Hospital Pharmacy - July/August 2019 - 212

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editorial2019

HPXXXX10.1177/0018578719829417Hospital PharmacyStemple et al

Editorial

Utilization of an Order Panel
to Encourage Safe Ordering and
Administration of Amphotericin B

Hospital Pharmacy
2019, Vol. 54(4) 212-216
© The Author(s) 2019
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https://doi.org/10.1177/0018578719829417
DOI: 10.1177/0018578719829417
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Krisi Stemple1, Jeffrey Schnoor1, John Ahern1,
and Anna Bunnell1
Safe administration of medications is a high priority
worldwide. Avoidance of medication errors is critical to
ensure a safe environment for our patients. The utilization
of technology to support medication management has had
positive impacts on patient safety and appropriate therapeutic selections.1 Given the significant number of adverse
drug events that are attributed to medication errors, it is
essential that we take measures to improve patient safety
especially regarding medication utilization. The use of
computerized order entry, best practice advisory alerts,
order sets, and order panels are only a handful of examples of how technology may assist in medication management. It is estimated that 56% of preventable adverse drug
events occur during order entry and these reminders may
guide providers in ordering appropriate ancillary fluids
and/or medications that can reduce or manage adverse
effects during drug therapy, in addition to ensuring safe
and effective dosing.2
One medication that may benefit from an order panel is
amphotericin B: an antimicrobial that is used to treat invasive fungal infections. Amphotericin B is available as a
deoxycholate salt and as a lipid-based or liposomal preparation. Although most are familiar with the high-alert and
look-alike/sound-alike concerns with amphotericin B secondary to the Institute for Safe Medication Practices (ISMP)
publications, this medication poses other significant risks as
well. Amphotericin B has been associated with nephrotoxicity-the greatest risk seen with the deoxycholate salt formulation in comparison with the liposomal formulations.3,4
Anaphylactic-like and infusion reactions have also been
reported with all formulations of amphotericin B. In addition, amphotericin B is incompatible with sodium chloride; therefore, it is important that this medication is not
infused concomitantly with saline containing solutions.
For providers and nurses that order and administer amphotericin B infrequently, it can be challenging to recall the
recommended hydration and supportive medications that
should be readily available at the time of amphotericin B
administration, as well as the appropriate sequencing of
these therapies.
To facilitate safe ordering and administration of amphotericin B, the University of Vermont Medical Center, a 562bed rural, academic medical center in Burlington, Vermont,

created an order panel for both the deoxycholate and liposomal formulations of amphotericin B available on formulary (Figure 1). The order panel was developed by pharmacy
with nursing and physician input. The order panel consists
of amphotericin B, a 0.9% sodium chloride 1000 mL intravenous solution, a 5% dextrose 50 mL piggy back, and an
anaphylaxis kit that contains epinephrine, diphenhydramine, and methylprednisolone (Figure 2). The 0.9%
sodium chloride is used to prehydrate or "salt load" the
patient as there are data to suggest that this may mitigate
amphotericin B-induced nephrotoxicity through inhibition
of tubuloglomerular feedback.5 Therefore, it is common
practice at our institution to administer a 0.9% sodium
chloride bolus prior to each amphotericin B infusion for
this salt loading effect. The volume is preset at 1000 mL;
however, the ordering provider may adjust the volume if
clinically indicated. A source of confusion we have
observed is the use of 0.9% sodium chloride as a bolus prior
to amphotericin B given that they are incompatible. A 5%
dextrose 50 mL piggyback is made available to the nurse to
flush the intravenous line following the 0.9% sodium chloride infusion and to clear the line after completion of the
amphotericin B infusion to prevent precipitation within the
intravenous line. The anaphylaxis kit is available in the
event that any emergent adverse or anaphylactic effects
arise during the infusion of amphotericin B. Preset administration instructions for the 0.9% sodium chloride intravenous solution, 5% dextrose 50 mL piggyback, and
amphotericin B help guide the nurse on safe administration
of amphotericin B as shown in Figures 3, 4, and 5.
One benefit of the amphotericin B order panel is that it
is comprised of all necessary medications with preset
administration instructions to provide immediate educational guidance at the time of order entry and medication
administration. This creates a safer environment, which
will ultimately benefit the patient. We describe the use of
an order panel specifically for amphotericin B; however,
1

The University of Vermont Medical Center, Burlington, VT, USA

Corresponding Author:
Krisi Stemple, The University of Vermont Medical Center, 111 Colchester
Avenue, Burlington, VT 05401, USA.
Email: Kristina.Stemple@UVMHealth.org
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