Intravenous Infusion Guidelines 2024 (MUHC)

EMERGENCY DEPARTMENT INTRAVENOUS INFUSION GUIDELINES Any infusion prepared on a nursing unit should be INITIATED within 1 h of preparation and discarded 24 h after preparation for reasons of sterility. Any infusion prepared by pharmacy should be discarded as per stability...

EMERGENCY DEPARTMENT INTRAVENOUS INFUSION GUIDELINES Any infusion prepared on a nursing unit should be INITIATED within 1 h of preparation and discarded 24 h after preparation for reasons of sterility. Any infusion prepared by pharmacy should be discarded as per stability indicated on the label. If medication is not present in this document, refer to the Injectable Medication Preparation and Administration Table on the MUHC intranet NOTE: FOR CONTINUOUS INFUSIONS: IF VOLUME OF MEDICATION TO MIX IS MORE THAN 10% OF BAG VOLUME, WITHDRAW EQUAL VOLUME FROM BAG BEFORE ADDING THE MEDICATION (UNLESS SPECIFIED OTHERWISE) Example: Milrinone: Withdraw 20 mL from 100 mL NS bag and add 20 mL (=20 mg) of milrinone DISCLAIMER: This summary does NOT include all information available about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to these medications. For more detailed information, refer to a pharmacist, physician or reliable medical references (see references at the end of the document). DRUG NAME RECONSTITUTION, CONCENTRATION AND COMMENTS SUGGESTED NURSING MONITORING DOSES FOR COMMON INDICATIONS IN PARAMETERS THE ED AND OTHER PERTINENT INFORMATION ADENOSINE Paroxysmal supraventricular tachycardia (PSVT) - Physician must be present at bedside Monitoring: 3 mg/mL x 2 mL Continuous 12-lead ECG monitoring with 12 leads Initial dose: 6 mg - Place IV access as proximal as possible to machine during administration Antiarrhythmic agent Repeat dosing if no effect after 1-2 min: 12 mg trunk (avoid lower arm, hand, lower leg or Continuous cardiac monitor, duration as per physician 3rd dose :12-18 mg foot). Antecubital is best. discretion Onset of action: immediate - Do not administer intraosseously. BP and HR Q 5 min after administration X 3 Duration : seconds Undiluted Monitor IV site Give IVP over 1-2 seconds via peripheral line then rapid flush Reduce dose by 50% : 20 mL normal saline flush (use stopcock). - if central line Do not give (unless functioning pacemaker) if: second or third - if patient on carbamazepine or dipyridamole degree AV block, symptomatic bradycardia or sick sinus syndrome. Alternatively: doses of 6 mg and 12 mg can also be prepared - if heart transplant patient using a single syringe method. Dilute the 6 mg or 12 mg of May cause: chest pressure, facial flushing, headache, dizziness, adenosine in up to 20 mL of NS. dyspnea and nausea. Inform patient they may feel unwell for a few seconds but it’s temporary. ALTEPLASE For pulmonary embolism (not associated with cardiac Preparation: Monitoring (intermittent IV infusion of doses 10 mg of greater): 1mg/mL x 100 mL arrest): - Insert transfer device vertically into the Baseline BP, HR and neuro-vital signs then Q1h during MUHC Anticoagulation Guidelines - stopper of the SWI vial. SWI vial must be kept infusion then Q1h X6, then if stable Q4h X 48h. Thrombolytic agent Acute Management of Pulmonary Embolism Adults upright. Visual assessment for signs and symptoms of bleeding Standard dose: - Holding the alteplase vial upside-down, push Q30 min during infusion, then Q1h X 6 then Q4h X 48h Duration: fibrinolytic activity - Dose: 100 mg over 2 h it so that the piercing pin is inserted in the Assess for frank or occult blood in stool, emesis, sputum persists for up to 1 h after end of - Administer directly from vial with vented IV tubing alteplase stopper. and urine for at least 72h after initiation of therapy. infusion and IV pump using library - Invert the 2 vials so that the Alteplase vial is Monitoring may differ per physician discretion if giving on the bottom and the SWI is upside-down. bolus doses. Reduced dose (if high bleeding risk: see linked document) - Allow the entire content of the SWI vial to - Dose for 50 kg and more: 50 mg total dose (10 mg IV flow into the alteplase vial. - Avoid unnecessary invasive procedures after thrombolytic bolus + 40 mg IV over 2 h) - Remove the empty vial and the transfer administration due to risk of bleeding. MADC = Medication Administration Double Check MPDC = Medication Preparation Double Check nd Document: Emergency department intravenous infusion guidelines MUHC P&T approved : May 22 2024 1  Cont. ALTEPLASE - Dose for 50 kg or less: 0.5 mg/kg total dose (10 mg IV device and swirl gently to dissolve the - No IM injection or NG tube insertion x 24h following alteplase 1mg/mL x 100 mL bolus + remainder over 2 h) powder. Do not shake. administration. For pulmonary embolism (associated with cardiac arrest): May cause: bleeding, nausea and vomiting *Preferred option in this case is Tenecteplase due to ease of preparation vs Alteplase (refer to Tenecteplase section)* Alteplase dosing: - Initial bolus of 50 mg over 2 min (Remove 50 mg (50 mL) from vial with syringe and administer IV push over 2 min) and continue CPR. - Can administer a 2nd bolus of 50 mg after 15 min if ROSC not achieved and CPR continued - Indication NOT programmed in pump For stroke: MUHC is phasing out alteplase for stroke, please use Tenecteplase AMIODARONE Supraventricular/ventricular arrhythmias - If given peripherally, as