There are a variety of reasons why drugs would be injected rather

than taken through other methods.

 Increased effect — Injecting a drug intravenously means that

more of the drug will reach the brain more quickly. This also
means that the drug will have a very strong and rapid onset (or
rush).
 More efficient usage — Injection ensures that all of the drug will
be absorbed.
 Bypasses the digestive system — Some people with sensitive
stomachs find it very unpleasant to swallow drugs because of
persistent cramps or nausea.
 Does not harm the lungs or mucous membranes — The mucous
membranes can be permanently damaged by habitual insufflation
(snorting), and the lungs can be damaged by smoking.
 Increased chance of infection
 Increased chance of overdose
 Scarring of the peripheral
veins
 Needle phobia
 Directly relaxes smooth muscle of the bronchial
airways and pulmonary blood vessels. Acts by
inhibition of the phosphodiesterase enzymes
 Used for treatment of acute asthmatic attack.
 Diluents: D5W, NS
 Concentration: 800 mg/500 ml =1.6 mg/ml
 Initial dosage: Loading dose 5 mg/kg over 20
mins
 Infusion rate: 0.2–0.6 mg/kg/h
 Precaution in severe cardiac, hepatic and peptic
ulcer disease
 Theophylline
 Drugs that cause decreased in theophylline
concentrations:

Barbiturates
Carbamazepine
Omeprazole
Phenytoin
Rifampin

Increased in concentrations:
◦ Cimetidine
◦ Ciprofloxacin
◦ Clarithromycin
◦ Erythromycin
 Type III anti arrhythmic that prolongs effective
refractory period of the atrial and ventricular
tissue.
 Diluent: D5W only (glass or polyolefin containers
for maintenance infusion)
 Loading dosage: 150 mg over 10 mins. (can
repeat), then 1 mg/min for 6 hrs
 Maintenance concentration: 450 mg/250 ml =
1.8 mg/ml
 Infusion rate: 0.5 mg/min (0.5 mg/min = 17
ml/hr)
 Contraindicated in sick sinus syndrome, 2nd and
3rd degree heart block, bradycardia and
hypotension
Amiodarone
 Amiodarone interactions
 Decreased concentrations
Barbiturates, rifanpicin, dilantin,
carbamazepine

 Increased concentrations
digoxin ,warfarin

When mixed in D5W Incompatible with:

aminophylline, cefazolin Na, heparin and
sodium bicarb
 Digitalis glycoside that enhance inotropic
capacity of the heart by sequestration of
calcium in the myocardium, thus improving
the cardiac output.
 Loading dose of 10 to 15 ug/kg divided in
12 to 24 hr at interval 6-8 hrs. Maintenance
of 0.125 to 0.5 mg/day
 Contraindication: heart block, digitalis
intoxication, V Fib
 Always correct electrolytes, especially K
Increased in concentrations:
Amiodarone
 Clarithromycin
 Erythromycin
 Quinidine
 Verapamil
 Cathecholamine that acts of the post
dopaminergic receptors
 Diluent: NS, D5W
 Concentration: 800 mg/500 ml = 1600 µg/ml
 Infusion rate: Usually start at 3 µg/kg/min;
titrate to effect (2-5 renal, 5-10 cardiac dose,
> 10 systemic/vasopressor dose)
 Fast onset of action 5 mins and fast diminish
action
 Maintain good hydration
 Incompatible with sodium bicarb,furosemide
and other alkaline solutions
 Dopamine
 DF – 13.3 Single concentration
 26.6 Double concentration.

Start dopamine drip at 10mcqtts/kg/min using

double concentration .Patient’s wt is 50 kgs.

Dose x kg =mcqtts/min
DF

Mcqtts/min x DF = ug/kg/min
kg
 Start dopamine drip at 10uq/kg/min using
double concentration. Pt’s weighs 50kgs.

 10ug/kg/min X 50 kgs
26.6
500 = 18.7 or 19 mcqtts/mjn
26.6

19 mcgtts/min X 26.6 = 505 =

10mcqtts/min.
50kgs 50 kgs
 Same with dopamine but with alpha agonist
activity, in low doses it increase myocardial
contractility without increasing the heart rate.
 Diluent: NS, D5W
 Concentration: 250 mg/250 ml = 1000 µg/ml
 Infusion rate: Usually start at 3 µg/kg/min;
titrate up to 20 µg/kg/min
 Incompatible with NaHCO3 and other alkaline
solution. Reconstituted solution is stable for
48 hours under refrigeration and 6 hours at
room temperature
 Potassium –painful and never give
bolus
 Sodium – slow correction to prevent
pontine myelinolysis
 Calcium –cardiac monitoring during
administration
 Don’t give calcium together with
sodium bicarbonate
 Stimulates alpha 1 and 2, beta 1 and 2
receptors.
 ACLS, asthma, anaphylaxis
 Diluent: NS or D5W
 Concentration: 5 mg/500 ml = 10 µg/ml
 Infusion rate: 1–4 µg/min initially; titrate to
effect (1 µg/min = 6 ml/hr)
 Do not use solution if it is brown or contains
precipitate. Protect from sunlight.
 An anticoagulate that binds with antithrombin III.
 Used for treatment and prevention of PTE, used in
AMI, DVT
 Diluent: NS, D5W, ½ NS
 Concentration: 25,000 units/250 ml = 100
units/ml
 Initial dose: 60–80 units/kg
 Infusion rate: Usually start at 14–18 units/kg/hr
 Contraindicated in active bleeding
 APTT, platelet and hematocrit are used to
monitor
 Anti arrhytmic used to treat ventricular
abnormalities.
 Diluent: NS, D5W
 Concentration: 2 g/500 ml = 4 mg/ml
Effect with in 10 to 20 minutes after IV bolus
 Contraindicated in patients with WPW, severe
hypertension, neurologic disorder.
 Incompatible with heparin and sodium
bicarb.
Preload 5ml syringe with 20mg/ml; total= 100mg.
Also in 5ml vial of 10mg/ml; total of 50mg.

