What are the guidelines for preparing and diluting anesthetic drugs in patients with varying demographics and medical conditions?

Drug Preparation and Dilution in Anesthesia

All anesthesia departments must implement validated, standardized protocols for drug preparation and dilution that specify exact concentrations, solvents, administration routes, rates, and container sizes to ensure practice uniformity and minimize fatal medication errors. 1

Mandatory Standardization Requirements

Department-Wide Protocols

• Establish formal written protocols that detail dilution specifications, solvent types, duration and rate of administration, and route for every anesthetic medication used in your facility 1
• Post these protocols in all locations where anesthesia trays are prepared, including operating suites and post-anesthesia care units 1
• Limit each anesthesia tray to a single concentration of any given medication unless absolutely indispensable 1

Anesthesia Tray Preparation

• Prepare all trays according to pre-established departmental protocols in a standardized manner 1
• Label each tray with: date and time of preparation, name of person who prepared it, and patient identification label 1
• Use pre-filled syringes for emergency medications not routinely used (atropine, ephedrine, phenylephrine) to reduce preparation errors 1

Syringe Labeling System

International Color Coding

• Apply ISO 26825 standard labels to every syringe showing international color coding for the pharmacological class 1
• Include preprinted blank space on each label for recording concentration (dose per volume) with units 1
• Write the administration route in full on each label using colored labels with distinctive borders 1

Special Precautions for Neuromuscular Blockers

• Add supplementary labels to neuromuscular blocking agent syringes beyond standard color coding, as their colors are similar to midazolam 1
• Place additional labels on the syringe plunger, at the base of the plunger, or overlapping the syringe and needle 1

Drug-Specific Dilution Guidelines

Propofol for ICU Sedation

• Dilute only with 5% Dextrose Injection, USP if dilution is necessary 2
• Never dilute to concentrations less than 2 mg/mL because propofol is an emulsion 2
• Initiate ICU sedation at 5 mcg/kg/min (0.3 mg/kg/h), increasing by 5-10 mcg/kg/min increments with minimum 5-minute intervals between adjustments 2
• Most adults require maintenance rates of 5-50 mcg/kg/min (0.3-3 mg/kg/h), not exceeding 4 mg/kg/hour unless benefits outweigh risks 2

Rocuronium Infusion Preparation

• Mix rocuronium with 5% glucose in water or lactated Ringer's solution for infusion 3
• Use infusion solutions within 24 hours of mixing; discard unused portions 3
• Prepare three standard concentrations: 0.5 mg/mL (50 mg in 100 mL), 1 mg/mL (100 mg in 100 mL), or 5 mg/mL (500 mg in 100 mL) 3
• Initiate infusion at 10-12 mcg/kg/min only after early evidence of spontaneous recovery from intubating dose 3

Local Anesthetic Maximum Doses

• Calculate maximum safe dose before administration to prevent toxic overdose 1
• Lidocaine maximum: 7.0 mg/kg with epinephrine, 4.4 mg/kg without epinephrine 1
• Bupivacaine maximum: 3.0 mg/kg with epinephrine, 2.5 mg/kg without epinephrine 1
• Reduce amide local anesthetic doses by 30% in infants younger than 6 months 1

Critical Safety Protocols

Neuraxial Anesthesia Double-Check System

• Read medication information aloud twice before preparing syringes for spinal or epidural anesthesia 1
• The person providing medications and the person receiving them under sterile conditions must both verbalize: International Nonproprietary Name (INN), amount of drug, volume, and concentration 1
• Use only colored antiseptics to prevent confusion with injectable anesthetics or saline, as inadvertent injection of chlorhexidine causes serious patient harm 1

Sedation Drug Administration

• Administer intravenous sedatives in small incremental doses or by infusion, titrating to desired endpoints 1
• Allow sufficient time between doses for peak effect assessment before subsequent administration 1
• For nonintravenous routes (oral, rectal, intramuscular, transmucosal), allow adequate time for absorption and peak effect before supplementation 1

Drug-Sparing Strategies During Shortages

• Prioritize regional anesthesia and infiltration techniques whenever possible to conserve propofol, midazolam, and neuromuscular blockers 1
• Implement drug-saving anesthetic strategies in both adults and children during supply shortages 1

Monitoring and Error Prevention

Storage System Appraisal

• Implement continuous processes to evaluate medication storage systems in operating rooms, post-anesthesia care units, and intensive care units 1
• Ensure storage systems comply with institutional general rules 1

Error Analysis and Feedback

• Analyze all actual or potential medication errors using validated methods (e.g., REMED) 1
• Provide feedback to involved teams and other departments as appropriate 1
• Establish regular links between feedback committees and risk projection models to refine preventive measures 1

Common Pitfalls to Avoid

• Never mix propofol with other therapeutic agents prior to administration 2
• Avoid using filters with pore size less than 5 microns for propofol unless demonstrated safe, as they may restrict flow or break down the emulsion 2
• Do not place antiseptics and injectable anesthetics in similar sterile cups during neuraxial procedures due to high confusion risk 1
• Recognize that drug combinations (sedatives plus opioids) require dose reduction of each component and continuous respiratory monitoring due to synergistic respiratory depression 1