REVIEWING THE
`
`“BIG THREE”
`INJECTION ROUTES
`
`Make sure you know
`
`how and why to infect
`
`drugs subcutaneously;
`
`intramuscular!» and
`
` intravenously.
`
` ea rn
`
`OU PRACTICE [Iv 5N AGE OF BURGEONING TECH-
`noiogy, rising health care costs, and per-
`sistent fear of acquired irnmunodefi-
`ciency syndrome. So nothing you do can
`be taken for granted anymore—espe-
`cially giving injections.
`That’s why you need to understand
`the advantages of the different injection
`routes. In this article, we’ll focus on the
`
`BY MARIAN NEWTON’ RN, MN PhD
`filinicol Nur|s£Ii1S eciolist
`'
`em‘ H90?
`WC
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`_
`Ezflfil 5' Smm°" Veteram Afiuws Medml
`Albany, New York
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`Albany, New York
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`
`“big three“ — subcutaneous (S.C.), intra-
`muscular (I.M.), and intravenous (I.V.)—
`and offer you tips for using each.
`
`Slower absorption from the S.C. route
`The S.C. injection route, which has been
`around since the 18605, makes use of
`adipose and connective tissue under the
`skin and above skeletal muscles to pro-
`mote systemic drug action. The best
`sites yield a 1-inch (2.5-cm) fat fold
`when pinched and havesrelatixieiy few
`sensor nerve endings.
`evera
`actors
`determyine how well the medication is
`absorbed from the site you’ve chosen:
`the patient's cardiovascular and fluid sta-
`tus, physical build, condition of subcuta-
`neous tissue, and your injection slcills.
`Absorption from an S.C.
`l[1_}ECtlUl'1 oc-
`curs by relatively slow diffusion into the
`capillaries—the rate is 1 to 2 ml per
`hour per injection site. So when a drug
`is given S.C. rather than [.M., initial
`
`Gmzv ELDRIDGE
`
`34
`
`NURSWG92, FEBRUARY
`
`MYLAN PHARMS. INC. EXHIBIT 1054 PAGE 1
`
`MYLAN PHARMS. INC. EXHIBIT 1054 PAGE 1
`
`

`
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`MYLAN PHARMS. INC. EXHIBIT 1054 PAGE 2
`
`MYLAN PHARMS. INC. EXHIBIT 1054 PAGE 2
`
`

`
`blood concentrations of the drug will be
`lower but the drug’s effects will last
`longer.
`Because of its high potency, however.
`epinephrine is usually effective when
`given S.C. for an acute allergic reaction.
`If it’s accidentally injected I.M., it could
`cause life-threatening hypertension and
`arrhythmias.
`Be aware that the SC. route‘s slow ab-
`sorption rate, as well as the drugs ef-
`fects, could markedIy— and danger-
`ous1y—increase if the patient exercises,
`warms, or elevates the site after an in-
`jection. For example, an insulin-
`dcpendent diabetic patient could develop
`acute hypoglycemia from previously un-
`absorbed insulin if he goes for a 2-mile
`jog.
`
`Potential dangers
`Speaking of insulin, it’s the drug most
`commonly injected S.C. But the route is
`also appropriate for many other drugs
`that are watery, not cytotoxic, nonirritat-
`ing, and well-absorbed from adipose and
`connective tissue. Keep in mind that
`technique is important when injecting
`these drugs—the patient could have a
`dangerous response if you mistakenly in-
`ject certain drugs (such as insulin) I.M.
`instead of S.C.
`
`To prevent subcutaneous tissue dam-
`age, irritating or concentrated drugs are
`usually given I.M. An irritating solution
`that's mistakenly given S.C. can cause
`tissue ischemia and necrosis. Also, con-
`centrated drug solutions injected S.C.
`can cause sterile abscesses.
`
`You’re probably careful to rotate sites
`when your patient needs repeated S.C.
`injections. But current research shows a
`strict rotation schedule isn’t always nec-
`essary. You can use a site until the pa-
`tient complains of discomfort, you notice
`pitting or lumping from lipodystrophy, or
`the drug—such as insulin—doesn‘t seem
`to be working (indicating poor absorp-
`tion from the site).
