RFDS Western Operations

HEA16 V3.0

Clinical Manual

PART 2 DRUG INFUSION GUIDELINES

INTRODUCTION...................................................................................................................... 1 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. ADRENALINE INFUSION ............................................................................................. 4 AMINOPHYLLINE INFUSION ....................................................................................... 5 AMIODARONE INFUSION............................................................................................ 6 DOBUTAMINE INFUSION ............................................................................................ 7 DOPAMINE INFUSION ................................................................................................. 8 GLYCERYL TRINITRATE INFUSION ........................................................................... 9 HEPARIN INFUSION .................................................................................................. 11 INSULIN INFUSION .................................................................................................... 12 ISOPRENALINE INFUSION........................................................................................ 13 LIGNOCAINE INFUSION ............................................................................................ 14 MAGNESIUM SULPHATE INFUSION ........................................................................ 15 METHYLPREDNISOLONE INFUSION ....................................................................... 17 MORPHINE INFUSION ............................................................................................... 19 MORPHINE & MIDAZOLAM INFUSION ..................................................................... 20 NORADRENALINE INFUSION ................................................................................... 21 OCTREOTIDE INFUSION........................................................................................... 22 SALBUTAMOL INFUSION OBSTETRIC.................................................................. 23 SALBUTAMOL INFUSION - RESPIRATORY ............................................................. 25 VECURONIUM INFUSION.......................................................................................... 26

Issue Date: 1 January 2006 Review Date: 31 Dec 2007

Part 2 Drug Infusion Guidelines

RFDS Western Operations

HEA16 - V3.0

Clinical Manual

INTRODUCTION
Standard Guidelines The guidelines which follow cover the common drugs used by the Service in patient transport. The guidelines are standardised to assist staff from widely differing clinical backgrounds. Use of standard guidelines assists in preventing drug administration errors and aids in the hand-over of patients. They do not preclude the infusion of other drugs or use of other concentrations, if these are required in individual patients. A brief list of notes, indications, precautions and side effects are attached to each table but these are by no means comprehensive. Refer to the manufacturers product information or the reference textbooks for full product details. Care has been taken to ensure that the information in the guidelines is accurate at the time of printing but the user is advised to check the doses carefully. RFDS Western Operations shall not be held responsible for any errors in the guidelines. The final responsibility for any drug administered during transfer lies with the RFDS medical officer supervising the flight / transfer. Use of Differing Concentrations In general the infusions are presented in two concentrations; a concentrated format and one more dilute. The former is for use in 50 mL syringes. A syringe driver with minimal volume tubing allows very small flow rates to be used and is the preferred method for transport in most instances. Syringe drivers are usually not available in country hospitals so more dilute infusions using standard 500 mL fluid bags are offered. 500 mL formats are generally for use through an intravenous rate controlling device such as an IVAC infusion pump. Although greater fluid volumes are necessary, there is a greater margin of safety in controlling rates, especially during transport and hand-over. Quantity of Infusions Where practical, the quantity of drugs used has been minimized so as to provide only that necessary for treatment during transport (up to 6 - 8 hours). This may differ from standard teaching hospital infusion guidelines, where many infusions are designed to last for 24 hours. Manual Administration in Special Circumstances Whilst an infusion pump should be used wherever possible, the infusions have been prepared to enable manual administration. This may be necessary in some remote locations without equipment, or when equipment fails. Caution must be exercised when administering drug infusions manually and only the more dilute solutions should be administered in this way. Please refer to the chart below to convert mL/min to drops/min with different giving sets.

READY RECKONER
Use this to convert mL/hour to drips per Minute for manual Administration of Drugs using various giving sets.

mL/hour
10 15 20 30 60 90

IVAC SET drips/min

4 5 7 10 20 30

TUTA SET MICRODRIP drips/min drips/min

4 5 7 10 20 30 10 15 20 30 60 90

Issue Date: 1 January 2006 Review Date: 31 Dec 2007

Part 2 - Drug Infusion Guidelines

Page 1

RFDS Western Operations

HEA16 - V3.0

Clinical Manual

INTRODUCTION (CONT) Escorting of Patients with Drug Infusions We do not consider it good clinical practice for ambulance officers to supervise and administer drug infusions. As a minimum, a patient receiving any of the following infusions should be escorted to the pick-up airstrip by a registered nurse from the referring centre. An RFDS flight nurse specialist or medical officer should escort them to the receiving hospital. Current exceptions to these guidelines are: patients receiving Heparin, provided the Heparin is in a burette or the infusion is stopped for the duration of the transfer (to prevent accidental infusion of a large dose) and patients who have been receiving Salbutamol infusion for the suppression of labour, provided that the infusion has been ceased prior to departure of the ambulance. Salbutamol should only be ceased if the patients contractions have settled and the patient will not be compromised by the cessation of treatment. The need for a medical (doctor) escort on the flight is discussed under special notes in each individual infusion guideline. Formulae for converting mL/hr to g/kg/min and vice versa: First work out the concentration of solution to be infused (in g/mL). Drug concentration (g/mL) = dose of drug added (mg) x 1000 volume (mL) eg Dopamine 200 mg in 500 mL = 200 x 1000 / 500 = 400 g/mL To convert g/kg/min to mL/hr: choose desired rate (in g/kg/min); rate (mL/hr) = desired rate (in g/kg/min) x 60 x wt (kg) drug concn (g/mL)

eg Dopamine @ 5 g/kg/min in a 40 kg patient using Dopamine 400 g/mL rate (mL/hr) = 5 x 60 x 40 / 400 = 30 mL/hr To convert mL/hr to g/kg/min: rate (g/kg/min) = infusion rate (mL/hr) x drug concn (g/mL) 60 x wt (kg) eg Dopamine @ 30 mL/hr in a 40 kg patient using Dopamine 400 g/mL rate (g/kg/min) = 30 x 400 / 60 x 40 = 5 g/kg/min References Enkin M et al. A Guide to Effective Care in Pregnancy & Childbirth. 2nd Ed, Oxford University Press, 1995. Shann F. Drug Doses. 10th Ed, Intensive Care Unit, Royal Childrens Hospital, Melbourne, 1998. Oh TE. (Ed) Intensive Care Manual. 4th Edition, Butterworth Heinemann, 1997. King Edward Memorial Hospital Clinical Guidelines. King Edward Memorial Hospital, 1998. Diabetic Clinic & Diabetic Working Party. Maintenance of Insulin Infusions. Royal Perth Hospital, 1994.

Issue Date: 1 January 2006 Review Date: 31 Dec 2007

Part 2 - Drug Infusion Guidelines

Page 2

RFDS Western Operations

HEA16 - V3.0

Clinical Manual

INTRODUCTION (CONT) References (cont) 1998 MIMS Annual, 22nd Ed, MIMS Australia, 1998. Royal Childrens Hospital Melbourne. Paediatric Handbook, 5th Ed, Blackwell Science, 1995. Therapeutic Guidelines: Cardiovascular. 3rd Ed, Therapeutic Guidelines Limited, 1999. Therapeutic Guidelines: Respiratory. 1st Ed, Therapeutic Guidelines Limited, 1994. Worthley LIG. Synopsis of Intensive Care Medicine. Churchill Livingstone, 1994. Australian Medicines Handbook, Australian Medicines Handbook Pty Ltd, 1998.

