Adult IV Push/Infusion Guidelines for Select Medications

ADULT IV PUSH/INFUSION GUIDELINES FOR SELECT MEDICATIONS Approved by P&T: 4/25/2019

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The ADULT IV Administration Guidelines are for commonly administered parenteral medications used in the Clinical Center (CC). These guidelines are not inclusive of all medications used in the CC and are meant to be used as a guide only. Nursing judgment and physician orders should be followed.

MONITORING PARAMETERS (medications may require one or more types of monitoring listed below):

No special monitoring required

Vital sign monitoring: blood pressure, oxygen saturation, heart rate, and/or respiratory rate Vital sign recommendations are guidelines only. Nursing judgment and LIP orders should be followed

Cardiac monitoring in the form of: Telemetry – central cardiac monitoring with oversight provided by a registered nurse

o Units with telemetry: 1NW, 3NW, 5SES, 5NES, 3SWS, 3SWN-IMC

o Note, staff with knowledge of using telemetry equipment must be present on the unit. If staff are not available, the patient may need to be relocated to a unit with both monitoring

equipment and staff with expertise.

Bedside – direct observation of cardiac rhythm is made by a nurse and/or LIP while a drug is being administered

o Bedside monitoring capability is available on 1NW, 5NES, 5SE, 3SWS, and 3SWN-IMC

Critical Care Monitoring – direct intensive observation by Nursing or LIP

Ventilatory support – authorization to administer these drugs is restricted to credentialed anesthesiologists and CCMD physicians

DEFINITIONS: Ordered by: Refers to order entered in electronic health record by the individual specified in the guidelines.

Course of therapy: A course of therapy is defined as a continuous use of the drug without any breaks in therapy.

Unit: location in which drug can be administered.

NOTE: ACLS medications may be administered in all hospital locations by Code Team members.

Even if not specifically denoted below, medications may be administered in the OR pursuant to LIP directives.

When the Special Clinical Studies Unit (SCSU)/5NES is under special respiratory isolation (SRI) precautions, this unit may function as an ICU and, therefore, all ICU medications may be given per these guidelines.


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Drug Name Location(s) Dosing Administration Guidelines Monitoring Parameters Comments/Precautions

Abciximab ICU, 5SE PCI dosing

Bolus dose

0.25 mg/kg IV push 10 - 60 minutes before start of PCI

Maintenance dose

0.125 mcg/kg/min continuous IV infusion (maximum: 10 mcg/min) for 12 – 24 hours

Bolus dose

IV push rate: over 1 minute

Vital signs every 15 minutes x 4, every

30 minutes x 2, then every 1 hour or

per patient’s condition

AND

Telemetry

Ordered by NIH cardiovascular catheterization laboratory and maintained per post procedure orders

Do not use in unstable angina / non ST elevation MI when early invasive management strategy not planned (Anderson, 2011)

Do not shake

Inspect drug for particles before administering

Filter with nonpyrogenic low protein binding 0.2 or 5 micron syringe filter when preparing drug

Monitor patient for any potential bleeding

Platelet counts should be monitored prior to treatment, two to four hours following the bolus, and at 24 hours or prior to discharge, whichever is first

AcetaZOLAMIDE All units Edema: 250 – 375 mg or 5 mg/kg daily x 1-2 days Urinary alkalinization (adults): 5 mg/kg/dose q 8-12 hours

IV Push: Administer as a direct bolus over at least 1 minute (100-500 mg/min). IV Infusion: administer over 15-30 minutes.

No special monitoring required • Avoid use in patients with a CrCl less than 10 mL/min (ineffective) • Monitor baseline and periodic CBC, electrolytes

Adenosine All units Initial dose: 6 mg IV push *initial dose should be reduced to 3 mg if patient is on carbamazepine or dipyridamole, has a transplanted heart, or if adenosine is given via central line Repeat dose: 12 mg IV push if SVT not eliminated within 1 - 2 minutes. May repeat 12 mg IV push x 1. Maximum single recommended dose: 12 mg Higher doses may be used if situation warrants

IV push rate: over 1 – 2 seconds

Administer in closest port to insertion site of IV line.

Flush each dose rapidly with 20 mL NS

Vital signs before, 5 minutes and 30 minutes after dose

AND

Bedside monitor during administration and for 30 minutes after dose, then telemetry.

AND

(If possible) Rhythm strip capture and printing capability (EKG or LifePak) at time of administration to capture conversion.

May only be administered by Cardiology or CCMD

ACLS Provider

May cause several seconds of asystole

Printout of rhythm data at time of conversion is

important diagnostic information. Please make

efforts to obtain if feasible. Caution in patients with asthma or obstructive

lung disease

Avoid use in antidromic AVRT and patients with AF if suspicion of WPW

Drug interactions o methylxanthines (caffeine, theophylline):

antagonize effect of adenosine o dipyridamole: potentiate effect of adenosine o Carbamazepine: increases degree of heart

block o Beta blockers, non-dihydropyridine calcium

channel blockers (diltiazem, verapamil), digoxin , or quinidine: additive or synergistic depressant effects on SA and AV nodes


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Albumin All units Variable dosing, dependent on patient condition Initial dose: 12.5 to 25 g IV; may repeat in 15 to 30 minutes if needed Maximum dose: 6 g/kg/24hr

Albumin may be given as rapidly as tolerated in shock

Non-shock states:

Albumin 5%: o Patients with normal plasma volume: max

rate of 4 mL/min o Patients with hypoproteinemia: max rate

of 10 mL/min

Albumin 25%: o Patients with normal plasma volume: max

rate of 1 mL/min o Patients with hypoproteinemia: max rate

of 3 mL/min

Vital sign monitoring Use with caution in patients with hepatic and renal insufficiency

Administration must be completed 4 hours after the vial has been spiked.