`Sterile and nonsterile abscesses, cysts,
`granulomas, and nodules are common
`among drug abusers who inject suspen-
`sions made from capsules and tablets.
`These immune reactions can be caused
`by injecting irritating solutions, solutions
`containing invisible microcrystals (such
`as talc and cellulose found in oral dos-
`age forms), or more than 1 ml of a drug
`per site. Overusing a site can also cause
`these problems.
`
`Advantages of LM. injections
`Properly administered, an I.M. injection
`deposits medication under the muscle
`36
`Nu RstNol)2. Fl:BRU'.v\RY
`
`Research new
`
`shows that at
`
`uric! rotation
`
`schedule for
`
`Insulin
`
`infections
`
`Isa’! always
`
`necessary.
`
`fascia below the fatty subcutaneous layer.
`This skeletal muscle has fewer pain-
`sensing nerves than the subcutaneous
`tissue. A larger volume of drug (up to 5
`ml) can be injected I.M. because fluid
`spreads rapidly among the muscles elas-
`tic fibers; it's also absorbed into the
`
`bloodstream more quickly. So you'll usu-
`ally choose a.n I.M. site over an S.C. site
`when you're giving an irritating drug or
`when you want a more rapid onset of ac-
`tion or a stronger pharmaeologic effect.
`Make sure you aspirate the plunger
`before injecting a drug l.M. so that you
`don’t mistakenly give it I.V. If you see
`blood flashback in the syringe, don’t in-
`ject the drug.
`The l.M. route has some advantages
`over the LV. route. It can be used for
`potent drugs that aren't cytotoxic, plus
`aqueous suspensions and solutions in
`vegetable oil that could cause emboli if
`givett LV.
`In some cases, though, the LV. route
`is replacing [.M. injections. Giving nar-
`cotics [.V. using a microcomputer pump,
`for example, spares the patient repeated
`I.M. injections, which could irritate the
`site and result in erratic absorption. Be-
`sides eliminating those problems. [M ad-
`ministration delivers an exact dose di-
`rectly into the bloodstream. so the onset
`of action is faster and more predictable.
`
`Comparing l.M. injection sites
`The I.M. injection site you choose will
`depend on the volume of the drug, how
`irritating it is, the patients age, and
`muscle condition. Here's what you should
`know about these sites.
`
`0 The donrogirtreal site may be the most
`dangerous: An injection given too low or
`too close to the buttocks crease could
`permanently damage the sciatic nerve or
`puncture the superior gluteal artery.
`0 The vcnrroglttrcal site (glutcus rnedius
`and minimus) lacks major nerves or
`blood vessels and has dense muscles. Its
`
`a better choice for debilitated patients
`and a safe alternative to the dorsogluteal
`site.
`
`0 The vastus laterafis site, which is also
`free from major nerves and blood ves-
`sels,
`is usually well-developed in adults
`and walking children, and it’s easily ac-
`cessible. However, it does have a number
`of small nerve endings, so many patients
`complain of pain after the injection.
`0 The rieltoirl site has a small muscle
`mass, so you can’t give more than 2 ml
`of medication in a single injection. It's
`close to the radial nerve and the deep
`brachial artery. But it provides easy ac-
`cess for I.M. injections, such as tetanus
`
`MYLAN PHARMS. INC. EXHIBIT 1054 PAGE 3
`
`MYLAN PHARMS. INC. EXHIBIT 1054 PAGE 3
`
`

`
`A CLOSER LOOK AT THE
`BIG THREE ROUTES
`
`liaule
`
`Site
`
`Needle
`
`Volume range (ml)
`
`$.C.
`
`Fat pads at the lateral
`abdomen, scopulae, hips,
`below beltline, lateral
`arms above the elbow
`
`25-27 gauge, ‘/2-
`1
`in (1.3-2.5 cm)
`
`I.M.
`
`I Deltaid
`
`22-25 gauge, 1-1 ‘/2
`in (2.5-3.8 cm)
`
`0.1-1
`
`0.1-2
`
`Onset and duration of
`action
`
`Onset: minutes
`(epinephrine, for example)
`to hours
`Duration: hours to weeks
`
`Onset: less than 1 hr
`Duration: hours to weeks
`
`I Dorsogluteal [gluteus
`maximus]
`
`20-23 gauge,
`(3.8-7.6 cm)
`
`1 ‘/2-3 in
`
`0.1-5
`
`Same as deltoid
`
`I Ventrogluteal (gluteus
`medius and minimus}
`
`I Vastus Iateralis {outer
`midthigh)
`
`l.V.
