Jan 29, 2018
jess asked
Hi. I need to hang Amiodarone, Ampicillin-Sulbactam, Cefepime, Diltiazem, Dopamine, Fentanyl, Propofol, and Phenytoin in a triple lumen catheter and a peripheral IV but cannot figure it out! thanks
Answer
Administration of medications in the ICU setting may be difficult when a patient is on several continuous and intermittent infusions. It is difficult to answer this question without knowing the specifics about which medications are continuous and which are intermittent. Also, drug dosing and concentration are important to understand in this situation. I would strongly recommend consulting with your institution’s pharmacist, but I can give some general advice for this type of situation. Also check out your institution’s policies and guidelines on this topic as each institution may vary.
Discontinuing unnecessary medications
First, it is important to ask the question “does the patient still need all of these medications?” The patient status is dynamic in the ICU setting and it is critical to continuously assess the need for each medication. Discuss with your pharmacist or physician as appropriate. A couple of questions that may help in this situation:
Sedatives (Fentanyl & Propofol)
- What is the sedation goal and when should we wean the drug?
Antibiotics (Ampicillin-sulbactam & Cefepime)
- Is this empiric treatment or for a specific pathogen?
- What is the duration of therapy?
- If giving multiple antibiotics: do these make sense to be used together?
Amiodarone
- Is this a maintenance or loading dose?
- What is the plan once the patient is stable?
Diltiazem
- What is the heart rate goal?
- What is the plan once the patient is stable?
Dopamine
- What is the indication and when can we wean the patient off?
Phenytoin
- Is this prophylaxis or treatment?
Administration specific questions
- Can this medication be given by a different route or infusion duration?
- Can any medication be given IV push or over shorter duration?
- Can the medication be crushed and given via G-tube?
- Should the timing of some medications be tweaked to better utilize the lines?
- Can this medication be temporarily paused?
- Which medications require central lines?
- Which medications are compatible?
Tips about your patient’s medications
Ampicillin-sulbactam (Unasyn)
- Can be given as IV infusion over 15-30 minutes. Given too quickly as IV push increases risk of causing seizures
Cefepime
- Can be given as 30 minute infusion
Phenytoin
- May be irritating to tissue and must be given via central line or peripheral vein at least as large as antecubital fossa vein
- Should use an in-line filter between 0.22 and 0.55 microns
- Max infusion rate of 50 mg/minute
- Not compatible with dopamine
Amiodarone
- Maintenance infusion typically 0.5 mg/minute
- In-line filter recommended
- Central line recommended when concentration exceeds 2 mg/mL for longer than 1 hour
Dopamine
- Large vein/central line recommended to avoid extravasation
- Not compatible with phenytoin
Propofol
- Should not be given through same line as blood or plasma
- Due to milky, lipid appearance may be difficult to assess precipitation
Fentanyl
- Should be titrated based on patient’s response and sedative goals
After assessing all of the above and you still don’t have enough lines you have a couple of options remaining. First, is it possible to add more lines? Second, is it possible to temporarily pause one of the continuous infusions? Both of these should be options should be discussed with the patient’s physician and/or pharmacist.
Source: Package inserts for each drug
