Markey Cancer Center Nurses Guide: Intravenous Push (IVP) Drug List Approved for RN Administration

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1 Bumetanide (Bumex) Butorphanol Tartrate (Stadol) Cosyntropin (Cortrosyn) Dexamethasone Sodium Phosphate (Decadron) Dextrose 50% Diazepam (Valium) Diphenhydramine HCL (Benadryl) Dolasetron Mesylate (Anzemet) Droperidol (Inapsine) Epinephrine (Adrenaline Chloride) Famotidine (Pepcid) Flumazenil (Romazicon, Mazicon) Furosemide (Lasix) Glucagon (Glua Gen) Glycopyrrolate (Robinul) Granisitron HCL (Kytril) Haldoperidol (Haldol) Heparin (Heparin, Hep-Lock) Hydralazine HCL (Apresoline) Hydrocortisone Sodium Succinate (Solu-Cortef) Hydromorphone (Dilaudid) Insulin Regular Only Ketorolac (Toradol) Labetalol (Normodyne, Trandate) Leucovorin Calcium (Wellcovorin) Levothyroxine (Synthroid) Lorazepam (Ativan) Meperidine (Demerol) Methylprednisolone Sodium Succinate (Solu-Medrol) Metoclopramide (Reglan) Morphine (MSO4) Muromonab-CD3 (Orthoclone, OKT3) *BMT Unit ONLY Naloxone (Narcan) Pantoprazole (Protonix) Promethazine (Phenergan) *Via Central or PICC Line Only Sodium Bicarbonate (NaHCO3, Bicarb) Torsemide (Demadex)

2 GENERIC NAME Atropine Bumetanide (Bumex) Butorphanol Tartrate (Stadol) Cosyntropin (Cortrosyn) Dexamethasone Sodium Phosphate (Decadron) Antiarrhythmic/ Anticholinergic/ Treat symptomatic bradycardia, Pre-op antidote for certain insecticide poisoning Diuretic/ Acute pulmonary edema, CHF, renal disease Narcotic-Opioid analgesic/ Relief of modsevere pain Pre-op: mg Bradycardia: mg q 3-5 min to max of 2 mg 0.5-2mg mg q 3-4 hours RATE 2 mg 1mg/ml 1 mg or less over 1 minute 10mg/d ay 4mg/do se 2mg over 2 minutes 2mg/ml 2mg over 3-5 minutes CONSIDERS Pain at injection site Also supplied as nasal spray 10mg.ml Dry mouth, dizziness, palpitations, urinary retention, nervousness, weakness. Risk of ototoxicity if concurrent use with aminoglycoside antibiotics. Multiple drug interactions. Dizziness, weakness, N&V, orthostatic hypotension, hypokalemia, polyuria N&V, sedation, diplopia, palpitations, respiratory depression, caution with ambulation Diagnostic Agent 0.25mg 1mg 2 minutes Peak cortisol concentration occurs min after administration Antiemetic esp. for 4mg 4mg/ml Over 1 minute Contraindicated Insomnia, nervousness, increased high dose chemo & maximum, in pts. with appetite, thrombocytopenia, fluid radiation; Antiinflammatory, slower if itching psychosis, AIDS, retention, Over 3-5 min is TB, VRE, fungal Watch for GI bleeding, epistaxis Cerebral edema better. infections Highly variable based on disease/ pt. respons e ( mg)

3 Dextrose 50% Diazepam (Valium) Diphenhydramine HCL (Benadryl) Dolasetron Mesylate (Anzemet) Symptomatic hypoglycemia Benzodiazipine; Seizure, Anxiety, Alcohol withdrawal Antihistamine; Histamine 1 Antagonist/ Alleviate allergic symptoms 5 HT3 Blocker Antiemetic/ Prevent & treat chemo induced and post-op N&V 20-50ml of 50% solution Seizures: 5-10 mg initial, repeat at 10 min intervals to max 30 mg Anxiety: 2-5mg initial, repeat q3-4 hrs prn Alcohol Withdrawal: 10 mg initial, repeat 5-10 mg q 3-4 hrs prn mg Q2-4H 12.5 mg over 30 seconds ml of 50% solution 30mg/8 hrs 50mg/d ose400 mg/day RATE 10ml/minute CONSIDERS Phlebitis risk, pain at injection site. Best per central line VAD 5mg/ml 2-5mg/minute -Phlebitis risk, pain at injection site-use large vein -Flumazenil (Romazicon) is the antagonist -Incompatible with most other drugs & solns. Push only in NS or D5NS very close to IV site 50mg/ml 25mg/minute Dilute to 25mg/ml in D5W or NS 12.5mg/ ml 100 mg/30 seconds Hyperglycemia, confusion, tissue necrosis with extravasation of peripheral infusion. Bradycardia; tachycardia, drowsiness, hypotension, hypoventilation, urinary retention, caution in elderly, do not use with acute narrow angle glaucoma Hypotension, tachycardia, sedation, dizziness, insomnia, caution in asthma HTN, Headache, dizziness, tachycardia and urinary retention. Caution in patients at risk for prolonged QT interval

