Intravenous Administration of Formulary Medications - Pediatric/Neonatal - Inpatient/Ambulatory Clinical Practice Guideline

Effective 7/8/2021. Contact [email protected] for previous versions

Table of Contents Executive Summary ...... 3 Scope ...... 4 Methodology...... 4 Definitions ...... 5 Introduction ...... 5 Recommendations ...... 6 UW Health Implementation ...... 72 References...... 72 Appendix A. Evidence Grading Scheme ...... 74 Appendix B. Medications Requiring Central Lines ...... 75

Contact for Content and Changes: Philip Trapskin, Manager, Patient Care Services and Drug Policy Program Phone Number: (608) 263-1328 Email: [email protected]

Guideline Authors: Joshua Vanderloo, PharmD Emily Zimmerman, PharmD

Coordinating Team Members: Joshua Vanderloo, PharmD; Philip Trapskin, PharmD, BCPS

Review Individuals/Bodies: AFCH Nursing Leadership: Barbara Byrne, VP AFCH Clinical Operations; Laura Ahola, Nurse Manager PUCU; Angela Baker, Nurse Manager NICU; Devon Christenson, Nurse Manager Diagnostic/Therapy Center; Carrie Cronk, Nurse Manager P4; Kirsten Koffarnus, CNS P5; Laura Konkol, CNS NICU; Kitty Montgomery, CNS P4; Anne Moseley, Director Pediatric Nursing; Sue Quamme, Nurse Manager PI44; Windy Smith, Nurse Manager P5 Deborah Soetenga, CNS PI44; Lori Williams, CNS PUCU

Pharmacists; Brian LaRowe, PharmD; Nicole Lubcke, PharmD; Mary Mably, Pharmacy Coordinator Oncology, PharmD, BCOP; Aaron Steffenhagen, Pharmacy Manager Critical Care, PharmD, BCPS; Meghann Voegeli, Pharmacy Manager Pediatrics, PharmD

Dan O’Connell, MD, Pediatric Gastroenterology Daniel Sklansky, MD, Hospitalist Benjamin Walker, MD, Pediatric Anesthesiology

Committee Approvals/Dates: Pharmacy and Therapeutics Committee (Last Periodic Review: September 2014) • Interim Revisions: November 2014, January 2015, September 2015, Novemeber 2015, November 2017, December 2017, January 2018

Release Date: October 2016 Next Review Date: October 2018

Executive Summary Guideline Overview This guideline directs the appropriate administration of intravenous medications to pediatric patients across UWHealth throughout inpatient, procedural, and ambulatory settings. Necessary elements include appropriate level of care, monitoring, and physicochemical considerations.

There are many medications given intravenously both in inpatient settings, procedural areas, or ambulatory care settings. The purpose of this guideline is to provide guidance for the administration of intravenous medications to pediatric patients across these care settings. The medications in this guideline were chosen based on their inclusion in the UWHC medication formulary and the units were administration is appropriate. These administration guidelines are not absolute; administration of intravenous medications should be tailored to fit the therapeutic needs of a pediatric patient as appropriate.

Key Revisions January 2018 Minor Revision • Addition of siltuximab

December 2017 Minor Revision • Midazolam use in general care areas for prolonged epilepsy monitoring

November 2017 Minor Revision • Addition of guidance for rapid infusion of infliximab

2016 Periodic Review • Addition of new intravenous medications since previous September 2014 revision: ethacrynic acid, tocilizumab, isavuconazole, eculizumab, C1 esterase inhibitor (CINRYZE®), peramivir, levofloxacin, dinutuximab, doripenem, laronidase, granisetron, sugammadex, vedolizumab, lacosamide, defibrotide, daratumumab, vincristine • Clarification of magnesium administration rates for repletion, torsades de pointes, and bronchospasm • Addition of appendix detailing medications requiring central line

Key Practice Recommendations The guideline includes recommendations for UWHealth formulary intravenous medications with respect to recommended infusion rates, considereations for administration, and monitoring of medications with administration. See table in Recommendations section for information on specific medications.

Companion Documents • Guideline for the Management of Extravasation of Chemotherapeutic Agents – Adult/Pediatric – Inpatient/Ambulatory Clinical Practice Guideline • Guideline for Non-chemotherapeutic Agents: Prevention and Treatment of Chemical Phlebitis and Extravasation of Peripherally Administered Non-chemotherapeutic Agents – Adult and Pediatric – Inpatient Clinical Practice Guideline • Acetylcysteine (N-Acetylcysteine) – Pediatric/Adult – Inpatient Clinical Practice Guideline • Procoagulant Therapy for Treatment of Non-Hemophiliac Bleeding – Adult Clinical Practice Guideline • Granulocyte Colony Stimulating Factor – Adult/Pediatric – Inpatient Clinical Practice Guideline • Fosphenytoin and Phenytoin – Adult and Pediatric – Inpatient Clinical Practice Guideline • Therapeutic Dosing of Unfractionated Heparin – Pediatric/Neonatal – Inpatient Clinical Practice Guideline • Intravenous Immunoglobulin (IVIG) – Adult/Pediatric – Inpatient /Ambulatory Clinical Practice Guideline • High-dose Methotrexate, Leucovorin, and Glucarpidase Dosing, Administration, and Monitoring –

Adult/Pediatric Intpatient Clinical Practice Guideline • Use of Rasburicase – Adult and Pediatric – Inpatient Clinical Practice Guideline • Intravenous Hypertonic Sodium Chloride – Adult and Pediatric – Inpatient Clinical Practice Guideline

Pertinent UWHC Policies and Procedures • Policy 8.31 Guidelines for Hospital Location Specific Administration of IV Medications • Policy 8.33 High Alert Medication Administration • Policy 8.56 Pediatric Sedation • Policy 6.1.11 Preventing Non-therapeutic Exposure to Hazardous Drugs • Factor 7a Recombinant Operating Procedure • Factor 9 Complex Concentrate (PCC) Operating Procedure • Policy 10.18 Parenteral Lidocaine for Neuropathic Pain

Scope Disease/Condition: Intravenous medication administration

Extravasation of medications is not addressed in this guideline. For this information, refer to: • UWHC Guidelines for the Management of Extravasation of Chemotherapeutic Agents – Adult/Pediatric – Inpatient/Ambulatory Clinical Practice Guideline • Guideline for Non-chemotherapeutic Agents: Prevention and Treatment of Chemical Phlebitis and Extravasation of Peripherally Administered Non-chemotherapeutic Agents – Adult and Pediatric – Inpatient Clinical Practice Guideline

Clinical Specialty: This guideline is intended for all personnel authorized to prescribe, to monitor, or to administer intravenous medications in all clinical specialties of pediatric practice.

Intended Users: Physicians, advanced practice providers, pharmacists, and nurses

Objective: To provide guidelines and monitoring parameters for the intravenous administration of UWHC formulary medications to pediatric patient.

Target Population: Pediatric patients requiring intravenous medications.

Interventions and Practices Considered: • Physiochemical properties of intravenous medications • Appropriate administration technique • Safe and effective dosing and administration rates • Key monitoring parameters for intravenous medications

Major Outcomes Considered: • Safe and standardized administration of intravenous medications to prevent patient harm.

Methodology Methods Used to Collect/Select the Evidence Electronic database searches, literature review,manufacturer labeling and tertiary care references were used to collect evidence for review.

Methods Used to Formulate the Recommendations Available evidence from the literature, manufacturer labeling and tertiary references was combined to formulate recommendations. Clinical expert consensus was utilized to formulate specific recommendations and levels of care for administration.

Methods Used to Assess the Quality and Strength of the Evidence Internally developed recommendations, or those adopted from external sources without an assigned evidence grade, were evaluated by the guideline workgroup using and algorithm adapted from the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology (see Figure 1 in Appendix A).1

Cost Analysis: No formal cost analysis was performed.

Recognition of Potential Health Care Disparities: No health care disparities were identified.

Definitions 1.0 IV administration routes and lines 1.1 Central: intravenous medication to be administered through a central IV line 1.1.1 A central line placed 1.1.2 Some medications cannot be administered through a peripheral IV line due to osmolarity of the drug or risk of vein irritation. A patient must have a central line available to receive these medications. 1.2 Peripheral: intravenous medication to be administered through a peripheral IV line 1.2.1 Mildline catheters should not be used in pediatric patients based on Policy 1.55A Midline Intravenous Midline Catheters 1.3 Vesicant: An agent that can produce local irritation, necrosis, and sloughing of tissues when inadvertently injected into subcutaneous or muscle tissue during intravenous administration 1.3.1 Guideline for the Management of Extravasation of Chemotherapeutic Agents – Adult/Pediatric – Inpatient/Ambulatory Clinical Practice Guideline 1.3.2 Guideline for Non-chemotherapeutic Agents: Prevention and Treatment of Chemical Phlebitis and Extravasation of Peripherally Administered Non-chemotherapeutic Agents – Adult and Pediatric – Inpatient Clinical Practice Guideline

Introduction The following table presents guidelines and monitoring parameters for the intravenous administration of UWHC formulary drugs. Although some recommendations may exist to prevent serious toxicities, often the rates of administration or amount of diluent can be different provided appropriate precautions are taken. When using this table, tailor the guidelines to fit the patient’s total therapeutic needs. Use of this guideline is encouraged but is not a substitute for researching drugs with which you are not familiar.

If a specific patient’s fluid or dosing requirements do not fit within the guidelines presented, the following questions should be asked: • What information exists regarding a faster rate (e.g., can cause hypotension, cardiac arrhythmias, etc.) or more concentrated dilutions (e.g., may cause thrombophlebitis, toxic peak blood concentrations, etc.)? • What is the incidence of this adverse reaction (i.e., is the reaction rarely induced versus always induced)? • What is the benefit/ risk ratio in this particular patient? • What parameters could be monitored to decrease the risk of serious adverse effects? • What other special precautions could be taken?

In accordance with Administrative Policy 8.31, a level has been assigned to each medication to designate the nursing units on which the drug may be administered. If a patient is in the process of being transferred to an Intermediate Care Unit (IMC) or ICU and requires a level 3 or 4 medication, the medication can be ordered and initiated in the transition process. The levels are defined as follows:

• Level 1 medications: May be administered on all General Care Nursing Units.. • Level 2 medications: May be administered on General Nursing Units with telemetry including the Pediatric Universal Care Unit, Pediatric Sedation, Hybrid Catheterization Lab, Day Treatment, and Campground. • Level 3 medications: May be administered on Intermediate Care Units (IMC) and in Interventional Radiology. Each IMC is qualified to administer different Level III drugs based on specialty populations served.

• Level 4 medications: May be administered on Intensive Care Units, the Emergency Department, Operating Room, Recovery Room, Medflight, Children’s Hospital Emergency Transport Ambulance (CHETA), the Diagnostic Pavilion (excluding Day Treatment). Interventional Radiology may monitor on- going infusions of Level 4 drugs based on appropriate competency assessment.

Administration of medications outside of indicated level on this guideline may occur if the unit nurse manager and pharmacist agree to deviate from this guideline in the interest of patient care.

Some medications (e.g. benzodiazepenes) may be used for more than one indication (e.g. benzodiazepenes for anxiolysis or sedation). Areas of administration and monitoring requirements may differ based on what the medication is being used for and the table contained within this guideline should be referenced to guide use.

Approved investigational protocols will detail specific administration guidelines and monitoring parameters.

Chemotherapeutic agents may only be administered by nurses certified in chemotherapy and only on P4 and Day Treatment. Exceptions may be made where chemotherapy certified nurses go to another unit to administer chemotherapy, but only by prior agreement and when appropriate monitoring can be accomplished following chemotherapy.

High-alert medications pose a heightened risk of causing significant patient harm or injury when administered in error and are noted in this guideline for convenience. Specific practices for high alert medications are included in Administrative Policy 8.33 High Alert Medication Administration.

Recommendations All recommendations within this guideline have been given a UWHealth Strong Recommendation, Moderat Quality of Evidence recommendation based on information obtained from initial clinical trials of the medications, product package inserts, and drug databases.2 When available, specific recommendations for neonates is called out; this information is derived from Neofax.3

For adolescent patients weighing 40 kg or more, the Adult Intravenous Administration Guidelines may be reasonable to use for guidance of the administration of medications. (UWHealth Weak/conditional Recommendation,Very Low Quality of Evidence).