Alteplase ICU, OR, 5SE Acute Ischemic Stroke: 0.9 mg/kg (max total dose: 90 mg) o Patients <100 kg:

o Bolus: 0.09 mg/kg o Maintenance: 0.81 mg/kg

o Patients >100 kg: o Bolus:9 mg o Maintenance: 81mg

Pulmonary Embolism:

o 100 mg IV infusion

STEMI: Accelerated regimen (weight-based) o 100 mg over 1.5 hours

Acute Ischemic Stroke: Administer bolus over 1 minute Administer maintenance infusion over 60 min Pulmonary Embolism: If stable, administer 100mg dose over 2 hours May be administered faster if in cardiac arrest STEMI: Accelerated IV infusion over 1.5 hours Patients over 67 kg:

15 mg IV bolus over 1-2 minutes, then

50 mg infusion over 30 minutes, then

35 mg infusion over 1 hour Patients under 67 kg

15 mg IV bolus over 1-2 minutes, then

0.75 mg/kg infusion over 30 min, then

0.5 mg/kg infusion over 1 hour

Telemetry For treatment of acute ischemic stroke, perform noncontrast-enhanced CT or MRI prior to administration

Initiation of anticoagulants or antiplatelets within 24 hours after starting alteplase is not recommended

For treatment of PE, resume parenteral anticoagulation near the end of or immediately following the alteplase infusion when the aPTT returns to twice normal or less

Aminocaproic acid All units Loading dose: 4 – 5 g for first hour followed by 1 g/hour for 8 hours (max daily dose: 30 g)

IV push: do not administer as IV push

Loading Dose: may administer loading dose over 15-60 minutes depending on indication

No special monitoring required Use caution in patients with renal insufficiency; drug may accumulate

Do not co-administer with factor IX complex concentrates or anti-inhibitor coagulant complexes

Monitor CPK; discontinue treatment if increase in CPK occurs


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Amiodarone ICU, 5SE Atrial arrhythmia and stable ventricular

tachycardia dosing

Loading dose

150 mg IV bolus

Maintenance dose

1 mg/min for 6 hours, then 0.5 mg/min continuous IV infusion x 18 hours. May continue longer if clinical situation warrants

Loading dose

Amiodarone 150 mg in 100 mL D5W IV over 10 minutes

Maintenance dose

Amiodarone 900 mg in 500 mL D5W (Final concentration 1.8 mg/mL)

1 mg/min = 33 mL/h

0.5 mg/min = 16.7 mL/h

Vital signs on initiation, every 15

minutes x 4, every 30 minutes x 2,

every 1 hour x 4 or until stable, then

every 4 hours

Currently infusing: routine vital signs

AND

On initiation of loading dose: bedside

monitoring, then telemetry

In non-ICU areas, must be ordered by Cardiology or CCMD LIP

If patient is on greater than maintenance dose for extended period of time, consider an ICU consult

Hold infusion for symptomatic bradycardia; call LIP

Use 0.2 micron in-line filter and PVC tubing

Concentrations > 2 mg/mL should be administered through a central line

If required for maintenance treatment, consider starting oral amiodarone at least 24 hours before discontinuing infusion

Arginine 10% 5NW, 1NW, ICU

Usual dosing: up to 30 g as a single dose IV Push: Do not administer as IV Push

IV infusion: Administer over 30 min *For hyperammonemia associated with urea cycle disorders, give loading dose over 90-120 min; maintenance dose should not exceed 150 mg/kg/h

Vital sign monitoring Administer undiluted Drug is a vesicant; if extravasation occurs, stop

infusion immediately and notify LIP Used for increased levels of ammonia and for

stimulation of growth hormone

Antithymocyte Globulin (Equine) [ATGAM]

1NW, 3NW, 3NE, 3SEN, ICU

IV infusion: 5 to 40 mg/kg/dose over a minimum of 4 hours (range 4-24 hours)

IV infusion:

Day 1 initial infusion rate: Start at a rate that is 10% or less of total infusion volume per hour for the first 15 minutes. If tolerated, advance rate. (e.g. a 500 mL bottle will start at 50 mL/h)

First infusion: Vital signs prior to start of infusion, then every 15 minutes x 4, then every 30 minutes x 2, then every hour until infusion completed.

o RN will remain with patient

during the first 15 minutes of the initial dose to monitor for adverse reaction.

o LIP will remain on the patient

care unit during the first 15 minutes of the initial dose.

