The UCL Hospitals Injectable Medicines Administration Guide has been designed to be concise and easy to interpret. On reading a monograph, regular users should be able to immediately understand how to prepare and administer a medicine. Those users who are new to the Guide, or who use it infrequently, should familiarise themselves with the layout of the monographs and the terminology used before giving a medicine.
It is assumed the user is trained and competent in administering medicines. You should be familiar with the equipment used to prepare medicines, administration sets and infusion pumps. You must also be aware of your legal and ethical obligations to your patient when administering a drug. At UCLH practitioners cannot administer injectable medicines until they have completed specific training to demonstrate both their theoretical knowledge of injectable therapy and their practical competence in the preparation and administration of a medicine.
In most cases the user of the Guide will be a nurse or midwife giving a medicine according to a prescription written by a hospital doctor. The monographs are written with this scenario in mind.
For detailed information about some of the features of the monographs, such as extravasation and flushing, you should refer to Section A of the Guide.
While reading through these descriptions you may find it useful to look at some of the real monographs in the later pages of the Guide. The descriptions given may seem complicated when written, but are easy to understand when related to real monographs. Alternatively work through the tutorial for the betablocamine monograph given below.
The drug name is stated at the top of the monograph. Where there are multiple recognised names for the drug, the most commonly used UK name is stated.
This column states the preparations in which the drug is available. The form, strength, brand name and marketing authorisation holder (also known as the license holder) are given. The country in which the drug has a marketing authorisation is stated in brackets after the company name. If the drug is not branded, the term ‘non-proprietary’ is stated. Note that only the preparations available at UCLH at the time of writing are included in this column.
For further information about the formulations of injectables available refer to Section A11.
This column describes how the drug can be injected or infused. It also states the device required to give the drug and the recommended route of administration. Many drugs are given using several different methods – each method is listed on a separate row. For some drugs the indication influences the method of administration, i.e. what the drug is being used for may determine how it is administered. Indications are stated in bold in the method box.
To understand the method column the user must be familiar with the terminology associated with intravenous administration. The tables below summarise each method of administration. Detailed information can be found in Section A6.
|Abbreviation||Method of administration||Description|
|IV bolus||Intravenous bolus||Introduction of a small volume of medicine into a VAD1, most often from a syringe. The fluid enters the patient rapidly, usually over 3–5 minutes|
|(I) IV infusion||Intermittent intravenous infusion||Introduction of a volume of fluid into a VAD over a prolonged period. Usually 50–250 mL is infused from a bag over 10 minutes to 2 hours|
|(C) IV infusion||Continuous intravenous infusion||Constant delivery of fluid into a VAD over 24 hours|
|SC bolus||Subcutaneous bolus||Injection of a small volume of fluid into the subcutaneous part of the skin|
|(C) SC infusion||Continuous subcutaneous infusion||Constant delivery of fluid into the subcutaneous part of the skin|
|IM injection||Intramuscular injection||Injection of a small volume of fluid into a muscle|
1 VAD = vascular access device, i.e. a cannula or catheter.
The user must also be familiar with the following terminology:
|Volumetric pump||A device that pumps fluid from a reservoir, such as an infusion bag or bottle, through an administration set at a preset rate. Pumps are usually programmed to deliver fluid in millilitres per hour|
|Syringe pump||A device that delivers fluid from a syringe into an administration set at a preset rate. Pumps are usually programmed to deliver fluid in millilitres per hour|
|Syringe driver||A device that delivers fluid from a syringe into an administration set at a preset rate. Drivers are usually smaller than syringe pumps. They are programmed to deliver fluid in millimetres per hour|
|Central line||A catheter that has its tip located in the superior or inferior vena cava of the right atrium of the heart|
Further information about vascular access devices is given in Section A4. Further details about infusion devices are given in Section A9.
NPSA risk rating
Each method box has a coloured bar indicating the NPSA risk rating. The risk rating refers to the method of preparation and administration described along the row. The risk rating is not essential for administration; however, you should understand that the colour of the bar is indicative of the complexity of the task. Medicines that are complex to prepare and require specialist equipment or infusion devices have a high NPSA risk rating and are coloured red. You should take additional time to plan and prepare these medicines and ensure that local protocols are adhered to before giving the medicine.