Doses ≥1000 mg, Discard any remaining drug administer from vial

Neonates: withdraw dose from vials and place into separate container Acetazolamide 500 mg/5 mL Dilute in D5W or NS Max rate: 500 mg/min Central or peripheral Vein irritation, Max conc: 100 mg/mL thrombophlebitis Level 1 Special IV push given 500mg over IM route not recommended dilutions: 3 min has been reported See Non-Chemotherapy • 5 mg/mL Extravasation Guideline • 20 mg/mL Acetylcysteine 20% Loading dose: 150 mg/kg Loading dose over 60 min Should be administered Blood pressure, in 250 mL D5W; 2nd dose: Over 4 hrs; within 24 hours of bronchospasm, wheezing Level 1 2nd dose: 50 mg/kg in 500 3rd dose: Over 16 hrs acetaminophen overdose. mL D5W; See Acetylcysteine 3rd dose: 100 mg/kg in IV Push not recommended Central or peripheral Guideline 1000 mL D5W; For children <40kg reduce diluent so that conc range is 5-37.5 mg/mL Acyclovir 50 mg/mL Dilute in D5W or NS; max Over at least 1 hr Central or peripheral Encephalopathic changes conc: (lethargy, tremors, confusion, Level 1 Special 7 mg/mL peripheral, 10 IV Push not recommended Concentrated solutions agitation, seizures), injection dilutions: mg/mL central (greater than 10 mg/mL or site reactions, maintain • 7 mg/mL greater) through central adequate fluid intake, •10 mg/mL line only extravasation

Irritant, avoid extravasation See Non-Chemotherapy Extravasation Guideline

≥50 kg: 6-12 mg over 1-2 seconds Albumin 5% or 25% No further dilution 5%: max rate: 2-4 mL/min Vital signs, fluid balance needed. May dilute in Level 1 NS or D5W 25% max rate: 1 mL/min

Central or peripheral IV Push not recommended Aldesleukin 18 million Dilute in 50 mL D5W; Over 15 min; Allow solution to reach room Continuous ECG, vital signs, HIGH ALERT international conc: 30 -70 mcg/mL or cont infusion for temperature respiratory status, pulse MEDICATION units/mL AML: 1.6 or 9 million oximetry units/m2/day daily Do NOT filter, flush with D5W CHEMOTHERAPY before and after infusion See Chemotherpeutic IV Push not recommended Extravasation Guidelines Hazardous Drug – Central or peripheral HIGH RISK See UW Health Clinical Doses >12 to 15 million Policy 6.1.11 units/m2 are associated with a moderate emetic potential; antiemetics are recommended to prevent nausea and vomiting Alemtuzumab 30 mg/mL Dilute in 100 mL NS or Infuse over 2 hrs Central or peripheral Vital signs, infusion HIGH ALERT single-use vial D5W reactions, headache, MEDICATION IV Push not recommended Consider premedication with parasthesias, rash, pruritis acetaminophen and CHEMOTHERAPY diphenhydramine See Chemotherpeutic Extravasation Guidelines Hazardous Drug – MODERATE RISK See UW Health Clinical Policy 6.1.11 Alfentanil 500 mcg/mL Dilute in D5W or NS, Inject slowly over 3-5 min Central or peripheral Respiratory status, vital HIGH ALERT Max conc 80 mcg/mL signs, cardiac status MEDICATION Cont infusion 0.5-1.5 mcg/kg/min Level 4 Allopurinol 20 mg/mL Dilute in D5W or NS; max Over at least 30 min Central or peripheral Nausea, vomiting, rash conc: 6 mg/mL Level 1 Special dilution: IV Push not recommended • 5 mg/mL

Level 1 Alprostadil 500 mcg/mL Pediatric max conc: 20 Neonates and infants: 0.05 After a therapeutic response Continuous respiratory status HIGH ALERT mcg/mL, use large vein to 0.1 mcg/kg/min. is achieved, the infusion rate and cardiac status, vein MEDICATION– Special dilution: should be reduced to the irritation/ thrombophlebitis. Continuous Infusion • 5 mcg/mL Neonate max conc: 10 IV Push not recommended lowest possible dosage that Neonates: Apnea is seen • 10 mcg/mL mcg/mL, use large vein maintains the response; most often in neonates Level 4 • 20 mcg/mL of umbilical artery range: 0.01-0.4 mcg/kg/min weighing fewer than 2 kg at catheter placed at the birth, and usually appears ductus arteriosus Must change infusion during the first hour of drug syringe every 24 hours infusion

Flushing of arm or face may indicate misplacement of catheter

See Non-Chemotherapy Extravasation Guideline

Also used perioperatively for liver transplant with different dosing regimen Alteplase 500 mcg/mL No further dilution; or Loading dose over 1 min; Central or peripheral Signs/symptoms of bleeding, HIGH ALERT may dilute to 0.5 mg/mL give remaining drug as blood pressure every 15 MEDICATION Special dilution: in NS or 12.5 mg/250 mL infusion. Catheter clearance – See minutes for 2 hours (excepting low-dose • 0.1 mg/mL for DVT pts with arterial Central Venous Access injections for line • 0.2 mg/mL or venous clots Systemic thrombosis: 0.1- Device Occlusion Guideline clearance) 0.6 mg/kg/hr; titrated to effect, optimum dose Level 4 unknown

Alteplase Flushes— Level 1 Amikacin Sulfate 250 mg/mL Dilute in D5W or NS; max Over 30 - 60 min Central or peripheral Respiratory status, vitals, conc: 10 mg/mL cardiac status Level 1 Special dilution: Neonates • 5 mg/mL Neonates Infuse over 60-120 min. Dilute to a final concentration of 2.5-5 mg/mL IV Push not recommended

Neonates IV bolus over 30-60 mins

IV Push not recommended

Infusions lasting longer than 2 hours should be administered in glass or polyolefin bottles containing D5W

Incompatible with heparin; flush with saline prior to and following infusion Amobarbital 100 mg/mL No information Max infusion rate 50 Administer IV only when IM is Respiratory rate and depth, mg/min not feasible blood pressure, CNS Level 4 changes, extravasation Amphotericin B 50 mg/10 mL IV infusion conc not to Infuse over 2-6 hrs, Central line only Vein irritation/ Conventional – exceed 0.1 mg/mL via increase rate as patient thrombophlebitis, heart rate, Fungizone® Special dilution: peripheral line; 0.5 tolerates Initiate therapy with slow blood pressure, fever, chills, • 0.1 mg/mL mg/mL for central venous infusion and increase rate as rigors. Level 1 • 0.5 mg/mL catheter Neonates tolerated. Infuse over 2 to 6 hrs See Non-Chemotherapy Consider premedication Extravasation Guideline Neonates IV Push not recommended Max conc 0.1 mg/mL Bolus infusion of normal saline immediately preceding and following infusion may reduce drug- induced nephrotoxicity. Incompatible with NS; must flush line with D5W before and after boluses

May use an in-line filter to administer

Incompatible with NS

Do not use an in-line filter to administer Amphotericin B 4 mg/mL Dilute in D5W, conc 1-2 Infuse over 2 hr. May Central or peripheral Liposomal – mg/mL reduce to 1 hr in patient AmBisome® Special dilution: who tolerate treatment Do not use and in-line filter • 2 mg/mL Infants and small less than 1 micron to Level 1 children: dilute to 0.2-0.5 Neonates administer mg/mL Infuse over 2 hours Flush line with D5W prior to administration Incompatible with NS Ampicillin Sodium 1 g/10mL max conc is 30 mg/mL IV Push not recommended Central or peripheral Anaphylaxis, rash, vein (intermittent infusion) or irritation, thrombophlebitis. Level 1 Special dilution: 100 mg/mL (piggy back) Rate not to exceed 100 • 30 mg/mL mg/min See Non-Chemotherapy Extravasation Guideline Infuse over 30 min Ampicillin/sulbactam 375 mg/mL Dilute to max of 45 IV Push not recommended Central or peripheral Anaphylaxis, venous (Unasyn®) mg/mL Unasyn (30mg irritation, phlebitis, seizure Special dilution: ampicillin, 15 mg Infuse over 30 min Level 1 • 30 mg/mL sulbactam) in D5W or NS See Non-Chemotherapy Extravasation Guideline Antihemophilic 1.2, 2.4 or 4.8 Bolus over 2-5 min Central or peripheral Hypersensitivity, signs and Factor, VII mg vials symptoms of bleeding. No information on infusion Level 1 rate

See Procoagulant Guideline

Level 1 No information on IV push rate See Procoagulant Guideline Antithrombin III, 100 units/mL 100 units/mL solution Infuse loading dose over Prior to administration, allow Vital signs, cardiac status, Human solution 10-20 min reconstituted solution to CNS changes, anaphylaxis warm to room temperature Level 1 No information on IV push rate Central or peripheral Antithymocyte 50 mg/mL Dilute to a minimum Infuse over at least 4 hrs Central or peripheral Infusion reactions, cardiac Globulin (ATG) – concentration of 4 mg/mL status, respiratory status Equine in NS, D51/4NS, or IV Push not recommended Administer via 0.2 or 0.22 HIGH ALERT D51/2NS mircon in-line filter MEDICATION Incompatible with D5W Level 1 Pretreat with antipyretic, antihistamine, corticosteroid Antithymocyte 5 mg/mL Dilute each dose in 250 Children: over 6-12 hrs Central line only Anaphylaxis, abdominal pain, Globulin (ATG) – (25 mg/mL) mL NS fever, headache, dyspnea, Rabbit Subsequent doses over at Administer via 0.2 or 0.22 dizziness, vital signs HIGH ALERT least 4 hrs mircon in-line filter MEDICATION IV Push not recommended Level 1 Consider premedication with acetaminophen, corticosteroids or antihistamine

Limited data: BSA ≤1.16m2, then 56 mg/m2/hr continuous; BSA >1.16 m2, cont infusion: 70 mg/m2/hr; Alternative cont infusion: 30,000 units/kg/hr

IV Push not recommended Arginine 100 mg/mL Dilute in D5W; conc: 100 Over 30 min; Central (recommended) or Vein irritation, flushing, mg/mL Loading dose for urea cycle peripheral nausea/ vomiting, Level 2 disorders: over 90 min; max anaphylaxis. May be infused without infusion rate: 1g/kg/hr, (max Administer via 0.2 or 0.22 dilution, however dilution dose: 60 g/hr) mircon in-line filter See Non-Chemotherapy recommended due to Extravasation Guideline vein irritation IV Push not recommended Change bottle and tubing every 24 hr Arsenic Trioxide 10 mg/mL Dilute in 100-250 mL of Infuse over 1-2 hours, may Central or peripheral Acute tachycardia, chest HIGH ALERT single-use NS or D5W extend to up to 4 hours for pain, hypotension, fever, MEDICATION ampules acute vasomotor reaction ECG, serum electrolytes

CHEMOTHERAPY See Chemotherpeutic Extravasation Guidelines Hazardous Drug – MODERATE RISK See UW Health Clinical Policy 6.1.11 Ascorbic Acid 500 mg/mL Dilute in D5W or NS Give slowly over a IM utilization better Dizziness, faintness with should be diluted in at minimum of 10 min rapid injection Level 1 least an equal volume of Central or peripheral fluid IV Push not recommended

Central or peripheral Atropine Sulfate 400 mcg/mL, IV Push: Over 1 min Central or peripheral Vital signs, ECG based on 100 mcg/mL specific situation Level 1 (as preop) IV infusion not Level 2 (other recommended indications) Azathioprine 100 mg/10 mL Max conc 10 mg/mL IV Push: Over 5 min, conc Central or peripheral Blood pressure, GI D5W or NS not to exceed 10 mg/mL hypersensitivity reaction Level 1 (severe nausea and Infusion over 15-60 min vomiting), WBC, CBC Hazardous Drug – MODERATE RISK See UW Health Clinical Policy 6.1.11 Azacitidine 10 mg/mL Dilute in 50-100 mL of Infuse over 10 to 40 min; Central or peripheral Rigors, blood pressure, chest HIGH ALERT NS or LR must complete infusion with pain, injection site reactions MEDICATION 60 min of reconstitution Incompatible with D5W See Chemotherpeutic CHEMOTHERAPY Extravasation Guidelines

Hazardous Drug – HIGH RISK See UW Health Clinical Policy 6.1.11 Azithromycin 100 mg/mL Dilute in D5W or NS; max Over 1 hr (2 mg/mL)-3 hrs Central or peripheral Vital signs, hypersensitivity, conc: 2 mg/mL (1 mg/mL) avoid extravasation. Level 1 Special dilution: • 2 mg/mL Pediatrics/Neonates See Non-Chemotherapy Infuse over 60 min Extravasation Guideline

IV Push not recommended Aztreonam 1 g/3 mL Max conc: 20 mg/mL IV Push: over 3-5 min, conc Central or peripheral Anaphylaxis, D5W or NS not to exceed 66 mg/mL thrombophlebitis. Level 1 Special dilution: • 20 mg/mL Infuse over 20-60 min, conc See Non-Chemotherapy not to exceed 20 mg/mL Extravasation Guideline

CHEMOTHERAPY See Chemotherpeutic Extravasation Guidelines Hazardous Drug – HIGH RISK See UW Health Clinical Policy 6.1.11 Benztropine 1 mg/mL No information No information IM or PO route preferred Heart rate and blood pressure Level 1 Bevacizumab 25 mg/mL Dilute in 100 mL NS Infuse first dose over 90 Central or peripheral Infusion reactions HIGH ALERT min; if tolerated may infuse (bronchospasm, chills, MEDICATION second dose over 60 min; if dyspnea, fever, hypotension, tolerated, may infuse third itching, rash) CHEMOTHERAPY dose (and subsequent doses) over 30 min See Chemotherpeutic Hazardous Drug – Extravasation Guidelines MODERATE RISK IV push not recommended See UW Health Clinical Policy 6.1.11

Copyright © 2021 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission Contact: [email protected] Last Revised: 06/2021 Effective 7/8/2021. Contact [email protected] for previous versions Drug Concentration Dilution Infusion Administration Considerations For IV Monitoring Supplied Rate Administration and Comments Bivalirudin 50 mg/mL Dilute in 50 mL NS or IV bolus and infusion Central or peripheral aPTT, blood pressure, HIGH ALERT D5W to conc 5 mg/mL bleeding MEDICATION For low-rate infusion, Level 1 may dilute 5 mg/mL with 500 mL NS or D5W to 0.5 mg/mL Bleomycin Sulfate 15 units Dilute in 50 mL NS Over 10-15 min, no greater Central or peripheral respiratory rate/ depth, HIGH ALERT than 1 unit/min, or 15-20 anaphylaxis, fever, chills, MEDICATION units/m2/day cont infusion Premedicate with injection site reactions, , for 3-5 days acetaminophen and vitals, avoid extravasation CHEMOTHERAPY diphenhydramine. IV Push Rate: Over 10 min, See Chemotherpeutic Hazardous Drug – no greater than 1 unit/min; Extravasation Guidelines HIGH RISK max conc: 3 units/mL See UW Health Clinical Policy 6.1.11 Bortezomib 1 mg/mL Not recommended 3-5 second bolus Central or peripheral Peripheral neuropathy, rash, HIGH ALERT dyspnea, nausea/vomiting MEDICATION Premedicate with acetaminophen, See Chemotherpeutic CHEMOTHERAPY diphenhydramine, and Extravasation Guidelines ondansetron Hazardous Drug – HIGH RISK See UW Health Clinical Policy 6.1.11 Bumetanide 0.25 mg/mL Dilute in NS or D5W Over 5 min; Central or peripheral Blood pressure, anaphylaxis HIGH ALERT For continuous infusion MEDICATION– Special dilution: dilute to 0.024 mg/mL continuous infusion • 0.05 mg/mL • 0.1 mg/mL IV Push Rate: Over 5 min Level 1 undiluted Busulfan 6 mg/mL Dilute in NS (preferred) Over 2 hrs Central line only Nausea/vomiting HIGH ALERT or D5W; conc: 0.5 mg/mL MEDICATION IV Push not recommended Flush with 5 mL NS or D5W See Chemotherpeutic before and after infusion Extravasation Guidelines CHEMOTHERAPY Antiemetics may be Hazardous Drug – recommended to prevent HIGH RISK nausea and vomiting See UW Health Clinical Policy 6.1.11

