IV Infusion Drug Handbook

IV Infusion Drug Handbook Revised December 2015 Abciximab (ReoPro) 2 Acetadote (acetylcysteine) Injection 4 Alteplase (Activase) 6 Aminophylline (Theophylline) 8 Amiodarone (Cordarone) 10 Argatroban 12 Bumetanide 14 Cisatracurium (Nimbex) 15 Dexmedetomidine (Precedex) 16 Diltiazem (Cardizem) 18 Dobutamine (Dobutrex) 20 Dopamine (Intropin) 22 Epinephrine (Adrenaline) Injection 24 Eptifibatide (Integrilin) 26 Esmolol (Brevibloc) 28 Fenoldopam (Corlopam) 29 Fentanyl 31 Flumazenil (Romazicon) 32 Furosemide (Lasix) Drip 34 Glucagon 35 Haloperidol (Haldol) 36 Heparin 37 Hydralazine 38 Ibutilide (Corvert) 39 Immune Globulin Intravenous (Gamimune, Gammagard, Gammar-P, Polygam, Sandoglubulin) 40 Infliximab (Remicade) 42 Insulin Drip 43 Isoproterenol (Isuprel) 44 Ketamine 46 Labetalol (Trandate) 47 Lepirudin (Refludan) 48 Lidocaine (xylocaine) 50 Lorazepam (Ativan) 52 Midazolam (Versed) 53 Milrinone (Primacor) 54 Naloxone (Narcan) 56 Nesiritide (Natrecor) 58 Nicardipine 60 Nitroglycerin 62 Nitroprusside (Nipride) 64 Norepinephrine (Levophed) 67 NovoSeven 69 Octreotide(Sandostatin) 70 Pantoprazole(Protonix) 71 Phentolamine (Regitine) 72 Phenylephrine (Neo-Synephrine) 73 Phenytoin (Dilantin) 75 Procainamide (Pronestyl) 76 Propofol (Diprivan) 78 Reteplase (Hetavase) 80 Rocuronium (Zemuron) 81 Tenecteplase (TNKase) 83 Tirofiban HCl (Aggrastat) 84 Tranexamic Acid (TXA) 86 Vasopressin (Pitressin) 87

Date: September 2004 Drug: Abciximab (ReoPro) 1. An adjunct to percutaneous coronary interventions for prevention of cardiac ischemic complications during or after the procedure. 2. Prevention of cardiac ischemia with unstable angina that is not responding to conventional therapy when cardiac intervention is planned within 24 hours. Mix the required dose of abciximab per the dosing chart into a 250 ml bag of D5W or NS. Drug must be withdrawn from the vial using a sterile, nonpyrogenic, low protein binding 0.2 or 0.22 micron filter. Abciximab is supplied in 10 mg/5 ml vials. Usual dose is 0.25 mg/kg IV bolus over 10 60 min utes before intervention. Immediately follow bolus with a 0.125 mcg/kg/ min infusion for 12 hours. Maxi mum dose is 10 mcg/min. See dosing chart. 1. Increased risk of bleeding, especially in the presence of anticoagulants or thrombolytics. 2. Heparin doses may be reduced during abciximab infusions. 3. Administration is contraindicated in cases of active internal bleeding, a history of GI bleeding within 6 weeks, CVA within 2 years, thrombocytopenia, or uncontrolled hypertension. 4. Platelet counts, PT, PTT, and ACT should be monitored at regular intervals. Bleeding is the major side effect. Major bleeding requiring transfusion has been reported. Intracranial hemorrhage or stroke is possible. Minor bleeding such as increased bruising, hematuria, and hematemesis is also possible. Abciximab should be administered in a separate IV line whenever possible. No incompatibilities have been reported with infusion IV fluids or commonly used cardiovascular medications. Nursing Considerations 1. Use a separate IV site and an IV filter for adminis tration. An infusion pump or controller should be used. 2. Watch closely for bleeding or anaphylaxis. 3. Arterial/venous sheaths may be removed while ab ciximab is infusing, provided that ACT is adequate and direct pressure is held for 30 minutes. 4. Minimize arterial and venous punctures. 5. Platelets may need to be administered if platelet counts drop below 100,000 or as treatment for active bleeding. Weight Based Dosing Chart for Abciximab (ReoPro) Initial Bolus and Continuous Infusion (0.125 mcg/kg/min for 12 Hours)