Abbreviations mL = millilitres mg = milligrams g = micrograms mEq = milliEquivalents IU = International Units

Issue Date: 1 January 2006 Review Date: 31 Dec 2007

Part 2 - Drug Infusion Guidelines

Page 3

RFDS Western Operations

HEA16 - V3.0

Clinical Manual

1.

ADRENALINE INFUSION A. Syringe Driver Adrenaline 3 mg/50 mL (60 g/mL)

Use Adrenaline 1 mg in 1 mL ampoules Dilute 3 mg (3 mL) up to 50 mL with Normal Saline or 5% Dextrose Commence at 2 g/min (2 mL/hr) and adjust rate according to clinical response Dose Range 2 g/min 5 g/min 10 g/min 20 g/min Rate of Infusion - Syringe Driver 2 mL/hr 5 mL/hr 10 mL/hr 20 mL/hr

50 mL Syringe

B. Infusion Pump

Adrenaline 3 mg/500 mL (6 g/mL)

Use Adrenaline 1 mg in 1 mL ampoules Dilute 3 mg (3 mL) up to 500 mL with Normal Saline or 5% Dextrose Commence at 2 g/min (20 mL/hr) and adjust rate according to clinical response Dose Range 2 g/min 5 g/min 10 g/min 20 g/min Indications Management of shock (after hypovolaemia has been excluded), status asthmaticus Precautions and Side Effects 1. Correct hypovolaemia prior to administration. 2. Administer via a central venous line or into a large peripheral venous line (extreme caution with concentrated solution in a peripheral vein because of the risk of vasoconstriction, ischaemic pain and local necrosis). 3. Monitor ECG and blood pressure closely. 4. Side effects include pulmonary oedema, arrhythmias, tachycardia, myocardial ischaemia, anxiety, palpitations, hypertension and peripheral ischaemia. Special Notes 1. Infusion should be titrated to achieve desired clinical endpoint e.g. systolic blood pressure 80 - 100 mmHg. Usual range is between 1 - 70 g/min in adults. 2. Double strength solution may be needed on some occasions. Rate of Infusion - Infusion Pump 20 mL/hr 50 mL/hr 100 mL/hr 200 mL/hr

500 mL Bag

3. Should

only be administered on a doctor-accompanied flight unless under exceptional circumstances.

Issue Date: 1 January 2006 Review Date: 31 Dec 2007

Part 2 - Drug Infusion Guidelines

Page 4

RFDS Western Operations

HEA16 - V3.0

Clinical Manual

2.

AMINOPHYLLINE INFUSION A. Syringe Driver Aminophylline 500 mg / 50 mL (10 mg /mL)

Use Aminophylline 250 mg in 10 mL ampoules Dilute 500 mg (20 mL) up to 50 mL with 5% Dextrose If the patient is not already on oral Theophylline give a loading dose of 3 mg/kg over 20 minutes (eg 200 mg [20 mL] for a 70 kg adult) Follow this with an infusion of 0.5 mg/kg/hr (eg 35 mg/hr [3.5 mL/hr] for a 70 kg adult)
Dose Range Rate of Infusion Syringe Driver 60 mL/hr for 20 min only 3.5 mL/hr

50 mL Syringe

Loading Dose over 20 min (70 kg patient) Maintenance Dose (70 kg patient)

200 mg (20 mL) 35 mg/hr

B. Infusion Pump

Aminophylline 500 mg / 500 mL (1 mg /mL)

Use Aminophylline 250 mg in 10 mL ampoules Dilute 500 mg (20 mL) up to 500 mL with 5% Dextrose If the patient is not already on oral Theophylline give a loading dose of 3 mg/kg over 20 minutes (eg 200 mg [200 mL] for a 70 kg adult) Follow this with an infusion of 0.5 mg/kg/hr (eg 35 mg/hr [35 mL/hr] for a 70 kg adult)
Dose Range Rate of Infusion - Infusion Pump 600 mL/hr for 20 min only 35 mL/hr

500 mL Bag
Indications Severe Asthma

Loading Dose over 20 min (70 kg patient) Maintenance Dose (70 kg patient)

200 mg (200 mL) 35 mg/hr

Precautions and Side Effects 1. The dose will need to be reduced in the elderly and patients with cirrhosis, congestive cardiac failure, acute fevers, patients receiving Cimetidine, Erythromycin or patients with acute viral infections. The dose may need to be increased in young patients, smokers without chronic obstructive airways disease or regular drinkers without liver disease. 2. Side effects include headache, nausea and vomiting, arrhythmias and convulsions. Special Notes Should only be administered on a doctor-accompanied flight unless under exceptional circumstances.

Issue Date: 1 January 2006 Review Date: 31 Dec 2007

Part 2 - Drug Infusion Guidelines

Page 5

RFDS Western Operations

HEA16 - V3.0

Clinical Manual

3.

AMIODARONE INFUSION A. Syringe Driver Amiodarone 600 mg / 50 mL (12 mg /mL)

Use Amiodarone 150 mg in 3 mL ampoules Dilute 600 mg (12 mL) up to 50 mL with 5% Dextrose In an emergency give 150 300 mg over 1-2 minutes, otherwise commence with a loading dose of 5 mg/kg over 20 minutes (eg 350 mg [29 mL] for a 70 kg adult) Follow this with an infusion of 0.4 - 0.7 mg/kg/hr for the next 24 hours (eg 28 - 50 mg/hr [2.3 - 4.2 mL/hr] for a 70 kg adult)
Dose Range Rate of Infusion Syringe Driver 87 mL/hr for 20 min only 2.3 - 4.2 mL/hr

50 mL Syringe

Loading Dose over 20 min (70 kg patient) Maintenance Dose (70 kg patient)

350 mg (29 mL) 28 - 50 mg/hr

B. Infusion Pump

Amiodarone 600 mg / 500 mL (1.2 mg /mL)

Use Amiodarone 150 mg in 3 mL ampoules Dilute 600 mg (12 mL) up to 500 mL with 5% Dextrose In an emergency give 150 300 mg over 1-2 minutes, otherwise commence with a loading dose of 5 mg/kg over 20 minutes (eg 350 mg [290 mL] for a 70 kg adult) Follow this with an infusion of 0.4 - 0.7 mg/kg/hr for the next 24 hours (eg 28 - 50 mg/hr [23 - 42 mL/hr] for a 70 kg adult)
Dose Range Rate of Infusion Syringe Driver 870 mL/hr for 20 min only 23 - 42 mL/hr

500 mL Bag
Indications

Loading Dose over 20 min (70 kg patient) Maintenance Dose (70 kg patient)

350 mg (290 mL) 28 - 50 mg/hr

Treatment and prophylaxis of serious arrhythmias refractory to other treatment, including ventricular arrhythmias, atrial tachyarrhythmias and junctional tachycardias. Precautions and Side Effects 1. Infuse via a large or central vein. 2. Contraindicated in 2nd or 3rd degree AV block (without pacemaker) and in pregnancy. 3. Caution with use in patients on beta-blockers, verapamil or diltiazem, (increased risk of bradyarrhythmias) and in patients with thyroid or hepatic disease. 4. Side effects include nausea and vomiting (especially while loading), headache, dizziness, fatigue, photosensitivity, bradycardia, atrio-ventricular block, torsades de pointes and liver dysfunction. Special Notes Should only be administered on a doctor-accompanied flight unless under exceptional circumstances.