`
`Basilic and cephalic veins
`in the forearm for adults
`and children; basilic,
`cephalic, marginal, scalp,
`and small saphenous
`veins for infants
`
`Same as dorsogluteal
`
`Same as dorsogluteal
`
`Same as deltoid
`
`Adults: 0.1-5; children,
`infants: 0.1-1
`
`Same as deltaid
`
`For adults and children,
`0.1 -1,000/hr [children
`are at the lower end); for
`infants, 0.1-10/hr
`
`Onset: instant
`Duration: seconds to
`hours
`
`Adults: 20-23 gauge,
`1‘/2-2 in (3.8-5.1 cm);
`children, infants: 23-26
`gauge, 1% in (3.3 cm]
`
`Needles for adults and
`children:
`l6—23 gauge,
`l—l '/2 in (2.5-3.8 cm);
`catheters for adults and
`children: 16-22 gauge,
`2-12 in (5.1-30.48 cm),-
`needles for infants: 23-
`25 gauge, 5/a-1 in (1.6-
`2.5 cm)
`
`9 STEPS TO REDUCING Tl-IE PAIN
`OF I.M. INJECTIONS
`
`1 . Encourage the patient to relax
`the muscle you'll be injecting; in-
`iecting into a tense muscle causes
`more bleeding and pain.
`The following techniques will re-
`lax the appropriate muscles. For
`gluteal infections, the patient
`should lie facedown, stand with his
`toes pointed inward, or lie on his
`side with the upper leg drawn up
`in front of the lower one. For a
`vastus lateralis infection, the pa-
`tient's toes should point in so the
`hip rotates internally. And for a
`deltoid injection, the patient should
`flex his elbow and support the
`lower arm.
`
`2. Avoid especially sensitive
`areas. When you choose an iniec-
`tion site, roll the muscle mass with
`your fingers and watch for twitch-
`ing, an indication that the area is
`too sensitive.
`
`3. If the patient is very appre-
`hensive, numb the site briefly by
`holding ice on it or by spraying an
`anesthetic coolant on it before
`you've applied an antiseptic.
`
`4.Woit until the antiseptic is dry.
`Wet antiseptic could cling to the
`needle and cause pain when you
`insert the needle.
`
`5. After you draw up the drug,
`change needles. A need|e's point
`and bevel can be dulled when you
`puncture the drug viaI’s stopper,
`and dull needles hurt. By changing
`needles, you eliminate another
`source of pain: medication that
`clings to the outside of the needle
`when you draw medication out of
`the vial or ampule.
`
`6. Insert the needle smoothly
`and rapidly to minimize puncture
`pain. As you're doing so, try to dis-
`tract the patient's attention.
`
`7. if the needle is properly
`placed, iniect the drug slowly to
`avoid creating high pressure in the
`muscle.
`
`8. Withdraw the needle smoothly
`and rapidly.
`
`9. Unless contraindicated by the
`medication (iron dextran, for exam-
`ple), gently massage the relaxed
`muscle to distribute the drug better
`and increase absorption. This helps
`reduce pain caused by tissue
`stretching from a large-volume in-
`jection. (Lightly exercising the in-
`jected muscle does the some
`thing.)
`
`MYLAN PHARMS. INC. EXHIBIT 1054 PAGE 4
`
`MYLAN PHARMS. INC. EXHIBIT 1054 PAGE 4
`
`

`
`
`
`
`
`
`
`A2-éinnclt
`1'[IN_-lEc_‘l_ON- t
`_ The-fIrt‘rdck_-me¥I1od''"
`'wustdesrgned'
`édn
`
`I
`
`'
`
`t
`
`~
`
`~
`
`béusa it-seats the med'Icut'ron inthe
`Ienku9e.'.But
`it for gther. LM. drugs
`
`ytcnycan
`
`"
`
`"
`'-
`
`.