Bolus dose (mg) (0.25 mg/kg) Abciximab to add to NS 250 ml (mg) for continuous infusion of 0.125 mcg/kg/min Patient weight (kg) Infusion into (ml/hr) 11.50 (5.8 ml) 4.14 (2.1 ml) 46 21 11.75(5.9 ml) 4.23 (2.1 ml) 47 21 12.00 (6.0 ml) 4.32 (2.2 ml) 48 21 12.25 (6.1 ml) 4.41 (2.2 ml) 49 21 12.50 (6.3 ml) 4.50 (2.3 ml) 50 21 12.75 (6.4 ml) 4.59 (2.3 ml) 51 21 13.00 (6.5 ml) 4.68 (2.3 ml) 52 21 13.25 (6.6 ml) 4.77 (2.4 ml) 53 21 13.50 (6.8 ml) 4.86 (2.4 ml) 54 21 13.75 (6.9 ml) 4.95 (2.5 ml) 55 21 14.00 (7.0 ml) 5.04 (2.5 ml) 56 21 14.25 (7.1 ml) 5.13 (2.6 ml) 57 21 14.50 (7.3 ml) 5.22 (2.6 rnl) 58 21 14.75 (7.4 ml) 5.31 (2.7 ml) 59 21 15.00 (7 5 ml) 5.40 (2.7 ml) 60 21 15.25 (7.6 ml) 5.49 (2.7 ml) 61 21 15.50 (7.8 ml) 5.58 (2.8 rnl) 62 21 15.75 (7.9 ml) 5.67 (2.8 ml) 63 21 16,00 (80 ml) 5.76 (2.9 ml) 64 21 16.25 (8.1 ml) 5.85 (2.9 ml) 65 21 16.50 (8.3 ml) 5.94 (3.0 ml) 66 21 16.75 (8.4 ml) 6.03 (3.0 ml) 67 21 17.00 (8.5 ml) 6.12 (3.0 ml) 68 21 17.25 (8.6 ml) 6.21 (3.1 ml) 69 21 17.50 (8.8 ml) 6.30 (3.1 ml) 70 21 17.75 (8.9 ml) 6.39 (3.2 ml) 71 21 18.00 (9.0 ml) 6.48 (3.2 ml) 72 21 18.25 (9.1 ml) 6.57 (3.3 ml) 73 21 18.50 (9.3 ml) 6.66 (3.3 ml) 74 21 18.75 (9.4 ml) 6.75 (3.4 ml) 75 21 18.75 (3.4 ML) 6.84 (3.4 ml) 76 21 19.25 (9.6 ml) 6.93 (3.5 ml) 77 21 19.50 (9.8 ml) 7.02 (3.5 ml) 78 21 19.75 (9.9 ml) 7.11 (3.6 ml) 79 21 20.00 (10.0 ml) 7.20 (3 6 ml) 80 21 21.30 (10.6 ml) 7.20 (3.6 ml) 85 21 22.50 (11.3 ml) 7.20 (3.6 ml) 90 21 23.80 (11.9 ml) 7.20 (3.6 ml) 95 21 25.00 (12.5 ml) 7.20 (3.6 ml) 100 21 26.30 (13.1 ml) 7.20 (3.6 ml) 105 21 27.50 (13.8 ml) 7.20 (3.6 ml) 110 21 28.80 (14.4 ml) 7.20 (3.6 ml) 115 21 Patients who weigh >80 kg will be infused at a fixed rate of 10 mcg/min (21 ml/hr) Refrigerate and reuse any remaining Abciximab within 7 days of initial use of vial. Abciximab is very expensive.

