LIST OF CONTENTS
Page
Chapter 1 : The Role of Pharmacist in Critical Careà Datin Fadilah
Chapter 2 : Protocols
2.1 Dilution Protocols àMasrahayu, Rahela, Maznuraini
2.2 DVT Prophylaxis à Thong
2.3 Stress Ulcer Prophylaxis à Ros Sakinah
2.4 Antibiotic Guidelines for Infections in Intensive Care Unit
2.5 Neuromuscular Blocking Agents in Critically Ill Patientsà Martina
2.6 Sedative Agents in Critically Ill Patientsà Azrina
2.7 Fluid Management in Critically Ill Patientsà Pn Rohana
2.8 Medication Administration through Enteral Feeding TubesàNgua
2.9 Prokinetic Agents à Ngua : Pls get the doc from Pn. Siti Hir and add into this file
CHAPTER 3 : DOSING
3.1 Renal Dosingà Pn Nik Mah, Pn Nurdita
3.2 Liver Dosingà Shafie
3.3 Special Dosing in Obese Patientsà Siti Hir
CHAPTER 4 : NUTRITION
4.2 Parenteral Nutrition in Critically Ill Patientsà Mazni
CHAPTER 5 : OTHERS
5.1 Drug Causing Haematological Disorderà Irma
5.2 Poisoningà Hasni
APPENDICES:
Appendix 1: Drugs that may unmask/exacerbate Myasthenia Gravis- Ain
Appendix 2: Categories of Safe & Unsafe Drugs in the Acute Porphyrias- Ain
Appendix 3: Drugs and Chemicals in Glucose-6-Phosphate Dehydrogenase Deficiency
Appendix 4 : Drug-Disease Interactionsà Pn Yam (Appendix 3 & 4)
CHAPTER 1
The Role of Pharmacist in Critical Care
CHAPTER 2
PROTOCOLS
2.1 Dilution Protocols
2.1.1 Antiarrhythmic Agents
DRUG / a. Digoxin / b. AdenosineSTRENGTH/UNIT / 500mcg/2ml ( Lanoxin ) / 6mg/2ml ( Adenocor )
STORAGE / Below 25˚C, Protect from light / Below 25ºC ( Do not refrigerate )
RECONSTITUITION / Already in solution / Already in solution.
STABILITY AFTER RECONSTITUITION / Immediate use is recommended / NA
DILUENTS FOR INFUSION / D5% / NA
NS
For direct IV injection can be administered undiluted or diluted with a 4 fold or greater volume of diluents. The use of less than a 4 fold volume of diluents could lead to precipitation of digoxin.
( eg. 2ml ampoule with 500mcg in 500ml of diluents for infusion)
METHOD OF ADMINISTRATION / IV infusion (over 10-20 mins or longer-Product Information Lanoxin Injection). ( To be given at least 2 hours - BNF) / IV bolus (2 seconds )
REMARKS / Intramuscular route are not recommended. The IM route is painful and associate with muscle necrosis. / IV bolus into central or large peripheral vein.
Rapid injection is not recommended; it may cause systemic and coronary arteriolar constriction. / If given into an IV line, it should be injected as proximally as possible, and followed by a rapid saline flush (5ml of NS ).
Mixing digoxin with other drugs in the same container or simultaneous administration in the same intravenous line is not recommended. / Administer with cardiac monitoring.
REFERENCES: / 1. Product information ( Lanoxin Injection).
2. Micromedex Healthcare series.
3. Pocket Guide to Injectable Drugs. Companion to the handbook on Injectable Drugs.13 th edition. Lawrence A. Trissel. 2005.
4. British National Formulary (BNF). 55 edition. March 2008. / 1. Product information Adenocor.
2. Micromedex Healthcare series.
3. Lexi-Comp's Drug Information Handbook, 13th Edition, Charles F, Lacy, et al.2005
4. BNF 50, September 2005.
DRUG / c. Amiodarone / d. Isoproterenol Hydrochloride
STRENGTH/UNIT / 150mg/3ml ( Cordarone ) / 1mg/5ml ( Isuprel )
STORAGE / Below 25ºC. / 20ºC - 25ºC. Protect from light.
RECONSTITUITION / Already in solution. / Already in solution.