Subsequent infusions: Vital signs

prior to start of infusion, then 30 minutes after initiating infusion, then every hour until infusion complete.

Refer to Nursing SOP regarding the care of the patient receiving ATG:

Administration through a high-flow central vein is recommended to minimize phlebitis and thrombosis.

Prepared dose should be diluted prior to administration with concentrations not to exceed 4 mg/mL.

Administer pre-medication (e.g. acetaminophen and diphenhydramine) 30 minutes prior to start of infusion.

Infuse through a 0.2 to 1 micron in-line filter

Emergency medications should be readily available due to high incidence of infusion-related toxicities.

Patient may not leave patient care unit during ATG infusion unless accompanied by RN.

Avoid administration within 2 hours (before or after) of blood products or amphotericin B formulations without approval or order from LIP.

Atropine All units Bradycardia dosing 0.5 mg IV push every 3 – 5 minutes Maximum dose 3 mg (0.04 mg/kg)

IV push: administer undiluted by rapid IV push

slow injection may cause paradoxical bradycardia


30 minutes x 2, then every 1 hour until

stable

AND Bedside monitor for first ten minutes then telemetry

Minimum dose is 0.5 mg; lower doses may cause paradoxical bradycardia

Caution in patients with acute coronary ischemia or myocardial infarction and heart failure patients

http://intranet.cc.nih.gov/nursing/practicedocs/sop_p%20df/SOP_Antithymocyte_Globulin.pdf


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Bumetanide All units Usual dose: 0.5 - 1 mg, may be repeated at 2-3 hour intervals (Max dose: 10 mg/day)

IV push: give undiluted over 1-2 minutes. No special monitoring required 1 mg : 40 mg ratio (bumetanide to furosemide) May affect serum electrolytes and renal function Monitor blood pressure and fluid status

Calcitriol 5NW, ICU Hypocalcemia (dialysis):

1 – 2 mcg three times a week

Adjust dose by 0.5 to 1 mcg at 2 to 4 week intervals (range: 0.5 to 4 mcg three times weekly)

IV push: may be given undiluted as a bolus dose

into the venous line at the end of hemodialysis.

No special monitoring required Monitor serum Ca, PO4

Calcium chloride All units IV push: 0.5 to 1 g; may repeat as necessary

IV infusion for beta-blocker or calcium channel blocker overdose: 20 to 50 mg/kg/h (10% solution)

IV push: maximum rate of 100 mg/min

except in emergency situations

IV infusion: infuse diluted solution over 1

hour or maximum of 90 mg/kg/h

Telemetry IV push over 2-5 minutes by Code Team ACLS provider during cardiac arrest

IV push over 10 minutes by LIP for emergency treatment of hypocalcemia or hyperkalemia

Administration via central line is preferred

Stop the infusion immediately if the patient complains of pain or discomfort

Calcium gluconate IV push only in 5NW and ICU

Infusion in all units

IV push: 0.5 to 2 g

IV infusion: o Mild hypocalcemia: 1 to 2 g over 2 hours o Moderate to severe hypocalcemia: 4 g over 4

hours

IV push: maximum rate 200 mg/min in adults

IV infusion: adjust rate as needed based on

serum calcium levels

Telemetry

AND Beside monitor required on 5NW

IV push during cardiac arrest by Code Team ACLS provider or by LIP for emergency treatment of hypocalcemia or hyperkalemia

Chlorothiazide All units Usual dosing: 0.5 g to 1 g once or twice daily Administer by slow IV push or infusion No special monitoring required Monitor serum electrolytes Ineffective with CrCl less than 30 mL/min unless used

in combination with a loop diuretic Do not use if CrCl less than 10 mL/min

Cisatracurium ICU, OR Bolus: 0.15 to 0.2 mg/kg IV push

Maintenance: initial rate of 1 to 3 mcg/kg/min continuous IV infusion

IV push: over 5 to 10 seconds

IV infusion: continuous infusion via infusion pump

Ventilatory support

For infusion, titrate to Train of Four

Dexmedetomidine ICU, OR Loading infusion dose: 1 mcg/kg

Maintenance infusion dose: 0.2 to 1.5 mcg/kg/h

Loading dose rate: administer over 10 minutes

Maintenance infusion: adjust rate no more than every 30 minutes to desired sedation level

Vital sign monitoring (may cause bradycardia and hypotension)

At recommended doses, dexmedetomidine does not provide adequate and reliable amnesia; therefore, use of additional agents (eg, benzodiazepines) may be necessary

DiazePAM All units Usual dose: 2 to 10 mg; may repeat in 3-4 hours if needed

IV push: administer undiluted as slow IV push (max rate of 5 mg/min)

IV infusion: Do not administer as infusion

Vital sign monitoring Do not mix or dilute with other solutions or drugs

Digoxin All units Usual loading dose: 0.25 – 0.5 mg bolus; may repeat 0.25 mg bolus every 6-8 hours up to maximum of 1 mg/day