`
`site w_‘rthT ahfisepfic and T
`-:'rf—5|.O dry
`tbisptnce the skin u1rIds_ubcu'tu-
`naogs=-tis_s.ue’ |c,:t'ar:I'll_y-"at fans: I
`inE_h flI!&l"1'h6 target
`(thigh;
`glutiat-5, orany
`-huge
`.anoug_h‘for a clasp LM. 'injec.tio'r|}.
`'.
`_ needla dt_cI_90-degree
`angle up to the hub;
`"9 Aspimte-to-‘be sure the needle
`'i'sn'.t' in dblood vessel.
`lniegt the medication slowly.
`".0 Wfiit 'l0,*sBc.‘oni'1s_.- than withdrflw '
`the
`.
`Ofletaase the retracted--tissue to
`cnegate at loakprdofzigzag‘ path.
`I"Dorn"t
`the iniection site,
`.Oth_atwise, the ma'di¢cI'tion' could .
`teak back along th" zigzag path.
`T|1is'w6uid cause 'rrritution_',-‘
`the
`_ patihnt wouldn5t- get the intended
`
`'
`
`Displuca t. skin -anW
`
`t1's',§I;':a‘-I::"le:r“|:ft1)}.
`
`
`
`Release
`
`tissuejto :"i7m:ita~u‘
`
`‘polh,
`
`‘
`
`I
`
`_=JI;:fH‘I§T.N1uiIFtIv
`MYLAN PHARMSJNQ EXHLBL1;1ds4tPAGE 5% J t “ %
`MYLAN PHARMS. INC. EXHIBIT 1054 PAGE 5
`
`

`
`toxoid boosters, that are often given in
`outpatient settings. Plus, medication is
`absorbed faster from this site, as we'll
`explain below.
`
`Problems with I.M. absorption
`Absorption rates from muscle tissue may
`vary from site to site. For example, ab-
`sorption is faster from the arm than the
`thigh, and faster from the thigh than the
`buttock. In fact, studies have shown that
`blood flow in the deltoid muscle is 7%
`greater than that of the vastus lateralis
`and 17% greater than that of the gluten]
`muscles. So injections in the deltoid pro-
`vide the fastest and highest peak serum
`concentrations of drugs such as haloperi~
`dol (Haldol), lorazepam (Ativan). and
`chlordiazepoxide HCl (Librium).
`But poor injection technique can
`impede absorption from any I.M. site. In
`a classic British study. researchers mea-
`sured serum levels of diazepam (Valium)
`after doctors injected 10 mg of the drug
`into their patients’ buttocks. Then they
`measured the levels of other patients af-
`ter nurses injected the drug. The result:
`Serum levels were two-and—n-hagfrimes
`higher in the patients injected by the
`doctors.
`
`Technique seemed to account for the
`difierence. The doctors routinely used
`1‘/2-inch (3.8-cm) needles; the nurses
`used smaller ll/4-inch (3.2-cm) needles,
`
`Deltoid
`
`infections
`
`provide the
`
`fastest and
`
`highest peak
`
`serum
`
`concentrations
`
`of some
`
`drugs.
`
`probably to save their patients from un-
`necessary pain.
`As you know, needles are usually in-
`serted to three—fourths of their length.
`So the nurses who used the shorter nee-
`dles probably injected the diazepam into
`subcutaneous tissue instead of muscle.
`No doubt the poor blood supply and
`high fat content of subcutaneous tissue
`limited the bioavailability of the diaze-
`pam, which tends to collect in fatty tis-
`sue anyway.
`Compared with oral drugs, l.M. drugs
`are generally absorbed faster. But that
`doesn’t always hold true. Chlordiazepox-
`ide, diazeparn, digoxin (Lanoxin), and
`phenytoin (Dilantin) are less dependable
`when given I.M. rather than orally.
`These I.M. solutions contain 10% alco-
`hol (ethanol), 40% propylene glycol, and
`nearly 50% water. These drugs are rap-
`idly diluted with tissue fluid, making
`them temporarily insoluble.
`
`Piggybacks and beyond
`Drugs given I.\/. usually take effect im-
`mediately. You can also infuse large vol-
`umes of nutrients or replacement fluids
`by this route. You'll administer these
`drugs and fluids one of three ways: I.V.