4 Droperidol (Inapsine) Epinephrine (Adrenaline Chloride) Nausea & vomiting Premed for OR Sympathomimetic, Cardiac Arrest, Hypersensitivity reactions mg per min 1mg q 3-5 min. during cardiac arrest RATE CONSIDERS 10 mg mg/min *Drug Carries Black Box Warning- Reserve for pts who do not respond to alternatives Usual conc. is 1mg/10ml 1 mg over 1-2 seconds Watch for injection site blanching/ extravasation Laryngospasm, hypotension especially orthostatic, hallucinations, sedation, prolonged QT interval. Check V/S at 30 min (peak effect) -Tachycardia, hypertension, nervousness, restlessness, headache, dizziness HR, BP -Note: One mg = 1ml of 1:1000 soln OR 10ml of 1:10,000 soln -Do not mix with alkaline solutions Famotidine (Pepcid) Flumazenil (Romazicon, Mazicon) Gastrointestinal, Histamine 2 Antagonist Benzodiazipine antagonist 20mg Q12H 40mg 20mg/5 to 10ml 0.2mg initial, them can repeat with 0.3mg Give no more than 1mg per dose or 3mg/ho ur 20mg/2 minutes 0.1mg/ml 0.2mg over seconds Transient irritation at IV site Dosage adjusted in renal failure Use large vein & free flowing IV to minimize pain at injection site Headaches, dizziness, confusion, mental status changes Pt. may need additional doses in case of re-sedation. Caution in pts. at risk for or being treated for seizures

5 Furosemide (Lasix) Loop Diuretic for pulmonary edema, fluid overload 40 mg 80 mg but can vary widely RATE CONSIDERS 10mg/ml 1-2 minutes Rapid and high dose admin. can cause irreversible hearing loss Hypotension, headache, dizziness Glucagon (Glua Gen) Glycopyrrolate (Robinul) -Emergency treatment of symptomatic hypoglycemia -Diagnostic aid in some radiological exams Anticholinergic/ Preop: to diminish secretions & block cardiac vagal reflexes mg. May be repeated 1-2 times mg./kg 30 min prior to anesthesia 1mg/minute 0.2mg.ml 0.2 mg over 1-2 minutes using free-flowing IV line May precipitate with NS, potassium & calcium. Compatible with D5W Unstable hypoglycemic diabetic may not respond & will need dextrose IV instead. N&V, hypokalemia in overdose, urticaria, respiratory distress, hypotension. Blurred vision, dry mouth, N&V, urinary hesitancy & retention Granisetron HCL (Kytril) Haldoperidol (Haldol) 5HT3 Blocker Prevention of N/V secondary to chemotherapy Antipsychotic/ Acute psychiatric episodes Nausea & vomiting 10 mcg/kg given 30 min prior to chemo dose 2-25 mg Varies with patient Undiluted over 30 seconds 100mg/ml 5mg/minute Start with lower doses in geriatric patients Headache, diarrhea, constipation, hypertension, fever. Drowsiness, extrapyramidal symptoms, hypotension, tachycardia, bradycardia, suppression of cough reflex, dry mouth, N&V

6 Heparin (Heparin Hep-Lock) Hydralazine HCL (Apresoline) Hydrocortisone Sodium Succinate (Solu-Cortef) Hydromorphone (Dilaudid) Anticoagulant/ DVT, Pulmonary Embolism, MI -Final flush for Groshong catheter in low dose Antihypertensive/ Severe essential hypertension, when need to lower BP is urgent Narcotic Analgesic units Initial bolus: units/kg Infusion: units/kg/hr mg Repeated as necessary Succinate = mg 1-4mg q 2-6 hrs prn units/ml RATE Over 1 minute CONSIDERS Reversal agent: Protamine Takes 6 hours to see effects of dose change 20 mg/ml Slow IVP -Do not give with dextrose containing solutions -Undergoes color changes in most IV solutions. This does not indicate loss of potency Succinate= over at least 30 sec 4mg/ml Each 2 mg over 2-5 minutes -Succinate comes in Mixo-vial, mix gently Nalxone (Narcan) is reversal agent Bleeding, APTT, Hct, Hgb Thrombocytopenia (HIT - Heparin Induced Thrombocytopenia) Caution in CVA-may increase intercranial pressure. Headache, N&V, palpitations, angina, tachycardia, diarrhea. Elderly may be more sensitive to hypotensive effects. *Do not confuse with hydroxyzine. Insomnia, nervousness. May cause hyperglycemia in diabetics. Caution in TB & fungal infections & antibiotic resistant infections. Alert: salt formations are not interchangeable Alert: do not confuse Solu-Cortef with Solu-Medrol Palpitations, hypotension, constipation, dizziness, drowsiness, BP, RR

7 Insulin (Regular Only) Ketorolac (Toradol) Labetalol (Normodyne) (Trandate) Leucovorin Calcium (Wellcovorin) Folinic acid Pancreatic Hormone/ Hyperglycemia, DKA, Hyperkalemia NSAID/ Short term management of mod-severe pain Antihypertensive -High dose methotrexate rescue. -Advanced colorectal cancer (followed by 5FU as 2 nd infusion) units/kg IV bolus 15 mg-30mg IV q 6 hours 20 mg initial. Additional doses of 40-80mg q 10 min. until max 300 mg Rescue: Based on methotrexate level but roughly 10mg/m2 Cancer: mg/m2 120 mg/day, max 5 days RATE Over 10 seconds 30 mg/ml Over > 15 seconds 25mg/ml 20 mg over 2 minutes Over 3 minutes or longer. Do not exceed 160 mg/minute CONSIDERS -ONLY Regular Insulin may be given IV -Hyperkalemia: 10 units in conjunction with dextrose and sodium bicarbonate Do not administer intrathecal or epidural routes Requires renal dose adjustment -Pain at injection site -Protect form heat & light Monitor Finger Stick Blood Sugars Edema, drowsiness, headache, renal toxicity. Do not administer to pts with active or recent bleeding. Do not use as pre-op analgesic. Avoid if already taking ASA or NSAIDS. Dizziness, orthostatic hypotension, vivid dreams, N&V, bronchospasm, dyspnea, arrhythmias, nasal stuffiness Allergic reactions. Do not confuse leucovorin (folinic acid) with folic acid. Follow leucovorin rescue schedule/protocol VERY closely.

8 Levothyroxine (Synthroid) Lorazepam (Ativan) Thyroid hormone/ Replacement therapy in hypothyroidism Benzodiazipine/ Anticonvulsant, sedation, anxiety, agitation Initial dose: mcg, then on day two, then maint mcg q day Maintenance = ½ of oral dose 1-2 mg 8mg/12 hrs, or 4mg per dose RATE 100mcg/min CONSIDERS -Do not mix with any other IV fluids -Do not further dilute drug 2mg/ml 2mg/minute -Flumazenil (Romazicon) is reversal agent used to treat respiratory depression. -Dilute with equal volume IVF Symptoms of hyperthyroidism (nervousness, tremor, headache tachycardia, heat intolerance, etc.) Sedation, hypotension, dizziness, headache, amnesia, HR, BP, RR. Can increase digoxin levels. Meperidine (Demerol) Narcotic Analgesic mg q 2-4 hrs prn 100mg/ml Over 4-5 minutes -Dilute to < 10mg/ml -Contraindicated in pt. taking MAO inhibitor & with pt. in kidney failure -Naloxone (Narcan) is reversal agent Sedation, hypotension, dizziness, constipation, BR, RR