Date: September 2004 Revised: November 2013 Drug: Acetadote (acetylcysteine) Injection Antidote for acetaminophen overdose. Treatment should begin within 8 hrs of ingestion or as soon as possible after ingestion. Patients who present > 24hrs after acute ingestion or present following ingestion at an unknown time may be candidates for acetylceysteine therapy. Consultation with a poison control center is highly recommended. An FDA approved form exists and is preferred (Acetadote), but the oral formulation may be used IV with proper preparations and precautions. (If the product is oral NAC, it must be passed through a 0.22 micron filter Acetadote dose not require this filtration step) Combine 150ml of 20% N-acetylceysteine in 850ml D5W (or 300cc of 10% N-acetylcysteine in 700ml D5W) -Final concentration should be 30mg NAC / ml of D5W Loading Administer 150mg per kg body weight over 1 hour (=5ml/kg/hr x 1 hr if 30mg/ml used) -cardiac and BP monitoring must be used during loading dose infusion -If pt experiences rash, shortness of breath, hypotension or any clinical worsening, stop the infusion, stabilize the patient and call the poison center. Maintenance At the end of the loading dose, begin NAC continuous infusion at 15 mg/kg/hr -If the patient did not have any adverse effect with the loading dose, there is no further need for cardiac monitoring (unless required due to co-ingestants) -The patient should receive 24hrs of treatment prior to the consideration of stopping treatment. Recommend consultation with the poison center prior to stopping treatment Monitoring Obtain laboratories 22 hours into maintenance and every 24 hours thereafter A) If AST, ALT was normal on admission and patient tolerating PO & has normal vitals, obtain AST, ALT. Obtain PT/INR if the AST, ALT become elevated (>1000 U/L). B) If AST, ALT was abnormal on admission OR patient is now symptomatic, obtain AST, ALT, PT/INR, electrolytes, and BUN/creatinine. C) Obtain a repeat acetaminophen level to ensure acetaminophen elimination is complete; this is not required if they already have had a negative acetaminophen level. Duration of N-acetylcysteine treatment: A) N-acetylcysteine treatment must be continued at 15 mg/kg/hr if: a. INR is greater than 2.0. Contact poison control if FFP was given. b. If AST and ALT rose by more than 15 IU/L. c. Patient is acidotic (ph < 7.25 or HCO3 < 20) or encephalopathic. d. Patient has an acetaminophen level > 10 micrograms/ml. B) Treatment may be stopped if: a. Patient asymptomatic at 24 hrs with normal AST and ALT levels, INR < 2.0 (if checked) and acetaminophen level < 10 micrograms/ml (if required) C) For other situations not covered above, contact the poison center Do not administer any acetaminophen-containing products

Plasma or serum acetaminophen concentrations are essential in assessing the potential risk of hepatotoxicity, and should be determined as early as possible, but no sooner than 4 hours following an acute overdose. Serum levels drawn sooner than 4 hours following ingestion will be misleading. If an assay for acetaminophen can not be obtained, it is necessary to assume that the overdose is potentially toxic. Interpretation of Acetaminophen Assays: 1. When results of the plasma acetaminophen assay are available, refer to the nomogram above to determine if plasma concentration is in the potentially toxic range. Values above the line connecting 200 mcg/ml at 4 hours with 50 mcg/ml at 12 hours (probable line) are associated with a probability of hepatic toxicity if an antidote is not administered. 2. If the predetoxification plasma level is above the line connecting 150 mcg/ml at 4 hours with 37.5 mcg/ml at 12 hours (possible line), continue with maintenance doses of acetylcysteine. 3. If the predetoxification plasma level is below the line connecting 150 mcg/ml at 4 hours with 37.5 mcg/ml at 12 hours (possible line), there is minimal risk of hepatic toxicity, and acetylcysteine treatment may be discontinued. Repeated Supratherapeutic Ingestion: Repeated Supratherapeutic Ingestion (RSI) is defined as ingestion of acetaminophen at doses higher than those recommended for extended periods of time. The nomogram does not apply to patients with RSI. Treatment is based on the acetaminophen and elevated AST/ALT levels indicative of potential toxicity due to acetaminophen. For the specific treatment information regarding the clinical management of RSI overdose, please contact your regional poison center at 1-800-222-1222, or alternatively, a special health professional assistance line for acetaminophen overdose at 1-800-525-6115.

