT

Immunoglobulin Subcutaneous  Groups The recommended Provided ready diluted Instruct the patient in the use of a syringe driver,
Human Normal infusion via 1,2,3,4 and 5 initial rate is 10 infusion techniques, the keeping of a treatment
(Subcuvia) syringe driver for Also ml/hour per syringe diary and measures to be taken in case of severe
16%=160mg/ml home treatment, administered driver. adverse events.
preferentially by patient or The infusion speed The infusion site should be changed every
Supplied by administered into patient’s can be increased by 1 5-15ml.
Pharmacy the abdominal guardian. ml/hour per syringe Monitor vital signs and observe patient during
wall, thigh and/or driver every infusion and for 20 minutes afterwards (for 1 hour
buttocks. subsequent infusion. after the first infusion, or after the first infusion
The recommended after a long interval in treatment eg. several
If Subcuvia is maximum speed is 20 weeks).
accidentally ml/hour.
administered into a More than one pump
blood vessel, can be used
patients could simultaneously.
develop
anaphylactic shock
or thromboembolic
events.

IM Injection-  Groups Provided ready diluted In exceptional cases where IM administration is

Only in exceptional 1,2,3,4 and 5 necessary, cumulative monthly dose should be
cases where divided up into weekly or bi-weekly applications,
subcutaneous in order to keep the injected volume low. To
administration is further minimize the discomfort for the patient,
not possible. each single dosage may need to be injected at
different anatomic sites.
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 106
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
Immunoglobulin Subcutaneous  Groups Initially the infusion Provided ready diluted Instruct the patient in the use of a syringe driver,
Human Normal infusion via 1,2,3,4 and 5 rate should be no more infusion techniques, the keeping of a treatment
(Subgam) syringe driver for Also than 10ml/hour for diary and measures to be taken in case of severe
16%=160mg/ml home treatment. administered each syringe driver. If adverse events.
by patient or well tolerated it can be Monitor vital signs and observe patient during
Supplied by If Subgam is patient’s increased at weekly infusion and for 20 minutes afterwards (for 1 hour
Pharmacy accidentally guardian. intervals by 2ml/hour after the first infusion).
administered per syringe driver to a
into a blood maximum of
vessel, patients 20ml/hour. The
could develop administration can be
shock. performed at two or
more different sites
simultaneously to
reduce infusion time.
IM Injection-  Groups Provided ready diluted In exceptional cases where IM administration is
Only in 1,2,3,4 and 5 necessary, cumulative monthly dose should be
exceptional divided up into weekly or bi-weekly applications, in
cases where order to keep the injected volume low. To further
subcutaneous minimize the discomfort for the patient, each single
administration is dosage may need to be injected at different
not possible. anatomic sites.
Immunoglobulin (I) IV infusion via  Groups Initially: Provided ready diluted. If side effects occur, reduce rate or interrupt
Human Normal pump. 1,2,3,4 and 5 0.6 – 1.2ml/kg/hour for infusion. Have adrenaline available in case of
(Vigam) 30 minutes. anaphylactoid reactions.
5%=50mg/ml Infuse via an IV Increase gradually up Monitor vital signs and observe patient during
infusion set fitted to 2.4ml/kg/hour infusion and for 20 minutes afterwards (for 1 hour
Supplied by with a 15 micron (Maximum of after the first infusion, or after the first infusion after
Pharmacy filter 180ml/hour). a long interval in treatment eg. several weeks).
Careful consideration needed before giving to
diabetic patients (contains sucrose). Flush with G or
N/S.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 107
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Indometacin (I) IV infusion  20 – 30 minutes Either reconstitute the 1mg of Do not reconstitute with glucose solutions.
(Indocid PDA®) 1 and 2 powder with 1ml of N/S or W to If anuria or marked oliguria (urinary output
produce a concentration of <0.6ml/kg/hour) is evident at the time of the
Single use vials 100micrograms in 0.1ml, or scheduled second or third dose, further doses must
reconstitute the 1mg of powder not be given until laboratory studies indicate that
with 2ml N/S or W to produce a renal function has returned to normal.
concentration of 50micrograms in If the ductus reopens, a second course of treatment
0.1ml. Do not further dilute. may be given.
Infliximab (I) IV infusion.  Groups Infuse over 2 hours. Reconstitute each 100mg vial Observe patients for at least 1-2 hours after the
Infusion pump is 1,2,3,4 and with 10ml W to make a 10mg/ml infusion for anaphylactic reactions.
(Both Remicade® required. 5 solution. Direct the stream of W Equipment and medication to treat anaphylaxis must
and Inflectra® ) In carefully selected to the glass wall of the vial and be immediately available.
patients who have gently swirl the solution. Avoid Use an infusion set with an in-line sterile non-
tolerated three 2- vigorous agitation and do not pyrogenic, low protein-binding filter (pore size 1.2
hour infusions, shake as foaming is common. micrometre or less). PIU (Planned Investigation Unit)
subsequent infusions Allow the reconstituted solution to use these filters routinely to administer infliximab and
may be given over stand for 5 minutes. First remove will know where to obtain them.
not less than 1 hour. from a 250ml bag of N/S a The displacement value is insignificant.
volume equal to the volume of
infliximab being added then add
in the required dose of infliximab.
Mix gently.

Pre-made bags from Bath ASU

Doses greater than 470mg
supplied pre-made by Bath ASU
will be in more than 250ml total
volume, and doses greater than
500mg will be diluted to 500ml.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 108
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
 Insulin Section
Important notes for all insulins
 When prescribing and administering insulin refer to the patient’s Insulin Passport to confirm the brand of insulin and type of injection device.
 Only use Insulin syringes to draw up insulin. Do not use intravenous syringes to draw up or measure insulin (Even for IV sliding scale infusion).
 Subcutaneous administration should be in the upper arms, thighs, buttocks, or abdomen.
 When administered subcutaneously, care should be taken when injecting to ensure that a blood vessel has not been entered (inject into a lifted skin-fold).
Keep the needle under the skin for at least 6 seconds to ensure that the entire dose is injected. After injection, the site of injection should not be massaged.
 Patients must be educated to use the proper injection techniques.
 Before first use store all insulin products in the refrigerator (2 – 80C). Do not freeze.
 If the package insert is missing, refer to the SPC on [Link] for instructions on how to use the various devices.
 Patients’ own insulin pens containing insulin do not need to be kept in a fridge when they are in current use.
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Insulin neutral (C) IV infusion  Groups In accordance with Inspect product before use: Actrapid Follow the appropriate PHNT protocols/pre-printed
(e.g. Human Infusion pump 1,2,3,4,5 and the sliding-scale and Humulin S injection should be prescriptions for the control of blood glucose:
Actrapid, is required. 8 instructions. clear and colourless.  Peri-operative/Fasting/Unstable Adults
Humulin S)  Adult patients with an acute MI
Multidose Vial Dilute with N/S to 1unit/1ml.  Hyperglycaemic Emergencies in diabetic
adults
See the guidelines for setting up  Critical Care Unit insulin protocol
and maintaining I.V Sliding Scale Loss of drug into bag, plastic syringe or giving set
Insulin Infusion in Section 8. may occur. If an infusion bag is used ensure
insulin is not injected into dead space of injection
port.
Compatible with IV glucose infusion/injection and
N/S or G containing potassium chloride for
infusion.
SC Injection  Groups Inspect product before use: Actrapid Refer to the Marsden Manual for guidance on SC
1,2,3,4,5 and and Humulin S injection should be injection.
8 clear and colourless. Actrapid: Discard vial 6 weeks after first use
Humulin S: Discard vial 4 weeks after first use
Record the date of first use on the vial.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 109
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD ADMINISTRATION COMMENTS

Humalog® (Insulin SC Injection Refer to the Marsden Manual for Give Humalog very close to mealtimes.
Lispro) by  Groups guidance on SC injection. Give Humalog Mix (25 or 50) shortly before meals. When necessary, Humalog Mix®
Humalog Mix 25 1,2,3,4,5 and 8 (25 or 50) can be given soon after meals.
Humalog Mix 50 Humalog should not be mixed with insulin produced by other manufacturers or with
animal insulin preparations.
Expiry after cartridge insertion, or after first use (vial and prefilled pen): 28 days.
After cartridge insertion or first use (pre-filled pen) store below 30°C. Do not
refrigerate. The pen with the inserted cartridge and the pre-filled pen should not be
stored with the needle attached.

Humulin I® SC Injection Refer to the Marsden Manual for Vials containing Humulin I or the Humulin M3 formulations should be rotated several
(Isophane) by  Groups guidance on SC injection. times in the palms of the hands before use to completely resuspend the insulin, until
Humulin M3® 1,2,3,4,5 and 8 it appears uniformly cloudy or milky. Cartridges and pre-filled pens containing
Humulin I and Humulin M3 formulations should be rolled in the palms of the hands
ten times and inverted 180° ten times immediately before use to resuspend the
insulin until it appears uniformly cloudy or milky. If not, repeat the above procedure
until contents are mixed. Cartridges contain a small glass bead to assist mixing. Do
not shake vigorously
Expiry after insertion of the cartridge in the pen or first use of a vial: 28 days.
Do not use beyond this period. When in use, the cartridges and vials should be
stored below 30°C.
Insuman Basal® SC Injection Refer to the Marsden Manual for The cartridge or pen in-use or carried as a spare may be stored for a maximum of 4
Insuman Comb 25® by  Groups guidance on SC injection. weeks not above 25°C and away from direct heat or direct light.
Insuman Rapid® 1,2,3,4,5 and 8 The pen containing a cartridge in-use or the solostar pen in-use must not be stored
in the refrigerator.
The pen cap must be put back on the pen after each injection in order to protect from
light. Before use, keep a new cartridge (in the pen) or the new solostar pen at room
temperature for 1 to 2 hours.

Apidra® SC Injection Refer to the Marsden Manual for As for Insuman preparations above.
(Insuline glulisine) by  Groups guidance on SC injection.
1,2,3,4,5 & 8

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 110
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD ADMINISTRATION COMMENTS

Lantus® SC Injection Inspect the cartridge, pen or vial If the Lantus has been in the refrigerator, it should ideally be taken out 1 to 2 hours
(Insulin Glargine) by  Groups before use. It must only be used if the before injection to allow it to warm up as cold insulin is more painful to inject.
1,2,3,4,5 and solution is clear, colourless, with no After first use, Lantus may be kept for a maximum of 4 weeks at a temperature
8 solid particles visible, and if it is of below 25°C. Record the date of first use on the vial.
water-like consistency
Levemir® SC Injection Inspect the Levemir injection: it must Shelf life after first opening: A maximum of 6 weeks when stored below 30°C.
(Insulin Detemir) by  Groups not be used if it does not appear clear Each Penfill cartridge, Flexpen or Innolet must only be used for a single patient.
1,2,3,4, 5 and and colourless.
8 Refer to the Marsden Manual for
guidance on SC injection.

NovoMix 30® SC Injection Refer to the Marsden Manual for Allow the NovoMix30 to warm up to room temperature (Makes mixing easier).
by  Groups guidance on SC injection. Alternate rolling the pen 10 times horizontally in your palm with tilting to get the glass
1,2,3,4,5 and ball to roll from one end to the other several times until the suspension of insulin
8 appears uniformly white and cloudy.
When stored at room temperature (less than 300C) the expiry date of a vial, Penfill or
Flexpen is 4 weeks from the date of first use.
Each Penfill cartridge or Flexpen must only be used for a single patient
Novorapid® Inspect product before use: Novorapid NovoRapid should generally be given immediately before a meal. When necessary
(Insulin Aspart) injection should be clear and NovoRapid can be given soon after a meal.
colourless. When stored at room temperature (less than 300C) the expiry date of a vial, Penfill or
Refer to the Marsden Manual for Flexpen is 4 weeks form the date of first use.
guidance on SC injection. Each Penfill cartridge or Flexpen must only be used for a single patient.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 111
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND SUITABLE COMMENTS
GIVE DILUENT
Intralipid® 20% IV bolus and  Group 1 Follow the Association of Anaesthetists of GB and Ireland guidelines. The  Continue CPR throughout
IV infusion Intralipid is located on the crash trolleys in Theatre, along with a laminated treatment with Intralipid®.
For the treatment of copy of the guideline.  Recovery from local anaesthetic
cardiac arrest due induced cardiac arrest may take
to toxic intravenous 1. Give IV bolus of 1.5ml/kg over 1 minute and start IV infusion at more than 1 hour.
concentrations of 15ml/kg/hour.  Propofol is not a suitable
local anaesthetic 2. After 5 minutes give a maximum of two repeat IV boluses of 1.5ml/kg if: substitute for Intralipid®.
 adequate circulation has not been restored or  Lidocaine should not be used as
 an adequate circulation deteriorates. an anti-arrythmic therapy.
Leave 5 minutes between boluses.
A maximum of three boluses can be given (including the initial bolus).

3. Continue the infusion at the same rate, but double the rate to
30ml/kg/hour at any time after 5 minutes if:
 cardiovascular stability has not been restored or
 an adequate circulation deteriorates.
4. Continue the infusion until stable and adequate circulation restored or
the maximum cumulative dose of Intralipid has been given.

Do not exceed a maximum cumulative dose of Intralipid of 12ml/kg

Ipilimumab (I) IV  Groups 1 Infuse over 90 A closed-system device must be used to Flush with N/S
▼ This product is infusion. and 2 minutes via a 0.2-1.2 prepare ipilimumab. Do not co-administer other medicinal
being intensively Infusion micron in-line filter products through the same infusion
monitored by the pump is The concentrate in the vials is a clear to slightly line.
CHM and MHRA. required. opalescent, colourless to pale yellow liquid that Very common side effects include
Please report all may contain light (few) particulates. Do not use if rash, pruritis, injection site reactions,
suspected reactions unusual amount of particles and signs of pyrexia, nausea and vomiting.
(including non- discoloration are present.
serious ones) using Dilute the prescribed dose with N/S to a final
a Yellow Card from concentration between 1mg/ml and 4mg/ml (First
the BNF remove a volume of N/S from the bag equal to the
volume of drug solution being added).

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 112
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Iron dextran Preferred method:  Groups Infuse the first 25mg over 15 Dilute 100-200mg iron (2 – 4ml) Monitor patient closely in case of
(Cosmofer®) 1,2,3,4 and minutes before each subsequent in 100ml of N/S or G. anaphylaxis.
(I) IV infusion.
infusion. If no adverse effects Resuscitation equipment should be
Infusion pump is 5
Each ml during this time infuse the available.
required.
contains remaining solution at maximum Stop the infusion or injection immediately if
50mg Iron(III) rate of 100ml/30 minutes. any signs of hypersensitivity or intolerance
Hospital Use  Groups Infuse the first 25mg of the For Total Dose Infusion add the occur.
▼ This product Only:Total Dose 1,2,3,4 and infusion over 15 minutes. If no required dose (determined by Observe the patient closely for signs of
is being IV Infusion. 5 adverse effects during this time the dosage table or calculation hypersensitivity during Cosmofer
intensively Infusion pump is infuse the remaining solution over in the product leaflet) to 500ml administration and for at least 30 minutes
monitored by required. 4 – 6 hours. The rate of infusion N/S or G. after IV administration (Especially after Total
the CHM and may be increased progressively Dose Infusion to monitor for delayed
MHRA. Please to 135-180ml/hour. hypersensitivity-like reactions).
report all IV bolus  Groups Administer the first 25mg over 1-2 Dose of 100-200mg iron (2-4ml) Do not infuse with any other drugs or fluids.
suspected (or injection into 1,2,3,4 and minutes before each subsequent preferably diluted in 10-20ml Flush with N/S.
reactions the venous limb 5 slow bolus. Wait 15 minutes and N/S or G.
(including non- of the dialyser monitor for adverse effects. If no Cosmofer® may alternatively be given by
serious ones) during adverse effects give remainder of deep IM injection – refer to the SPC for
using a Yellow haemodialysis) each dose at 10mg/minute further instructions ([Link])
Card from the (0.2ml/minute) Do not give Cosmofer® to patients with a
BNF history of asthma, allergic eczema or other
atopic allergy by the IV route (For these
patients IM is the preferred route for
Cosmofer®).
For use on the Planned Investigation
Unit, follow the PIU Cosmofer® Pathway.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 113
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Iron sucrose IV bolus  Groups 1ml/minute (5ml Undiluted Do not give Venofer by IM injection.
(Venofer®) (or injection into 1,2,3,4,5 ampoule over 5 The patient should be monitored closely for
the venous limb and 8 minutes). signs of hypersensitivity during administration
Each ml of the dialyser and for 30 minutes after every dose of Venofer
contains 20mg during Maximum 10ml (200mg) given. If hypersensitivity reactions or signs of
Iron haemodialysis ) per injection. intolerance occur during administration, the
treatment must be stopped immediately
(I) IV infusion.  Groups 100mg over at least 15 Dilute each 5ml ampoule to a Resuscitation equipment should be available.
Infusion pump 1,2,3,4,5 minutes maximum of 100ml with N/S. Do not infuse with any other drugs or fluids.
is required. and 8 Extravasation may cause tissue damage.
200mg over at least 30 Two 5ml ampoules should not be
minutes diluted to more than 200ml with
N/S
Isoniazid IV bolus  Groups Give slowly. Suggestion: Recommended to administer
1,2,3,4 and 3-5 minutes undiluted but can be further diluted
5 with W if needed.
Isophane Isophane insulin should be prescribed by brand. See Insulin Section page
insulin

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 114
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Isoprenaline (C) or (I) IV  Groups For severe Via a central IV line (or large ECG monitoring required.
infusion. 1,2,3,4 and 5 bradycardia: Dose peripheral vein if central access is
Infusion pump range 0.5 – 10 not available) dilute 2mg or
is required. micrograms/minute 2.25mg isoprenaline sulphate
Preferably Adjust rate according (depending on the brand of
administer via a to response ampoule available) in 500ml G.
central venous In fluid restricted patients 2mg or
catheter to 2.25mg isoprenaline sulphate
avoid potential (depending on the brand of
venous irritation ampoule available) may be diluted
as the to 50ml with G and given via a
preparation has central line.
a low pH

Pump rate (ml/hour) =Prescribed rate(micrograms/minute) x 60(minutes in an hour)

Concentration of the infusion(micrograms/ml)

Infusion using 2mg isoprenaline sulphate in 500ml G: 0.5 – 10micrograms/minute = 7.5 – 150ml/hour
Infusion using 2.25mg isoprenaline sulphate in 500ml G: 0.5 – 10micrograms/minute = 6.7 – 133ml/hour
If patient is fluid restricted then via a central line:
Infusion using 2mg isoprenaline sulphate in 50ml G: 0.5 – 10micrograms/minute = 0.75 – 15ml/hour
Infusion using 2.25mg isoprenaline sulphate in 50ml G: 0.5 – 10micrograms/minute = 0.67 – 13.3ml/hour
IV bolus  Group 1 Using the 100microgram in 2ml
ampoule, dilute 2ml
(100micrograms) to 5ml with N/S
or G.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 115
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Isosorbide (C) or (I) IV  Groups 1 Usually 2-12mg/hour. Up Provided ready-diluted 25mg of Use a plastic syringe with a PVC-free or PE-lined
dinitrate infusion via and 2 to 20mg/hour if needed. isosorbide dinitrate in 50ml. extension set. The following extension sets are suitable
(Isoket®) pump This equates to 4 -24 and are available to order from NHS Supplies:
ml/hour (Max 40ml/hour) of
0.05% (25mg in 50ml) Codan PVC-free extension set 71.4001, order code
solution. FKA064.
Alaris G30302M line, order code FKA058
Vygon PE-lined extension set 6222.151, order code
FSB147.
BMS PE-lined extension set 30-7200, order code
FSB646.
Other suitable sets include the Vygon 71100.15 PE
extension set and the Vygon 0832.211R PE-lined
extension set.
Flush with N/S or G. Monitor blood pressure and pulse
during infusion.
Intra-  Group 1 1mg bolus given prior to Manufacturer recommends Further doses may be given, not exceeding 5mg within a
coronary balloon inflation dilution to 0.5mg/ml with N/S or G. 30 minute period.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 116
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Itraconazole (I) IV  Groups Administer 60 ml (200mg) Following the package insert To avoid incompatibility problems, after infusing the
infusion. 1,2,3,4 and over 1 hour instructions remove the outer itraconazole flush the extension line with 15-20ml N/S at
Infusion 5 Stop the infusion when wrap from the 50ml bag of N/S the two-way stop cock, just before the 0.2 micron in-line
pump is 60ml (200mg) has been provided. Inject 250mg filter as directed in the package insert instructions.
required. administered itraconazole (25ml) into the bag in Do not infuse any other drug solutions together with
(About 15ml will remain in a slow single action (up to 60 itraconazole down the same line/lumen.
the bag and infusion set to seconds) and agitate gently.(The Protect prepared infusion from direct sunlight.
be discarded) bag now contains 250mg in Do not administer if the solution is a milky white colour that
75ml). Close the infusion set does not disappear after gentle mixing.
clamp then push the pin of an
infusion set into the flexible port of
the infusion bag. Then prime the
infusion set in the usual manner.
Connect the infusion set to the
two-way stop cock of the
extension line and open the
clamp to allow all the air to be
expelled from the infusion set and
extension line.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 117
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY GIVE ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
AND SUITABLE DILUENT
Ketamine Induction &  Group 1 Minimum 60 seconds 50mg/ml is the recommended Flush IV bolus with N/S or G.
maintenance of maximum concentration.
anaesthesia
IV bolus
Low dose as  Groups 1 and 2 3-5 minutes 50mg/ml is the recommended
premedication prior maximum concentration.
to invasive or
painful procedures
IV bolus
(C) IV infusion.  Group 1 Can be diluted to 1mg/1ml with G Resuscitation equipment should be
Infusion pump is Can be given by or N/S or infused as 10mg/ml or available.
required. Group 2 staff to a 50mg/ml (undiluted product). Monitor cardiac and respiratory functions.
ventilated patient in Ketamine is chemically incompatible with
level 3 critical care. barbiturates and diazepam because of
Induction &  Group 1 Refer to the Marsden Manual for precipitate formation. Therefore, these
maintenance of guidance on IM injection. should not be mixed in the same syringe
anaesthesia or infusion fluid.
IM Injection
Post-operative Only to be 1 – 2ml/hour via anti- Draw up 0.1ml/kg of ketamine Refer to the subcutaneous ketamine
(C) SC Infusion. prescribed by an siphon/reflux line. 50mg/ml injection. Dilute this to protocol (Copy on page 199).
Use a locked anaesthetist or the Titrate to response. 50ml with N/S. Add 1mg Dexamethasone is now added to reduce
infusion pump Acute Care Team. dexamethasone (0.3ml of tissue irritation. At this dosage (1mg in
designated for Group 2 staff can 3.3mg/ml injection) before making 50ml), blood glucose levels should not be
ketamine. administer. the infusion upto 50ml with N/S. adversely affected.
Ketorolac IV bolus  Groups 1,2,3,4 Over no less than 15 Not usually diluted further. Compatible with N/S, G and H. Do NOT
and 5 seconds mix in the same syringe as morphine or
pethidine. Flush with N/S.
IM Injection  Groups 1,2,3,4 Refer to the Marsden Manual for
and 5 guidance on IM injection.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 118
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND SUITABLE COMMENTS
GIVE OVER DILUENT
Kidney Kidney Chill to 4oC then
 Group 1 Do not further dilute. Not for Intravenous Infusion
perfusion perfusion via or Group 2 rapidly perfuse
solution kidney trained in kidney with 8 litres,
Follow the operating instructions for
(Soltran) transplant the use of followed by slower the LifePort system.
catheter the LifePort perfusion of 75-
system 100ml/minute
Kiovig® See Immunoglobulin Human Normal
Labetalol IV bolus  Groups 1 50mg bolus over at IV bolus can be repeated every 5
and 2 least 1 minute. minutes to a maximum dose of
Lower doses are 200mg.
used during ECG and blood pressure monitoring
anaesthesia. required.
(C) or (I) IV  Groups Usual maximum Dilute to 1mg/1ml with G or G/S. Suggested volume The patient should remain supine for
infusion. 1,2,3,4 and rate 120mg/hour 200ml. at least 3 hours after administration.
Infusion pump 5 Flush with G.
is required. For patients in critical care areas who are fluid Neat labetalol injection has a pH of 3-
restricted undiluted labetolol injection (5mg/ml) may 4.5 (5% glucose has a pH of 4.2).
be given by IV infusion via a central IV line -this
method is unlicensed (See page 4)
Lacosamide (I) IV infusion.  Groups All doses over 15 Can be given undiluted. Alternatively, dilute the dose IV and oral dosage (dose and
Infusion pump 1,2,3,4 and to 60 minutes with a suitable volume of N/S, G or H (eg. Dilute to frequency) are the same. No
is required. 5 50ml or 100ml). adjustment is needed when switching
between these routes.
Flush with N/S or G.
Do not infuse down the same IV line
as other medicinal products.
Lantus ® See Insulin Section page