continuous drip: Monitoring: 50 mg/mL x 3 mL (hemodynamically stable): use in-line filter (0.22 micron) to reduce Direct IV (cardiac arrest): LD 150 mg/100mL D5W (RVH) or NS (MGH) incidence of phlebitis. No filter required for ECG and HR monitoring as per cardiac arrest team leader Antiarrhythmic agent, Class III IV over 10 min central administration. MD 450 mg/250mL D5W polyolefin bag (RVH) - Solution in vial can foam easily Intermittent IV infusion (infusion over less than 2 h) Onset (electrophysiologic Continuous cardiac monitoring during administration or NS polyolefin bag (MGH) effects): within hours Baseline BP and HR then Q 15 min post infusion X 4 final [ ] = 1.8 mg/mL Duration: half-life is days to Run at 1 mg/min IV x 6 h (VTBI 200 mL) then 0.5 mg/min months Continuous IV infusion (infusion 2 h and longer) IV x 18h Continuous cardiac monitoring during administration Breakthrough doses: 150 mg over 10 min can be given up to BP and HR Q 15 min X 4 until stable then Q 4h during 6-8 times/24h from a separate 100 mL bag (do not use 450 infusion mg/250 mL maintenance bags for boluses). If hypotension or bradycardia occurs: hold infusion and call physician Monitor IV site: avoid extravasation. Ensure proper Cardiac arrest due to ventricular fibrillation or pulseless catheter placement prior to infusion. ventricular tachycardia Other recommended monitoring as per physician First dose: 300 mg IV undiluted rapid bolus discretion: Serum electrolytes, acid-base balance, sCr, Repeat dose: 150 mg IV undiluted rapid bolus if needed. LFTs If ROSC: start continuous infusion Do not give if: Second or third degree AV block, symptomatic bradycardia or sick sinus syndrome; (unless functioning pacemaker). May cause: Hypotension (up to 20%), bradycardia, heart block, QTc interval prolongation, arrhythmias or pulmonary edema. MADC = Medication Administration Double Check MPDC = Medication Preparation Double Check nd Document: Emergency department intravenous infusion guidelines MUHC P&T approved : May 22 2024 2  CALCIUM CHLORIDE 10% Use prefilled syringes: no further dilution needed - Central line preferred to avoid extravasation Monitoring: 100mg/mL X 10mL - If peripheral administration, use large vein Direct IV or intermittent IV infusion rates greater than 50 mg/min Cardiac arrest (with hypomagnesemia, hypocalcemia or - Calcium chloride is only recommended in of calcium chloride salt (= 1g over 20 min or less) Electrolyte supplement hyperkalemia): emergency or very serious conditions. For Continuous cardiac/respiratory monitoring 1g IVP, repeat as necessary other situations, use calcium gluconate. Intermittent IV infusion (less than 50 mg/min of calcium chloride Severe life-threatening hyperkalemia (ECG changes or - Contains three times more elemental salt= 1g over more than 20 min) serum potassium over 6.5 mEq/L): calcium than calcium gluconate. BP, HR, RR, SpO2 Q5 min X 3, then Q30 min X 2, then 1 g over 2-5 min; may repeat after 5 min if ECG Q1h during infusion. changes persist or recur, then Q30-60 min PRN Serum calcium and albumin levels (when given for hypocalcemia) as per physician discretion Calcium channel or beta-blocker overdose: Monitor IV site for pain, redness or swelling 20 mg/kg (max: 1-2g/dose) IV over 5-10 min, may repeat Q10-20 min for 3-4 additional doses May cause: tingling sensations, a sense of oppression or heat waves, calcium or chalky taste. With rapid administration, may also cause: bradycardia, vasodilation, hypotension, cardiac arrhythmias, syncope and cardiac arrest. CALCIUM GLUCONATE 10 Severe life-threatening hyperkalemia (ECG changes or - Rapid IV peripheral administration may Monitoring: % serum potassium over 6.5 mEq/L): cause local phlebitis, Direct IV or intermittent IV infusion rates greater than 145 mg/min 100 mg/mL x 10 mL 1 to 2 g IV undiluted over 2-5 min; may repeat after 5 - Central line preferred to avoid extravasation of calcium chloride salt (= 1g over 7 min or less) min if ECG changes persist or recur, then Q30-60 min - If peripheral administration, use large vein Continuous cardiac/respiratory monitoring Electrolyte supplement PRN Intermittent IV infusion (less than 145 mg/min of calcium chloride Severe hyperkalemia, severe hypocalcemia, massive salt = 1g over more than 7 min) transfusion protocol: BP, HR, RR, SpO2 Q5 min X 3, then Q30 min X 2, then Q1h during infusion. 1-2 g in 100 mL D5W (RVH) or NS (MGH) over 15 Serum calcium and albumin levels (when given for min. May repeat bolus doses after 10-60 min if hypocalcemia) as per physician discretion symptoms persist. Monitor IV site for pain, redness or swelling Non urgent indications (Hypocalcemia in otherwise stable patient, prevention of hypocalcemia during massive blood Do not give if: hypercalcemia transfusion protocol) 1 g in 100 mL of D5W (RVH) or NS (MGH) IV over May cause: tingling sensations, a sense of oppression or heat waves, 1 h ( max rate = 75 mg /min) calcium or chalky taste. With rapid administration, may also cause: bradycardia, vasodilation, hypotension, cardiac arrhythmias, Calcium channel or beta-blocker overdose: syncope and cardiac arrest. 