Issue Date: 1 January 2006 Review Date: 31 Dec 2007

Part 2 - Drug Infusion Guidelines

Page 6

RFDS Western Operations

HEA16 - V3.0

Clinical Manual

4. DOBUTAMINE INFUSION A. Syringe Driver Dobutamine 250 mg/50 mL (5000 g/mL)

Use Dobutamine 250 mg in 5 mL ampoules Dilute 250 mg (5mL) up to 50 mL with 5% Dextrose Commence at a low dose (eg 2.5 g/kg/min) Dose Range Rate of Infusion (mL/hour) - Syringe Driver
40kg 60kg 70kg 80kg 100kg

50 mL Syringe

2.5 g/kg/min 5 g/kg/min 10 g/kg/min

1 2 5

2 4 7

2 4 8

2 5 10

3 6 12

B. Infusion Pump

Dobutamine 250 mg/500 mL (500 g/mL)

Use Dobutamine 250 mg in 5 mL ampoules Dilute 250 mg (5mL) up to 500 mL with 5% Dextrose Commence at a low dose (eg 2.5 g/kg/min) Dose Range Rate of Infusion (mL/hour) - Infusion Pump 40 kg 2.5 g/kg/min 5 g/kg/min 10 g/kg/min Indications Management of shock (where hypovolaemia has been excluded), especially cardiogenic shock. Precautions and Side Effects 1. Hypovolaemia must be fully corrected prior to administration. 2. Administer via a central venous line or into a large peripheral venous line (extreme caution with concentrated solution in a peripheral vein because of the risk of vasoconstriction, ischaemic pain and local necrosis). 3. Side effects include ectopic beats, tachycardia, hypertension, angina, palpitations, nausea, vomiting, headache and dyspnoea. Special Notes 1. Not currently stocked by RFDS but stocked at some regional hospitals. 2. Predominantly a 1 stimulant of the myocardium. 3. Infusion should be titrated to achieve desired clinical endpoint e.g. systolic blood pressure 80 - 100 mmHg. Usual dose range is 2.5 - 10 g/kg/min. Discuss with receiving Intensive Care Unit before use. 4. Should only be administered on a doctor-accompanied flight. 12 24 48 60 kg 18 36 72 70 kg 21 42 84 80 kg 24 48 96 100 kg 30 60 120

500 mL Bag

Issue Date: 1 January 2006 Review Date: 31 Dec 2007

Part 2 - Drug Infusion Guidelines

Page 7

RFDS Western Operations

HEA16 - V3.0

Clinical Manual

5. DOPAMINE INFUSION A. Syringe Driver Dopamine 200 mg/50 mL (4000 g/mL)

Use Dopamine 200 mg in 5 mL ampoules Dilute 200 mg (5mL) up to 50 mL with Normal Saline Commence at a low dose (eg 2.5 g/kg/min) and adjust rate to obtain desired blood pressure and urinary output > 0.5 mL/kg/hr (1 mL/kg/hr in children). Dose Range Rate of Infusion (mL/hour) - Syringe Driver 40kg 60 kg 70 kg 80 kg 100 kg 2 3 6 2 5 9 3 5 10 3 6 12 4 8 15

50 mL Syringe

2.5 g/kg/min 5 g/kg/min 10 g/kg/min

B. Infusion Pump

Dopamine 200 mg/500 mL (400 g/mL)

Use Dopamine 200 mg in 5 mL ampoules Dilute 200 mg (5 mL) up to 500 mL with Normal Saline Commence at a low dose (eg 2.5 g/kg/min) and adjust rate to obtain desired blood pressure and urinary output > 0.5 mL/kg/hr (1 mL/kg/hr in children). Dose Range Rate of Infusion (mL/hour) - Infusion Pump 40 kg 2.5 g/kg/min 5 g/kg/min 10 g/kg/min Indications 1. Management of shock (where hypovolaemia has been excluded). 2. Improvement in renal blood flow in oliguria. Precautions and Side Effects 1. Hypovolaemia must be fully corrected prior to administration. 2. Administer via a central venous line or into a large peripheral venous line (extreme caution with concentrated solution in a peripheral vein because of the risk of vasoconstriction, ischaemic pain and local necrosis). 3. Side effects include ectopic beats, tachycardia, angina, palpitations, nausea, vomiting, headache and dyspnoea. Special Notes 1. Low doses (2.5 - 5 g/kg/min) are used to improve urinary output. Higher doses (5-10 g/kg/min) have an additional inotropic effect. Doses greater than 10 g/kg/min are rarely indicated - if additional effects are required Adrenaline, Noradrenaline or Dobutamine are more effective inotropic agents. 2. Most if not all patients requiring Dopamine will require a medical escort on board. 15 30 60 60 kg 23 45 90 70 kg 26 53 105 80 kg 30 60 120 100 kg 38 75 150

500 mL Bag

Issue Date: 1 January 2006 Review Date: 31 Dec 2007

Part 2 - Drug Infusion Guidelines

Page 8

RFDS Western Operations

HEA16 - V3.0

Clinical Manual

6.

GLYCERYL TRINITRATE INFUSION A. Syringe Driver Glyceryl Trinitrate 50 mg/50 mL (1,000 g/mL)

Use Glyceryl Trinitrate 50 mg in 10 mL ampoule Dilute 50 mg (10 mL) up to 50 mL with 5% Dextrose Commence at 25 - 50 g/min (1.5 - 3 mL/hr) Increase by 1 mL/hr every 5 -10 minutes according to response Dose Range Rate of Infusion - Syringe Driver 3 mL/hr 6 mL/hr 9 mL/hr 12 mL/hr

50 mL Syringe

50 g/min 100 g/min 150 g/min 200 g/min

B. Infusion Pump

Glyceryl Trinitrate 50 mg/100 mL (500 g/mL)

Use Glyceryl Trinitrate 50 mg in 10 mL ampoule Dilute 50 mg (10 mL) up to 100 mL with 5% Dextrose, preferably in a glass bottle Commence at 25 - 50 g/min (3 - 6 mL/hr) Increase by 2 mL/hr every 5 -10 minutes according to response Dose Range Rate of Infusion - Infusion Pump 6 mL/hr 12mL hr 18 mL/hr 24 mL/hr

100 mL Bag

50 g/min 100 g/min 150 g/min 200 g/min

Indications 1. Ischaemic chest pain or unstable angina not adequately relieved by oral, sublingual or transdermal nitrates. 2. Acute left ventricular failure. 3. Acute hypertension. Precautions and Side Effects 1. Up to 80% of active agent may be absorbed by PVC giving sets or IV fluid bags. Absorption increases with increased concentration and increased exposure time to the plastic. Plastic syringes and minimum volume tubing reduce absorption but the dose may still need to be gradually increased. Use clinical response rather than calculated dose to get a dose that is appropriate for the patient. 2. Headache is common. Other CNS effects can include restlessness, dizziness, apprehension, vomiting. CVS side effects include hypotension, reflex tachycardia, palpitations and circulatory collapse. 3. Usual starting dose is 50 g/min but some patients, particularly those with low blood pressure or pulmonary oedema, may require a lower starting dose.