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 119
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND SUITABLE COMMENTS
GIVE OVER DILUENT
Lenograstim (I) IV infusion.  Groups 30 minutes Using the 19G needle provided, reconstitute with Flush with N/S.
Infusion pump 1,2,3,4 and the 1.05ml W provided and agitate gently to ensure
is required. 5 complete dissolution (do not shake vigorously).
Dilute with N/S or G up to 50ml/vial for Granocyte-
13 or up to 100ml/vial for Granocyte-34.
SC Injection  Groups Reconstitute as above using the 19G needle. Keep Refer to the Marsden Manual for
1,2,3,4 and the19G needle and the syringe attached to the vial guidance on SC injection.
5 and withdraw the required volume of reconstituted
solution from the vial. Replace the needle used for
reconstitution and fit the syringe with the 26G
needle provided for subcutaneous injection.
Leucovorin See Folinic Acid
calcium
Levemir® See Insulin Section page
Levetiracetam (I) IV infusion.  Groups Give all doses Dilute all doses with 100ml N/S or G. IV and oral dosage (dose and frequency)
Infusion pump 1,2,3,4 and over 15 are the same. No adjustment is needed
is required. 5 minutes when switching between these routes.
Flush with N/S or G.
Sodium content: 1.5g dose contains
25mmol sodium.
The SPC states that there is no
experience with administration of IV
levetiracetam for longer than 4 days.
Levobupivacaine Epidural  Group 1 Administer in accordance with standard anaesthetic All syringes containing solution for
injection practice epidural administration should be
Local Infiltration labelled “For Epidural Use Only”
Intrathecal (NPSA/2007/21)
injection
Peripheral
nerve block
Peribulbar
block

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 120
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Levofloxacin (I) IV infusion.  Groups 250mg over at least 30 Provided ready diluted. Flush with N/S or G.
Infusion pump is 1,2,3,4 and minutes. 500mg over at Sodium content : 15.4mmol/100ml bottle.
required. 5 least 60 minutes Rarely, profound hypotension may occur
during infusion. If this happens halt the
infusion immediately.
Levofloxacin is well absorbed from the GI
tract so consider an early switch to the oral
route.
The bag should only be removed from the
outer covering at the time of infusion as
the shelf life reduces to 7 days once this
outer covering is removed.
Levomepromazine IV bolus  Groups 1 3-5 minutes Dilute with at least an equal Protect infusion from light. Discard injection
and 2 volume of N/S before if pink or yellow colouration occurs.
administration. Flush with N/S.
Postural hypotension can occur, particularly
in patients over 50; monitor blood pressure.
Sodium content: 0.037mmol/1ml
SC injection for  Groups Refer to the Marsden Manual Follow the PHNT Care of The Dying
use in palliative 1,2,3,4 and for guidance on SC injection. Pathways.
care 5
(C) SC infusion  Groups Continuous over 24 hours Dilute with W when 2 or more Follow the PHNT Care of The Dying
via syringe driver 1,2,3,4 and drugs are being mixed in the Pathways and the PHNT Syringe Driver
in palliative care 5 same syringe. Policy.
W or N/S may be used when the For combinations of 2 or 3 drugs in the
syringe only contains this drug. same syringe, refer to the Syringe Driver
Drug Compatibility chart provided in the
pump kit. Contact Pharmacy on ext. 39976
for further compatibility advice if
necessary.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 121
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Levosimendan IV infusion  Groups 1 Loading dose of 6* to12 Add the contents of one vial *The lower loading dose of 6 microgram/kg is
using infusion and 2 microgram/kg over 10 (12.5mg in 5ml) to 500ml G to recommended for patients already on IV
(Unlicensed pump via minutes followed by make a 25 microgram/ml dilution. vasodilators and/or inotropes.
product – see peripheral or infusion of Or add the contents of one vial Run a single infusion over 24 hours to produce
page 7) central IV line 0.1microgram/kg/minute (12.5mg in 5ml) to 250ml G to haemodynamic effects that last 7-10 days.
over 24 hours, adjusted if make a 50 microgram/ml Avoid using levosimendan if the eGFR<30ml/min,
N.B. The duty necessary. Concentration. or in patients with severe hepatic impairment.
consultant on
ITU may 25 microgram/ml dilution (One 12.5mg vial diluted to 500ml with 5% glucose)
decide not to Patient’s Loading dose is given as an infusion over 10 minutes with the Continuous infusion rate (ml/hour)
give the weight (kg) infusion rate (ml/hour) below
loading dose Loading dose of Loading dose of 0.05 microgram/kg/min 0.1 microgram/kg/min 0.2 microgram/kg/min
6 microgram/kg 12 microgram/kg
40 58 115 4.8 9.6 19.2
45 65 130 5.4 10.8 21.6
50 72 144 6 12 24
55 79 158 6.6 13.2 26.4
60 86 173 7.2 14.4 28.8
65 94 187 7.8 15.6 31.2
70 101 202 8.4 16.8 33.6
75 108 216 9 18 36
80 115 230 9.6 19.2 38.4
85 122 245 10.2 20.4 40.8
90 130 259 10.8 21.6 43.2
95 137 274 11.4 22.8 45.6
100 144 288 12 24 48
105 151 302 12.6 25.2 50.4
110 158 317 13.2 26.4 52.8
115 166 331 13.8 27.6 55.2
120 173 346 14.4 28.8 57.6
For 50 microgram/ml dilution see table on next page

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 122
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Levosimendan IV infusion  Groups 1 Loading dose of 6* to12 Add the contents of one vial *The lower loading dose of 6 microgram/kg is
using infusion and 2 microgram/kg over 10 (12.5mg in 5ml) to 500ml G to recommended for patients already on IV
(Unlicensed pump via minutes followed by make a 25 microgram/ml dilution. vasodilators and/or inotropes.
product – see peripheral or infusion of Or add the contents of one vial Run a single infusion over 24 hours to produce
page 7) central IV line 0.1microgram/kg/minute (12.5mg in 5ml) to 250ml G to haemodynamic effects that last 7-10 days.
over 24 hours, adjusted if make a 50 microgram/ml Avoid using levosimendan if the eGFR<30ml/min,
N.B. The duty necessary. Concentration. or in patients with severe hepatic impairment.
consultant on
ITU may 50 microgram/ml dilution (One 12.5mg vial diluted to 250ml with 5% glucose)
decide not to Patient’s Loading dose is given as an infusion over 10 minutes with the Continuous infusion rate (ml/hour)
give the weight (kg) infusion rate (ml/hour) below
loading dose Loading dose of Loading dose of 0.05 microgram/kg/min 0.1 microgram/kg/min 0.2 microgram/kg/min
6 microgram/kg 12 microgram/kg
40 28.8 57.6 2.4 4.8 9.6
45 32.4 64.8 2.7 5.4 10.8
50 36 72 3 6 12
55 39.6 79.2 3.3 6.6 13.2
60 43.2 86.4 3.6 7.2 14.4
65 46.8 93.6 3.9 7.8 15.6
70 50.4 100.8 4.2 8.4 16.8
75 54 108 4.5 9 18
80 57.6 115.2 4.8 9.6 19.2
85 61.2 122.4 5.1 10.2 20.4
90 64.8 129.6 5.4 10.8 21.6
95 68.4 136.8 5.7 11.4 22.8
100 72 144 6 12 24
105 75.6 151.2 6.3 12.6 25.2
110 79.2 158.4 6.6 13.2 26.4
115 82.8 165.6 6.9 13.8 27.6
120 86.4 172.8 7.2 14.4 28.8
For 25 microgram/ml dilution see table on previous page

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 123
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY GIVE ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
OVER AND SUITABLE DILUENT
Lidocaine Slow IV bolus  Groups 1 and 2 2 – 3 minutes ECG monitoring required.
Loading Dose  Groups 1 and 2 Infusion for Dilute with N/S or G. Usual Flush with N/S.
(Slow IV bolus adults: concentration of 1mg/ml or 50mg bolus dose for patients who have
as above) 4mg/minute for 2mg/ml but concentrations up to gross circulatory impairment or low body
followed by (C) 30 minutes then 8mg/ml have been used in fluid weight.
or (I) IV 2mg/minute for restricted patients. Use reduced dosage for patients with CCF,
infusion. 2 hours than hepatic failure and cardiac surgery.
Infusion pump 1mg/minute. If an IV infusion is not immediately
is required. commenced, the slow bolus may be
repeated once or twice at intervals of at
least 10 minutes.
Anaesthesia: ♠ Group1 Administer in accordance with
Infiltration ♠ Group 2 in accordance with standard anaesthetic practice
Regional IV specific PGDs.
Nerve blocks ♠ Selected Group 8 Assistant
Practitioners in accordance
with AP protocols
Linezolid (I) IV infusion.  Groups 1 and 2 30 to 120 Provided ready diluted Flush with N/S or G.
Infusion pump minutes Linezolid is a reversible non-selective
is required. With the new FreeFlex bag inhibitor of Monoamine Oxidase (MAOI)
containing linezolid, the spike of and may theoretically enhance increases
the giving set should be pushed in blood pressure produced by
into the blue port, after twisting sympathomimetics (e.g. dopamine,
off the cap marked with a down- noradrenaline, adrenaline). Theoretically it
ward pointing arrow. The white may cause serotonin syndrome with
port is not intended to be used. serotonin re-uptake inhibitors e.g. SSRI’s
(fluoxetine etc).
Sodium content 5mmol/600mg.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 124
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE OVER SUITABLE DILUENT
Liothyronine Slow IV bolus  Groups 3-5 minutes Reconstitute the 20microgram vial with 1 to Flush with N/S.
20micrograms 1,2,3,4 and 5 2ml W and shake gently until the powder has Sodium content 1.49mmol/1g.
dissolved.
Displacement 0.2ml/20micrograms.
(For example, to give 10micrograms,
reconstitute with 1ml W which expands to
1.2ml. Then withdraw 0.6ml = 10micrograms)
Lorazepam IV bolus  Groups Usual Can be diluted 1:1 with N/S or W.
1,2,3,4 and 5 maximum rate
2mg/minute
except in
control of status
epilepticus
where rapid
injection is
required.
IM injection  Groups For IM administration the injection must be Absorption from an IM injection is too slow
(Give IV to treat 1,2,3,4 and 5 diluted 1:1 with N/S or W. Refer to the for a rapid effect, and no more rapid than
status Marsden Manual for guidance on IM injection. oral administration.
epilepticus)
(DL)-Lysine acetyl IV bolus  Groups Suggestion: 2 – Immediately before use, reconstitute the Do not mix with other injectable products in
salicylate 1,2,3,4 and 5 3 minutes contents of each 500mg vial with the 5ml of the same line.
(Aspegic®) W provided to make a 100mg/5ml solution.
(I) infusion  Groups Suggestion: 30 Reconstitute as above then dilute the dose Minimum interval between doses is 4 hours.
(Unlicensed 1,2,3,4 and 5 minutes (500mg or 1g) with N/S or G – suggested
product – volume 100ml.
see page 4) Deep IM  Groups Reconstitute as above. Refer to the Marsden
injection 1,2,3,4 and 5 Manual for guidance on IM injection.
MabCampath® See Alemtuzumab

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 125
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Magnesium sulphate (I) IV  Groups Arrythmias: 2g (8mmol
2+
10% (1g in 10ml) magnesium Flush with N/S.
infusion. 1,2,3,4 and Mg ) over 10-15 minutes sulphate injection may be given Monitor blood pressure and pulse. Also monitor
2g (8mmol Mg2+) Infusion 5 repeated once if necessary. undiluted. for signs of Mg overdose which include
magnesium sulphate= pump is Dilute 50% (5g in 10ml) weakness, nausea, drowsiness & slurred
20ml of 10%(1g in 10ml) required. Treatment of magnesium sulphate injection to speech.
injection or hypomagnesaemia: a maximum concentration of
4ml of 50%(5g in 10ml) 2g (8mmol Mg2+) over a 200mg/1ml with N/S or G (e.g. 2g
injection. minimum of 30 minutes or (4ml of 50% injection) diluted to
5g (20mmol Mg2+) over a at least 10ml).
4g (16mmol Mg2+) minimum of 1 hour
magnesium sulphate= For patients requiring rehydration
40ml of 10%(1g in 10ml) Prevention of Re-Feeding or larger volumes of fluid, the
injection or Syndrome: magnesium replacement dose
8ml of 50%(5g in 10ml) 0.2mmol/kg (0.05g/kg) over may be diluted with 500ml or 1L
injection. a minimum of 1 hour of N/S or G.
Treatment of seizures and Loading dose: Draw up 4g (8ml Continue the infusion for at least 24 hours after
5g (20mmol Mg2+) and prevention of of 50% magnesium sulphate the seizure or delivery, whichever is later. If
magnesium sulphate= recurrence in Eclampsia: injection). Dilute to 20ml in a seizure recurs, increase the infusion rate to 1.5-
50ml of 10%(1g in 10ml) 4g loading dose over 5-15 50ml syringe with N/S. Mix well. 2g/hour or give an additional IV bolus of 2g over
injection or minutes. 5 minutes (Dilute 4ml of 50% magnesium
10ml of 50%(5g in 10ml) sulphate injection to 10ml with N/S).
injection. Maintenance infusion:
1g/hour. Using 5g in 50ml Maintenance infusion: Draw up Monitor the patellar reflex and oxygen saturation
dilution set pump at 5g (10ml of 50% magnesium levels hourly during administration of
10ml/hour. sulphate injection). Dilute to 50ml magnesium sulphate (including overnight) to
in a 50ml syringe with N/S. Mix exclude signs of toxicity.
well.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 126
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE SUITABLE DILUENT
Magnesium IM Injection,  Groups For adults, administer the dose using IM injection of magnesium sulphate is painful.
sulphate only if IV 1,2,3,4 and 50% (1g in 2ml) injection undiluted, or Refer to the Marsden Manual for guidance
(Continued access is not 5 dilute to 25% (1g in 4ml) with N/S. on IM injection.
from previous possible or For children a maximum
page) impractical recommended concentration for IM
injection is 20% (200mg/ml) eg. For a
500mg dose, dilute 1ml of 50%
magnesium sulphate injection to 2.5ml
with N/S.
SC infusion,  Groups Keep the concentration as low as There is little published data to support
only if no other 1,2,3,4 and possible, preferably not greatly administration of magnesium sulphate by the
route is 5 exceeding the isotonic concentration of S/C route. There are isolated case reports of
possible or 6.3% w/v in Water For Injections (6.3g between 2 and 4mmol magnesium sulphate
practical =25.2mmol in 100ml Water For added to 500ml - 1 litre of N/S being tolerated
Injections). Discuss and check by S/C infusion. Administration via the S/C
dose/concentration/route with a route is not licensed in the UK (See page
Pharmacist. 124).
Mannitol (I) IV infusion.  Groups Reduction of intracranial 500ml of ready-to-use 10% (50g in Flush with N/S
Infusion pump 1,2,3,4 and pressure: 500ml) mannitol is routinely stocked. Infusion may crystallise at low temperatures;
is required. 5 0.25g -0.5g/kg over 30-60 redissolve by warming.
minutes. (If using 20% mannitol, infuse through Extravasation causes inflammation and
Can be repeated as necessary. an administration set incorporating a thrombophlebitis.
filter*). 20% mannitol should preferably be
Urgent reduction of intra-ocular administered via a central IV line or at least
pressure before eye surgery: through a large peripheral vein due to its high
Up to 500ml of 20% mannitol osmolarity.
given by slow IV infusion until the *Suitable filters to administer mannitol are
intra-ocular pressure has been PALL 0.22 micron,
satisfactorily reduced. Braun Sterifix 0.2 micron, Technopharm
codan 0.2 micron filters. These filters should
be ordered via ORACLE.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 127
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Meropenem IV bolus for doses  Groups 5 minutes Reconstitute each 250mg Flush with N/S or G.
of 1g or less 1,2,3,4 and meropenem with 5ml W. This Sodium content: 4mmol/gram.
5 provides an approximate
concentration of 50mg/ml.
(I) IV infusion.  Groups 15-30 minutes Reconstitute and dilute to 50- The preferred method for administering doses
Infusion via pump 1,2,3,4, 5 200ml using N/S or G. greater than 1g is intermittent IV infusion.
Mesna (I) IV infusion when  Groups 15-30 minutes Dilute the required dose of mesna When protection against urothelial toxicity is
ifosfamide or 1,2,3,4 and (Usually 20% of the dose of required, three doses of mesna are typically given
cyclophosphamide 5 cyclophosphamide or ifosfamide) with each dose of cyclophospamide or ifosfamide.
are given as an (I) to 50ml or 100ml with N/S. The first dose of mesna is usually IV and given just
infusion over 1-2 prior to the injection/infusion of cyclophosphamide
hours or as IV or ifosfamide. Intravenous second and third doses
bolus, or are given at 4 hours and 8 hours (after the injection
cyclophosphamide or after the end of an infusion). Alternatively, the
has been given second and third doses of mesna can be given
orally orally, in which case each oral dose is 40% of the
dose of cyclophosphamide or ifosfamide given,
given at 2 hours and 6 hours (after the injection or
after the end of an infusion), using mesna injection
by the oral route.
(C) IV infusion  Groups Typically, for the duration of Dilute with N/S or G to any On occasions Pharmacy Technical Services add the
1,2,3,4 and a (C) infusion of ifosfamide, convenient volume required dose of Mesna into the bag containing
5 and then for a further 12 ifosfamide.
hours afterwards.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 128
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Metaraminol IV bolus  Groups 1 Undiluted. Bolus dose: 0.5 – 5mg (0.05 – 0.5ml)
Emergency use and 2 Flush with N/S or G.
only. Sodium content : 0.087mmol/ml.
IV bolus  Groups 1,2 0.5 – 1ml over a few Dilute 10mg in 1ml with 19ml of Follow each bolus dose with a 20ml flush of
and (Group 8 seconds via a large N/S to make 10mg in 20ml. N/S. The bolus dose of 0.5 – 1ml of the
Assistant peripheral vein or a central prepared dilution may be repeated every 1 – 5
Practitioners vein. minutes as indicated by the mean arterial
working in pressure (MAP) and patient response.
Cardiac
Catheter Labs)

(C) IV infusion.  Groups 1 Adjust rate according to

Dilute 15-100mg in 500ml N/S or Metaraminol injection from Torbay
Infusion pump and 2 response. G. Manufacturing Unit is unlicensed (See page
is required. The volume may be varied 7).
depending on the rate of
administration and the patient's
fluid needs.
Methotrexate When methotrexate is prescribed to treat conditions including multiple sclerosis, glomerular kidney disease, severe psoriasis or rheumatoid
arthritis, it may be administered by Group 1 or 2  practitioners who have previous experience of administering parenteral cytotoxics. Read
For use in Appendix 3 for guidance on the handling of cytotoxic drugs. Explicitly inform the patient of the once a week dosing schedule for ongoing therapy
haematology and and determine a fixed weekday as the day of injection. This should be stated on the prescription.
oncology refer to IV bolus injection Group 1 or 2 Consider folic acid supplementation.
chemotherapy (Not for children or  Refer to the SPC for Metoject® on
protocols adolescents) [Link] for details of the
SC bolus injection Group 1 or 2 Refer to the Marsden Manual for recommended monitoring to detect signs of
 guidance on SC injection. toxicity (Mouth and throat examinations, full
IM injection Group 1 or 2 Refer to the Marsden Manual for blood counts, liver function tests, renal
 guidance on IM injection. function etc). Refer to specific protocols as
appropriate:
IM methotrexate for ectopic pregnancy (EPU
and Monkswell).

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 129
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Methylthioninium Important: Only Proveblue brand ampoules are suitable for intravenous use Dose to treat hypotension in septic shock
chloride (I) IV infusion.  Groups 15 – 60 minutes Dilute to a suggested refractory to fluids and vasopressors is
Proveblue Infusion pump is 1 and 2 concentration of 1mg/ml with G. 1-2mg/kg over 15-60 minutes. May be repeated
(Methylene Blue) required. . as required, alternatively after 2 hours set up a
(C) IV infusion.  Groups 0.25-2 mg/kg/hour Dilute to a suggested continuous infusion.
To treat hypotension Infusion pump is 1 and 2 concentration of 1mg/ml with G. Do not infuse down the same lumen/line as any
refractory to fluids required. other drugs.
and vasopressors in Do not dilute with N/S.
septic shock Extravasation can cause tissue damage.
The use of methylene blue to treat hypotension
in septic shock is unlicensed (See page 7)
Methyl-prednisolone IV bolus (doses  Groups Give slowly minimum Reconstitute with diluent provided. Flush with N/S, G or G/S.
sodium succinate up to 250mg) 1,2,3,4 and 5 5 minutes. Sodium content: 2mmol/g.
(I) IV infusion  Groups Minimum 30 minutes Reconstitute as above then dilute For Acute Spinal Cord Injury refer to protocol
(Solu-Medrone) (doses over with G, N/S or G/S to any suitable on Pencarrow.
1,2,3,4 and 5
250mg) via pump volume (e.g. 50-250ml).
IM injection  Groups Reconstitute with diluent provided.
1,2,3,4 and 5 Refer to the Marsden Manual for
guidance on IM injection.
Methyl-prednisolone IM injection  Groups Inject deeply into the gluteal Refer to the Marsden Manual for guidance on
acetate 1,2,3,4 and 5 muscle. IM injection.
Intra-articular  Group 1 Prior to intra-articular injection the joint fluid
(Depo-Medrone) Peri-articular should be examined to exclude a septic
Intrabursal process. Administer under strictly aseptic
Intralesional conditions.
Into tendon Do not give via the intrathecal route
sheaths (potentially neurotoxic) or the IV route.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 130
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Metoclopramide Slow IV bolus  Groups At least 3 minutes Give undiluted. Flush with N/S or G.
10mg in 2ml 1,2,3,4,5 and Sodium content 10mg/2ml = 0.26mmol.
8
IM injection  Groups Refer to the Marsden Manual for
1,2,3,4 and 5 guidance on IM injection.
SC injection for  Groups Refer to the Marsden Manual for Follow the PHNT Care of The Dying
use in palliative 1,2,3,4 and 5 guidance on SC injection. Pathways.
care
(C) SC infusion  Groups Continuous over 24 Dilute with W when 2 or more Follow the PHNT Care of The Dying
for us in 1,2,3,4 and 5 hours drugs are being mixed in the Pathways and the PHNT Syringe Driver
palliative care same syringe. Policy. For combinations of 2 or 3 drugs in
W or N/S may be used when the the same syringe refer to the compatibility
syringe only contains this drug. charts in the pump kit or contact Pharmacy
on ext. 39976 for advice.
If an infusion containing metoclopramide
becomes discoloured it should be discarded.
Metoprolol IV bolus  Groups Cardiac arrhythmias: Give undiluted Early intervention post MI:
1,2,3,4 and 5 1-2 mg/minute 5mg every 2 minutes up to a maximum of
During anaesthesia: 15mg total as determined by blood pressure
2-4mg injected “slowly” and heart rate.
Further injections of 2mg
up to a maximum overall Monitor blood pressure, heart rate and ECG.
dose of 10mg may be
given Flush with N/S or G.
Metronidazole (I)IV infusion via  Groups Adults: Provided ready diluted. Flush with N/S, G or G/S. Cefuroxime can be
an infusion pump 1,2,3,4 and 5 100ml over 20 minutes = mixed into an infusion of metronidazole.
100 drops/minute via a Sodium content: 13.5mmol/500mg infusion.
standard blue gravity set