Date: September 2004 revised February 2010 Drug: Alteplase (Activase) 1. As a thrombolytic for treatment of acute Ml, with chest pain >20 minutes and onset within <12 24 hours, to improve ventricular function. 2. For acute pulmonary embolism, age <75 years and within 5 days of thrombus formation. 3. For acute ischemic stroke, age <75 years and within the first 3 hours of the onset of symptoms. Reconstitute 100 mg vial alteplase in 100 ml sterile water. Final concentration: 1 mg/ml. 1. AMI (front loaded dose): The recommended total dose is based on weight, not to exceed 100 mg. For patients >67 kg, give 15 mg (15 ml) bolus, followed by 50 mg (50 ml) infused over 30 minutes, and then 35 mg (35 ml) infused over the next 60 minutes. For patients < 67 kg: give 15 mg (15 ml) bolus, followed by 0.75mg/kg infused over the next 30 minutes, not to exceed 50 mg, and then 0.5 mg/kg over the next 60 minutes not to exceed 35 mg. 2. PE: 100 mg over 2 hours, infuse at 50 ml/hr. Begin / Restart heparin per weight-based DVT/PE protocol once PTT returns to twice normal or less. 3. Stroke: 0.9 mg/kg (up to 90 mg). Infuse 10% (0.09 mg/kg) as a bolus dose, followed by the re mainder (0.81 mg/kg) as a continuous infusion over 60 minutes. Maximum total dose is 90 mg. 1. Increased risk of bleeding, especially in the presence of anticoagulation. 2. For AMI patients: Heparin doses of 5000 U bolus and 1000 U/hr or 800 U/hr for patients <80 kg may be used. For stroke patients: Start heparin infusion without loading bolus doses. 3. Administration of alteplase is contraindicated in cases of active internal bleeding, history of GI bleeding within 6 weeks, trauma or surgery within 1 month, thrombocytopenia, uncontrolled hyper tension (SBP >185, DBP >110, unresponsive to nitrates or calcium antagonists) intracranial neo plasm, arteriovenous malformations, or aneurysm. Also contraindicated with history of CVA within 1 month, seizure occurring at the time of stroke, or any suspicion of hemorrhagic stroke. 1. Bleeding is the major side effect Intracranial hem orrhage (0.4% 0.87%) or stroke has been reported as a complication. Minor bleeding such as in creased bruising, hematuria, GI bleeding, bleeding at the injection site (up to 15.3%), and genitouri nary hemorrhage is possible 2 Allergic reactions and anaphylaxis are rare. 3. Hypotension and arrhythmias are also possible. Dobutamine Heparin Dopamine Nitroglycerin Compatibility Dextrose 5% Normal saline Lidocaine Propranolol Metoprolol Nursing Considerations 1. Use a separate IV site: do not administer with heparin because of incompatibility. 2. Watch closely for bleeding, particularly within the first hour of administration, or anaphylaxis. 3. Minimize arterial and venous punctures for at least 24 hours after administration. 4. Heparin and aspirin (160 325 mg) should be used with alteplase to reduce the risk of rethrombosis

AItepIase (Activase, t PA) Dosing Chart Acute Myocardial Infarction Alteplase 100 mg Added to 100 ML Sterile Water (Concentration: 1 mg/ml) Patient Weight Initial Loading over 1-2 min Second dose (0.75 mg/ kg) over 30 min Final dose 0.5 mg/kg over 60 min 50 kg 15 mg 38 mg (75 ml/hr) 25 mg (25 ml/hr) 60 kg 15 mg 45 mg (90 ml/hr) 30 mg (30 ml/hr) 70 kg 15 mg 50 mg (100 ml/hr) 35 mg (35 ml/hr) 80 kg 15 mg 50 mg (100 ml/hr) 35 mg (35 ml/hr) 90 kg 15 mg 50 mg (100 ml/hr) 35 mg (35 ml/hr) AItepIase (Activase, t PA) Dosing Chart Acute Ischemic Stroke Alteplase 100 mg Added to 100 ML Sterile Water (Concentration: 1 mg/ml) Patient Weight Initial Loading (0.09 mg/kg) Second dose (0.81 mg/ kg) over 60 min Total dose (0.9 mg/kg) 50 kg 4 mg 41 mg (41 ml/hr) 45 mg 60 kg 5 mg 49 mg (49 ml/hr) 54 mg 70 kg 6 mg 57 mg (57 ml/hr) 63 mg 80 kg 7 mg 65 mg (65 ml/hr) 72 mg 90 kg 8 mg 73 mg (73 ml/hr) 81 mg >100 kg 9 mg 81 mg (81 ml/hr) 90 mg