Issue Date: 1 January 2006 Review Date: 31 Dec 2007

Part 2 - Drug Infusion Guidelines

Page 9

RFDS Western Operations

HEA16 - V3.0

Clinical Manual

6. GLYCERYL TRINITRATE INFUSION (CONT) 4. Monitor blood pressure at least 15 minutely until stable. Once a blood pressure response is noted increments should be made more cautiously. Titrate rate against patients tolerance and therapeutic response rather than a precise dose. Cease infusion if the systolic blood pressure falls below 95 mmHg. 5. Avoid skin contact with concentrated solution when preparing infusion. Special Notes The need for a medical escort on board for a patient with a GTN infusion should be critically reviewed.

Issue Date: 1 January 2006 Review Date: 31 Dec 2007

Part 2 - Drug Infusion Guidelines

Page 10

RFDS Western Operations

HEA16 - V3.0

Clinical Manual

7.

HEPARIN INFUSION A. Syringe Driver Heparin 25,000 IU/50 mL (500 IU/mL)

Use Heparin 5,000 International Units (IU) in 1 mL ampoule or 25,000 IU in 5 mL ampoule Give a loading dose of 5,000 IU intravenously Dilute 25,000 IU (5 mL) up to 50 mL with Normal Saline or 5% Dextrose Infuse at 1,000 IU/hr (2 mL/hr)

50 mL Syringe

Dose Range 1,000 IU/hr

Rate of Infusion - Syringe Driver 2 mL/hr

B. Infusion Pump

Heparin 25,000 IU/500 mL (50 IU/mL)

Use Heparin 5,000 International Units (IU) in 1 mL ampoule or 25,000 IU in 5 mL ampoule Give a loading dose of 5,000 IU intravenously Dilute 25,000 IU (5 mL) up to 500 mL with Normal Saline or 5% Dextrose Infuse at 1,000 IU/hr (20 mL/hr)

500 mL Bag
Indications 1. Unstable Angina

Dose Range 1,000 IU/hr

Rate of Infusion - Infusion Pump 20 mL/hr

2. Deep Venous Thrombosis or Pulmonary Embolism Precautions and Side Effects Contraindicated in the presence of actual or potential haemorrhagic states e.g. haemophilia, threatened abortion, severe hypertension, active peptic ulcer disease Special Notes Modify infusion rate according to APTT (where available)

Issue Date: 1 January 2006 Review Date: 31 Dec 2007

Part 2 - Drug Infusion Guidelines

Page 11

RFDS Western Operations

HEA16 - V3.0

Clinical Manual

8.

INSULIN INFUSION A. Syringe Driver Insulin 50 IU/50 mL (1 IU/mL)

Use Actrapid Insulin 1,000 IU / 10 mL ampoules (100 IU /mL) Give a loading dose of 10 IU intravenously (0.1 mL) (not in children) Dilute 50 IU (0.5 mL) up to 50 mL with Gelofusine Commence infusion at 5-10 IU/hr (5-10 mL/hr) (0.1 IU/kg/hr in children) Dose Range Rate of Infusion - Syringe Driver 5 mL/hr 10 mL/hr 15 mL/hr

50 mL Syringe

5 IU/hr 10 IU/hr 15 IU/hr

B. Infusion Pump

Insulin 50 IU/500 mL (0.1 IU/mL)

Use Actrapid Insulin 1,000 IU / 10 mL ampoules (100 IU /mL) Give a loading dose of 10 IU intravenously (0.1 mL) (not in children) Dilute 50 IU (0.5 mL) up to 500 mL with Gelofusine Commence infusion at 5-10 IU/hr (50-100 mL/hr) (0.1 IU/kg/hr in children) Dose Range Rate of Infusion -Infusion Pump 50 mL/hr 100 mL/hr 150 mL/hr

500 mL Bag

5 IU/hr 10 IU/hr 15 IU/hr

Indications 1. Diabetic Ketoacidosis 2. Non Ketotic Hyperosmolar Coma Precautions and Side Effects Some insulin will be adsorbed by the tubing and so the actual dose of insulin delivered may vary. Gelofusine gives better delivery of insulin than normal saline. Special Notes 1. In diabetic ketoacidosis the replacement of fluid and electrolyte losses should be given a higher priority than the control of blood glucose per se. 2. In diabetic ketoacidosis, if decrease in BSL is < 4 mmol/l/hr, double the rate of insulin infusion every hour until decrease in BSL is > 4 mmol/l/hr or until BSL < 15 mmol/l. 3. When decrease in BSL is > 4 mmol/l/hr, maintain insulin infusion until BSL < 15 mmol/l. 4. When BSL < 15 mmol/l decrease rate of infusion to 0.5 - 2 IU/hr with an aim of keeping BSL between 10 - 14 mmol/l. 5. Should only be administered on a doctor-accompanied flight unless under exceptional circumstances.

Issue Date: 1 January 2006 Review Date: 31 Dec 2007

Part 2 - Drug Infusion Guidelines

Page 12

RFDS Western Operations

HEA16 - V3.0

Clinical Manual

9.