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 131
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Midazolam IV bolus for sedation  Groups Administer over at least 30 seconds an Use 1mg/ml midazolam For sedation in conscious adult
in conscious adult 1,2,3,4 and initial dose of midazolam guided by: patients follow the Sedation
(Monograph patients 5  Age Policy on Plymouth Healthnet
continues on  Weight (under Clinical Guidelines).
the next  Other medications All healthcare practitioners
page) involved directly or participating
 Medical history and co-existing in sedation techniques must
disease
have the necessary knowledge,
 Planned procedure skills and competences required
Assess the level of sedation after 2-5 Flush with N/S.
minutes and repeat as necessary Respiratory depression and
(minimum of 2 minutes between arrest have occurred when doses
subsequent doses). were given too rapidly.
During the procedure, additional doses Flumazenil and resuscitation
may be given. equipment must be immediately
IV bolus for induction  Groups Induction of anaesthesia and loading Use 1mg/ml midazolam available.
of anaesthesia 1,2,3,4 and dose for ICU sedation for adults: Each
5 increment over 20-30 seconds allowing
2 minutes between successive
increments.
(I) or (C) IV infusion  Groups 1 Dilute with N/S, G or G/S. For
following initial and 2 adults the usual dilution is 50mg in
loading dose via 50ml.
infusion pump

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 132
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Midazolam Slow IV bolus for  Groups 1 2.5 – 5mg over 1-2 minutes repeated at Use the 5mg in 5ml pre-filled For the Management of Carotid
(Continued) Carotid Artery and 2 2 minute intervals if sedation is not syringe prepared by Pharmacy and Artery Rupture (Carotid Blow
Rupture adequate. kept in the patient’s bedside locker. Out) follow the specific additional
If a pre-filled syringe is not available guideline on Lynher ward.
use a 5mg in 5ml ampoule.
SC injection for  Groups Use the 10mg in 2ml ampoules. Follow the PHNT Care of The
terminal restlessness 1,2,3,4 and Refer to the Marsden Manual for Dying Pathways and the PHNT
and agitation 5 guidance on SC injection. Syringe Driver Policy. For
(C) SC infusion via  Groups Continuous over 24 hours Use the 10mg in 2ml ampoules. combinations of 2 or 3 drugs in
syringe driver for 1,2,3,4 and Dilute with W when 2 or more drugs the same syringe, refer to the
terminal restlessness 5 are being mixed in the same Syringe Driver Drug
and agitation syringe. Compatibility chart provided in
W or N/S may be used when the the pump kit. Contact Pharmacy
syringe only contains this drug. on ext. 39976 for further
compatibility advice if necessary.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 133
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY GIVE ADMINISTER OVER INSTRUCTION FOR COMMENTS
DILUTION AND SUITABLE
DILUENT
Milrinone (I) or (C) IV  Groups 1 and 2 Loading dose (50microgram/Kg) Dilute to 200 microgram/ml Monitor blood pressure, heart rate, ECG,
infusion. over 10 minutes followed by with N/S or G (e.g. 10mg fluid balance and renal function.
Infusion pump infusion at 0.375-0.75 ampoule diluted to 50ml). Do not mix with other drugs.
is required. microgram/kg/minute according Flush with N/S or G.
to haemodynamic response (For However solutions of different Using a 200microgram/ml dilution the
help setting the infusion pump concentrations may be used recommended maintenance infusion rate
rate see table below). according to the patient’s fluid is 0.11-0.22ml/kg/hour.
requirements.
Milrinone 10mg in 50ml G dilution For patients with renal impairment (eGFR < 50ml/minute) using Milrinone 10mg in 50ml G dilution
eGFR >50ml/minute
Maintenance infusion rate: Infusion pump rate eGFR Initial maintenance infusion rate Initial Infusion pump rate
Titrate from 0.375 to 0.750 ml/kg/hour ml/minute/1.73m2 micrograms/kg/minute (titrate ml/kg/hour (titrate according to
micrograms/kg/minute according to haemodynamic response). haemodynamic response).
0.375 0.11 5 0.20 0.06
0.400 0.12 10 0.23 0.07
0.500 0.15 20 0.28 0.08
0.600 0.18 30 0.33 0.10
0.700 0.21 40 0.38 0.11
0.750 0.22 50 0.43 0.13

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 134
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Morphine Staff prescribing, administering and/or screening prescriptions for opioid medications should be familiar with the PHNT Policy for Reducing Errors
with Opioid Medicines in Adults using the following link:
[Link]
Errors%20with%20Opioid%20Medicines%20in%[Link]?timestamp=1443106367868
SC injection  Groups Follow the SC Morphine Do not dilute Flush each SC dose with 0.5ml N/S
Preferred route 1,2,3,4 and 5 Protocol for Adults (Copy on Flush with N/S, G or G/S.
for treating acute page 196) Sodium content negligible.
pain on general
wards
IV bolus  Groups 1 Follow the algorithm from Dilute 10mg morphine to 10ml
(Theatre Recovery) and 2 Recovery 2 with N/S
IV bolus  Groups 1 Follow the IV Morphine Dilute 10mg morphine to 10ml
(Acute Care Areas) and 2 Protocol for Adults in Acute with N/S
Areas (Copy on page 197)
IV bolus  Groups 1 Follow the IV Morphine For monitoring required when IV morphine is
(Emergency and 2 Protocol for Adults in the given in the Emergency Department, see the
Department) Emergency Department (Copy protocol on page 198.
on page 198) Monitor blood pressure, heart rate, respiratory
(C) or (I) IV  Groups 1 Vials of ready-diluted morphine rate. Have naloxone and resuscitation
infusion in Critical and 2 50mg in 50ml N/S are available equipment available.
Care areas from Pharmacy).
via infusion pump.
Patient Controlled  Groups See comments Vials of ready-diluted morphine Adult PCA: Usual bolus dose 1mg. Usual
Analgesia (PCA) 1,2,3,4 and 5 50mg in 50ml N/S are available lock-out period is 5 minutes. Refer to Acute
from Pharmacy. Pain/Care Service Protocols. Background
IM injection  Groups Refer to the Marsden Manual morphine infusion may only be prescribed by
1,2,3,4 and 5 for guidance on IM injection. a member of the Acute Pain/Care Team.
Nurse-led Controlled Analgesia via the PCA
pump is available – seek advice from the
Acute Pain/care Team.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 135
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE SUITABLE DILUENT
Morphine 40mg (C) Intrathecal  Group 1 or Prepare and administer in accordance with * Restricted to those persons who are
in 1ml infusion or Group 2* the Pain Management Centre protocols. trained and competent to administer
preservative-free Intrathecal bolus medication via the intrathecal route.
(Unlicensed)
Mycophenolate (I) IV infusion  Groups 2 hours. Infusion to be prepared by Pharmacy. Wear gloves, gown and safety glasses
1,2,3,4 and 5 Telephone Ext. 31083. Doctor to prescribe when handling. Avoid handling drug if
dose in 100ml G. pregnant or trying to become pregnant.
Mycozyme® See Alglucosidase alfa

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 136
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Naloxone IV bolus for:  Groups Adults: Bolus dose of 100 micrograms may be Dilute to a concentration of Use infusions within 12
Reversal of opiate 1,2,3,4,5 repeated at intervals of not less than 2 minutes 100micrograms/ml with N/S. If hours.
induced respiratory and 8 to achieve desired response. repeated bolus doses are insufficient Monitor for possible
depression in adults a continuous infusion may be hypotension, hypertension,
prescribed opiates as required using an infusion pump – ventricular tachycardia and
part of their Dilute 2mg naloxone with 500ml N/S fibrillation and withdrawal
palliative, chronic or G (Resulting concentration syndrome.
pain or peri-operative 4micrograms/ml). Starting rate is 60% Flush with N/S or G.
or peri-procedure of the initial IV bolus infused over 1 Note that 4mg in 20ml is an
care hour then titrate to response. unlicensed dilution (see
IV bolus followed by  Groups 40microgram IV bolus (=0.1ml of 400mcg/ml For the infusion, dilute page 7).
(C) infusion to treat 1,2,3,4 and injection) followed by 200micrograms infused 200micrograms in 1 litre N/S infused When using a continuous
PCA or epidural 5 over 6 – 8 hours. over 6 – 8 hours. infusion to treat opiate
opiate-induced induced respiratory
pruritis depression in adults
IV boluses to treat  Groups 1 Initially 400 micrograms, then 800 micrograms prescribed opiates as part
Acute opiate and 2 for up to 2 doses at 1 minute intervals. If no of their palliative, chronic
overdose/poisoning response to preceding dose, then increase to pain or peri-operative care
2 mg for 1 dose if still no response, then do not suddenly stop the
review diagnosis; further doses may be infusion. Once the patient
required if respiratory function deteriorates, is stabilised and it is
4 mg dose may be required in seriously deemed appropriate, the
poisoned patients naloxone infusion should
IV infusion to treat  Groups 1 Adjust rate according to response (initially, Dilute 10mg in 50ml N/S or G. be titrated down rather
Acute opiate and 2 rate may be set at 60% of the initial than just turned off. Close
overdose/poisoning resuscitative intravenous injection dose per monitoring is essential at
hour). The initial resuscitative intravenous this stage for the possibility
injection dose is that which maintained of opioid toxicity recurring
satisfactory ventilation for at least 15 minutes again especially when it is
IM Injection only if IV  Groups Refer to the Marsden Manual for guidance on due to long acting opioids.
administration is not 1,2,3,4 and IM injection.
possible 5

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 137
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE OVER SUITABLE DILUENT
Natalizumab (I) IV infusion.  Groups Approximately 1 Check that the solution is clear and free of
Observe the patient during the infusion and
(Tysabri®) Infusion 1,2,3,4 and 5 hour particles. Draw up 15 ml from the vial and
for 1 hour after the completion of the infusion
▼ This product is being pump is add to 100ml N/S. Gently invert the bag to
for signs and symptoms of hypersensitivity
intensively monitored required. mix completely. Do not shake. Visually reactions.
by the CHM and inspect the diluted product for particles or
Do not administer as a bolus injection.
MHRA. Please report discolouration prior to [Link] and medication to treat
all suspected reactions Flush the line with N/S when the infusion
anaphylaxis must be immediately available.
(including non-serious has finished. Discontinue administration of natalizumab
ones) using a Yellow Do not mix with any other drugs or and initiate appropriate therapy at the first
Card from the BNF diluents. symptoms or signs of hypersensitivity.
Neostigmine IV bolus  Groups Minimum 3-5 Give undiluted. Flush with N/S. Protect from light.
1 and 2 minutes. Have atropine or glycopyrollate available to
However, for counteract possible cholinergic reactions.
reversal of For use in Critical Care for acute colonic
neuromuscular pseudo-obstruction, follow the Critical Care
block, administer Bowel Management Protocol (Use for this
over 1 minute. indication is unlicensed -see page 7).
(I) or (C) IV  Groups Start at 0.4mg/hour Dilute 5mg neostigmine to 50ml with N/S to Use atropine or glycopyrronium if necessary
infusion to 1 and 2 (4ml/hour). If no make a concentration of 0.1mg/ml. to treat bradycardia, and for patients with
treat severe response after 8 spinal cord lesions.
constipation hours increase to Follow the Critical Care Bowel Management
in Critical 0.8mg/hour Protocol (Use for this indication is unlicensed
Care (8ml/hour) - see page 7). The only confirmed Y-Site
compatibilities are with heparin,
hydrocortisone and potassium chloride.
SC Injection  Groups Refer to the When treating Myaesthenia Gravis,
1 and 2 Marsden Manual 500micrograms of neostigmine metilsulfate
for guidance on IM by intravenous injection is equivalent in
IM injection  Groups effect to about 1 to 1.5mg of neostigmine
or SC injection.
1 and 2 metilsulfate by intramuscular or
subcutaneous injection, and to about 60mg
of oral pyridostigmine

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 138
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Nimodipine (I) IV infusion via a  Groups 500microgram Provided ready diluted (10mg in Draw up solution into 50ml syringe and use the
central IV line. 1 and 2 s-2mg/ hour 50ml). polyethylene line provided in the box. Administer via a
Infusion pump is =2.5 – central catheter through a Y-piece connector into an
required. 10ml/hour infusion of N/S, G, H, Dextran 40, human albumin 5%
or mannitol 10% running at 40ml/hour.
Protect infusion from direct sunlight.
Flush with N/S or G. Incompatible with PVC
Niopam® In accordance with  Groups In accordance Not for further dilution Although the product is labelled for “Single use”, each
Radiology Dept. 1 and 6 with Radiology bottle of Niopam can be used with the Bracco CT
protocols Dept. Expres pump injector system in a multi-dose
protocols technique for one or more patients, in accordance
with local Radiology Dept. protocols. Niopam can be
followed with a flush of N/S in accordance with
Radiology Dept. protocols.
Injection via the  Group 8 In accordance with Cardiac
balloon catheter for (Cardiac Catheter Labs. and Assistant
angioplasty or Catheter Practitioner protocols.
valvuloplasty Labs.)
Nitroprusside See Sodium Nitroprusside
Nivolumab (C) IV infusion.  Groups Infuse over 60 A closed-system device must be used Flush with N/S.
▼ This product is Infusion pump is 1 and 2 minutes via a to prepare nivolumab. Do not co-administer other medicinal
being intensively required. 0.2-1.2 micron products through the same infusion line.
monitored by the in-line filter Either give the prescribed dose undiluted
CHM and MHRA. (10mg/ml), or dilute the dose in N/S so
Please report all that the final concentration is at least
suspected 1mg/ml. The final concentration should
reactions therefore be within the range 1-10mg/ml.
(including non- (First remove a volume of N/S from the
serious ones) bag equal to the volume of drug solution
using a Yellow being added).
Card from the
BNF

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 139
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND
GIVE OVER SUITABLE DILUENT
Noradrenaline (C) or (I) IV  Groups Adjust rate “Single Strength” Infuse via a central venous catheter. Loss
(Norepinephrine) infusion via a 1 and 2 according to 4ml (4mg noradrenaline base) diluted to of potency occurs if diluent is N/S. Discard
base 1mg/1ml central IV line. response. 50ml with G (or G/S) = 80micrograms/ml. infusion if brown colour develops.
Infusion pump “Double strength” Flush with G or N/S.
(=Noradrenaline is required. 8ml (8mg noradrenaline base) diluted to Protect infusion from direct sunlight.
tartrate 2mg/ml) 50ml with G (or G/S) = 160micrograms/ml. Haemodynamic monitoring required.
“Quadruple Strength”
16ml (16mg noradrenaline base) diluted to
50ml with G (or G/S)= 320micrograms/ml.
Rate (micrograms/kg/minute) = Pump rate (ml/hour) x concentration (micrograms/ml)
Patient’s weight (kg) x 60

Pump rate (ml/hour) =Prescribed rate(micrograms/kg/minute) x 60(minutes in an hour) x Patient’s weight (kg)
Concentration of the infusion(micrograms/ml)
Novomix 30® Insulin See Insulin Section, page 107
Novorapid® Insulin
Octagam® See Immunoglobulin Human Normal
Octreotide SC injection  Groups Refer to the Marsden Manual for
Subcutaneous injection is preferred method of
1 and 2 guidance on SC injection. administration.
IV bolus  Groups 3-5 minutes ECG monitoring necessary with IV injection (Not
Dilute each 1ml octreotide injection
1 and 2 with a minimum of 1ml and awith SC injection). Flush after IV injection with N/S.
maximum of 9ml of N/S. It is not recommended to use G to dilute octreotide
(except for treatment of variceal bleeding below).
The rubber caps of the Multidose vials should
not be punctured more than 10 times.
(C) SC  Groups Continuous over Dilute with W when 2 or more drugs Follow the PHNT Care of The Dying Pathways and
infusion via 1 and 2 24 hours are being mixed in the same syringe. the PHNT Syringe Driver Policy.
syringe driver W or N/S may be used when the For combinations of 2 or 3 drugs in the same
in palliative syringe only contains this drug. syringe refer to the compatibility charts in the
care. pump kit or contact Pharmacy on ext. 39976 for
(Unlicensed – advice.
see page 7)

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 140
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Octreotide Instructions for IM injection of Sandostatin LAR for deep intragluteal injection only
Depot 1. Remove the cap from vial containing Sandostatin LAR. Ensure that the powder is settled at the bottom of the vial by lightly tapping the vial.
IM injection Remove the cap from the vehicle syringe. Attach one of the supplied needles to the vehicle syringe.
by  Groups 2. Insert needle through centre of rubber stopper of the Sandostatin LAR vial.
1 and 2 3. Without disturbing the Sandostatin LAR powder, gently inject the vehicle into the vial by running the vehicle down the inside wall of the vial.
Do not inject the vehicle directly into the powder. Withdraw any excess air present in the vial.
4. Do not disturb the vial until the vehicle has wetted the Sandostatin LAR powder for suspension. Once complete wetting (approximately 2-5
minutes) has occurred, the vial should be moderately swirled until a uniform suspension is achieved. Do not vigorously shake the vial.
5. Immediately draw 2ml of air into the syringe and re-insert the needle through the rubber stopper. Inject the 2ml of air into the vial and then,
with the bevel down and the vial tipped at approximately 45 degree angle, slowly draw the entire contents of the vial containing the
suspension into the syringe. Immediately change the needle (supplied).
6. Gently invert the syringe as needed to maintain a uniform suspension. Eliminate air from syringe and disinfect the injection site. Insert
needle into right or left gluteus and draw back to ensure that no blood vessel has been penetrated. Immediately inject IM by deep
intragluteal injection.
7. Sandostatin LAR must be given only by intragluteal injection, never IV If a blood vessel has been penetrated, select another injection site.
Olanzapine IM injection  Groups 1 Reconstitute the vial contents Use the solution immediately within 1 hour of reconstitution.
10mg and 2 with 2.1ml W. Rotate the vial until Administration of olanzapine 10mg injection via the SC and
injection the contents have completely IV routes is unlicensed. The safety via these routes has not
dissolved making a 5mg/ml been fully established. However, in one published study, IV
solution (The vial actually boluses of 5mg olanzapine were tolerated by patients. Due
contains 11mg drug with 0.1ml to possible bradycardia and hypotension, use with caution in
displacement). patients with serious cardiovascular disease.
10mg dose – draw up 2ml
5mg dose – draw up 1ml
2.5mg dose – draw up 0.5ml

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 141
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE OVER SUITABLE DILUENT
Ofatumumab (I) IV infusion  Groups 1 See tables below Dilute all doses to 1000ml with N/S (remove A closed-system device must be used to
via infusion and 2 a volume of N/S from the bag first equal to prepare Ofatumumab.
pump. the volume of drug solution being added). Patients should always be pre-medicated 30
Do not shake. Mix by gentle inversion. minutes to 2 hours prior to Ofatumumab infusions
Rates of infusion for Ofatumumab with paracetamol, antihistamine & intravenous
corticosteroid.
First Infusion Second Infusion Subsequent Infusions Patients should be closely monitored during
administration of ofatumumab for the onset of
infusion reactions (ADRs), including cytokine
Start at If no adverse reactions to the first infusion, start the second and release syndrome, particularly during the first
Previously 12ml/hour. subsequent infusions at 25ml/hour. Increase rate every 30 infusion.
untreated Increase rate minutes to a maximum of 400ml/hour.
CLL every 30 minutes •In case of a mild or moderate ADR, the infusion
to a maximum of should be interrupted and restarted at half of the
400ml/hour infusion rate at the time of interruption, when the
patient's condition is stable. If the infusion rate had
Start first and second infusions at If no adverse reactions to the first and second not been increased from the starting rate of 12
Refractory 12ml/hour. Increase rate every 30 infusions, start subsequent infusions at ml/hour prior to interrupting due to an ADR, the
CLL minutes to a maximum of 200ml/hour. 25ml/hour. Increase the rate every 30 minutes
infusion should be restarted at 12 ml/hour, the
to a maximum of 400ml/hour.
standard starting infusion rate. The infusion rate can
Titration of infusion rates continue to be increased according to standard
Previously untreated CLL Refractory CLL procedures, according to physician discretion and
Infusion 1 over 4.5 Infusions 2 to 13 Infusions 1 and 2 Infusions 3 to 12 over patient tolerance (not to exceed increasing the rate
hours Over 4 hours over 6.5 hours 4 hours every 30 minutes).
Time
(minutes)
Rate
(ml/hour)
Time
(minutes)
Rate
(ml/hour)
Time
(minutes)
Rate
(ml/hour)
Time
(minutes)
Rate
(ml/hour)
•In case of a severe ADR, the infusion should be
0-30 12 0-30 25 0-30 12 0-30 25 interrupted and restarted at 12 ml/hour, when the
patient's condition is stable. The infusion rate can
31-60 25 31-60 50 31-60 25 31-60 50 continue to be increased according to standard
61-90 50 61-90 100 61-90 50 61-90 100 procedures, according to physician discretion and
patient tolerance (not to exceed increasing the rate
91-120 100 91-120 200 91-120 100 91-120 200
every 30 minutes).
121-150 200 121+ 400 121+ 200 121+ 400 Flush line with N/S before and after ofatumumab
151-180 300 infusion.
Do not co-administer other medicinal products
180+ 400
through the same infusion line.
 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 142
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Omalizumab SC injection in  Groups 1 Available in pre-filled syringes. Alternatively, the injections can be administered in
the deltoid region and 2 the thigh if there is any reason precluding
of the arm. administration in the deltoid region.
Omeprazole (I) IV infusion.  Group 20-30 minutes Reconstitute each 40mg with Flush with N/S.
Infusion pump is 1,2 and 3 approximately 5ml N/S or G. Sodium content 0.1mmol/40mg vial. Use infusion in
required. Dilute each 40mg to 100ml with N/S within 12 hours, 3 hours if in G. Incompatible:
N/S or G. do not infuse with any other drugs.
Omeprazole IV Loading dose  Groups 80mg in 100ml N/S For each 40mg vial, withdraw Use infusion in N/S within 12 hours.
For the specialist of 80mg 1,2,3,4 and over 30 minutes 5ml of N/S from a 100ml bag Omeprazole infusion must not be infused through
treatment of 5 and use to reconstitute the vial. the same venflon or line lumen as any other drug
endoscopically Then inject the reconstituted solution.
controlled omeprazole into the bag. Do Each bag is for single use only and must be used
bleeding peptic not add more than 80mg immediately after preparation.
ulceration omeprazole to 100ml of diluent.
(C) IV infusion.  Groups After loading dose, Reconstitute and dilute each * The Gastroenterologists have agreed to a 70-hour
Infusion pump is 1,2,3,4 and infuse at 8mg/hour 40mg vial as above. treatment (rather than 72 hours). A pre-printed
required. 5 for 70 hours* prescription is available.
(This is 10ml//hour
with each 80mg in
100ml N/S)
Omnipaque® In accordance  Group 1 In accordance with Not for further dilution Although the product is labelled for “Single use”,
with Radiology or Group 6 Radiology Dept. each bottle of Optiray can be used with the Bracco
Dept. protocols protocols CT Expres pump injector system in a multi-dose
technique for one or more patients, in accordance
with local Radiology Dept. protocols. Optiray can be
followed with a flush of N/S in accordance with
Radiology Dept. protocols.
Injection via the  Group 8 In accordance with Cardiac
balloon catheter (Cardiac Catheter Labs. and Assistant
for angioplasty or Catheter Practitioner protocols.
valvuloplasty Labs.)