Usual maintenance dose: 0.0625 - 0.25 mg daily

IV Push: ICU Only

IV Infusion (preferred): Administer over 5 to 15 minutes

Vital sign monitoring for infusion Telemetry for IV Push

Short stability once diluted Check product for visible precipitate before

administration; do not use if present

Adjust dosing based on renal function


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DilTIAZem ICU, 5SE, 3NW

Bolus dose Initial dose: 0.25 mg/kg IV push

Repeat dose after 15 minutes if inadequate response: 0.35 mg/kg IV

Maintenance dose (ICU and 5SE ONLY)

5 – 15 mg/h continuous IV infusion

Bolus dose IV push rate: administer over 2 minutes

Maintenance dose

Maximum infusion rate: 15 mg/h


30 minutes x 2, every 1 hour x 4 or

until stable, then every 4 hours

AND

Bedside monitor for first ten minutes then telemetry


Do not use if there is a concern for systolic dysfunction


Use caution when used with other AV nodal blockers such as metoprolol and amiodarone

DOPamine ICU, OR, 5SE Usual dose range: 2 to 20 mcg/kg/min

IV infusion: titrate in 5 to 10 mcg/kg/min increments to desired response Gradually decrease infusion rate when

discontinuing drug


2 hours x 4, and then every 4 hours

AND

Telemetry

Dopamine extravasation may cause tissue necrosis Contraindicated in pheochromocytoma and

patients receiving MAO inhibitors

Sudden discontinuation of infusion may cause hypotension

EPHEDrine OR, ICU only Usual dose range: 5 to 25 mg/dose slow IV push Repeat as needed to maintain BP Max total dose: 50 mg

IV push: administer diluted solution as slow IV push

Bedside Monitoring

Look-alike Sound-alike: Do not confuse with

EPINEPHrine

EPINEPHrine 0.1 mg/mL All units Infusion:

ICU only

Dosing: 1 mg IV push every 3 to 5 min IV push: rapid IV push during cardiac arrest

IV infusion: ICU only

Bedside monitoring Must be an ACLS provider to administer. Look-alike Sound-alike: Do not confuse with

EPHEDrine

Epoetin Alfa ICU, 5SW-DH (dialysis)

Dosing: 50 – 150 units/kg 3 times per week OR

40,000 units once weekly, titrated to effect or Hgb IV push: administer slow IV push

*IV route preferred for hemodialysis; all other patients generally receive SubQ administration

No special monitoring required Do not shake Evaluate iron status in all patients before and during

treatment Target Hgb range of 10 g/dL should be considered

Decrease dose if Hgb increases > 1 g/dL in 2 weeks

Drug may increase risk of thromboembolism

Eptifibatide ICU, 5SE PCI dosing

Bolus dose

180 mcg/kg IV push (maximum: 22.6 mg) immediately before start of PCI and another 180 mcg/kg IV push bolus dose 10 minutes after first bolus dose

Maintenance dose

2 mcg/kg/min (maximum: 15 mg/h) continuous IV infusion for up to 18 to 24 hours or until discharge, whichever comes first

ACS dosing

Bolus dose

180 mcg/kg IV push (maximum: 22.6 mg)

Maintenance dose

2 mcg/kg/min (maximum: 15 mg/h) continuous IV infusion up to 72 hours

IV push: administer over 1 – 2 minutes

IV infusion: immediately follows bolus administration o administer undiluted directly from vial o the 100 mL vial should be spiked with a

vented infusion set


30 minutes x 2 then every 1 hour or

per patient’s condition

AND

Telemetry

Approved for the treatment of patients with ACS (unstable angina / non ST elevation MI) who are treated medically or with PCI (Anderson, 2011)

PCI dosing ordered by Cardiology LIP; maintained per post procedure orders

ACS dosing ordered by Cardiology or CCMD LIP.

Inspect drug for particles before administering

Monitor patient for any potential bleeding

Decrease maintenance dose for CrCl < 50 ml/min Contraindicated in hemodialysis Heparin infusion after PCI is discouraged


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Esmolol ICU, OR Loading dose: 0.25 – 0.5 mg/kg IV push

Maintenance dose: 50 to 300 mcg/kg/min continuous IV infusion

Loading dose: Administer IV push over 30 seconds to 1 minute

Bedside monitoring

If extravasation occurs, stop infusion immediately and disconnect; gently aspirate extravasated solution (do NOT flush the line)

Ethacrynic Acid All units Usual dose: 0.5 to 1 mg/kg dose (maximum: 100 mg/dose)

IV push: Administer slowly through the tubing of a running infusion or by direct IV injection over several minutes If second dose is needed, it is recommended

to use a new injection site to avoid possible thrombophlebitis

No special monitoring required • Monitor serum electrolytes • Do not give IM or SubQ

Etomidate ICU, OR Usual dose: 0.2 to 0.3 mg/kg IV push IV push: administer over 30 to 60 seconds Ventilatory support

Monitor for signs of adrenal insufficiency (including hypotension and hyperkalemia)

FentaNYL All units Usual dose: Bolus doses up to 1 mcg/kg IV in non-ICU patients

IV push: administer over 2 minutes

Vital sign monitoring

Ferumoxytol All units Usual dose: 510 mg as IV infusion, followed by a second 510 mg IV infusion 3 to 8 days thereafter

IV infusion: Administer over at least 15 minutes

No special monitoring Monitor closely for hypersensitivity (BBW) during and until 30 minutes after infusion is complete

Filgrastim All units Usual dose: 5 – 10 mcg/kg/dose by IV infusion IV infusion: 15 to 30 minutes, but may be infused over a maximum of 24 hours

No special monitoring required Filgrastim concentrations of 5 to 15 mcg/mL require addition of albumin to bag prior to addition of filgrastim (final albumin concentration should be 2 mg/mL). o Concentrations of filgrastim greater than 15

mcg/mL do not require addition of albumin. o Filgrastim should not be diluted to less than 5

mcg/mL. Do not shake.