`push. I.V. piggyback, or I.V. infusion.
`(See Comparing IJ/.' Push, Ll/. Piggyback,
`and IV. Infusion.)
`In the 1.9703, piggyback infusions were
`
`
`
`COMPARING I.V. PUSH, I.V. PIGGYBACK,
`AND IN. INFUSION
`Major characteristics
`Method
` Injection rate
`Can be given through a peripheral or central line
`Push or bolus
`0.1-‘I0 ml in 30 sec-5
`l'l"lll'l
`or implanted port. Undiluted drug is injected into
`the vein, catheter cap, or tubing Y site for the most
`intense, rapid effect. Injection free from resistance
`ensures an open vein for vesicunt drugs and drugs
`that can cause tissue necrosis if they extravasate.
`Greatest danger is to the central nervous system
`and cardiopulmonary function.
`
`Piggyback or
`intermittent
`infusion
`
`Constant and
`variable-rate
`infusions
`
`25-100 ml in 15-60 min
`(diluted drugs)
`5-20 ml over 15-60 min
`(more concentrated
`drugs)
`
`0.2-1,000 ml/hr
`
`Can be given through a peripheral or central line
`or implanted port. Drug is diluted to provide good
`response without toxicity and to reduce
`hypertonicity of the solution. Used for multipl daily
`closes. Central line used for concentrated drugs.
`
`Can be given through a peripheral or central line
`or implanted port. Used for drugs that need to be
`highly diluted (some ontineoplostics, for example),
`for high-volume hydration and nutrition, and for
`keep-vein—open infusions {D,,W, 0.5-5 ml/hr].
`Ensures constant or circadian-patterned blood
`levels of drugs.
`
`MYLAN PHARMS. INC. EXHIBIT 1054 PAGE 6
`
`MYLAN PHARMS. INC. EXHIBIT 1054 PAGE 6
`
`NuRsiNG92, FEBRUARY
`
`

`
`a popular improvement in patient care.
`Before piggybacks, I.V. antibiotics and
`other irritating drugs had to be given by
`I.V. push, increasing the risk of phlebitis
`and drug toxicity. These complications
`declined dramatically when irritating
`drugs were diluted in S0 or 100 ml of
`DSW or normal saline solution injection.
`The 1980s, though, were dominated
`by Diagnosis-Related Groups (DRGS)
`and other cost-containment pressures.
`Because of preparation and administra-
`tion time, plus the extra bottle or bag of
`diluent solution, piggybacking has be-
`come relatively more expensive in the
`new, competitive market. Recent cost-
`effective innovations include syringe in-
`fusion pumps, vial-to-line adapters (such
`as the CRIS system), liquid and frozen
`premixed drug admixtures, and vial and
`diluent bag systems (such as the ADD-
`Vantage system).
`
`Hazards of I.V. therapy
`Postinfusion phlebitis is one of the most
`common local injuries that may develop
`during or after an infusion. It‘s charac-
`terized by a reddened area or red streak
`along the vein, with tenderness, warmth,
`and edema at the venipuncture site.
`Most cases of postinfusion phlebitis can
`be attributed to microparticles in the so-
`lution, a cannula that’s too large for the
`vein, a vein that’s small and thin-walled,
`overly acidic or alkaline I.V. solutions, or
`hypertonic solutions with an osmolarity
`higher than 300 mOsm/liter, the osmo-
`larity of human blood. (However, hyper-
`osmolar phlebitis is generally associated
`with solutions that have osmolarities
`above 400 mOsm/liter.)
`To minimize the eflects of postinfu-
`sion phlebitis, regularly inspect the veni-
`puncture site and change sites at the
`first sign of tenderness and redness. You
`can check for tenderness by palpating at
`the catheter tip and observing the pa-
`tient’s response Assess the site for red-
`ness, warmth. edema, and induration of
`the vein at the same time. If the phlebi—
`tis is advanced, you’ll feel a rigid venous
`cord at the site.
`
`Thrombophlebitis adds to the problem
`by producing a clot at the cannula tip or
`along the veins inner wall. More compli-
`cations can develop if bacteria grow in
`the thrombus, causing septic thrombo-
`phlebitis. And if the clot breaks off, your
`patient could be at risk for life-
`threatening complications from the em-
`bolism.