60 mg/kg (max: 3-6 g/dose) IV undiluted over 5-10 min, may repeat Q10-20 min for 3-4 additional doses MADC = Medication Administration Double Check MPDC = Medication Preparation Double Check nd Document: Emergency department intravenous infusion guidelines MUHC P&T approved : May 22 2024 3  DRUG NAME RECONSTITUTION, CONCENTRATION AND COMMENTS SUGGESTED NURSING MONITORING DOSES FOR COMMON INDICATIONS IN PARAMETERS THE ED AND OTHER PERTINENT INFORMATION DIAZEPAM Alcohol withdrawal syndrome: IV diazepam contains propylene glycol: high Monitoring: 5 mg/mL X 2 mL 5-10 mg IV undiluted over 1-2 min PRN as per CIWA doses and prolonged courses can cause Direct IV: (max rate 5 mg/min), follow MedUrge structured propylene glycol accumulation and toxicity Baseline BP, HR, RR, then Q 5 min X 1, then Q 15 min X Benzodiazepine prescription or Physician orders for frequency of - Avoid IM administration, erratic and slow 2 CIWA assessment and frequency of medication absorption Monitor IV injection site Onset: 1-3 min administration - Available antidote in case of severe overdose: Flumazenil (flumazenil may cause Do not give if: acute narrow-angle glaucoma withdrawal in patients receiving long-term benzodiazepine therapy) May cause: respiratory depression, hypotension, dizziness, - Use with caution in patients with hepatic anterograde amnesia, CNS depression. impairment (preference for lorazepam in these patients). DIGOXIN Atrial fibrillation/atrial flutter or - A decrease in dose should be considered in Monitoring 250 mcg/mL X 2 mL supraventricular tachycardia, rate elderly patients and in those with decreased Direct IV: for rapid Digitalizing Dose control: renal function. HR and BP prior to each dose and Q15 min X 4 post Antiarrhythmic, cardiac glycoside - Less than fourfold dilution may lead to drug administration Total loading dose of 8-12 mcg/kg (using lean or ideal precipitation. Continuous cardiac monitoring during administration and Onset: 5-60 min body weight) or 500-1000 mcg divided in 3 doses at 4- for a minimum of 2 h after first digitalizing dose (the Duration: 3-4 days 8h administration intervals as follows (maximum: 1.5 - Hypokalemia, hypercalcemia, largest dose). For the subsequent lower doses continuous mg over 24 h): hypomagnesemia and hypothyroidism cardiac monitoring during administration and for a - First dose H0: 50% of calculated dose predispose patients to digoxin toxicity. minimum of 1 h following each dose. - Second dose H4: 25% of calculated dose Hold dose and notify physician if HR is less than 50 bpm. - Third dose H8: 25% of calculated dose - If required, serum drug levels should be Notify physician before administration of subsequent doses taken at least 6-8 h after last dose. of digoxin if there are any significant changes in heart Loading doses: 125 - 500 mcg (0.5 to 2 mL) IV in 10 rhythm, HR, or other signs of digoxin toxicity (ex: cardiac mL of NS or D5W over 5 min. - Available antidote in case of severe toxicity arrhythmias, confusion, weakness, GI symptoms, visual (ex: cardiac arrhythmias, confusion, changes) Maintenance dose: 62.5 - 125 mcg (0.25 to 0.5 mL) IV weakness, GI symptoms, visual changes): Serum electrolytes (including calcium, magnesium and in 50 ml of NS or D5W over 10 minutes Digoxin Immune Fab (DigiFab) potassium) and creatinine as per physician discretion. Monitor infusion site for signs of extravasation and - When switching from PO to IV therapy, vesication, ensure proper catheter placement prior to and decrease dose by 20-25% during administration. Do not give if: ventricular fibrillation May cause: cardiac manifestations (arrhythmias, heart block, asystole), nausea, vomiting, diarrhea, abdominal pain, headache, dizziness, confusion, visual disturbances (blurred or yellow vision) and muscle weakness. DRUG NAME RECONSTITUTION, CONCENTRATION AND COMMENTS SUGGESTED NURSING MONITORING DOSES FOR COMMON INDICATIONS IN PARAMETERS THE ED AND OTHER PERTINENT INFORMATION MADC = Medication Administration Double Check MPDC = Medication Preparation Double Check nd Document: Emergency department intravenous infusion guidelines MUHC P&T approved : May 22 2024 4  DILTIAZEM Atrial fibrillation or atrial flutter, rate control: - keep vials in fridge Monitoring: 5 mg/mL x 5 mL Bolus dose: 0.25 mg/kg IV undiluted over 2 min. - infusion should not exceed 24h or more Direct IV: Repeat with 0.35 mg/kg IV in 15 min if no response. than 15 mg/h due to potential for drug Continuous cardiac monitoring during administration and Calcium channel blocker, Patients who respond after 1-2 bolus doses can be started on a accumulation for a minimum of 15 min after dose. nondihydropyridine continuous infusion or oral medication. - Immediate release PO diltiazem can be Baseline BP, then Q 3 to 5 min X 15 min and until stable started approximately 1 h before stopping Onset: 3 min For continuous infusion: infusion or immediately after bolus dose Continuous IV infusion: 125 mg (25 mL diltiazem) in 100 mL D5W (RVH) or NS Continuous cardiac monitoring during administration Duration: (MGH) – no prior removal of fluid from D5W or NS bag BP Q 3 to 5 min X 15 min and until hemodynamically Bolus: 1-3 h required stable, then Q 1h, at baseline and with any dosage change Continuous infusion: 30-60 min final [ ] = 1 mg/mL Observe for signs of new or worsening heart failure (such after end of infusion MD : 5-15 mg/h: physician to specify dose/titration parameters as: edema, new cough, difficulty breathing, fatigue).. Usual titration: increase infusion rate in 5 mg/hr increments (up Monitor IV site to 15 mg/h) every h according to ventricular response Do