Hospital protocols submitted

Alteplase – blocked catheter:

Dosing: 2mg per lumen. Dose may be repeated after following the steps listed below.
Initially, only 2mg should be sent for each blocked lumen.
Absolutely worst case scenario would be a triple lumen catheter – all lumens blocked. –> 6 mg would
be sent up initially, and may have to be repeated after 2 hours or a total of 12mg. However, always
require a new order for the second dose.

Summary: send one 2mg syringe for each blocked lumen. 

Instructions for Administration
Preparation of Solution
Reconstitute Cathflo Activase to a final concentration of 1 mg/mL:

1. Aseptically withdraw 2.2 mL of Sterile Water for Injection, USP (diluent is not provided). Do not use Bacteriostatic Water for Injection.
2. Inject the 2.2 mL of Sterile Water for Injection, USP, into the Cathflo Activase vial, directing the diluent stream into the powder. Slight foaming is not unusual; let the vial stand undisturbed to allow large bubbles to dissipate.
3. Mix by gently swirling until the contents are completely dissolved. Complete dissolution should occur within 3 minutes. DO NOT SHAKE. The reconstituted preparation results in a colorless to pale yellow transparent solution containing 1 mg/mL Cathflo Activase at a pH of approximately 7.3.
4. Cathflo Activase contains no antibacterial preservatives and should be reconstituted immediately before use. The solution may be used for intracatheter instillation within 8 hours following reconstitution when stored at 2-30°C (36-86°F).

No other medication should be added to solutions containing Cathflo Activase.

Instillation of Solution into the Catheter

1. Inspect the product prior to administration for foreign matter and discoloration.
2. Withdraw 2 mL (2 mg) of solution from the reconstituted vial.
3. Instill the appropriate dose of Cathflo Activase into the occluded catheter.
4. After 30 minutes of dwell time, assess catheter function by attempting to aspirate blood. If the catheter is functional, go to Step 7. If the catheter is not functional, go to Step 5.
5. After 120 minutes of dwell time, assess catheter function by attempting to aspirate blood and catheter contents. If the catheter is functional, go to Step 7. If the catheter is not functional, go to Step 6.
6. If catheter function is not restored after one dose of Cathflo Activase, a second dose of equal amount may be instilled. Repeat the procedure beginning with Step 1 under Preparation of Solution.
7. If catheter function has been restored, aspirate 4-5 mL of blood in patients 10 kg or 3 mL in patients <10 kg to remove Cathflo Activase and residual clot, and gently irrigate the catheter with 0.9% Sodium Chloride, USP

 Amiodarone Drip:

V-TACH:
Type: IVPB
Additive: Amiodarone  150mg
Solution: DEXTROSE 5% 100ml
Infusion rate: 10 minutes
Med route: IVPB
Schedule: ONCE
Other Print:

Bacitracin – Gentamicin Irrigation:

(Note: print 3 labels)

BACKGROUND:
Santucci RA, et al. Penile Prosthesis Implantation Treatment & Management. Jan 15, 2014 [Source: http://emedicine.medscape.com/article/446761-treatment#showall]

Next, the bladder is catheterized to drain the urine; then, it is irrigated with antibiotic solutions (bacitracin 50,000 U and gentamicin 160 mg in 1 L NaCl).

 BCG VACCINE (TICE):

 Continuous or Prolonged Infusion of Antibacterial Drugs:

Cefepime
Minimum Stability:  37ºC: 8 hr;  25ºC: 24 hr;   4ºC: 24 hr
Recommended Dose
Initial dose: 15 mg/kg over 30 min, then immediately begin:
If CrCl > 60: 6 gm (over 24 hr) daily
If CrCl 30-60: 4 gm (over 24 hr) daily
If CrCl 11-29: 2 gm (over 24 hr) daily

Meropenem
Minimum Stability:  37ºC: <4 hr;   25ºC: 4 hr;  4ºC: 24 hr
Recommended Dose (Initial 1 gram dose may be given to start – (Intensive Care Med 37:632, 2011)).
CrCl 50: 2 gm (over 3 hr) q8h
CrCl 30-49: 1 gm (over 3 hr) q8h
CrCl 10-29: 1 gm (over 3 hr) q12h

Piperacillin-Tazobactam  (Zosyn)
Minimum Stability:  37ºC: 24 hr;   25ºC: 24 hr;  4ºC: ND
Recommended Dose
Initial dose: 4.5 gm over 30 min, then 4 hrs later start:
CrCl 20: 3.375 gm (over 4 hr) q8h
CrCl < 20: 3.375 gm (over 4 hr) q12h

Vancomycin
Minimum Stability: 37ºC: 48 hr;   25ºC: 48 hr;  4ºC: 58 days (at conc 10 µg/mL)
Recommended Dose
Loading dose 15-20 mg/kg administered over 30-60 minutes, then 30 mg/kg by continuous infusion over 24h
Adjust regimen to target plateau concentration of 20-25 µg/mL. Higher conc e.g. (30-40 µg/mL) increase risk of nephrotoxicity.

