SARASOTA MEMORIAL HOSPITAL DEPARTMENT POLICY

PS1006 SARASOTA MEMORIAL HOSPITAL DEPARTMENT POLICY TITLE: PHARMACEUTICALS FOR CRITICAL CARE AREAS, HEMODIALYSIS, PACU, EMERGENCY CARE CENTER, CARDIAC CARE AREAS, NEURO PROGRESSIVE CARE, AND THE MECKLER EFFECTIVE DATE: REVISED DATE: POLICY TYPE: (Pharmacy) (Patient Care) 9/07 4/16 DEPARTMENTAL INTERDEPARTMENTAL DEPARTMENTS PROVIDING NURSING CARE 1 of 14 Job Title of Responsible Owner: Director, Pharmacy PURPOSE: POLICY STATEMENT: EXCEPTIONS: DEFINITIONS: To provide an institutional protocol for titration of selected intravenous pharmaceuticals administered by continuous infusion to be utilized when the prescriber does not provide specific instructions for titration or when the prescriber requests titration per SMH protocol. Selected pharmaceuticals administered by continuous intravenous infusion that require titration of dose to achieve an optimal therapeutic response may potentially put a patient at risk for an adverse drug event. To minimize this risk, the following guidelines have been developed to allow for the administration of the lowest effective dose by standardization of dose titrations. The Pharmacy and Therapeutics Committee will approve the pharmaceuticals and corresponding titrations. 1. Neonatal Intensive Care Unit. 2. Pediatrics. Standard (Low) Dose: Medication administration guidelines to be utilized for non-emergent situations. Emergent (High) Dose: accelerated dosing titrations to be utilized for emergent situations as identified by the prescribing prescriber. PROCEDURE: 1. The dosing parameters and titrations listed in the table below may be utilized whenever the prescriber does not provide specific titration parameters, or when the prescriber requests dose or titrate per protocol. 2. Specific prescriber orders for titration parameters varying Prepared by: Karen Diffley \\smhfile01\paperless\department policies\nursing\nur_patientcare\126_156.doc 4/29/2016

2 of 14 from these guidelines are permitted. The pharmacist will review these orders for appropriateness prior to dispensing. 3. Refer to Standard Titrations of Selected Pharmaceuticals ( Appendix A) RESPONSIBILITY: It is the responsibility of the Department of Pharmacy leadership to ensure that all appropriate pharmacy staff members are aware of, and adhere to, this policy. It is the responsibility of Nursing leadership to ensure that all appropriate nursing staff members are aware of, and adhere to, this policy. It is the responsibility of all appropriate pharmacy and nursing staff members to be aware of, and adhere to, this policy. REFERENCES: Micromedex Solutions database, 2016. Nursing Fast Facts Critical Care Nursing 2010 Intravenous Medications: a handbook for nurses and health professional, 26 th edition. REVIEWING AUTHOR(S): Anit Legare, Clinical Pharmacy Specialist, Critical Care Pharmacy Benny Kruger, RN, MSN, CCRN, CNN, APN, Critical Care Jacqueline Krusewski, BSN, RN, PCCN, CPS, Cardiac Mahira Moreira, MSN, RN, APN, Critical Care Amy Giovino, PharmD, Formulary Management ATTACHMENT(S): Appendix A: Standard Titrations of Selected Pharmaceuticals

3 of 14 APPROVALS: Signatures indicate approval of the new or reviewed/revised policy Date Committee/Sections (if applicable): Pharmacy & Therapeutics Committee 1/27/16 Clinical Practice Council 2/4/16 2/15/16 Signature: Title: David W. Jungst, Director, Pharmacy Signature: Title: Signature: Title: Signature: Title: Vice President/Administrative Director (if applicable): 2/25/16 Signature: Name and Title: Lorrie Liang, Chief Operating Officer Signature: Name and Title: Jan Mauck, Vice President and Chief Nursing Officer 2/29/16