Solution will be colorless or slightly blue. Caffeine Citrate 20 mg/mL May administer undiluted Infuse loading dose over at Central or peripheral\ Respiratory rate, heart rate, or dilute with D5W to 10 least 30 min blood pressure Level 2 Special dilution: mg/mL • 5 mg/mL Infuse maintenance dose Neonates over at least 10 min Heart rate, number of apnea spells, agitation Neonates Infuse loading dose over 30 min; maintenance dose as slow IV push Caffeine Sodium (not 250 mg/mL Dilute in 1000 mL D5W Over 60-90 min; follow with Central or peripheral Respiratory rate, heart rate, Citrate) Benzoate or NS 1000 mL NS infused over 1 blood pressure hour Not for use in neonates Level 2 Not for use in neonates IV Push not recommended Calcitriol 1 mcg/mL No information IV Push rate: 2-3 mL/min Hemodialysis catheter Signs and symptoms of Undiluted vitamin D intoxication (bone Level 1 pain, dry mouth, headache, No information on infusion metallic taste, muscle pain) rate Calcium Chloride 100 mg/mL Max conc: 20 mg/mL Infuse 45-90 mg/kg over 1 Central line preferred or Cardiac status, extreme (1.36mEq) D5W or NS hr ( 0.6-1.2 mEq/kg over 1 deep vein (do not use scalp, irritant, avoid extravasation. Level 2 hr); max rate: 50-100 small hand or foot veins) Special dilution: mg/min Monitor ECG if infused at > • 0.02 g/mL (20 2.5mEq/min, stop infusion if mg/mL) Pediatrics/Neonates complaints of pain/discomfort • 0.05 g/mL (50 Slow IV push over 3-5 mg/mL) mins, max rate of 50-100 See Non-Chemotherapy mg/min Extravasation Guideline

IV Push not recommended

Infuse over 120-240 mg/kg over 1 hr (0.6- 1.2 mEq/kg over 1 hr).; max rate: 50- 100 mg/min

IV Push not recommended Carboplatin 10 mg/mL Max conc 2 mg/mL NS or give over 15 min to 1 hr or Central or peripheral Anaphylaxis HIGH ALERT D5W cont infusion MEDICATION Antiemetics are See Chemotherpeutic IV Push not recommended recommended to prevent Extravasation Guidelines CHEMOTHERAPY nausea and vomiting

Hazardous Drug – HIGH RISK See UW Health Clinical Policy 6.1.11 Carfilzomib 60 mg vial, Dilute in 50 mL D5W Infuse over 2-10 min Recommend prehydration Infusion reactions, dyspnea, HIGH ALERT reconstituted to with 250-500 mL NS or other hypotension, fever, tumor MEDICATION 2 mg/mL IV push not recommended IV fluid prior to dose lysis syndrome, fluid overload, worsening of CHF CHEMOTHERAPY Recommend premedication with dexamethasone See Chemotherpeutic Hazardous Drug Extravasation Guidelines Carmustine 10 mg/3 mL Dilute in D5W (0.2 - 1 Over at least120 min Central or peripheral; Vein irritation, flushing , vital HIGH ALERT mg/mL) central line if undiluted or signs MEDICATION IV Push not recommended doses ≥300 mg/m2 Patients should be supine CHEMOTHERAPY Antiemetics are during infusion and may recommended to prevent require the Trendelenburg Hazardous Drug – nausea and vomiting position, fluid support, and HIGH RISK vasopressor support See UW Health Clinical Policy 6.1.11 See Chemotherpeutic Extravasation Guidelines

Pediatrics/Neonates Infuse over 10-60 min at conc of 20 mg/mL min Cefepime 1 g/50 mL Dilute in NS or D5W IV Push: over 3-5 min, max Central or peripheral Hypersensitivity conc: 100 mg/mL (anaphylaxis, rash), phlebitis Level 1 Special dilution: • 40 mg/mL Infusion Rate: Over 30 min; max conc: 40 mg/mL

Pediatrics/neonates IV Push: over 3-5 min, max conc: 40 mg/mL Cefotaxime 500 mg, 1 g, 2 Dilute to conc 20-60 At 20-60 mg/Ml infuse over Central or peripheral Itching, injection site irritation, g vials mg/mL with NS or D5W, 15-30 min hypersensitivity (anaphylaxis, Level 1 max conc 200 mg/mL rash), extravasation Special dilution: At 200 mg/mL may infuse • 50 mg/mL Neonates over 3-5 min IV push conc 50-100 mg/mL Neonates Infusion conc 10-40 At 50-100 mg/mL IV push mg/mL At 10-40 mg/mL infuse over 10-30 min Cefoxitin 1 g, 2 g powder Dilute in NS or D5W IV Push: over 3-5 min, max Central or peripheral Hypersensitivity conc: 100 mg/mL (anaphylaxis, rash), phlebitis Level 1 Special dilution: • 40 mg/mL Infuse over 10-60 min, max conc: 40 mg/mL

Pediatrics/neonates IV Push: over 3-5 min, max conc: 200 mg/mL Ceftaroline Fosamil Reconstituted Dilute in 50-250 mL Infuse over 60 min Central or peripheral Hypersensitivity with 20 mL D5W, NS, or LRS (anaphylaxis, rash) Level 1 sterile water to 20 or 30 mg/mL

Pediatrics/Neonates IVP over 5 min, max conc: 40-100 mg/mL Cefuroxime 90 mg/mL Dilute in NS or D5W IV Push: over 3-5 min, max Central or peripheral Hypersensitivity conc: 100 mg/mL (anaphylaxis, rash), phlebitis Level 1 Special dilution: • 30 mg/mL Infusion Rate: Over 15-30 min, max conc: ≤ 30 mg/mL Cetuximab 2 mg/mL No further dilution Infuse first dose over 2 hrs Central or peripheral Vital signs, infusion reaction HIGH ALERT and subsequent doses over (chills, fever, dyspnea, MEDICATION 1 hr. Administer via 0.2 or 0.22 hypotension, bronchospasm) mircon in-line filter CHEMOTHERAPY Max rate 10 mg/min See Chemotherpeutic Extravasation Guidelines Hazardous Drug – MODERATE RISK See UW Health Clinical Policy 6.1.11 Chloramphenicol 1 g powder Dilute in D5W IV Push: over 5 min, max Not recommended for IM Serum levels, conc: 100 mg/mL use. hypersensitivity (anaphylaxis, Level 1 rash), Gray Syndrome (circ. Infusion Rate: Over 15-30 Central or peripheral collapse, acidosis, Hazardous Drug – min, max conc: ≤ 20 mg/mL myocardial depression and MODERATE RISK abdominal distension), blood See UW Health Clinical Pediatrics/Neonates: counts. Policy 6.1.11 Infusion Rate: Over 15-60 min, max conc: ≤25 mg/mL

Copyright © 2021 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission Contact: [email protected] Last Revised: 06/2021 Effective 7/8/2021. Contact [email protected] for previous versions Drug Concentration Dilution Infusion Administration Considerations For IV Monitoring Supplied Rate Administration and Comments Chlorothiazide 500 mg vial NS, D5W IV Push: 500 mg vial in 18 Central or peripheral Avoid extravasation, blood mL sterile water (27.8 pressure. Level 1 Special dilution: mg/mL) over 3-5 min • 5 mg/mL See Non-Chemotherapy Infusion Rate: Over 30 min Extravasation Guideline Chlorpromazine 25 mg/mL Max conc 1 mg/mL Max infusion rate 0.5 Central or peripheral Hypotension, vital signs mg/min Level 1 Patient must remain lying down during and for 30 min after injection due to hypotension Cidofovir 75 mg/mL vial Dilute in NS or D5W, max Over 60 min Central or peripheral Flushing, rash, conc: 8 mg/mL signs/symptoms of Level 1 IV Push not recommended Hydration with NS pre and uvetitis/iritis post dose also probenecid Hazardous Drug – pre and post dose to avoid HIGH RISK nephrotoxicity See UW Health Clinical Policy 6.1.11 Ciprofloxacin 10 mg/mL vial Dilute in D5W or NS to Over 60 min into a large Central or peripheral Skin reaction at infusion site, final conc: 1-2 mg/mL vein phlebitis. Level 1 Special dilution: • 2 mg/mL IV Push not recommended See Non-Chemotherapy Extravasation Guideline Cisatracurium 1 mg/mL, 2 Dilute in D5W or NS; IV Push: over 5-15 seconds Patient must be intubated. Blood pressure, cardiac HIGH ALERT mg/mL, conc: 0.1-0.4 mg/mL Ensure patient is adequately status, respiratory rate/depth, MEDICATION or 10 mg/mL Infusion Rate: Children ≥ sedated prior to use neuromuscular blockade 2yrs: 1-4 mcg/kg/min administration of monitor Level 4 neuromuscular blockade

Central or peripheral Cisplatin 1 mg/mL Dilute in NS; max conc: 1 Over 2-24 hrs; max rate: 1 Central or peripheral Nausea/ vomiting, renal HIGH ALERT mg/mL mg/min function, infusion reactions MEDICATION Ensure proper needle or (facial edema, hypotension, Also see chemo protocol catheter placement prior to tachycardia, wheezing) CHEMOTHERAPY and during infusion IV Push not recommended See Chemotherpeutic Hazardous Drug – Antiemetics are Extravasation Guidelines HIGH RISK recommended to prevent See UW Health Clinical nausea and vomiting Policy 6.1.11 Pre/post-treatment hydration with 1 to 2 L of fluid

Dedicated IV line required Hydration status Colistimethate 75 mg/mL Dilute in NS or D5W 2.5 to 5 mg/kg/day; 50% of Central or peripheral Tingling of extremities daily dose over 3-10 min. Level 1 Special dilution: Then infuse remaining 50% • 10 mg/mL over 22-23 hrs

2.5 to 5 mg/kg/day in 2 to 4 divided doses over 30 min each Cosyntropin 250 mcg/mL Dilute in D5W or NS IV Push: over 2 min Central or peripheral Continuous observation for at least first 30 minutes, blood Level 1 Infusion Rate: Children >2 pressure, hypersensitivity yrs: over 4-8 hrs

Level 4

Hazardous Drug – MODERATE RISK See UW Health Clinical Policy 6.1.11 Cytarabine 100 mg/mL Dilute in D5W or NS, max High dose (> 1g/m2) infuse Central or peripheral Hypersensitivity, signs and HIGH ALERT conc: 100 mg/mL over 1-3 hrs or longer or symptoms of bleeding MEDICATION cont infusion Avoid extravasation See Chemotherpeutic CHEMOTHERAPY IV Push Rate: Over 15 min Antiemetics are Extravasation Guidelines recommended to prevent Hazardous Drug – nausea and vomiting HIGH RISK See UW Health Clinical Policy 6.1.11 Cytomegalovirus 50 mg/mL No further dilution (50 15 mg/kg/hr for 15 min, Central or peripheral Flushing, fever, chills, immune globulin mg/mL) then 30 mg/kg/hr for 15 nausea, vomiting, shortness minutes, then 60 mg/kg/hr; Administer via 15 mircon of breath, Level 1 Central or peripheral max rate: 75 mL/hr filter; a 0.2 micron filter may be used Vital signs prior to infusion IV Push not recommended and at each rate change Dacarbazine 10 mg/mL Dilute in D5W or NS; max IV push: Dilute vial with 2 Central or peripheral Vein irritation, HIGH ALERT conc: 10 mg/mL mL D5W or NS, then further thrombophlebitis, MEDICATION with 5-10 mL, give over 2-3 Avoid extravasation anaphylaxis min CHEMOTHERAPY Antiemetics are See Chemotherpeutic Infusion Rate: Over 15-120 recommended to prevent Extravasation Guidelines Hazardous Drug – min nausea and vomiting HIGH RISK See UW Health Clinical Policy 6.1.11

Level 1 Dactinomycin 500 mcg/mL Dilute in D5W or NS; max IV push: into running IV Central or peripheral Vesicant, avoid extravasation HIGH ALERT conc: 500 mcg/mL over 1-5 min MEDICATION IV Infusion Rate: Avoid extravasation See Chemotherpeutic Over 15 min Extravasation Guidelines CHEMOTHERAPY

Hazardous Drug – HIGH RISK See UW Health Clinical Policy 6.1.11 Dantrolene 1 mg/3 mL No further dilution IV push: rapid Central or peripheral Respiratory rate, ECG, vital signs, and urine output Level 2 Prevention and treatment of continuously malignant hyperthermia: over 60 min Daptomycin Reconstitute in Ages 2-6 years dilute in Ages 2-6 years infuse over Central or peripheral Muscle pain or weakness 10 mL NS to 50 25 mL NS 60 min Level 1 mg/mL Ages 7-17 years dilute in Ages 7-17 years infuse Special dilution: 50 mL NS over 30 min • 10 mg/mL Neonates no dilution Neonates information Infuse over 60 min Daratumumab 100 mg/5 mL Dilute in 1000 mL NS for First and second infusion: Central or peripheral Complete blood counts as vial first infusion 50 mL/hour for first hour, clinically necessary; type and CHEMOTHERAPY then increase by 50 Premedicate with an IV screen (blood type) prior to 400 mg/20 mL Dilute in 500 mL NS for mL/hour every hour to a corticosteroid, initiating therapy; Hazardous Drug – vial subsequent infusions maximum rate of 200 acetaminophen, and an IV or signs/symptoms of infusion HIGH RISK mL/hour oral antihistamine reactions See UW Health Clinical approximately 60 minutes Policy 6.1.11 Subsequent infusions: 100 prior to administration mL hour for first hour, then increase by 50 mL/hour Administer with an infusion every hour to a maximum set fitted with a flow regulator rate of 200 mL/hour only if and with an inline, sterile, no grade 1 infusion non-pyrogenic, low protein- reactions noted in the first 2 binding polyethersulfone filter infusions (0.22 or 0.2 micrometer) Darbepoetin 25, 40, 60, 100, No additional dilution IV push: over at least 1 min Central or peripheral Blood pressure, line clotting 150, 200, 300, Level 1 or 500 mcg Infusion Rate: Over 1-3 min

Chronic: 15mg/kg/hr over 8- 12 hours, 5-7 days/week Defibrotide 200 mg/2.5 mL Dilute in NS or D5W to a Infuse over 2 hours Central or peripheral Hypersensitivity, bleeding final concentration of 4- Level 1 20 mg/mL Flush IV line with NS or D5W before and after administration

0.2 micron in-line filter required Desmopressin 4 mcg/mL Dilute in NS; max conc: Over 15-30 min Central or peripheral Blood pressure and pulse 0.5 mcg/mL during infusion Level 1 Special dilution: IV Push not recommended • 0.5 mcg/mL Dexamethasone 4 mg/mL or Dilute in D5W or NS IV Push: 4 mg/mL solution Central or peripheral Burning sensation, 10 mg/mL over 1 to 4 min if dose is hypersensitivity (anaphylaxis) fewer than 10 mg Level 1 Special dilution: • 0.02 mg/mL Infusion preferred to avoid • 0.075 mg/mL perineal clawing • 0.5 mg/mL • 1 mg/mL Infusion Rate: Over 15-60 min, or cont infusion

Hazardous Drug – HIGH RISK See UW Health Clinical Policy 6.1.11 Diazepam 5 mg/mL Dilute in D5W Max rate for infants & Central or peripheral Blood pressure, respiratory children: 1-2 mg/min rate/ depth, avoid IV Push – Level 1 extravasation. Infusion – Level 3 Continuous infusion not recommended If used for conscious sedation: see Policy 8.56: Pediatric Sedation Policy for monitoring requirements.