Compatible only in D5W. Flush line with D5W before and after infusion.

Flumazenil All units Usual dose: 0.2 to 0.5 mg IV push; may be repeated up to a total maximum cumulative dose of 3 mg in 1 hour

IV push: administer over 30 seconds Vital sign monitoring Administer in freely-running IV into large vein

Folic acid All units Usual dose: up to 1 mg/day IV push: administer doses less than 5 mg over 1 minute or longer IV infusion: administer over 30 min

No special monitoring required Protect from light

Furosemide All units Usual dose: 20 to 40 mg/dose; may repeat same dose or increase dose in increments of 20 mg and administer 1 to 2 hours after previous dose (maximum of 200 mg/dose)

IV Push: Undiluted direct IV push may be

administered at a rate of 20 to 40 mg/min

IV Infusion: Maximum rate of 10 mg/h in non-

ICU areas

For infusion: Vital signs every 15 minutes x 4, every 30 minutes x 2, every 1 hour x 4 or until stable, then every 4 hours

Give bolus dose of furosemide before starting infusion

Protect from light

In non-ICU setting, Cardiology or nephrology consult required for continuous infusions.

Frequent monitoring of electrolytes (sodium, potassium, magnesium, calcium) and urine output is required

Risk of ototoxicity is increased with infusion rates > 4 mg/min


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Ganciclovir All units Usual dose: 0.625 – 5 mg/kg/dose every 12 to 24 hours IV Push: Do NOT administer IV push

IV Infusion: administer over a minimum of 60

minutes

No special monitoring required Dose reductions begin once CrCl is less than 70 mL/min

Flush line well with NS before and after administration

Glycopyrrolate All units Usual dose: 0.1 to 0.2 mg IV push IV push: Administer over 1 to 2 minutes Vital sign monitoring (with the exception of Hospice/Comfort Care)

Anticholinergic side effects; caution with elderly

Granisetron All units Prevention of Post-op Nausea & Vomiting: 5-20 mcg/kg (0.35-3 mg) IV one time dose

Prevention of Chemotherapy-Induced Nausea and Vomiting: 10 mcg/kg or 1 mg by IVP or infusion

IV push: administer over 30 seconds

IV Infusion: Administer over 5 to 15 minutes


Heparin Deep vein thrombosis/ pulmonary embolism

All units Low bleeding risk (initial dosing)

Loading dose: 80 units/kg (not to exceed 8000 units) IV bolus

Maintenance dose: 18 units/kg/h continuous IV infusion (not to exceed 1800 units/h)

High bleeding risk (initial dosing)

Loading dose: 40 – 60 units/kg (not to exceed 6000 units) IV bolus

Maintenance dose: 12 – 14 units/kg/h continuous IV infusion (not to exceed 1400 units/h)

IV Push: Administer bolus doses at a rate of 5000 units/min.

Maintenance dose: see heparin nomogram or MD orders for infusion rate

Routine monitoring Monitor UFH anti-factor Xa levels every 6 hours for the first 24 hours of starting infusion or changing infusion rate then every 8 hours thereafter if stable for ICU and non-ICU patients

CBC daily while on heparin

Monitor patient for signs of bleeding

Avoid in known or suspected HIT or where pre-

existing coagulopathy increases risk over benefit

Heparin Acute Coronary Syndromes

5SE, ICU No fibrinolytic treatment (initial dosing)

Loading dose: 60 – 70 units/kg (not to exceed 5000 units) IV bolus

Maintenance dose: 12 – 15 units/kg/h continuous

IV infusion (not to exceed 1000 units/h) x 48 hours

With fibrinolytic treatment (initial dosing)

Loading dose: 60 units/kg (not to exceed 4000 units) IV bolus

Maintenance dose: 12 units/kg/h continuous IV infusion (not to exceed 1000 units/h) x 48 hours

IV Push: Administer bolus doses at a rate of 5000 units/min.

Maintenance dose: see heparin nomogram or MD orders for infusion rate

Routine monitoring For use in acute coronary syndromes, must be ordered by Cardiology or CCMD LIP

Monitor UFH anti-factor Xa levels every 6 hours for the first 24 hours of starting infusion or changing infusion rate then every 8 hours thereafter if stable for ICU and non-ICU patients

CBC daily while on heparin

Monitor patient for signs of bleeding

Avoid in known or suspected HIT or where pre- existing coagulopathy increases risk over benefit


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HydrALAZINE All units Usual dose: 10 – 20 mg every 4 – 6 hours

Maximum single dose generally 20 mg, but higher doses may be used in the ICU where close cardiac monitoring is available

IV Push: administer as slow IV push Vital sign monitoring Do not refrigerate Dilution not recommended

Changes color in most infusion solutions. This does not indicate loss of potency.

