Outpatient IV Antibiotic Order Form

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  • Alteplase 2mg IV to declot central IV access per Infusion Solutions protocol as needed for occlusion.
  • Flush line with D5W, 0.9% NaCl and/or Heparin 10 units/ml or 100 units/ml per Infusion Solutions protocol.
  • Lidocaine 1% - up to 0.2ml intradermally PRN (may buffer with sodium bicarbonate 8.4% in 10:1 ratio).
  • Infusion Reaction Management per Infusion Solutions protocol as needed.

Last Dose in Hospital:

First Dose in Home:

Clinical Pharmacy orders for Drug level monitoring:

Nursing Orders:

Line Flush

** This standard Flush Protocol is for ADULTS only. MD/NP must complete specific flush protocol below for any paediatric clients on IV therapy.

Type of pm Adaptor: Positive Pressure Device (PPD) Pre-Infusion Flush: 3 cc NS Maintenance Flush: 3 cc NS q 24 hours Pre and Post Blood Drawing: N/A Pre and Post Intermittent TPN Flushing Protocol for Continuous Infusion Pumps: Change site q72 hours

Type of pm Adaptor: (PPD) Pre-Infusion Flush: 10 cc NS Maintenance Flush: 10 cc NS q 24 hours Pre and Post Blood Drawing: N/A Pre and Post Intermittent TPN: N/A Flushing Protocol for Continuous Infusion Pumps: Flush with 10 cc NS with each tubing change

Type of pm Adaptor: PPD Pre-Infusion Flush: 10 cc NS Maintenance Flush: 10 cc NS Weekly Pre and Post Blood Drawing: Pre: 20 cc NS. Post: 20 cc NS Pre and Post Intermittent TPN: Pre: 20 cc NS. Post: 20 cc NS Flushing Protocol for Continuous Infusion Pumps: Flush with 10 cc NS with each tubing change

Type of pm Adaptor: PPD Pre-Infusion Flush: 10 cc NS Maintenance Flush: 10 cc NS Weekly Pre and Post Blood Drawing: Pre: 20 cc NS. Post: 20 cc NS Pre and Post Intermittent TPN: Pre: 20 cc NS. Post: 20 cc NS Flushing Protocol for Continuous Infusion Pumps: Flush with 10 cc NS with each tubing change

Type of pm Adaptor: PPD Pre-Infusion Flush: 10 cc NS Maintenance Flush: 10 cc NS Weekly Pre and Post Blood Drawing: Pre: 20 cc NS. Post: 20 cc NS Pre and Post Intermittent TPN: Pre: 20 cc NS. Post: 20 cc NS Flushing Protocol for Continuous Infusion Pumps: Flush with 10 cc NS with each tubing change

Type of pm Adaptor: N/A Pre-Infusion Flush: 10 cc NS followed by 5cc 100 U/ml hepalean Maintenance Flush: 10 cc NS followed by 5 cc 100 U/ml hepalean q 4 weeks Pre and Post Blood Drawing: Pre: 20 cc NS. Post: 20 cc NS followed by 5 cc 100 U/ml hepalean Pre and Post Intermittent TPN: Pre: 20 cc NS. Post: 20 cc NS followed by 5 cc 100 U/ml hepalean Flushing Protocol for Continuous Infusion Pumps: Flush with 10 cc NS with each tubing change

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