DATE: 9/2015 Critical Care Guidelines TARGET AUDIENCE: Nurses, Pharmacists, Physicians Standard Concentration. Drug

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1 DATE: 9/2015 TOPIC: Critical Care Guidelines TARGET AUDIENCE: Nurses, Pharmacists, Physicians Drug Abciximab (Reopro) (Antiplatelet- Glycoprotein 2B-3A inhibitor) Bolus/Loading Give undiluted (use 0.22 micron filter) 9 mg/ 250 ml (0.036 mg/ml) 0.25 mg/kg IVPB over 30 minutes 0.125, max of 10 mcg/min, 15 ml/hr (weight 80 kg or greater will receive max dose) Infuse for 12 hours Assess PTT after 6 hrs of starting infusion If PTT greater than 70, stop infusion, and modify heparin dose per nomogram or physician order. Resume Abciximab when PTT less than 70 MAX dose, regardless of wt, 15 ml/hr, 10 mcg/min N/A In-line filter preferred (0.2 or 0.22 micron filter) Obtain baseline CBC, PT, PTT and start infusion if PTT less than 50 Repeat CBC in 3 hrs after completion of infusion. Notify physician if platelets decrease by 25% of baseline or to 100, 000 OR if Hgb falls> 2Gms in 24 hours OR is < 8 Prepare for simultaneous administration of heparin, always used with heparin (maximum heparin dose is 800 units/hour) Notify physician stat if serious bleeding occurs: risk when used with other agents affecting coagulation. Stop if symptoms of allergic rxn or anaphylaxis; notify physician Usually started 10 to 60 min prior to the start of PCI, and continued for 12 hours post-pci, but may be infused for hrs before PCI and continued for 1 hr after PCI. Duration of effect ~ 48 hrs; If emergent CABG required within 48 hrs of infusion, will need to infuse platelets

2 Alteplase (tpa) (Thrombolytic agent) Alteplase (tpa) (Thrombolytic agent) Acute Ischemic Stroke 100 mg / 100 ml (1 mg/ml) NS Acute STEMI 100 mg / 100 ml (1 mg/ml) NS Acute Ischemic Stroke Total dose = 0.9 mg/kg IVPB x 1, maximum 90 mg Bolus Loading 10% of the total dose IVP over 1 minute Infuse the remaining 90% of the dose over 60 min Bolus Loading, All Weights 15 mg IVP over 1-2 min from vial Less than or equal to 67 kg mg/kg over 30 min (not to exceed 50 mg), then 0.50 mg/kg over 60 min, (not to exceed 35 mg) Greater than 67 kg - 50 mg over 30 minutes, then 35 mg infused over 60 Max dose 90 mg Max dose is 100 mg total N/A N/A Monitor VS and neuro status q 15 min for 2 hrs, the q 30 min for 6 hrs, then q 60 min X 16 hrs and PRN (protocol) Blood pressure must be maintained at less than 185/110 to administer thrombolytic During and post-treatment, if SBP is more than 180 or DBP is more than 105 on two readings 5 minutes apart, then treat. Finger stick glucose every hour x 4 hours, then every 4 hours for the next 20 hours. Need non-contrast CT of head ASAP Monitor for signs of bleeding, including change in LOC notify physician Place on bleeding precautions: Place sign above patient bed: See RN before drawing blood If possible, use saline lock for blood draws during and 24 hours post-alteplase infusion If possible, avoid IM injections and arterial punctures; minimize and group together venous punctures Use dedicated IV line Independent verification required No anticoagulation or antiplatelets for 24 hours after initiation of alteplase Monitor VS q 15 min during infusion, continuous cardiac monitoring Assess for signs of reperfusion: arrhythmias, chest pain relief, resolution of ST segment elevation Monitor for signs of major and minor bleeding and notify physician; discontinue if sudden change in LOC (possible Intracranial bleed) or major bleeding Place on bleeding precautions: Place sign above patient bed: See RN before drawing blood If possible, use saline lock for blood draws during and 24 hours post-alteplase infusion If possible, avoid IM injections and arterial punctures; minimize and group together venous punctures Use dedicated IV line Independent verification required May receive IVUFH, LMWH, and/or aspirin concurrently

3 Alteplase (tpa) (Thrombolytic agent) Alteplase (tpa) (Thrombolytic agent) Pulmonary Embolism 100 mg / 100 ml (1 mg/ml) NS Peripheral Arterial Occlusion 5 mg / 500 ml (0.01 mg/ml) NS 50 mg/50 ml NS (1 mg/ml) 50 mg/500 ml NS (0.1 mg/ml) min Infuse 100 mg over 2 hrs Bolus Dosing- Code situations only- Unlabeled Indication Give 50 mg IV Push, assess for clinical response, if responded, give an additional 50 mg IV Push mg/kg/hr IA continuously N/A N/A N/A N/A Monitor VS q 15 min during infusion Monitor for signs of major and minor bleeding and notify physician; discontinue if sudden change in LOC (possible Intracranial bleed) or major bleeding, notify physician Place on bleeding precautions: Place sign above patient bed: See RN before drawing blood If possible, use saline lock for blood draws during and 24 hours post-alteplase infusion If possible, avoid IM injections and arterial punctures; minimize and group together venous punctures Independent verification required Stop heparin drip to administer tpa, then re-start after tpa has been infused and the PTT is less than or equal to 2 times baseline, or begin heparin drip if not already begun Monitor for signs of major and minor bleeding and notify physician; discontinue if sudden change in LOC (possible Intracranial bleed) or major bleeding, notify physician May give with heparin drip Monitor fibrinogen levels per vascular surgeon or interventional radiologist Usual duration 1 day up to one week. Monitor VS per ICU protocol Independent verification required 0.01mg/mL concentration is stable for 24 hours; all other concentrations are stable for 8 hours Amiodarone (Cordarone) (Antiarrhythmic- Class 3) Ventricular Tachycardia 150 mg / 100 ml (1.5 mg/ml), plastic bag Continuous Infusion 450 mg / 250 ml (1.8 mg/ml) Ventricular Tachycardia/Atrial Fibrillation 150 mg IVPB over 10 min. (15 mg/min = 600 ml/hr for 10 min) Continuous Infusion 1 mg/min infusion over 6 hrs, May repeat bolus (150 mg) for breakthrough VT Usually do not wean, but convert to PO or D/C Monitor VS, rhythm before initiation of therapy, q 15 min x 4 after initiation, then at least q 4 hrs Monitor for hypotension and conduction abnormalities In-line filter (0.22 micron) required for bolus and continuous infusions Infuse via central line, if one is available If a central line is not available, infuse peripherally using one dedicated line for amiodarone. Assess the IV site frequently during infusion of amiodarone for phlebitis or extravasation See Extravasation Treatment guidelines in Lippincott for additional information Document causative arrhythmia, any breakthrough