See Non-Chemotherapy Extravasation Guideline Digoxin 250 mcg/mL, Dilute in D5W or NS, IV push: over 5-10 min IM erratic absorption Heart rate, blood pressure, 100 mcg/mL minimum 4-fold dilution baseline ECG, avoid Level 1 Infusion Rate: Over 5-15 Central or peripheral extravasation Special dilution: min • 25 mcg/mL Vesicant See Non-Chemotherapy Extravasation Guideline Digoxin Immune FAB 38 mg/4 mL vial No further dilution Over at least30 min Administer via 0.2 or 0.22 Vital signs, ECG, signs and necessary, conc: 9.5 mircon in-line filter symptoms of acute allergic Level 4 mg/mL. Can be further IV Push Rate: If clinical Central or peripheral reaction (angioedema, diluted using NS condition warrants, bolus bronchospasm, tachycardia) over 2-3 min (caution – infusion related reaction may occur) Dihydroergotamine 1 mg/mL Not recommended Infuse over 2-3 min Central or peripheral Vital signs, localized edema, Mesylate dizziness, somnolence Antiemetic administration Level 2 prior to dihydroergotamine administration is recommended

Dinutuximab 17.5 mg/5 mL Dilute in 100 mL NS Do not administer as IV Central or peripheral Infusion reaction during and HIGH ALERT push or bolus at least four hours following MEDICATION Do not shake completion of infusion Administer as IV infusion CHEMOTHERAPY only Premedicate with antiemetic, Blood pressure, pain, analgesic, antihistamine, peripheral neuropathy, Hazardous Drug – Administer NS 10 mL/kg IV antipyretic capillary leak syndrome, HIGH RISK over 1 hour just prior to hemolytic uremic syndrome, See UW Health Clinical each dinutuximab infusion and ocular toxicity Policy 6.1.11 Initiate infusion at a rate of 0.875 mg/m2/hour for 30 minutes. Increase infusion rate gradually as tolerated to a maximum rate of 1.75 mg/m2/hour to infuse over 10 to 20 hours each day Diphenhydramine 50 mg/mL Dilute in D5W or NS; max IV Push Rate and Infusion Central or peripheral Vital signs conc: 25 mg/mL Rate: Over 15 min Level 1 Special dilution: • 5 mg/mL Dobutamine 12.5 mg/mL Dilute in D5W or NS; Initial: Central line preferred, Continuous blood pressure, HIGH ALERT max conc: 5 mg/mL Neonates: 2-15 however, heart rate, ECG, and urine MEDICATION– mcg/kg/min, titrate to peripheral/intraosseous flow. continuous infusion desired response access may be used when benefit outweighs risks See Non-Chemotherapy Level 3 Children and adults: 2.5-15 Extravasation Guideline mcg/kg/min titrate to response, max rate: 40 mcg/kg/min

IV Push not recommended

Doripenem 250 mg/10 mL Dilute with NS or D5W Infuse over 1 hour Central or peripheral Anaphylaxis 500 mg/10 mL • 250 mg: further dilute Level 1 with 50 or 100 mL • 500 mg: further dilute with 100 mL Doxacurium 1 mg/mL D5W or NS IV push: 5-10 seconds Blood pressure, cardiac status, respiratory rate/ depth Level 4 Infusion Rate: Children 2 - 12yrs: 0.1-0.2 mcg/kg/min or 6-12 mcg/kg/hr; Children >12yrs: same Doxorubicin 2 mg/mL Dilute in D5W or NS IV push: over 3-10 min into Central or peripheral; Cardiac status, vesicant, HIGH ALERT running IV Central line required for avoid extravasation MEDICATION continuous infusion Infusion Rate: Over 1-4 hrs See Chemotherpeutic CHEMOTHERAPY at a conc not to exceed 2 Antiemetics are Extravasation Guidelines mg/mL, or by cont infusion recommended to prevent Hazardous Drug – nausea and vomiting HIGH RISK See UW Health Clinical Policy 6.1.11

IV Push not recommended Edrophonium 10 mg/mL Dilute in D5W or NS IV Push Rate: Children: Central or peripheral Blood pressure, cardiac Chloride 0.04 mg/kg over 1 min status followed by 0.16mg/kg Level 2 given within 45 seconds (if no response, max total dose 10 mg)

Infusion: No information

Infants Initial: 0.1 mg, followed by 0.4 mg (if no response, total dose 0.5mg)

Cycle 1, Dose 3, 4 and all subsequent doses: If no infusion reaction occurred during prior infusion, initiate at 120 mL/hr based on tolerability

After 4 cycles may increase to a maximum rate of 300 mL/hr

Do not administer as IV push or IV bolus Enalaprilat 1.25 mg/mL Dilute in D5W or NS; can IV push: Over 5 min Central or peripheral Vital signs frequently, allergic give undiluted reaction Level 1 Special dilution: Infusion: Over 15-30 min Consider test dose • 0.025 mg/mL • 0.1 mg/mL Ephedrine 50 mg/mL No information Slow IV push Blood pressure and heart rate every 5 minutes, ECG Level 4 Infusion: No information Epinephrine 1 mg/mL Dilute in D5W or NS; IV push: Over 15-30 Central line only Continuous blood pressure HIGH ALERT conc: 4 mcg/mL; max seconds (invasive arterial line), heart MEDICATION Special dilution: cont infusion conc: 64 rate, ECG, and urine flow. • 0.1 mg/mL mcg/mL Infusion: Infants and Vasoconstrictor, avoid Level 4 children: 0.05-1 mcg/kg/min extravasation cont infusion titrate to response See Non-Chemotherapy Extravasation Guideline Epoetin Alfa 2000, 10,000 or Dilute 1:1 in NS IV Push Rate: Over 1-3min Venous line at end of Blood pressure, monitor line 40,000 units/mL dialysis procedure for clotting Level 1 Infusion: No information

Level 4 Ertapenem 1g 20mg/mL in NS Intermittent Infusion: Central or peripheral Neurologic assessment 20mg/mL may be Level 1 Special dilution: administered over 30 Do not co-infuse with other • 20 mg/mL minutes medications Erythromycin 50 mg/mL Dilute in NS or D5W; Intermittent infusion: Over Central or peripheral Vital signs, if vein irritation/ lactobionate conc 1-5 mg/mL 20-60 min. thrombophlebitis, decrease Special dilution: rate of infusion or increase Level 1 • 5 mg/mL Neonate and pediatrics volume of dilution or add Infuse over at least 60 min; lidocaine 10 mg. to decrease vein irritation dilute to ≤ 1 mg/mL See Non-Chemotherapy Extravasation Guideline Esmolol 10 mg/mL, 250 Dilute to final conc: 10 IV push: Over 1 minute Central line preferred; use Continuous blood pressure HIGH ALERT mg/mL or 2.5 mg/mL max large peripheral vein (invasive arterial line), MEDICATION– g/250 mL Infusion50-1000 respiratory rate, heart rate continuous infusion mcg/kg/min and ECG.

Level 4 See Non-Chemotherapy Extravasation Guideline Ethacrynic acid 1 mg/mL Max conc: 2 mg/mL Infuse over a period of Central or peripheral Blood pressure several minutes or infuse Level 1 slowly through the tubing of a running infusion Etomidate 2 mg/mL No further dilution IV push: Over 30-60 Patient should be intubated. Airway, blood pressure, heart HIGH ALERT seconds Avoid small vessels of the rate MEDICATION head or hand. Infusion: 10-20 mcg/kg/min Level 4 Etoposide 20 mg/mL Dilute in NS or D5W (for Over at least 60 min; do not Central line required if Blood pressure, avoid HIGH ALERT stability), conc: 0.2-0.4 exceed 100 mg/m2/hr (or undiluted extravasation MEDICATION mg/mL in peripheral line 3.3 mg/kg/hr) Use with in-line 0.2 or 0.22 See Chemotherpeutic CHEMOTHERAPY IV Push: Not recommended micron filter Extravasation Guidelines

Hazardous Drug – HIGH RISK See UW Health Clinical Policy 6.1.11

Neonates and younger infants: 0.5-1 mcg/kg/hr titrated up;

Older infants and children 1-12 yrs: 1-3 mcg/kg/hr titrate up Ferric Sodium Avoid dilution in D5W Infusion: Over at least 1 Central or peripheral Vital signs, signs of Gluconate hour. Do not exceed anaphylactic reaction For test dose: In 50mL 12.5mg/min Level 1 NS IV push: 12.5mg iron per minute

IV Push not recommended Fludarabine 25 mg/mL Dilute in D5W or NS Intermittent infusion: 0.25- Central or peripheral Infusion reactions HIGH ALERT Max conc 1 mg/mL 1mg/mL over 15-30 min; or MEDICATION cont infusion over 24 hrs or See Chemotherpeutic per protocol Extravasation Guidelines CHEMOTHERAPY IV Push not recommended Hazardous Drug – HIGH RISK See UW Health Clinical Policy 6.1.11

Flumazenil 100 mcg/mL No information IV push: Over 15-30 Blood pressure, heart rate, Level 1 seconds into free running respiratory status. IV infusion

Infusion: do not exceed 0.2 mg/min Fluorouracil 50 mg/mL Dilute in D5W or NS to IV push: over 5-15 min Central or peripheral Dose limiting factor for HIGH ALERT any convenient volume infusion is mucous MEDICATION – for infusion Infusion: over 22-24 hrs Avoid extravasation membrane toxicity continuous infusion (stomatitis, diarrhea)

CHEMOTHERAPY See Chemotherpeutic Extravasation Guidelines Hazardous Drug – HIGH RISK See UW Health Clinical Policy 6.1.11

Intermittent IV infusion: Children 5-18 years: 1-3mg See Non-Chemotherapy PE/kg/min; max 150mg Extravasation Guideline PE/min Furosemide 10 mg/mL Dilute in D5W or NS IV push: max of Central or peripheral Blood pressure, hearing HIGH ALERT 0.5mg/kg/min or 4mg/min MEDICATION – Special dilution: continuous infusion • 1 mg/mL Pediatric: Intermittent infusion: Level 1 Max of 10mg/mL over 10- 15 min

Neonates Intermittent infusion: 2-10mg/mL over 15 to 30 minutes Ganciclovir 50 mg/mL Dilute in D5W or NS, max Over 60 min Central or peripheral Pain at site of infusion, conc: 10 mg/mL phlebitis. Level 1 Special dilution: IV Push not recommended Larger veins with higher •5 mg/mL blood flow preferred due to See Non-Chemotherapy Hazardous Drug – high pH of drug (pH=11) Extravasation Guideline MODERATE RISK See UW Health Clinical Policy 6.1.11 Gemcitabine 38mg/mL Dilute with NS to final Infusion: Over 30-90 Central or peripheral Vascular irritant, avoid HIGH ALERT concentration as low as minutes. Infusion time > 60 extravasation MEDICATION 0.1mg/mL minutes has been shown to prolong gemcitabine’s half- See Chemotherpeutic CHEMOTHERAPY life and increase toxicity in Extravasation Guidelines adults. Hazardous Drug – HIGH RISK See UW Health Clinical Policy 6.1.11

Copyright © 2021 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission Contact: [email protected] Last Revised: 06/2021 Effective 7/8/2021. Contact [email protected] for previous versions Drug Concentration Dilution Infusion Administration Considerations For IV Monitoring Supplied Rate Administration and Comments Gentamicin 40 mg/mL, 10 Dilute in D5W or NS; max Infuse over 30-60 min Central or peripheral Respiratory rate/ depth mg/mL conc: 10 mg/mL IV Push not recommended Level 1 Administer beta-lactams at Special dilution: Neonates least 1 hour before or after • 4 mg/mL Infuse over 30-60 min gentamicin. • 10 mg/mL Glucagon 1 mg/vial Dilute with solution 1-5 mg/hr Easily absorbed IM or provided, max conc: 1 subcutaneously. Level 1 mg/mL IV Push: no information Central or peripheral Glucarpidase 1000 unit vial Infuse over 5 minutes Flush IV line before and after Hypersensitivity, reconstituted administration hypotension, flushing, Level 1 with 1 mL parasthesias Ensure adequate hydration Glycopyrrolate 200 mcg/mL Dilute in D5W or NS Over 15-20 min; max rate: Central or peripheral Apical pulse, HR 20 mcg/min Level 1 Max conc: 200 mcg/mL IV Push: no information Granisetron 1 mg/mL May be diluted with 2-20 Undiluted: infuse over 30 Central or peripheral EKG changes including QT mL of D5W or NS for secs prolongation Level 1 infusion Diluted: infuse over 5 mins Haloperidol Lactate 5 mg/mL Dilute in D5W, usual No information for infusion Haloperidol decanoate not Blood pressure, cardiac conc: 1 mg/mL, max or IV Push rate for IV use conduction (QTc), Level 1 Special dilution: conc: 5 mg/mL extrapyramidal symptoms • 0.5 mg/mL Central or peripheral Heparin 50 units/mL Dilute in D5W or NS IV Push Rate: over 10 min Central or peripheral Allergic reactions, signs and HIGH ALERT symptoms of bleeding MEDICATION Infusion: titrate to aPPT or Do NOT administer IM (excepting <500 unit anti-Xa goal flushes) Level 1