ISOPRENALINE INFUSION A. Syringe Driver Isoprenaline 1 mg/50 mL (20 g/mL)

Use Isoprenaline hydrochloride 1 mg in 5 mL ampoules Dilute 1 mg (5 mL) up to 50 mL with 5% Dextrose Give 20 g (1 mL), repeated according to clinical response, followed by an infusion at 1 4 g/min (3 - 12 mL/hr) Dose Range Rate of Infusion - Syringe Driver 3 mL/hr 6 mL/hr 12 mL/hr

50 mL Syringe

1 g/min 2 g/min 4 g/min

B. Infusion Pump

Isoprenaline 1 mg/500 mL (2 g/mL)

Use Isoprenaline hydrochloride 1 mg in 5 mL ampoules Dilute 1 mg (5 mL) up to 500 mL with 5% Dextrose Give 20 g (10 mL), repeated according to clinical response, followed by an infusion at 1 - 4 g/min (30 - 120 mL/hr) Dose Range Rate of Infusion - Infusion Pump 30 mL/hr 60 mL/hr 120 mL/hr

500 mL Bag

1 g/min 2 g/min 4 g/min

Indications Bradycardia with poor perfusion. Most commonly complete heart block. Precautions and Side Effects 1. Side effects include palpitations, headache, flushing of the skin, angina, nausea, vomiting, tremor, dizziness, weakness and sweating. 2. If heart rate exceeds 80 or patient develops chest pain or other arrhythmias decrease dose or temporarily discontinue infusion. 3. Administer with caution in the elderly, diabetic, hyperthyroid, patients with ischaemic heart disease or concurrently with other inotropes. 4. Administer via a central venous line or into a large peripheral venous line (extreme caution with concentrated solution in a peripheral vein because of the risk of vasoconstriction, ischaemic pain and local necrosis). Special Notes 1. Required response usually achieved at < 3 g/min, though may increase up to 20 g/min if necessary to obtain required response 2. Should only be administered on a doctor-accompanied flight unless under exceptional circumstances.

Issue Date: 1 January 2006 Review Date: 31 Dec 2007

Part 2 - Drug Infusion Guidelines

Page 13

RFDS Western Operations

HEA16 - V3.0

Clinical Manual

10.

LIGNOCAINE INFUSION Infusion Pump Lignocaine 2 gm/500 mL (4 mg/mL)

Use Lignocaine hydrochloride 2 g in 20 mL ampoules (10% solution) Dilute 2 g (20 mL) in 500 mL of 5% Dextrose Loading dose of 1 mg/kg slowly over 1-2 minutes if Lignocaine not given previously (use Minijet, or 10 mL 1% plain Lignocaine or 25 mL of 2gm/500 mL solution) Commence infusion at 4 mg/min for 1 hour, then 2 mg/min for the next 2 hours then 1 mg/min maintenance Dose Range Rate of Infusion - Infusion Pump 60 mL/hr 30 mL/hr 15 mL/hr

500 mL Bag

1st hour next 2 hours maintenance

4 mg/min 2 mg/min 1 mg/min

Indications Ventricular tachycardia where the patient is haemodynamically compromised or if significant symptoms are present or if the tachycardia is persistent (e.g. greater than 30 seconds). Precautions and Side Effects 1. Hypotension 2. Moderate overdose results in dizziness and drowsiness. 3. Larger overdose results in CNS stimulation (agitation, convulsions) or CNS depression (respiratory depression). Special Notes Should only be administered on a doctor-accompanied flight unless under exceptional circumstances.

Issue Date: 1 January 2006 Review Date: 31 Dec 2007

Part 2 - Drug Infusion Guidelines

Page 14

RFDS Western Operations

HEA16 - V3.0

Clinical Manual

11.

MAGNESIUM SULPHATE INFUSION A. Syringe Driver Magnesium Sulphate 9.88 g [40 mmol] / 20mL (0.5 g/mL)

For Pre-Eclampsia, use 4 ampoules of Magnesium Sulphate (2.47 g [10 mmol] per 5 mL ampoule) (NB dose and rate are different for treatment of pre-term labour, see special notes) Use 4 ampoules (9.88 g) of Magnesium Sulphate undiluted (20 mL) Give a loading dose of approx 4 g (8 mL) over 20 min (6g pre-term labour) Follow the loading dose with an infusion of 1 g/hr (2mL/hr) (2g/hr pre term labour) If further seizures occur, give 2 g (4 mL) over 5 minutes (48 mL/hr for 5 minutes) Dose Range 4 g (8 mL) 1 g/hr 2 g (4 mL) Rate of Infusion Syringe Driver 24 mL/hr for 20 min only 2 mL/hr 48 mL/hr for 5 min only

50 mL Syringe

Loading Dose (20 min) Maintenance Dose If further seizures, give 2 g over 5 min

B. Infusion Pump

Magnesium Sulphate 9.88 g [40 mmol] /120 mL (0.08 g/mL)

For Pre-Eclampsia, use 4 ampoules of Magnesium Sulphate (2.47 g [10 mmol] per 5 mL ampoule) (NB dose and rate are different for treatment of pre-term labour, see special notes) Add to a 100 mL bag Normal Saline to equal 120 mL Give a loading dose of approx 4 g (50 mL) over 20 min (6g pre term labour) Follow the loading dose with an infusion of 1 g/hr (12 mL/hr) (2g/hr pre term labour) If further seizures occur, give 2 g (25 mL) over 5 minutes (300 mL/hr for 5 minutes) Dose Range Rate of Infusion Infusion Pump 150 mL/hr for 20 min only 12 mL/hr 300 mL/hr for 5 min only

120 mL Bag

Loading Dose (20 min) Maintenance Dose If further seizures, give 2 g over 5 min

4 g (50 mL) 1 g/hr 2 g (25 mL)

Indications 1. 2. Prevention of Eclampsia Suppression of labour where Salbutamol is contra-indicated or ineffective. Obtain obstetric advice before use.

Issue Date: 1 January 2006 Review Date: 31 Dec 2007

Part 2 - Drug Infusion Guidelines

Page 15

RFDS Western Operations

HEA16 - V3.0

Clinical Manual

11. MAGNESIUM SULPHATE INFUSION (CONT) Precautions and Side Effects 1. Urine output should be maintained at > 30 mL/hr. Caution with fluid administration should be exercised to avoid fluid overload. 2. Magnesium toxicity is suggested by: The disappearance of the patella reflex (check hourly) Disappearance of the patella reflex mandates cessation of the infusion. Serum Magnesium levels should be done when possible. Respiratory depression (<12/min), Respiratory rate should ideally be maintained at >16/min and the infusion should be definitely be ceased if the rate drops below 12/min. Bradycardia (HR<60/min) may result from complete heart block. 3. Magnesium is contraindicated in the presence of myasthenia gravis and heart block and should be used with extreme caution in patients with impaired renal function. 4. Maternal visual disturbance is common with Magnesium infusion, most commonly blurred vision, diplopia and ptosis. Neuro-ophthalmic effects resolve promptly with cessation of infusion. 5. Treatment of overdose Cease infusion. Intravenous administration of 5-10 mEq of 10% Calcium Gluconate (10 - 20 mL) to reverse respiratory depression or heart block.

Special Notes 1. Should only be administered on a doctor-accompanied flight unless under exceptional circumstances. 2. Magnesium Sulphate infusion may also be used for suppression of labour where Salbutamol is contraindicated or ineffective. There is evidence to suggest that the drug is synergistic with Salbutamol in its effect on uterine contractions. Obtain Obstetric advice before use. Increased dosages and rate are used for suppression of preterm labour. NB Eight ampoules are required (take extra supplies from hangar or base hospital) Give a loading dose of 6g (12mL of undiluted or 75mL of diluted solution) over 30 minutes. Commence infusion at 4g/hr (8mL/hr of undiluted or 50mL/hr of diluted solution) for 2 hours. Maintenance dose is 2g/hr (4mL/hr of undiluted or 25mL/hr of diluted solution). Increase at 0.5g per hour if uterine activity persists and levels (when measurable) are sub-therapeutic.