`
`ln—linc filters can reduce the risk of
`phlebitis by removing microorganisms
`and other particulates. But these filters
`I-0
`NURSlNG92, FEBRUARY
`
`If you inied
`
`an l.V. drug
`
`too fast, you
`
`could expose
`
`fhe patient’:
`
`vital organs
`
`to many times
`
`the safe
`
`canton frafion.
`
`are another economic casualty of DRGs,
`and they‘re generally reserved for immu-
`nosuppressed patients who are at risk
`for complications and for patients receiv-
`ing total parenteral nutrition.
`Another dangerous local injury is ex-
`travasation. This occurs when the can-
`nula punctures or slips out of the vein
`lumen, allowing l.V. fluid to leak into the
`surrounding tissue.
`The patient may be the one to alert
`you to extravasation if he complains of
`tightness at the venipuncture site, burn-
`ing, or pain. But he may be asleep, un-
`conscious, or unable to communicate for
`some other reason when it occurs. So
`with any patient, you should frequently
`monitor the infusion site for extravasa-
`tion. Watch for swelling, coolness,
`blanching, discoloration, stretched skin,
`tight tissue, and leakage around the LV.
`site. Compare skin turgor around the
`site with that of the opposite extremity.
`You’ll want to be especially vigilant if
`the patient is receiving hypertonic pe-
`ripheral parenteral nutrition or cytotoxic
`antineoplastics. When those extravasate,
`they can cause extensive necrosis that
`might even require amputation.
`If the extravasated solution is isotonic
`(or close to isotonic) with normal pH.
`the patient probably won’t be too un-
`comfortable. After discontinuing the in-
`fusion, in most cases you can apply
`warm packs or warm, moist towels to in-
`crease circulation to the affected area
`and accelerate fluid absorption. Propping
`up the arm or leg with pillows will also
`help if a large area is affected.
`But if the extravasated drug is irritat-
`ing, stop the infusion and call the doctor
`immediately. Many vcsicants have special
`antidotes. and he may order one. You’d
`do the same thing if you were giving the
`drug I.V. push. but you’d leave the sy-
`ringe in place to aspirate the medication
`from the tissue. Double—check your hos-
`pital’s policy and procedure manuals for
`what to do next: one intervention ac-
`cepted at most institutions is applying
`ice immediately.
`Acute drug toxicity is another problem
`that can occur if the drug isn’t properly
`diluted or the infusion rate isn’t con-
`trolled. Remember, blood from periph-
`eral veins reaches the heart and brain in
`10 to 20 seconds; blood flow through an
`adult’s entire circulatory system normally
`takes just 1 minute. So if you inject a
`dose too fast, you could expose the pa-
`ticnt’s vital organs to many times the
`maximum safe concentration. With a
`drug such as potassium chloride, that
`can be a fata.l error.
`
`MYLAN PHARMS. INC. EXHIBIT 1054 PAGE 7
`
`MYLAN PHARMS. INC. EXHIBIT 1054 PAGE 7
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`

`
`TRENDS OF TODAY
`AND TOMORROW
`
`Health care changed in the 19805, spurred by cost consciousness
`and increasingly sophisticated technology. Consider these trends in
`the way you give iniectable drugs:
`0 Bedside and portable electronic microprocessor infusion-rate-
`control devices are more readily available. And multiple-channel
`pumps can control more than one infusion at a time.
`0 For pain control, postoperative and cancer patients are receiv-
`ing narcotics through patient-controlled analgesia pumps. Analge-
`sics are also given epidurally, intrathecally, and intrapleurally.
`I Drugs and nutrients can be administered for months through
`percutaneous and long-line peripherally inserted central venous
`catheters and subdermally implanted iniection ports.
`I New microscopic emulsions, liposomes (phospholipid vesicles),
`and particles are increasing l.V. drug safety and effectiveness.
`Some drugs can target specific cells, thanks to antibody, enzyme,
`macromolecule, and magnetic labels. Controlled and targeted in-
`iectable delivery products (such as microprocessor pumps] will re-
`duce the chances of adverse reactions or failed therapy. You may
`spend less time monitoring this type of therapy, but you'll need
`additional skills to know exactly what and how to monitor.