Elderly may be more sensitive to hypotensive effects

HYDROmorphone All units Usual dose: 0.1 to 2 mg IV Push IV Push: administer over 2 – 3 minutes Vital sign monitoring Intravenous hydromorphone is 6.7 times more potent than IV morphine. Use caution when administering high doses to opioid naïve patients

Titrate using repeated low doses Use with caution in patients with high intracranial

pressure or elevated intraocular pressure Ibutilide ICU, 5SE Patients > 60 kg

1 mg IV

If arrhythmia is sustained, may repeat x 1 ten minutes after completion of first infusion

Patients < 60 kg

0.01 mg/kg IV

If arrhythmia is sustained, may repeat x 1 ten minutes after completion of first infusion

IV Infusion: administer over 10 minutes Vital signs every 15 minutes x 4, every


until stable

AND

Bedside monitor during infusion and for at least 90 minutes, then Telemetry

In both ICU and 5SE, must be ordered by Cardiology or CCMD LIP, who must be present for its administration

Correct electrolytes (potassium and magnesium) before administering ibutilide

Keep code cart at bedside during infusion of ibutilide

Discontinue ibutilide infusion once atrial fibrillation or atrial flutter terminates

Continuous EKG monitoring for four hours after infusion ends or until QTc returns to baseline

Caution with concomitant use of other QTc prolonging drugs

Isoproterenol ICU, OR Usual Dosing: 2 to 10 mcg/min IV Infusion: administer as continuous infusion Vital Sign monitoring AND

Bedside Monitoring

Check product for visible precipitate and changes in color (pinkish to darker than slightly yellow).

Ketamine IV push in ICU only

Infusion on 5SE, 3rd floor

Usual Dosing: 0.5 to 2 mg/kg IV Push IV push (ICU only): administer at rate of 0.5 mg/kg/min or over at least 1 minute IV Infusion: administer at rate of 0.1 mg/kg/h

Ventilatory support for IV Push only

Only LIP may administer IV Push

Monitor for psychological emergence reactions

Reference Ketamine Nursing SOP

Labetalol 5SE, 3NW, ICU, OR

Infusion in ICU only

Usual Dosing: 2.5 – 20 mg IV Push

Maximum total daily dose: 300 mg IV

IV push: administer at rate of 10 mg/min IV infusion (ICU only): 0.5 to 2 mg/min


15 minutes x 4, every 30 minutes x 2,

every 1 hour x 4 or until stable, then

every 4 hours

AND

Bedside monitor for 30 minutes after initial dose, then telemetry


Protect vial from light Caution in patients with asthma or obstructive

airway disease

Beta blockers may mask the signs and symptoms of acute hypoglycemia

Lacosamide All units Status Epilepticus: Loading dose: 200 to 400 mg Maintenance: 200 to 600 mg daily in 2 divided

doses

IV Infusion: administer doses over 30 to 60 min

Vital sign monitoring IV administration should not exceed 5 days of therapy; switch to oral therapy as soon as possible


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LevETIRAcetam All units Seizure Prophylaxis: Initial: 500 mg twice daily Maximum of 1500 mg twice daily Status Epilepticus: Initial: 1 to 3 g Maximum: 4.5 g

Seizure Prophylaxis: Infuse over 15 min Status Epilepticus: Infuse at rate of 2 to 5

mg/kg/min

No special monitoring required Final concentration should not exceed 15 mg/mL

Lidocaine ICU, 5SE, OR Bolus dose: 0.5 to 1.5 mg/kg IV push Maintenance dose: 1 to 4 mg/min continuous IV infusion

IV Push: Administer at rate of 25 to 50 mg/min unless cardiac arrest IV Infusion: 1 to 4 mg/min

Telemetry Only Code Team ACLS providers may administer bolus dose.

LORazepam All units Usual Dose: 0.5 to 4 mg IV Push or Infusion IV Push: maximum rate of 2 mg/min IV Infusion: 1 to 4 mg/h (do not exceed 10 mg/h)

Vital sign monitoring Avoid extravasation

Solutions for continuous infusion should have an in-line filter and periodically checked for potential precipitation

Magnesium sulfate IV push: ICU, OR only

Infusion: all units

Usual dose: 1 to 4 g IV Push

IV push (for severe symptomatic hypomagnesemia): maximum rate of 150 mg/min IV Infusion: maximum rate of 1 g/h

Telemetry

For patients not in cardiac arrest, too rapid administration may result in hypotension and/or asystole.

Slower administration may improve magnesium retention

Mannitol ICU, OR

Usual Dosing: 0.25 to 2 g/kg IV IV push: administer over 3 to 5 min IV Infusion: administer over 30 to 60 min

Vital sign monitoring Check for particulates before administration

In-line filter required

Avoid extravasation

Meperidine All units Rigors/post-operative shivers: 12.5 – 50 mg once Acute pain: 50 – 150 mg every 3-4 h PRN (max total dose <600 mg/24 h – do not exceed 48 hours)

IV push: administer as slow IV Push IV Infusion: administer diluted solution (10 mg/mL)

No special monitoring required Not recommended for use in pain. If use for acute pain cannot be avoided, limit to ≤ 48 hours and total dose <600 mg/24 hours. Do not abruptly discontinue; dosing should be tapered

Methadone All units Acute pain: 2.5 to 10 mg every 8-12 hours. Titrate slowly.