4 of 14 APPENDIX A: Standard Titrations of Selected Pharmaceuticals Amiodarone 150 mg/100 ml 900 mg/500 ml CP2, CP3, NPCU CAC/CP, PACU CP4, Meckler, NOTE: Continuous cardiac monitoring required Loading Dose: - Add 3 ml (150 mg) amiodarone into 100 ml D5W and run at 600 ml/hour for 10 minutes Maintenance Dose: - Add 18 ml (900 mg) to D5W 500ml PVC free bag and infuse at 34 ml/hour (1 mg/min) x 6 hours, then decrease the infusion rate to 17 ml/hr (0.5 mg/min) x 18 hr. Nurse to contact the physician before 24 hours is up to obtain orders to either continue or discontinue the drip. Do not stop the infusion before contacting the physician. If infusion is to continue beyond 24 hours, consider obtaining a central line. Clevidipine 25mg/50ml 50mg/100ml Critical Care Emergency Dept. (ECC) PACU Radiology Nursing Contraindicated in patients with: * allergy to soybeans, soy products, eggs or egg products * Defective lipid metabolism (pathologic hyperlipidemia, lipoid nephrosis, acute pancreatitis with hyperlipidemia) * Severe aortic stenosis- afterload reduction can reduce myocardial O2 delivery * Bottles and lines must be changed every 12 hours * Monitor daily lipid intake Beginning infusion and titrating the rate: Step Down Neuro (NP Start at 2mg/hr. Increase by 2mg/ hour every 2 minutes may only Usual dose 4-6mg/hr. Max 32mg/hr. accept patients with order sets for

5 of 14 stroke/post-op craniotomy Diltiazem 125 mg/125 ml CP2, CP3, CAC/CP, CP4, PACU, Meckler, Endo, NPCU, * Call physician and hold dose for SBP less than 90 mmhg. or as determined by MD order * Goal of therapy is a heart rate equal to 90 to 120 beats/minute or conversion to normal sinus rhythm, whichever comes first, if not otherwise specified by physician. Initial Bolus Dose: - Administer 0.25 mg/kg (max 20 mg) IV over 2 min. If inadequate response after 15 minutes, may give a second bolus. If heart rate/rhythm goal is met, begin infusion dose. Second Bolus Dose: If after 15 minutes of initial bolus dose there is an inadequate response, administer 0.35 mg/kg (max 25 mg) over 2 minutes. If heart rate/rhythm goal is met after second bolus, begin infusion dose. Infusion Dose: If bolus dose(s) are successful, begin infusion at 5 mg/hour. May increase by 5 mg/hour every 15 minutes, to a maximum rate of 15 mg/hour Dobutamine 250 mg/250 ml 500 mg/250 ml PACU, NPCU, * Recommended to administer via central line, unless emergent. * Goal of therapy is MAP greater than 65 or SBP greater than or equal to 90 mmhg if not otherwise specified by physician. * Do not exceed maximum rate 40 mcg/kg/min without consulting the physician (Max rate of 10 mcg/kg/min for NPCU)

6 of 14 * Caution: Call prescriber or clinical pharmacist immediately for extravasation due to high risk of tissue necrosis Standard (Low) Dose: - Begin infusion at 2 mcg/kg/min. May double the rate as often as every 2 minutes to maintain SBP goal or until maximum rate is reached. Emergent (High) Dose: - Begin infusion at 5 mcg/kg/min. May double the rate as often as every 2 minutes to maintain SBP goal or until maximum rate is reached. Dopamine 400 mg/250 ml 800 mg/250 ml PACU, NPCU, * Recommended to administer via central line, unless emergent. * Goal of therapy is MAP greater than 65 or SBP greater than or equal to 90 mmhg if not otherwise specified by physician. * Do not exceed maximum rate 20 mcg/kg/min without consulting the physician (Max rate of 10 mcg/kg/min for NPCU) * Caution: Call prescriber or clinical pharmacist immediately for extravasation due to high risk of tissue necrosis. Standard (Low) Dose: - Begin infusion at 2 mcg/kg/minute. May increase by 2mcg/kg/min as often as every 2 minutes until SBP goal is met or the maximum rate is reached. Emergent (High) Dose: - Begin infusion at 5 mcg/kg/minute. May increase by 5 mcg/kg/min as often as every 2 minutes until SBP goal is met or the maximum rate is reached.

7 of 14 Epinephrine 5 mg/250 ml 10 mg/250 ml PACU, * Recommended to administer via central line, unless emergent. * Goal of therapy is SBP greater than or equal to 90 mmhg if not otherwise specified by physician. * Do not exceed maximum rate of 0.1 mcg/kg/min for standard (low) dose therapy or 0.15 mcg/kg/min for emergent (high) dose therapy without consulting the physician. * Caution: Call prescriber or clinical pharmacist immediately for extravasation due to high risk of tissue necrosis. Standard (Low) Dose: - Begin infusion at 0.03 mcg/kg/min. May increase by half (50%) of the current rate as often as every 2 minutes until SBP goal is met or maximum rate is reached. Emergent (High) Dose: - Being infusion at 0.07 mcg/kg/min. May increase by half (50%) of the current rate as often as every 2 minutes until SBP goal is met or maximum rate is reached. Esmolol 2.5 gm/250 ml Critical Care PACU, * Goal of therapy is HR less than or equal to 100 beats/minute if not otherwise specified by physician. * Titrate infusion to goal per titration schedule listed below * Do not exceed maximum rate of 300 mcg/kg/min without consulting the physician.