 Formalin for bladder irrigation:

Fortified Ophthalmic Drops:

2] Consider using a 0.2 or 0.22 micron Millipore filter: Sterilizing-grade filter to remove possible microorganisms or micro particles.

3] When adding a drug to artificial tears e.g. Tears Naturale, aseptically remove the dropper head in a laminar flow hood. Do not attempt to use a needle through the dropper head, which may alter the intended drop size).

Fortified Gentamicin or Tobramycin (14 mg/ml):

Start with the commercially available solution: Gentamicin 0.3% 5ml (15 mg/5 ml) ophthalmic solution or Tobramycin 0.3% 5ml (15 mg/5 ml) ophthalmic solution (Add 2 ml of gentamicin or tobramycin injection (80mg/2ml) to the respective ophthalmic solution.  Note: actual concentration ~ 13.6mg/ml.

Label: 
Concentration: 14 mg/ml.
For the eye. Protect from light. Store at room temperature.
Do not use if solution becomes cloudy or discolored.
Expires: 7- 10 days. (variable)

Fortified Amikacin (14 mg/ml):

Withdraw 0.56 mL of Amikacin (500 mg/2mL) and add to 9.5 mL ml sterile water (without preservative).
Alternatively, use  9.5mL of artificial tears.  Pull the entire contents of the artificial tears into the syringe and discard excess to ensure the correct volume is used. 

Label: 
Concentration: 14 mg/ml.
For the eye. Protect from light. Store at room temperature.
Do not use if solution becomes cloudy or discolored.
Expires: 7 days.

Fortified Ancef (Cefazolin) (50 mg/ml):

Reconstitute 1 gram cefazolin powder with 5ml (200mg/ml) sterile water (without preservative) or reconstitute 500mg vial with 2.5 ml. Then you may use any of the following dilutions:

• Add 1 ml to 3 ml artificial tears. Final concentration: 50 mg/ml. Refrigerate. Reported stability: 4-7 days.
• Add 2 ml to 6 ml of artificial tears. Final concentration: 50 mg/ml. Refrigerate. Reported stability: 4-7 days.
• AAdd 4 ml to 12 ml artificial tears. Final concentration: 50 mg/ml. Refrigerate. Reported stability: 4-7 days.

Alternative procedure:  Add 9.2 mL of artificial tears to 1 gram of Ancef – dissolve.   Take 5 mL of solution from this vial and add it to 5 mL of artificial tears. 

Label: 
Concentration: 50 mg/ml.
For the eye. Protect from light. Refrigerate.
Do not use if solution becomes cloudy or discolored.
Expires: 7 days.

Vancomycin ophthalmic drops :

(Usual concentration: 25-50 mg/ml). Some studies have found the 25 mg/mL concentration to have similar efficacy compared to the 50mg/ml concentration and with better patient tolerance.
Preparation (50 mg/ml):
Reconstitute 500mg Vancomycin powder with 10 ml sterile water (without preservative).
Alternatively, use 10ml of artificial tears.

Label:
Concentration: 50 mg/ml,
For the eye. Protect from light. Refrigerate.
Do not use if solution becomes cloudy or discolored.
Expires: 4 days.

Dosing: (Adult Dose) 1 drop hourly for first 24 hours, then taper gradually according to clinical improvement

 INSULIN, ASPART sliding scale:

 METHACHOLINE CHALLENGE:

Medication is in a 100mg glass bottle – 4ml NS is added to the bottle which is designated as “VIAL A” (the “stock solution”).  25 mg/ml

Serial dilution continues as follows:
Obtain five 10 ml NS vials, and label as follows:

METHACHOLINE CHLORIDE (VIAL B):  Conc: 0.625 mg/ml.
0.2  ML VIAL A + 8 ML NS  (10ml NS vial – REMOVE 2.2 ml. Add 0.2ml from vial A)

METHACHOLINE CHLORIDE (VIAL C): Conc: 1.25 mg/ml.
0.2  ML VIAL A + 4 ML NS   (10ml NS vial – REMOVE 6.2 ml. Add 0.2ml from vial A)