See Heparin Infusion Guideline See Heparin Use in ECMO Guideline

Do not administer blood and hetastarch through same administration set. Flush line between hetastarch and blood. Hydralazine 20 mg/mL Max conc: 20 mg/ mL IV Push max rate: 0.2 Central or peripheral Heart rate, blood pressure mg/kg/min Level 1 Special dilution: • 0.5 mg/mL Infusion not recommended • 10 mg/mL Hydrocortisone 50 mg/mL Dilute in D5W or NS, max Pediatrics and neonates Central or peripheral Blood pressure, blood Sodium Succinate conc: 1 mg/mL IV push: Dilute to 50mg/mL glucose Special dilution: and give over at least 30 Level 1 • 0.25 mg/mL sec. Doses ≥500 mg give • 1 mg/mL over 10 minutes. • 5 mg/mL • 10 mg/mL Intermittent infusion: over 20-30 min, max conc 5 mg/mL Hydromorphone 1-2 mg/mL Dilute in D5W or NS, IV push: Over at least 3-5 Central or peripheral Vital signs, respiratory HIGH ALERT usual conc: 1 mg/mL min rate/depth, pain relief MEDICATION – Special dilution: PCA, infusion • 0.1 mg/mL Infusion: no information

Level 1 Hydroxocobalamin Infusion: First dose over 15 Solution should be dark red Blood pressure, heart rate minutes, second dose over Level 4 15 min to 2 hours Chemically incompatible with sodium thiosulfate and sodium nitrite and separate IV lines must be used if concomitant administration is desired. Hydroxyzine 50 mg/mL DO NOT ADMINISTER AS Give as an IM injection Blood pressure IV - Vesicant Level 1 Special dilution: • 5 mg/mL

Hazardous Drug – HIGH RISK See UW Health Clinical Policy 6.1.11 Ifosfamide 50 mg/mL Dilute in D5W or NS, Infusion Rate: Over at least Central or peripheral Urinalysis for blood in urine, HIGH ALERT conc: 0.6-20 mg/mL; max 30 min, usual infusion time neurologic symptoms MEDICATION conc: 40 mg/mL 2 hours, or as 24 hour Administer with mesna infusion See Chemotherpeutic CHEMOTHERAPY Extravasation Guidelines IV Push not recommended Hazardous Drug – HIGH RISK See UW Health Clinical Policy 6.1.11 Imipenem/ cilastatin 500 mg/100 mL Max conc: 5 mg/mL Doses ≤ 500 mg over 15-30 Central or peripheral Seizures, hypersensitivity Level 1 or 1 g/250 mL min, >500 mg over 40-60 (including anaphylaxis), min phlebitis, slow infusion if Special dilution: nausea develops. • 5 mg/mL IV Push not recommended See Non-Chemotherapy Neonates Extravasation Guideline Infuse over 15-30 min Immune Globulin Gammagard No further dilution See IVIG Guideline for Central or peripheral Anaphylaxis, blood pressure, (IVIG) Liquid 20 g/200 infusion rate instructions temperature, fever, chills, mL Gammagard Liquid requires infusion site discomfort, vital Level 1 IV Push not recommended no filter signs, observe continuously. Gammagard See IVIG Guideline S/D 50-100 Gammagard S/D requires 15 See Non-Chemotherapy mg/mL micron filter Extravasation Guideline See IVIG Rate Calculator (follow link Flebogamma filter is and choose to recommended “download”) Indigotindisulfonate 8 mg/mL No information IV Push Rate: Rapid Sodium injection

Level 1 Infusion rate: no information

Neonatal: Infusion: Over at least 30 minutes.

IV Push: No recommendation Infliximab 10 mg/mL Dilute to final volume of Standard Infusion Rate Do not infuse with other Vitals prior to infusion and HIGH ALERT 250 mL NS, conc: 0.4-4 (over at least 2 hours): drugs. Administer with 0.2 or every 15-30 minutes during MEDICATION mg/ mL Administer at 10 mL/hr for 0.22 mircon in-line filter infusion including blood 15 minutes, then 20 mL/hr pressure, pulse, and Level 1 for 15 minutes, then 40 Standard Infusion Rate respiratory mL/hr for 15 minutes, then Adverse Reactions: 80 mL/hr for 15 minutes, For adverse reactions, stop then 150 mL/hr for 30 infusion. When symptoms minutes, then 250 mL/hr resolve, resume infusion at until completed. 10 mL/hr and follow same titration schedule Rapid Infusion Rate for use in Day Treatment or Rapid Infusion Rate Campground for IBD Adverse Reactions: patients who have For adverse reactions, stop tolerated at least three infusion. When symptoms previous doses of resolve, resume infusion at infliximab with Standard 10 mL/hr and follow the Infusion Rate: standard titration schedule Administer at 100 mL/hr for 15 min, then 300 mL/hr until Central or peripheral completed

IV Push Rate: No information Insulin, Regular 100 units/mL Dilute in NS or D5W; IV push: Over 10-15 Central or peripheral Frequent blood glucose HIGH ALERT usual conc: 0.5-1 unit/mL seconds levels MEDICATION – continuous infusion Infusion: Give at desired rate Level 4

CHEMOTHERAPY

Hazardous Drug – MODERATE RISK See UW Health Clinical Policy 6.1.11 Ipilimumab 50 mg/10 mL; Dilute with NS or D5W to Over 90 minutes Central or peripheral Electrolytes, LFTs, TSH prior 200 mg/40 mL a final concentration of 1- to each dose Level 1 2 mg/mL Administer with 0.22 micron filter Hazardous Drug – MODERATE RISK

See UW Health Clinical Policy 6.1.11 Irinotecan 20 mg/mL Dilute in D5W (preferred) Infusion: Over 90 min Central or peripheral Vital signs, diarrhea HIGH ALERT or NS, conc: 0.12-2.8 MEDICATION mg/mL IV Push not recommended Avoid extravasation See Chemotherpeutic Extravasation Guidelines CHEMOTHERAPY

Hazardous Drug – HIGH RISK See UW Health Clinical Policy 6.1.11

Infusion Rate: Over 2-6 hrs as tolerated; max rate: 50 mg/min

Neonates Infusion Rate:0.4 to 1 mg/kg (400 to 1000 mcg/kg) per day IV continuous infusion in Dex/AA solutions containing at least 2% amino acids. Iron Sucrose 20 mg/mL Dilute in NS IV push rate: 20 mg/min Central or peripheral Vital signs during and (usually in dialysis) immediately after Level 1 Special dilution: Central or peripheral administration, • 2 mg/mL Infusion Rate: Over 15-30 hypersensitivity reaction min Isavuconazonium 372 mg as Dilute to 1.5 mg/mL or Infuse over at least 1 hour. Infuse through a dedicated Hypersensitivity reactions sulfate lyophilized 250 mL Complete infusion within 6 line with a 0.2-1.2 micron with initial doses (isavuconazole) powder in hours inline filter single use vial Infusion-related reactions Level 1 Do not administer as a Central or peripheral (hypotension, dyspnea, bolus dizziness, paresthesias, Do not shake hypoesthesia) Isoproterenol 200 mcg/mL Dilute D5W or NS, conc: Infusion rate: 0.05-2 Central or peripheral Continuous blood pressure HIGH ALERT 4 mcg/mL; max conc: 20 mcg/kg/min (invasive arterial line), heart MEDICATION mcg/mL rate, ECG IV Push rate: no information Level 4 Ketamine 50 mg/mL or Dilute in D5W or NS to IV push: Over 2-3 min Central or peripheral Pain rating, sedation level, HIGH ALERT 100 mg/mL conc: 1-2 mg/mL respiratory rate MEDICATION Infusion: Sedation, children: Special dilution: 5-20 mcg/kg/min; max rate: Continuous ECG (if used Level 1 for continuous • 10 mg/mL 0.5 mg/kg/min Level 4), vital signs, sedation infusion analgesia level

Level 4 for continuous infusion sedation

A total infusion volume of 100 mL NS and slower infusion rate may be considered for patients with cardiac or respiratory compromise who weigh up to 30 kg Leucovorin Calcium 10 mg/mL or 20 Dilute in 100-500 mL IV push: Over 3 min, max Central or peripheral finflix mg/mL D5W or NS rate: 160 mg/min Level 1 Infusion Rate: Over 1- 6 hrs Levetiracetam 100 mg/mL Infusion: Pediatrics <16 Central or peripheral Dizziness, somnolence, vital years: Dilute in NS to conc signs Level 1 Special dilution: of 15mg/mL, infuse over 15 • 15 mg/mL min

Neonates: Dilute to conc 5- 15mg/mL and infuse over 15 min

Level 4 for arrhythmia Linezolid 600 mg/300 No further dilution Infusion rate: Over 30-120 Central or peripheral mL, 400 min Level 1 mg/200 mL, 200 mg/100 mL IV Push not recommended Liothyronine Do not admix with other IV push: Min rate: Administer doses at least 4 solutions 10mcg/min hours and no more than 12 Level 1 hours apart. Lorazepam 2 mg/mL or 4 Dilute in D5W, conc: 0.1- IV push: Dilute with equal Central or peripheral Respiratory rate/depth, blood HIGH ALERT mg/mL 0.2 mg/mL volume D5W, SW or NS; pressure MEDICATION – max rate: 2 mg/min or 0.05 Avoid extravasation continuous infusion Special dilution: mg/kg over 2-5 min If used for conscious • 0.2 mg/mL sedation see Hospital Level 1 - push Infusion Rate: 0.02-0.19 Administration Policy 8.56: Level 4 - infusion mg/kg/hr Pediatric Sedation Policy for monitoring requirements.

See Non-Chemotherapy Extravasation Guideline

For bronchospasm or Torsades de Pointes, infuse over 20 min Mannitol 250 mg/mL No further dilution IV push: 0.2 g/kg (max 12.5 Central line only Cardiac status, fluid status, (25%), 200 mg/ g) over 3-5 min avoid extravasation. Level 1 mL (20%) Administer via 0.2 or 0.22 Infusion: Over 30-90 min mircon in-line filter; observe See Non-Chemotherapy solution for crystals Extravasation Guideline Mechlorethamine 1 mg/mL IV Push Rate: Over 3-5 min Central line only Hypersensitivity, HIGH ALERT into running IV line; max extravasation MEDICATION conc: 1 mg/mL Vesicant, avoid extravasation See Chemotherpeutic CHEMOTHERAPY Infusion: Not recommended Extravasation Guidelines

Hazardous Drug – HIGH RISK See UW Health Clinical Policy 6.1.11 Melphalan 5 mg/mL Dilute in NS; usual conc: Infusion: Over 15 -30 min, Administration through Infusion site reaction, HIGH ALERT 0.1-0.45 mg/ mL max rate: 10 mg/min but central or peripheral lines extravasation MEDICATION total infusion should be depends on concentration; Central or peripheral administered within 1 hr Central line required if See Non-Chemotherapy CHEMOTHERAPY Doses ≤ 0.45 mg/mL use undiluted; central line Extravasation Guideline peripheral line, doses ≤ IV push: no information preferred when diluted Hazardous Drug – 2 mg/ mL use central HIGH RISK See UW Health Clinical Avoid extravasation Policy 6.1.11 Meperidine 25 - 100 mg/mL Dilute in D5W or NS, IV Push rate: Over 4-5 min, Central or peripheral Blood pressure, vital signs, HIGH ALERT conc: 1 mg/mL dilute to fewer than 10 respiratory rate/ depth. MEDICATION mg/mL

Level 1 Infusion not recommended Infusion: Dilute to 1mg/mL and give over 15-30 min

Neonates Infuse over 30 min conc of 1 to 20 mg/mL Mesna 100 mg/mL Dilute in D5W or NS, Infusion: Over 15-30 min or Given as adjuvant to conc: 1-20 mg/mL 1000 mL over 24 hrs chemotherapy. Level 1 IV Push: No information Central or peripheral

May be added to solutions containing ifosfamide or cyclophsphamide Methadone 10 mg/mL May dilute each mL (10 IV Push: Over at least 5 Central or peripheral Vital signs, respiratory status mg) in 1-5 mL NS min Level 1 Special dilution: • 0.2 mg/mL Infusion: Not recommended • 1 mg/mL Methotrexate 25 mg/mL Doses >100 mg: dilute in Infusion: Rate determined Central or peripheral Close patient observation for HIGH ALERT D5W or NS by protocol (over 30 min- 4 toxicity – CBC, platelets, skin MEDICATION hr) or cont infusion over 24 reactions hrs. Concentration not to CHEMOTHERAPY exceed 25mg/mL See Chemotherpeutic Extravasation Guidelines Hazardous Drug – IV push: no information HIGH RISK May be given at a See UW Health Clinical concentration no more than Policy 6.1.11 25mg/mL

See Methotrexate IV push rate: no information Guideline Methylene Blue 10 mg/mL Dilute in NS IV Push: 1 mL/1-2 min Central or peripheral

Level 1 Infusion: Dilute in 50mL NS and infused over at least 5 minutes

IV Push: LOW DOSE ONLY- ≤1.8 mg/kg or ≤125 mg/dose): I.V. push over 3- 15 minutes; maximum concentration: 125 mg/mL

Infusion: Moderate dose (eg, ≥2 mg/kg or 250 mg/dose): Administer over 15-30 minutes