8 of 14 * Call physician and hold dose for SBP less than 90 mmhg or as determined by MD order Beginning infusion and titrating the rate: - Begin infusion 50 mcg/kg/min for 4 minutes - If HR goal not met at previous rate, increase to 100 mcg/kg/min for 4 min - If HR goal not met at previous rate, increase to 150 mcg/kg/min for 4 min - If HR goal not met at previous rate, increase to 200 mcg/kg/min for 4 min - If HR goal not met at previous rate, increase to 250 mcg/kg/min for 4 min - If HR goal not met at previous rate, increase to 300 mcg/kg/min for 4 min If HR goal not met previous rate (maximum rate), call physician. Isoproteronol 1 mg/250 ml Emergency Care, PACU, * Goal of therapy is SBP greater than 90 mmhg if not otherwise specified by physician. * Do not exceed maximum rate of 20 mcg/min without consulting the physician. Beginning infusion and titrating the rate: - Begin infusion at 2 mcg/min. May double the rate as often as every 3 minutes until goal is met or maximum rate is reached. Labetalol

9 of 14 200 mg/200 ml 400 mg/200 ml Emergency Care, PACU, * Goal of therapy either SBP or MAP to be specified by physician. * Monitor closely and do not titrate quickly. * Do not exceed maximum of 3 mg/min (180mg/hr) without consulting the physician. Do not exceed 300 mg maximum dose without consulting the prescriber. It is recommended to add on another agent or switch medications at this dose. * Call physician and hold dose for SBP less than 90 mmhg or as determined by MD order Initial Bolus Dose: - Administer 0.25 mg/kg over 2 minutes. If inadequate response after 10 minutes, may give second bolus. If adequate response, begin infusion dose. Second Bolus Dose: - If after 10 min of initial bolus dose there is an inadequate response, may repeat 0.25 mg/kg over 2 minutes. Begin infusion dose. Infusion Dose: - Begin infusion at 1 mg/min (60 mg/hr). May increase by 1 mg/min (60 mg/hr) every 15 minutes, to a maximum rate of 3 mg/min (180 mg/hr). Lidocaine 2 gm/500 ml Emergency * Goal of therapy to be specified by physician. * Do not exceed maximum infusion rate of 4 mg/min without consulting prescriber. * Call physician if SBP less than or equal to 90 mmhg, bradycardia, or

10 of 14 Care, NPCU CP2CP3, other signs of toxicity CAC/CP, CP4 PACU, Initial Bolus Dose:. - Administer 1 mg/kg (max 300 mg). For bolus, do not exceed 50 mg/min IV slow push. If inadequate response after 10 minutes, may give second bolus. If adequate response, begin infusion dose. Infusion Dose: - Begin infusion at 2 mg/min (120 mg/hr). May increase by up to half (50%) of the current rate as often as every 3 minutes, to a maximum rate of 4 mg/min (240 mg/hr). Milrinone 20 mg/100 ml 40 mg/100 ml * Goal of therapy to be specified by physician. * Never infuse in the same IV line with furosemide (Lasix) or bumetanide (Bumex) * Call pharmacy for dose adjustment when CrCl is less than 50 ml/min. Emergency Care, PACU, * Do not exceed 1.13 mg/kg/24 hours in these patients. * Do not exceed maximum 0.75 mcg/kg/min without consulting physician. * Call physician if maximum dose is reached and goals of therapy are not Loading Dose: - 50 mcg/kg over 10 minutes undiluted or diluted in up to 20 ml NS or D5W. Maintenance Dose: - Begin infusion at 0.375 mcg/kg/min, may increase the current rate by up to 100% (may double the rate) based on hemodynamic and clinical response as often as every 10 minutes. - The rate may be titrated between 0.375 mcg/kg/min and 0.75 mcg/kg/min as needed. :