METHACHOLINE CHLORIDE (VIAL D): Conc: 2.5 mg/ml.
0.5  ML VIAL A + 5 ML NS   (10ml NS vial – REMOVE 5.5 ml. Add 0.5ml from vial A)

METHACHOLINE CHLORIDE (VIAL E):  Conc: 5 mg/ml.
0.5  ML VIAL A + 2 ML NS  (10ml NS vial – REMOVE 8 ml. Add 0.5ml from vial A)

METHACHOLINE CHLORIDE (VIAL F): Conc: 10 mg/ml.
1.0  ML VIAL A + 1.5 ML NS  (10ml NS vial – REMOVE 8.5 ml. Add 1 ml from vial A)

 MITOMYCIN for ophthalmic use:

Morphine PCA settings:

(6) Schedule Type: FILL on REQUEST
*(8) Schedule: PRN
(9) Admin Times: **(10) Provider: —–
(11) Special Instructions: (see below)
LOADING DOSE=0 MG, LOCKOUT=6 MINUTES, 4 HOUR LIMIT=30 MG, DOSE LIMIT=1MG, CONTINUOUS RATE: = 0 MG/HR

Pain service protocol:
SPECIAL INSTRUCTIONS:
1. For PCA, Intermittent Dose __1__mg (usual dose 0.5-2 mg) 2. Lockout Interval _8_minutes (usual 6-10 minutes) 3. 4 Hour Limit _30_mg (usual 20-30 mg) 4. If pain not controlled after 1 hour, increase the Intermittent PCA Dose by ____mg and maintain at increased dose (usual increase is by 50 %) 5. If pain still not controlled in one additional hour, reduce Lockout Interval to ___minutes and maintain at reduced interval (usual 1-2 minutes reduction). 6. Continue for 3 days. 7.Call Service for uncontrolled pain.

 Neomycin Irrigation:

Ropivacaine cocktail (Knee arthroplasty):

Studie(s):
Andersen KV, Nikolajsen L, Haraldsted V, Odgaard A, Søballe K.   Local infiltration analgesia for total knee arthroplasty: should ketorolac be added?   Br J Anaesth. 2013 Aug;111(2):242-8. doi: 10.1093/bja/aet030. Epub 2013 Mar 20.

BACKGROUND:
Adequate postoperative analgesia with minimal side-effects is essential for early mobilization and recovery in patients undergoing total knee arthroplasty (TKA). High-volume local infiltration analgesia (LIA) with ropivacaine has been introduced, but effects of adjuvants are still debated. We tested the hypothesis that the addition of ketorolac to LIA significantly improves analgesia after TKA.
METHODS:
Sixty patients undergoing TKA were randomized to receive intraoperative LIA (ropivacaine 300 mg and epinephrine 0.5 mg) combined with either ketorolac 30 mg (ketorolac group) or saline (control group). After surgery, eight bolus doses of ropivacaine 100 mg combined with either ketorolac 15 mg (ketorolac group) or saline (control group) were administered every 6 h via an intra-articular catheter. The primary outcome was postoperative consumption of i.v. morphine patient-controlled analgesia (PCA). Secondary outcomes were time to first request of i.v. morphine PCA, pain intensity, side-effects, and readiness for hospital discharge.
RESULTS:

Consumption of i.v. morphine PCA was lower in the ketorolac group vs control group {0-6 h: 0 (0-0) vs 5 (0-10) mg, P<0.0001; 0-48 h: 10 (0-22.5) vs 48.75 (30-82.5) mg, P<0.0001 [median (inter-quartile range, IQR)]}. Time to first request of i.v. morphine PCA was longer in the ketorolac group vs the control group [490 (248-617) vs 223 (115-319) min, P=0.02, median (IQR)]. Early postoperative pain (<48 h) and readiness for hospital discharge were also significantly reduced in the ketorolac group.
CONCLUSIONS:
LIA with ketorolac results in reduced morphine consumption, reduced pain intensity, and earlier readiness for hospital discharge.

 Tumescent solution for liposuction (Lidocaine + Epi):

VA Central Lines – Flush Protocols:

*Use 10cc syringes only
*Change IV tubing every 24 hours when administering blood, blood products, Lipids, or TPN
*Change all central venous access dressomgs 24 hours after insertion of line and every 7 days thereafter.
*Securement devices, i.e. Statlocks are recommended.