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 143
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 144
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE SUITABLE DILUENT
Ondansetron IV bolus only for:  Groups 3-5 minutes Either give undiluted or dilute to any Flush with N/S.
 4mg dose in 1,2,3,4,5 and convenient volume of N/S or G. Sodium content 0.16mmol/1ml.
any adult 8 As recommended in MHRA Drug Safety
patient. Update July 2013 to prevent lengthening of
 8mg dose in the QT-interval and possible Torsade De
patients Pointes.
younger than  8mg doses for patients aged 65 or older
65 years. should be given by IV infusion over 15
(I) IV infusion via  Groups 15 minutes Dilute with 50ml to 100ml N/S or G minutes.
infusion pump is 1,2,3,4,5 and  8mg is the maximum dose for patients
required for: 8 aged 75 or older.
 8mg doses in  All 16mg doses should be given by IV
patients aged infusion over 15 minures.
65 and older.  Repeat doses should be given at least 4
 16mg doses hours apart.
(only allowed  Ondansetron should be avoided in
for patients patients with congenital long QT
younger than syndrome.
75 years).  Caution must be used if administering
(C) IV infusion.  Groups 1mg/hour ondansetron to patients with risk factors
Infusion pump is 1,2,3,4 and 5 for QT interval prolongation or cardiac
required. arrhythmias. These include: electrolyte
IM injection  Groups Refer to the Marsden Manual for abnormalities; use of other medicines that
1,2,3,4 and 5 guidance on IM injection. prolong QT interval (including cytotoxic
drugs) or that may lead to electrolyte
abnormalities; congestive heart failure;
bradyarrhythmias; or use of medicines
that lower heart rate .
 Hypokalaemia and hypomagnesaemia
should be corrected before ondansetron
administration.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 145
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE SUITABLE DILUENT
Optiray® In accordance  Group 1 or In accordance with Not for further dilution Although the product is labelled for “Single
with Radiology Group 6 Radiology Dept. use”, each bottle of Optiray can be used
Dept. protocols protocols with the Bracco CT Expres pump injector
system in a multi-dose technique for one
or more patients, in accordance with local
Radiology Dept. protocols. Optiray can be
followed with a flush of N/S in accordance
with Radiology Dept. protocols.
Oxytocin (C) infusion.  Groups 1 Increase the rate Dilute 3 units of oxytocin (3 units = For detailed instructions it is essential
Infusion pump is and 2 every 30 minutes 0.6ml of the 5 units/ml injection) to to read the PHNT Guidelines for
required. until contractions are 50ml with N/S. Augmentation of Labour
satisfactory (4 – 5/10)
Using the 3 unit in 50ml dilution:
Continuous electronic fetal monitoring
Time from start of infusion Infusion rate Infusion rate during administration is required.
(Minutes) (milliunits/minute) (ml/hour
0 1 1
30 2 2 Stop the infusion during a prolonged
60 4 4 deceleration or definite fetal distress (if
CTG is abnormal perform FBS first).
90 8 8
120 12 12
150 16 16 Do not infuse through the same line as
180 20 20 blood or plasma.
Only increase the rate beyond this point following review and at the discretion of the specialist
registrar or consultant.
210 24 24
240 28 28
270 32 32
Orencia® See Abatacept

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 146
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE SUITABLE DILUENT
Oxycodone Staff prescribing, administering and/or screening prescriptions for opioid medications should be familiar with the PHNT Policy for
Reducing Errors with Opioid Medicines in Adults using the following link:
[Link]
osing%20Errors%20with%20Opioid%20Medicines%20in%[Link]?timestamp=1443106367868
SC bolus  Groups Refer to the Marsden Manual for Follow the PHNT Care of the Dying
1,2,3,4 and 5 guidance on SC injection. Pathway in Advance Kidney Disease and
(C) SC infusion  Groups 24 hours Dilute with W when 2 or more drugs the PHNT Syringe Driver Policy.
via syringe driver 1,2,3,4 and 5 are being mixed in the same syringe. For combinations of 2 or 3 drugs in the
for use in W or N/S may be used when the same syringe refer to the compatibility
palliative care. syringe only contains this drug. charts in the pump kit or contact
Pharmacy on ext. 39976 for advice.
Patient  Groups See comments Dilute 50mg to 50ml with N/S. Adult PCA: Usual bolus dose 1mg. Usual
Controlled 1,2,3,4 and 5 lock-out period is 5 minutes. Refer to
Analgesia (PCA) Acute Pain/Care Service Protocols.
Background oxycodone infusion may only
be prescribed by a member of the Acute
Pain/Care Team. Nurse-led Controlled
Analgesia via the PCA pump is available
– seek advice from the Acute Pain/care
Team.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 147
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE SUITABLE DILUENT
Pabrinex ® IV (I) IV infusion  Groups 1 30 minutes The contents of the pair(s) of ampoules Flush with N/S or G.
high potency (Preferred and 2 should be diluted with 50 to 100ml N/S or Mild allergic reactions are warning signs
injection method) via G. (Up to 3 pairs of 5ml ampoules can be that further doses may cause
infusion pump diluted with 50-100ml N/S or G). anaphylactic shock
IV bolus  Groups 1 10 minutes Mix contents of one 5ml Ampoule No.1 and Facilities for treating anaphylaxis must be
and 2 one 5ml Ampoule No.2 (Maximum volume available.
10ml) in a single syringe immediately
before use.
Pabrinex ® IM IM injection  Groups 1 The contents of one ampoule number 1 Do not give the IM formulation via the IV
high potency and 2 and one ampoule number 2 of Pabrinex route. Refer to the Marsden Manual for
injection Intramuscular High Potency (total 7ml) are guidance on IM injection.
drawn up into a syringe to mix them just Mild allergic reactions are warning signs
before use, then injected slowly high into that further doses may cause
the gluteal muscle, 5cm below the iliac anaphylactic shock. Facilities for treating
crest. anaphylaxis must be available.
Pamidronate (I) IV infusion.  Groups Maximum 1mg/minute. For some brands the vials contain solution Flush with N/S. Sodium content
Infusion pump is 1,2,3,4 and 5 that requires further dilution. 0.11mmol/15mg.
required. A dose of 90 mg should Monitor serum electrolytes, calcium and
normally be For vials that contain powder needing phosphate.
administered as a 2- reconstitution before further dilution: Aredia® and Wockhardt® brands state
hour infusion. reconstitute each 15mg vial with 5ml W. that they should not be given if eGFR<30
Reconstitute each 30mg and 90mg vial unless the hypercalcaemia is life-
In renally impaired with 10ml W. threatening and the benefit outweighs the
patients the maximum risk.
recommended rate is Further dilution is necessary: In order to minimise local reactions at the
20mg/hour. Dilute 30mg to at least 125ml with N/S infusion site, the cannula should be
Dilute 60mg to at least 250ml with N/S inserted carefully into a relatively large
Dilute 90mg to at least 375ml with N/S vein.

(If needed, pamidronate can be diluted with

G instead of N/S).

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 148
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE SUITABLE DILUENT
Pancuronium IV bolus preferably  Groups 1 Flush with N/S or G.
via a central IV line and 2
or through tubing of
flowing N/S or G
drip.
Panitumumab (I) IV infusion via a  Groups Approximately 60 A closed-system device must be Do not mix with other drugs in the same
0.2-0.22 micron in- 1,2,3,4 andminutes. If the first used to prepare panitumumab. line or lumen.
line filter. Infusion 5 infusion is tolerated, Flush with N/S.
pump is required. then subsequent Draw up the required dose and dilute
infusions may be with N/S to a final concentration not
administered over 30 exceeding 10 mg/ml. (First remove a
to 60 minutes. Doses volume of N/S from the bag equal to
higher than 1000 mg the volume of drug solution being
should be infused added).The diluted solution should be
over approximately mixed by gentle inversion, do not
90 minutes shake.
Paracetamol Intravenous paracetamol must only be used when a patient cannot take any medicines by mouth and paracetamol cannot be given via an
enteral feeding tube. Peri-operative patients able to take sips of water can take paracetamol orally with a little water.
(I) IV infusion.  Groups 100ml over 15 Provided ready-diluted Can be flushed with N/S.
Infusion pump is 1,2,3,4,5 minutes Each bottle is for single use only.
required. and 8
Parecoxib IV bolus  Groups Rapid bolus directly Reconstitute 40mg vial with 2ml N/S (can Do not administer parecoxib together
1,2,3,4 and into a vein or into be reconstituted with 2ml G instead of with opioids in the same syringe.
5 an existing line N/S if necessary). Dissolve the powder Do not reconstitute with Hartmann’s as
through which N/S, with a gentle swirling motion. this will cause precipitation.
G or H is running.
Deep IM injection  Groups Reconstitute as above. Refer to the
1,2,3,4 and Marsden Manual for guidance on IM
5 injection.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 149
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER
INSTRUCTION FOR DILUTION AND COMMENTS
GIVE SUITABLE DILUENT
Parenteral nutrition (C) IV infusion.  Groups Adults: Each bag Do not infuse with any other drugs.
(TPN) Infusion pump is 1,2,3,4 and 5 should run over no See back of Pharmacy TPN order
required. longer than 24 hours form for required monitoring of
electrolytes, and LFT’s etc.
1. TPN must be ordered by 12 noon on the day it is required. Ensure that biochemistry results are available before the TPN is
prescribed. It is advised to “Red Spot” the samples to speed the results.
2. All patients (except those on Penrose or Pencarrow) should be referred to the Nutrition Support Team (NST). If you wish to contact
or refer a patient to the NST contact Dr Stephen Lewis Consultant Gastroenterologist on bleep 89756, Nutrition Nurse Specialist
bleep 89755 or 89760, Dietitian on Ext 32243 or Pharmacy Technical Services on Ext 31084.
3. For patients on ICU please follow the ICU TPN protocol.
4. The protocol for connecting TPN bags and monitoring should be followed with meticulous attention.
5. TPN should not be commenced out-of-hours on weekdays (Between 5pm and 9am). On a Saturday, Sunday or Bank Holiday TPN
is only available after discussion with the on-call Gastroenterologist. Once the on-call Gastroenterologist has agreed on the
commencement of TPN, then he will contact the on-call pharmacist for a supply. This applies to all wards other than Penrose and
Pencarrow (TPN bags are no longer available from the Pharmacy Night Cupboard).
Pembrolizumab (C) IV infusion.  Groups 1 Infuse over 30 Infusion to be prepared by Pharmacy. Flush with N/S.
▼ This product is Infusion pump is and 2 minutes via a 0.2-5 Telephone ext. 31083. Doctor to Do not co-administer other
being intensively required. micron in-line filter prescribe dose diluted in N/S with a medicinal products through the
monitored by the final concentration between 1mg/ml same infusion line.
CHM and MHRA. and 10mg/ml.
Please report all
suspected reactions
(including non-
serious ones) using
a Yellow Card from
the BNF

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 150
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Pentamidine (I) IV infusion with patient  Groups Minimum 1 hour Pharmacy must prepare this. Flush with N/S or G. Sodium content
(Pentamidine supine, via an infusion 1,2,3,4 and 5 Contact Ext. 31083 nil.
isethionate) pump, Blood pressure must be closely
for the treatment of monitored. To reduce the risk of
Pneumocystis jirovecii severe, sudden hypotension, patient
(formerly known as should be supine. Do not infuse with
Pneumocystis carinii) any other drugs.
pneumonia, or
Trypanosomiasis

IM injection for the  Groups 1 Refer to the Marsden Manual for

treatment of and 2 guidance on IM injection.
Leishmaniasis or
Trypanosomiasis
Pertuzumab (I) IV infusion. Infusion  Groups Loading dose over A closed-system device must An observation period of 30 to 60
pump is required. 1,2,3,4 and 5 60 minutes. be used to prepare minutes is recommended after each
▼ This product is pertuzumab. Perjeta infusion and before
being intensively Maintenance commencement of any subsequent
monitored by the doses over 30-60 Draw up the prescribed dose and infusion of trastuzumab or
CHM and MHRA. minutes add to a 250ml bag of N/S. Gently docetaxel.
Please report all invert the bag to mix the solution Do not mix in the same line or lumen
suspected reactions in order to avoid foaming. as any other drug solution or
(including non- glucose.
serious ones) using
a Yellow Card from
the BNF

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 151
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Pethidine IM injection  Groups Refer to the Marsden Manual for Flush after IV bolus with N/S or G
1,2,3,4 and 5 guidance on IM injection. Monitor blood pressure, heart rate
Slow IV bolus  Groups 2 - 5 minutes Can be diluted with N/S or G. and respiratory rate. Have naloxone
1,2,3,4 and 5 and resuscitation equipment
available.
SC injection  Groups Refer to the Marsden Manual for
Sodium content nil.
1,2,3,4 and 5 guidance on SC injection.
Phenobarbitone IV bolus  Groups For status epilepticus Dilute to 10 times its own volume Flush with N/S.
1,2,3,4 and 5 in adults: 10mg/kg at with W. Sodium content 0.79mmol/200mg.
a rate of no more The injection is highly alkaline and
than 100mg/minute. may produce local tissue damage.
Maximum dose 1g. Extravasation may cause tissue
damage. Monitor sedation score,
respiratory rate, heart rate and blood
pressure.
Phentolamine IV bolus  Group 1 May be diluted with N/S if Flush with N/S or G.
mesylate To treat hypertensive required. Monitor blood pressure and ECG.
episodes due to Protect from light.
phaeochromocytoma Use with care in asthmatics: monitor
for hypersensitivity reactions.
Rapid IV bolus or IM  Group 1 Refer to the Marsden Manual for Refer to the translation of the
injection for guidance on IM injection. package insert for details of how to
perform the test and the monitoring
Diagnosis of required.
phaeochromocytoma -
Rogitine blocking test
(C) IV infusion  Group 1 0.2-2mg per minute Dilute with a suitable volume of Note that IV infusion of phentolamine
titrating the dose to N/S or G. is unlicensed.
the desired blood
pressure response

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 152
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Phenylephrine IV bolus  Group 1 100-500micrograms slowly Dilute to 1mg in 1ml with N/S. Flush IV bolus with N/S or G.
over 3-5 minutes, repeated Extravasation may cause tissue damage.
if necessary after at least Monitor blood pressure and heart rate.
15 minutes. When an IV infusion is discontinued,
(I) IV infusion.  Groups 1 Adults: Maximum initial Add 10mg to 500ml of N/S or G. slow the infusion rate gradually; do not
Infusion pump is and 2 rate 180micrograms/ stop it abruptly
required. minute reduced according
to response to 30 – 60
micrograms/minute
IM injection  Groups 1 Refer to the Marsden Manual for
and 2 guidance on IM injection.
SC injection  Groups 1 Refer to the Marsden Manual for
and 2 guidance on SC injection.
Phenytoin (I) IV infusion  Groups Adults: Maximum If a suitable in-line filter is not ECG and blood pressure monitoring
sodium through a large 1,2,3,4 and 50mg/minute. available then give as undiluted essential. Monitor for possible respiratory
vein via an in-line 5 injection via a syringe pump as depression. Flush with N/S before and
0.22-0.5 micron After dilution: Use below. If a suitable filter is available after administration of each injection or
filter, using an immediately, complete dilute with N/S to a final infusion to avoid venous irritation.
infusion pump. infusion within 1 hour. concentration not exceeding Sodium content 0.91mmol/250mg.
10mg/1ml. Do not use if solution is Incompatible: Do not infuse with any other
hazy or contains precipitate. drugs.
Slow IV bolus or (I)  Groups Adults: Maximum Give undiluted. Resuscitation equipment should be
IV infusion into a 1,2,3,4 and 50mg/minute. available.
For children, large vein. A pump 5 Suitable filters to administer phenytoin
refer to the is required for diluted in N/S include PALL 0.22 micron,
Paediatric infusion. Braun Sterifix 0.2 micron, Technopharm
Injection This method, codan 0.2 micron filters. These filters
Administration (undiluted infusion) should be ordered through ORACLE.
Guide. may only be used Note that dilution of Kent/Hikma brand
for adults. phenytoin injection is not licensed.
 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 153
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE SUITABLE DILUENT
Phosphate (I) IV infusion via  Groups Infuse over 6 – 12 Provided ready-diluted. Do not Dosage: Serum phosphate 0.5-0.7mmol/L
Polyfusor peripheral or 1,2,3,4 and 5 hours. further dilute. infuse 1 - 2ml/kg. Serum phosphate <0.5mmol/L
central IV line. Maximum rate: infuse 2 – 5ml/kg. Maximum dose 500ml per
Infusion pump is 150ml/hour infusion. Infusion can be repeated if necessary.
required. To treat Re-feeding Syndrome, 500ml (50mmol
phosphate) is typically infused over 12 hours.
Incompatible with
This dose may be repeated depending on serum
other solutions
phosphate levels.
containing calcium
or magnesium, Consider reduced dosage in the elderly or
Hartmann’s patients with impaired renal function. Monitor
solution, Ringer’s serum electrolytes including phosphate and
solution, calcium (frequently in renal impairment). Monitor
ciprofloxacin, renal function, ECG and fluid balance.
dobutamine and Pain and phlebitis may occur at the infusion site.
TPN Sodium content 162mmol/L
Potassium content 19mmol/L
Phosphate content 100mmol/L
Flush with N/S.
Phytomenadione IV bolus  Groups Over at least 30 May be given undiluted. Product has been reformulated without
(Konakion MM® 1,2,3,4 and 5 seconds, usually 3-5 Alternatively, draw up the required polyethoxylated castor oil, however there is still a
vitamin K) minutes per 10mg. dose from the ampoule then dilute risk of anaphylaxis with rapid IV administration.
10mg in 1ml further with a small volume (eg. Protect infusion and giving set from light.
10-20ml) of G. Flush with G.
Do not dilute the 10mg in 1ml with The contents of the 10mg in 1ml ampoules can
G and take the fraction of the be given by mouth, but this use is unlicensed
diluted injection corresponding to (See page 7)
the required dose, as the MM Do not administer via the IM route.
formulation does not distribute
evenly in the diluent.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 154
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE SUITABLE DILUENT
Phytomenadione IV bolus.  Groups Do not further dilute. Product has been reformulated without
(Konakion MM® The dose may be 1,2 and 4 polyethoxylated castor oil, however there is
Paediatric injected into the still a risk of anaphylaxis with rapid IV
vitamin K) lower part of an administration.
2mg in 0.2ml infusion set
containing 5% Flush with G.
dextrose or 0.9% The contents of the 2mg in 0.2ml ampoules
sodium chloride are also licensed to be given by mouth.
running at
0.7ml/minute
IM injection  Groups For neonatal use following the protocols Further neonatal information can be found
1,2 and 4 on NICU in the Neonatal Formulary 6th Edition.
Konakion MM Paediatric must be
administered by IV injection when used as
an antidote to anticoagulant drugs such as
warfarin & phenindione, as IM injections
may result in significant bleeding in these
patients.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 155
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE OVER SUITABLE DILUENT
Piperacillin/Tazobactam (= Tazocin®) contains a penicillin – check patient’s allergy status before administration
Piperacillin/ (I)IV infusion  Groups Give over 30 Reconstitute each 2.25g with 10ml and Flush with N/S.
Tazobactam using an infusion 1,2,3,4 and 5 minutes each 4.5g with 20ml of W, or N/S. Sodium content: 4.7 - 5.58mmol/2.25g vial
pump. Swirl until dissolved. When swirled and 9.4 – 11.2mmol/4.5g vial.
constantly reconstitution should occur Incompatible with all aminoglycosides.
Slow IV bolus of within 3 minutes. Do not mix with or give through the same
this medication Displacement ranges 1.5 – 1.7ml per line at the same time as gentamicin,
is no longer 2.25g. amikacin, tobramycin etc. If only one line
recommended The reconstituted solution may be available separate the doses and flush well
or licensed. further diluted with N/S or G to the with N/S before and after each dose.
desired volume (eg. dilute to 50ml or
add to a 100ml mini-bag). Do not give through the same line as
Hartmann’s

In paediatrics, the maximum

concentration for infusion is 90mg/ml.
Pitressin ® See vasopressin

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 156
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE OVER SUITABLE DILUENT
Potassium chloride (C) IV infusion.  Groups Adults: Usual If a concentration of potassium other Pain or phlebitis may occur during
ready prepared Infusion pump 1,2,3,4 and 5. maximum rate than 20, 40 or 80mmol/litre is peripheral administration of solutions
infusion bags is required. 20mmol prescribed contact the ICU pharmacist containing 30mmol or more
Selected
containing potassium/hour. or the on-call pharmacist. potassium/litre. Solutions containing more
Group 8
20mmol/L than 40mmol/litre potassium should ideally
Assistant
or 40mmol/L be given via a central line. However, in
Practitioners
potassium in N/S, G cases of serious hypokalaemia with no
can administer
or G/S. central access up to 80mmol/litre
potassium
Can be kept as stock potassium may be tolerated peripherally if
chloride
by all wards and given via a large vein (e.g. femoral vein).
20mmol in 1L
departments. N/S in Extravasation will cause tissue damage.
Ready-made bags accordance *In adults, the rate of administration may
containing with the AP be increased to 40mmol/hour in the initial
80mmol/litre are also protocols. management of diabetic ketoacidosis, and
available if necessary in Cardiothoracic ICU, so long
as the patient’s ECG is monitored and
resuscitation equipment is available.
Administration of IV potassium at a rate
Potassium chloride (I) IV infusion  Groups 1 Adults: Usual Critical care areas only may give exceeding 40mmol/hour poses a serious
15% injection via central IV and 2 maximum rate undiluted 2mmol/ml potassium risk of asystole.
line via infusion 20mmol injection via a central line with ECG Flush with N/S.
Potassium chloride pump. potassium/hour* monitoring, or dilute to the required For instructions on the use of potassium
concentration with N/S, G, G/S or H chloride injection during cardiopulmonary
50mmol in 50ml with thorough mixing. bypass refer to the Blood Cardioplegia
pre-filled syringes
Management section of the Clinical
From October 2015 Penrose and Perfusion policy.
May only be stocked Pencarrow will be using pre-filled
by Critical Care syringes containing 50mmol potassium
areas chloride in 50ml.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 157
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE OVER SUITABLE DILUENT
Potassium chloride (C) SC infusion  Groups Adults: maximum Use the ready-made infusion bags There is anecdotal evidence that up to
ready prepared Only use gravity- 1,2,3,4 and 5 rate 20mmol containing 20mmol/L potassium 40mmol/L potassium can be given by SC
infusion bags feed potassium/hour. chloride available from Pharmacy. infusion. However, SC potassium infusion
containing administration can cause ulceration and the risk is greater
20mmol/L sets. Never use at 40mmol/L than at 20mmol/L.
potassium in N/S, G an infusion Monitor the infusion site regularly for early
or G/S. pump for SC signs of irritation and inflammation.
infusions.
Potassium chloride Intra-cardiac for  Group 1 To be administered in accordance with A single ampoule may be ordered as a
15% injection feticide procedures for feticide on the Early Controlled Drug by these Units. Records of
Pregnancy Unit or the Emergency receipt and administration are as for
Gynaecology Unit. Controlled Drugs.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 158
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE OVER SUITABLE DILUENT
Potassium (I) infusion.  Groups 1 Adult patients on a Critical care areas only may give Flush with N/S
phosphate Infusion pump is and 2 critical care unit: undiluted potassium phosphate Up to 0.3 – 0.6mmol/kg/day of phosphate
(Dipotassium required. Usual maximum injection via a central line with ECG may be required during the treatment of
hydrogen rate 20mmol monitoring. For administration via a Refeeding Syndrome.
phosphate) potassium/hour peripheral line dilute with N/S, G or G/S Dipotassium phosphate 17.42 % injection
injection (30mmol phosphate to a usual maximum concentration of contains 1mmol phosphate/ml and 2 mmol
over 3 hours) 40mmol potassium/litre. potassium/ml.
*May only be
stocked by Critical It is suggested that
Care areas. general wards ask
the doctor to
prescribe a dose of
Phosphate
Polyfusor instead
(See page 182)
Privigen® See Immunglobulin Human Normal
Prochlorperazine Deep IM injection  Groups Refer to the Marsden Manual for Flush IV bolus with N/S.
1,2,3,4 and 5 guidance on IM injection. Prochlorperazine is unlicensed (See page
IV bolus  Groups Maximum rate Dilute 1 part with 5 parts N/S before 7) by the IV route.
1,2,3,4 and 5 6.25mg/minute administration. IV administration can cause hypotension
and venous irritation.
Procyclidine IV bolus  Groups Suggestion: over 1 Dilution is not recommended. Flush with N/S
1,2,3,4 and 5 minute