High dose (eg, ≥15 mg/kg or ≥500 mg/dose): Administer over 30-60 minutes; doses ≥1000 mg: Administer over 60 minutes. Metoclopramide 5 mg/mL Dilute in 50 mL to 0.2 mg/ Infusion: Doses >10 mg Central or peripheral Vital signs, dystonic mL, max conc: 5 mg mL should be diluted in 50mL reactions, agitation, Level 1 Special dilution: in D5W or NS of NS or D5W and confusion • 0.2 mg/mL administered over 15 -30 min

IV Push: Max rate: 10 mg over 2 min Metronidazole 500 mg/100 mL No further dilution Infusion: Conc of 5-8mg/mL Central or peripheral Thrombophlebitis, neurologic over 30-60 min symptoms Level 1 Avoid extravasation IV Push: Not recommended See Non-Chemotherapy Extravasation Guideline Micafungin Dilute in NS or D5W to Pediatrics and neonates Prior to administration, flush Histamine-mediated infusion Special dilution: final conc of 0.5-4mg/mL Infusion: Conc of 0.5- line with NS. reactions, IV site irritation Level 1 • 1 mg/mL 4mg/mL over 1 hour. Conc 0.5-1.5mg/mL preferred in Concentrations >1.5mg/mL Reduce rate of infusion with pediatrics should be administered via histamine-mediated reactions central line Pediatrics and neonates: IV push: Not recommended

See Hospital Administration Policy 8.56: Pediatric Sedation Policy Milrinone 1 mg/mL Dilute in D5W; usual IV Push Rate: Loading Central or peripheral Continuous blood pressure HIGH ALERT conc: ≤200 mcg/mL dose of 50 -75 mcg/kg over (invasive arterial line), heart MEDICATION – 15 min rate, ECG, and urine flow, continuous infusion extravasation Infusion Rate: Level 4 0.25 - 0.75 mcg/kg/min See Non-Chemotherapy Extravasation Guideline Premature infants fewer than 30 weeks GA: Loading dose 135mcg/kg IV infused over 3 hours, immediately followed by maintenance infusion of 0.2mcg/kg/min Mitomycin 500 mcg/mL Final conc: 20-40 IV Push Rate: Dose over 5- Central line only See Chemotherpeutic HIGH ALERT mcg/mL; 50-250 mL of 10 min through Y site of Extravasation Guidelines MEDICATION D5W or NS running IV, conc not to Vesicant, avoid extravasation exceed 0.5 mg/mL CHEMOTHERAPY Infusion Rate: Over 30-60 Hazardous Drug – min HIGH RISK See UW Health Clinical Policy 6.1.11

Hazardous Drug – HIGH RISK See UW Health Clinical Policy 6.1.11 Morphine 2-10 mg/mL Dilute in D5W or NS, Infuse 0.5-5mg/mL over 15- Central or peripheral Respiratory rate and depth, HIGH ALERT usual conc: 1mg/mL 30 min oxygen saturation, mental MEDICATION – Special dilution: status, blood pressure, heart PCA, infusion, • 0.05 mg/mL IV Push: 0.5-5 mg/mL over rate, pain relief, level of epidural • 0.1 mg/mL at least 5 minutes sedation

Level 1 Neonates If used for conscious Initial rate 0.01 mg/kg/hr, do sedation see Hospital not exceed infusion rates of Administration Policy 8.56: up to 0.02 mg/kg/hr; Pediatric Sedation Policy for max dose 0.2 mg/kg/dose monitoring requirements. over at least 5 minutes See Non-Chemotherapy Extravasation Guideline Moxifloxacin 400 mg/250 mL No further dilution Infusion: Over 60 min Central or peripheral Allergic reaction (including anaphylaxis, rash, and Level 1 IV Push: not recommended hypotension).

See Non-Chemotherapy Extravasation Guideline Multivitamins 10 mL Dilute in D5W or NS Over 30 min Central or peripheral Vital signs, anaphylaxis

Level 1 IV Push: not recommended Mycophenolate 500 mg vial Dilute in D5W to 6 mg/mL Infuse over minimum of 2 Do not administer as bolus Blood pressure hrs or rapid infusion. Level 1 Special dilution: See Non-Chemotherapy • 5 mg/mL IV Push rate: not Central or peripheral Extravasation Guideline Hazardous Drug – recommended HIGH RISK See UW Health Clinical Policy 6.1.11 Nalbuphine 10 mg/mL or 20 IV Push Rate: Over 5-10 Central or peripheral Vital signs, respiratory rate mg/mL min, larger dose over 10-15 Level 1 min

Infusion: No information

Hazardous Drug – See Chemotherpeutic HIGH RISK Extravasation Guidelines See UW Health Clinical Policy 6.1.11 Neostigmine 1 mg/mL No information Pediatrics and neonates Central or peripheral Respiratory rate/ depth, IV push: undiluted by slow blood pressure, telemetry Level 2 IV injection over several MD presence required at required minutes bedside at least 30 minutes after administration Telemetry required to monitor Infusion: No information for bradycardia or asystole Recommend administration with atropine or MD presence required glycopyrrolate to prevent possible bradycardia, increased salivation and hyperperisalsis. Nicardipine 2.5 mg/mL Dilute in D5W or NS to Infusion Rate: 0.5 to 5 Central or peripheral: Blood pressure, heart rate HIGH ALERT conc: 0.1 to 0.5 mg/mL mcg/kg/min Central line preferred; use extravasation MEDICATION – Neonates: Dilute to large peripheral vein continuous infusion concentration of 0.1 IV Push: Not recommended mg/mL or use premixed Change infusion site every See Non-Chemotherapy Level 4 12 hours if administered Extravasation Guideline peripherally. Nitroglycerin 5 mg/mL Dilute in D5W or NS, Initial: 0.25-0.5 mcg/kg/min Central or peripheral Continuous blood pressure HIGH ALERT conc: 25 mcg/mL is usual; max rate: 5 (invasive arterial line), heart MEDICATION – mcg/kg/min; doses up to 20 rate, ECG continuous infusion Do not exceed 400 mcg/kg/min have been mcg/mL. used Level 3 IV Push: Not recommended

Copyright © 2021 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission Contact: [email protected] Last Revised: 06/2021 Effective 7/8/2021. Contact [email protected] for previous versions Drug Concentration Dilution Infusion Administration Considerations For IV Monitoring Supplied Rate Administration and Comments Nitroprusside 50 mg/250 mL Dilute in D5W Initial 0.3-0.5 mcg/kg/min Protect from light. Continuous blood pressure HIGH ALERT titrate to patient response (invasive arterial line), heart MEDICATION – (usual range: 0.3-10 Central or peripheral rate, ECG, avoid continuous infusion mcg/kg/min) extravasation, cyanide levels (for long-term therapy). Level 4 IV Push not recommended See Non-Chemotherapy Extravasation Guideline Norepinephrine 1 mg/mL Dilute in D5W; max conc: Initial: 0.05-0.1 mcg/kg/min Central line only Blood pressure every 2 HIGH ALERT 4-16 mcg/mL Max rate: 1-2 mcg/kg/min. minutes until stabilized, then MEDICATION Avoid extravasation every 5 minutes; heart rate; Neonates: dilute to conc IV Push not recommended ECG; extravasation Level 4 16-100 mcg/mL Neonates See Non-Chemotherapy Initial 0.2-0.5 mcg/kg/min Extravasation Guideline Obinutuzumab 1000 mg/40 mL Dilute in 250 mL NS only Initial: 25-50 mg/hr Central, midline, or peripheral CBC, LFTs to a final concentration of (disease state dependent) Infusion reactions, tumor CHEMOTHERAPY 0.4-4 mg/mL Dedicated IV line required lysis syndrome Subsequent: may increase Hazardous Drug – to 400 mg/hr if no infusion Premedicate with MODERATE RISK reactions noted acetaminophen, See UW Health Clinical antihistamine and steroids; Policy 6.1.11 antihyperuricemics if needed for tumor lysis syndrome Octreotide 100 or 500 Dilute in 50-250 mL D5W IV push: Over 3 min in Central or peripheral Hypotension, cardiac status HIGH ALERT mcg/mL or NS emergent situations, may MEDICATION – be undiluted Neonates continuous infusion Special dilution: Neonates Blood glucose, • 10 mcg/mL Consider dilution of 10-25 Infuse over 15-30 min or signs/symptoms of Level 1 mg/mL cont infusion over 24 hours necrotizing enterocolitis

Neonates Infuse at 1 mcg/kg/hr, max rate 10 mcg/kg/hr Ondansetron 2 mg/mL For infusion, dilute with Infuse over 15 min Central or peripheral Hypotension, transient ECG NS or D5W to max conc changes, CNS changes, Level 1 Special dilution: 1 mg/mL IV push over 2-5 minutes pruritus, injection site • 1 mg/mL undiluted reactions

Neonates IV push over 10 min at max conc 100 mg/mL IV infusion over 15-60 min at conc 10-40 mg/mL Oxaliplatin 5 mg/mL Dilute in D5W Over 120 min; extend DO NOT DILUTE WITH NS Hypersensitivity reactions HIGH ALERT infusion to 6 hours for acute Flush line with D5W prior to (including anaphylaxis, rash, MEDICATION DO NOT DILUTE WITH toxicities administration of any bronchospasm), hypotension NS or any chloride- concomitant mediation CHEMOTHERAPY containing diluent IV Push not recommended See Chemotherpeutic Avoid mucositis prophylaxis Extravasation Guidelines Hazardous Drug – with ice chips – may HIGH RISK exacerbate acute Avoid cold compress if See UW Health Clinical neurological symptoms extravasation occurs – may Policy 6.1.11 cause peripheral neuropathy Avoid extravasation

Central or peripheral Oxytocin 10 units/mL Dilute in D5W, NS or LR Adjust as necessary; usual Central or peripheral Blood pressure at least every 0.001-0.002 units/min 15 minutes, continuous Level 4 observation of patient IV Push not recommended Paclitaxel 6 mg/mL Dilute in D5W or NS, final Over 3-24 hrs Administer via non-PVC Cardiac status, EKG, HIGH ALERT conc: 0.3-1.2 mg/mL tubing and 0.2 or 0.22 mircon anaphylaxis, extreme irritant. MEDICATION IV Push not recommended non-PVC in-line filter See Chemotherpeutic CHEMOTHERAPY Central or peripheral Extravasation Guidelines

Hazardous Drug – Extreme irritant, avoid HIGH RISK extravasation See UW Health Clinical Policy 6.1.11 Dexamethasone premedication required

Hazardous Drug – HIGH RISK See UW Health Clinical Policy 6.1.11 Palonosetron Infants, children, and Infants, children, and Flush IV line with NS prior to Hypersensitivity reactions, adolescents: May adolescents: Infuse over and following administration cardiac status Level 1 administer undiluted or 15 minutes further dilute in NS or D5W Adolescents ≥17 years: Infuse over 30 seconds Adolescents ≥17 years: Administer undiluted Pamidronate 3 mg/mL Dilute in D5W or NS to a Over 2- 24 hrs Central or peripheral Vein irritation, final concentration of thrombophlebitis, cardiac Level 1 Special dilution: 0.06-0.36 mg/mL IV Push not recommended status • 0.1 mg/mL Hazardous Drug – MODERATE RISK See UW Health Clinical Policy 6.1.11 Pancuronium 1 mg/mL For cont infusion dilute to IV push: Over 60-90 Patient must be intubated. Blood pressure, cardiac HIGH ALERT 0.01-0.8 mg/mL in D5NS, seconds Ensure patient is adequately status, respiratory rate/ MEDICATION D5W, LR, NS sedated prior to depth, use neuromuscular Neonates and infants: 0.02- administration of blockade monitor Level 4 0.04 mg/kg/hr; Children: neuromuscular blockade 0.03-0.1 mg/kg/hr Central or peripheral Pantoprazole Sodium 4 mg/mL Dilute doses of ≤ 40 mg IV push over 2 min, conc: 4 No filter required Vital signs, anaphylaxis. in 50 mL NS; dilute doses mg/mL See Non-Chemotherapy Level 1 of >40 mg in 100 mL NS; Central or peripheral Extravasation Guideline conc: 0.4-0.8 mg/mL Infusion Rate: Over 15 min; do not exceed 7 mL/min Papaverine 30 mg/mL IV Push rate: Over 2 min Central or peripheral Allergic reaction (pruritus, rash), arrhythmias and apnea Level 1 Neonates: Administer via (with rapid IV use), flushing, intra-arterial catheter in cardiac status infusion solution of NS or ½ NS with heparin (1 unit/mL). Infusion Rate: No information

See UW Health Clinical Policy 6.1.11 Pemetrexed 500 mg vial; 25 Dilute to 100 mL in PF Over 10 minutes Pretreat with folic acid, Rash HIGH ALERT mg/mL after NS vitamin B12, and MEDICATION reconstitution corticosteroid See Chemotherpeutic Extravasation Guidelines CHEMOTHERAPY Central or peripheral

Hazardous Drug – HIGH RISK See UW Health Clinical Policy 6.1.11 Penicillin G 500,000 units/ Dilute in 100 mL D5W or Over 20-60 min Central or peripheral Hypersensitivity reactions, Potassium mL NS vein irritation, Neonates and infants: thrombophlebitis, CNS Penicillin G Sodium Special dilution: 100,000 to 500,000 changes, cardiac status. • 25,000 units/mL over 15-60 min Level 1 units/mL See Non-Chemotherapy • 50,000 May be administered as Extravasation Guideline units/mL continuous infusion

Consider the potassium or sodium content when determining rate. Penicillin G potassium contains 1.7 mEq K/ million units

IV Push not recommended Pentamidine 300 mg/vial Dilute in D5W; max conc: Over 60-120 min Central or peripheral Continuous blood pressure, 6 mg/mL phlebitis, CNS changes Level 1 Special dilution: IV Push not recommended Avoid extravasation • 6 mg/mL See Non-Chemotherapy Extravasation Guideline

See Non-Chemotherapy Extravasation Guideline Pentostatin 2 mg/mL May further dilute in 25- Over 20-30 min or IV bolus Hydrate with fluid prior to and Cardiac status, CNS HIGH ALERT 50 mL NS or D5W over 5 min after infusion changes, phlebitis, allergic MEDICATION reaction

CHEMOTHERAPY See Chemotherpeutic Extravasation Guidelines Hazardous Drug – HIGH RISK See UW Health Clinical Policy 6.1.11 Peramivir 200 mg /20 mL Dilute in NS, D5W, or LR Administer over 15-30 mins Central or peripheral Hypersensitivity reactions, to conc ≤ 6 mg/mL dermatologic reactions, Level 1 Max total volume 100 mL neuropsychiatric events and unusual behavior Phenobarbital 130 mg/mL IV Push Rate: No more Central or peripheral Vital signs every hour, than 1 mg/kg/min; max rate: respiratory rate/ depth, Loading - Level 2 Special dilution: 30 mg/min Irritant, avoid extravasation paradoxical stimulatory Maintenance - Level 1 • 2 mg/mL Neonates: Over 10-15 response, irritant. • 10 mg/mL minutes, 2 mg/kg/min; max rate: 30 mg/min See Non-Chemotherapy Extravasation Guideline Infusion not recommended Phentolamine 5 mg/mL Dilute in 100 mL NS No information Central or peripheral Vital signs every 2 minutes initially, cardiac status Level 4 Phenylephrine 10 mg/mL Dilute in 250 mL D5W or IV push: dilute 1 mL in 9 mL Central or peripheral; Central continuous blood pressure HIGH ALERT NS; usual cont infusion SW, conc: 1 mg/mL over line preferred. Infuse into (invasive arterial line), heart MEDICATION conc: 20-60 mcg/mL 20-30 seconds large veins. rate, ECG, urine flow, and hypersensitivity reaction Level 4 Infusion: Children: 0.1-0.5 Vasoconstrictor - avoid mcg/kg/min, titrated to extravasation Potent vasoconstrictor, avoid effect extravasation.