Issue Date: 1 January 2006 Review Date: 31 Dec 2007

Part 2 - Drug Infusion Guidelines

Page 16

RFDS Western Operations

HEA16 - V3.0

Clinical Manual

12.

METHYLPREDNISOLONE INFUSION A. Syringe Driver Methylprednisolone 2g/50mL (40mg/mL)

Use Methylprednisolone Sodium Succinate (Solu-Medrol) 500mg or 1g ampoules. Use supplied diluent or Water for Injection to reconstitute (10mL for 500mg, 20mL for 1g). Loading dose. Dilute loading dose of 30mg/kg body weight (see below) further to 50mL with Normal Saline or 5% Dextrose in a syringe. Administer over 15 minutes, then wait 45 minutes. Dose may be approximated to nearest 0.5g. Infusion. Dilute 2g (40mL) of reconstituted Methylprednisolone to 50mL in a syringe making 40mg/mL. (This should provide for a minimum of 4 hours infusion). Commence at 5.4mg/kg/hr (see rates below). Infusion should run for 23 hrs total. Weight (kg) Loading Dose 1.0g 1.5g 2.0g 2.0g 2.5g 2.5g 3.0g Infusion Dose (mg/hr) 216 270 324 378 432 486 540 Infusion Rate (mL/hr) 5.4 6.8 8.1 9.5 10.8 12.2 13.5

50 mL Syringe

40 50 60 70 80 90 100

B. Infusion Pump

Methylprednisolone 2g/500mL (4mg/mL)

Use Methylprednisolone Sodium Succinate (Solu-Medrol) 500g or 1g ampoules. Use supplied diluent or Water for Injection to reconstitute (10mL for 500mg, 20mL for 1g). Loading dose. Add loading dose of 30mg/kg body weight (see below) to 100mL bag of Normal Saline. Administer over 15 minutes, then wait 45 minutes. Dose may be approximated to nearest 0.5g. Infusion. Add 2g (40mL) of reconstituted Methylprednisolone to 500mL bag of Normal Saline or 5% Dextrose making 4mg/mL. (Provides for a minimum of 4 hours infusion). Commence at 5.4mg/kg/hr (see rates below). Infusion should run for 23 hrs total. Weight (kg) Loading Dose (G) 1.0g 1.5g 2.0g 2.0g 2.5g 2.5g 3.0g Infusion Dose (mg/hr) 216 270 324 378 432 486 540 Infusion Rate (mL/hr) 54 68 81 95 108 122 135

500mL Bag

40 50 60 70 80 90 100

Indications Acute spinal cord injuries (< 8 hours old).

Issue Date: 1 January 2006 Review Date: 31 Dec 2007

Part 2 - Drug Infusion Guidelines

Page 17

RFDS Western Operations

HEA16 - V3.0

Clinical Manual

12. METHYLPREDNISOLONE INFUSION (CONT.) Precautions and Side Effects 1. Contraindicated in open injuries (stab wounds, missile injuries). 2. Patients should receive prophylaxis against gastrointestinal haemorrhage (i.e. IV Ranitidine or oral Sucralfate). 3. Elevated blood sugar is a known side-effect. Monitor blood sugar levels 4 hourly and treat as appropriate. Special Notes 1. Infusions are based on minimum quantities of Methylprednisolone carried and should be sufficient for duration of transfer. Ensure receiving hospital is aware of when treatment commenced and continues drug infusion for full 23 hours. 2. If volume to be delivered by IVAC is considered excessive, use 100mL bag instead and recalculate rates (dividing by 5).

References
1. Bracken MB, Shepard MJ, Collins WF et al. NEJM 322(20):1405-11 2. Pharmacy Department & Spinal Injuries Unit, Austin Hospital. Preparation of Methylprednisolone for Acute Spinal Injury. Nov 1990. http://www.health.qld.gov.au/qscis/pdf/QSCIS%20Information/Methylprednisolone%20Protocol.pdf

Issue Date: 1 January 2006 Review Date: 31 Dec 2007

Part 2 - Drug Infusion Guidelines

Page 18

RFDS Western Operations

HEA16 - V3.0

Clinical Manual

13.

MORPHINE INFUSION A. Syringe Driver Morphine 30 mg/ 30mL (1 mg/mL)

Use Morphine 15 mg/mL or Morphine 10 mg/mL Dilute 30 mg Morphine up to 30 mL with Normal Saline (or 45 mg to 45 mL) Administer a loading dose of 2 - 10 mL (2mg - 10mg) Commence infusion at 2 - 5 mL/hr and adjust according to clinical response Dose Range 2 mg/hr 4 mg/hr 5 mg/hr Rate of Infusion - Syringe Driver 2mL/hr 4 mL/hr 5 mL/hr

50 mL Syringe

B. Infusion Pump

Morphine 50 mg/ 500mL (0.1mg/mL)

Use Morphine 15 mg/mL or Morphine 10 mg/mL Dilute 50 mg Morphine up to 500 mL with Normal Saline Administer a loading dose of 20 - 100 mL (2mg - 10mg) Commence infusion at 25- 50 mL/hr and adjust according to clinical response Dose Range 2 mg/hr 4 mg/hr 5 mg/hr Rate of Infusion - Infusion Pump 20 mL/hr 40 mL/hr 50 mL/hr

500 mL Bag

Indications Analgesia Precautions and Side Effects Side effects include nausea and vomiting, hypotension, CNS and respiratory depression. Special Notes 1. Adjust rate according to clinical response. 2. Smaller volume solutions (e.g. 30mg made up to 30 mL) should be used for shorter flights. 3. Morphine infusion is preferable to Pethidine infusion because of the risk of nor-Pethidine induced fitting with large doses of Pethidine. 4. Treat nausea or vomiting with Prochlorperazine 12.5 mg IV or IM 6/24 or Metoclopramide 10 mg IV or IM 6/24. 5. If respiratory rate < 8 breaths / min, excessive sedation or symptomatic hypotension develops cease infusion and contact duty RFDS Medical Officer. 6. Overdose can be reversed with Naloxone 0.1 - 0.4 mg IV, repeated if necessary.

Issue Date: 1 January 2006 Review Date: 31 Dec 2007

Part 2 - Drug Infusion Guidelines

Page 19

RFDS Western Operations

HEA16 - V3.0

Clinical Manual

14.