not give if: sick sinus syndrome or 2nd/3rd degree AV block (except if functioning pacemaker), severe hypotension, severe bradycardia (less than 40 bpm), cardiogenic shock, atrial fibrillation or flutter with accessory bypass tract (WPW syndrome, short PR syndrome), ventricular tachycardia with wide-complex tachycardia or pregnancy. May cause: Bradycardia, 1st-degree AV Caution: monitor closely if concomitant use of other agents that block, hypotension, vasodilation, flushing, impair AV nodal conduction (eg, beta-blockers, digoxin) as may dizziness and arrhythmia. cause: bradycardia, sinus pause, first-degree atrioventricular (AV) block, second-degree atrioventricular block, or complete heart block MADC = Medication Administration Double Check MPDC = Medication Preparation Double Check nd Document: Emergency department intravenous infusion guidelines MUHC P&T approved : May 22 2024 5  DRUG NAME RECONSTITUTION, CONCENTRATION AND COMMENTS SUGGESTED NURSING MONITORING DOSES FOR COMMON INDICATIONS IN PARAMETERS THE ED AND OTHER PERTINENT INFORMATION DOBUTAMINE Inotropic support: - Administer in large vein Monitoring: 12.5 mg/mL x 20mL 250 mg/ 250 mL NS (MGH) or D5W (RVH) Continuous IV infusion Inotrope, adrenergic agonist Do not withdraw from minibag - Available antidote in case of extravasation: If hypovolemia present; correct before initiating medication final [ ] = 1 mg/mL phentolamine perfusion Prior to use, correct electrolyte disturbance, especially Onset: 1-10 min hypokalemia or hypomagnesemia, to minimize the risk of MD 2.5-20 mcg/kg/min IV Can initiate at 0.5 to 5 mcg/kg/min. arrhythmias. Physician to specify dose/titration parameters (usual titration: Continuous cardiac/respiratory monitoring increase infusion rate in 2.5-5 mcg/kg/min increments every BP Q 5 min X 3, then Q 30 min X 2, then Q 1h for the 10 min according to hemodynamic parameters) duration of therapy. Monitor urine output Q 1h. Maintain urine output greater than or equal to 0.5 mL/kg/h Monitor creatinine as per physician discretion. Peripheral line: monitor infusion site for extravasation Q 15 min Closely monitor for arrhythmias in patients with decompensated heart failure. Ensure ventricular rate is controlled in atrial fibrillation/flutter before initiating; may increase ventricular response. Do not give if: hypersensitivity to sulfites, hypertrophic cardiomyopathy with outflow tract obstruction May cause: increased HR, increased/decreased systolic BP, ventricular premature contractions, hypokalemia and dyspnea. EPINEPHRINE Continuous infusion: - Central line preferred: if central line not Monitoring: 1 mg/mL x 1mL 4 mg/ 250 mL NS (MGH) or D5W (RVH) available, may be administered through a Direct IV 0.1 mg/mL X 10 mL (pre-filled final [ ] = 16 mcg/mL peripheral IV catheter placed in a large vein Continuous cardiac/resp monitoring during administration syringes) MD : initial 1-5 mcg/min at a proximal site for a short duration. BP Q 5 min X 3, then Q 30 min X 2, then Q 4h until Physician to specify dose/titration parameters - IV bolus may be associated with cardiac hemodynamically stable Alpha/Beta-agonist (Usual titration: increase infusion rate in 1 to 5 mcg/min arrhythmias and cardiac ischemia. Continuous IV infusion increments every 5 min according to hemodynamic Continuous cardiac/respiratory monitoring Onset: within 1-2 min parameters BP Q 5 min X 3 min, then Q 15 min x 2h at beginning of - Available antidote in case of extravasation: phentolamine treatment and at each dosage change followed by vital signs Q Duration: 5-10 min Cardiac arrest: 1h or more frequently according to patient hemodynamic 1 mg IV push Q 4 min (3-5 min) status Use 1 mg/10mL pre-filled syringes Serum potassium 1h after initiation and Q 4-8h or as per physician orders. Hypotension or shock: Capillary/serum blood glucose QID or as per physician orders Bolus dose (“push dose epinephrine”): Urine output and creatinine as per physician discretion 10-20 mcg IV Q 2 min PRN Correct hypovolemia prior to and during therapy if used to Preparation: treat hypotension. Step 1) Transfer 1 mL (=100 mcg) from the epinephrine mini- Peripheral line: monitor infusion site for jet (1 mg/10mL) into an empty 10 mL syringe extravasation/blanching Q 15 min. Vesicant: ensure proper Step 2) Complete up with 9 mL of NS for a total volume of needle or catheter placement prior to infusion. 10 mL (Final [ ] = 10 mcg/mL) May cause: tachycardia, palpitations, arrhythmia, hypertension, chest pain, dyspnea, anxiety and agitation. MADC = Medication Administration Double Check MPDC = Medication Preparation Double Check nd Document: Emergency department intravenous infusion guidelines MUHC P&T approved : May 22 2024 6  DRUG NAME RECONSTITUTION, CONCENTRATION AND COMMENTS SUGGESTED NURSING MONITORING DOSES FOR COMMON INDICATIONS IN PARAMETERS THE ED AND OTHER PERTINENT INFORMATION ESMOLOL Hypertensive emergencies/supraventricular tachycardia - Do not administer through small veins (can Monitoring: 10 mg/mL x 10 (SVT)/thyrotoxicosis or thyroid storm: cause thrombophlebitis) Direct IV: mL vials LD : 250-500 mcg/kg IV undiluted over 1 min Continuous cardiac/respiratory monitoring during 10 mg/mL x 250 mL premixed - If loading dose not administered, a administration bags Use premixed bags for continuous infusion continuous infusion at a fixed dose reaches BP Q 5min X 3 min, then Q 30 min