4 Argatroban (Anticoagulant- Direct Thrombin Inhibitor), excel bag Ventricular Fibrillation 300 mg IVP loading dose undiluted from the vial 50 mg/50 ml (1 mg/ml) NS 125mg / 125 ml (1 mg/ml) NS (1mg/min = 33.3 ml/hr x 6 hrs), then 0.5 mg/min infusion (16.7 ml/hr for 18 hrs) Ventricular Fibrillation/Pulseless V Tach 300 mg rapid IVP, may follow with 150 mg undiluted Recommended Starting Dose 2, measure PTT after 2 hrs In hepatic impairment or critically ill patient, start at 0.5 No bolus required Refer to Argatroban order set for titration MAX dose is 10 N/A arrhythmias with a rhythm strip Potentiates effect of warfarin, beta blockers, calcium blockers, predisposes to digoxin toxicity May require 50% reduction in daily digoxin dose Binds to PVC, continuous drip must be mixed in non-pvc bag. Monitoring: PTT, PT, INR as per order form Infuse alone, do not mix with other IV meds Argatroban order set is strongly recommended Obtain baseline coagulation profile Half-life ~ 45 min, no antidote Co- administration of argatroban and warfarin results in false elevation of INR. Bleeding precautions: Place sign above patient bed: See RN before drawing blood If possible, use saline lock for blood draws during infusion If possible, avoid IM injections and arterial punctures; minimize and group together venous punctures The premix 50 mg/50 ml will be utilized for doses less than 1 and the 125 mg/125 ml will be utilized for doses greater than or equal to 1 CONVERSION to warfarin - If dose is < 2 when warfarin is started, may D/C argatroban when INR > 4, repeat INR in 4 hrs, may restart argatroban if INR falls below therapeutic level, repeat process daily until INR is therapeutic on warfarin alone. - If dose is > 2, reduce the dose to 2 and measure an INR 4-6 hr after the dose reduction. Argatroban can be stopped when the INR on warfarin and argatroban is >4. Repeat INR in 4-6 hrs and if INR is below the therapeutic level, argatroban infusion can be re-started. Repeat

5 Cisatracurium (Nimbex) (Neuromuscular Blocking Agent) Dexmedetomidine (Precedex) (alpha2- adrenoceptor agonist, sedative) Loading dose: If on an infusion, bolus from infusion 200 mg/100 ml (2 mg/ml) NS From infusion 400 mcg/100 ml (4 mcg/ml) NS Loading dose mg/kg slow IV push or from infusion Start 3, max dose of 10 Obtain baseline TOF prior to initiation of infusion/bolus Recommended Starting Dose Bolus dose (optional): 1 mcg/kg IV over 10 min If the patient did not receive a bolus dose, initiate infusion at a rate of 0.4 mcg/kg/hr Adjust dose based on TOF assessment If 1-3:4 twitch and pt does not demonstrate respiratory effort, maintain infusion at current dose. If 1-3:4 twitch and pt does demonstrate respiratory effort, then infusion by 25%. If 0:4, turn off infusion, recheck TOF q 15 min until TOF 1-2:4, then resume drip at 50% prior infusion rate. If TOF 3-4:4, give initial bolus then restart infusion at 50% of previous dose. Maximum dose- 10 May titrate based on level of sedation to a recommended max infusion rate of 0.7 mcg/kg/hr. Usual maintenance dose is mcg/kg/hr. Titrate to achieve the desired level of sedation every 15 process daily until INR therapeutic on warfarin alone. No wean necessary NMBA electronic order set or paper order form must be completed Ensure airway control: patient MUST be intubated Always administer SEDATION and/or ANALGESIA prior to NMBA Patient must be adequately sedated with midazolam or lorazepam +fentanyl prior to administration (RASS score of - 5 prior to initiation of NMBA) DO NOT USE propofol or dexmedetomidine for sedation while on NMBA Neuromuscular blocking agents DO NOT possess sedative or analgesic properties Independent verification required Ascertain goal of clinical paralyzation, i.e. maintain oxygenation, peak airway pressure, ICP, TOF Document baseline vital signs, pain and sedation scores before administration of NMBA and within 15 min after For continuous infusion, document TOF response within 15 min after dose change, hourly and PRN Correlate train of four (TOF) with clinical picture Eye care with lubricating ointment or drops required Warning label MUST be on all NMB agents Protect from light Incompatible with propofol, barbiturates, ketorolac, and alkaline solutions (bicarb) Daily cessation recommended of paralytic for paralysis assessment and prevention of prolonged paralysis or polyneuropathy Abrupt discontinuation of dexmedetomidine after a prolonged infusion time (greater than 7 days) may rarely result in withdrawal symptoms similar to those observed with clonidine Dexmedetomidine CPOE order set or dexmedetomidine paper order form must be completed Use is restricted to intensivists, ED physicians, or CV surgeons for use in the following clinical situation: Transition from benzodiazepine, propofol, or opioids to facilitate ventilator weaning for an extubation expected to occur within 24 hours in patients who have failed previous weaning attempts. Immediately post-cv surgery to facilitate extubation within 24 hours