Less complicated tasks are likely to have a lower NPSA risk rating and are coloured amber (moderate risk) or green (low risk).
How the risk rating is assigned
Each injectable practice has been assessed against eight criteria:
|Number||Risk factor||Applies when|
|1||Therapeutic risk||There is significant risk of patient harm if the injectable medicine is not used as intended1|
|2||Use of a concentrate||The product must be further diluted (after reconstitution) before it can be injected|
|3||Complex calculation||A complicated calculation must be performed in order to prepare or administer the product. This includes calculations with more than one step, or conversions between dose units, e.g. percentage to milligrammes per millilitre|
|4||Complex method||More than five non-touch manipulations are required to prepare the product, or when syringe-to-syringe transfer or a filter is used|
|5||Reconstitution of powder in a vial||Where a dry powder preparation must be reconstituted|
|6||Use of a part vial or ampoule, or use of more than one vial or ampoule||Part or multiple vials/ampoules are required to fulfil the prescription|
|7||Use of a pump or syringe driver||An infusion device is required to give the injectable|
|8||Use of a non-standard giving set/device required||A low sorption, air inlet or light-protected administration set needs to be used to administer the injectable|
1 As the first item, therapeutic risk, is open to interpretation; it was applied for any drug that could cause serious adverse effect if administered incorrectly, including if there was a risk of extravasation with the drug. The injectable was also given this score if patient harm was likely or if the patient did not receive the correct dose of the drug or did not receive the drug at all because of an error in preparation or administration.
If 0–2 of the criteria apply to a task, it is considered low risk (green), if 3–5 criteria apply, it is moderate risk (amber), and if 6 or more criteria apply, it is considered high risk (red).
The bar indicates which ofthe above criteria apply to the method of administration in the row. For example, if criteria 1, 5 and 6 apply, the corresponding boxes are highlighted. The colour of the boxes relates to the total score for the method, so in this example the boxes are amber as the total score is 3.
NPSA risk rating: 3
Boluses tend to be low risk as they are simple to prepare and administer. Infusions are generally higher risk.
This column tells the user how to prepare the medicine so that it is ready to administer to the patient. To understand the instructions you should be familiar with the abbreviations and terminology outlined in the following tables.
|Abbreviation||Fluid||Composition (per litre)|
|NS||Sodium chloride 0.9%. This fluid has previously been called normal saline or physiological saline||Sodium 154 mmol Chloride 154 mmol|
|W||Water for injections|
|G||Glucose 5% (also called dextrose monohydrate)||Glucose 50 g|
|G10||Glucose 10%||Glucose 100 g|
|G20||Glucose 20%||Glucose 200 g|
|H||Compound sodium lactate (commonly called Hartmann’s or lactated Ringer’s)||Sodium 131 mmol|
Potassium 5 mmol
Calcium 2 mmol
Lactate 29 mmol
Chloride 111 mmol
|GS||Glucose 4% and sodium chloride 0.18%||Glucose 40 g|
Sodium 30 mmol
Chloride 30 mmol
|Reconstitute||Add fluid to a dry powder to produce a solution or suspension|
|Dissolve||Add fluid to a dry powder to give a solution|
|Diluent||The fluid used to either reconstitute a powder or further dilute a drug solution or suspension|
|Dilute to X mL fluid||Add fluid to the container so the final volume is X. For example, if the instruction says ‘dilute dopamine 200 mg/5 mL to 20 mL water’ the user should take the dopamine and mix it with water for injections so that the final volume is 20 mL. The final concentration is dopamine 200 mg/20 mL, or 10 mg/mL|
|Dilute with X mL fluid||Add X mL to the container. For example, if the instruction says ‘dilute dopamine 200 mg/5 mL with 20 mL water’ the user should take the dopamine and add 20 mL water so that the final volume is 25 mL (20 mL from the water, 5 mL from the drug). The final concentration is dopamine 200 mg/25 mL, or 8 mg/mL|
The dilution column will advise how much diluent should be added to a vial to reconstitute a dry powder formulation. It also advises which fluids the drug solution can be further diluted with, and the final volume and/or concentration the drug should be made up to, so that it is ready to be administered to the patient.