DOSE: bolus 0.5-3mg/kg

DRIP: 30-50mcg/kg/min or continue if circulation
returns at
2-4mg/min.

PRECAUTIONS:
Watch out for lidocaine toxicity (disorientation,
seizures,respiratory compromise).
Watch out for lidocaine heart block.
 Calcium channel blocker used to treat
hypertension
 Diluent: NS, D5W
 Concentration: 25 mg/250 ml = 0.1
mg/ml
 Infusion rate: 2–15 mg/hr
 Monitor for hypotension
 Organic nitrates that relaxes smooth muscle. Used in
anginal pain and hypertensive crisis.
 Most effective agent used for acute pulmonary
edema.
 Diluent: NS, D5W (glass or polyolefin containers only)
 Concentration: 50 mg/250 ml = 200 µg/ml
 Infusion rate: Initially 10 µg/min; titrate to effect (10
µg/min = 3 ml/hr)
 Most frequent side effect is headache.
 Sticks on IV plastic tubing, glass containers should be
used. Stable in room temperature at 48 hours and7
days in refrigeration. Flush the tubings if the line will
be used for another solution
 Used to treat acidosis
 Slow IV push at 1 meq/Kg initially,
then 0.5 meq/kg q 10 mins
 Incompatible with cathecholamines
and calcium contining solutions
(precipitates)
50ml pre loaded syringe (8.4% sodium bicarb @ 50meq/50ml).

DOSE
1mEq/kg IV bolus then depending on ABG result thereafter.

PRECAUTIONS:
Watch out for respiratory depression.
Observe for hypotension.
Sodium bicarbonate can produce a variety of side effects
including the ff:
- Mixed venous intracellular acidosis.
-Hyper osmolality
-hyper natremia
-Metabolic alkalosis
- Acute hypokalemia
 Penicillins and its derivatives testing (skin or
IV) is done prior to administration.
 Aminoglycosides are mainly given via IV or
IM. Renal and vestibulocochlear
complications.
 Tetracyclines are irritant to IV administration
and usually causes phlebitis.
 Always read the drug literature prior to
administration of specific antibiotics.
Mannitol
 Indications: cerebral edema, decrease
intraocular pressure, oliguric phase of acute
renal failure
 Usual dose: varies w/ clinical indication
 Mode of adm.: intermittent; give 200 mg/kg
to produce 40 ml of urine in 1 hr
 Maj. Side effects: convulsions, blurred
vision, vertigo, headache, urinary
retention, polyuria ffd by oliguria, chills,
chest pain, edema, fluid and electrolyte
imbalance.
 Nursing considerations: administer test
dose over 3-5 mins; monitor for inc urine
output, serum electrolytes, IV site;
maintain hydration; crystals must be
dissolved before adm; use a 170 – micron
in-line filter
 Px/ caregiver education: instruct px to
report changes in sensorium.
 Many injectable drugs cannot be mixed
together in syringes or infusions.

 Some cannot be safely diluted in infusion

bags.

 Incompatibility can involve precipitation,

ionic reactions, evolution of gas and
denaturation of biological molecules.

 If drugs are mixed together, the mixture

should be inspected for precipitates,
turbidity or changes in colour, however not
all incompatibilities are visible.
 compelling reasons for mixing two or more
parenteral drug solutions
◦ multiple drugs requiring parenteral administration within a
short time frame
◦ difficulties with venous access
◦ Patients requiring many drugs by simultaneous continuous
infusion
◦ If intravenous drugs are not mixed but are given
consecutively, the infusion line should be flushed through
with compatible fluid between each administration.
◦ small concentrated volumes are mixed in a syringe (pH
changes) The absence of any visible change to a solution
upon mixing does not automatically exclude degradation
of either or both components.
◦ Drugs that precipitate upon dilution
◦ Precipitation of a drug from its concentrated injection
solution when it is diluted with water or saline is counter-
productive.
 The problem is frequently observed when
diazepam injection is diluted. Diazepam is
very poorly water soluble so it is formulated
as an injection solution in a vehicle
comprising 50% propylene glycol and 10%
ethanol.
 At first, dilution produces a slight turbidity
which clears upon mixing, but dilution
beyond fourfold produces an opaque white
precipitate which does not clear until
substantial further dilution.
 Other drugs which demonstrate solubility
problems and which are formulated in
injection vehicles other than simple aqueous
solutions include digoxin, clonazepam,
phenytoin, amiodarone and phytomenadione.