6 Diltiazem (Cardizem) (Antihypertensive, Antiarrhythmic- Class 4) From the infusion 125 mg / 125 ml (1 mg/ml) If the patient received a bolus dose, the infusion may be initiated at 0.2 mcg/kg/hr 0.25 mg/kg (~20mg) over 2 min If no response after 15 min, 0.35 mg/kg (~25 mg) over 2 min minutes until stable, then every 2 hours. See order set for titrating dexmedetomidine while titrating propofol or a benzodiazepine off. infusion by increments of 5 mg q 5 10 min Maximum dose is 15 mg/hr for 24 hrs Discontinue infusion 1-2 hours post administration of oral dose No wean necessary For short-term treatment of severe agitation in non-intubated patients when antipsychotics are ineffective and/or contraindicated and the use of benzodiazepines is not preferred As monotherapy for short-term sedation in non-intubated patients during imaging studies when the use of benzodiazepines is not preferred Loading doses may increase risk of adverse effects (changes in blood pressure and heart rate). May cause arrhythmias DO NOT PARALYZE PATIENTS WHILE ON DEXMEDETOMIDINE May cause changes in blood pressure or heart rate. Risk of hypotension and bradycardia is significantly increased in the following situations: Concomitant use of negative inotropic and vasodilator medications Hypovolemia History of diabetes mellitus History of chronic hypertension Patients older than 65 years of age Consider dose reduction in patients with mild or moderate hepatic impairment (Child-Pugh Class A or B). Abrupt discontinuation of dexmedetomidine after a prolonged infusion time (greater than 7 days) may rarely result in withdrawal symptoms similar to those observed with clonidine. Monitor ECG rhythm, rate and B/P q 5-10 min for 30 min after bolus or in dose. Most common ADE: hypotension, bradycardia. Duration: generally limited to 24 hrs Convert to PO ASAP, same effects Start infusion at 5 15 mg/hr Dobutamine 1000 mg / 250 ml (4 mg/ml) by 2 5 Taper by 2 q min until D/C Independent verification required Monitor B/P, heart rate and rhythm q min after

7 (Dobutrex) (Inotrope) Dopamine (Catecholamine Vasopressor) 800 mg / 250 ml (3.2 mg/ml) 2 5 Hypotension: 5 increments q 15 min to goal dose/effect Maximum dose is 20 for sepsis and 40 for heart failure infusion by 1-4 increments every 3 5 min Recommended max dose is 20, doses greater than 20 up to 40 have been used but provide limited clinical benefit and may increase the risk of tachyarrhythmias. Taper by increments q 5 10 min until D/C d once blood pressure goals met initiation of tx or dose Side effects include tachyarrhythmias or ischemia Generally, not useful for hypotension, affects beta-1 receptors in heart, plus mild dilating effects Continuous telemetry on dosing greater than 5 See Extravasation Treatment guidelines in Lippincott for extravasation treatment information Central line preferred, but not required Monitor B/P, heart rate and rhythm q 5 min during titration up and down, then at least hourly during infusion. Monitor every 4 hours if renal perfusion dose. Ascertain goal B/P Monitor for tachyarrhythmias Correct hypovolemia Independent verification required If being used as vasopressor agent, patient must be in the ICU Continuous Telemetry on all doses greater than 5 Central line preferred, but not required Max dose for peripheral infusion is 20, if higher dose is required, a central line is required Nurse should contact a physician for orders if doses greater than 20 are required If the patient is receiving a dose of 20 and goal BP is not reached, consider adding a more direct acting vasopressor, such as norepinephrine or epinephrine. Monitor peripheral site routinely for extravasation See Extravasation Treatment guidelines in Lippincott for treatment information Epinephrine (Catecholamine Vasopressor) IV undiluted Only for cardiac arrest and anaphylactic reaction, must use as diluted infusion if used Cardiac Arrest 1 mg q 3-5 min Hypotension Continuous Infusion, Vasopressor dose, may titrate infusion mcg/min q 5 min Usual range is 2 10 mcg/min, max 10 mcg/min dose by mcg/min q 5 min Monitor baseline B/P, rhythm and q 5 min when titrating up or down; monitor for tachyarrhythmias Central line required. May use peripheral line for code situations. See Extravasation Treatment guidelines in Lippincott for treatment information Check blood sugar, hyperglycemia protocol recommended

8 as vasopressor with pulse present Cardiac arrest: 1 mg/10 ml prefilled syringe (1:10,000) Allergic reaction: Epi pen 0.3 mg/0.3 ml mcg/min (high-end doses generally required in septic shock) Do NOT mix with sodium bicarbonate, lidocaine, aminophylline Sensitive to light and air, Protect from light (the pre-mix IVPB are stable for 7 days unprotected from light per manufacturer). Epoprostenol (Flolan) (Prostacyclin vasodilator) 4 mg / 250 ml (0.016 mg/ml) NS or IV infusion (hospital pump) 0.5mg/100 ml IV infusion (ambulatory CADD pump) Varies IV infusion Per physician order (usual starting dose is 2 ng/kg/min) Per physician order Per physician order (not usually done) For adults, see Parenteral Epoprostenol (Flolan) and Treprostinil (Remodulin) Order Set and Pulmonary Hypertension Medication Ordering and Dispensing Policy ( ) Initiation of therapy for adults to be done in ICUs, step down units, or 9EW only IV infusion bag or IV infusion cartridge with drug to be changed every 8 hours. Contact pharmacy when refill is needed. Eptifibatide (Integrilin) (Antiplatelet- Glycoprotein 2B-3A inhibitor) 2 mg/ml 10mL vial undiluted 75 mg / 100 ml (0.75 mg/ml) premixed vial 180 mcg/kg from vial, IVP over 2 min, maximum 22.6 mg A 2 nd loading dose 10 minutes later if PCI to be performed Infuse 2, not to exceed 15mg/hr Max loading dose, 22.6mg Max infusion rate for creatinine clearance 50 ml/min or greater is 15mg/hr Max infusion rate for creatinine clearance less than 50mL/min is 7.5mg/hr N/A Monitor VS based on clinical status Stat CBC, PT, PTT, creatinine and in AM Draw CBC 4 hours after bolus CBC 3 hrs after completion of infusion. Notify physician if platelets decrease by 25% of baseline or to 100, 000 or if Hgb falls > 2gms in 24 hours or is < 8 Notify physician of bleeding, abnormal labs Alert physician to other meds patient may be taking that may increase bleeding risk Platelet function returns approx 4 hrs after drug D/C Place on bleeding precautions: Place sign above patient bed: See RN before drawing blood

