Revised 9/08 ADULT INTRAVENOUS MEDICATIONS STANDARD AND MAXIMUM ALLOWABLE CONCENTRATIONS, GUIDELINES FOR CONTINUOUS OR TITRATED INFUSIONS MEDICATION STANDARD MAXIMUM CONC./ DOSING MONITORING/COMMENTS ADMIXTURE INFUSION INSTRUCTIONS Adenosine 6 mg/2 mL vial Give undiluted directly into 6 mg initially. If SVT not ECG, heart rate, blood pressure (Adenocard®) (3 mg/mL) given undiluted vein over 1-2 seconds. resolved in 1-2 minutes, may Administer as proximal as follow with 12 mg dose. If Extremely short half life: possible to trunk (i.e., not in not resolved in 1-2 minutes, < 10 seconds Slows conduction time through the AV node, interrupting the re-entry lower arm, hand, lower leg, may follow with an Not effective for converting A. pathways through the AV node, or foot). If administered additional 12 mg dose. flutter, A. fib, or ventricular restoring normal sinus rhythm. through IV line, administer tachycardia. as close to pts heart as Contraindicated if symptomatic Onset of action: immediate Duration: seconds possible. NS flush must be bradycardia, sick sinus given rapidly, immediately syndrome, 2nd or 3rd degree AV following injection of block (unless pt. has functioning adenosine pacemaker) Amiodarone Load: Dilute 150 mg (3mL) in Peripheral line: Up to 2 Load: 150 mg/100 mL over Telemetry monitoring, BP (Cordarone®) 100 mL D5W (1.5 mg/mL) mg/mL 10 minutes. (hypotension occurs frequently (PVC bag suitable for loading (Not to eXceed 30 mg/mL) with initial rates), HR Antiarrhythmic agent that dose) (Concentrations over 2 (arrhythmias: AV block, depresses conduction velocity, mg/mL administered for THEN bradycardia, VT/VF, torsades de slows AV node conduction, raises Maintenance infusion: longer than 1 hour must be pointes), electrolytes the threshold for VF, and eXhibits Dilute 900 mg (18 mL) in infused via central line) Infusion: 1 mg/min for 6 some α and β blockade activity. It possesses vasodilatory effects 500 mL D5W (1.8 mg/mL) hours (33.3 mL/hr = 360 Pulmonary function test within 1 which decrease cardiac workload Central line: Up to 6mg/mL mg), followed by 0.5 week if possible and decrease myocardial oxygen INFUSION MUST BE mg/min for 18 hours (16.6 demand. Myocardial uptake is ADMIXED IN GLASS BOTTLE mL/hr = 540 mg) Thyroid function rapid and anti-arrhythmic effects are clinically relevant within hours, OR NON-PVC BAG. but full effect may take days. Amiodarone will leach ACLS: 300 mg IV push, may Liver enzymes (AST/ALT) Exceptionally long half life of 40-55 plastic from PVC bag repeat with 150 mg X 1. Significant interactions with days digoxin and warfarin (enhances MaXimum daily dose: effect of each, ↓ dose, monitor 2.1 g/day digoxin levels, PT/INR) *Shaded medications require a double check* MEDICATION STANDARD MAXIMUM CONC./ DOSING MONITORING/COMMENTS ADMIXTURE INFUSION INSTRUCTIONS Atropine 1 mg/10 mL Abboject May be administered Asystole/PEA: No longer Vital signs and/or EKG syringe (0.1 mg/mL) without further dilution recommended per 2010 Blocks the action of acetylcholine at ACLS guidelines Doses < 0.5 mg may lead to parasympathetic sites in smooth paradoxical bradycardia muscle, secretory glands, and the CNS; increases cardiac output Bradycardia: 0.5 mg