 In other cases, care needs to be taken to

ensure that if the injection solution is
diluted, the dilution is adequate to ensure
continuing solubility over the duration of the
infusion.
Precipitation of drugs due to pH
change upon mixing
 Any change in pH towards the other
end of the pH scale will reduce the
proportion of ionized to un-ionized
drug in solution and will therefore
reduce the water solubility of the
drug.
 The most prominent example of a pH-related
reduction in solubility is dilution of phenytoin
sodium injection.
 Dilution of injectable phenytoin by adding it to an
infusion bag lowers its pH and therefore reduces
its solubility resulting in precipitation of the drug.
 Glucose 5% infusion solution, which has a pH of
4.3-4.5, will precipitate phenytoin almost
immediately. Indeed, phenytoin injection is so
incompatible that it should generally not be mixed
with any other solution.
 IV Drug Stabilities when added to IV solutions
Drug Stability at Stability Other Information
Room Temp Under
Refrigeration
Aminophylline 48 hours n/a
Amiodarone (Cordarone) 30 days n/a Mix only in dextrose
Calcium Gluconate 24 hours n/a
Clindamycin (Cleocin) 16 days 32 days
Dexamethasone (Decadron) 28 days 28 days
Diltiazem (Cardizem) 24 hours 24 hours
Dobutamine 24 hours 24 hours
Dopamine 48 hours 7 days
Epinephrine 24 hours 24 hours ***Protect from Light***
Furosemide (Lasix) 24 hours 24 hours
Gentamicin (Garamycin) 7 days 30 days
Heparin 12 months 12 months
Magnesium Sulfate 60 days 60 days
Nitroglycerin 48 hours 7 days Mix in glass only
Nitroprusside (Nipride) 24 hours 24 hours ***Protect from Light***
Norepinephrine (Levophed) 48 hours 30 days ***Protect from Light***
Octreotide (Sandostatin) 48 hours 7 days ***Protect from Light***
Dexmedetomidine (Precedex) 48 hours n/a
Ranitidine (Zantac) 24 hours 24 hours ***Protect from Light***
Sodium Bicarbonate 7 days 60 days
Thiamine 24 hours 24 hours ***Protect from Light***
Tobramycin (Nebcin) 24 hours 96 hours
Vitamin K (Aquamephyton) 24 hours 24 hours ***Protect from Light***
 Don’t mix cathecholamines with sodium
bicarbonate
 Don’t mix blood with sodium bicarbonate.
 Epinephrine, atropine and lidocaine can be given
via ET tube, but not sodium bicarbonate.
 Amniodarone increases digoxin levels
 Amniodarone and Lidocaine is given mainly for
ventricular arrhythmia
 Adenosine is the IV drug of choice for SVT
 Don’t give lidocaine and digoxin in patients with
WPW
 Elevate the limb where medications were given.
 Toxic Reactions- exaggerated response to
overdosing of the drug

 Side effects -effects of drug other than those

desired. No drug exerts a single effect.

 Allergic reactions -immune exaggeration to certain

component of the drug. The most dreaded drug
reaction is the Steven-Johnson-Syndrome

 Idiosyncraatic reaction -genetically determined

e.g. hemolytic anemia to sulfonamides
 Refers to the process whereby the response
to a drug is modified by the presence of
another factor, usually a drug or other
chemical agent. When 2 drugs are
administered in close sequence to each other,
they may interact either to enhance or
diminish the intended effect of 1 or both
drugs, or they may produce an unintended
and potentially harmful reaction.
 2 TYPES:
 PHARMACOKINETICS – result from alteration
in the delivery of drugs to their sites of
action.

 PHARMACODYNAMICS – the responsiveness

of the target organ or system is modified by
other agents.
Management of IV Therapy Interaction

 The beneficial effects of drugs are coupled

with the inescapable risk that they may also
cause untoward effects. The morbidity and
mortality that result from these untoward
effects often present diagnostic problems,
for these drugs can involve every organ and
system of the body
 Ampicillin
 Aminophylline
 Amphotericin B
 Corticosteroids
 Dextran
 Diazepam (& other benzodiazepines)
 Diazoxide
 Digoxin
 Mannitol
 Phenobarbital (and
other barbiturates)
 Phenothiazines
 Phenytoin
 Propanolol (& other beta blockers)
 INCOMPATIBLE DRUGS
 Calcium Cholride- Mg SO4,Na HCO3
 Dobutamine –furosemide, insulin
 Furosemide – dobutamine,
midazolam,norepinephrine
 Humulin R- Norepinephrine,phenylephrine
 NaHCO3 – calcium cl,dobutamine,midazolam,
norepinephrine
K cl iv- diazepam,dilantin,epi
AtSO4-NaHCO3,diazepam,heparin
Lidocaine-heparin,NaHCO3
Dopamine-furosemide,NaHCO3
Maria Cristina S. Alteran, RN MN