9 If estimated serum creatinine clearance is less than 50 ml/min, dosing will decrease to 1, maximum 7.5mg/hr If possible, use saline lock for blood draws during and 8 hours post-eptifibatide infusion If possible, avoid IM injections and arterial punctures; minimize and group together venous punctures Pre-printed order set available Initiate Weight Based Heparin - cardiac orders Compatible with heparin and several other meds (see Micromedex), NOT Lasix Must be renally adjusted, contraindicated in dialysis Esmolol (Brevibloc) (Antihypertensive, Antiarrhythmic- Class 2, blocker) Fentanyl (Sublimaze) (Opioid analgesic. Sedative (alone or adjunctive) (optional) From infusion 2500 mg / 250 ml (10 mg/ml) Loading dose Given from infusion 2,500mcg/250ml (10 mcg/ml) NS (optional) 500 mcg/kg over 1 min Loading dose can be repeated while drip is being titrated up Start infusion at 50 Loading dose mcg/kg slow IV push mcg/hr infusion by 50 increments q5 min to achieve desired HR or B/P Maximum dose for atrial fibrillation/svt is generally 200, but may require up to 300 for hypertensive crisis Increase infusion by 25 mcg/hr at 30 minute intervals to a maximum of 250mcg/hr Contact physician if higher doses needed No true maximum exists 30 min after the 1 st dose of the alternative agent, esmolol infusion rate by 50% May titrate down in increments q min after oral agent initiated If infusion greater than 1 week at higher doses, taper dose slowly. Initially decrease dose by 20-40%, then decrease rate by 10% every hours. Monitor B/P, heart rate and rhythm q 5-10 min during titration up, then at least hourly during infusion Monitor: bradycardia and hypotension Ascertain goal HR or B/P; usual goal HR is beats per minute Use numerical pain scale (0 10) or BPS pain scale to assess If pt. unable to communicate pain score, assess for pain behaviors (facial expression, posturing), physiological indicators (heart rate, B/P, RR, BPS for intubated patients) before and after tx Assess RR, B/P, pain and sedation scores q 15 min x 2 hrs, then q 4 hrs and PRN If not mechanically ventilated, dosing requirements in patients with sleep apnea, significant cardiovascular/pulmonary disease, elderly, and obesity (correlation with sleep apnea) Can be used alone or in conjunction with other sedatives, such as propofol or midazolam. Anticipate heightened response if used with other opiate or sedative/hypnotics. Respiratory depression effects (RR < 8/min) may be reversed with Naloxone 0.4 mg diluted in 10 ml NS in 1mL increments q 1 2 minutes until RR increased to 10 12/min and notify physician. Note: Naloxone ½ life is

10 30 min; will need VS assessment q 30 min x 2 hrs after Naloxone is given Furosemide (Lasix) (Loop diuretic) Heparin (Anticoagulant- Thrombin inhibitor) Loading dose Given undiluted from vial Continuous infusion 100 mg / 100 ml (1 mg/ml) or NS OR 1000 mg / 250 ml (4 mg/ml) or NS Bolus Per protocol (1000 units/ml), give undiluted from vials : 25,000 units / 250 ml (100 unit/ml) NaCl 0.45% mg IVP, slow, no greater than 20 mg/min Greater than 100mg must be given IVPB, do not exceed 4mg/min Continuous infusion mg/hr Do not exceed 4 mg/min with continuous infusion Dosing depends on diagnosis, concomitant anti-coagulation Cardiac Indication/Moderate Intensity Bolus 60 units/kg, max of 4,000 units, infusion of 12 units/kg/hr, max initial dose is 1,000 units/hr Thromboembolism Indication (DVT, PE)/ High Intensity Bolus 80units/kg ( max of 10,000 May to effect, A maximum daily dose of 1 gm is generally recommended No wean necessary. May switch to intermittent dosing when D/C d For Thromboembolism, Cardiac, and Reduced Intensity Indications Utilizing the Weight Based Heparin Nomogram: See Weight based heparin orders for titration Adjust rate according to PTTs (no weaning) Generally, use of infusion only appropriate if intermittent IVP dosing resulted in diuresis Do not give faster than 20 mg/min for bolus to prevent ototoxicity Monitor for drug incompatibilities Monitor electrolytes Record I & O and daily weight Protect from light Doses greater than 100mg must be infused slowly as an IVPB, rate not to exceed 4mg/min Obtain baseline coagulation (CBC with platelets, and PTT/INR) profile, if not done within the past 24 hours Obtain PTT 6 hrs after initiation of drip OR dose change. PTT can be ordered daily once the PTT is in the therapeutic range for two consecutive draws, six hrs apart D/C approximately 4 hrs prior to sheath removal Patients with fibrinolytics or GB IIb/IIIa platelet inhibitors, the cardiac indication on the weight based heparin nomogram is suggested for use. Bleeding precautions: Place sign above patient bed: See RN before drawing blood If possible, use saline lock for blood draws during infusion If possible, avoid IM injections and arterial punctures; minimize and group together venous punctures Monitor for bleeding, in platelets For weight based heparin, must use weight based heparin nomogram Two RN must perform independent verification IV boluses must be drawn from the vials Use programmable medication software of IV pump to infuse heparin infusion Heparin can be reversed with protamine, see the Antithrombotic Reversal Guidelines on the Pharmacy Intranet site

11 units), infusion of 18 units/kg/hr Reduced Intensity/ No Bolus DO NOT USE weight based heparin nomogram for pt on the therapeutic hypothermia protocol see therapeutic hypothermi order form for dosing Ibutilide (Corvert) (Antiarrhythmic- Class 3) Insulin Regular (Hypoglycemic) IV Bolus : 1mg/ 50mL (0.02 mg/ml) From infusion Continuous infusion 100 units / 100 ml (1 unit/ml) NS No Bolus dose Infusion of 12 units/kg/hr, max initial infusion rate of 1,000 unit/hr Initial infusion: If >60kg = 1mg over 10 minutes; if <60kg 0.01 mg/kg over 10 minutes Second Infusion: If arrhythmia does not terminate within 10 minutes, a second 10 minute infusion of equal strength may be administered May be given off the insulin infusion for hyperglycemiaoptional. 10 units regular insulin IVP x 1 + Dextrose 25gm IVP x 1 for Hyperkalemia treatment None None Adjust according to blood glucose monitoring. Hyperglycemia is often corrected before acidosis in DKA, but insulin drip generally continues until acidosis is corrected Long acting SQ insulin is given 2 hr before drip is stopped Pt must be monitored for at least 4 hours after administration or until QTc returns to baseline Physician MUST be available for the first 40 minutes of medication administration A defibrillator MUST be available at bedside for the first 40 minutes Monitor VS q 15 min x 4, then 30 min. x 2 then hourly x 4 then routine May cause torsades de pointes especially if QTc >440 msec Must be on a telemetry monitor K must be greater than or equal 4 and Mg greater than or equal to 2 PRIOR to infusion ADR: VT, and other arrhythmias such as heart block, CHF, HTN, hypotension, palpitations Infusion should be stopped if the patient s arrhythmia terminates, if a sustained or nonsustained ventricular tachycardia occurs, or if marked prolongation of QT/QTc occurs. Monitor blood glucose hourly and PRN Two RN must perform independent verification Patient must have source of dextrose when on insulin infusion

