Adult Critical Care Intravenous Infusions Titration Protocol

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1 Adult Critical Care Intravenous Infusions Protocol Nursing staff to titrate drip to achieve goal ordered by provider in assigned time intervals. Amiodarone (Pacerone ) Argatroban Non-heparin anticoagulant / Direct thrombin inhibitor Atracurium Bumetanide (Bumex ) Loop diuretic 1.8 mg/ml 1.8 mg/ml mg/min 1 mg/min N/A N/A 1 mg/ml 1 mg/ml mg/ml 5 mg/ml 4 mg/ml mg/ml 0.5 mg/hour Based on PTT goal **SEE NOTE** mg/hour 0.5 mg/hr 2 hours 1 mg/min x 6 hours, then 0.5 mg/min x 18 hours **For doses >10 consider alternative agent** Titrate to goal urine Titrate for negative fluid balance of ml per day Contact provider for SBP Order comment: If goal urinary output not met after 6 hours or if rate reaches 2 mg/hr, contact provider. AU Medical Center Original Medical Executive Committee Approval Date: 10/12/15 Review and Revision Dates: 12/14/15, 09/11/17

2 A d u l t C r i t i c a l C a r e I n t r a v e n o u s I n f u s i o n s T i t r a t i o n P r o t o c o l P a g e 2 Cisatracurium (Nimbex ) Dexmedetomidine (Precedex ) Diltiazem (Cardizem ) Calcium channel blocker Dobutamine Dopamine Epinephrine Esmolol (BreviBloc ) Beta-blocker/ Fentanyl Narcotic analgesic 2 mg/ml 2 mg/ml min 1 mg/ml 1 mg/ml 5 mg/hr mg/hr 5 mg/hr 15 min 2 mg/ml 2 mg/ml mg/ml.2 mg/ml mg/ml 10 mg/ml (pure drug) (cardiac decomp) (sepsis/ shock) 2 0 (SVT/ tachycardia) 00 (post op HTN) min 0 min Titrate to maintain sinus rhythm Hold for HR Hold for SBP Titrate to cardiac output goal of Titrate to a goal HR Hold for HR less than

3 A d u l t C r i t i c a l C a r e I n t r a v e n o u s I n f u s i o n s T i t r a t i o n P r o t o c o l P a g e Furosemide (Lasix ) Loop diuretic Insulin Regular DKA/HHS Short-acting insulin Insulin Regular Non-DKA/HHS Short-acting insulin Labetalol Alpha/beta blocker Lidocaine (Xylocaine ) 10 mg/ml 10 mg/ml mg/hr 50 mg/hr 5 mg/hr 2 hours 1 mg/ml 1 mg/ml 1 mg/ml 1 mg/ml 0.1 (no maximum rate) 1 unit/hr (no maximum rate) No maximum rate No maximum rate 2 mg/ml 2 mg/ml mg/min 6 mg/min 0.5 mg/min 15 min 4 mg/ml 4 mg/ml 1 4 mg/min 4 mg/min **1.5 mg/min for CHF/Shock or Hepatic disease** N/A N/A Titrate to goal urine Titrate for negative fluid balance of ml per day Contact provider for SBP Order comment: If goal urinary output not met after 6 hours or if rate reaches mg/hr, contact provider. Titrate to maintain MAP Titrate to maintain SBP Hold for HR less than only to titrate Notify physician for arrhythmias

4 A d u l t C r i t i c a l C a r e I n t r a v e n o u s I n f u s i o n s T i t r a t i o n P r o t o c o l P a g e 4 Lorazepam (Ativan ) Midazolam (Versed ) Milrinone (Primacor ) PDE inhibitor/inotrope 1 mg/ml 1 mg/ml 1 mg/hr mg/hr 0.5 mg/hr 0 min 1 mg/ml 1 mg/ml 1 mg/hr mg/hr 0.5 mg/hr 0 min min Naloxone 6.25 mg/hr 6.25 mg/hr mg/hr Nicardipine (Cardene ) Nitroglycerin Vasodilator 0.1 mg/ml 0.2 mg/ml 5 15 mg/hr 15 mg/hr 2.5 mg/hr 5 min mcg/min 400 mcg/min 10 mcg/min Contact physician if adequate sedation not reached at 10 mg/hr Contact physician if adequate sedation not reached at 10 mg/hr Titrate to maintain MAP Titrate to goal cardiac Titrate to RASS of Titrate to a respiratory rate of Hold for respiratory rate less than _ Titrate to relief of chest pain Hold for SBP less than

5 A d u l t C r i t i c a l C a r e I n t r a v e n o u s I n f u s i o n s T i t r a t i o n P r o t o c o l P a g e 5 Nitroprusside (Nipride ) Vasodilator Norepinephrine (Levophed ) Alpha-beta agonist Phenylephrine (Neosynephrine ) Alpha agonist Procainamide Propofol (Diprivan ) Vasopressin (Pitressin ) Vasopressin (V1) agonist Non-sepsis indications & organ donation Vasopressin (Pitressin ) Vasopressin (V1) agonist Sepsis Vecuronium (Norcuron ) May titrate up with continued MAP response May titrate up with continued MAP response mg/ml 4 mg/ml 1 4 mg/min 4 mg/min N/A N/A 10 mg/ml 10 mg/ml 5 80 unit/ml unit/ml min 1 unit/ml 1 4 units/hr 4 units/hr 0.5 units/hr 1 unit/ml units/hr 2.4 units/hr N/A N/A 1 mg/ml 1 mg/ml Hold for SBP less than Physician only to titrate Notify physician for arrhythmias Continuous infusion Do not titrate Consider IV fluid therapy or additional agent with provider intervention if there is failure to maintain MAP/BP goal with continued dosing increase.

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