Date: September 2004 Updated: November 2014 Drug: Aminophylline (Theophylline) 1 Symptomatic relief or prevention of bronchial asthma and reversible bronchospasm associated with chronic bronchitis and emphysema. 2 May significantly improve pulmonary function and dyspnea in patients with chronic obstructive pulmonary disease. Loading -mix desired dose (typically 6mg/kg) in D5W 100 ml and run over 30 minutes Maintenance Infusion -mix to a concentration of 1 mg/ml (typically 500 mg in 500 ml D5W) 1. Dosage will vary and depend on patient s condi tion, concomitant disease state, and prior Theoph ylline use (serum Theophylline level). 2. Loading dose a. Patients not currently receiving Theophylline, give aminophylline 6 mg/kg in D5W 100 ml over 30 minutes b. To increase levels in patients currently receiving Theophylline, give aminophylline 0.5 mg/kg to increase Theophylline level by 1 mcg/ml. c. Goal serum level: 5 15 mcg/ml. 3. Maintenance infusion (concentration 1mg/ml) a. Adjust dose according to serum Theophylline levels. b. Usual dosage range: Aminophylline 0.25 0.75 mg/kg/hr.** ** Aminophylline infusion rate should not exceed 21 mg/hour in patients with cor pulmonale, cardiac decompensation, liver dysfunction, patients >60 years of age, or patients taking medications which reduce theophylline clearance. 1. Toxicity warning: Monitor serum levels to avoid toxicity; normal levels are 5 15 mcg/ml. Incidence of toxicity increases significantly with serum levels >20 mcg/ml, with symptoms including ventricular arrhythmias, convulsions, and death. 2. Patients with decreased ability to clear plasma of aminophylline (eg., those with impaired liver function, congestive heart failure, >55 years of age, sus tained high fever) are at increased risk of toxicity. 3. Aminophylline may cause arrhythmia; monitor lev els if significant changes in HR or rhythm occur. Ventricular arrhythmias will respond to lidocaine. 1. Adverse reactions rarely occur when serum levels are <20 mcg/ml, a. Serum levels >20 mcg/ml: Nausea, vomiting, diarrhea, headache, insomnia, irritability. b. Serum levels >35 mcg/ml: Hyperglycemia, hypotension, cardiac arrhythmias, tachycardia. 2. CNS: Irritability, restlessness, headache, insomnia, reflex hyperexcitability, muscle twitching, convul sions. 3. GI: Nausea, vomiting, epigastric pain, hematemesis, diarrhea; may induce gastroesophageal reflux. 4 Cardiovascular: Palpitations, tachycardia, extrasys toles, hypotension, circulatory failure, ventricular arrhythmias. 5. Other: Tachypnea, proteinuria, fever, hyperglycemia, rash. Amiodarone (Cordarone) Meperidine (Demerol) Atracurium (Tracriuml Morphine Chlorpromazine (Thorazine) Norepinephrine Clindamycin Ondansetron (Zofran) Codeine Phenytoin (Dilantin) Dobutamine Prochlorperazine (Compazine) Hydralazine Promethazine(Phenergan) Hydroxyzine (Vistaril) Verapamil Insulin Isoproterenol Compatibility Amrinone (Inocor) Dopamine Labetalol Potassium chloride Bretylium Esmolol Lidocaine Diltiazem Heparin Nitroglycerin

Nursing Considerations 1. Consult the Aminophylline Drip Rate Calculation Chart to determine the drip rate. 2 Aminophylline should be administered by an IV pump to ensure controlled infusion. 3. Monitor serum aminophylline levels; call physician if elevated levels are noted. Monitor patients for signs of toxicity. Aminophylline Drip Rate Calculation Chart Theophylline 800 mg in 1000 ml (Concentration: 0.8 mg/ml of theophylline and 1 mg/ml of aminophylline) (mg/hr) Infusion Rate (ml/hr) (mg/hr) Infusion Rate (ml/hr) Aminophylline Theophylline 5 5 5 6 10 10 10 12.5 15 15 15 19 20 20 20 25 25 25 25 31 30 30 30 37.5 35 35 35 44 40 40 40 50 45 45 45 56 50 50 50 62.5 55 55 55 69 60 60 60 75 65 65 65 81 70 70 70 87.5 75 75 75 94