12 Per Insulin Infusion Orders Isoproterenol (Isuprel) (Nonselective β- agonist) 2 mg / 250 ml (0.008 mg/ml) 2-5mcg/min - infusion by 0.5 mcg/min q5 min -Usual range is 2-10mcg/min infusion by 0.5 mcg/min q5min Monitor baseline B/P, rhythm and HR q 5 min when titrating up or down; monitor for tachyarrhythmias Check blood sugar, hyperglycemia protocol recommended Ketamine (Ketalar) (noncompetitive NMDA receptor antagonist) IV Bolus From infusion or 10 mg/ml vial 500mg / 250 ml (2 mg/ml) NS IV Bolus mg/kg IV over 1 minute followed by mg/kg IV every 5-10 minutes as needed. After loading dose may initiate infusion at 0.5mg/kg/hr Titrate by 0.25mg/kg/hr every min. Max infusion dose is 2mg/kg/hr Once at goal sedation, infusion by 0.25mg/kg/hr q30 min until off or evidence of agitation If using 100mg/mL concentration for IV push, it must be diluted with equal volume of diluents (SWFI, NS, or ) Give IV push over at least 1 minute, faster rates of administration have been associated with respiratory depression and enhanced pressor response. For increased secretions, may give atropine or glycopyrrolate May produce psychosis including auditory and visual hallucinations, restlessness, disorientation, vivid dreams, and irrational behaviors; pretreatment with a benzodiazepine reduces incidence of psychosis. Rule out hypoxemia or pain as causes of agitation Monitor and document baseline B/P, HR, RR, O2 saturation, and sedation score within 5 min after initiation or change in dose, then hourly during infusion May enhance sedative and analgesic effects of concurrent sedative and analgesic agents. Not recommended for patients with increased ICP Intubation not required If indication is procedural sedation, follow procedural sedation policy and procedures (policy # )

13 Labetalol (Normodyne, Trandate) (Antihypertensive, / blocker) Either of 2 methods of administration may be used: Loading or Intermittent Full strength from vial 300 mg / 300 ml (1 mg/ml) IV Injection mg IV over 2-5 min Double the above bolus q 10 min. until B/P decrease OR until max is reached Max single dose is 80 mg Continue until goal B/P is reached Titrate hourly by 1mg/min rate up to max of 6 mg/min Both bolus and up titration of the continuous infusion should be used concurrently D/C when goal blood pressure reached Transition to oral medication No wean needed Monitor B/P, heart rate and rhythm at baseline, q 5-10 min during titration to goal B/P Duration of effect persists 4 6 hrs after IV dose is D/C d Switch to oral dosing ASAP Lidocaine (Antiarrhythmic, Class 1B) Lorazepam 1 (Ativan) (Benzodiazepine Sedative/hypnotic) IV Bolus (Loading Dose of 2%): 100 mg/5 ml (20 mg/ml) syringe, premixed 2,000 mg / 500 ml (4 mg/ml) Loading or Intermittent Dilute with equal volume of NS If on an infusion, bolus from infusion 2 mg/min initially Less than 70 yrs of age, 1 mg/kg IVP over 5 minutes Greater than 70 yrs of age, HF or liver disease, 0.5 mg/kg IVP over 5 minutes Less than 70 yrs of age, 2 4 mg/min Greater than 70 yrs of age, HF or liver disease, 1 mg/min 2 mg IVP q 30 min until goal sedation score (RASS, CIWA, etc). May repeat ½ the original bolus dose q 5 10 min if needed Maximum loading dose is 3 mg/kg total Max infusion dose is 4 mg/min Intermittent Bolus After sedation score is achieved with loading doses, give mg/kg (1 4 mg) q 2 6 hrs as needed Higher intermittent boluses may be used in NA Monitor cardiac rhythm q 15 min x 1 hr, then at least q 4 hrs during infusion Ascertain previous allergy history Be vigilant for signs of toxicity such as change in mental status, paresthesias. Cardiac toxicities include: bradycardias, hypotension, arrhythmias. risk of ADE if infusion > 24 hrs, geriatrics and the renal or hepatically impaired patient If toxicity is suspected, may get lidocaine level; but stop drug, do not cont infusion while waiting for lab results Therapeutic reference level: mcg/ml Turn lorazepam completely off daily and assess with sedation scale. If agitated, give midazolam as ordered. If agitation cont, resume at ½ the previous rate and titrate PRN NOTE: If pt. with DT s, or on prolonged continuous infusion, greater than 7 days, do not Must use 0.22 micron filter for continuous infusions When patient acutely agitated utilize boluses of midazolam until acute agitation is controlled. Rule out hypoxemia or pain as causes of agitation Best for ongoing sedation, not for acute agitation Ascertain goal sedation score and readjust as clinically indicated Monitor vital signs and agitation score prior to IVP doses and/or increase in infusion and 15 min after IVP dose 1 SCCM and ASHP, Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult Crit Care Med 2002; 30:

14 Mannitol (Osmitrol) 100 mg / 100 ml (1 mg/ml) NS Bolus/Loading Administer IV undiluted using 20% premix bag 100g/500mL Start at 1 mg/hr Increased intracranial pressure, cerebral edema g/kg/dose IV over min; may repeat every severe alcohol withdrawal Start infusion after bolus doses are given to obtain goal sedation score. infusion by 1-2 mg every hour until goal sedation achieved or relative maximum dose of 15mg/hour is reached Maximum recommended infusion rate: 15 mg/hr, contact physician for higher doses (excluding alcohol withdrawal or status epilepticus) Higher doses may be needed in alcohol detoxification or status epilepticus, refer to prescribing physician No true maximum dose exists Maintain serum osmolality <320 mosm/l Monitor renal function, I&O, serum electrolytes, suddenly D/C (may precipitate seizure), rather taper off gradually, i.e % per day or substitute with equivalent po dosing 2 A daily sedation vacation may not be appropriate for all patients (i.e. receiving paralytics, ARDS, or in status epilepticus). Contact physician prior to discontinuing infusion. Monitor pulse oximetry continuously if on drip Lower dose needed if combined with narcotics or other sedatives/ hypnotics Daily drug-free period is required to assess ongoing dose needed for sedation If clinically appropriate conduct daily cessation trial per sedation protocol. May reverse effects with flumazenil 0.2 mg IV over 30 sec, max 3 mg; but use with caution for those with hx of prolonged use, may cause withdrawal seizures Consider alternate agent if > 20 mg/hr needed, as prolonged infusion > 20 mg/hr have been assoc with metabolic acidosis and renal insufficiency due to solvent (propylene glycol) N/A in-line filter required (0.2 micron filter) Notify pharmacy if crystals present in solution Central line preferred for administration If extravasation occurs, consider using hyaluronidase (most beneficial when used within 2 hours of 2 American College of Clinical Pharmacy, Pharmacotherapy Self-Assessment Program, Book 6, 4 th Edit, 2002, p57. 3 Ibid.