Rifampin Irrigation:

Background:
Penile prosthesis infection risk reduced with solution
Rifampin-gentamicin formula found efficacious against S. epidermidis, E. coli

“Dr. Dhabuwala said that he now employs two rifampin-gentamicin solutions during implant procedures. He irrigates the surgical bed with a solution of rifampin, 1 mg/mL, plus gentamicin, 1 mg/mL (R1/G1 solution) throughout the procedure and then, using a syringe, he coats the surface of the implant with a rifampin, 10 mg/mL, plus gentamicin, 1 mg/mL solution (R10/G1 solution).”

“The solutions Dr. Dhabuwala now uses were the result of a series of tests designed to identify the combination of antimicrobials that would provide the greatest protection against S. epidermidis and E. coli infection. He tested six different solutions against a saline control and against strips of InhibiZone (American Medical Systems, Minnetonka, MN), the antibiotic impregnating the surface of AMS penile implants. The solutions included varied concentrations of rifampin alone, rifampin plus gentamicin, rifampin plus gentamicin plus vancomycin, and bacitracin plus gentamicin. These were coated on strips of the Titan implant material and subjected to zone of inhibition studies.”

“Dr. Dhabuwala and colleagues found that two rifampin-based solutions (R1/G1 and R10/G1) produced the strongest bactericidal effects. Their zones of inhibition appeared to be 40% to 56% greater than those produced by InhibiZone-coated strips.”

– See more at (SOURCE): http://urologytimes.modernmedicine.com/urology-times/news/modernmedicine/modern-medicine-news/penile-prosthesis-infection-risk-reduced-solu?page=full#sthash.SedyXbTH.dpuf

:

Orderable Item:
Dosage Ordered:
Med Route:
Schedule Type:
Schedule:
Special Instructions:

Consult Note Section

Dose by levels patient (Vanco):

Pharmacokinetic Dosing Service:
Date:            Time:

Diagnosis:
Scr:      height:    weight:
Relevant medical/social history:     Culture and sensitivities:      Other labs:

IBW:   kg    Dosing wt:   kg
Estimated CrCL:     mL/min
Estimated pk parameters:   kel:      Vd:

—————————————-
Recommendations:
—————————————-
Patient will be dosed by levels.  A PRN order for Vanco (dose:     mg) will be entered.
DOSE WILL BE REPEATED WHENEVER THE RANDOM TROUGH LEVEL
FALLS BELOW 20 MCG/ML.

First dose was infused at:   Time:        Date:
A random level will be ordered  for Date:            Time:

Estimated regimen:
Vancomycin ____mg q48-72 hrs.
Expected trough:  <20 mcg/mL  [range: 15-20 mcg/mL)

A/P:
1]  Recommend Vancomycin ___mg IV q__
2]  Measure BUN and SCR three times/week.
     Consider I/O monitoring (urine output).
3]  Monitor trough level prior to 4th dose.

Will continue to follow with medical team.

ELEVATED or Sub-therapeutic Vanco Level Obtained:

PHARMACOKINETIC DOSING: Vancomycin
Date:    
Time:

Diagnosis:
—–
Patient responding to therapy:  WBC decreasing?      Signs/SX: decreasing?
—–

CURRENT VANCOMCYIN REGIMEN:
CURRENT VANCOMYCIN TROUGH/LEVEL:    mcg/mL   @______ AM/PM
TARGET VANCOMYIN TROUGH:  15 -20 mcg/mL   (Peak: 28-40 mcg/mL)

INTERPRETATION: 
1] Level was drawn ___hours early. 
2] The last dose was hung @_____ (early or late?) [REVIEW]
3] Based on the estimated elimination constant (Kel ) __optional__, the extrapolated
or actual trough would be ______ mcg/mL (e.g. just prior to next scheduled dose).
  
TIP:  (use following program  to calculate estimated future trough: trough.htm)

———————————–
if HIGH trough obtained:
———————————–
A/P:
1]  Skip the next dose and restart Vanco @_____  Dose: ____ mg.   Schedule:____
2] A trough level will be ordered just before the 4th dose of the new regimen.
3] Please obtain BUN/SCR 3x/week.

———————————–
if LOW trough obtained:
———————————–
A/P:
1]  The current vancomycin dose will be increased in order to target the desired
       trough range of 15-20 mcg/mL.
2]  New regimen:  Give Vanco @_____  Dose: ____ mg.   Schedule:____
3] A trough level will be ordered just before the 4th dose of the new regimen.
4] Please obtain BUN/SCR 3x/week.

———————————–
if DESIRED trough obtained:
———————————–
A/P:
1]  Continue with the current vancomycin regimen for now.  [TARGET trough: 15-20 mcg/mL]
2]  Curent regimen:  Vanco ____ mg   q__hr
3]  Will request a follow-up trough early next week.
4]  Please obtain BUN/SCR 3x/week.