Preparation of Ribavirin solution for Nebulisation: 6g in 100ml The following guidelines for the safe reconstitution (in the patients room) of ribavirin solution for nebulisation were prepared by : Gill Shanks (Medicines Safety Manager), Royal Hallamshire Hospital, Sheffield Teaching Hospital trust. In conjunction with: Sister Marie Downes (Clinical Nurse Educator) Royal Hallamshire Hospital, Sheffield Teaching Hospital Trust. May 2010

Preparation of Ribavirin solution for Nebulisation: 6g in 100ml Kit Contents (supplied by pharmacy) : 1 x Ribavirin 6g vial 1 x Water for Injections 100ml 1 x Empty Di mix EVA -parenteral bag 125ml 1 x Baxter Control-A-Flo set (EMC5908P) 2 x BD Plastipak Syringe luer loc 60ml 2 x B Braun Mini-Spike Dispensing pin with Safsite valve (DP-1500) 1 x Label for EVA bag 3 x Label for giving set line and EVA (For Nebulisation Only) 1 x Instruction sheet for preparing Ribavirin Nebuliser soln. 6g in 100ml N.B. This kit is to prepare Ribavirin Nebuliser solution for use only with the Aiolos device for nebulisation as per protocol.

1.Take a 60ml luer loc syringe and attach to the dispensing pin. 2. Remove the protective cap from the dispensing pin and insert via the bung into the water for injection vial.

3.Withdraw 50ml of water for injections. Disconnect the syringe from the dispensing pin, leaving the dispensing pin in situ.

4. Attach a second dispensing pin to the same syringe. Peal back the aluminium seal from the Ribavirin vial Safety note: Fold metal flap back down the side of vial neck - DO NOT remove metal seal completely. Keeping the aluminium ring in tact holds the rubber bung in place and prevents it being pushed in to the vial or coming out of the vial during fluid transfer.

Remove the protective cap from the dispensing pin and insert the dispensing pin into the Ribavirin vial via the bung. 5. Gently transfer the 50ml of water in the syringe into the Ribavirin vial. Safety note: When transferring the contents of the syringe, tilt the syringe and dispensing pin at an angle to ensure that the fluid runs down the side of the vial. This reduces the chance of ribavirin powder exiting via the vented spike. The vented spike should equalise the pressure automatically.

6.Leaving the dispensing pin and syringe in situ, shake vial well to dissolve the ribavirin powder. Note: At this stage, the ribavirin may not totally dissolve.

7. Disconnect the syringe from the dispensing pin in the Ribavirin vial and attach the same syringe to the dispensing pin in the water for injection vial. Withdraw a further 25ml.

8. Attach this syringe to the dispensing pin in the Ribavirin vial, gently transfer the contents of the syringe into the Ribavirin vial. When transferring the contents of the syringe, tilt the syringe and dispensing pin at an angle to ensure that the fluid runs down the side of the vial. 9. Leave the dispensing pin and syringe in situ and shake vial well until the drug is fully dissolved. N.B. Ensure the solution is fully dissolved before proceeding to the next stage.

10. Withdraw 50ml of solution from the Ribavirin vial into the attached syringe. Disconnect the syringe from the dispensing pin, leaving dispensing pin in situ.

11. Remove the cap from the long additive tube on the EVA bag. Attach the syringe containing the 50 ml Ribavirin solution to the long tube. Transfer the contents of the syringe to the EVA bag. Leave this now empty syringe attached to the long tube. Safety note: If you remove the syringe, the ribavirin will leak from the bag.

12. Take the second 60ml luer loc syringe and attach to the dispensing pin in the Ribavirin vial and withdraw the remaining contents of the vial. Disconnect this syringe from the dispensing pin.

13. Remove the empty syringe from the long tube on the EVA bag and attach the syringe containing the remaining Ribavirin solution. Transfer the contents of the syringe into the EVA bag. Leave this now empty syringe attached to the long tube.

14. Take the now empty 60ml luer loc syringe and attach to the dispensing pin in the water for injection vial. Withdraw 25ml.

Disconnect this syringe from the dispensing pin, then remove the empty syringe from the long tube and replace with the syringe containing water for injections, taking care not to let any of the Ribavirin solution leak from the bag. Transfer the final 25ml water in this syringe to the bag.

Close the clamp on the long tube

15. After the clamp is secured, remove the syringe and fit cap to the long tube on the EVA bag. Mix the contents of the EVA bag thoroughly. 16. The EVA bag now contains a solution of Ribavirin 6g in 100ml.

17.Take the large label and fill in the patient name, ward, date, start time and the initials of the person preparing the product in the spaces provided. Attach this label to the EVA bag.

18. Take the Baxter Control-A-Flo giving set and insert the spike into the giving set port of the EVA bag. Clamp off the line until ready to prime.

19.Take the three red print labels. Attach one label to the EVA bag and the other two labels to the giving set line – one at the top of the line (underneath the burette) and one at the bottom of the line (near the luer lock connection). N.B Flag the giving set line labels so the labels can be read easily to avoid any possible connection to an IV line.

20. Discard all used materials (2 x 60ml syringes, 1 x empty water for injections vial with dispensing pin still attached, 1 x empty Ribavirin vial with dispensing pin still attached) in a sharps bin with purple lid (hazardous waste).