15 (Osmotic Diuretic) (0.2 gm/ml) (use 0.2 micron filter) 20% premix bag 100g/500mL (0.2 gm/ml) (use 0.2 micron filter) 6-8 hours as needed (maintain serum osmolality <320 mosm/l) Reduction of intraocular pressure g/kg/dose IV over min; may repeat every 8-12 hours as needed blood pressure, cardiovascular status extravasation). If hyaluronidase used, apply warm compress to the site. If hyaluronidase NOT used, apply cold compress to the site. See Extravasation Treatment guidelines in Lippincott for additional information Hold therapy for serum osmolality >320 mosm/l Contraindicated in patients with anuria due to severe renal disease Severe traumatic brain injury 1 gm/kg IV over min prior to neurosurgery with concurrent fluid replacement Midazolam 4 (Versed) (Benzodiazepine Sedative/hypnotic) Undiluted from vial for IV Push From infusion if on a continuous drip Minimal data exists for continuous infusion dosing of mannitol 5 mg IVP (Undiluted) Start at 2 mg/hr Intermittent Bolus After goal sedation achieved, mg/kg q hrs infusion by 1-2mg per hour until goal Turn midazolam off completely daily and assess with sedation scale. If agitated, give midazolam as ordered. If agitation continues, resume infusion at ½ the previous rate and titrate as directed A daily sedation vacation may not be appropriate for all patients (i.e. receiving paralytics, ARDS, or in status epilepticus). Contact physician prior to discontinuing When patient is acutely agitated utilize boluses of midazolam until acute agitation is controlled. Rule out hypoxemia or pain as causes of agitation Ascertain goal sedation score and readjust as clinically indicated Monitor vital signs, SpO2 and agitation score prior to IVP doses and/or in infusion and 15 min after IVP dose Lower dose needed if combined with narcotics or other sedatives/ hypnotics Daily drug-free period is recommended to assess ongoing dose needed for sedation 4 Ibid.

16 Milrinone (Primacor) (Phosphodiesterase inhibitor- Inotrope) Morphine (Opioid analgesic/sedative) : 100 mg / 100 ml (1 mg/ml) Loading dose From infusion 20 mg / 100 ml (0.2 mg/ml) Bolus dose Bolus from the infusion if on a continuous drip : 100 mg / 100 ml (1 mg/ml) 50 mcg/kg slow IV over 10 min , usual start dose is 0.5 (decreased with renal failure) 2 4 mg q 5 15 min until pain controlled (e.g., Pain Score of < 5 on a 10 point scale) in Opiate Naïve Patients 1 3 mg/hr sedation achieved or relative maximum dose of 25mg/hr is reached Max infusion rate: 25 mg/hr contact physician for higher doses (excluding alcohol withdrawal or status epilepticus) No true maximum dose exists Not usually titrated, but dose may be adjusted for best effect between Maximum dose Wait ~ 2 hrs before increasing dose 2-4 mg q 5 15 min until pain controlled If goal pain score not achieved, give 1 5 mg IVP, then infusion by 1 2 mg/hr q 30 minutes, to a maximum dose of 10mg/hr, contact physician for higher doses infusion. If clinically appropriate conduct daily cessation trial per sedation protocol. May reverse effects with Flumazenil 0.2 mg IV over 30 sec, max 3 mg; but use with caution for those with hx prolonged benzodiazepine use or in pts with a history of seizures No wean necessary If receiving regularly for > 1 week, do not suddenly D/C, taper gradually (e.g., 10 25% daily) in order to prevent physical withdrawal. Weaning not necessary if replaced with equianalgesic dosing by alternate route. Monitor VS q10minutes x 3 while giving loading dose Assess and document baseline B/P, HR, rhythm and 15 min after infusion is started, then according to unit protocol. Notify physician if heart failure symptoms not improved after 2 hrs, may want to increase infusion rate Monitor for arrhythmia, hypotension, chest pain, HA Document response to therapy, improvement in heart failure signs and symptoms. Use lower dose for those with renal dysfunction Continuous telemetry for the first 24 hours after initiation or changing the dose on all doses Use numerical pain scale (0 10) to assess If pt. unable to communicate pain score, assess for pain behaviors (facial expression, posturing), physiological indicators (heart rate, B/P, RR, BPS) for intubated patients before and after tx Assess RR, B/P, pain and sedation scores q 15 min x 2 hrs, then q 4 hrs and PRN If not mechanically ventilated, dosing req ts in patients with sleep apnea, significant cardiovascular/pulmonary disease, elderly, and obese (correlation with sleep apnea) Anticipate heightened response if used with other opiate or sedative/hypnotics. Respiratory depression effects (RR < 8/min) may be reversed with Naloxone 0.4 mg diluted in 10 ml NS in 1mL increments q 1 2 minutes until RR increased to 10 12/min and notify physician. Note: Naloxone ½ life is 30 min; will need VS assessment q 30 min x 2 hrs after