See Non-Chemotherapy Extravasation Guideline

IV Push not recommended Phosphate (Sodium) 3 mmoL Peripheral: max conc: Over 4-6 hrs for mild- Do not infuse with calcium- (Phos)/ mL 0.05 mmol/mL; moderate containing IV fluids. Level 1 hypophosphatemia; over 8- Central: max conc: 0.12 12 hrs for severe mmol/mL Max rate of infusion: 0.06 mmol/kg/hr

IV Push not recommended Physostigmine 1 mg/mL Do not dilute further IV Push: Infuse over 5 Central or peripheral Cardiac status, vital signs, Salicylate minutes. Max rate: 0.5 respiratory status, mg/min hypersalivation Level 4 Infusion not recommended Phytonadione 10 mg/mL Dilute in 5-10 mL D5W or Subcutaneous route Fever/ chills, anaphylaxis, (Vitamin K) NS preferred Oral route preferred blood pressure, respiratory Special dilution: status, flushing, injection site Level 1 • 1 mg/mL Infuse over 60 min, max Central or peripheral reactions rate: 1 mg/min See Procoagulant Guideline Neonates: max rate 1 mg/min

IV Push not recommended

IV push not recommended Polymyxin B 500,000 units/ Dilute 500,000 units in Over 60-90 min or cont Avoid parenteral use when Respiratory status, CNS 10 mL 300-500 mL D5W infusion or over 24 hrs at a possible changes, vein irritation, Level 1 conc: 1000-1667 units/mL thrombophlebitis IV Push not recommended Central or peripheral Posaconazole 300 mg/16.7 Diluted with 150 mL NS Infuse over 90 min Central line only Cardiac status and ECG, mL or D5W CNS changes, rash Level 1 IV push not recommended May infuse through peripheral line one time in patient who will be receiving central line

Must infuse through 0.2 or 0.22 micron in-line filter Potassium Acetate Peripheral max conc: 8- 0.3-0.5 mEq/kg/hr; max 1 Central or peripheral Cardiac status, weakness, Special dilution: 10 mEq/100 mL mEq/kg/hr parasthesias, irritant, avoid K+ rates less than 0.2 • 0.1 mEq/mL Avoid extravasation extravasation mEq/kg/hr – Level 1 • 0.2 mEq/mL Central max conc: 15 mEq/100 mL Rates ≥0.2 mEq/kg/hr require K+ rates greater than cardiac monitor 0.2 mEq/kg/hr – Level 2

Potassium Phosphate 7.5 or 15 Peripheral: 0.05 Max 0.06 mmol/kg/hr Central or peripheral Cardiac status, weakness, mmol/100 mL mmol/mL parasthesias K+ rates less than 0.2 bag Do not infuse with calcium- mEq/kg/hr – Level 1 Central: 0.12 mmol/mL containing IV fluids Special dilution: K+ rates greater than • 0.12 mmol/mL Recommend using 0.2 or 0.2 mEq/kg/hr – Level 2 0.22 micron in-line filter Pralatrexate 20 mg/mL Do not dilute Over 3-5 minutes into free- Central or peripheral Dyspnea, mucositis, tumor HIGH ALERT 40 mg/2 mL flowing line of NS lysis syndrome, tachycardia MEDICATION Patients must be receiving folic acid and See Chemotherpeutic CHEMOTHERAPY cyanocobalamin while Extravasation Guidelines receiving pralatrexate Hazardous Drug – HIGH RISK See UW Health Clinical Policy 6.1.11 Pralidoxime 50 mg/mL Dilute in NS to 10-20 Infusion: Over 15-30 min Central or peripheral Continuous vital signs and mg/mL, max conc 50 IV Push Rate: Max: 200 blood pressure, muscle Level 4 mg/mL mg/ min fasiculations and strength

Neonates: loading dose over 30-60 min

Infants and children: IV loading dose over 30 -60 min, not to exceed 50 mg/min

Adolescents: 20-50 mg/min, not to exceed 50 mg/min Prochlorperazine 5 mg/mL Dilute in D5W or NS IV Push rate: 1-2 mL given Central or peripheral Blood pressure and pulse slowly; max rate: 5 mg/min before administration and Level 1 Consider pretreatment with between doses, mental Infusion: Over 30 min diphenhydramine status Promethazine 25 mg/mL Dilute in NS; max conc: IV Push rate: 25 mg/min Central or peripheral Continuous vital signs, HIGH ALERT 25 mg/mL into running IV Central line required if respiratory rate/depth, irritant, MEDICATION Special dilution: infusing by secondary IV line tissue injury • 2.5 mg/mL Infusion rate: Over 30 min Level 1 Administer in large bore vein See Non-Chemotherapy (not hand or wrist) Extravasation Guideline

Avoid extravasation; may cause necrosis if extravasated Propofol 10 mg/mL Do not dilute IV Push rate: induction Central or peripheral Continuous blood pressure HIGH ALERT dose over 20-30 seconds and ECG, respiratory rate/ MEDICATION depth. Infusion Rate: Titrate to Level 4 response; See Hospital Administration 50 mcg/kg/min to 300 Policy 8.56: Pediatric mcg/kg/min Sedation Policy for monitoring requirements.

See Non-Chemotherapy Extravasation Guideline

Ranitidine 25 mg/mL Dilute in D5W or NS; cont IV Push: over at least 5 Central or peripheral Vital signs, burning/itching at infusion: 150 mg/250 mL min; not to exceed 10 injection site Level 1 Special dilution: mg/min at max conc: 2.5 Intermittent infusion preferred • 2.5 mg/mL mg/mL to IV Push

Intermittent infusion: over at least 5 min, not to exceed 10 mg/min; max conc 2.5 mg/mL

Infusion: Single dose of 1 mg/kg, then 0.08 – 0.17 mg/kg/hr; max conc: 0.6 mg/mL

Neonates Slow IV push or cont infusion 0.04-0.1 mg/kg/hr

Neonates IV Push over 60 seconds Infusion: 0.4-1 mcg/kg/min Rho D Immune 1500 units/3 mL May further dilute in NS if Infuse over 3-5 min Central or peripheral Signs/symptoms of Globulin desired intravascular hemolysis (IVH), chills/shaking, observe Level 1 patient for side effects for 8 hours following administration Rifampin 60 mg/mL Dilute in D5W or NS; max Infusion rate: Central or peripheral Vein irritation, avoid conc: 6 mg/mL 100 mL: over 30 min 500 extravasation. Level 1 Special dilution: mL: over 3 hrs Avoid extravasation • 6 mg/mL See Non-Chemotherapy IV Push not recommended Extravasation Guideline

Neonates IV infusion over 30 minutes

Fewer than 50 kg: Start infusion at 1 mg/kg/hour for 30 minutes. If no infusion reactions occur, rate may be increased by 1 mg/kg/hour every 30 minutes to a maximum of 7 mg/kg/hour.

IV Push not recommended Rocuronium 10 mg/mL NS, D5W, LR to conc of IV push: Dose over 1-2 min Patient must be intubated. Blood pressure, cardiac HIGH ALERT 0.5-1 mg/mL status, respiratory rate/ MEDICATION Special dilution: Infusion: 10-12 mcg/kg/min Central or peripheral depth, use neuromuscular • 0.5 mg/mL Ensure patient is adequately blockade monitor Level 4 • 2.5 mg/mL sedated prior to administration of neuromuscular blockade Romidepsin 10 mg vial; 5 Dilute in 500 mL NS Infuse over 4 hrs Central or peripheral ECG and electrolytes at HIGH ALERT mg/mL after baseline and periodically in MEDICATION reconstitution May consider antiemetics patients with prolonged QT prior to administration syndrome, significant CHEMOTHERAPY cardiovascular disease, or an antiarrhythmic or QT- Hazardous Drug – prolonging medications HIGH RISK See UW Health Clinical See Chemotherpeutic Policy 6.1.11 Extravasation Guidelines

Copyright © 2021 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission Contact: [email protected] Last Revised: 06/2021 Effective 7/8/2021. Contact [email protected] for previous versions Drug Concentration Dilution Infusion Administration Considerations For IV Monitoring Supplied Rate Administration and Comments Sargramostim 250 mcg/mL or Dilute in NS; if conc< 10 Infusion rate: Over 2- 24 Central or peripheral Flushing, blood pressure, 500 mcg/mL mg/mL, add 1 mL hrs syncope (especially with first Level 1 albumin 5% to each 1of Do not shake; avoid foaming dose) IV fluid; add albumin to IV Push rate: not NS prior to sargramostim recommended Albumin acts as carrier molecule for medication Prefer to keep conc ≥ 10 mcg/mL Scopolamine 0.4 mg/mL Dilute with an equal IV Push rate: Over 3-4 min Central or peripheral Blood pressure volume of sterile water Level 1 for preop use for injection Infusion: no information Secretin 2 mcg/mL IV Push rate; Dose over 1 Central or peripheral Allergic reactions (including minute anaphylaxis) Level 1 Infusion rate: no information Siltuximab 20 mg/mL Dilute to 250 mL with Infuse over 1 hour Central or peripheral Monitor for signs of an HIGH ALERT D5W infusion related reaction or MEDICATION Administer using sets lined hypersensitivity. Stop the with PVC, polyurethane (PU), infusion if the patient CHEMOTHERAPY or polyethylene (PE) with a develops a mild to moderate 0.2-micron inline infusion reaction. If the polyethersulfone (PES) filter. reaction resolves, the infusion may be restarted at Do not administer with other a lower infusion rate. agents in the same IV line. See Chemotherpeutic Complete infusion within 4 Extravasation Guidelines hours of dilution. Sincalide 1 mcg/mL Dilute in 50 mL NS IV push: Dose over 30-60 Central or peripheral Abdominal pain/ discomfort seconds Level 1 Infusion may improve GI Infusion: Over 30 min tolerance Sodium Acetate 2 mEq/mL Dilute in D5W or NS Infusion: Max rate: 1 Central or peripheral Cardiac status mEq/kg/hr Level 2 IV Push not recommended Sodium Bicarbonate 1 mEq/mL Dilute in D5W or sterile IV push: over 1-2 min Central or peripheral Cardiac status, extreme water for injection Central line preferred if irritant, avoid extravasation. Level 1 Infusion: conc of 0.5 undiluted, however, Neonates and infants: 0.5 mEq/mL over 2 hrs; max peripheral/intraosseous See Non-Chemotherapy mEq/mL rate: 1 mEq/kg/hr access may be used when Extravasation Guideline benefit outweighs risks Children: 1 mEq/mL Neonates and infants: max rate 10 mEq/min Avoid extravasation

Level 3

See Hypertonic Sodium Chloride Guideline Sodium Chloride 3% 513 mEq/L No further dilution Max rate: 1 mEq/kg/hr Central line only Vital signs, extravasation, HIGH ALERT sodium concentration, ICP MEDICATION IV Push not recommended Avoid extravasation See Non-Chemotherapy Level 4 Extravasation Guideline

See Hypertonic Sodium Chloride Guideline Sodium Phosphate Peripheral: 0.05 Max rate: 0.06 mmol/kg/hr Central or peripheral Cardiac status, weakness, mmol/mL parasthesias Level 1 Special dilution: IV Push not recommended Do not infuse with calcium- • 0.05 mmol/mL Central: 0.12 mmol/mL containing IV fluid

Recommend using 0.2 or 0.22 micron in-line filter Sodium Thiosulfate 25% No dilution required Infuse over at least 10 min Central or peripheral Vital signs, hypotension, respiratory rate Level 3 Infusion: no information Streptozocin 1 g vial; 100 May dilute in D5W or NS No information Central or peripheral Vesicant, risk of HIGH ALERT mg/mL after extravasation MEDICATION reconstitution Avoid extravasation See Chemotherpeutic CHEMOTHERAPY Extravasation Guidelines

Hazardous Drug – HIGH RISK

Hazardous Drug – HIGH RISK See UW Health Clinical Policy 6.1.11

Use with caution in patients with fractures or muscle spasms as initial fasiculations may cause additional trauma Sufentanil 50 mcg/mL IV Push rate: Over 30 Central or peripheral Assess blood pressure, HIGH ALERT seconds pulse, and respirations MEDICATION before and periodically during Infusion: no information administration, neurologic Level 4 status Sugammedex 500 mg/5 mL Two years and older: No Over 10 seconds Central, midline, or peripheral Hypersensitivity and dilution required anaphylaxis, bradycardia, Level 4 Flush lV line with NS before recurrence of neuromuscular Younger than two years: and after administration of blockade, respiratory Dilute in NS to 25 mg/mL sugammadex function, skeletal muscle tone