MORPHINE & MIDAZOLAM INFUSION A. Syringe Driver Morphine 30 mg + Midazolam 30 mg/30 mL (1 mg Morphine + 1 mg Midazolam /mL)

Use Morphine 15 mg/mL or Morphine 10 mg/mL and Midazolam 15 mg/3 mL Dilute 30 mg Morphine plus 30 mg Midazolam up to 30 mL with Normal Saline (or 45mg + 45mg to 45 mL or 50mg + 50mg to 50 mL) Administer a loading dose of 2 - 10 mL (2mg+2mg 10mg+10mg) Commence infusion at 2.5 - 5 mL/hr Dose Range 2.5mg + 2.5 mg/hr 5mg + 5mg/hr 10mg + 10mg/hr 15mg +15mg/hr Rate of Infusion - Syringe Driver 2.5 mL/hr 5 mL/hr 10 mL/hr 15 mL/hr

50 mL Syringe

B. Infusion Pump

Morphine 50 mg + Midazolam 50 mg/500 mL (0.1 mg Morphine + 0.1 mg Midazolam /mL)

Use Morphine 15mg/mL or Morphine 10mg/mL and Midazolam 15mg/3 mL Dilute 50mg Morphine plus 50mg Midazolam up to 500 mL with Normal Saline Administer a loading dose of 20-100 mL (2mg+2mg 10mg+10mg) Commence infusion at 25 50 mL/hr Dose Range 2.5mg + 2.5 mg/hr 5mg + 5 mg/hr 10mg + 10mg/hr 15mg +15mg/hr Rate of Infusion - Infusion Pump 25 mL/hr 50 mL/hr 100 mL/hr 150 mL/hr

500 mL Bag

Indications Sedation Precautions and Side Effects Side effects include hypotension, CNS and respiratory depression Special Notes 1. Adjust rate according to clinical response. 2. Smaller volume solutions (e.g. 30mg + 30mg made up to 30 mL) should be used for shorter flights. 3. Should only be administered on a doctor-accompanied flight unless under exceptional circumstances.

Issue Date: 1 January 2006 Review Date: 31 Dec 2007

Part 2 - Drug Infusion Guidelines

Page 20

RFDS Western Operations

HEA16 - V3.0

Clinical Manual

15.

NORADRENALINE INFUSION A. Syringe Driver Noradrenaline 4 mg/50 mL (80 g/mL)

Use Noradrenaline 1:1,000 (2 mg/2mL) ampoules Dilute 4 mg (4 mL) up to 50 mL with 5% Dextrose Commence at 1 g/min (0.8 mL/hr) and adjust rate according to clinical response Dose Range 1 g/min 5 g/min 10 g/min 20 g/min Rate of Infusion - Syringe Driver 1 mL/hr 4 mL/hr 8 mL/hr 15 mL/hr

50 mL Syringe

B. Infusion Pump

Noradrenaline 4 mg/500 mL ( 8 g/mL)

Use Noradrenaline 1:1,000 (2 mg/2mL) ampoules Dilute 4 mg (4 mL) up to 500 mL with 5% Dextrose Commence at 1 g/min (8 mL/hr) and adjust rate according to clinical response Dose Range 1 g/min 5 g/min 10 g/min 20 g/min Indications Management of shock (after hypovolaemia has been excluded) Precautions and Side Effects 1. Correct hypovolaemia prior to administration. 2. Administer via a central venous line or into a large peripheral venous line (extreme caution with concentrated solution in a peripheral vein because of the risk of vasoconstriction, ischaemic pain and local necrosis). 3. Monitor ECG and blood pressure closely. 4. Side effects include pulmonary oedema, arrhythmias, tachycardia, myocardial ischaemia, anxiety, palpitations, hypertension and peripheral ischaemia. 5. Incompatible with Normal Saline. Special Notes 1. Infusion should be titrated to achieve desired clinical endpoint e.g. systolic blood pressure 80 - 100 mmHg. Usual dose is between 1 - 70 g/min. Discuss with receiving Intensive Care Unit before use. 2. Should only be administered on a doctor-accompanied flight. Rate of Infusion - Infusion Pump 8 mL/hr 37 mL/hr 75 mL/hr 150 mL/hr

500 mL Bag

Issue Date: 1 January 2006 Review Date: 31 Dec 2007

Part 2 - Drug Infusion Guidelines

Page 21

RFDS Western Operations

HEA16 - V3.0

Clinical Manual

16.

OCTREOTIDE INFUSION Octreotide 0.1 mg/50 mL (2g/mL)

A. Syringe Driver

Use Octreotide 0.1 mg/mL in 1 mL ampoules Dilute 0.1 mg (1 mL) up to 50 mL with Normal Saline or 5% Dextrose Commence at 25 g/hr (10 mL/hr) Dose Range

50 mL Syringe B. Infusion Pump

25 g/hr 50 g/hr

Rate of Infusion - Syringe Driver 12.5 mL/hr 25 mL/hr

Octreotide 0.1 mg/500mL(0.2 g/mL)

Use Octreotide 0.1 mg/mL in 1 mL ampoules Dilute 0.1 mg (1mL) up to 500 mL with Normal Saline or 5% Dextrose Commence at 25 g/hr (125 mL/hr) Dose Range

500 mL Bag
Indications

25 g/hr 50 g/hr

Rate of Infusion - Infusion Pump 125 mL/hr 250 mL/hr

First line control of acute variceal bleeding. Precautions and Side Effects 1. Blood glucose should be monitored regularly during administration. 2. At low doses, (less than 100 micrograms), there are generally no side effects. Greater doses may cause nausea, delayed abdominal pain and diarrhoea. 3. A loading bolus of 25-50 micrograms may be given. 4. Increase infusion rate to 50 micrograms per hour if bleeding is not adequately controlled. 5. Check ampoule concentration carefully. May be supplied at 0.05 mg/mL, 0.1 mg/mL or 0.5 mg/mL. Special Notes 1. Octreotide (Sandostatin) is an analogue of somatostatin which inhibits intestinal motility, secretion of gastric acid, pepsin and intrinsic factor, splanchnic blood flow and bile flow. It also blocks secretion of growth hormone, thyroid stimulating hormone, insulin, glucagon, gastrin, VIP and secretin. Half-life is approximately 90 minutes. 2. Clinical uses include acromegaly, carcinoid tumours, VIPoma, Zollinger-Ellison syndrome, glucagonoma and dumping syndrome. It is widely used for variceal bleeding, although not formally approved by the TGA. 3. Studies have shown less morbidity with Octreotide than balloon tamponade in variceal bleeding. Reference Drug Sub-committee, Royal Perth Hospital. Indications for Octreotide. Revised 1998.