If a preparation does not need to be reconstituted or diluted this column will state ‘ready diluted’.
Some dry powders displace a small volume of fluid when reconstituted. Instructions for how to take this into account are given in the dilution column. A full explanation of displacement values is given later in the betablocamine example and Section A12.
This column states the time period over which the drug should be given. Bolus injections simply state ‘over X minutes’, while intermittent infusion usually state ‘over X minutes’ or ‘over X hours’.
When the monograph recommends to give the drug via an infusion device, the rate is stated in millilitres per hour, since most pumps are programmed using millilitres per hour.
The term ‘unlicensed’ is used in some monographs. If a drug does not have a UK marketing authorisation, ‘unlicensed’ is stated in the monograph title.
If a drug is licensed in the UK but the monograph describes how to use the drug for an unlicensed indication, the term ‘unlicensed’ is used in the method box. If a method of preparation or administration is different to that suggested by the manufacturer, ‘unlicensed’ is stated in the dilution or rate boxes.
Users should be aware of the additional requirements and safeguards that should be in place when administering an unlicensed medicine.
The information in this column is divided into headings:
Infusion-related adverse effects: describes the side effects that patients may experience as they receive the drug. Only reactions that can be monitored at the bedside are listed. In particular, effects on blood pressure, respiration and level of consciousness, pain and gastrointestinal effects such as vomiting are included. Users should refer to this list prior to administering the drug so they can prepare themselves in the event the effect occurs.
Extravasation: if a drug is known to cause tissue damage, or theoretically may cause tissue damage because of its pharmacological properties, an extravasation warning is given. For full details about extravasation you should refer to Section A7.
ECG monitoring required: if an electrocardiogram (ECG) is required before or during infusion, an ECG statement is included. ECG monitoring may be required because the drug is given to cause a change in the rhythm or rate of the heart, or because it may cause these changes as a side effect, i.e. regardless of whether the cardiac effects are intentional or incidental, ECG monitoring may be recommended.
pH: where available, the pH of the solution injected into the patient is stated. If not available, the pH of undiluted solution is given. The pH of the drug may affect how irritating it is to veins; see Section A7 for further details. It may also influence its compatibility with other drugs.
Osmolarity or osmolality: where available, the tonicity of the solution injected into the patient is stated. The tonicity may influence how irritating the drug is to the patient’s veins; see Section A7.
Flush: lists the fluids that may be used to flush the medicine through an administration set and/or catheter/cannula. If it is not appropriate to flush, a statement to this effect is given. See Section A8 for further information about flushes.
Sodium content: the amount of sodium in each preparation listed in the formulation column. The amount does not include any sodium from the diluents or any infusion fluids to which the drug may be added. The sodium content of medicines may be important in sodium-restricted patients.
Displacement value: if a dry powder medicine has a displacement value it is stated here. See Section A12 or the betablocamine example for an explanation.
Other comments: additional information that may help the user administer the medicine is given here. You may be referred to other documents which may give further detailed information about the drug.
This column lists the fluids that can be used to dilute the drug in the monograph. It also lists the drugs that can be safely infused into a Y-site with the drug. A Y-site (also known as a Y-connector or three way tap) is usually used to connect two administration sets to the same lumen of a catheter or a cannula. The fluid from the two administration sets mixes before it enters the patient. Different fluids may also be infused into the same cannula by use of an extension set, e.g. the Vygon Octopus. These sets can be attached to a cannula and may have multiple lumens. Fluid given via these lumens mixes prior to entry into the patient.
It is essential that the compatibility of the substances infused into a Y-site or extension set is established before they are connected. Administration of incompatible medicines or infusion fluids may result in a chemical reaction between the two substances resulting in drug inactivation and possibly drug precipitation. Patient death has resulted from the infusion of incompatible medicines. If a combination is not listed as compatible in this section, the drug combination should not be infused without prior consultation with the user’s local pharmacy department and the patient’s doctor.
Before a drug is given via a Y-site it should first be established that coadministration is unavoidable. Other options should be explored, including giving the medicines one after the other, or giving one of the medicines by another route, as a subcutaneous or intramuscular injection for example.
Before compatibility can be checked in the Guide, you must establish two key pieces of information: