Download SHEET L.14 SLIDE 5 (IV drug preparation guidelines)

)SHEET L.14 SLIDE 5 (IV drug preparation guidelines
April 2, 2017
practice 2
Sheet Number : 14
Dr. Name : Eman Elayeh
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)SHEET L.14 SLIDE 5 (IV drug preparation guidelines
April 2, 2017
Record 15
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We talked about Drugs that should be avoided in geriatrics, Including NSAIDs --> all the NSAIDs
family have an issue because it may cause GI bleeding, and Nephrotoxicity therefore leading to
Chronic kidney disease
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Geriatrics taking NSAID must take a protectant of peptic ulcer (proton pump inhibitor), depending
on the risk factors (high, intermediate, low)
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Risk factors for NSAID induced peptic ulcers:
1- Age (>60 years old)
2- Concurrent use of antiplatelet or anticoagulant or glucocorticoids
3- High dose of NSAID or 2 NSAIDs
4- History of GI bleeding or complicated peptic ulcer disease (we consider it complicated if
perforation or GI bleeding occurs as a result of the peptic ulcer)
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History alone can put the patient in High risk category
Zero risk factor --> Low risk
One or two risk factors --> Intermediate risk, needs protection
High risk --> needs protection
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Usually we don't use an NSAID, instead we use COX2 inhibitor + Proton inhibitor --> To lower GI
bleeding risk
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GI risk increase with cumulative period of use , During the first 3 or 6 months the possibility of having
a GI bleeding is 6%, while it's more after a year of use.
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The most NSAID drug associated with increasing the risk of GI bleeding is (Ketorolac), that's why it's
written on the label (Don't use for more than 5 days) because it directly causes GI bleeding.
Ketorolac isn't available here and it's considered of the Protocol NSAIDs
The second to go after ketorolac regarding side effects is (Indomethacin)
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Naproxen and Ibuprofen are some of the NSAIDs which are gentle on the GIT and can be used in the
lowest dose for the least duration possible
I can switch, if I don't want it to have an anti-inflammatory effect I can use Paracetamol instead (For
mild and moderate pain) , Or Opioids (for severe pain)
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We also talked about skeletal muscle relaxants, one the most popular ones is Orphenedrine, we
should stay away from it because of the anticholinergic effect.
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(Table 3) includes medications based on medical condition; like in a case of HF what drugs should be
avoided in geriatrics? (generally they aren't to be used in all adults but they have greater risk in
geriatrics)
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)SHEET L.14 SLIDE 5 (IV drug preparation guidelines
April 2, 2017
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CCB (Non-dihydroperidines verapamil, Diltiazem), TZD (pioglitazone, rosiglitazone), NSAIDs, COX2
inhibitors, Dronedarone (Anti arrhythmic)
They can all cause fluid overload, and the CCBs have –ve inotropic effect
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IF the patient has HF and Arrhythmia --> The best anti arrhythmic to be used is Amiodarone, while
Dronedarone should be avoided in HF
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In case of Dementia or Cognitive impairment --> there are drugs that can cause dementia or
cognitive impairment such as (Benzodiazipines, Anticholinergics, H2 receptor antagonist (famotidine,
ranitidine))
H2 receptor antagonists are unsafe in case of geriatrics with dementia or cognitive impairment and
delirium
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Anticholinergics --> increase the risk of stroke in patients with dementia. That's why it should be
avoided in patients with dementia.
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If someone has a history of fall or fracture we should avoid (Antipsychotics, Benzodiazepines,
Tricyclic antidepressants, Opioids or anything that increases the risk of sedation all should be
avoided)
Also if we had bone fracture we should avoid SSRI (selective serotonin reuptake inhibitors)And nonbenzodiazepine hypnotics (zaleplon, zolpidem)
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In cases of insomnia we should avoid anything that would increase the alertness of the patient such
as :
1- Decongestants (Systemic: pseudoephedrine, phenylephrine)
2- All stimulants (amphetamines, methylphenidate)
3- Theophylline
4- Caffeine
They are all considered CNS stimulants so they should be avoided
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History of gastric or duodenal ulcers --> we should avoid Aspirin (>325 mg) and Non-COX2 selective
NSAIDs
Patients with benign prostate hyperplasia (especially in geriatric men) ---> we should avoid any drug
associated with anticholinergic effects, because they increase fluid retention, and these patients as a
result of enlargement of the prostate usually have fluid retention.
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(Table 4) talks about drugs used with caution in geriatrics
1- Aspirin
For primary prevention of cardiac events (in patients >80 years old)
 For example if a patient who's 82 years old isn't taking aspirin for primary prevention, question is
why would he be on aspirin? Because he may have diabetes without a history of IHD, MI or stroke
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For diabetes we give aspirin as a primary prevention:
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)SHEET L.14 SLIDE 5 (IV drug preparation guidelines
April 2, 2017
Age >55 or >50 years old male or female with other risk factor (HTN, Family history...)
*As the patient in the example is 82 years old so the use of aspirin may develop a risk of GI bleeding,
therefore its use should be with great caution
2- Dabigatran
Anticoagulant, a substitute for warfarin
 Should be used with caution in patients >75 years old ,because it increases the risk of GI bleeding
more than it can benefit the patient
 Age itself increases the risk plus the risk from the medication, therefore we'll have an additive effect
3-
Prasugrel
The most Antiplatelet agent which increases the risk of bleeding
 Should be use with caution in patients >75 years old
4-
There is a group of medications even if they were indicated (Antipsychotic for bipolar or
schizophrenia) but still should be used with caution
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The thing in common between these medications is that they increase the risk of syndrome of
inapropriate ADH secretion --> Increase the risk of water retention --> cause Hyponatremia -->
cerebral edema (confusion is the first sign appearing on the patients specially in geriatrics)
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The medications are:
A- Antipsychotics
We once said AVOID and other times USE WITH CAUTION
With caution: with appropriate indication (Bipolar, Schizophrenia)
Avoid: If using it only for behavioral problems in Dementia
B- Diuretics
Such as furosemide, thiazide diuretics
Should be use with caution
C- Carbamazepine
One of the drugs hitch increase ADH secretion
D- SSRIs, SNRIs
E- TCAs (Tricyclic antidepressants)
Should be avoided because they have a significant anticholinergic effect and orthostatic hypotension
unless they become my only option, if I want to use them --> should be used with caution
 3 Cautions: caution because of the Anticolinergic effect, Orthostatic hypotension and syndrome of
inappropriate ADH secretion
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)SHEET L.14 SLIDE 5 (IV drug preparation guidelines
April 2, 2017
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Vasodilators
Should be used also with caution in geriatric patients
 Like Isosorbidedinitrate, because they can cause Significant Hypotension and may also cause
syncope or fracture
 These are the most important things required from Beers Criteria.
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IV drug preperation guidelines:
IV medications are used significantly in hospitals (inpatient)
We should be familiar with IV preparations, because we will be asked about whether we can give two
drugs in the same syringe or in the same IV line Or how to reconstitute it and how to be given t the
patient
IV medications --> can come as a vial with a solution or a powder
(The powder needs two steps: Reconstitution, and may need a second step which is dilution)
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Reconstitution : we add a reconstitution fluid solvent on the drug, then it can be withdrawn with a
syringe
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The drug may be given as an IV push, I withdraw the needed amount then it's given to the patient ,
or it may be given as an infusion which the drug here will need to be diluted
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We'll talk about reconstitution process and what are the appropriate solvents, and how long the vial
is usable, storage conditions, and the right diluents for each drug.
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Other thing is that in Pediatrics there is always a Maximum concentration that we can't overcome,
while in adults generally there isn't a maximum concentration, and based on the max. concentration
in pediatrics the dilution takes place for the medication.
We'll also talk about chemotherapeutic drugs, how are they prepared as they need special conditions
which differs from any other mediations
All these things will be discussed and are in the Injectable drugs guide book.
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One of the things we're concerned about while preparing IV medications is the sodium content,
there a lot of medications especially antibiotics are prepared as salts
 Why it's important to watch for the sodium content in IV medications?
Because of patients who have HF, HTN, CKD (if the patient has volume overload), Ascitis (Abdominal fluid
overload)
Usually if there was a significant Na content, if it was more than 1 mmol Na per dose, it's written on drug's
monograph.
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How much Na is allowed for a HF patient?
800 mg Na (0.8 g) / <2 g of NaCl
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)SHEET L.14 SLIDE 5 (IV drug preparation guidelines
April 2, 2017
Na ---2.5(factor) ---> NaCl
Na -------> NaCl *2.5
NaCl ------> Na /2.5
NaCl's weight is higher than Na alone (We care about the Na alone more than NaCl)
 If w want to convert mmol Na to mg Na ----> ( Conversion factor = 23)
1 mmol Na --------> 23 mg Na
Mmol ---->mg
*23
Mg--------->mmol
/23
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We don't need to memorize the conversion from mmol Na to mg NaCl , we FIRST convert from mmol
Na to mg Na (*23), THEN we convert from Na to NaCl (*2.5) , the result eventually is = 58.5
(ultimately the conversion factor)
 The table in the slide:
Most medications which have a high content of Na are Antibiotics, mostly Penicillins
Piperacillin-tazobactam ---> 64 mg Na/1 g of AB
We calculate Na depending on the total daily dose, it can be given:
4.5 g/6 hr
3.375 g/6 hr
Depending on the renal clearance and indication
2.25 g/6 hr
If we took the highest dose (1g piper-tazo/64 Na)
--> 4.5*4*64= 124 mg which is high Na load (without any food or drinks)
Even at the lowest dose the Na reaches 512 mg (generally high)
Ticarcillin-clavulanate ---> 1g/103.6 mg Na
Dose: 3.1 g/4 hr (6 times) --> total Na =1864 mg (high content) one or two folds the allowed value
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Ampicillin-sulbactam ----> 1.5 g q6h = 460 mg Na
3 g q6h = 920 mg Na
(High Na content)
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Oxacillin ---------> 690 mg Na
(High content)
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Nafcillin ----------> 698 mg Ba
(High content)
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Cephalosporines :
Cefepime ----------> 0 Na
Very safe, doesn't cause volume overload
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)SHEET L.14 SLIDE 5 (IV drug preparation guidelines
April 2, 2017
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Ceftriaxone----------> 2g/day = 166 mg Na
1g/day = 83 mg Na
(Acceptable Na content)
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Ceftazoline ----------> Low Na content
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Cefazoline ------------>Not usually used
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Carbapenem :
Meropenem
Imipenem-cilastatin --> 500mg/6 hr = 15 mg Na (Very good)
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Ciprofloxacin, Levofloxacin ------> 0 Na
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Vancomycin -------------> 0 Na
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Metronidazole -----------> Rich in Na, 500 mg/8 hr = 938 mg Na
TO SUMMERIZE:
 AB with high Na content:
Pipercillin-tazobactam, Ticarcillin-clavulanate, Oxacillin, Nafcillin, Ampicillin-sulbactam
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Cephalosporins--> none of them has a significant amount of Na content
Carbapenem--> don't contain high amounts of Na
Fluroquinolons--> don't contain Na at all
Vancomycin--> don't contain Na
Metronidazole--> rich in Na
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If we want to choose an agent for a HF patient ==> should avoid Pipercillin-tazo, Ampicillinsulbactam, Nafcillin / Oxacillin
Prefer to use Cefepime, Cefazoline
The preferred choice depends on the patient's status,
 For example the patients has CHF and developed Pyelonephritis, usually we use broad spectrum AB
like: Piper-tazo, Imipenem-cilastatin, Fluroquinolones, So The Best choice out of these in this case is
Fluroquinolones, Imepenem-cilastatin and we Avoid Piper-tazo
 We refer to the guidelines then choose the best to suit the patient
 If within the options was an alternative with the same efficacy and lower Na content then we choose
it
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If there wasn't an alternative with lower Na content --> I measure the risk-benefit ratio, if there was
an infection that should be treated or a possibility of HF exacerbation I refer to the clinical judgment,
but generally we try to avoid high Na content.
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)SHEET L.14 SLIDE 5 (IV drug preparation guidelines
April 2, 2017
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If the infection can be treated with this high Na content AB only, then I can sacrifice the HF
exacerbation to treat the infection (I can aid the HF exacerbation treatment with increasing the
Diuretic dose) to be specific for the m.o.
Cefazoline isn't used in infections; the only use for it is for surgical prophylaxis
Other important factors in IV medications is the PH, The IV medication can be a solution or needs
reconstitution
The importance in finding out the PH for the medication is Solubility, for example: a drug with low
PH, the appropriate solvent for it must guarantee that the drug will be ionized
If the drug has very low or very high PH and extravasation occurred , it will cause extracellular tissue
damage
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One of the drugs having high PH is Phenytoin (PH=12)--> if extravasation happened , it's like NaOH
was applied on the vein
 One of the drugs having low PH is Haloperidol (PH=3)--> Problematic if extravasation occurred
Extensive tissue damage can happen and may lead to necrosis
*Drugs which have extreme PHs must be dealt with very carefully to avoid extravasation
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If I want to use 2 drugs and I have to combine them together ( one with PH=12 and other with PH=3),
it's hard to do this combination (To do the mixing I have to consider Compatibility)
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There are multiple types of compatibility (depending on the site) :
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Compatibility in the same syringe--> (Try to avoid combining the 2 drugs in the same syringe if not
compatible)
Y site IV compatibility--> 2 portions--> every drug is given as a separate portion, Then they combine
either in the chamber or vein site
If I want to give a drug with PH=12 with a drug PH=3 , a precipitation will occur in the IV line
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 The drug itself isn't compatible with the IV container
For example: some drugs are incompatible with plasticsso can be put into a special container like glass
container
EX: Cisplatin---> we can't withdraw it with an Aluminum needle because it sabotages the drug, therefore
it needs special needle (Material-drug Incompatibility)
 The compatibility can viewed from different ways, PH is one way that helps me to determine the
compatibility between drugs
 there shouldn't be a great difference in PH between the drugs i want to administer them together
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If I have an emulsion or oil preparation--> the PH is only for the aqueous solution
The PH is important for us to determine:
Irritation (If it greatly decreased or increased, The irritation will increase)
Compatibility.
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)SHEET L.14 SLIDE 5 (IV drug preparation guidelines
April 2, 2017
‫لن تستطيع أن تمنع طيور الهم أن تحلق‬
‫فوق رأسك و لكنك تستطيع أن تمنعها‬
‫أن تعشش في رأسك‬.
Lana Abu Khadija
Christine Haddadin
Raghad Qamareldeen
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