X 2, then Q 4h until MD : 25-50 mcg/kg/min IV steady-state in approximately 30 min. hemodynamically stable Beta-blocker, beta-1 selective Physician to specify dose/titration parameters. (Usual titration: If inadequate response, can repeat loading Continuous IV infusion Onset: 2-10 min dose and increase infusion by 25-50 mcg/kg/min, increments Continuous cardiac/respiratory monitoring during Duration: 10-30 min, prolonged if no more frequently than every 5 min) administration extended use Maximum dose = 300 mcg/kg/min. BP Q 5 min X 3, then Q 30 min X 2, then Q 1 h while on perfusion Strict monitoring of urine output Correct hypovolemia Monitor creatinine as per physician discretion Monitor serum potassium especially with renal impairment (esmolol can increase potassium) as per physician discretion. Monitor site of infusion for extravasation Q 15 min if a peripheral line is used. Extravasation can lead to skin necrosis and sloughing. Do not give if: severe sinus bradycardia, hypotension, 2nd/3rd degree AV block (except if functioning ventricular pacemaker), sick sinus syndrome, cardiogenic shock, decompensated heart failure, IV administration of calcium channel blockers in close proximity to esmolol or pulmonary hypertension. May cause: hypotension, bradycardia, heart block, flushing and bronchospasm. ETOMIDATE Rapid sequence intubation: - Provides no analgesia Monitoring: 2 mg/mL X 10 mL 0.3 mg/kg (use ideal body weight for BMI ≥ 40 kg/m2) - Solution is highly irritating; avoid Continuous cardiac/respiratory monitoring during undiluted IV push over 30-60 seconds administering into small vessels administration. General anesthetic Baseline BP, HR, RR and SpO2, BP Q5 min during procedure and then Q 15 min X 30 min post-procedure or Onset: 30-60 seconds until recovery. Duration: 2-5 min (dose dependent) Renal function tests as per physician discretion. Monitor injection site Do not give if: no absolute contraindications May cause: myoclonus, adrenal suppression, nystagmus MADC = Medication Administration Double Check MPDC = Medication Preparation Double Check nd Document: Emergency department intravenous infusion guidelines MUHC P&T approved : May 22 2024 7  DRUG NAME RECONSTITUTION, CONCENTRATION AND COMMENTS SUGGESTED NURSING MONITORING DOSES FOR COMMON INDICATIONS IN PARAMETERS THE ED AND OTHER PERTINENT INFORMATION FENTANYL Analgesia and sedation in intubated patients: continuous - Prescribed in mcg/h for the continuous Monitoring: 50 mcg/mL x 2 mL or 5 mL infusion: infusion Refer to the following document on the intranet 20 mcg/mL or 100 mL premade Use minibags prepared by pharmacy (final [ ] = 20 - Compatible in NS or D5W Assessment, Administration, Monitoring, and Documentation of minibags by pharmacy mcg/mL): - Should administer additional small bolus Pain in Adult Patients Receiving Opioid Analgesics dose when increasing the infusion rate. Opioid LD 1-2 mcg/kg IV undiluted over 1-2 min or through pump - Rapid IV infusion may result in respiratory May cause: constipation, nausea and vomiting, peripheral edema, using minibag depression and hypotension. dizziness, confusion, drowsiness, bradycardia, hypotension, Onset: Immediate MD 25-200 mcg/h (0.5-3 mcg/kg/h) IV. Physician to titrate hypertension, respiratory depression Duration: 30-60 min dose. - Available antidote in case of severe Usual titration: Titrate in 25-50 mcg/h increments every 30- toxicity: naloxone 60 min to clinical effect (pain control and/or sedation), usual max dose = 300 mcg/h. If minibags unavailable, can prepare as followed: Recipe for 2000 mcg / 100 mL NS Inject 40 mL (2000 mcg) of fentanyl in 50 mL minibag of NS and add 10 mL of NS. Final volume: 100 mL in 50 mL minibag. Final [ ] = 20 mcg/mL For other indications: please refer to MUHC resources for procedural sedation, palliative sedation or major distress protocol FUROSEMIDE Edema: - protect from light (not required during Monitoring for bolus doses: 10 mg/mL X 2mL or 4mL Bolus dose: 20-40 mg IV undiluted over 2-4 min, can repeat infusion) Monitor BP before and during therapy per physician discretion Q2h PRN. If initial dose does not result in diuresis, may - Dose equivalence IV:PO = 1:2 ratio Follow up on serum electrolytes, should not be initiated if severe Loop diuretic double after 2 h until diuresis occurs. Usual maximum ex: 20 mg IV = 40 mg PO hypokalemia effective dose: 80-200 mg. (Maximum recommended total Monitor In/Out ratio: monitor for dehydration and hypovolemia. Onset: 15-30 min daily dose: 600 mg/day) Consider foley if patient unable to mobilize or unstable. Duration: 2 h Assess for signs and symptoms of ototoxicity (especially if high Specific administration guide according to dose: doses or rapid IV administration) 10-80 mg IV undiluted over 1-8 min (max rate: 10 Monitor creatinine per physician discretion mg/min) 81-120 mg IV in total of 20 mL NS over 30 min Do not give if: anuria, hypovolemia or hypotension 121-240 mg IV in total of 30 mL NS over 60 min 241-400 mg IV in total of 50 mL NS (max rate: 4 May cause: orthostatic hypotension, electrolyte imbalance mg/min) (hypokalemia, hypernatremia, hypocalcemia, hypomagnesemia, hypochloremia), hypovolemia, dizziness, blurred vision, tinnitus and acute kidney injury. Continuous infusion Monitoring for continuous infusion: 100 mg/ 100 mL NS Monitor BP before and during therapy per physician discretion final [ ] = 1 mg/mL Follow up on serum electrolytes, should not be initiated if severe MD : 4-20 mg/h hypokalemia Max dose = 100 mg/h Strict In/Out ratio: monitor for dehydration and hypovolemia. Consider foley if patient unable to mobilize or unstable. Assess for signs and symptoms of ototoxicity (especially if high doses or rapid IV administration) Monitor creatinine per physician discretion MADC = Medication Administration Double Check MPDC = Medication Preparation Double Check nd Document: Emergency department intravenous infusion guidelines MUHC P&T approved : May 22 2024 8  DRUG NAME RECONSTITUTION, CONCENTRATION AND DOSES COMMENTS SUGGESTED NURSING MONITORING FOR COMMON INDICATIONS IN PARAMETERS THE ED AND OTHER PERTINENT INFORMATION HYDRALAZINE Hypertensive emergency: Monitoring: 20 mg/mL X 1 mL 10 - 20 mg undiluted IV slow push Q4-6 h PRN, may Baseline BP and HR, then Q 3 to 5 min until stable, then Q increase dose to a maximum of 40 mg/dose if necessary 15 min X 2, then Q 30 min X 2 Vasodilator Monitor for hypotension, tachycardia, syncope, CNS effects (headache, dizziness, anxiety), flushing, sweating, dry Onset: 10-80 min mouth, unpleasant state. May aggravate angina and/or CHF. Duration: up to 12 h Advise patient to make position changes slowly to minimize orthostatic hypotension. Do not give if: coronary artery disease, mitral valve rheumatic disease, severe tachycardia and heart failure with high cardiac output (ex, in thyrotoxicosis), myocardial insufficiency due to mechanical obstruction (ex, aortic or mitral stenosis), isolated right ventricular heart failure due to pulmonary hypertension, acute dissecting aortic aneurysm, porphyria or idiopathic systemic lupus erythematosus. May cause: reflex tachycardia, hypotension, flushing, edema, acute myocardial infarction, skin rash, hydralazine-induced lupus-like syndrome, dizziness. ISOPROTERENOL Bradyarrhythmias/bradycardia: Monitoring: 0.2 mg/mL x 1 mL LD 0.2 mg/50 mL D5W (RVH) or NS (MGH) Continuous IV infusion: IV over 30 mins (LD not recommended), Continuous cardiac/respiratory monitoring during Beta1/Beta2 Agonist follow with 20 mL NS flush to ensure administration distribution to circulation. BP Q 5 min X 3 at beginning of treatment and at each dosage Onset: immediate change, then Q 15 min for duration of treatment Duration: 10-15 min MD 1 mg/250 mL D5W (RVH) or NS (MGH) Monitor Urine output, serum glucose, serum potassium and IV at 1-10 mcg/min magnesium as per physician discretion Physician to specify dose/titration parameters. Peripheral line: monitor infusion site for extravasation Q 15 (Usual titration: increase infusion by 1 mcg/min increments min every 5 min) Do not give if: pre-existing ventricular arrhythmias or cardiac Maximum dose = 10 mcg/min. glycoside intoxication. Alternative: 0.4 mg/100 mL May cause: angina, arrhythmias, palpitations, hypo/hypertension, Final [ ] = 4 mcg/mL flushing, dizziness, headache, nausea, vomiting, dyspnea, pulmonary edema, increased serum glucose. KETAMINE For IV continuous infusion (adjunct/alternative sedation - Administer bolus doses over ＞30-60 Monitoring: 10 mg/mL x 2 mL and 20 mL for mechanically ventilated patients): seconds to decrease risk of respiratory Direct IV and intermittent IV infusion 50 mg/mL x 2 mL (high 200 mg in 100 mL D5W (RVH) or NS (MGH) (use the depression and apnea (can be given faster for Baseline: BP, HR, RR and SpO2, sedation scale concentration vials) ketamine 10 mg/mL formulation) rapid sequence intubation) During administration of doses 0.25 mg/kg up to 1.5 mg/kg: withdraw 20 ML from NS or D5W bag and add ketamine - For class 3 obese patients (BMI ≥ 40 continuous cardiac monitoring/pulse oximetry and end-tidal General anesthetic: noncompetitive 200 mg=20mL kg/m2): use adjusted body weight or ideal CO2 monitoring until recovery is well established. At these NMDA receptor antagonist that Final [ ] : 2mg/mL body weight doses, if patient is not intubated, patient must be under the blocks glutamate. Bolus: 0.1-0.5mg/kg - For IM injection: inject deep IM into large direct supervision of a nurse. MD: 15-35 mg/h, titrate to a max dose of 175 mg/h muscle mass Continuous IV infusion Onset: 30 seconds (0.1-0.5 mg/kg/h, titrate to a max dose of 2.5 mg/kg/h) - IM onset of action: 3-4 min for anesthesia Continuous cardiac /pulse oximetry and end-tidal CO2 Duration: 5-10 min and within 10-15 min for analgesia monitoring. At start of infusion and with each dosage increase: For rapid sequence intubation (induction agent): baseline BP and RR (unless intubated), then Q 5 min until IV: 1-2 mg/kg undiluted IV push stable, then Q 1 h for duration of treatment MADC = Medication Administration Double Check MPDC = Medication Preparation Double Check nd Document: Emergency department intravenous infusion guidelines MUHC P&T approved : May 22 2024 9  DRUG NAME RECONSTITUTION, CONCENTRATION AND DOSES COMMENTS SUGGESTED NURSING MONITORING FOR COMMON INDICATIONS IN PARAMETERS THE ED AND OTHER PERTINENT INFORMATION Cont. KETAMINE For refractory acute/severe agitation: Notify physician if HR is above 120 bpm 10 mg/mL x 2 mL and 20 mL IV: 0.5-1 mg/kg undiluted over 30-60 seconds Monitor injection site. 50 mg/mL x 2 mL (high IM: 2-4 mg/kg undiluted (use high concentration ketamine 50 concentration vials) mg/mL) Do not use if: conditions in which increase in BP would be hazardous, known or suspected