STABILITY AFTER RECONSTITUITION / NA / NA
DILUENTS FOR INFUSION / D5% / NS ( for IV bolus only )
D5% ( for IV bolus and IV infusion )
METHOD OF ADMINISTRATION / IV ( Central line )
Loading Dose : Dilute 300mg in 50 mL D5%, run over 1 hour.
Maintenance Dose : Dilute 600mg in 500mL D5% run over 23 hours. / IV bolus : dilute 0.2mg ( 1ml ) to 10 ml NS or D5%.
IV infusion : dilute 2mg ( 10ml ) in 500 ml D5%.
IM : use undiluted ( 0.2mg )
SC : use undiluted ( 0.2mg )
Intracardiac : use undiluted ( 0.02mg )
REMARKS / Do not use concentrations of less than 2 ampoules ( 300mg) in 500 ml.
Incompatible with NS.
Do not add any other products to the infusion solution.
Must be administered via the central venous route. / Concentration up to 10 times greater have been used when limitation of volume is essential
Rate over 30mcg/min have been used in advanced stages of shock.
If heart rate exceed 110 beats /min,decrease or temporarily discontinue the infusion.
Do not use if is pinkish or darker than slightly yellow or contain precipitate.
REFERENCES: / 1. Product information Cordarone.
2. Micromedex Healthcare series.
3. Lexi-Comp's Drug Information
Handbook, 13th Edition,
Charles F, Lacy, et al.2005
4. BNF 50, September 2005. / 1. Product information Isuprel.
2. Micromedex Healthcare series.
3. Lexi-Comp's Drug Information Handbook, 13th Edition, Charles F, Lacy, et al.2005
4. BNF 50, September 2005.
DRUG / e. Streptokinase
STRENGTH/UNIT / 1 500 000 IU ( Streptase )
STORAGE / 2ºC - 25ºC.
RECONSTITUITION / 5ml NS.
STABILITY AFTER RECONSTITUITION / 24 hours at 2ºC - 8ºC.
DILUENTS FOR INFUSION / NS
D5%
METHOD OF ADMINISTRATION / IV infusion : dilute up to 20 - 250mL NS or D5% over 60 mins.
REMARKS / Avoid IM use.
REFERENCES: / 1. Product information Streptase.
2. Micromedex Healthcare series.
3. Lexi-Comp's Drug Information Handbook, 13th Edition, Charles F, Lacy, et al.2005
4. BNF 50, September 2005.
2.1.2 Antibiotics
DRUG / a. Amikacin / b. Ampicilin / c. AzithromycinSTRENGTH/UNIT / 250mg/2ml
500mg/2ml / 500mg / 500mg (Zithromax)
STORAGE / Below 25˚C, Protect from light, Do not freeze / Below 25˚C / 15ºC - 30ºC
RECONSTITUITION / Already in solution / 5ml Water for Injection / 4.8ml Water for Injection
STABILITY AFTER RECONSTITUITION / NA / use within 1 hour / 24 hours at room temperature
1 week in refrigerator
DILUENTS FOR INFUSION / D5%
NS
D5% 1/2 NS
D5% 1/4 NS
Lactated Ringer's Injection / NS
Infusion concentration should not exceed 30mg/ml. / NS
1/2NS
D5%
Lactated Ringer's Injection
Infusion concentration: 1mg/ml - 2mg/ml
METHOD OF ADMINISTRATION / IV infusion : Adults and paed over 30 to 60 minutes. Infant over 1 to 2 hours.
IM injection in large muscle mass. / IV Bolus : 3 - 5 min
IV Infusion : 30 - 60 min
IM (Dissolve 500mg in 1.8ml Water for Injection) / IV infusion 1mg/ml over 3 hours
IV infusion 2mg/ml over 1 hour
REMARKS / Amikacin should not be mixed with other antibiotics in the same solution and must be administered separately. / Rapid infusion may cause seizures. / Should not be given as IV bolus or IM
REFERENCES / 1. Product information Amikozit.