IV Onset of action: very rapid Duration: 2-3 hours Bumetanide (BumeX®) 0.25 mg/mL (2 mL, 4 mL, May be given undiluted. IV push: 0.5-1 mg/dose HR, BP, electrolytes, UOP, CO2, 10 mL) Not usually added to IV May repeat in 2-3 hours BUN, glucose Potent loop diuretic. Works in the solutions but compatible ascending Loop of Henle and Infusion: 12 mg/48 mL with D5W, NS, and LR Infusion: 0.25-2 mg/hr Routine BMP and uric acid proximal renal tubule to eXcrete (0.25 mg/mL) checks necessary during + + - H2O, Na , K , Cl DO NOT EXCEED 10 MG/24 treatment Onset of action: 2-3 minutes PROTECT FROM LIGHT HOURS Duration: 4-6 hours Non-formulary at HH 1 mg Bumex = 40 mg Lasix Calcium Chloride 1 g/10 mL Abboject syringe May be administered 8-16 mg/kg IV at 100 Vital signs without further dilution mg/min Electrolyte (Typical dose = 1g) Central line recommended May repeat as necessary at 10 minute intervals Calcium chloride not recommended for uses other than cardiac resuscitation or management of calcium channel blocker toxicity. Contains three times more elemental calcium than calcium gluconate. MEDICATION STANDARD MAXIMUM CONC./ DOSING MONITORING/COMMENTS ADMIXTURE INFUSION INSTRUCTIONS Calcium Gluconate 1 g/10 mL (10%) May be administered Emergency elevation of Vital signs, EKG without further dilution or serum calcium: 15-30 mL Electrolyte may be further diluted in up (7-14 mEq). Repeat in 1-3 Rapid administration may cause to 1,000 mL of NS days per pt. response vasodilation, ↓BP, arrhythmias, syncope, or cardiac arrest. Hyperkalemia: 4.1-30 mL (2.25 - 14 mEq). May repeat in 1-2 minutes if indicated as per EKG. Do not exceed 2mL/min Diltiazem (Cardizem®) Bolus: 5 mg/mL vial Bolus: No dilution required Bolus: 0.25 mg/kg IV ↓HR, arrhythmias May be given undiluted (typical dose = 20 mg) ↓BP, flushing, edema Non-dihydropyridine calcium through Y-tube or 3-way Infusion: 1 mg/mL May repeat with 0.35 mg/kg channel blocker that blocks Ca2+ ion stopcock of tubing if no response after 15 min. EKG monitoring during infusion influX during depolarization of containing NS, D5W, or (typical repeat dose (25 mg) preferred cardiac and vascular smooth muscle. It decreases SVR and D5 ½ NS causes relaxation of the vascular Infusion: 5 – 15 mg/hr Stored in refrigerator smooth muscle resulting in ↓BP. Infusion: Add 125 mg (25mL) (5 -15 mL/hr). Initiate at Slows conduction through the AV to 100mL D5W or NS 5 mg/hr. node, prolongs the refractory period, and reduces ventricular (1 mg/mL) MaX dose: 15 mg/hr rate. Decreases HR by 10% with a single dose. May only use for 24 hours Dobutamine Infusion: 500 mg/250 mL MAX: 5 mg/mL (1,250 Infusion: 2 – 20 mcg/kg/min ↑HR, ↑BP or ↓BP (typically (DobutreX®) D5W premiXed bag mg/250 mL) in D5W or NS associated with overdose) (2,000 mcg/mL) Gradually adjust rate at 2 to Arrhythmia, myocardial 10 minute intervals. AHA ischemia, ↑CO Synthetic sympathomimetic catecholamine that stimulates the β [concentrated 1000 mg/250 Preferably given via central guidelines recommend receptors of the heart. Positive mL available if necessary line titrating so that HR does not Decreased effect seen in inotrope (↑ CO, ↑contractility, (4,000 mcg/mL)] increase by > 10% from profoundly acidotic