schizophrenia (when used as analgesia or procedural sedation), severe cardiac decompensation, surgery of pharynx, larynx or bronchial tree unless adequate muscle relaxants are used. May cause: emergence reactions (hallucinations, excitement, irrational behavior, confusion, vivid dreams and/or frank delirium), increased BP and HR (can also cause bradycardia and hypotension), arrhythmias, hypertonia (tonic-clonic movements resembling seizures), apnea, respiratory depression especially with rapid IV administration, laryngospasm, diplopia and nystagmus. LABETALOL Severe hypertension: - Accumulation may occur with high-dose Monitoring: 5 mg/mL x 20 mL Intermittent IV: 10-20 mg undiluted over 1-2 min, followed continuous infusions and may result in Direct IV: by 20-80 mg over 2 min Q10 min until target HR and BP severe hypotension and bradycardia. Continuous cardiac/respiratory monitoring during Antihypertensive; beta1/beta2- (usual maximum cumulative IV dose: 300 mg) - Use with caution in hepatic dysfunction, administration blocker with alpha1-blocking Consider a continuous infusion if targets not achieved patients may need a dose reduction. BP Q 5 min X 3, then Q 30 min X 2, then Q 4 h until activity hemodynamically stable For IV continuous infusion Onset: within 5 min 300mg/300 mL D5W or NS Continuous IV Infusion: Duration: 16-18 h (dose dependent) Withdraw 10 mL from a 250 mL bag and add 60mL Continuous cardiac/respiratory monitoring during (=300mg) of labetalol administration final [ ] = 1 mg/mL BP Q 5 min X 3, then Q 30 min X 2 at beginning of treatment and at each dosage change, then Q 1 h while on MD 0.5-2 mg/min IV continuous infusion (higher doses up to infusion. 10 mg/min may be required in certain situations). Monitor urine output, creatinine and serum glucose as per Physician to specify dose/titration parameters. physician discretion. (Usual titration: may repeat intermittent IV bolus and increase Monitor site of infusion for extravasation if a peripheral line infusion by 0.5 mg/min increments every 30-60 min is used. Use large proximal vein if possible. Maximum dose = 2 mg/min (up to 10 mg/min in some situations, such as aortic dissection) Do not use if: severe bradycardia or hypotension, 2nd or 3rd degree heart block (except if pacemaker present), cardiogenic shock or uncompensated cardiac failure, bronchial asthma or history obstructive airway disease. May cause: orthostatic hypotension, bradycardia, ventricular arrhythmia, dizziness, fatigue, paresthesia, nausea, diaphoresis and dyspnea. LEVETIRACETAM Status epilepticus - When switching IV to PO: use same dose Monitoring: 100 mg/mL x 5mL 1 to 3 g or 40-60 mg/kg (round to the nearest 250 mg up to a Monitor for CNS depression (somnolence and fatigue) max dose of 4.5g) diluted in 50 mL NS over 5-10 min Monitor for psychiatric and behavioral symptoms (psychosis, Anticonvulsant hallucinations, psychotic depression, agitation, anger, Some studies support giving up to 4.5g undiluted IV push aggression, apathy…) Time to peak: 5-30 min over 5 min May cause: headache, drowsiness, dizziness, asthenia, ataxia and nausea. MADC = Medication Administration Double Check MPDC = Medication Preparation Double Check nd Document: Emergency department intravenous infusion guidelines MUHC P&T approved : May 22 2024 10  DRUG NAME RECONSTITUTION, CONCENTRATION AND DOSES COMMENTS SUGGESTED NURSING MONITORING FOR COMMON INDICATIONS IN PARAMETERS THE ED AND OTHER PERTINENT INFORMATION Cont. LEVETIRACETAM Seizure prophylaxis in SAH or TBI (severe acute) 100 mg/mL x 5mL LD: 20 mg/kg IV (rounded to nearest 250 mg) over 15 min (give over 5 min if actively seizing) MD: 1g IV over 15 min Q12h X 7 days Seizure (non urgent): - Dilute doses of 250-750 mg in 50 mL D5W (RVH) or NS (MGH) and infuse over 15 min - Dilute doses of 751-1500 mg in 100 mL D5W (RVH) or NS (MGH) and infuse over 15 min LIDOCAINE HCl Ventricular arrhythmias - For prolonged infusion (after 24 h): reduce Monitoring: Prefilled syringes rate of infusion by half to compensate for Direct IV: 20 mg/mL x 5mL Intermittent IV: reduced elimination rate Continuous cardiac/pulse oximetry monitoring during Premixed bags Use prefilled syringes (100mg/5mL). Final [ ] 20 mg/ml - Reduce maintenance dose in renal and administration and until stable 4 mg/mL x 250 mL LD : 1 to 1.5 mg/kg over 1-2 min (push in cardiac arrest) hepatic dysfunction and CHF May repeat 0.5 to 0.75 mg/kg bolus Q 5-10 min PRN Continuous IV Infusion: Antiarrhythmic agent, class Ib Maximum cumulative dose: 3 mg/kg - Available antidote in case of severe Continuous cardiac/pulse oximetry monitoring during toxicity: IV lipid emulsion (Intralipid®) administration Onset: 45-90 seconds Continuous IV infusion: Monitor IV site: Local thrombophlebitis may occur with Duration: 10-20 min (single bolus Use premixed bags (1000 mg/250 mL) Final [ ] : 4 mg/mL prolonged infusions dose) MD : 1 to 4 mg/min after return of spontaneous circulation Potential signs of CNS toxicity include ringing in ears, circumoral numbness, metallic taste, nausea, dizziness, sedation. Severe toxicity symptoms: muscle spasms, seizures, CNS depression, respiratory arrest, coma Monitor LFTs as per physician discretion Do not give if: severe allergy to corn-related products or amide-type local anesthetics, Adam-Stokes syndrome, WPW syndrome, severe degrees of SA, AV, or intraventricular