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 159
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE SUITABLE DILUENT
Propofol IV bolus  Groups 1 Do not dilute. Can be administered Monitor ECG and blood pressure. Also
and 2* through tubing (close to the injection monitor for airway obstruction and oxygen
site) of infusions of N/S, G or G/S. saturation. Resuscitation equipment should
be available.
*Boluses of propofol may only be given by
Group 2 nurses to ventilated patients in
level 3 critical care.
(C) IV infusion.  Groups 1 Dependent on Infuse undiluted or dilute with G to a Administer immediately after preparation of
and 2 indication. concentration of not less than 2mg/1ml. the syringe or infusion.
Anaesthetics Directorate policy: Administer
[Link] Propfol-Lipuro can be diluted propofol within 30 minutes of drawing up
with G, N/S or G/S to a concentration into syringe.
of not less than 2mg/1ml. Use propofol diluted with G, N/S or G/S
within 6 hours of preparation.
When using [Link] (Propofol –Lipuro),
Generics UK and Fresenius kabi brands of
propofol in bottles for infusion, the bottle
and line should be changed at least every
If diluted in a PVC bag withdraw a 12 hours.
volume of infusion fluid and replace it To reduce pain on injection 20ml 1%
with an equal volume of propofol 1%. propofol may be mixed with up to 1ml of 1%
lignocaine immediately before use.
Flush with N/S.
Propranolol IV bolus  Group 1 Adults: 1mg over 1 Can be diluted with N/S or G. ECG monitoring required.
Emergency minute. May be Flush with N/S. Sodium content nil.
use. repeated at 2-minute If IV used as temporary substitute for oral
intervals until desired propranolol 1mg IV = 10mg orally.
response observed or *Maximum dose of 10mg in conscious
until maximum dose* patients or 5mg in patients under
anaesthesia.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 160
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY
ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Protamine Reversal of IV heparin  Groups Slow injection over Can be diluted with N/S. Flush with N/S.
sulphate infusion 1,2,3,4 and 10 minutes. Monitor APTT coagulation tests.
IV bolus 5 Maximum rate
5mg/minute
Reversal of SC heparin:  Groups Slow IV injection Dilute to a suitable volume with Too rapid administration of protamine
Dose: 1mg protamine per 1,2,3,4 and (maximum rate N/S or G. sulphate may cause severe hypotension
100 units heparin. Give 25- 5 5mg/minute) and anaphylactoid reactions. Facilities for
50mg of this dose by slow followed by resuscitation and treatment of shock
IV bolus followed by (C) IV infusion of the should be available.
infusion of the remainder of remainder of the
the calculated protamine calculated
dose via an Infusion pump. protamine dose
over 8-16 hours
Partial (60% maximum)  Groups Maximum rate Can be diluted with N/S. Decisions regarding the necessity and
reversal of enoxaparin 1,2,3,4 and 5mg/minute dose of subsequent protamine injections
Within the first 8 hours after 5 should be based on clinical response
enoxaparin administration: rather than measurement of anti Xa or
1mg protamine per 1mg anti XIIa results. The physician should
enoxaparin (maximum dose also consider that the amount of
50mg protamine) by slow IV enoxaparin in the body drops to 50%
bolus after 8 hours and 33% or less after 12
hours. The dose of protamine should be
adjusted depending on the length of time
since enoxaparin was administered.
Protirelin IV bolus  Group 1 30-60 seconds Suggestion: Over 30-60 seconds Diagnostic test.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 161
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Quinine (I) IV infusion.  Groups 4 hours Flush with N/S
Dilute required dose in 250ml or
dihydrochloride Infusion pump 1 and 2 500ml N/S or G. Therapy should be changed to oral as soon as
is required. possible. Sodium content: negligible.
However, in fluid restricted
See comments
Usual loading dose is 20mg/kg (upto a maximum
patients a maximum dilution of
for alternative
of 1.4g) quinine dihydrochloride over 4 hours. On
30mg/ml may be infused via a
possible
central IV line, ICU the loading dose can alternatively be given
administration of
as 7mg/kg quinine dihydrochloride infused over
loading dose on
30 minutes followed immediately by 10mg/kg
ICU.
over 4 hours.
Ramucirumab (I) IV infusion.  Groups Infuse over A closed-system device must *The infusion rate of ramucirumab should be
▼ This product is Infusion pump 1,2,3,4 and 5 approximately 60 be used to prepare reduced by 50% for the duration of the infusion
being intensively is required. minutes* via a ramucirumab. and all subsequent infusions if the patient
monitored by the 0.22 micron in- experiences a grade 1 or 2 infusion-related-
CHM and MHRA. line filter. Dilute the prescribed dose to reaction.
Please report all 250ml N/S (first remove a Monitor for: rigors/tremors, back-pain/spasms,
suspected reactions (Maximum rate of volume of N/S from the bag, chest pain and/or tightness, chills, flushing,
(including non-serious 25mg/minute – equal to the volume of dyspnoea, wheezing, hypoxia, paraesthesia,
ones) using a Yellow for very large ramucirumab solution being bronchospasm, supraventricular tachycardia,
Card from the BNF patients the added). Gently invert the bag to and hypotension.
infusion time may ensure adequate mixing. DO Temporarily discontinue the infusion in the event
need extending) NOT SHAKE the infusion of severe hypertension, until controlled with
solution. antihypertensives.
Resuscitation equipment should be immediately
available.
Flush with N/S’
DO NOT dilute with other solutions or co-infuse
with other electrolytes or medicinal products.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 162
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Ranitidine IV bolus  Groups Adults: at least 2 May be diluted further with G or Flush with N/S, G or G/S.
1,2,3,4,5 and minutes* N/S (20ml for example) Sodium content 0.12mmol/2ml.
8 Children: at least 3 *A slower bolus over 5 minutes is
minutes* recommended by some references because of
the risk of causing bradycardia on
(I) IV infusion  Groups 2 hours at Add 50mg ranitidine to 100ml
administration.
via pump. 1,2,3,4 & 5 25mg/hour N/S or G.
(C) IV infusion  Groups 125-250 Dilute 150mg ranitidine to 250ml
via pump, after 1,2,3,4 and 5 micrograms/ with N/S or G.
initial IV bolus. kg/hour
IM injection  Groups Refer to the Marsden Manual
1,2,3,4 and 5 for guidance on IM injection.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 163
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Radio-  Groups 1 Refer to Group Protocols/PGD’s within the
Pharmaceuticals and 7 Department of Nuclear Medicine.
Rasburicase (I) IV infusion.  Groups 30 minutes Reconstitute each 1.5mg vial with Infuse through a different line to that used for
Infusion pump 1,2,3,4 and the 1ml of solvent provided. chemotherapy agents. If this is not possible,
is required. 5 Reconstitute each 7.5mg vial with flush between the chemotherapy agents and
the 5ml solvent provided. Swirl the rasburicase with N/S.
vials gently to dissolve the powder. Rasburicase is not cytotoxic or mutagenic
Do not shake. The reconstituted Rasburicase is not compatible with glucose
solution will be 1.5mg/ml. Draw up solutions.
the prescribed dose from the Pharmacy will dispense a 50ml EasyFlex bag of
reconstituted vials and add to a N/S for each dose of rasburicase when it
50ml EasyFlex bag of N/S. dispenses the rasburicase vials.
Usual dosages:
Prophylactic: 3mg once daily for 1-3 days
Treatment: 0.2mg/kg rounded to the nearest
1.5mg, once daily, depending on seum uric acid
levels.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 164
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE OVER SUITABLE DILUENT
Remifentanil IV bolus infusion at  Groups 1 If not using Reconstitute to a concentration of 1mg/ml IV bolus infusion not necessary if intubation is
induction of and 2 pre- with N/S or W. Further dilute to a to occur more than 8-10 minutes after
anaesthesia. programmed concentration of 20-250 micrograms/ml with commencing remifentanil infusion.
(C) IV infusion syringe pump N/S or G. IV bolus infusion is not recommended for
during maintenance see table (20 -25 micrograms/ml is recommended for induction in cardiac anaesthesia .Instead
of anaesthesia or for below paediatric patients aged 1 year and over). intubate at least 5 minutes after start of
sedation of For TCI (Target Controlled Infusion) the infusion.
ventilated patients in recommended dilution is 20-50 Monitor cardiovascular and respiratory
intensive care. micrograms/ml. However, 100 microgram/ml functions.
(eg 5mg in 50ml) is often used for TCI and Resuscitation equipment must be available.
Infusion pump is
for sedation of ventilated ICU patients. Do not flush line. Sodium content: Nil.
required.

REMIFENTANIL INFUSION RATES

Anaesthesia in adults Anaesthesia in children Sedation in Intensive Care
including cardiac anaesthesia 1 – 12 years of age (Standard Remifentanil Protocol for
Penrose & Pencarrow wards, Derriford Hospital)
Bolus infusion Continuous infusion Bolus infusion Continuous infusion  Dilute the reconstituted remifentanil to 100mcg/ml with N/S
0.5 –1 0.025 –2 1 microgram/kg 0.05 –1.3 (equivalent to 5mg in 50ml).
microgram/kg microgram/kg/minute over at least 30 microgram/kg/minute  Start the infusion at 5ml/hour, and titrate rate in 1ml/hour increments
over at least 30 (rate dependent on seconds. (rate dependent on every 5 minutes to achieve the desired analgesia/sedation.
seconds. choice of general choice of general  Usual range 1 – 10ml/hour.
anaesthetic(s)) anaesthetic(s))  At rates above 10ml/hour, monitor for bradycardia and hypotension.
 Do not bolus remifentanil. However, when infusing remifentanil and
propofol through the same lumen, propofol may be bolused, as the
volume of remifentanil between the 3-way tap and the tip of the
catheter is not considered significant.
 N.B. the use of remifentanil, and the bolusing of propofol often require
mandatory ventilation.
 For patients <50kg, start infusion at 2.5ml/hour and titrate in 0.5ml
increments.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 165
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY GIVE ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
SUITABLE DILUENT
Rifampicin (I) IV infusion.  Groups 1,2,3,4 2-3 hours Reconstitute with diluent provided (10ml) and Flush with N/S.
Infusion and 5 shake vigorously for 30 seconds. Then dilute to Discard remaining infusion after 6
pump is a concentration of 600mg in 500ml N/S, G or hours. Sodium content less than
required. G10%. 0.5mmol/600mg.
If patient is fluid restricted 600mg may be Displacement volume for a
diluted in 100ml G and given over 30 minutes. 600mg vial is 0.48ml.
Do not infuse with any other
drugs.
Rocuronium Rapid IV  Group 1- must No specific recommendations. Dilute to Flush with N/S or G.
bolus only be given by appropriate volume with N/S, H or G. Compatible with G/S and H.
doctors proficient in Sodium content 0.72mmol/50mg.
advanced airway If the patient is ventilated IV
management. Also bolus can be administered by
see comments Group 2 staff.
(C) IV  Groups 1 and 2 300-600
infusion. micrograms/kg/hour
Infusion
pump is
required.
Rituximab SC injection  Groups 1 and 2 Draw up the 1400mg in 11.7ml from the vial Common side effecs: injection site
For treating using a closed-system device. erythema, pain or oedema
lymphoma

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 166
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Rituximab Read and print off the full guideline from the Royal College of Nursing:
For treating [Link]
severe active (I) IV  Groups 1 (Premedication is required – see comments) Although rituximab may be diluted Premdication:
Rheumatoid infusion via and 2 First infusion on Day 1: with N/S to a concentration Dose of oral paracetamol 60 minutes
Arthritis in an infusion between 1mg/ml and 4mg/ml, the before each rituximab infusion (not if
50mg/hour (25ml/hour of 1g in 500ml dilution)
adults, or for pump usual concentration is 2mg/ml. paracetamol already given in the last
for the first 30 minutes then
treating 4 hours).
100mg/hour (50ml/hour of 1g in 500ml Rituximab infusion should be Chlorphenamine 10mg IV 60 minutes
lymphoma or
dilution) for the second 30 minutes, prepared by Pharmacy. before each rituximab infusion.
leukaemia
then the rate can be increased by 50mg/hour Telephone Ext. 31083. Methylprednisolone 100mg in 100nl
(25ml/hour of 1g in 500ml dilution) every 30 N/S infused over 30 minutes to be
minutes to a maximum rate of 400mg/hour commenced 60 minutes before each
(200ml/hour of 1g in 500ml dilution) providing rituximab infusion (not always in
no adverse reactions occur. Haematology).
Full resuscitation facilities must be
(Premedication is required – see comments) immediately available.
Monitoring:
Second infusion on Day 15:
1st hour – blood pressure, pulse,
100mg/hour (50ml/hour of 1g in 500ml temperature and O2 sats every 15
dilution) for the first 30 minutes then minutes. Thereafter, every 30
200mg/hour (100ml/hour of 1g in 500ml minutes after increasing the infusion
dilution) for the second 30 minutes, rate, and throughout the course of
then the rate can be increased by the infusion once maximum rate is
100mg/hour (50ml/hour of 1g in 500ml reached.
dilution) every 30 minutes to a maximum rate Possible reactions:
of 400mg/hour (200ml/hour of 1g in 500ml Low grade fever, BP drop of
dilution) providing no adverse reactions occur. <30mmHg from baseline: halve the
infusion rate.
Fever >38.50C, chills, mucosal
swelling, dyspnoea, BP drop of >
30mmHg from baseline: stop the
infusion and contact the doctor.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 167
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD

Romiplostim 1. Remove the plastic cap from 5. Holding the pre-filled syringe of
Romiplostim powder vial and clean water for injections with one hand,
(Nplate®)
rubber stopper using the provided bend the tip of the white plastic cover
SC Injection by alcohol swab. downward with your other hand. This
 Groups 1 and 2 will break the seal of the white plastic
cover. Once the seal is broken, pull
cover off to separate the grey rubber
Each vial is for cap from the clear plastic syringe tip.
single use only.
2. Attach vial adapter to Romiplostim 6. Keeping the vial on the bench,
Do not mix with
vial by peeling off paper backing attach the pre-filled syringe of water
N/S or any drug from vial adapter, keeping the vial for injections to vial adapter: hold the
solutions adapter in its packaging. Keeping outer edge of the vial adapter with
the vial on the bench, push the vial one hand and twist the syringe tip
Refer to the adapter down onto the centre of the clockwise onto the adapter with the
Marsden Manual vial until it is firmly in place. other hand until you feel a slight
for guidance on resistance.
SC injection.

3. Remove and discard vial adapter 7. Very slowly and gently expel all
packaging. water (0.72ml) into the 250
microgram powder vial. Water should
flow slowly onto powder. GENTLY
swirl the vial until all of the powder
has dissolved and the fluid in the vial
is clear and colourless. Do not shake
or agitate vial

4. Attach plunger rod to the pre- 8. Visually inspect the reconstituted solution for particulate matter and/or
filled syringe of water for discoloration. The reconstituted solution should be clear and colourless and
injections by twisting the plunger rod should not be administered if particulate matter and/or discolouration are
clockwise onto the syringe plunger, observed. Make sure solution is fully dissolved before removing syringe.
until you feel a slight resistance. Instructions continued on next page…

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 168
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD (Continued from previous page)

Romiplostim 9. Remove the empty pre-filled 13. Twist off administration

syringe from the vial adapter. syringe from vial adapter.
(Nplate®)
10. Remove 1 ml administration Attach safety needle to the filled
SC Injection by syringe from package. Attach the administration syringe by twisting
 Groups 1 and 2 1 ml syringe to vial adapter of needle clockwise into syringe Luer
reconstituted solution by twisting the lock tip.
(Continued) syringe tip onto the vial adapter until
you feel a slight resistance.

11. Turn assembled syringe-vial 14. Prepare injection site with a new
unit upside down, so the vial of alcohol swab. Pull back on the
reconstituted product is above the pink safety cover toward the
syringe. Withdraw all of the syringe and away from the needle.
medicinal product solution into the Remove clear needle shield from
administration syringe. prepared needle by holding syringe
in one hand and carefully pulling
shield straight off with the other
hand.
12. Ensure the correct amount of 15. Administer subcutaneous injection following local protocols and
solution for the patient dose is in good aseptic technique.
the administration syringe by
16. After injecting, activate the
expelling any excess solution back
pink safety cover by pushing the
into the vial.
cover forward using the same hand
until you hear and/or feel it
0.5ml of reconstituted solution
click/lock.
contains 250micrograms

17. Immediately discard syringe and needle into an approved Sharps

Container

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 169
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Salbutamol IV bolus  Groups 3-5 minutes Dilute 500micrograms in 1ml Flush with N/S or G.
1and 2 salbutamol injection with 9ml W, ECG monitoring recommended.
N/S or G to give a concentration of Sodium content 0.15 mmol/ml.
50micrograms in 1ml. If necessary in adult or paediatric
SC injection  Groups 1 Refer to the Marsden Manual for intensive care salbutamol 5mg/5ml IV
and 2 guidance on SC injection. solution for infusion may be given
(C) IV infusion.  Groups Asthma: Asthma: Dilute 5ml (5mg) of undiluted via a central IV line (this method
Infusion pump 1,2,3,4 and 3-20 micrograms/minute Ventolin Solution for Infusion to is unlicensed -see page 7) 3 – 20
is required. micrograms/minute = 0.18 – 1.2ml/hour
5 = 18 -120ml/hour of the 5mg in 500ml with G or N/S to make a
concentration of 10micrograms/ml using this dilution.
500ml dilution
(I) IV infusion  Groups 1 Premature Labour: Premature labour: Dilute 10ml
using syringe and 2 10 micrograms/minute (10mg) of Ventolin Solution for
pump. increasing the rate at 10 minute Infusion to 50ml with G or N/S to
intervals to maximum rate of 45 make a concentration of 200
micrograms/minute. Once micrograms/ml
(I) IV infusion.  Groups 1 uterine contractions have Premature Labour: Dilute 10ml
Using and 2 ceased the infusion rate should (10mg) of Ventolin Solution for
volumetric be maintained at the same level Infusion to 500ml with G or N/S to
pump. for one hour and then reduced make a concentration of
by 50% decrements at six 20 micrograms/ml
hourly intervals

10 – 45micrograms/minute =
3 -13.5ml/hour of the 10mg in
50ml dilution.

10 – 45micrograms/minute =
30 – 135ml/hour of the 10mg in
500ml dilution.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 170
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Secretin IV bolus  Groups 1 For exocrine Reconstitute each vial with the Can be given as infusion using a syringe
pentahydrochloride and 2 pancreatic function test 10ml N/S provided making a pump depending on how the test is run.
(Secrelux®) inject over 1 – 2 concentration of 10 Clinical
minutes Units/ml. Draw up the prescribed 1 Clinical Unit/kg dose = 0.1ml/kg of
(Secrelux® is an dose. reconstituted secretin
unlicensed product- (I) IV infusion.  Groups 1 1 hour Reconstitute each vial with the
see page 7) Infusion pump is and 2 10ml N/S provided making a 2 Clinical Unit/kg dose = 0.2ml/kg of
required. concentration of 10 Clinical reconstituted secretin.
Units/ml. Draw up the prescribed
dose and infuse over 1 hour. Administer immediately after preparation.
Sodium benzoate Loading dose  Groups 1 90 minutes Draw up 250mg/kg = 1.25ml/kg Follow the BRHC guidelines for the
2g in 10ml (I) IV infusion and 2 of injection and dilute in 5ml/kg of management of hyperammonaemia –
10%G. [Link]
(Unlicensed product- Maintenance  Groups 1 24 hours Draw up 250mg/kg = 1.25ml/kg Click on “Clinical Guidelines” then
see page 7) (C) IV infusion and 2 of injection and dilute in 5ml/kg of “Hyperammonaemia”
10%G.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 171
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Sodium bicarbonate (C) IV infusion.  Groups Ready prepared infusions are Flush with N/S or G.
Infusion pump is 1,2,3,4 and 5 available from pharmacy. Concentrations for IV infusion greater
required. Can be diluted with N/S or G. than 1.4% should be given via a central IV
line
IV bolus  Group 1
Sodium chloride (C) or (I) IV  Groups Ready prepared infusions are Concentrations over 1.8% should be
infusion. 1,2,3,4,5 and available from pharmacy. given via a central line. Sodium content of
N.B. All bags of 8 0.9% injection is 150mmol/1 litre.
sodium chloride are IV bolus  All groups Can be diluted with G, G/S or H.
for single use only.
(C) SC infusion  Groups Usual rate is 500ml Maximum concentration of sodium
Only use gravity- 1,2,3,4 and 5 over 8 hours (21 drops chloride by subcutaneous infusion is
feed per minute). Maximum 0.9%.
administration rate is 500ml over 1 Usual maximum of 2 litres in 24 hours.
sets. Never use hour (167 drops per However, 3 litres may be given if
an infusion minute) necessary over 24 hours using two SC
pump for SC sites. The needle and giving set should
infusions. preferably be changed every 72 hours.
However, infusion sets can be left in place
for up to 5-7 days if there are no
complications. Refer to potassium
chloride monograph for SC potassium.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 172
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Sodium fusidate/ (I) IV infusion into  Groups 2 hours Displacement is negligible. Add
Fusidic acid a central venous 1,2,3,4 and 5 10ml buffered diluent for 500mg in G can be used as diluent but opalescence
line (preferred 10ml (50mg in 1ml). may occur with more acidic samples
method). Infusion Reconstitute with 10ml buffered (infusion must be discarded).
pump is required diluent provided then dilute with Flush with N/S.
500ml N/S or G. When reconstituted with 10ml buffer,
6 - 8 hours For fluid restricted patients preparation contains 3.1mmol sodium and
reconstitute as above then dilute 1.1mmol phosphate.
with 100ml N/S (unlicensed dilution Sodium fusidate is well absorbed from the
- see page 7) GI tract so consider an early switch to
(I) IV infusion into  Groups 6 -8 hours Reconstitute and dilute with 500ml tablets or mixture.
wide bore 1,2,3,4 and 5 as above. Alternatively for fluid
peripheral vein. restricted patients dilute with 250ml
Infusion pump is N/S or G (unlicensed dilution - see
required. page 7).