2. Micromedex Healthcare series.
3. Lexi-Comp's Drug Information Handbook, 13th Edition, Charles F, Lacy, et al.2005
4. BNF 50, September 2005. / 1. Product information Pamecil.
2. Micromedex Healthcare series.
3. BNF 50, September 2005. / 1. Product information Zithromax.
2. Micromedex Healthcare series.
3. Lexi-Comp's Drug Information Handbook, 13th Edition, Charles F, Lacy, et al.2005
4. BNF 50, September 2005.
DRUG / d. Cefepime / e. Cefotaxime / f. Ceftazidime
STRENGTH/UNIT / 1gm (Maxipime) / 1gm / 1gm , 2gm ( Fortum )
STORAGE / 15ºC - 30ºC / 15ºC - 30ºC , Protect from light / Below 25ºC, Protect from light
RECONSTITUITION / 10ml Water for Injection, D5%, NS / 10ml Water for Injection / 10ml Water for Injection ( both 1gm and 2gm)
STABILITY AFTER RECONSTITUITION / 24 hours at room temperature
1 week in refrigerator / Not to be stored above 25ºC
Not longer than 24 hours / 18 hours at below 25ºC
1 week in refrigerator
DILUENTS FOR INFUSION / NS
D5%
Infusion concentration:
1mg/ml - 40mg/ml / NS
D5% / NS
D5%
METHOD OF ADMINISTRATION / IV infusion over 30 minutes
IM ( Dissolve 1gm in 3ml Water for Injection, D5%, 1% Lidocaine ) / IV bolus over 3-5 minutes.
IV infusion: 100ml over 50 - 60 minutes.
IM ( Dissolve 1gm in 4ml Water for Injection ) / IV bolus over 3-5 minutes.
IV infusion: diluent up to 50ml over 30 minutes.
IM ( Dissolve 1gm in 3ml Water for Injection )
REMARKS / IV preferable for patient with severe or life-threatening infection. / IV preferable for dose exceed 1gm / IV preferable for dose exceeds1gm.
May be used in peritoneal dialysis and CAPD.
Concentration : 125 - 250mg for 2L of dialysis fluid
REFERENCES / 1. Product information Maxipime.
2. Micromedex Healthcare series.
3. Lexi-Comp's Drug Information Handbook, 13th Edition, Charles F, Lacy, et al.2005
4. BNF 50, September 2005. / 1. Product information Rekaxime.
2. Micromedex Healthcare series.
3. Lexi-Comp's Drug Information Handbook, 13th Edition, Charles F, Lacy, et al.2005
4. BNF 50, September 2005. / 1. Product information Fortum.
2. Micromedex Healthcare series.
3. Lexi-Comp's Drug Information Handbook, 13th Edition, Charles F, Lacy, et al.2005
4. BNF 50, September 2005.
DRUG / g. Ceftriaxone / h. Cefuroxime / i. Ciprofloxacin
STRENGTH/UNIT / 500mg ( Rocephin ) / 750mg, 1.5gm (Zinacef ) / 100mg/50ml, 200mg/ 100ml ( Ciprobay )
STORAGE / Below 30ºC / 25ºC / Below 25ºC, Do not freeze
RECONSTITUITION / 5ml of solvent / 6ml Water for Injection for 750mg
15ml Water for Injection for 1.5gm / Already in solution
STABILITY AFTER RECONSTITUITION / 6 hours at room temperature
24 hours in refrigerator / 5 hours at room temperature
48 hours in refrigerator / NA
DILUENTS FOR INFUSION / NS
D5% / NS
0.45%NS
D5% / NS
D5%
Ringer lactate
METHOD OF ADMINISTRATION / IV bolus over 2-4 minutes.
IV infusion: 50 to 100ml over at least 30 minutes.
IM ( Dissolve 500mg in 2ml 1% Lidocaine ) / IV bolus over 3-5 minutes.
IV infusion : 50 to 100ml over 30 minutes.
IM ( Dissolve 750mg in 3ml Water for Injection ) / IV Infusion over 60 minutes
REMARKS / Neonates : IV infusion should at least 60 minutes.
Dose exceed 1gm not be given by IM.
Only use Calcium-free infusion solutions. / Slow infusion into a large vein minimize local IV site reactions
Ciprofloxacin solution can be infused directly or mixing with compatible infusion diluents.
REFERENCES / 1. Product information Rocephin.