9 Methylprednisolone Sodium Succinate (Solu-Medrol) Metoclopramide (Reglan) Anti-inflammatory agent Adrenal Corticosteroid/ Severe inflammation Immunosuppression Prevent infusion/allergic reactions Antiemetic/ Relief of symptomatic GE Reflux, facilitate small bowel intubation, N&V post-op and assoc mg -High dose regime ns will require IVPB route of admin 5-10 mg 1-2mg/kg IV 30 min prior to chemo with chemo Morphine Narcotic Analgesic 2-10 mg q 2-4 hours prn RATE 62.5mg/ml Over 3-60 minutes 125mg / 3-5 min 250mg/15-30min 500mg/ 30min 1Gm/60min 10 mg 5mg/ml 1-2 minutes High doses >10mg require IVPB over 15 min. CONSIDERS -Rapid admin of high doses can cause circulatory collapse. -* Only the succinate form can be given IV Admin over < 1 min. may cause intense anxiety & restlessness 10mg/ml 1 mg/min - Naloxone (Narcan) is reversal agent Insomnia, nervousness BP, monitor blood glucose levels in diabetic pts. Monitor Na+ and potassium levels Caution with hypertension. Contraindicated in GI bleed. Mental depression, BP changes, restlessness, drowsiness, dizziness, dystonic reactions (extrapyramadal effects treated Benadryl). Sedation, dizziness, heart palpitation, hypotension, bradycardia, constipation BP, RR, Oxygen saturation Muromonab-CD3 (Orthoclone, OKT3) *BMT Unit ONLY Immunosuppressive Agent 5mg 5mg 1mg/ml <1minute Filter each dose through a low protein binding 0.22 micron filter Fever, chilling, dyspnea, wheezing, chest pain, tachycardia, dizziness, shortness of breath. Monitor all vital signs including temperature.

10 Naloxone (Narcan) Pure Opiod Antagonist/ Treat respiratory depression from narcotic intake 0.4-2mg mg q 2-3 min until desired reversal of post-op narcotic depression RATE CONSIDERS 24mg 1mg/ml Over 2 minutes -If pt. on chronic opioids, give <0.1 mg at a time to avoid reversal of pain relief Tachycardia, narcotic withdraw, hypertension, hypotension, anxiety, restlessness, HR, BP, RR Note: duration of narcotic may exceed that of Naloxone, monitor for return of respiratory depression Pantoprazole (Protonix) Promethazine (Phenergan) Via CENTRAL or PICC line only, or IVPB over 20 min. Gastrointestinal; Proton pump inhibitor Antiemetic Antihistamine 40 mg 80 mg 4mg/ml 40mg/ 2 min Reconstitute with 10ml, 0.9% NaCl mg 50mg 50mg/ml 25mg/min ALERT! Extravasation can lead to EXTENSIVE tissue damage. Give ONLY via Central or PICC Line Injection site reactions, headache, dyspepsia, and nausea ALERT ONLY given via Central or PICC Line due to potential for tissue damage with extravasation. Hypotension, tachycardia, dizziness, drowsiness. Sodium Bicarbonate (NaHCO3) (Bicarb) Alkalinization Agent/ -Metabolic acidosis (from cardiac arrest, renal failure, DKA, etc) -Maintain alkaline urine: tumor lysis syndrome, trauma, tricyclic antidepressant drug overdose meq/kg Dose for renal failure & DKA based n ABG 1mg/ml Rapid: 1-2 seconds -Push in cardiac arrests only -Tissue necrosis if extravasation. -inactivates catecholamines such as dopamine, epinephrine -Precipitates if given with calcium Edema, fluid overload, hypernatremia, metabolic alkalosis

11 Torsemide (Demadex) Diuretic/ HPT, CHF with fluid overload, renal & hepatic disease RATE mg 20mg over at least two min CONSIDERS Contraindicated in anuria. Hypokalemia, hyperglycemia, N&V, headache, dizziness. If the medication is not approved for IV push administration and alternative routes of administration are not available, approval for this individual 02/04/03 Developed by: Jeanne Bouvier, Staff Development and Kim Hopper, PharmD Approved by: Kimberley Hite, Tukea Talbot, Mary Lindsey Merrill Contact person for revisions: Kimberley Hite

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