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 173
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Sodium (C) IV infusion.  Groups Increase rate slowly until Reconstitute 50mg with the 5ml G Intra-arterial blood pressure monitoring
nitroprusside Infusion pump is 1 and 2 desired effect occurs. provided then further dilute with
necessary.
required. The maximum rate is 500ml or 1000ml of [Link] infusion and administration set
(N.B Nitroprussiat 8micrograms/kg/minute from light: Use the tin foil provided to wrap
fides brand is in order to avoid
Intensive care areas or Theatres the bag and administration set, or the line.
unlicensed – see excessive levels of
only may use a dilution of 1mg/ml Use an amber syringe if giving by syringe
page 7) cyanide and thiocyanate
50mg in 50ml) in G via a central IV pump.
and to lessen the
line. Discontinue infusion gradually over 15-30
possibility of a sudden minutes to avoid rebound hypertension.
drop in blood pressure. Discard infusion solution if it is highly
coloured.
When using the Nitroprussiat fides
brand the prepared infusion should be
discarded after 4 hours.
Do not flush - replace giving set.
Sodium content 0.34mmol/50mg.
Using the 50mg in 50ml dilution for Intensive Care areas or Theatres:
Hypertensive crisis 0.5 – 8micrograms/kg/minute = 0.03 – 0.48ml/kg/hour
Maintenance of blood pressure at 30-40% lower than pre- 20 – 400micrograms/minute =1.2 – 24ml/hour
treatment diastolic (Lower doses if treated with other
antihypertensives)
Controlled hypotension in surgery Up to a maximum of =Up to a maximum of 0.09ml/kg/hour
1.5micrograms/kg/minute
Heart failure 10 – 200micrograms/minute =0.6 – 12ml/hour

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 174
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Sodium Loading dose  Groups 1 About 90 minutes Draw up 250mg/kg = 1.25ml/kg of Follow the BRHC guidelines for the
phenylbutyrate (I) IV infusion and 2 injection and dilute in 5ml/kg of management of hyperammonaemia –
2g in 10ml 10%G. [Link]
Maintenance  Groups 1 24 hours Draw up 250mg/kg = 1.25ml/kg of Click on “Clinical Guidelines”, then “ALL”
(Unlicensed (C) IV infusion and 2 injection and dilute in 5ml/kg of then “Hyperammonaemia”
product- see page 10%G.
7)

For a ready-made phosphate infusion that can be given via a peripheral or central vein, see the monograph for Phosphate Polyfusor
Sodium (I) or (C) IV  Groups Adult patients on a Via a peripheral vein dilute dose Flush with N/S.
Phosphate infusion. Infusion 1,2,3,4 and 5 critical care unit: with a suggested volume of 500ml
(Disodium pump is required Suggested maximum N/S or G. Up to 0.3 – 0.6mmol/kg/day of phosphate
Hydrogen infusion rate of may be required during the treatment of
Phosphate) 10mmol phosphate per Undiluted sodium phosphate Refeeding Syndrome.
hour (30mmol injection may be infused via a
phosphate in 50ml central IV line using a syringe Disodium hydrogen phosphate 21.49%
over 3 hours). pump. injection contains 6mmol phosphate in
It is suggested that 10ml
general wards infuse (30mmol phosphate in 50ml).
the dose of phosphate
over 12 hours or ask
the doctor to prescribe
a dose of Phosphate
Polyfusor instead (See
page 146)

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 175
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Sodium valproate IV bolus  Groups 3 - 5 minutes. Wockhardt brand is supplied as Flush with N/S, G or G/S.
Usual method 1,2,3,4 and 5 a 400mg in 4ml solution. No Sodium content 2.41mmol/400mg vial.
further dilution needed for slow Usually continue the patient’s current oral
IV bolus. dosage as repeated slow bolus injections.
Alternatively continue total usual oral daily
Epilim® brand: Reconstitute with dosage as a continuous IV infusion over
4ml diluent provided. 24 hours.
Due to the product displacement For patient’s not previously treated with
this produces a solution of sodium valproate a slow bolus of 400 –
95mg/ml. 800mg depending on patient’s weight (up
(C) IV infusion.  Groups Divide total infusion Reconstitute as above then to 10mg/kg) is given followed by
Infusion pump 1,2,3,4 and 5 volume by 24 to set the dilute with N/S or G to any continuous infusion (Max. 2500mg per
is required. hourly rate on the pump suitable volume of at least 50ml day).
(I) IV infusion.  Groups 1 hour Reconstitute as above then Do not infuse with any other drugs.
Infusion pump 1,2,3,4 and 5 dilute with N/S or G to any
is required. suitable volume of at least 50ml
Streptokinase (C) or (I) IV  Groups 1,2 Myocardial Infarction: Streptase brand reconstitute all ECG and blood pressure monitoring
infusion. and 3 1.5 MU over 60 sizes with 5ml N/S. Further required.
Infusion pump minutes. dilute 1.5 MU dose in 50- 1 MU= 1,500,000 units
is required. Embolism/thrombosis 200mlN/S, G or H. Flush with N/S.
250,000 units over 30 Dilute other doses in any Duration of infusion: 72 hours for DVT or
minutes followed by suitable volume of N/S or G e.g. 24 hours for PE or 24-72 hours for arterial
100,000units/hour. 50-250ml. thrombosis or 12 hours for central retinal
thrombosis.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 176
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Streptomycin Deep IM  Groups 1 Refer to the Marsden Reconstitute the 1g vial with In the treatment of tuberculosis the usual
injection and 2 Manual for guidance on 2 -3ml W. dose for adults and children 1month to
(Unlicensed product IM injection. The concentration for IM 18 years is 15mg/kg up to a maximum of
– see page 7) Change the injection should not exceed 1000mg, given daily or three times a
injection site 500mg/ml week. For the elderly and adults over 40
each time. years of age or less than 50kg body
The displacement volume is weight give 500mg-750mg once daily or
approximately 0.8ml 750mg three times a week.

So if you dissolve the powder Monitor serum levels, particularly in

with 3.2ml W the solution patients with renal impairment, and
produced will be 250mg/ml adjust dosage accordingly.
(I) IV infusion  Groups 1 30-60 minutes Reconstitute the 1g vial as
into a and 2 above then draw up the required The vial labelled for IM-only use may be
peripheral or dose and add it to 100ml N/S. reconstituted with W, diluted in 100ml
central venous N/S and infused over 30-60 minutes as
line via a pump described.
Subcuvia® See Immunoglobulin Human Normal
Subgam® See Immunoglobulin Human Normal

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 177
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Sugammadex Rapid IV bolus  Group 1 Rapid injection within Adult dose for immediate If sugammadex is administered via the
10 seconds reversal of rocuronium block is same infusion line that is also used for
Approved use in this 16mg/kg of undiluted 500mg in other medicinal products, flush before
Trust: Immediate 5ml injection. and after sugammadex administration
reversal of with N/S.
neuromuscular block 16mg/kg = 0.16ml/kg of the
by rocurronium when 500mg in 5ml injection However, sugammadex can be injected
intubation and into the intravenous line of a running
ventilation have failed. infusion with the following intravenous
solutions: N/S, G, H, and sodium chloride
It will also be effective 0.45% and glucose 2.5%.
in a similar emergency
situation to reverse
vecuronium.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 178
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY GIVE ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
AND SUITABLE DILUENT
Sulphadiazine (I) IV infusion.  Groups 1,2,3,4 and Minimum 30-60 Dilute dose with N/S to a Flush with N/S.
Infusion pump 5 minutes maximum concentration of Sodium content approximately 4mmol/1g.
is required. 50mg/1ml. Preferably dilute To reduce the risk of crystallisation in the
required dose to 500ml to 1 litre urine a high fluid intake (2.5-3.5 litres in
to reduce risk of crystallisation in 24 hours) should be maintained with
the urine. urinary output of not less than half that
amount. In addition the urine should be
rendered alkaline.
Suxamethonium IV bolus  Group - must only Ready diluted Flush with N/S or G.
be given by doctors
proficient in advanced
airway management.
(C) IV infusion.  Groups 1 and 2 2.5 - 4mg/minute Infuse as a 1mg/ml to 2mg/ml Infusion not usually recommended due to
Infusion pump solution diluted in N/S or G. development of phase II neuromuscular
is required. block and likelihood of exceeding
maximum dose.
Synacthen® See Tetracosactide.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 179
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Tacrolimus (C) IV  Groups Infuse daily Draw up the correct dose in a 1ml Tacrolimus is adsorbed to PVC and must be infused though a
infusion. 1,2,3,4 and dose in 48ml syringe (See table below). PVC-free or PE-lined extension set (Torcross, Penrose and NICU
Give by mouth Infusion 5 over 24 hours Transfer and dilute to 48ml with stock these).
or enteral pump is (Pump set at N/S or G in a 50ml Terumo or BD Wear gloves when preparing the infusion
feeding tube required. 2ml/hour) syringe. The final concentration Not Y-site compatible with ganciclovir or aciclovir.
routes if at all should be between 4 and 100 Flush with N/S or G.
possible. micrograms/ml. Infuse through a
PVC-free or PE-lined extension
set.
Oral to IV tacrolimus conversion chart Oral to IV tacrolimus conversion chart (continued)
Total oral dose of Approximately Volume of tacrolimus Total oral dose of Approximately Volume of tacrolimus
tacrolimus in 24 hours equivalent IV dose injection (5mg in 1ml) to tacrolimus in 24 hours equivalent IV dose injection (5mg in 1ml) to draw
over 24 hours draw up for further dilution over 24 hours up for further dilution
0.5mg 100micrograms 0.02ml 5.5mg 1.1mg 0.22ml
1mg 200micrograms 0.04ml 6mg 1.2mg 0.24ml
1.5mg 300micrograms 0.06ml 6.5mg 1.3mg 0.26ml
2mg 400micrograms 0.08ml 7mg 1.4mg 0.28ml
2.5mg 500micrograms 0.1ml 7.5mg 1.5mg 0.3ml
3mg 600micrograms 0.12ml 8mg 1.6mg 0.32ml
3.5mg 700micrograms 0.14ml 8.5mg 1.7mg 0.34ml
4mg 800micrograms 0.16ml 9mg 1.8mg 0.36ml
4.5mg 900micrograms 0.18ml 9.5mg 1.9mg 0.38ml
5mg 1mg 0.2ml 10mg 2mg 0.4ml

Tazocin® See Pipercillin/Tazobactam

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 180
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE OVER SUITABLE DILUENT
Tedizolid (I) IV infusion. via  Groups 1 hour Reconstitute the 200mg vial with 4ml W. Swirl Flush with N/S.
▼ This product is pump 1,2,3,4 & 5 gently to dissolve the powder (Avoid shaking). Tedizolid is a reversible non-selective
being intensively This will produce a 50mg/ml solution. inhibitor of Monoamine Oxidase (MAOI)
monitored by the and may theoretically enhance increases in
CHM and MHRA. Further dilute in 250ml N/S. Do not shake the blood pressure produced by
Please report all bag. sympathomimetics (e.g. dopamine,
suspected reactions noradrenaline, adrenaline). Theoretically it
(including non- may cause serotonin syndrome with
serious ones) using serotonin re-uptake inhibitors (SSRIs).
a Yellow Card from Incompatible with Hartmann’s and solutions
the BNF containing calcium or magnesium.
Teicoplanin IV bolus  Groups 3 – 5 minutes Slowly reconstitute each 200mg or 400mg vial Flush with N/S.
Usual method. 1,2,3,4 and for all doses. with the 3.2ml of W provided. Roll the vial Sodium content less than 0.5mmol/vial
Refer to the 5 gently until the powder has completely (200mg and 400mg).
Plymouth Healthnet For doses greater dissolved. Take care to avoid formation of foam. Incompatibile with aminoglycosides (eg.
Clinical than 600mg, give If it does foam, leave the vial to settle for 15 gentamicin).
Guidelines/Infection as an infusion minutes until the foam subsides. Reconstituted Teicoplanin solutions will precipitate when
Control for the use over 30 minutes – in this manner you will be able to extract 200mg they come into contact with gentamicin –
and current dosage see below. in 3ml from the 200mg vial and 400mg in 3ml flush the catheter well with N/S between
of gentamicin, from the 400mg vial. giving these two antibiotics.
teicoplanin and (I) IV infusion. via  Groups 30 minutes Reconstitute as above then dilute the required
vancomycin. pump 1,2,3,4 & 5 dose further with N/S, G, G/S or H (e.g. 50ml or
100ml).
IM injection of  Groups Reconstitute as above. Refer to the Marsden Manual for guidance
doses up to 1,2,3,4 and on IM injection.
400mg possible 5
only when IV
access cannot be
established and
after discussion
with Microbiologist

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 181
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE OVER SUITABLE DILUENT
Temocillin is a penicillin – check patient’s allergy status before administration
Temocillin Slow IV bolus  Groups 3 – 4minutes Reconstitute each 1g with 10ml W and Incompatible with aminoglycosides e.g.
1,2,3,4 and 5 shake vigorously. The final volume is gentamicin, tobramycin & amikacin – if
10.7ml (i.e. displacement volume is 0.7ml) administering down the same IV line, flush
(I) IV infusion  Groups 30-40minutes Reconstitute as above then add the dose with N/S between the temocillin and the
to 100ml N/S. aminoglycoside.
Infusion pump is 1,2,3,4 and 5
required.
IM injection  Groups Reconstitute each 1g with 2ml W and Refer to the Marsden Manual for guidance
1,2,3,4 and 5 shake vigorously. The final volume is on IM injection.
2.7ml (i.e. displacement volume is 0.7ml).
If pain is experienced at the site of IM
injection each 1g can be reconstituted with
2ml of lidocaine 0.5% or 1% injection
instead of W.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 182
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND SUITABLE DILUENT
GIVE OVER
Tenecteplase IV bolus  Groups About 10 seconds 1) Remove the flip-off cap from the vial.
1and 2 2) Remove the tip-cap from the syringe. Then immediately screw the pre-filled
syringe onto the vial adapter and penetrate the vial stopper in the middle with the
Follow the protocol for
spike of the vial adapter.
the treatment of Acute
3) Add the water for injections into the vial by pushing the syringe plunger down
Myocardial Infarction
slowly to avoid foaming.
(See Plymouth
4) Reconstitute by swirling gently.
Healthnet Clinical
5) The reconstituted preparation results in a colourless to pale yellow, clear solution.
Guidelines)
Only clear solution without particles should be used.
6) Directly before the solution will be administered, invert the vial with the syringe still
attached, so that the syringe is below the vial.
7) Transfer the appropriate volume of reconstituted solution of Metalyse into the
syringe, based on the patient's weight.
8) Disconnect the syringe from the vial adapter.
9) Alternatively the reconstitution can be performed with the included needle.

Do not inject into a line containing glucose. Compatible with N/S

Patient Weight Vial size to Reconstitute with Dose Volume to give
pick the W provided
<60kg 40mg 8ml 30mg 6ml
>60kg to <70kg 40mg 8ml 35mg 7ml
>70kg to <80kg 40mg 8ml 40mg 8ml
>80kg to <90kg 50mg 10ml 45mg 9ml
>90kg 50mg 10ml 50mg 10ml

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 183
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Terbutaline SC injection  Groups Refer to the Marsden Manual for
1,2,3,4 and 5 guidance on SC injection.
IM injection  Groups Refer to the Marsden Manual for
1,2,3,4 and 5 guidance on IM injection.
Slow IV bolus  Groups Suggestion: 3 – 5 SC and IM injection are usually preferable to slow IV
1,2,3,4 and 5 minutes bolus, but if slow IV bolus is necessary monitor the
patient’s pulse.
(C) IV infusion for  Groups Adult dosage: Dilute 3 – 5ml (1.5 – 2.5mg) of
bronchodilation via 1,2,3,4 and 5 30 – 60ml/hour for 8 terbutaline injection in 500ml G, N/S
a volumetric pump – 10 hours or G/S.
(C) IV infusion for  Groups Initially 3ml/hour Dilute 10ml (5mg) of terbutaline Titrate the hourly rate with reference to suppression
premature labour 1,2,3,4 and 5 (5microgram/minute) injection to 50ml with G. of contractions, increase in pulse rate and changes
via syringe pump. for 20 minutes. in blood pressure, which are limiting factors. These
(Recommended Titrate dosage in parameters should be carefully monitored during
method to avoid fluid increments of treatment. A maternal heart rate of more than 135
overload) 1.5ml/hour beats/min should be avoided. In order to minimise
(2.5microgram/minut the risk of hypotension associated with tocolytic
e) therapy, special care should be taken to avoid caval
compression by keeping the patient in the left or
(C) IV infusion for  Groups Initially 30ml/hour Dilute 10ml (5mg) of terbutaline
premature labour (5microgram/minute) injection to 500ml with G (remove right lateral positions throughout the infusion.
1,2,3,4 and 5
via volumetric pump. for 20 minutes. 10ml G from the bag first). Infusion via a syringe pump is preferable to keep
Titrate dosage in the volume of fluid administered to a minimum and
increments of to avoid maternal pulmonary oedema.
15ml/hour The recommended diluent in premature labour is G.
(2.5microgram/minut If it is necessary to use N/S monitor for maternal
e) pulmonary oedema.
SC infusion treating  Groups Typical dose range: Can be infused undiluted or diluted SC infusion of terbutaline is unlicensed – see page 7
brittle asthma 1,2,3,4 and 5 5 – 15mg/24 hours with N/S to the required volume.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 184
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE SUITABLE DILUENT
Terlipressin IV bolus  Groups Suggestion: Each 1mg Variquel® solution: Monitor blood pressure, serum sodium
Acetate 1,2,3,4 and 5 over 1 minute Ready diluted (1mg in 5ml) and potassium and fluid balance. Flush
with N/S.
Variquel® powder:
Slowly add the entire contents of the
solvent ampoule (5ml) to the powder
vial and roll the vial gently until the
powder is completely dissolved. This
may be further diluted to 10 ml with
N/S if required.
Glypressin®:
Ready diluted (1mg in 8.5ml)
Terlipressin to(C) infusion in  Groups 1 1.3micrograms/kg/hour For Variquel®: This is an unlicensed regimen (see page
treat septic Critical Care and 2 =0.065ml/kg/hour of a Either reconstitute one 1mg powder 7) to reduce noradrenaline requirements
shock in areas only via 1mg in 50ml G dilution. vial as above, or take one ready diluted in patients with septic shock based on
critical care central IV line. 1mg in 5ml vial, and dilute the contents the following reference:
areas only, [Link]
(Preceded by an (Infusion rate may be further to 50ml with G.
when IV bolus of 0.5mg [Link]
titrated to effect at the
vasopressin is or 1mg at the N/S is not a suitable diluent for
discretion of the For Glypressin® brand:
unavailable discretion of the terlipressin infusion.
consultant intensivist) Dilute the contents of a 1mg ampoule
consultant The suggested expiry for terlipressin in G
further to 50ml with G.
intensivist) infusion is 12 hours after preparation.
Tetracosactide IV bolus  Groups Suggestion: Give over Ready diluted. Flush with N/S.
(Synacthen®) 1,2,3,4 and 5 30 to 60 seconds Keep patient under observation for 30
minutes after the injection –
hypersensitivity reactions are possible.
The Planned Investigation Unit (PIU) have
copies of the “Short Synacthen test”
protocol.
IM injection  Groups Inject deep into the Refer to the Marsden Manual for
1,2,3,4 and 5 deltoid muscle guidance on IM injection.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 185
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE SUITABLE DILUENT
Thiopental IV bolus  Group 1 Anaesthesia – Reconstitute 500mg vial with 20ml W Flush with N/S.
(Thiopentone) induction: to produce a 2.5% (25mg/ml) solution. Check for haze or precipitation before
100 –150mg over 10- administering.
15 seconds Longer in Extravasation causes local tissue necrosis
the elderly or and severe pain. This can be relieved by
debilitated) repeated application of an ice pack and local injection
after 1 minute if of hydrocortisone.
necessary.
Control of The reconstituted solution should be
convulsions: discarded after 7 hours.
75 –125mg over 3-5
minutes
Lowering raised
intracranial
pressure:
1.5 –3mg/kg over 3-
5 minutes. Repeat
as necessary.
(C) infusion  Groups 1 For the management Reconstitute three 500mg vials, each (C) IV infusion is not a licensed method of
via a central and 2* of refractory with 20ml W, making an infusion of administration of thiopentone (See page
IV line Pump intracranial 1500mg in 60ml (2.5% solution). 126)
is required. hypertension or Sodium content: 2.31mmol/500mg
Status Epilepticus, In intensive care areas or Theatres Use the prepared solution within 7 hours.
refer to the only, the 2.5% (25mg/ml) solution may For the management of refractory
appropriate critical be infused without further dilution intracranial hypertension or Status
care protocol. through a central line (local practice). Epilepticus, refer to the appropriate critical
care protocol.
*Group 2 nurses may only administer
prescribed additional boluses of thiopental to
ventilated patients in level 3 critical care.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 186
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE OVER SUITABLE DILUENT
Ticarcillin with See Timentin®
clavulanic acid
Tigecycline (I) IV infusion  Groups 30 – 60 minutes Reconstitute the powder in the vial with Flush with N/S or G.
Infusion pump is 1,2,3,4 and 5 5.3ml N/S or G to make a 10mg/ml Tigecycline in N/S is compatible at a Y-
May only be initiated required. solution. Gently swirl to dissolve the Site with dobutamine, dopamine,
on the advice of a powder. Then withdraw 5ml (50mg) gentamicin, lidocaine,morphine,
consultant from the vial and add to a 100ml bag of potassium chloride, propofol, ranitidine
microbiologist N/S or G. For the 100mg dose and Hartmann’s
reconstitute two vials as above and add The solution should be inspected for the
▼ This product is 10ml to a 100ml bag of N/S or G. presence of particulate matter or green
being intensively or black discolouration before use.
monitored by the Tigecycline should be yellow/orange in
CHM and MHRA. colour once reconstituted, if it is not, it
Please report all should be discarded.
suspected reactions
(including non-
serious ones) using a
Yellow Card from the
BNF.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 187
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE OVER SUITABLE DILUENT
Timentin contains a penicillin – Check patient’s allergy status before administration
Timentin® (I) IV infusion  Groups 30-40 minutes Reconstitute the 3.2g vial with 10ml W Incompatible with gentamicin and other
Infusion pump is 1,2,3,4 and 5 to form a pale straw-coloured solution. aminoglycosides.
required. Heat is released when the powder Each 3.2g of Timentin® contains
dissolves. Further dilute 3.2g with 100 - approximately 15.9mmol of sodium.
150ml G. Do not administer Timentin® by IV bolus
or IM injection.
Displacement value: 2.2ml for 3.2g of Flush with N/S.
Timentin® so reconstitute 3.2g vial with
7.8ml W to get 3.2g in 10ml.
Tinzaparin Injection into the  Groups No further dilution required. Follow the PHNT guidelines for the use
2,500units arterial limb of 1,2 and 8 of tinzaparin (sodium) for preventing
3,500units the dialyser at clotting in the haemodialysis circuit.
4,500units the start of (Firstly, prime the circuit with 1 litre N/S).
Pre-filled syringes haemodialysis
Tinzaparin SC injection  Groups Refer to the Marsden Manual for Tinzaparin must not be administered by
40,000units in 2ml 1,2,3,4 and 5 guidance on SC injection. intramuscular injection due to the risk of
Multidose vial haematoma. Do not administer
(Non-Formulary) intravenously.

Discard the vial 14 days after first use.