Issue Date: 1 January 2006 Review Date: 31 Dec 2007

Part 2 - Drug Infusion Guidelines

Page 22

RFDS Western Operations

HEA16 - V3.0

Clinical Manual

17. SALBUTAMOL INFUSION OBSTETRIC A. Infusion Pump (concentrated) Salbutamol 5 mg/100 mL (50 g/mL)
Use Salbutamol 5 mg in 5 mL ampoule Dilute 5 mg (5 mL) up to 100 mL with Normal Saline Commence infusion at 10 g/min (12 mL/hr) Increase in increments of 10 g/min (12 mL/hr) at 30 minute intervals until contractions cease or limits (as listed below) are reached Dose Range 10 g/min 20 g/min 30 g/min 40 g/min 50 g/min Rate of Infusion - Infusion Pump 12 mL/hr 24 mL/hr 36 mL/hr 48 mL/hr 60 mL/hr

100 mL Bag

B. Infusion Pump (dilute)

Salbutamol 5 mg/500 mL (10 g/mL)

Use Salbutamol 5 mg in 5 mL ampoule Dilute 5 mg (5 mL) up to 500 mL with Normal Saline Commence infusion at 10 g/min (60 mL/hr) Increase in increments of 10 g/min (60 mL/hr) at 30 min intervals until contractions cease or limits (as listed below) are reached Dose Range 10 g/min 20 g/min Rate of Infusion - Infusion Pump 60 mL/hr 120 mL/hr

500 mL Bag

180 mL/hr 30 g/min If rate exceeds 180 mL/hr double the concentration of Salbutamol (10 mg/ 500 mL, 20 g/mL) and halve rates accordingly 40 g/min 50 g/min Indications: Inhibition of labour Precautions and Side Effects 1. Cease infusion if contractions cease or maternal pulse = 130/min or there are signs of fetal distress or FHR exceeds 190 or the maximum drip rate of 50 g/min is reached (CONT) 120 mL/hr (of 20 g/mL solution) 150 mL/hr (of 20 g/mL solution)

Issue Date: 1 January 2006 Review Date: 31 Dec 2007

Part 2 - Drug Infusion Guidelines

Page 23

RFDS Western Operations

HEA16 - V3.0

Clinical Manual

17. SALBUTAMOL INFUSION - OBSTETRIC (CONT) Precautions and Side Effects (cont) 2. Side effects include palpitations, tachycardia, tremor, hypotension, pulmonary oedema, cardiac arrhythmias, myocardial ischaemia, hypokalaemia, hyperglycaemia, flushing, headache, dizziness, anxiety, nausea and vomiting. 3. Use with caution in patients with heart disease, diabetes or hypertension 4. Absolute obstetric contraindications include fetal death in utero and severe antepartum haemorrhage. 5. May be use when relative contraindications exist, if risks outweighed by the risk of delivery during transport. Special Notes: 1. In this RFDS protocol both the rate of increase of infusion and the maximum limits are greater when compared with the King Edward Memorial Hospital protocol. This reflects the different risks involved in the delivery of the pre-term infant outside the tertiary Hospital setting. Care must be exercised at high doses. 2. Alternatives / adjuncts to Salbutamol infusion for tocolysis include Nifedipine, Ritodrine, Indomethacin and GTN. Consult Clinical Guideline on Preterm Labour.

Issue Date: 1 January 2006 Review Date: 31 Dec 2007

Part 2 - Drug Infusion Guidelines

Page 24

RFDS Western Operations

HEA16 - V3.0

Clinical Manual

18.

SALBUTAMOL INFUSION - RESPIRATORY A. Syringe Driver Salbutamol 5 mg/50 mL (100 g/mL)

Use Salbutamol 5 mg in 5 mL ampoule Dilute 5 mg (5 mL) up to 50 mL with Normal Saline Administer a loading dose of 4 - 5 g/kg [eg 250 g (2.5 mL) in an adult] over 10 min Commence at 3 mL/hr (5 g/min) [1-5 g/kg/min in children] Increase in increments of 5 g/min (3 mL/hr) at 15 min intervals up to a maximum dose of 20 g/min Dose Range 5 g/min 10 g/min 15 g/min 20 g/min Rate of Infusion - Syringe Driver 3 mL/hr 6 mL/hr 9 mL/hr 12 mL/hr

50 mL Syringe

B. Infusion Pump

Salbutamol 5 mg/500 mL (10 g/mL)

Use Salbutamol 5 mg in 5 mL ampoule Dilute 5 mg (5 mL) up to 500 mL with Normal Saline Administer a loading dose of 4 - 5 g/kg [eg 250 g (25 mL) in an adult] over 10 min Commence at 30 mL/hr (5 g/min) [1-5 g/kg/min in children] Increase in increments of 5 g/min (30 mL/hr) at 15 min intervals up to a maximum dose of 20 g/min Dose Range 5 g/min 10 g/min 15 g/min 20 g/min Rate of Infusion - Infusion Pump 30 mL/hr 60 mL/hr 90 mL/hr 120 mL/hr

500 mL Bag

Indications: Severe bronchospasm. Precautions and Side Effects: 1. Additional side effects included palpitations, tachycardia, tremor, lactic acidosis, pulmonary oedema, hypokalaemia, hyperglycaemia, flushing, headache, dizziness and anxiety. 2. Side effects include palpitations, tachycardia, tremor, hypotension, pulmonary oedema, cardiac arrhythmias, myocardial ischaemia, hypokalaemia, hyperglycaemia, flushing, headache, dizziness, anxiety, nausea and vomiting. 3. Consider continuous nebulised Salbutamol, intravenous Aminophylline and/or Adrenaline infusion as alternative or additional therapies.

4. Should only be administered on a doctor-accompanied flight unless under exceptional

circumstances. Infusions can be made up using either Ventolin Obstetric Injection (Salbutamol 5 mg / 5 mL) or Ventolin Injection (Salbutamol 500 g / mL, 1 mL).
Issue Date: 1 January 2006 Review Date: 31 Dec 2007 Part 2 - Drug Infusion Guidelines Page 25

RFDS Western Operations

HEA16 - V3.0

Clinical Manual

19.

VECURONIUM INFUSION A. Syringe Driver Vecuronium 20 mg / 20 mL (1 mg /mL)

Use Vecuronium 4 mg or 10 mg ampoules Reconstitute the powder in the ampoules with water for injection Dilute 20 mg up to 20 mL with Normal Saline (or 10 mg to 10 mL or 30 mg to 30 mL) After patient has been intubated give a loading dose of 0.05 mg/kg (eg 4 mg for an 80 kg patient)

Run infusion at 0.1 mg/kg/hr (eg 8 mg/hr in a 80 kg patient)

50 mL Syringe
Indications

Dose Range 8 mg/hr (for 80 kg patient)

Rate of Infusion - Syringe Driver 8 mL/hr

Maintenance of muscle relaxation in ventilated patients. Precautions and Side Effects 1. Patient must be adequately sedated with Morphine and Midazolam in addition to being paralysed. 2. Patients with hepatic or renal disease may have reduced excretion resulting in prolongation of neuromuscular blockade. Use lower doses in these patients. Special Notes Should only be administered on a doctor-accompanied flight.

FILENAME: G:\HEALTH\MEDICAL\CLINICAL MANUAL\CURRENT VERSION OF SECTIONS\PART 2 - DRUG INFUSION GUIDELINES JANUARY 2006.DOC LAST PRINT:12/01/06 6:53 PM

Issue Date: 1 January 2006 Review Date: 31 Dec 2007

Part 2 - Drug Infusion Guidelines

Page 26