`0 Biotechnology proteins manufactured from genetic cloning and
`recombinant DNA synthesis have become available. They're given
`S.C.,
`|.M., or |.V., depending on the drug, for the best absorption
`and safety. Drugs in this category include alteplase (tissue plas-
`minogen activator or t-PA), epoetin alpha, filgrastim (granulocyte
`colony-stimulating factor or G-CSFl, HA-1A gram-negative anti-
`body antitoxin, hepatitis B vaccine, interferon alfa-2a and -2b, in-
`terferon gamma-lb, muromonab—CD3, and sargramostim
`(granulocyte-macrophage colony-stimulating factor or GM-CSFl.
`More than 100 other biotechnology proteins are currently being
`tested; most are for cancer or AIDS therapy.
`0 The big three iniection routes are being challenged by nonin-
`iectable, controlled drug delivery systems that conveniently and
`precisely regulate drug levels and time delivery with biologic
`rhythms. Examples include peptides in nasal sprays, oral tablets
`with osmotic and enzymatic action, and transdermal patches
`(clonidine and nitroglycerin, for example). Polymer devices, which
`can be applied to the skin or implanted in tissue, respond to ei-
`ther chemical changes (involving antibodies, enzymes, or pH val-
`ues} or electronics (transmission of drugs through the skin by di-
`rect current or ultrasound and magnetic force).
`
`Watch for signs and symptoms of in-
`fusion specd shock (facial flushing, head-
`ache, dyspnea, tightness in the chest, ir-
`regular pulse, tachycardia, decreased
`blood pressure, and progressive syncope).
`Speed shock is rare. but it is scrious—it
`can cause circulatory collapse and car-
`diac arrest. Also, be alert for circulatory
`overload, characterized by increased
`pulse and blood pressure. distended neck
`veins, dyspnca, abnormal breath sounds,
`and generalized discomfort.
`
`Meeting the challenges
`As technology introduces more and
`more sophisticated drugs, you’ll be
`seeing orders for drugs to be given in-
`tranasally, intrathecally, cpidurally, and
`intra—arterially. But S.C., I.M., and LV.
`will remain the “big three”—in fact,
`most drugs that arc-:n’t given orally are
`given by one of these three routes.
`Sometimes, though, these basic ad-
`ministration routes can result in injury
`or, more rarely, death. To protect your
`patients. you need to maintain your
`command of injection skills. And to do
`that, you should continually reassess
`your knowledge and technique by read-
`ing articles, attending workshops, and
`thinking about how you practice. E
`SELECTED REFERENCES
`Hahn, K.: "Brush Up on Your Injection Technique."
`NurSi.ug90. 2tl(9):5-1-58, September l9“)0.
`Holder, C, and Alexander, J.: "A New and Im raved
`Guide to LV. Therap_v." American Journal of urring.
`90(2):43-47. February I990.
`Keen. M.: "Comparison of Intramuscular Injection
`Tcchniqucs to Reduce Sitc Discomfort and Lesions."
`Nur.o'ng Rcseurcli. 3S(4):2[l1'-lit). Julymugust 1986.
`Newton. D.: "Biotechnology Frontier: Targeted Drug
`Delivery." -115. Plmrnm<'r'.rr. 16:38-39. -13-44. ~t(i—tl8.
`St)-5]. June 199].
`Wickharri. R.: “Advances in Venous. Access Dcviccs
`and Nursing Management Strategies," Nursing Clinics
`oj'NorrIr.4rm’rr'ra. §S(2):345—3I"t4, June 1990.
`Complete reference list available on request.
`
`
`
`
`Take the test on the next page—and earn CEUs. Here's what to do:
`1 . Write your answer in the cor-
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`2. Fill in your name, address,
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`In 4 to 6 weeks, you'll be noti-
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`
`TEST RESULTS
`MUST BE
`POSTMARKED BY
`JANUARY 31, 1993
`
`total program of continuing edu-
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`MYLAN PHARMS. INC. EXHIBIT 1054 PAGE 8
`
`MYLAN PHARMS. INC. EXHIBIT 1054 PAGE 8
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`NURSING92, FEBRUARY
`
`41