11 of 14 Naloxone 4mg/500 ml Critical Care ECC Critical Care and ECC ONLY Level of sedation, using the Pasero Opioid-Induced Sedation Scale (POSS), must be 1-2 and respiratory rate 10 or more prior to the start of the Narcan infusion. If not, call MD. Beginning infusion and titrating the rate: Starting dose 0.2mg/hour If on a Narcan drip and the patient s level of sedation=1; respiratory rate=12; pulse oximetry is more than 92% and pain is greater than 4 at rest; decrease Narcan drip to 12 mls/hour (0.1 mg/hour). Contact MD if any other dose adjustments are needed. If after one hour of Narcan infusion, level of sedation is 3 or 4 and respiratory rate is 8 or less, increase Narcan infusion to 37 ml/hour (0.3 mg/hour). Contact MD if any other dose adjustments are needed or untoward symptoms of opioid overdose reoccur (nausea/vomiting/severe itching). Nicardipine Peripheral line: 25 mg/250 ml NS 50 mg/500 ml NS Central line: 25 mg/50 ml 50 mg/100 ml * Goal of therapy to be specified by prescriber. * Do not exceed maximum 15 mg/hr without consulting prescriber. It is recommended to add on another agent or switch to a different med at this dose. * Call prescriber if maximum rate is reached and goals of therapy are not * Call physician and hold dose for SBP less than 90 mmhg or as determined by the MD order Critical Care., Beginning infusion and titrating the rate: - Begin infusion at 5 mg/hr. - Increase by 2.5 mg/hr as often as every 5 minutes until max rate is

12 of 14 PACU, NPCU, Nitroglycerin 25 mg/250 ml 50 mg/250 ml Critical Care, Emergency Care, NPCU CP2, CP3, CAC, PACU, Meckler, reached or hemodynamic goals : * Goal of therapy chest pain 0/10 or limits of side effects reached. * Call physician and hold dose for SBP less than 90 mmhg or as determined by MD order. * Maximum rate 200 mcg/min (Max 100mcq/min CP2, CP3, CAC, Meckler) * Call prescriber if maximum rate is reached and goals of therapy are not Hypertension Infusion and Titration: - Begin infusion at 5 mcg/min. - Increase by 5 mcg/min as often as every 2 minutes until goals of therapy are met or maximum rate is reached. Chest Pain Infusion and Titration: - Begin infusion at 5 mcg/min. - Increase by 5 mcg/min as often as every 2 minutes until goals of therapy are met or 20 mcg/min is reached. - If goal of therapy is not met at 20 mcg/min, may increase by 10 mcg/min as often as every 2 minutes until goals are met or max rate is reached. Norepinephrine 4 mg/250 ml 8 mg/250 ml Critical Care, Emergency * Recommended to administer via central line, unless emergent. * Goal of therapy is MAP greater than 65 or SBP greater than or equal to 90 mmhg if not otherwise specified by physician. * Do not exceed maximum rate 25 mcg/min without consulting the physician

13 of 14 Care, PACU, * Caution: Call prescriber or clinical pharmacist immediately for extravasation due to high risk of tissue necrosis. Standard (Low) Dose: - Begin infusion at 1 mcg/min and increase double the current rate as often as every 2 minutes until goal of therapy reached. See important notes above. Emergent (High) Dose: - Begin infusion at 4 mcg/min and double the current rate as often as every 2 minutes until goal of therapy reached. Phenylephrine 10 mg/250 ml 20 mg/250 ml Critical Care Emergency Care, PACU, NPCU, * Recommended to administer via central line, unless emergent. * Goal of therapy is MAP greater than 65 or SBP greater than or equal to 90 mmhg if not otherwise specified by prescriber. * Do not exceed maximum rate 350 mcg/min without consulting the physician * Call prescriber if maximum rate is reached and goals of therapy are not * Caution: Call prescriber or clinical pharmacist immediately for extravasation due to the high risk of tissue necrosis. Cardiac infusion and titration: - Begin infusion at 100 mcg/minute - May titrate by half (50%) of current rate as often as every 2 min until goals are - Once goals are met and stable, may begin to decrease the infusion to 60 mcg/minute in the same fashion it was titrated up.

14 of 14 Neurologic infusion and titration: - Begin infusion at 150 mcg/minute, once goals are met, may begin to decrease infusion to 60 mcg/minute based on maintaining therapeutic goals. Vasopressin Septic Shock: 40 units in 100 ml Critical Care, PACU, Invasive Cardiology * Recommended to administer via central line, unless emergent. * Goal of therapy is MAP greater than 65 or SBP greater than or equal to 90 mmhg if not otherwise specified by physician. * See maximum rates under each heading for septic shock and GI bleed below. * Caution: Call prescriber or clinical pharmacist immediately for extravasation due to the high risk of tissue necrosis. Septic shock: adjunct therapy: * Do not exceed maximum rate 0.04 units/min without consulting the physician - Begin infusion at 0.01 units/minute - May increase by 0.01 units/minute every 2 minutes until goals are met or maximum rate is reached.