Date: September 2004 Drug: Amiodarone (Cordarone) 1. Initiation of treatment and prophylaxis of recurring ventricular fibrillation and unstable ventricular tachycardia in patients refractory to other therapy. 2 In patients for whom oral amiodarone is indicated but who are NPO. Loading : Add 150mg (3ml) of amiodarone to 100 ml bag of D5W and dose as below. Final concentration: 1.5 mg/ml. Maintenance : Add either 450mg of amiodarone to 250 ml D5W or 900mg to 500 ml D5W. Final concentration: 1.8 mg/ml. Mix maintenance dose in a PVC-Free bag of D5W. Use a 0.22 micron in-line filter. Use central access if possible. 1. Loading Bolus: Infuse 150 mg over 10 minutes (15 mg/min or 600 ml/hr). Pre pare solution with 150 mg amiodarone in 100 ml D5W bag. The initial infusion rate should not exceed 30 mg/min. 2. Follow loading dose with a slow infusion of 360 mg over the next 6 hours (1 mg/min or 33 ml/hr). 3. Follow slow infusion with a maintenance infusion of 540 mg over the remaining 18 hours (0.5 mg/min or 16.5 ml/hr). 4. After the first 24 hours, infusion may be continued at a rate of 0.5 mg/min. 5. If breakthrough episodes of ventricular fibrillation or tachycardia should occur, an additional infusion of 150 mg over 10 minutes may be administered (150 mg in 100 ml D5W). 6. When switching from IV to PO, use the following as a guide: a. <1 week IV 800 1600 mg/day b. 1 3 weeks IV 600 800 mg/day c. >3 weeks IV 400 mg/day 7. During cardiac arrest, 300 mg (2 ampules 150 mg each) may be given IV push. May repeat 150 mg IV push in 3 5 minutes, up to a maximum cumulative dose of 2.2 g IV in 24 hours. 1 Although IV amiodarone has been used safely in some patients with AMI, it is clearly a negative in otrope. Use cautiously in patients with left ventric ular dysfunction. 2. Hypotension is the main complication of IV ther apy; therefore use with caution in hypotensive patients. 3 Marked cardiomegaly, particularly resulting from myocardiopathy, is a relative contraindication to IV use of amiodarone. 4 Use cautiously in patients with thyroid dysfunc tion. Amiodarone has been reported to produce hypothyroidism or hyperthyroidism. 5 Because of extensive tissue distribution and pro longed elimination period, the time at which a life threatening arrhythmia will recur following discon tinued therapy or an interaction with subsequent treatment may be unpredictable. Patients must be observed carefully when other antiarrhythmic agents are substituted after amiodarone is stopped. The incidence of side effects increases over time; many ADRs may be related to the total dose administered over time (i.e., accumulation). 1. Cardiovascular: Sinus bradycardia, hypotension, heart block, proarrhythmic effects. 2. Pulmonary: Within the first few weeks, may pres ent with acute onset of nonspecific symptoms (e.g., fever, shortness of breath, and cough). These are probably symptoms of a hypersensitivity reac tion associated with an eosinophilic lung infiltrate (e.g., pulmonary fibrosis, interstitial pneumonitis). 3. Thyroid: Interferes with T4. T3 conversion (hypothyroidism occurs more often than hyperthyroidism). 4. GI: Nausea/vomiting, anorexia, abdominal pain, and constipation. 5. Hepatic: Abnormal liver function tests, especially elevated aminotransferase and alkaline phos phatase levels 25% of patients. Increased pro thrombin time (PT) international normalized ratio (INR.) 6. Dermatologic: Allergic rash, photosensitivity, and unusual blue gray skin discoloration. 7. Neurologic: Tremor, ataxia, peripheral neuropathy, fatigue, and weakness. 8. Ophthalmologic: High occurrence of corneal microdeposits caused by the secretion of amiodarone by the lacrimal

gland with accumulation on corneal surface. This does not seem to affect vision and is reversible once the drug is discontinued. 9. Hematologic: Thrombocytopenia <1%. Aminophylline Heparin Cefazolin Sodium bicarbonate Compatibility Dobutamine Lidocaine Dopamine Nitroglycerin Esmolol Norepinephrine Insulin Phenylephrine Isoproterenol Potassium Labetalol Procainamide Drug Interactions Warfarin Increased anticoagulation effect Beta blockers Beta blocker effects are enhanced Calcium channel blockers Additive effects of both drugs are enhanced, resulting in reduced cardiac sinus and AV nodal conduction, and contractility Digoxin Increased digoxin concentrations, thus increasing toxic potential Flecainide Increased flecainide concentrations Phenytoin Increased phenytoin concentrations Procainamide Increased procainamide concentrations Quinidine Increased quinidine concentrations, which can cause fatal cardiac arrhythmias Simvastatin Increased simvastatin concentrations, which can cause rhabdomyoloysis; must lower dosage to < 20 mg Nursing Considerations 1. Consult the amiodarone drip rate calculation chart to determine the drip rate. 2 Muscle weakness may present a great hazard for ambulation. 3. Give PO dosage with food. 4. Monitor ECG and rhythm throughout therapy. 5. Assess patient for signs of lethargy, edema of the hands and feet, weight loss, and pulmonary toxic ity (e.g., shortness of breath, cough, rales, fever, pulmonary function tests) Amiodarone (Cordarone) Drip Rate Calculation Chart Concentration Infusion Rate 15 mg/min 150mg/100ml D5W (1.5 mg/ml) 600 ml/hr 1 mg/min 450mg/250ml D5W (1.8 mg/ml) 33 ml/hr x 6 hours 0.5 mg/min 450mg/250ml D5W (1.8 mg/ml) 16.5 ml/hr x 18 hours