IV push: administer undiluted over several minutes.

No special monitoring required Caution when converting from oral to IV

Monitor respiratory rate

Dose reduction if Creatinine Clearance <10 mL/min

Metoprolol All units Usual Dosing: 2.5 – 10 mg IV Maximum single dose: 15 mg IV

Acute MI dosing : metoprolol 5 mg IVP every 5 minutes x 3 doses

IV push: Administer over 2 min

IV Infusion: Administer over 15 – 30 min

Stable Scheduled Doses (All units)


Dose Titrations or PRN Doses (3NW,

5SE, ICU)



until stable, then every 4 hours

AND

Bedside monitor for 30 minutes after initial dose, then Telemetry


Use caution when used with other AV nodal blockers such as diltiazem and amiodarone

Protect vial from light

Caution in patients with asthma or obstructive airway disease


Beta blockers may mask the signs and symptoms of acute hypoglycemia


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Midazolam ICU, OR, 3SWN (and other procedural areas)

Usual Dosing: Anesthesia induction: 0.05 to 0.35 mg/kg IV push Anesthesia maintenance: IV Push: 0.05 mg/kg as needed IV infusion: 0.015 to 0.06 mg/kg/h

Procedural sedation/anxiolysis: 0.5 to 2 mg IV push; may repeat every 2 to 3 minutes if needed (total dose: 2.5 to 5 mg) Sedation in mechanically ventilated ICU patients: IV Push: 0.01 to 0.05 mg/kg; may repeat at 10-15

minute intervals until adequate sedation IV infusion: 0.02 to 0.1 mg/kg/h; titrate to desired

sedation level

IV push: Anesthesia induction: administer over 5 to 15 seconds Procedural sedation/anxiolysis: administer over at least 2 minutes IV infusion: continuous infusion rate variable; titrated to desired sedation level

Ventilatory support

Potential for significant drug interactions that may require dose or frequency adjustment

Morphine All units Usual Dosing: Variable; titrated to pain relief IV push: Administer slowly over 4 – 5 min

IV Infusion: Continuous infusion rate variable

Vital sign monitoring Rapid IVP administration may result in chest wall rigidity

Naloxone All units Usual Dosing for Opioid Overdose: 0.1 to 2 mg IV push

IV push: Administer 0.4 mg over 30 seconds IV Infusion: Administer continuous infusion 0.4 mg/h and titrate to patient response

Vital sign monitoring Continuous infusion may be used with reversal of long-acting opioids (e.g., methadone) or sustained-release products

Infusion is generally used to treat opioid-induced pruritus

Neostigmine ICU, OR Usual Dosing: 0.5 to 2 mg IV push IV push: Administer over at least 1 minute Bedside Monitoring Dose reduction for ClCr <50 mL/min

Nitroglycerin ICU, OR, 5SE Usual Dosing: 5 – 200 mcg/min continuous IV infusion.

*Maximum rate of 400 mcg/min *Doses >30 mcg/min must be administered in ICU

IV Infusion: titrate by 5-10 mcg/min every 5-10 min


30 minutes x 2, then every 1 hour

AND

Telemetry

Must be ordered by Cardiology or CCMD LIP

Nitroglycerin is contraindicated in patients receiving sildenafil or other phosphodiesterase 5 inhibitors

Use non-PVC tubing

Do not use in-line filter

Use only non PVC bags or glass bottles

Side effects include headache and

methemoglobinemia

Ondansetron All units Post-op Nausea & Vomiting prevention: 4 mg IVP

Chemotherapy- Induced Nausea and Vomiting

prevention: 8 mg IV or 0.15 mg/kg/dose IV

IV push: Administer over 2 to 5 min; not recommended to administer over less than 30 seconds IV Infusion: Administer over 15 minutes *Doses >4 mg must be infused

No special monitoring required For CINV Prevention, give first dose 30 min prior to beginning chemotherapy

PENTobarbital

ICU, OR Usual dose: 100 mg (max dose range: 200 – 500 mg) IV push: Administer at a rate ≤ 50 mg/min IV infusion: Administer as prescribed

Vital sign monitoring IV route usually reserved for critical situations Monitor sedation, respiratory rate Rapid injection may lead to symptoms of overdose Avoid extravasation


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PHENobarbital ICU, OR Status epilepticus:

Loading Dose: 10 – 20 mg/kg; may repeat after 10 minutes if needed

Maintenance: 1 – 3 mg/kg over 24 h

IV Infusion: maximum rate of administration for adults is 60 mg/min

Vital sign monitoring Use in-line filter Maintenance doses usually started 12 hours after

loading dose Avoid extravasation and administration into small or

varicose veins Phenytoin All units Status epilepticus:

Loading dose: 15 – 20 mg/kg Maintenance: 100 mg q 6 – 8 hours

IV Infusion: maximum rate of administration for adults is 50 mg/min

Cardiac and vital sign monitoring

required for doses >300 mg

See Phenytoin/Fosphenytoin

Administration Guidelines for more

information.