Drug interaction with hormonal contraceptive agents Tacrolimus 5 mg/mL Dilute in D5W or NS; IV Push not recommended Avoid PVC-containing Blood pressure, anaphylaxis, conc: 0.004-0.02 mg/mL containers and tubing tacrolimus concentrations Level 1 Central or peripheral Hazardous Drug – MODERATE RISK See UW Health Clinical Policy 6.1.11 TBO-filgrastim 300 mcg, 480 Final conc 15 mcg/mL Infusion over 15-30 min or Do not shake; avoid foaming Temperature, CBC, cardiac mcg continuous infusion or 4- or status, hypersensitivity Level 1 If final conc 5 to <15 24-hr infusion reaction mcg/mL, add albumin to a final conc of 2 mg/mL

Avoid conc <5 mcg/mL

Hazardous Drug – Premedicate with HIGH RISK diphenhydramine See UW Health Clinical Policy 6.1.11 Terbutaline 1 mg/mL Dilute 5 mg in NS; max IV push: Undiluted over 5- Central or peripheral Blood pressure, heart rate conc for infusion: 1 10 min Level 4 mg/mL Infusion rate: Over 12-24 hrs Thiamine 100 mg/mL Dilute in D5W, NS, or LR IV push: 10-25 mg over 3-5 Central or peripheral Anaphylaxis, hypersensitivity min reactions Level 1 Infusion rate: Give at any convenient rate. Use longer infusion for dose ≥100 mg Thiotepa 10 mg/mL Dilute in NS; max conc: 1 Central line only Vein irritation, HIGH ALERT mg/mL Low doses infuse over 5 thrombophlebitis MEDICATION min See Chemotherpeutic CHEMOTHERAPY High doses infuse over 2-4 Extravasation Guidelines hr Hazardous Drug – HIGH RISK See UW Health Clinical Policy 6.1.11

Tigecycline 10 mg/mL Dilute in D5W or NS; max Infuse over 30-60 min Central or peripheral Hypersensitivity, infection, conc: 1 mg/mL nausea/vomiting Level 1 Tobramycin 40 mg/mL, Dilute in D5W or NS; max Infusion rate: Over 30-60 Central or peripheral Respiratory rate/ depth 20 mg/2 mL conc: 10 mg/mL min Level 1 Administer beta-lactam Special dilution: antibiotics at least one hour • 4 mg/mL before or after tobramycin • 10 mg/mL Tocilizumab 80mg/4mL, 200 Dilute with NS: Infuse over 60 min Use dedicated line Infusion-related reactions, mg/10 mL, • < 30 kg: dilute dose to including hypersensitivity/ Level 2 400mg/20mL 50 mL Do not administer as IV Central or peripheral anaphylaxis; hypertension vials • ≥ 30 kg: dilute dose to push or IV bolus 100 mL Topotecan 1 mg/mL Dilute in D5W or NS Infusion Rate: Over 30 min Central or peripheral Vital signs, extravasation HIGH ALERT or cont infusion with conc MEDICATION not to exceed 0.5 mg/mL Avoid extravasation, irritant See Chemotherpeutic Extravasation Guidelines CHEMOTHERAPY IV Push not recommended

Hazardous Drug – HIGH RISK See UW Health Clinical Policy 6.1.11 Trace elements 3 mL Dilute in D5W or NS Give at convenient rate, Central or peripheral usually included in Level 1 parenteral nutrition

IV Push: no information Tranexamic Acid 100 mg/mL Dilute single dose in at Max rate 100 mg over 1 Central or peripheral Giddiness, skin reaction, risk least 50 mL D5W or NS min of thromboembolic events Level 1 Neonates Neonates Rapid administration may See Procoagulant 50-100 mg/mL Max rate 100 mg/min cause hypotension Guideline

Must have immediate backup line Trimethoprim/ 80 mg TMP/ Dilute each 5 mL in 50- Infusion rate: Over 60-90 Central or peripheral Phlebitis, CNS changes, sulfamethoxazole 400 mg Sulfa/ 125 mL D5W or NS, NS min allergic reaction, nausea, 5 mL preferred Avoid extravasation vomiting, rash Level 1 IV Push: not recommended Special dilution: See Non-Chemotherapy • 1 mg TMP/5 Extravasation Guideline mg Sulfa/mL Tromethamine 3.6 g/100 mL Max conc: 0.3 molar Infusion Rate: Over 1 hr, or Central line only ECG, extravasation HIGH ALERT 3-16 mL/kg/hr up to 33-40 MEDICATION – mL/kg/day Avoid extravasation See Non-Chemotherapy continuous infusion Extravasation Guideline IV Push not recommended Level 4 Neonates Infuse over at least 30 min Valproic Acid 500 mg/5 mL Dilute in 50 mL D5W or Infusion rate: Over 60 min; Central or peripheral Abdominal pain, nausea, NS max rate: 20 mg/min vomiting Level 1 Special dilution: • 25 mg/mL Rapid IV loading doses: Rapid infusions related to • 50 mg/mL dilute 1:1 with NS or Rapid IV loading dose may increased adverse events D5@ be considered at 1.5-3 mg/kg/min Vancomycin 100 mg/mL Dilute in D5W or NS; max Infusion rate: Over at least Central or peripheral Extreme vein irritation, avoid conc: 5 mg/mL 60 min extravasation, continuous Level 1 Special dilution: Neonates Slow infusion to 90-120 min blood pressure, histamine- • 5 mg/mL Max conc: 5 mg/mL IV Push not recommended and increase dilution volume like reaction or flushing, by the manufacturer if histamine-like reaction hypotension. occurs Neonates See Non-Chemotherapy Max rate: 10 mg/min Extravasation Guideline

Hazardous Drug – MODERATE RISK See UW Health Clinical Policy 6.1.11 Verapamil 2.5 mg/mL Dilute in D5W or NS; Infuse over 2-3 min; Infuse Not recommended for infants ECG for infusion, blood HIGH ALERT max conc: 2.5 mg/mL over 3-4 min if BP on lower younger than 1 year pressure and heart rate every MEDICATION – range of normal 5 minutes until stable, then continuous infusion Central or peripheral every 15 minutes for 1 hour, then at least every hour Level 4

Light therapy to begin 15 minutes following the start of 10-minute infusion VinBLAStine 1 mg/mL Dilute in D5W or NS for IV push: Over 1 minute into Central or peripheral Vesicant, avoid cont infusion running IV line as 1mg/mL extravasation, neurologic CHEMOTHERAPY conc Avoid extravasation status

Hazardous Drug – Infusion rate: Daily dose See Chemotherpeutic HIGH RISK over 24 hrs Extravasation Guidelines See UW Health Clinical Policy 6.1.11 VinCRIStine 1 mg/mL Dilute in D5W or NS IV push: Over 5 minutes Central or peripheral Vesicant, avoid extravasation CHEMOTHERAPY into running IV line as 1mg/mL conc Avoid extravasation See Chemotherpeutic Hazardous Drug – Extravasation Guidelines HIGH RISK Infusion rate: no information See UW Health Clinical Policy 6.1.11 VinCRIStine Dose in 100 mL No further dilution Infuse over 1 hour Central or peripheral Vesicant, avoid extravasation Liposomal NS or D5W CHEMOTHERAPY infusion bag Do not give as IV push or Avoid extravasation See Chemotherpeutic bolus Extravasation Guidelines Hazardous Drug – HIGH RISK Must complete infusion See UW Health Clinical within 12 hours of Policy 6.1.11 preparation

Vinorelbine 10 mg/mL Dilute in D5W or NS; IV push: Dose over 6-10 Central or peripheral Phlebitis, irritant, avoid conc: 0.5-2 mg/mL min into side port of free extravasation CHEMOTHERAPY flowing IV line See Chemotherpeutic Hazardous Drug – Infusion rate: Over 20 min Extravasation Guidelines HIGH RISK See UW Health Clinical Policy 6.1.11

Level 1 Infusion not recommended Zinc trace metal 1 mg/mL, and Dilute in D5W or NS Infusion rate: Give at Central or peripheral 5mg/mL as convenient rate Level 1 sulfate IV Push not recommended Zidovudine 10 mg/mL Dilute with D5W, max Infuse over 60 min Cardiac status (ECG), chills, conc: 4 mg/mL fever, CNS changes, rash, Level 2 Special dilution: Neonates allergic reactions • 1 mg/mL Infuse over 60 min • 4 mg/mL Zoledronic Acid 4 mg/5 mL Dilute in NS or D5W Infusion rate: Over at least Avoid extravasation 15 min Level 1 See Non-Chemotherapy IV Push not recommended Extravasation Guideline Hazardous Drug – MODERATE RISK See UW Health Clinical Policy 6.1.11

UW Health Implementation Potential Benefits: • Safety and efficacy through standardizaton of intravenous administration of medications • Direction on important monitoring areas

Potentail Harms: • Standardized intravenous administration may not optimize medication therapy for all patients

Qualifying Statements Recommendations in this guideline are based on available evidence. Administration of medications should be evaluated in a patient-specific manner and should take into account the urgency of a given situation when determining administration rate and route.

Pertinent UWHC Policies and Procedures • Policy 8.31 Guidelines for Hospital Location Specific Administration of IV Medications • Policy 8.33 High Alert Medication Administration • Policy 8.56 Pediatric Sedation • Policy 8.89 Preventing Non-therapeutic Exposure to Hazardous Drugs • Factor 7a Recombinant Operating Procedure • Factor 9 Complex Concentrate (PCC) Operating Procedure • Policy 10.18 Parenteral Lidocaine for Neuropathic Pain

Patient Resources None

Guideline Metrics Patient Safety Net reports can be monitored for errors or adverse events associated with IV medication administration.

Implementation Plan/Clinical Tools 1. Guideline will be posted on uConnect in a dedicated location for Clinical Practice Guidelines. 2. Release of the guideline will be advertised in the Physician/APP Briefing newsletter. 3. Content and hyperlinks within clinical tools, documents, or Health Link related to the guideline recommendations will be reviewed for consistency and modified as appropriate.

Disclaimer Clinical practice guidelines assist clinicians by providing a framework for the evaluation and treatment of patients. This guideline outlines the preferred approach for most patients. It is not intended to replace a clinician’s judgment or to establish a protocol for all patients. It is understood that some patients will not fit the clinical condition contemplated by a guideline and that a guideline will rarely establish the only appropriate approach to a problem.

References 1. Jacobs AK, Kushner FG, Ettinger SM, et al. ACCF/AHA clinical practice guideline methodology summit report: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology. 2013;61(2):213-265. 2. Lexi-Comp Online™, Lexi-Drugs Online™ Hudson, OH: Lexi-Comp,Inc; Accessed July 2016. 3. Neofax Online®. Micromedex® Ann Arbor, MI: Truven Health Analytics™: Accessed July 2016.

Appendix A. Evidence Grading Scheme1 Figure 1. GRADE Methodology adapted by UWHealth

GRADE Ranking of Evidence High We are confident that the effect in the study reflects the actual effect.

We are quite confident that the effect in the study is close to the true effect, but it is also Moderate possible it is substantially different.

Low The true effect may differ significantly from the estimate.

Very Low The true effect is likely to be substantially different from the estimated effect.

GRADE Ratings for Recommendations For or Against Practice

The net benefit of the treatment is clear, patient values and circumstances are Strong unlikely to affect the decision.

Recommendation may be conditional upon patient values and preferences, the Weak/conditional resources available, or the setting in which the intervention will be implemented.

Appendix B. Medications Requiring Central Lines 1. Acyclovir – Central line for concentrations ≥ 10 mg/mL 2. Adenosine – Central line preferred (or site as proximal to trunk as possible) 3. Amiodarone – Central line preferred. Central line required for 600 mg/250 mL or any infusion concentrations ≥2 mg/mL 4. Anti-thymocyte globulin RABBIT – Central line required for doses diluted in <500 mL 5. Busulfan 6. Calcium chloride – Central line preferred 7. Carmustine – Central line if undiluted or doses ≥ 300 mg/m2 8. Copper-selenium-zinc 9. Continuous renal replacement therapy (CRRT) – all bags 10. Dobutamine – Central line preferred, however, peripheral/intraosseous access may be used when benefit outweighs risks 11. Dopamine – Central preferred, however, peripheral/intraosseous access may be used when benefit outweighs risks 12. Doxorubicin conventional – central line required for continuous infusion 13. Epinephrine – Central line preferred, however, peripheral/intraosseous access may be used when benefit outweighs risks 14. Epoprostenol – Central line required for continuous infusion; may give peripherally on a temporary basis until central line placed 15. Esmolol – Central line preferred for concentrations ≥ 20 mg/mL 16. Etoposide – Central line required if undiluted 17. Foscarnet – Central line required if undiluted 18. Melphalan – Central line required if undiluted; central line preferred when diluted, however or peripheral infusion is acceptable 19. Micafungin – Central line required for concentrations >1.5 mg/mL 20. Nicardipine – Central line required for concentrations >0.5 mg/mL 21. Norepinephrine – Central line preferred, however, peripheral/intraosseous access may be used when benefit outweighs risks 22. Phenylephrine – Central line preferred, however, peripheral/intraosseous access may be used when benefit outweighs risks 23. Posaconazole – Central line preferred, however, if unavailable, may administer one dose through a peripheral catheter (over 30 min) 24. Potassium acetate – Central line for concentrations ≥20 mEq/100 mL 25. Potassium chloride – Central line for concentrations ≥ 20 mEq/100 mL 26. Potassium phosphate – Central line recommended for concentration >15 mMol/100 mL. Central line required for rate >10 mEq/hr 27. Promethazine – Central line required if infusing by secondary IV line 28. Sodium Bicarbonate – Central line preferred if undiluted, however, peripheral/intraosseous access may be used when benefit outweighs risks 29. Sodium Chloride 3% – Central line preferred, however, peripheral/intraosseous access may be used when benefit outweighs risks 30. Thiotepa 31. TPN 32. Treprostinil – Central line preferred, however, peripheral administration on a temporary basis has been documented 33. Vancomycin – Central line for concentrations ≥10 mg/mL 34. Vasopressin – Central line preferred, however, peripheral/intraosseous access may be used when benefit outweighs risks