Date: September 2004 Drug: Argatroban Anticoagulation in patients with heparin-induced thrombocytopenia (HIT) with or without thrombosis. Argatroban should be diluted in 0.9% Sodium Chloride Injection, 5% Dextrose Injection, or Lactated Ringer s Injection to a final concentration of 1 mg/ml. The contents of each 2.5-mL vial should be diluted 100-fold by mixing with 250 ml of diluent. Use 250 mg (2.5 ml) per 250 ml of diluent or 500 mg (5 ml) per 500 ml of diluent. The constituted solution must be mixed by repeated inversion of the diluent bag for 1 minute. Upon preparation, the solution may show slight but brief haziness due to the formation of microprecipitates that rapidly dissolve upon mixing. (Obtain and use Argatroban Protocol on the intranet) Before administering, discontinue heparin therapy (e.g. heparin, enoxaparin) and obtain a baseline aptt. (Allow time for heparin therapy to be excreted before obtaining baseline measurement.) The recommended initial dose for patients without hepatic impairment is 2 mcg/kg/min administered as a continuous infusion. (See chart.) Therapy is monitored using the aptt. adjustment may be required to attain a target aptt of 1.5 to 3 times the patient s baseline aptt value not to exceed 100 seconds. Check the aptt 2 hours after initiation of therapy to confirm the desired therapeutic range has been attained. Dosages should not exceed greater that 10 mcg/kg/min. The initial rate should be reduced to 0.5 mcg/kg/min in patients with moderate hepatic impairment. 1. Hemorrhage can occur at any site in the body in patients receiving Argatroban. An unexplained fall in hematocrit, a fall in blood pressure, or any other unexplained symptom should lead to consideration of a hemorrhagic event. 2. Argatroban should be used with extreme caution in disease states and other circumstances in which there is an increased danger of hemorrhage. These include severe hypertension; immediately following lumbar puncture; spinal anesthesia; major surgery, especially involving the brain, spinal cord, or eye; hematologic conditions associated with increased bleeding tendencies such as congenital or acquired bleeding disorders and gastrointestinal lesions such as ulcerations. 1. Incidence > 10%: Minor hemorrhage from gastrointestinal and/or genitourinary tracts, decrease in hemoglobin/ hemotocrit 2. Incidence < 10%: Minor hemorrhage into groin, hemoptysis, brachial bleeding, intracranial hemorrhaging (rare), hypotension, fever, diarrhea, nausea, vomiting, coughing, cardiac arrest Argatroban should not be mixed with other drugs prior to dilution in a suitable intravenous fluid. Compatibility None known Nursing Considerations 1. Obtain and use Argatroban Protocol 2. Consult argatroban drip rate calculation chart to determine drip rate. 3. Argatroban should be administered by an IV pump to ensure controlled infusion. 4. Monitor patients for signs/symptoms of hemorrhage; contact physician if symptoms occur. 5. Monitor PTT 2 hours after drip initiation and after each rate change. Therapeutic range is generally 1.5-3 times baseline. 6. Reduce the initial infusion rate to 0.5 mcg/kg/min in patients with moderate hepatic impairment.

Argatroban Drip Rate Calculation Chart Argatroban 250mg in 250ml (Concentration: 1mg/ml) Without Hepatic Impairment = 2 mcg/kg/min With Hepatic Impairment = 0.5 mcg/kg/min Body Weight (kg) Infusion Rate (ml/hr) Body Weight (kg) Infusion Rate (ml/hr) 50 6 50 1.5 60 7 60 2 70 8 70 2 80 10 80 2.5 90 11 90 3 100 12 100 3 110 13 110 3 120 14 120 3.5 130 16 130 4 140 17 140 4