heart block (except if pacemaker present), supraventricular arrhythmias or severe myocardial depression. May cause: bradycardia, cardiac arrhythmia, CNS toxicity (see above), heart block, flushing and respiratory depression. MADC = Medication Administration Double Check MPDC = Medication Preparation Double Check nd Document: Emergency department intravenous infusion guidelines MUHC P&T approved : May 22 2024 11  DRUG NAME RECONSTITUTION, CONCENTRATION AND DOSES COMMENTS SUGGESTED NURSING MONITORING FOR COMMON INDICATIONS IN PARAMETERS THE ED AND OTHER PERTINENT INFORMATION LORAZEPAM Intermittent IV: - Do not dilute in NS for continuous infusion Monitoring: 4 mg/mL x 1mL Preparation of intermittent doses: dilute IV lorazepam dose - IM lorazepam is not recommended due to Direct IV: with equal volume of NS or D5W erratic absorption and slow time to peak drug Baseline BP, HR, RR, SpO2, RASS then Q 5 min X 1, then Benzodiazepine levels. Q 15 min X 2 Seizures: - IV lorazepam contains propylene glycol: Onset: within 10 min 0.1 mg/kg (up to maximum of 4 mg/dose) at a maximum rate high doses, continuous use can cause Continuous IV Infusion: Duration: 6-8 h of 2 mg/min. May repeat at 3-5 min if seizures continue. propylene glycol accumulation and toxicity Continuous cardiac monitoring. If IV access is not available, use IM midazolam (especially if renal impairment). Monitor administration injection/infusion site Anxiety and agitation, acute/severe: Do not give if: acute narrow-angle glaucoma, severe respiratory - Follow structured prescription in MedUrge - Available antidote in case of severe insufficiency (except during mechanical ventilation). overdose: Flumazenil (flumazenil may cause Alcohol withdrawal: withdrawal in patients receiving long-term May cause: anterograde amnesia, dizziness, hypotension, asthenia, - Follow structured prescription in MedUrge benzodiazepine therapy) respiratory and CNS depression. Continuous infusion: 20 mg/100 mL D5W Final [ ] = 0.2 mg/mL MD: 1-3 mg/h Max dose 10 mg/h MAGNESIUM Hypomagnesemia: - Unless urgent indication: max rate = 150 Monitoring: SULFATE 1-5g/250 mL D5W (RVH) or NS (MGH) IV over 1-5 h mg/min Direct IV (for ventricular arrhythmias only): 500 mg/mL x 10 mL (1g/h) (Med/surg pump library) - May cause hypotension and asystole with HR and ECG monitoring as per ACLS protocol For fluid restricted: 1-5g/100 mL D5W (RVH) or NS rapid administration Anti-arrhythmic: Continuous IV Infusion: Electrolyte supplement (MGH) IV over 1-5 h (1g/h) (Critical care pump library) - Slow IV administration (1g/h) may provide Continuous cardiac monitoring more efficient repletion due to potential for Baseline BP, RR, temperature, urine output, then Q 1 h. Severe symptomatic hypomagnesemia with hemodynamic rapid urinary eliminations. Baseline creatinine, calcium and magnesium levels, repeat Q instability: can give 1-2g in 100 mL D5W (RVH) or NS - For hypomagnesemia in patients with renal 4-8 h until stable, or as ordered. (MGH) over 2-15 min dysfunction: reduce dose by 50% Hypomagnesemia: Intermittent IV infusion/loading dose: - If local pain or burning sensation present Baseline BP, RR, temperature, urine output, then 1 h after Torsade de pointes (TdP): during infusion via peripheral vein, increase initiation and once half-way during infusion. 2 g in 100 mL D5W (RVH) or NS (MGH) over 15 min primary solution IV rate Baseline renal function tests, calcium and magnesium levels, If pulseless: give 1-2 g in 10 mL NS over 1-2 min repeat daily while on magnesium replacement - Available antidote in case of severe toxicity: Obstetrics: Preeclampsia and Eclampsia: Asthma (severe exacerbation): Calcium chloride For antepartum patient: continuous fetal monitoring and uterine 2 g in 100 mL D5W (RVH) or NS (MGH) over 15 min activity IV Loading Dose: Eclampsia/preeclampsia protocol: ○ Baseline BP, HR, RR, SpO2 Q 5 min x 20 min. LD: 4 g in 100 mL NS over 20 min ○ Assess level of consciousness ○ Monitor for side effects and toxicity Continuous infusion MD: Continuous IV Infusion: MD: 20g in 500 mL NS at 1 g/h (25mL/h) ○ Baseline BP, HR, SpO2 Q 15 min x 1 h and until stable, then Q 1 h until infusion is discontinued. Do not give if: 2nd or 3rd degree heart block (unless pacemaker present) May cause: flushing, hypotension, vasodilation, circulatory collapse and muscle weakness. MADC = Medication Administration Double Check MPDC = Medication Preparation Double Check nd Document: Emergency department intravenous infusion guidelines MUHC P&T approved : May 22 2024 12  DRUG NAME RECONSTITUTION, CONCENTRATION AND DOSES COMMENTS SUGGESTED NURSING MONITORING FOR COMMON INDICATIONS IN PARAMETERS THE ED AND OTHER PERTINENT INFORMATION MANNITOL 20% Intracranial pressure (ICP)/cerebral edema reduction: - 20% = 20g/100 mL Monitoring: 200mg/mL x 500mL Final [ ] 200mg/mL - Use 0.2 micron filter tubing and inspect for Monitor Vital Signs (BP, HR, RR, Sat) before and Q 10 min Premixed bags MD : 0.25-1 g/kg/dose over 15-30 min crystals prior to administration. during treatment May repeat Q 4-6h PRN May cause renal dysfunction: urinary catheter recommended to Osmotic diuretic measure In/Out given diuretic effect of drug. May cause fluid/electrolyte imbalance: monitor for new onset or Onset: 15-30 min worsening cardiac or pulmonary congestion (circulatory Duration: 1.5-6 h overload). Assess fluid volume status and correc