2. Micromedex Healthcare series.
3. Lexi-Comp's Drug Information Handbook, 13th Edition, Charles F, Lacy, et al.2005
4. BNF 50, September 2005. / 1. Product information Zinacef.
2. Micromedex Healthcare series.
3. Lexi-Comp's Drug Information Handbook, 13th Edition, Charles F, Lacy, et al.2005
4. BNF 50, September 2005. / 1. Product information Ciprobay
2. Micromedex Healthcare series.
3. Lexi-Comp's Drug Information Handbook, 13th Edition, Charles F, Lacy, et al.2005
4. BNF 50, September 2005.
DRUG / j. Amoxicillin and Clavulanate Potassium / k. Cloxacillin / l. Sulfamethoxazole and Trimethoprim
STRENGTH/UNIT / 1.2gm / 500mg / 480mg/5ml
STORAGE / Below 25ºC. / Below 25ºC. / Below 30ºC, Do not refrigerate. Protect from light.
RECONSTITUITION / WFI / 10ml Water for Injection. / Already in solution
STABILITY AFTER RECONSTITUITION / Solution should be made up to full infusion volume, immediately after reconstitution. / 30 minutes after reconstitution. / NA
DILUENTS FOR INFUSION / WFI
NS / NS
D5% / NS
D5%
METHOD OF ADMINISTRATION / IV Infusion: 50-100ml over 30-40 minutes
IV Infusion complete within 4 hours of reconstitution. / IV bolus over 3-5 minutes.
IV Infusion over 20-30 minutes
IM ( Dissolve 500mg in 2.5ml Water for Injection ) / IV Infusion over 60-90 minutes
REMARKS / Less stable in infusions containing glucose, dextran or bicarbonate. / 1 amp(5ml) to 125ml, 2amp(10ml) to 250ml, 3amp(15ml) to 500ml diluent.
Fluid restriction required, 1amp(5ml) to 75ml diluent.
Infusion commenced within 30 minutes after preparation.
Duration of infusion not exceed 1.5 hours.
REFERENCES / 1. Product information Moxied-CLV
2. 2. BNF 50, September 2005. / 1. Product information Monoclox / 1. Product information DBL
2. Micromedex Healthcare series.
3. Lexi-Comp's Drug Information Handbook, 13th Edition, Charles F, Lacy, et al.2005
4. BNF 50, September 2005.
DRUG / m. Fusidic Acid / n. Gentamicin / o. Imipenem with cilastatin
STRENGTH/UNIT / 500mg ( Fucidin) / 80mg/2ml / 500mg
STORAGE / 15 - 20ºC / Below 25ºC / 15 - 30ºC
RECONSTITUITION / 10ml of buffer solution provided. / Already in solution. / 10ml of diluent for infusion
STABILITY AFTER RECONSTITUITION / NA / NA / 4 hours at room temperature
24 hours in refrigerator
DILUENTS FOR INFUSION / NS
D5% ** / NS
D5% / NS
D5%
D10%
D5%NS
Mannitol 5% and 10%
METHOD OF ADMINISTRATION / IV Infusion: 250 -500ml over 2-4 hours / IV infusion : 100-200ml over 30 minutes. / IV infusion : 500mg in 100m diluent for infusion. Rate depend on dose.
Dose ≤ 500mg over 20 - 30 minutes , ≥ 500mg over 40 -60 minutes.
REMARKS / Give through central venous line to minimize venospams and thrombophlebitis.
If superficial vein used, infusion over 6 hours.
Never be injected undiluted.
Must not be given intramuscularly or subcutaneously.
** Precipitation may occur in infusion solution pH below 7.4
( more acidic samples of dextrose 5% ) / For extended-interval doses, an infusion period of 60 minutes recommended.
Administer other antibiotic at least 1 hour before or after gentamycin. / Must use the same diluent for reconstitution and as infusion solution.
Reconstitution of Tienam : add ≈ 10 ml of appropriate infusion solution to vial. Shake well and transfer the suspension to infusion solution container. Repeat with additional 10ml infusion solution to ensure complete transfer of vial contents to infusion solution. Resulting mixture should be agitated until clear.
REFERENCES / 1. Product information Fucidin.
2. Micromedex Healthcare series.
3. BNF 50, September 2005. / 1. Product information Garasent.
2. Micromedex Healthcare series.
3. Lexi-Comp's Drug Information Handbook, 13th Edition, Charles F, Lacy, et al.2005
4. BNF 50, September 2005. / 1. Product information Tienam.
2. 2. Micromedex Healthcare series.
3. Lexi-Comp's Drug Information Handbook, 13th Edition, Charles F, Lacy, et al.2005
4. BNF 50, September 2005.
DRUG / p. Meropenem / q. Metronidazole / r. Linezolid