Record the date of first use on the vial.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 188
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION COMMENTS
GIVE OVER AND SUITABLE DILUENT
Tirofiban Loading dose  Groups See below for Withdraw 50ml from a 250ml bag of Intravenous infusion of unfractionated heparin (5,000unit IV
followed by 1,2,3,4 and indication- N/S or G and replace with 50ml of bolus followed by IV infusion at initial rate of 1,000units per
(C) IV infusion 5 specific infusion Tirofiban solution to make a hour: target APTTR approximately 2) should be
via Infusion rates. concentration of 50 micrograms/ml. administered concurrently with Tirofiban and may be
pump Mix well before use. infused through the same catheter/Venflon as the Tirofiban.
For patients diagnosed with NSTE-ACS and managed with an invasive For NSTE-ACS patients managed with an early invasive strategy and not
strategy undergoing angiography within 4 hours after the diagnosis, planned to undergo angiography for at least 4 hours and up to 48 hours after
tirofiban is given IV initially by 25 microgram/kg bolus dose given over 3 diagnosis, tirofiban is given IV at an initial infusion rate of 0.4 microgram/kg/min
minutes initiated at the start of PCI followed by a continuous infusion of 0.15 for 30 minutes. At the end of the initial infusion, tirofiban is continued at a
microgram/kg/min for 18-24 hours and up to 48 hours. maintenance infusion rate of 0.1 microgram/kg/min.
When administering the bolus dose, always pre-set the infusion pump with the When administering the loading infusion, always pre-set the infusion pump with the
total bolus volume to be administered total loading infusion volume to be administered.
Patient weight(kg) Bolus (ml) 3 minute bolus Maintenance infusion rate Patient weight(kg) 30 minute loading 30 minute loading infusion Maintenance infusion
infusion rate (ml/hour) (ml/hour) infusion (ml) rate (ml/hour) rate (ml/hour)
30 – 37 17 340 6 30 – 37 8 16 4
38 – 45 21 420 7 38 – 45 10 20 5
46 – 54 25 500 9 46 – 54 12 24 6
55 – 62 29 580 11 55 – 62 14 28 7
63 – 70 33 660 12 63 – 70 16 32 8
71 – 79 38 760 14 71 – 79 18 36 9
80 – 87 42 840 15 80 – 87 20 40 10
88 – 95 46 920 16 88 – 95 22 44 11
96 – 104 50 1000 18 96 – 104 24 48 12
105 – 112 54 1080 20 105 – 112 26 52 13
113 – 120 58 1160 21 113 – 120 28 56 14
121 – 128 62 1240 22 121 – 128 30 60 15
129 – 137 67 1340 24 129 – 137 32 64 16
138 – 145 71 1420 25 138 – 145 34 68 17
146 – 153 75 1500 27 146 – 153 36 72 18
In patients with an eGFR<30ml/min reduce the dosage by 50% In patients with an eGFR<30ml/min reduce the dosage by 50%

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 189
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE OVER SUITABLE DILUENT
Tobramycin IV bolus  Groups 3 – 5 minutes Flush with N/S.
1,2,3,4 and 5 N.B. Current recommended dose of 10mg/kg once
(I) IV infusion for  Groups 30 minutes 10mg/kg dose in Cystic Fibrosis daily in Cystic Fibrosis patients exceeds the dose
once daily dosing 1,2,3,4 and 5 diluted to 50ml or 100ml with N/S or G. stated in the package insert.
in cystic fibrosis Maximum once daily dose in Cystic Fibrosis is
via pump 660mg with trough levels measured before the 2nd
and 8th doses (Target trough level <1mg/L. Modify
IM injection  Groups Refer to the Marsden Manual for dose interval if trough level >2mg/L.
1,2,3,4 and 5 guidance on IM injection.
TPN See Parenteral Nutrition
Tramadol Staff prescribing, administering and/or screening prescriptions for opioid medications should be familiar with the PHNT Policy for Reducing
Errors with Opioid Medicines in Adults using the following link:
[Link]
%20Errors%20with%20Opioid%20Medicines%20in%[Link]?timestamp=1443106367868
IV bolus  Groups Slowly over 2 – 3 Undiluted Maximum total IV/IM dose in 24 hours is 600mg
1,2,3,4 and 5 minutes IV infusion is incompatible with diazepam,
(I) IV infusion via  Groups 12 – 24mg/hour Dilute 200mg tramadol in 500ml N/S, diclofenac, indometacin, midazolam and piroxicam.
pump 1,2,3,4 and 5 (=30 – 60ml/hour) G or H
IM injection  Groups Refer to the Marsden Manual for
1,2,3,4 and 5 guidance on IM injection.
Tocilizumab (I) IV infusion  Groups 1 hour Dilute the prescribed dose of Bristol Royal Chidrens’ Hospital Infusion
Infusion pump is 1,2,3,4 and 5 tocilizumab to 100ml with N/S. First Regime:
required. remove a volume of N/S from the bag  10 ml/ hour for 15 minutes followed by
equal to the volume of tocilizumab  130 ml/hour to complete dosing over 1 hour
being diluted. Mix by gently inverting  Check TPR & BP prior to commencing the
the bag to avoid foaming. infusion every 30 minutes during the infusion.
On completion of the infusion flush through the
giving set with 20 ml of 0.9% saline ensuring all the
drug has been given. Monitor vital signs every 30
minutes for 2 hours.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 190
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE SUITABLE DILUENT
Tranexamic acid IV bolus  Groups 100mg/minute Can be diluted with any convenient volume Flush with N/S or G.
1,2,3,4 & 5 of N/S or G (e.g. 20-50ml for a bolus or
(C) IV infusion  Groups 25-50mg/kg/24 hours more for an infusion) or given undiluted.
via pump 1,2,3,4 & 5
Trastuzumab (I) IV infusion  Groups 1 Loading dose over 90 Infusion to be prepared by Pharmacy. Patients should be observed for at least
(Herceptin®) Infusion pump and 2 minutes. If the initial Telephone ext. 31083. Doctor to prescribe six hours after the start of the first
is required. loading dose was well dose diluted with 250ml N/S. infusion and for two hours after the start
tolerated, the of the subsequent infusions for
subsequent doses symptoms like fever and chills or other
can be administered infusion-related symptoms.
over 30 minutes Do not dilute with glucose solutions since
these cause aggregation of the protein.
SC Injection  Groups 1 Slow SC injection Draw up the 600mg in 5ml solution from The injection site should be alternated
and 2 over 2-5 minutes the vial. between the left and right thigh. New
injections should be given at least 2.5 cm
from the old site and never into areas
where the skin is red, bruised, tender, or
hard.
Patients should be observed for six
hours after the first injection and for two
hours after subsequent injections for
signs or symptoms of administration-
related reactions.
Tri-iodothyronine See Liothyronine

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 191
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE OVER SUITABLE DILUENT

Triptorelin IM injection  Groups Draw up the mannitol diluent provided This is a single-use vial
(Decapeptyl®) 1,2,3,4 and 5 into the syringe provided using one of
the injection needles and inject in to
Refer to the Marsden Manual for
the vial containing the powder. Gently
guidance on IM injection.
swirl the vial until a uniform suspension
is formed, then draw the mixture back
into the syringe without inverting the
vial. The injection needle should then
be changed and the second needle
used to administer the injection. As the
product is a suspension, the injection
should be administered immediately
after reconstitution to prevent
sedimentation.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 192
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE OVER SUITABLE DILUENT
Tysabri® See natalizumab
Urokinase Lock for unblocking  Groups Retain in the Reconstitute one 10,000unit vial of If the lumen is completely blocked do not force
midlines and PICC 1,2 and 8 line for 1-2 urokinase with 3ml of N/S. Instil 1.5ml urokinase into the [Link] to the full PHNT
lines (Adults) hours (5,000units) of the reconstituted solution into
guidelines:
(or longer) each lumen of the catheter. [Link]
aldepartments/Pages/[Link]
Catheter lock for  Groups  Reconstitute urokinase 25,000unit vial with N/S in a volume equal to the priming volume of both catheter lumen
unblocking 1and 2 plus an additional 0.2mls (e.g. ‘A’ lumen = 1.7, ‘V’ lumen = 1.9, therefore 1.7 + 1.9 + 0.2 = 3.8 ml of N/S).
haemodialysis  Draw up solution into two syringes: one equal to arterial lumen volume + 0.1ml and one equal to venous
CVC lumen + 0.1ml (e.g. ‘A’ lumen syringe = 1.7 + 0.1 = 0.8 ml; ‘V’ lumen syringe = 1.9 + 0.1 = 2ml)
(Adults)  All staff must be aware that any connection/disconnection to a haemodialysis CVC must be performed using
aseptic technique
o Flush each lumen with 10ml of N/S
o Inject 12,500unit urokinase into each lumen to the priming volume
o Positively lock the lumen and place the red obdurate, then wait for 30 minutes
o Aspirate 5mls from each lumen and flush with 10-20ml of N/S if flows have restored
 Commence dialysis treatment
Inter-dialysis  Groups The decision to use an inter-dialysis infusion of urokinase must be agreed beforehand with one of the
infusion via the 1and 2 Trust consultant nephrologists each time it is used, and after assessment of any increased bleeding risk.
haemodialysis  Reconstitute two 100,000unit vials of urokinase each with 2ml N/S and add both vials to 100ml N/S
CVC (200,000unit urokinase in 100ml N/S).
(Adults)  Draw up the urokinase solution into two 50ml luer-lock syringes.
 Attach the 50ml syringes to the lumens of the dialysis CVC.
 Using a syringe driver, infuse a 50ml syringe containing the urokinase solution (100,000iu in 50ml N/S) down
each lumen over 90 minutes (34ml/hour).
 When the infusion is complete, flush each lumen with 10–20ml N/S to establish blood-flow.
 Commence haemodialysis.
Intraperitoneal  Groups Retain in Dilute 12,500 international units with 5ml Follow the Renal Services Directorate Peritoneal
catheter lock for 1and 2 catheter for 2 N/S. Dialysis Protocols
unblocking the hours
catheter.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 193
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE SUITABLE DILUENT
Vancomycin (I) IV infusion  Groups Adults: 500mg over 1 Reconstitute 1g vial with 20ml W and Flush with N/S or G.
preferred 1,2,3,4 and hour. Doses over 500mg vial with 10ml W. In practice 1g in 100ml may be used in
Refer to the method. 5 500mg maximum rate Dilute 500mg with at least 100ml N/S or fluid restricted patients; but the use of
Plymouth Healthnet Infusion pump 10mg/minute. G. such high concentrations may increase
Clinical is required. Dilute 750mg with at least 150ml N/S or the risk of infusion related events when
Guidelines/Infection (C) IV infusion.  Groups 24 hours G. administered via a peripheral vein. Note
Control for the use Infusion pump 1,2,3,4 and Dilute 1g with at least 200ml N/S or G. that the current recommended target
and current dosage is required. Dilute 1.5g with at least 300ml N/S or G. trough level is higher than that in the SPC
5
of gentamicin, Dilute 2g with at least 400ml N/S or G. and is therefore unlicensed (See page 7).
teicoplanin and
vancomycin.
Example IV Set pump rate at :
calculations 500mg vancomycin (in 10ml W) added to a 100ml bag N/S = 110ml over 1 hour 110ml/hour
750mg vancomycin (in 15ml W) added to a 250ml bag N/S = 265ml over 1½ hours 177ml/hour
1g vancomycin (in 20ml W) added to a 250ml bag N/S = 270ml over 2 hours 135ml/hour
1.5g vancomycin (in 30ml W) added to a 500ml bag N/S = 530ml over 2½ hours 212ml/hour
2g vancomycin (in 40ml W) added to a 500ml bag N/S = 540ml over 3⅓ hours (200 minutes) 162ml/hour
Intrathecal  Group 1 Refer to the Neurosurgical Antibiotic
Injection Therapy Guidelines for Adults on
Plymouth Healthnet (Under Clinical
Guidelines)
Intraperitoneal  Groups 1 Follow the Renal Services Directorate
and 2 Peritoneal Dialysis Peritonitis Protocol

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 194
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
GIVE SUITABLE DILUENT
Vasopressin (I) IV infusion.  Groups 1 Dosage for use in Dilute 20 units to 50ml with G. Flush with G.
=Argipressin Infusion and 2 critical care for Note that Regent and Sandoz brand vials
pump is refractory septic shock: are only labelled for IM and SC use.
For use in Critical required. 0.6–2.4 units/hour However, they are also suitable for IV
Care to reduce Administer (= 1.5 -6ml/hour using use. Regent and Sandoz brands are
noradrenaline via a central 20 units/50ml dilution) unlicensed in the UK (see page 7).
requirements in IV line.
patients with Note that Sandoz brand vials are
refractory septic multidose 40units in 2ml. Part-used vials
shock. should be stored at room temperature
Regent and Sandoz and discarded 28 days after initial use.
brands must be kept
at room (Unlicensed indication- see page 7).
temperature

Pitressin ® - keep in
the fridge

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 195
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY GIVE ADMINISTER OVER INSTRUCTION FOR DILUTION AND COMMENTS
SUITABLE DILUENT
Vecuronium IV bolus  Group 1– must See Data Sheet The 10mg vial can be reconstituted with Flush with N/S or G.
only be given by 5ml W to produce 2mg/ml solution. The reconstituted solution can be injected
doctors proficient in Alternatively reconstitute the 10mg vial or infused in to the line of a running
advanced airway with 10ml W, G, N/S or H to produce a infusion of Hartmann’s.
management. Also 1mg/ml solution. The reconstituted If the patient is ventilated IV bolus can be
see Comments. solution can be given undiluted or administered by Group 2 staff.
diluted further with N/S or G to a
(I) IV infusion.  Groups 1 and 2 Bolus of 40-100
maximum dilution of 4mg/100ml.
Infusion micrograms/kg
pump is followed by 48 - 84
required. micrograms/kg/hour.
Using a 2mg/ml dilution e.g. 100mg in 50ml 48 – 84micrograms/kg/hour = 0.024 – 0.042ml/kg/hour
Using a 1mg/ml dilution e.g. 100mg in 100ml 48 – 84micrograms/kg/hour = 0.048 – 0.084ml/kg/hour
Vedolizumab (I) IV infusion.  Groups 1 and 2 30 minutes Allow the vial to warm to room temperature All patients should be observed
Infusion then reconstitute with 4.8 ml of W. Direct continuously during each infusion. For
▼ This product
pump is the stream of liquid to the wall of the vial to the first two infusions, they should also
is being avoid excessive foaming. Gently swirl the
intensively required. be observed for approximately two hours
vial for at least 15 seconds. Do not
monitored by following completion of the infusion for
vigorously shake or invert. Let the vial sit
the CHM and for up to 20 minutes to allow for any foam signs and symptoms of acute
MHRA. Please to settle; the vial can be swirled and hypersensitivity reactions. For all
report all inspected for dissolution during this time. If subsequent infusions, patients should be
suspected not fully dissolved after 20 minutes, allow observed for approximately one hour
reactions another 10 minutes for dissolution. following completion of the infusion.
(including non- Prior to withdrawing reconstituted solution Do not infuse down the same line as any
from vial, gently invert vial 3 times. other drugs.
serious ones)
Withdraw 5 ml (300 mg) of reconstituted
using a Yellow solution and add to 250ml N/S. Gently mix
Card from the the infusion bag.
BNF.

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 196
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Verapamil IV bolus  Group 1 or 2 minutes Ready diluted. ECG and blood pressure monitoring
Emergency use. Group 2 (elderly patients necessary.
minimum 3 minutes) Flush with N/S.
Sodium content 0.15mmol/ml.
Vigam® See Immunoglobulin Human Normal
Vitamins B and C See Pabrinex
High Potency IV
injection
Vitamin K See phytomenadione
Voriconazole (I) IV infusion.  groups Over 1-2 hours. Add 19ml W to each 200mg vial. Do not infuse concomitantly with other
Infusion pump is 1,2,3,4 and 5 Maximum rate Resulting concentration is 200mg drug solutions through the same
required. 3mg/kg/hour. in 20ml (Displacement 1ml/200mg lumen/Venflon.
vial). Dilute the required dose with
N/S, G, H or 0.45% saline to a final
concentration of 0.5 to 5mg/ml.
Xiapex® See Collagenase Clostridium histolyticum
X-ray Contrast IV bolus  Groups According to X-ray Do not dilute. Monitor for possible anaphylaxis or other
Medium, 1 and 6 Department protocol. allergic reactions. Resuscitation
Non-ionic, equipment should be immediately
tri-iodinated available.
X-ray Contrast IV bolus  Groups According to X-ray Do not dilute Monitor for possible anaphylaxis or other
Medium, 1and 6 Department protocol allergic reactions. Resuscitation
Gadolinium based. equipment should be immediately
available.
Zanamivir (I) IV infusion  groups Approximately 30 Either give undiluted (10mg/ml), or Do not infuse down the same line/lumen
1,2,3,4 and 5 minutes dilute with N/S to a concentration as other IV medications, or glucose, or
(Unlicensed not less than 200 micrograms/ml. electrolytes other than N/S.
product – see Flush with N/S.
page 7)

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 197
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
DRUG METHOD WHO MAY ADMINISTER OVER INSTRUCTION FOR DILUTION COMMENTS
GIVE AND SUITABLE DILUENT
Zidovudine (I) IV infusion  groups 1 hour Dilute the prescribed dose to Example: For a 63mg dose you would
1,2,3,4 and 5 2mg/ml or 4mg/ml with G – see draw up 6.3ml of zidovudine
comments for examples. injection(10mg/ml) and dilute to 31.5ml
with G in a 50ml syringe to make a final
concentration of 2mg/ml, and set the
pump rate at 31.5ml/hour.
Example for doses > 100mg:
For a 130mg dose, you would draw up
13ml zidovudine injection(10mg/ml) and
dilute to 32.5ml with G in a 50ml syringe
to make a final concentration of 4mg/ml,
and set the pump rate at 32.5ml/hour.
Do not give by IM injection.
Zoledronic acid (I) IV infusion  groups Infuse all doses over at Ready diluted. Do not mix with magnesium or calcium
(Aclasta® 5mg in 1,2,3,4,5 and least 15 minutes. containing solutions such as Hartmann’s.
100ml bags) 8 Set the pump rate at a
maximum of
400ml/hour
Zoledronic acid (I) IV infusion  groups Infuse all doses over at Draw up the prescribed dose Do not mix with magnesium or calcium
(Zometa® 4mg in 1,2,3,4,5 and least 15 minutes. (dependent on renal function – see containing solutions such as Hartmann’s.
5ml vials) 8 When diluted with below) and add to 100ml N/S or G. For the treatment of tumour-induced
100ml N/S set the hypercalcaemia ensure the patient is well
pump rate at a hydrated before and after administration
maximum of of zoledronic acid.
400ml/hour
Dosing according to renal function
GFR > 60 4mg dose Draw up 5ml from the vial
GFR 50 – 60 3.5mg dose Draw up 4.4ml from the vial
GFR 40 – 49 3.3mg dose Draw up 4.1ml from the vial
GFR 30 -39 3mg dose Draw up 3.8ml from the vial

 Intravenous fluids and drug solutions prepared in clinical areas must be changed every 24 hours unless otherwise specified in the drug monograph. 198
 Unless described in the monograph as “Multidose”, ALL injectable products, including bags of sodium chloride and glucose must be treated as single-use-only and discarded
immediately after use.
 For additional paediatric and neonatal information refer to the Bristol Royal Hospital for Children guidelines [Link] - for drug monographs click on
“Intravenous Drug Administration Guide”), current BNF For children which is accessible via [Link] or the Neonatal Formulary.
 For more detailed information refer to the current BNF which is accessible via [Link] . For full details of the licensed indications, dosage,
contraindications and side effects refer to [Link]
Procedures for Administering Injectable Drugs, Pharmacy Department, Derriford Hospital, Version 11, December 2015. Version 11.4 (Interim amendmends & additions) May 2016
199
 200

Protocol for subcutaneous morphine for acute pain

Rationale
Intermittent subcutaneous administration of morphine is an alternative to repeated intramuscular or
intravenous injections for the management of acute severe pain. An indwelling subcutaneous cannula can
reduce procedural pain and patient anxiety regarding repeated im injections. It can also reduce needle
stick injuries associated with im analgesia. The cost of disposable needles is also reduced.
Use where patient is unable to take oral medication and im or iv morphine boluses would have been
previously considered. Do not give opioids via any other route when subcutaneous protocol in use. Long
term oral or patch opioid use is an exception to this rule.

This protocol is intended for use in surgical inpatients with acute pain. Do not use when peripheral
perfusion is impaired such as shock, gross oedema or hypothermia.

Equipment required
1. Sub-cutaneous cannula eg: BD Saf-T-Intima
2. Sharps bin
3. Appropriate skin cleaning device (Chloraprep)
4. Appropriate dressing (eg. C-View 6cm x 7cm)

Procedure
1. Choose site for insertion (eg: upper arm).
2. Clean skin and allow to air dry
3. Pinch a fold of skin and subcutaneous tissue and insert cannula at base of fold
4. Dispose of sharps carefully
5. Cover insertion site with a clear dressing, label with date and time of insertion
6. Document date, time and place of cannula insertion in the medical or nursing notes.

Prescription
Please ensure that a specific dose is prescribed, not a range. Dosing frequency should be 2 hourly when
required. Dose is age dependant. Morphine should be avoided if eGFR <30mls/min. Ensure that there are
no other contra-indications to morphine use. Discuss with ACT if eGFR < 30mls/min – it may be
appropriate to use an alternative opioid.
Age Dose
18-59 10-15mg
60-69 5-10mg
70-89 2.5-5mg
90+ 2.5mg

A 0.5ml saline flush should also be prescribed.

Administration
1. Check morphine prescription according to trust opioid prescribing policy
2. Draw up prescribed dose of morphine
3. Check insertion site prior to administration:
a. Cannula must be re-sited if red, painful, inflamed or has been in situ for more than 72 hours
4. Use 10mg/ml morphine undiluted
5. Inject morphine slowly
6. Flush the cannula with 0.5ml normal saline after each dose of morphine
7. If pain score acceptable to patient and last dose was 4-6 hours ago, remove cannula and switch to
oral analgesia if appropriate

Observations after each injection of morphine

At 15 minutes, 30 minutes, 60 minutes and 4 hourly thereafter
Author: Dr Mark Rockett Lead Inpatient Pain Consultant for the Acute Care Team, 04/2014.
Version 5.0 Review date: 04/2016
201
202
 203

Emergency Department Adult Intravenous Morphine Guideline

 This guideline is to be used in conjunction with BNF & PHNT joint

formulary & Trust acute pain analgesic ladder.

 No intravenous morphine to be given in minors.

 Always take into account age, weight and co-morbidities – use with extreme
caution in renal impairment. Give 1/2 or 1/3 of below doses in elderly and
frail.

 Consider non-pharmacological methods of analgesia – eg splintage, LA

blocks.

 Actively seek out times and doses of prior (including pre-hospital) analgesia.

 Patients with high pain scores should be asked if they require further pain
relief. Only prescribe if the patient says they do.

 Seek senior advice for non-responsive pain.

Severe Pain = 8-10

Moderate Pain = 4-7
Mild Pain = 1-3
No Pain = 0 Prescribe multi-modal analgesia (paracetamol
+/-NSAIDs) to be given simultaneously.

Assess with pain score & consider IV

morphine for moderate or severe pain.

Prescribe IV morphine on STAT section

of the drug chart 0.1mg/kg titrated to
effect over 2-3 minutes but see above

Reassess at 20 minutes with

observations including RR, conscious
level & pain score

Repeat up to above dose as required but no

sooner than 20 mins
If a second dose is given in ED apply monitoring –
minimum of pulse oximetry
 204

Author: Dr Mark Rockett 2012

Protocol for subcutaneous ketamine for difficult to manage pain

Rationale
Ketamine is an anaesthetic agent with analgesic properties. A low dose ketamine infusion
provides safe and effective analgesia. Ketamine is usually used together with an opioid to
improve pain relief and reduce opioid side effects. At low doses Ketamine may cause
sedation; however respiratory depression is minimal and psychotomimetic effects are
uncommon. There is evidence to support that ketamine has an opioid sparing effect in
postoperative pain and NMDA receptor antagonist drugs show preventive analgesic effects.
Ketamine is also effective in treating acute neuropathic pain and in reducing hyperalgesia
and the transition to persistent post surgical pain. Ketamine may reduce opioid tolerance in
patients already on high dose strong opioids, and reverse opioid induced hyperalgesia.

Indications
 Where pain is inadequately controlled by opioids alone
 When opioid tolerance has developed i.e. patient requiring increasing amounts of
opioids
 To reduce opioid side effects e.g. respiratory depression, nausea
 Acute neuropathic pain

Subcutaneous administration of ketamine is an alternative to intravenous infusion for the

management of complex acute severe pain. Do not use the subcutaneous route when
peripheral perfusion is impaired such as shock, gross oedema or hypothermia.

Equipment required
5. Sub-cutaneous cannula eg: BD Saf-T-Intima
6. Sharps bin
7. Appropriate skin cleaning device (eg Chloraprep)
8. Appropriate dressing (eg. C-View 6cm x 7cm)

Procedure
7. Choose site for insertion (eg: upper arm).
8. Clean skin and allow to air dry
9. Pinch a fold of skin and subcutaneous tissue and insert cannula at base of fold
10. Dispose of sharps carefully
11. Cover insertion site with a clear dressing, label with date and time of insertion
12. Document date, time and place of cannula insertion in the medical or nursing notes.

General Management
Nursing staff caring for patients with advanced analgesic systems must attend the
mandatory training every two years.
 Prescriptions should only be altered by a member of the Acute Care Team
 Use only the CME Medical TPCA pumps labelled ‘Ketamine infusion’ with lockable
covers
 205

 Patients should remain on oxygen as prescribed

 Patients may mobilise with support as required
 Anti-syphon and anti-reflux lines must be used
 The ketamine infusion line must be clearly labelled
 A dedicated venous line is preferable as this reduces the risk of the patient receiving
boluses of ketamine
 Ketamine syringe driver keys should be kept with controlled drug keys

N.B Any patient receiving opioids via an analgesic system are not permitted to leave the
ward, unless for medical investigation, x-ray etc.
Prescription
Use the pre-printed prescription label (White) and ketamine information sheet.

5mg/kg ketamine made up to 50mls with normal saline using 50mg/ml ketamine solution
(0.1mls/kg of solution). Maximum dose in syringe 500mg (10mg/ml). Add 1mg
dexamethasone (0.3mls of 3.3mg/ml solution) to the syringe.

The ketamine infusion should be started at 1ml/hr. This delivers 0.1mg/kg/hr. If necessary,
increase the rate in 0.5ml/hr increments until either good analgesia is obtained or the patient
begins to experience dysphoria. Psychotomimetic reactions increase in parallel with plasma
concentration. Therefore do not give boluses or increase above 2mls/hr. If the patient does
experience mild dysphoria, stop the infusion for 30 minutes and recommence at a lower rate.
If the dysphoria is more severe or there are hallucinations, contact the Acute Care Team.
Dexamethasone is added to reduce tissue irritation. At this dose (1mg in 50mls) it will not
adversely affect blood glucose levels.

As a general rule, ketamine infusions should be run for no more than 48 hours (lack of
evidence of ongoing benefit), although this can be extended after discussion with the Acute
Care Team.

In addition to the ketamine infusion, all patients should receive regular paracetamol and
NSAID (unless contra-indicated). You should aim for a pain score of ‘none’ or ‘mild’ on
movement .

Professional Accountability
As a Registered nurse, midwife or specialised public health nurse, you must maintain your
professional knowledge and every nurse must adhere to the Plymouth Hospitals NHS Trust
protocols on management of a ketamine infusion, in addition to all other relevant Trust
policies.

