BNF for Children 2011-2012

BNFC 2011–2012 791A4Intravenous infusions forneonatal intensive careIntravenous policy A local policy on the dilution ofdrugs with intravenous fluids should be drawn up by amulti-disciplinary team and issued as a document to themembers of staff concerned.Centralised additive services are provided in a numberof hospital pharmacy departments and should be usedin preference to making additions on wards.The information that follows should be read in conjunctionwith local policy documents.Guidelines1. Drugs should only be diluted with infusion fluidwhen constant plasma concentrations are neededor when the administration of a more concentratedsolution would be harmful.2. In general, only one drug should be mixed with aninfusion fluid in a syringe and the componentsshould be compatible. Ready-prepared solutionsshould be used whenever possible. Drugs shouldnot normally be added to blood products, mannitol,or sodium bicarbonate. Only specially formulatedadditives should be used with fat emulsions oramino-acid solutions (section 9.3).3. Solutions should be thoroughly mixed by shakingand checked for absence of particulate matterbefore use.4. Strict asepsis should be maintained throughout andin general the giving set should not be used for morethan 24 hours (for drug admixtures).5. The infusion syringe should be labelled with theneonate’s name and hospital number, the name andquantity of drug, the infusion fluid, and the expirydate and time. If a problem occurs during administration,containers should be retained for a periodafter use in case they are needed for investigation.6. Administration using a suitable motorised syringedriver is advocated for preparations where strictcontrol over administration is required.7. It is good practice to examine intravenous infusionsfrom time to time while they are running. If cloudiness,crystallisation, change of colour, or any othersign of interaction or contamination is observed theinfusion should be discontinued.ProblemsMicrobial contamination The accidental entry andsubsequent growth of micro-organisms converts theinfusion fluid pathway into a potential vehicle for infectionwith micro-organisms, particularly species of Candida,Enterobacter, and Klebsiella. Ready-prepared infusionscontaining the additional drugs, or infusionsprepared by an additive service (when available) shouldtherefore be used in preference to making extemporaneousadditions to infusion containers on wards etc.However, when this is necessary strict aseptic procedureshould be followed.Incompatibility Physical and chemical incompatibilitiesmay occur with loss of potency, increase in toxicity,or other adverse effect. The solutions may becomeopalescent or precipitation may occur, but in manyinstances there is no visual indication of incompatibility.Interaction may take place at any point in the infusionfluid pathway, and the potential for incompatibility isincreased when more than one substance is added tothe infusion fluid.Common incompatibilities Precipitation reactions arenumerous and varied and may occur as a result of pH,concentration changes, ‘salting-out’ effects, complexationor other chemical changes. Precipitation or otherparticle formation must be avoided since, apart fromlack of control of dosage on administration, it mayinitiate or exacerbate adverse effects. This is particularlyimportant in the case of drugs which have been implicatedin either thrombophlebitis (e.g. diazepam) or inskin sloughing or necrosis caused by extravasation (e.g.sodium bicarbonate and parenteral nutrition). It is alsoespecially important to effect solution of colloidal drugsand to prevent their subsequent precipitation in order toavoid a pyrogenic reaction (e.g. amphotericin).It is considered undesirable to mix beta-lactam antibiotics,such as semi-synthetic penicillins and cephalosporins,with proteinaceous materials on the groundsthat immunogenic and allergenic conjugates could beformed.A number of preparations undergo significant loss ofpotency when added singly or in combination to largevolume infusions. Examples include ampicillin in infusionsthat contain glucose or lactates.Blood Because of the large number of incompatibilities,drugs should not be added to blood and blood productsfor infusion purposes. Examples of incompatibility withblood include hypertonic mannitol solutions (irreversiblecrenation of red cells), dextrans (rouleaux formationand interference with cross-matching), glucose (clumpingof red cells), and oxytocin (inactivated).If the giving set is not changed after the administrationof blood, but used for other infusion fluids, a fibrin clotmay form which, apart from blocking the set, increasesthe likelihood of microbial growth.Intravenous fat emulsions These may break downwith coalescence of fat globules and separation ofphases when additions such as antibacterials or electrolytesare made, thus increasing the possibility of embolism.Only specially formulated products such as VitlipidN c (section 9.3) may be added to appropriateintravenous fat emulsions.Appendix 4: Intravenous infusions for neonatal intensive care