17 No true Maximum dose exists Naloxone is given Active metabolite may accumulate in elderly and renal insufficiency ( in sedation); monitor duration of therapy Nesiritide (Natrecor) (Natriuretic) Nicardipine (Cardene) (Antihypertensive Calcium Channel Blocker) Nitroglycerin (Tridil) Loading dose (Optional) From infusion 0.75 mg/125 ml (0.006 mg/ml) 50 mg/250 ml (0.2 mg/ml) NaCl 0.9% 25 mg/125 ml OR 50 mg / 250 ml (0.2 mg/ml) 2 mcg/kg over 1 min 0.01 Initial Infusion rate Initiate infusion at 5 mg/hr (25 ml/hr) 10 mcg/min Most patients respond to 0.01, but if dose is desired: bolus of 1 mcg/kg and infusion by q 3 hrs Contact physician if no clinical improvement at initial dose OR hypotension Max dose is 0.03 Increase infusion by 2.5mg/hr (12.5ml/hr) every 5-15 minutes depending on need for gradual BP reduction. Max dose = 15 mg/hr by 5 mcg q 3-5 min If no response at 20 mcg/min, by 10 mcg increments q 3-5 min. Low-end doses in HF. Max dose 400 mcg/min (used for HTN), but if doses > 100 mcg/min are needed, may N/A N/A Taper by mcg/min q min Assess and document baseline B/P, HR then q 15 min x 4, then q 2 hrs while on drip Use dedicated IV line D/C if hypotension develops (SBP < 90), notify physician. Physician may resume when resolved without a bolus, at a dose 30% lower than the original. Hypotension rate is similar to nitroglycerin (4% vs. 5%), but nesiritide s effect is significantly longer in duration: 2.2hrs vs. only 0.7 hrs with nitroglycerin IV No inotropic effect, not reported to produce arrhythmias Infusion time is usually 48 hrs. Contact physician after 48 hrs of infusion for possible change in orders. Do NOT draw BNP levels during infusion Change peripheral IV site every 12 hours to lessen vein irritation. Ascertain goal B/P, Monitor B/P q 5-15 min during titration, then at least hourly, monitor patients for tachycardia, hypotension, and headache Transition patient to oral therapy as soon as their clinical condition permits Caution should be exercised in using nicardipine in CHF patients, especially those also taking a beta-blocker Use cautiously in patients with either hepatic or renal dysfunction Protect from light. Monitor B/P, heart rate, relief of angina q 5 min during titration, then at least hourly Obtain parameters for titration, i.e. chest pain, B/P, PCWP Use vented nitroglycerin tubing Monitor: hypotension, reflex tachycardia, flushing, HA Tolerance may develop with infusions > 24 hrs

18 Nitroprusside (Nipride) (Vasodilator) Norepinephrine (Levophed) (Catecholamine Vasopressor) Octreotide 50 mg / 250 ml (0.2 mg/ml) 16 mg / 250 ml (0.064 mg/ml) mcg Hypertension: HF: 0.1 (dosing in HF is lower initially and in maintenance) 5 mcg/min consider another vasodilator by q min Rates greater than 4 ute may lead to cyanide toxicity within 3 hours. Doses exceeding 10 are rarely required. If the blood pressure is not adequately reduced after 10 minutes at 10, nitroprusside should be stopped by 5 mcg/min q 5 minutes Maximum dose is 199 mcg/min Generally not titrated; doses up to 100 mcg/hr studied Taper by q min Taper by 5 mcg/min q10 minutes once BP goals reached Physician may evaluate conversion to reduced dose subq, depending on indication. Nitroprusside should be reserved for diagnostic purposes in OR and Cath Lab and for urgent blood pressure reduction where nitroglycerin, nicardipine, or IV beta blockers are either not preferred, contraindicated, or partially effective. Avoid in renal or hepatic impairment Ascertain goal B/P or PCWP Monitor B/P q 3-5 min during titration, then at least hourly Monitor for s & s of cyanide toxicity such as mental status changes (restlessness, lethargy), tachycardia, seizure, or unexplained metabolic acidosis, especially in those with renal/hepatic impairment, for doses greater than 2 or when used > 72 hrs Avoid sudden rate increase of the main IV through which Nitroprusside is infusing, it may result in a bolus dose of Nitroprusside being administered. Monitor thiocyanate/cyanide levels if requiring prolonged infusion (>3 days), dose 2 or renal dysfunction Protect bag from light during infusion (use protective bag) Monitor B/P, heart rate and rhythm q 3-5 min during titration, then at least hourly Monitor for: HA, N/V, tachy/bradycardia, chest pain, HTN Ascertain goal B/P First line vasopressor in septic shock Central line required Extravasation: assess regularly for infiltration - See extravasation treatment guidelines in Lippincott for treatment information Very effective in low SVR states; less effect on HR than dopamine, preferred if tachyarrhythmia Higher doses may be needed if -receptors are downregulated in sepsis Correct hypovolemia Do NOT mix with alkaline agents (ph > 6.0 e.g., NaHCO3, lidocaine or aminophylline Monitor VS according to clinical condition of patient Bolus and 50 mcg/hr infusion will immediately portal pressure, stop bleeding in 80% of pts

19 (Sandostatin) (Somatostatin analog, Antisecretory) IVP undiluted 1000 mcg/100ml (10 mcg/ml) in NS or mcg/hr Major side effects are nausea, bradycardia, diarrhea and hyperglycemia or hypoglycemia. Watch for edema, flushing, vertigo, HA, abdominal pain, constipation/diarrhea, N/V Elderly patients may require lower doses Pancuronium (Pavulon) (Neuromuscular blocker) : From infusion 100mg/100ml (1 mg/ml) in or NS Obtain baseline TOF prior to initiation of infusion/bolus mg/kg IVP over 1-2 minutes Continuous infusion Start continuous infusion at 0.8, titrate per TOF up to a max dose of 2 Intermittent Dosing mg / kg Q 1 hr as needed for TOF 1-2 Adjust dose based on TOF assessment If 1-3:4 twitch and pt does not demonstrate respiratory effort, maintain infusion at current dose. If 1-3:4 twitch and pt does demonstrate respiratory effort, then infusion by 25%. If 0:4, turn off infusion, recheck TOF q 15 min until TOF 1-2:4, then resume drip at 50% prior infusion rate. If TOF 3-4:4, give initial bolus then restart infusion at No wean necessary NMBA electronic order set or paper order form must be completed Ensure airway control: patient MUST be intubated Patient must be adequately sedated with midazolam or lorazepam + fentanyl prior to administration (RASS score of - 5 prior to initiation of NMBA) DO NOT USE propofol or dexmedetomidine for sedation while on NMBA Independent verification required Daily cessation of paralytic recommended for paralysis assessment and prevention of prolonged paralysis or polyneuropathy If neuromuscular blocker administered continuously, then sedation/analgesia must also be administered as continuous infusion. Explain effects to family: hearing, sense of touch are still intact Ascertain goal of clinical paralyzation, i.e. maintain oxygenation, peak airway pressure, ICP Document baseline vital signs, pain and sedation scores before administration of NMBA and within 15 min after For continuous infusion, document TOF response within 15 min after dose change, hourly and PRN Correlate train of four (TOF) with clinical picture Protect eyes with ocular lubricant Warning label MUST be on all NMB agents Avoid in renal insufficiency Pancuronium has vagolytic properties which may induce tachycardia

20 50% of previous dose. Phenylephrine (Neo-synephrine) (Catecholamine Vasopressor) 50 mg / 250 ml (0.2 mg/ml) NS or IV Push 100 mcg/ml (1,000 mcg/10 ml premade syringe) Start at mcg/min, with downward tapering after goal B/P achieved Usual dose needed to maintain B/P is mcg/min. IV Push mcg (0.5-1 ml) IV Push PRN by mcg/min every min Max dose is generally 300 mcg/min If hypotension persists, alternate pressor, i.e. norepinephrine IV Push- Max dose of 1,000 mcg total (10 ml total) Taper by 25 mcg/min ~ q 1 hr d/t longer ½ life Titration down/off is slower than other pressors; if done rapidly, more likely to have recurrent hypotension Monitor B/P, heart rate and rhythm q 5-10 min during titration, then at least hourly Adverse Effects include: bradycardia, HTN, anxiety, tremors, arrhythmias Ascertain goal B/P Infuse via central line if possible See Extravasation Treatment guidelines in Lippincott for treatment information Not a first-line pressor in most cases IV Push Indicated for Peri-procedural setting in pts with <80% of baseline MAP, adequate fluid challenge attempted, and hypotension is anticipated to be transient secondary to drug therapy. Indicated for peri-code settings prior to a vasopressor infusion being initiated. Must be administered by an ED Attending or an MICU or SINI Intensivist. Premade syringes must be utilized for administration outside of the OR setting. Procainamide (Pronestyl) (Antiarrhythmic, Class 1A) 500 mg/50 ml NS 1000 mg / 250 ml (4 mg/ml) NS or 0.45 NS Usual dose is 500 mg (up to 17 mg/kg) over 30 min (no > than 50 mg/min) until conversion 2 4 mg/min May give additional loading dose & increase drip if max dose not initially used Max loading is 17 mg/kg or 1 gram, max infusion is 4 mg/min May convert to oral one hour prior to stopping infusion Obtain baseline B/P, HR, PR and QRS interval, when loading dose is complete, then q 4 hrs Notify physician if PR or QRS interval widens, B/P drops, or rhythm convert during loading dose or during the infusion Monitor for prolonged QT and proarrhythmic effects; flushing, tachycardias In an arrest, ACLS guidelines are 20 mg/min up to a max of 50 mg/min Dose for renal impairment Propofol (Diprivan) Continuous infusion Premixed, 1000 mg / 100 Start infusion at 5 Titrate q 5 min by 5 until goal sedation Once at goal sedation, decrease infusion by 5-10 q 5 minutes until off or evidence of FOR VENTILATED PATIENTS ONLY Monitor and document baseline B/P, HR, RR, sedation score and within 5 min after initiation or change in dose,

21 (Sedative/hypnotic, general anesthetic) ml (10 mg/ml) achieved Max dose is 75 Bolus dosing is not recommended due to risks of hypotension agitation. then hourly during infusion HYPOTENSION, do NOT bolus (dose related, without an in HR) No analgesic properties DO NOT PARALYZE PATIENTS WHILE ON Propofol Rule out hypoxemia or pain as causes of agitation Ascertain goal sedation score Daily drug-free period is recommended If clinically appropriate conduct daily cessation trial per sedation protocol. Propofol syndrome may occur with prolonged use or in higher doses. Monitor triglycerides when infuse started, again after 3 days, and weekly for prolonged infusions (greater than 3 days) Urine may turn green color Drug-Drug Interaction: May need dose if combine with narcs or sedatives May vecuronium s neuromuscular blockade Lipid (Fat) Emulsion: Change IV vented tubing every time the bottle is changed and the tubing/bottle must be changed at a minimum of q 12 hr to risk of bacterial growth Should be counted as caloric source Caution food allergies: contains soybean oil, egg Tranexamic Acid (Cyklokapron) (Antifibrinolytic) Bolus/Loading 1,000 mg in 100mL (10 mg/ml) 0.9NS 2,000 mg/100 ml (20 mg/ml) 0.9NS 1,000 mg in 500mL (2 mg/ml) 0.9NS Trauma -Associated Hemorrhage 1,000mg IVPB x 1 over 10 min followed by 1,000mg IVPB x 1 over 8 hours Orthopedic Surgery 1,000 mg/100 ml NS IVPB over 10 min pre-incision followed by 1,000 Not titrated N/A Utilize in patients with traumatic injury, current blood loss, and/or massive transfusion criteria. and to reduce blood loss associated with surgery Avoid use in patients with known isolated intracranial hemorrhage Use with caution in patients with a history of venous thromboembolism Should not be administered with anti-inhibitor coagulant concentrate (FEBIA), as risk of thrombosis may be increased May cause hypotension if infused too rapidly Should not be administered through the same IV line as blood products

22 mg/100 ml NS over 10 min post-op Cardiac Surgery Anesthesia: 10mg/kg IVPB x 1 over 10 min, followed by 2mg/kg/hr IVPB continued for up to 2 hours after transfer to ICU Perfusion: 2mg/kg added to the cardiopulmonary bypass circuit Renal dose adjustment recommended: o For serum creatinine mg/dl reduce maintenance infusion to 1.5 mg/kg/hr o For serum creatinine mg/dl reduce maintenance infusion to 1 mg/kg/hr o For serum creatinine >6.6 mg/dl reduce maintenance infusion to 0.5 mg/kg/hr Can be ordered by any physician Tranexamic acid is available in the post-partum OB hemorrhage kit in the L&D Omnicell (TXA is an alternative agent if uterotonic agents do not stop the bleeding)

23 Spinal Surgery 2,000mg IVPB x 1 over 20 minutes prior to incision followed by 100 mg/hour IV during surgery and for 5 hours postoperatively or 10 mg/kg IVPB x 1 prior to incision followed by 1 mg/kg/hour IV for the remainder of the surgery; discontinue at time of wound closure Obstetrics Patients < 120 kg: 1,000 mg/100 ml NS IVPB over 10 min Patients 120 kg: 2,000 mg/100 ml NS IVPB over 10 min May repeat dose a dose in 30 min if bleeding continues or recurs Treprostinil (Remodulin) SQ 1 mg/ml, 2.5 mg/ml, 5 SQ Per physician order (usual starting dose is 1.25 ng/kg/min or ng/kg/min Per physician order Per physician order (not usually done) For adults, see Parenteral Epoprostenol (Flolan) and Treprostinil (Remodulin) Order Set and Pulmonary Hypertension Medication Ordering and Dispensing Policy ( )