Observations after commencing ketamine infusion

Use the PCA observation chart and record standard PCA observations
Standard observations one hourly for 4 hours, 2 hourly for 8 hours & 4 hourly thereafter.
Additionally, please record the ketamine infusion rate, the syringe volume remaining and
each syringe change.
Also record psychotomimetic side effects on a scale of 0-2:
0 = None
1 = Dysphoria
2 = Hallucinations

Converting from Ketamine infusion to oral analgesia

 Review the need for ketamine infusion daily. Ketamine infusions will usually be
limited to 24-48 hours duration. Expect opioid requirements to fall from day-2 post
operatively
 206

 Ensure the patient has received a recent dose of paracetamol, NSAID (if appropriate)
and an opioid (codeine / oramorph)
 Switch ketamine infusion off
 If pain
 If pain scores unacceptable call the ACT with view to restarting the ketamine infusion

Risk management:
Action to be taken following clinical incidents with ketamine infusions
If the incident involves a drug error take the following action:
 Identify original source of error and take appropriate action to prevent further risk to
patient
 Monitor patient for adverse effects and perform observations every 5 minutes until
medical review
 Contact Ward Doctor urgently and inform ACT immediately
 Complete Datix incident form as per Trust guidelines and follow appropriate
procedure
 Please forward a copy of the Datix incident form to the Acute Care Team Level 4

If the incident involves equipment error or failure, in addition to the guidelines above take the
following action:
 Follow the MEMS guidelines for Accidents / Incidents / Near Misses Involving
Medical Equipment (MEMS Medical Equipment Users’ Guide)

For any other incidents take the following action:

 Establish whether there could be any adverse effects to the patient and monitor
accordingly
 Contact the Ward Doctor urgently and inform the ACT
 Complete incident form as per Trust guidelines and follow appropriate procedure

Authors: Dr Mark Rockett Lead Inpatient Pain Consultant for the Acute Care Team and Dr
Tim Wilson, 07/2016
Version 5 Review date: 07/2018

References

 The Electronic Medicines Compendium 2012 published by Datapharm Communications Ltd

([Link]
 The Injectable Medicines Guide produced by the network of UK hospital pharmacists,
published by the Pharmacy Dept. Charing Cross Hospital, London, and endorsed by the UK
Medicines Information service ([Link]
 The British National Formulary No.64 (September 2012) ([Link]
 The British National Formulary for Children (2012-2013)
([Link]
 UK Resuscitation Council Anaphylaxis Algorithm
([Link]
 207

Appendix 1
Protocol for administering intramuscular adrenaline 1:1000 (1mg/ml) for treating
anaphylaxis, when there is no prescription available
Date Version
September 2013 1
Purpose
To instruct staff on how to correctly identify when a person is suffering an anaphylactic reaction and to
treat the person correctly with intramuscular adrenaline, when there is no prescription for this medication
Scope of this document
Applies to all non-medical clinical staff working in any area with the skill and competence to assess a
patient’s condition and administer intramuscular medication.
Key Message
Non-medical clinical staff working for or on behalf of Plymouth Hospitals NHS Trust may legally
administer adrenaline injection to treat anaphylaxis without a prescription. They must do so in
accordance with this protocol.
Accountabilities
Production Peter Gray, Senior Pharmacist
Review and approval Medicines Utilization and Assurance Committee
Ratification Medicines Utilization and Assurance Committee
Dissemination Peter Gray, Senior Pharmacist
 208

Links to other policies and procedures

Pharmacy Documents:
 PHNT Medicines Management Policy
 Procedures For Administering Injectable Medicines
Other Documents:
 Emergency Treatment of Anaphylactic Reactions- Guidelines For Healthcare Providers: Working Group of
the Resuscitation Council (UK) 2008
 Medicinal products for parenteral administration in an emergency. The Human Medicines Regulations
2012, Regulation 238, Schedule 19.
Version History
Version 1 October 2013
Version 2 December 2015
Last Approval Due for Review
Version 2 December 2017

1.1 Adrenaline (1:1000) can legally be administered without a prescription for

the purpose of treating anaphylaxis
Medicines legislation restricts the administration of Prescription-Only injectable medicines.
Unless self administered, they may only be administered by in accordance with a prescription.
However, in the case of 1:1000 adrenaline there is an exemption to this restriction which means
in an emergency, a suitably trained person (eg. nurse or ODP) is permitted to administer it by
(intramuscular) injection for the purpose of treating anaphylaxis without a prescription or
instruction from a doctor.
1.2 Persons who can be treated under this protocol
Individuals displaying the signs and symptoms described below who are:
 Hospital in-patients
 Hospital out-patients attending out-patient or diagnostic departments
 Visitors or members of staff
1.3 Anaphylaxis

Anaphylaxis is a severe, life-threatening, generalised or systemic hypersensitivity reaction. This

is characterised by rapidly developing life-threatening airway and/or breathing and/or circulation
problems usually associated with skin and mucosal changes.

Administration of intramuscular (IM) adrenaline should be considered for individuals who show
signs and symptoms of an anaphylactic reaction.

Anaphylaxis is likely when all of the following three criteria are met:

 Sudden onset and rapid progression of symptoms.

 Life-threatening airway and/or breathing and/or circulation problems.
 Skin and/or mucosal changes (flushing, urticaria, angioedema).

1.4 Assessing the patient

 209

The ABCDE approach to assess and treat a patient should be followed, as patients can have an
Airway, Breathing or Circulation Problem or any combination which is life threatening.

Airway
 Airway swelling, e.g. throat and tongue
 Hoarse voice, unable to speak
 Stridor
Breathing
 Shortness of breath
 Wheeze
 Confusion caused by hypoxia
 Patient becoming tired
 Cyanosis – late sign
 Respiratory arrest

Circulation
 Signs of shock, pale, clammy
 Increased pulse rate
 Low blood pressure, feeling faint, collapse
 Decreased conscious level or loss of consciousness
 Cardiac arrest

The above Airway, Breathing and Circulation problems can all alter the patient’s neurological
status (Disability problems) because of decreased brain perfusion. There may be confusion,
agitation and loss of consciousness.

Patients can also have gastro-intestinal symptoms (abdominal pain, incontinence, vomiting)

Exposure

The patient must be exposed ensuring dignity to observe for skin and/or mucosal changes. This
is often the first feature present in over 80% of anaphylactic reactions.

 They can be subtle or dramatic.

 There may be just skin, just mucosal, or both skin and mucosa changes.
 There may be erythema – a patchy, or generalised, red rash.
 There may be urticaria which can appear anywhere on the body. The weals may be pale,
pink or red, and may look like nettle stings. They can be different shapes and sizes and
are often surrounded by a red flare. They are usually itchy.
 Angioedema is similar to urticaria but involves swelling of deeper tissues, most
commonly in the eyelids and lips, and sometimes in the mouth and throat.

1.5 Explanation of treatment to the patient

Prior to the administration of adrenaline the patient should receive an explanation that they are
having an allergic reaction and that IM adrenaline is going to be administered to relieve the
symptoms and help reverse the reaction.

1.6 Patient Consent

Prior to the administration of the drug, consent should be obtained either from the patient, parent,
guardian or person with parental responsibility. Verbal consent is acceptable in the emergency
scenario. This should be documented in the patient’s medical records once the patient’s
 210

condition is stable.

If the patient, parent or guardian does not wish treatment to be given under this protocol they
should be advised of the potential risks.

If the patient is unable to give consent due to a life-threatening situation, or if parents or

guardians are not present, adrenaline should be administered where treatment is judged
to be in the best interests of the patient.

1.7 Exclusions from treatment under this protocol

None

1.8 Contra-indications to administration of adrenaline to treat anaphylaxis

There are no absolute contra-indications to the administration of adrenaline under this protocol.

1.9 Immediate Treatment – Also refer to treatment algorithm on page 195

 Reassure and explain the situation to the patient.

 Assess airway and breathing and identify signs and symptoms of anaphylaxis (see 2.1).
 Identify and discontinue trigger factors.
 Call for help, e.g. 999, a doctor, 2222 Clinical Emergency Team.
 Patients with airway or breathing problems may prefer to sit up as this will make
breathing easier.
 Assess circulation (see Section 2). Laying the patient flat with or without leg elevation
may be helpful for patients with hypotension. If the patient feels faint, do not sit or stand
them up as this may cause cardiac arrest. NB. A sudden change to a more upright
position may be dangerous due to the effect on blood flow to the heart.
 If the patient presents with signs of clinical shock and/or stridor, administer IM adrenaline
1:1000 as recommended, noting the time given and the response.
 Continue to observe the patient supporting and maintaining a clear airway, observing
breathing.
 Continuous assessment of the patient is important using the ABCDE approach.
 Patients who are breathing and unconscious should be placed in the recovery position.
 Pregnant patients should lie on their left side to prevent caval compression.
 If the patient is not breathing or has no pulse, commence cardio pulmonary resuscitation
(CPR) using current guidelines.
 Continue until:
o More qualified help arrives
o You become exhausted
o Patient shows signs of recovery
1.10 Source of Adrenaline

Use ampoules of adrenaline 1:1000 (1mg/1ml). If these are not available, use any pre-filled auto-
injector (eg. Epipen or Anapen) that the patient may be carrying.

1.11 Dosage of Adrenaline

Dose for Adults: 500micrograms (0.5mL) of adrenaline 1:1000 (1mg/mL).

Dose for Infants and Children:

 211

Age Dose of Volume of 1:1000

Adrenaline (1mg/mL) solution
Under 6 years 150 micrograms IM 0.15mL
6 - 12 years 300 micrograms IM 0.3mL
Over 12 years 500 micrograms IM 0.5mL
(300 micrograms IM if the (0.3mL)
patient is small or pre-pubertal)

Frequency
The dose stated above can be repeated once, as necessary after 5 minutes if there is no
improvement in the patient’s condition or on assessment of the patient’s blood pressure, pulse and
respiratory function.

1.12 Adverse Effects

Adverse effects are extremely rare with correct doses injected intramuscularly

1.13 Follow-Up

Hospital in-patients require close observation on the ward (or Theatre/Recovery). They may need
to be transferred to HDU depending on the severity of reaction and medical decision. Any
affected hospital out-patients, staff or visitors, patients in the community or those attending
clinics/health centres/lectures/training need to be transferred to the Emergency Department.

1.14 Documentation of all events and actions once the patient is stable

For patients, document all events and actions in the medical notes. For affected members of
staff, visitors or other persons, all events and actions must be documented on admission to the
Emergency Department. Details recorded should include:

 Full details of the event

 Time course of the reaction
 Whether consent to treatment has been given
 All drugs and treatments administered, including details of dose(s) given
 Resuscitative measures
 Patient’s response to treatment
 Any previous adverse reactions
 Signature and printed name of person administering treatment under this protocol
 Date
 Statement that adrenaline was administered to treat suspected anaphylaxis without a
prescription in accordance with the hospital protocol.

 If the anaphylactic reaction is considered to be drug-induced, the medical practitioner should

consider completing a “Yellow Card” from the BNF and sending it to the MHRA or reporting
the reaction via the MHRA website at [Link]

1.15 References

 Emergency Treatment of Anaphylactic Reactions- Guidelines For Healthcare Providers:

Working Group of the Resuscitation Council (UK) 2008
 Medicinal products for parenteral administration in an emergency. The Human Medicines
Regulations 2012, Regulation 238, Schedule 19.
 212

1.16 Management of Anaphylaxis

213
 214

For more information please contact the Resuscitation Department on 52851

Appendix 2
Choice of Infusion device

2.1 Introduction

All individuals that operate infusion devices within the remit of their role have a responsibility to
ensure that they are competent to operate the equipment in a safe and effective manner, seek
advice and training where necessary and complete relevant documentation with their assessor in
line with the Trusts Policy and Procedure document for the ‘Training of Plymouth Hospitals NHS
Staff in the Use of Medical Devices.’

It is the responsibility of the person administering the drug to select the appropriate
infusion pump for the therapy required. Alterations to the pump setting may only be
made and recorded by a person entitled to administer intravenous drugs. The volume of
fluid administered must be recorded on the fluid chart. All pumps must be checked 2
hourly throughout the infusion and details of the infusion should be recorded on the
relevant infusion chart.

Infusion Devices must always be operated and serviced in accordance with the
Manufacturers operating instructions and the MEMS Medical Equipment Users’ Guide.
Every area should maintain a library of user manuals for commonly used equipment,
which may be kept in the Ward Equipment File. Manuals for commonly used infusion
devices can be found on the Medical Devices Training webpage on TrustNet. The MEMS
Medical Equipment Users Guide is available on the Trust documents drive.

2.2 Choice of Infusion device

The choice of infusion device should be based upon the clinical application it is intended
for, and the safety features incorporated within the device. Infusion devices may be
grouped into the following categories:

a. Volumetric pumps

 Pump of choice for medium and high flow rates, and large volume infusions.
 Pressure sensitivity of pump: Some pumps have selectable occlusion pressure alarm
levels. Selecting low levels will help to prevent excessive delivery pressures and
possible vein damage.
 Some may allow for the addition of piggyback or secondary infusions.
 The majority of volumetric pumps will perform satisfactorily at rates down to 5 ml/hr.
Although the controls can set rates below 1ml/hr, these pumps are not considered
appropriate for delivering drugs at such low rates.
 215

 Once the infusion has been connected to the patient, the vertical position of the
device should be altered as little as possible as an increase in height of the device
above the infusion site may result in a bolus of infusate being delivered to the patient.
 Blood transfusions may be given through a Baxter Colleague Volumetric Pump safely
if given with correct blood giving set.
 Most volumetric pumps also incorporate the following safety features:
o Automatic alarm and stopping of infusion following detection of air in line,
upstream/downstream occlusion, and reservoir/bag empty alert.
o Facility to pre-set volume to be infused (VTBI) and digital read out of total
volume infused.
o Automatic switch to ‘keep vein open’ (KVO) rate towards end of infusion.
o Automatic battery operations in the case of mains supply failure.

 PHNT has standardised on the Baxter Colleague pump as the volumetric pump of
choice, although others may still be in service in some areas.

b. Syringe pumps

 The preferred choice for lower volumes and low rate infusions.
 Capable of delivering very low flow rates of < 1ml/hr.
 Operated by driving a syringe plunger forward at a controlled rate to deliver the
infusate to the patient.
 The syringe is located and clamped within the device, with the plunger attached to a
moving carriage.
 Users should be aware that the flow delivered at the start of an infusion might be
considerably less than the rate set on the device. At low flow rates, the mechanical
slack must be taken up before the set rate is achieved. Mechanical slack can be
eliminated by operating the syringe pump to purge the line prior to connection to the
patient.
 Some pumps have a selectable occlusion pressure alarm levels. Selecting low levels
will help to prevent excessive delivery pressures and possible vein damage.
 Additional features may include:
o In line pressure monitoring
o Syringe barrel clamp alarm
o Syringe plunger disengagement alarm
o ‘Volume to be infused’ (VTBI) display
o ‘Volume infused’ (VI) display
o Automatic ‘keep vein open’ (KVO) rate facility
o Patient history log
o Drug name library

PHNT has standardised in the Alaris GH syringe pump of choice. Other syringe pumps
may still be available in some areas.

c. Patient Controlled Analgesia pumps (IVPCA)

 216

 Used specifically for the patient to administer a prescribed intravenous dose of opioid
as required, by activating a demand button, which has a pre-set lockout interval.

 PCA pumps (the Alaris IVAC PCAM) contains a memory log, to enable the clinician to
determine how frequently the patient has made a demand, and the total volume of
drug infused over a given time.

 Monitoring of patients with PCA devices may only be performed by those individuals
who have received formalised training from the Department of Pain Management or
those that have already been deemed competent in the use of PCA.

d. Ketamine Infusions

 Ketamine is an anaesthetic agent with analgesic properties. A low dose Ketamine infusion
can provide safe and effective analgesia. It is usually used with IVPCA to improve pain relief
and reduce opioid side effects.

 The Graseby 3300 pump must always be used for these infusions. This is a locked pump.
The responsibility of Ketamine infusions falls to the Acute Care Team / Anaesthetic team.
Ward areas should not be the key holder unless under specific instructions of the Pain Team.
In an emergency situation ward nurses should be aware of how to stop the infusion pump.

Specific guidelines / protocols are in place within the Trust on all Advanced Pain Management
Systems and must be followed. Please refer to the Acute Pain Resource Manuals or on the
Hospital Healthnet

e. Ambulatory pumps

 Allows for the mobility of the patient due to the small nature of the device.
 Preferred pump of choice for treatment in palliative care.
 Ambulatory pumps may be powered by electricity or by other means.
 The previously used Graseby MS26 has now been replaced, in this Trust, with the
Mckinley T34 ambulatory syringe pump. The T34 is calibrated in ml/hr in common with
other types of infusion device.
 The ‘Syringe Driver Infusion Chart’ should be used in conjunction with every infusion
given via an ambulatory syringe driver device.

f. Gravity feed

 Gravity feed involves the control of infusion rate by means of the height of the
infusion reservoir being sufficiently greater than the infusion site to allow a slow flow
of the infusate. Control is further refined by use of a clamp on the infusion line.
 217

 Generally suited to the delivery of fluids containing no added drugs or drugs with no
potential for vaso-irritation or damage. This is due to the poor reliability of flow rate
and pressure sensing in the delivery system.
 Provides a cheap and readily available delivery system.

2.3 Additional Information

 Only luer-lock syringes should be used within syringe pumps/drivers, PCA pumps.
This is a standard instruction issued by all infusion device manufacturers, as there is
a risk of the pressure generated in the infusion line causing the line to come apart
from the syringe. Plymouth Hospital NHS Trust currently uses BD Plastipak syringes
for this purpose.
 Anti-syphon lines must be used on all syringe pump infusions in all areas.
 Gravity lines may be used for administration of electrolytes and most antibiotics. If
considered necessary however, an infusion device may be used.

2.4 References

Medical Devices Agency (2000) Equipped to Care

CQC Essential Standards of Quality & Safety

Medicines and Healthcare products Regulatory Agency (2008) Devices in Practice

 218

Appendix 3
Copy of the PHNT Policy for maintenance of patency, flushing and locking of
intravascular lines catheters or devices

3.1 Introduction

This appendix contains tables of instructions which have been copied from the PHNT Medicines
Management Policy. The full ratified copy of this policy can be found on Plymouth Healthnet
using the link:
[Link]
c6475cdb7ee7/prowsea_TRW.[Link].265.6%20Medicines%20Management%[Link]

These tables were produced following review of current local practice and extensive local
consultation, and in response to the National Patient Safety Agency Rapid Response Alert No.2
(2008) “Risks with Intravenous Heparin Flush Solutions”.

3.2 Policy

 All flushes (Bolus and infusions) and line/catheter locks must be prescribed.
 Administration of all flushes and line/catheter locks must be recorded on the
prescription chart.
 Always attempt to aspirate the heparin lock before use of the line. If unable to aspirate the
heparin from the line, discuss with the duty consultant whether the heparin may be flushed
into the patient.
 Heparin must not be used in a patient with recognised or suspected HIT, or at risk of HIT
(Heparin-induced thrombocytopenia) without discussion with a Consultant Haematologist.

Type of intravascular line, Maintenance of Patency, Flushing and Locking

catheter or device
Short-term Peripheral Venous Flush with 5 -10ml 0.9% sodium chloride
Catheters
(Adults and children)

 Cannula, venflon
Arterial Lines Maintain patency with an infusion of 0.9% sodium chloride.
(Adults and children)
Central Venous Lines Flush with 0.9% sodium chloride (at least 10ml for adult
(Inpatient Adults) patients) and lock with 0.9% sodium chloride (volume stated
 Tunnelled lines eg. Hickman on the line) using a positive pressure clamp technique.
or Broviac lines
 PICCs and Midlines
 Short-term CVCs
 Long Lines
Short-term Central Venous All lines without a continuous infusion running should be
Catheters flushed with 0.9% sodium chloride 6-hourly. To avoid blood
(Children) flashing back into the lumen, “positive pressure” is applied
at the end of the flush.

Above table continued on the next page

 219

Type of intravascular line, Maintenance of Patency, Flushing and Locking

catheter or device

Table continued from the previous page

 220

Long-term Central Venous Lines  Hickman, Cook & Broviac Lines: Flush with 0.9%
(Children) sodium chloride and lock with 3ml of 10 units/ml
heparin.
 Groshong Lines: Flush with 0.9% sodium chloride and
lock with 5ml sodium chloride 0.9%.
Long Lines (Children) Use 10 units/ml heparin to flush and lock Long Lines in
children
Long Lines (Neonates) Maintain patency with an infusion of 0.9% sodium chloride.
In the case of an extremely premature infant maintain
patency with an infusion of 0.45% sodium chloride.
Umbilical Arterial Catheters Maintain patency with an infusion of 1unit/ml heparin,
(Neonates) prepared by diluting 10 units/ml heparin, according to the
Neonatal ICU protocol.
Vascaths Lock the catheter with trisodium citrate 46.7% solution (If no
(In General and Cardiothoracic allergy). The locking volume will be stated on the catheter.
Intensive Care) Before use, aspirate the trisodium citrate solution from the
catheter and flush with 10ml of 0.9% sodium chloride. If
unable to aspirate the trisodium citrate solution, discuss with
the duty consultant whether the trisodium citrate solution
may be flushed into the patient.
Renal-type large bore lines Flush the line with at least 10ml 0.9% sodium chloride then
(On Adult Renal and lock the line/catheter with trisodium citrate 46.7% solution (If
Haemodialysis Units, and in Adult no allergy). The locking volume will be stated on the
Haematology patients) catheter. Before use, aspirate the trisodium citrate 46.7%
solution from the line/catheter. If this is not possible, the
 Dialysis lines trisodium citrate 46.7% solution may be slowly flushed into
 Vascaths the patient. Then flush with at least 10ml 0.9% sodium
chloride.
Ports When in use with the needle in, flush with at least 10ml
(Adults and children) 0.9% sodium chloride. Lock the device with the appropriate
 Totally implantable venous volume of 10 units/ml heparin. Before the needle is
access devices eg. removed, flush with at least 10ml 0.9% sodium chloride then
Portacaths lock the device with the appropriate volume of
100 unit/ml heparin.
Central Lumen of Intra-aortic Use Heparin Sodium 2000 units/L in 0.9% Sodium Chloride
Balloon Pump Catheter IV Infusion, 500mL bags, REF Baxter B0953, as a
continuous flush of the central lumen of the Intra-Aortic
Balloon Catheter, as per protocol.

Central Venous Lines Flush the line with at least 10ml 0.9% sodium chloride then
(Outpatient or Day Case Adults) lock the line/catheter with trisodium citrate 46.7% solution (If
 Tunnelled lines eg. Hickman no allergy). The locking volume will be stated on the
or Broviac lines catheter. Before use, aspirate the trisodium citrate 46.7%
solution from the line/catheter. If this is not possible, the
trisodium citrate 46.7% solution may be slowly flushed into
the patient. Then flush with at least 10ml 0.9% sodium
chloride.
Line lock in patients receiving Lock the line with the appropriate volume of Taurolock®
TPN who have had a previous (This contains taurolidine and sodium citrate).
line infection
 221

Appendix 5
Document accountability, responsibility and dissemination

4.1 Accountability

Production Peter Gray, Pharmacist

Review and approval Medicines Utilization and Assurance Committee
Dissemination Peter Gray, Pharmacist

4.2 Overall responsibility for this document

The Director of Pharmacy has overall responsibility for the safe preparation and administration of
medicines in this Trust, and therefore has overall responsibility for this document.

4.3 Dissemination and Implementation

 Following approval and ratification by the Medicines Utilization and Assurance Committee
this eleventh edition of the injectable drug monographs with appendices will be rolled out
across the Trust.
 Publication of the eighth issue will be publicised in Vital signs and in the weekly staff news
brief. The new edition will be held in the Pharmacy Dept. Section of PHNT StaffNet.
 Paper copies will be printed by the Print Room, and together with electronic copies for
selected recipients, will be distributed according to a distribution list held in Pharmacy.
 222

Approval by Medicines Governance Group (MGG)

Chief Pharmacist (Chair of MGG)

Name: Steve Cooke

Signature:…

Date: 20.07.2016

Final Approval by Plymouth Community Healthcare

Medical Director

Name: Dr. Adam Morris

Signature

Date: 20.07.2016