patients. ↑CI). Produces minimal increases baseline. in rate and BP. Provides the eXtra “squeeze” in patients with cardiac Vial: 250 mg/20 mL decompensation. (12.5 mg/mL) If rates > 20 – 30 mcg/kg/min required, Onset of action: 1-10 minutes should consider alternate inotropic agent MEDICATION STANDARD MAXIMUM CONC./ DOSING MONITORING/COMMENTS ADMIXTURE INFUSION INSTRUCTIONS Dopamine (Inotropin®) Infusion: 400 mg/250 mL MAX: 6.4 mg/mL Infusion: 2.5 – 20 ↑BP, palpitations, arrhythmias, D5W premiXed bag (1,600 mg/250 mL) mcg/kg/min ↑HR, peripheral necrosis with Catecholamine precursor to (1,600 mcg/mL) ↑doses norepinephrine that activates α, β, If more than 20 mcg/kg/min and DA receptors. Vial: 200 mg/5 mL Preferably given via central is required to maintain BP, Infuse via central line to avoid line consider use of extravasation 5-10 mcg/kg/min: renal, mesenteric, coronary dilation norepinephrine in addition 10-20 mcg/kg/min: increased Fluid resuscitate pts. prior to contractility, HR vasopressor therapy. >20 mcg/kg/min : vasoconstriction, increased HR and BP Effect diminished in acidosis. Do Onset of action: 5 minutes not administer through same line as sodium bicarbonate! Epinephrine 1 mg/10 mL (1:10,000) 4 mg/ 250 mL NS or D5W ACLS Bolus: 1 mg/10 mL ↑HR, ↑BP (monitor BP and HR (Adrenalin®) Abboject syringe (16 mcg/mL) (1:10,000 syringe) q3-5 min q5min) [1mg/ mL (1:1,000) must be Arrhythmias, tremor, anxiety, 1 mg/1 mL (1:1000) vial Some institutions report diluted in 10 mL NS before pulmonary edema, myocardial Natural symmpathomimetic catecholamine, both an α and β higher concentrations, if IV administration] ischemia agonist. Can ↑SVR, ↑BP (via Infusion: 1 mg/250 mL NS needed ACLS infusion: *30mg/250 vasoconstriction). It is a potent (4 mcg/mL) (Duke = 10mg/250 mL) mL at 100 mL/hour then Monitor for signs of peripheral cardiac stimulant (↑HR, [concentrated 2 mg/250 mL (Lit = 30 mg/250 mL) titrate necrosis ↑contraction) and dilates bronchi or 4 mg/250 mL available if *10mg/250 mL at .01-1.2 necessary) mcg/kg/min 10 mg/250 mL NS (cardiac Vasopressor or maintenance arrest infusion) infusion: 1 – 10 mcg/min Rates > 10 mcg/min, should consider alternate or additional vasopressor *Shaded medications require a double check* MEDICATION STANDARD MAXIMUM CONC./ DOSING MONITORING/COMMENTS ADMIXTURE INFUSION INSTRUCTIONS Eptifibatide (Integrilin®) 200 mg/100 mL vial Bolus: Over 1-2 minutes ACS Platelets, Hgb, SCr, PT/aPTT (2,000 mcg/mL) Infusion: Administered Bolus: 180 mcg/kg Signs of bleeding – avoid BP Blocks platelet glycoprotein IIb/IIIa directly from vial administered over 1-2 cuffs, watch IV sites, monitor for receptor, the binding site for Bolus: Dose administered minutes black tarry stools etc. fibrinogen, von Willebrand factor, from 100mL vial, given MaX bolus dose = 22.6 mg and other ligands. Reversibly undiluted over 1-2 minutes MaX infusion rate = 15 Infusion: 2 mcg/kg/min (maX Modified Cockroft-Gault blocks platelet aggregation and prevents thrombosis mg/hr of 15 mg/hr) equation to determine CrCl: ***Give with heparin or (140 – age/SCr) [x 0.85 if lovenoX*** Renal Dysfunction: If CrCl < female] 50 mL/min, ↓ infusion to (this equation provides a rough 1 mcg/kg/min.