Use in-line filter Vesicant; monitor for extravasation

Flush line with NS after infusion

Infusion must be completed within 4 hours after dilution in normal saline

Physostigmine ICU, OR Usual Dosing: 0.5 to 2 mg IV push IV push: minimum rate of administration for adults is 1 mg/min

Bedside Monitoring

Too rapid administration can cause bradycardia, respiratory distress, and seizures

Propofol ICU, OR Loading Dose: 1 to 2 mg/kg IVP Maintenance Dose: 5 to 100 mcg/kg/min IV continuous infusion

IV push: Administer over 1 minute IV Infusion: Titrate as directed every 5 minutes to achieve sedation goals

Ventilatory support

Administration must be completed 12 hours after the vial has been spiked.

Discard tubing after 12 hours.

Protamine All units Usual Dosing: 25 to 50 mg IV IV Infusion: maximum rate of 50 mg over 10 minutes

Vital sign monitoring In general, 1 mg of protamine neutralizes 100 units of heparin

Rapid administration may cause hypotension and shock.

Risk factors for hypersensitivity reactions include previous exposure to protamine, fish allergy, and vasectomy

Pyridostigmine ICU, OR Usual Dosing: 0.1 to 0.25 mg/kg IV push IV push: administer over 60 seconds Bedside monitoring Full recovery usually occurs within 15 – 30 min

Remifentanil ICU, OR Usual loading dose: 0.1 to 1 mcg/kg/min Continuous infusion: up to 0.25 mcg/kg/min

IV push: administer over 30 to 60 seconds IV infusion: administer as continuous infusion

Ventilatory support

Restricted to CCMD and credentialed anesthesiologists

Flush tubing after infusion

Decrease loading dose by 50% if giving with midazolam

Rocuronium ICU, OR Usual Dosing: 0.6 to 1.2 mg/kg IV push IV push: administer rapid IV push Ventilatory support

Sargramostim All units Usual Dosing: 250 mcg/m2/day by IV infusion

IV infusion: rate is indication specific, ranging from 2 to 24 hour infusions.

No special monitoring required For IV administration, sargramostim concentrations <10 mcg/mL require addition of albumin to bag for a final albumin concentration of 1 mg/mL. Albumin should be added to the bag prior to sargramostim.

Do not shake.

Compatible only in NS.

Do NOT use an in-line membrane filter during administration

Lower sargramostim doses are administered by intradermal or percutaneous injection as an adjunct in vaccine protocols. Dose is protocol dependent.


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Sodium Bicarbonate All units IV Push: 1 mEq/kg/dose IV Infusion: 2 to 5 mEq/kg over 4 to 8 h *subsequent doses should be based on patient’s acid-base status

IV push: administer over 1 to 3 min IV Infusion: Administer at a rate of ≤ 50 mEq/h

Vital sign monitoring Sodium bicarbonate 8.4% must be diluted with at least an equal volume of NS or D5W prior to administration through peripheral vein if not in cardiac arrest.

Infusion via Central line preferred – extravasation may cause chemical cellulitis/necrosis/ulceration

Flush line before and after administration

Rapid administration may produce abnormal electrolyte shifts

Succinylcholine ICU, OR Usual Dosing: 0.6 to 1.5 mg/kg IV push IV push: administer as rapid IV Push Ventilatory support

Avoid in patients with hyperkalemia, acidosis, myopathy, upper/lower motor neuron disease, and high intracranial or intraocular pressure

Vasopressin ICU, OR Usual shock dosing: 0.01 – 0.04 units/min

IV Infusion: administer by continuous infusion Bedside monitoring

Avoid extravasation during IV infusion. May cause severe vasoconstriction and localized tissue necrosis

Recommended to infuse through central line

Vecuronium ICU, OR Bolus/Loading Dose: 0.1 to 0.2 mg/kg IV push Infusion/Maintenance: 0.8 to 1.2 mcg/kg/min

IV push: administer as rapid IV push IV Infusion: administer as continuous infusion

Ventilatory support

Verapamil ICU, OR SVT/Atrial arrhythmia: 5 – 10 mg (0.075 – 0.15 mg/kg) Repeat dose: If no response, administer 10 mg (0.15 mg/kg) 30 min after 1st dose followed by an infusion at 5 mcg/kg/min

IV push: administer over at least 2 minutes (3 minutes in elderly patients) IV Infusion: administer as continuous infusion; titrate to goal heart rate

Vital sign monitoring AND

Bedside monitoring AND

Telemetry

Avoid concurrent administration with IV beta-blockers since both can depress myocardial contractility and AV conduction. Doses should be spaced apart if both are needed.

Contraindicated in wide-complex ventricular tachycardia (QRS > 0.12 sec)

General Drug References include:

Lexicomp

Micromedex

Product prescribing Information

Documents

Adult IV Push/Infusion Guidelines for Select Medications