Date: March 2014 Drug: Bumetanide (Bumex) Bumetanide is a loop diuretic. Continuous infusion bumetanide is typically used for edema associated with CHF and renal insufficiency. Bumetanide comes in a 2.5mg / 10ml vial. Place contents of 4 vials in an empty bag to make a 10mg / 40ml IVPB (0.25mg/ml concentration). Bumetanide is typically run at a range of 0.5mg 2mg / hr rate. Rates > 2mg / hr are associated with higher adverse reactions. Monitoring Monitor for electrolyte depletion, dehydration, and thrombocytopenia. Side Effects Include but are not limited to: electrolyte depletion, hypokalemia, hyponatremia, ototoxicity, thrombocytopenia, hypotension

Date: September 2004 Drug: Cisatracurium (Nimbex) Skeletal muscle relaxation during mechanical ventila tion to prevent ventilator resistance and or decreased energy expenditure states. To prepare Nimbex infusion, add 250 mg (25 X 5 ml each vials) Nimbex to 125 ml D5W (waste 125 ml D5W from a 250 ml bag). Final concentration: 1 mg/ml. Continuous infusion 1. Start 3 mcg/kg/min (range 0.5 10 mcg/kg/min). 2. Titrate dose to effect. 3. Increase dose as needed to achieve desired degree of neuromuscular blockade. 1. Sedation should be ordered and given in addition to the cisatracurium because it does not alter the level of consciousness and does not relieve pain. 2. Nimbex drip may be interrupted to assess neuro logic status based on physician s orders. Neuro logic assessment will include responsiveness, orientation, extremity movement, and pupillary reaction. Bradycardia (0.4%), hypotension 10.2%), flushing (0.2%), bronchospasm (0.2%), rash (0.1 %) Diprivan Toradol Compatibility Alfenta Sufenta Droperidol Versed Sublimaze Nursing Considerations 1. Use infusion control device and monitor ECG, respirations, and vital signs continuously. 2. Monitor for malignant hyperthermia. 3. Tachyphylaxis is possible in long term use. 4. Anticholinesterase reversal agents, endotracheal intubation equipment, and mechanical ventilation equipment should be available. 5. No dosage reductions are needed for renal or hepatic insufficiency. Cisatracurium (Nimbex) Drip Rate Calculation Chart Nimbex 250 mg in 250 ml (Concentration: 1 mg/ml or 1000 mcg/ml) Patient Weight 3 mcg/kg/min Infusion Rate 50 kg 9 mg/hr 9 ml/hr 60 kg 11 mg/hr 11 ml/hr 70 kg 13mg/hr l3 ml/hr 80 kg 14 mg/hr 14 ml/hr 90 kg 16 mg/hr 16 ml/hr

Date: October 2009 Drug: Dexmedetomidine (Precedex) Dexmedetomidine is an alpha-2 agonist with sedative properties. There is no evidence of respiratory depression within recommended dose infusion ranges. Indicated for short-term use as a sedative for patients undergoing mechanical ventilation in the ICU setting. Infusion should generally not exceed 24 hours in length. Indicated as sedation of non-intubated patients prior to and/or during surgical and other procedures. Dexmedetomidine has been continuously infused in mechanically ventilated patients prior to extubation, during extubation, and postextubation. It is not necessary to discontinue dexmedetomidine prior to extubation. Dexmedetomidine comes as vials of 200 mcg/2ml or 100mcg/ml. Dilute 2 ml of dexmedetomidine into 48 ml NS (total = 50 ml) before IV administration for any purpose. Dilution should equal 4 mcg/ ml. For ICU Sedation: Generally initiate at 1 mcg/kg over 10 minutes, followed by a maintenance infusion of 0.2 to 0.7 mcg/kg/hr. The rate of maintenance infusion should be adjusted based on desired clinical effect. For Procedural Sedation: Generally initiate at 1 mcg/kg over 10 minutes, followed by a maintenance infusion initiated at 0.6 mcg/kg/hr and titrated to achieve desired clnical effect with doses ranging from 0.2 to 1 mcg/kg/hr. For patients over 65 years, a dose reduction should be considered. For patients with impaired renal and/or hepatic function, a dose reduction should be considered. Contraindications 1. Patients should be continuously monitored while receiving dexmedetomidine by skilled personnel with experience in the ICU. 2. Bradycardia and sinus arrest have occurred in healthy volunteers with high vagal tone or with rapid intravenous or bolus administration. 3. Hypotension and bradycardia may necessitate medical intervention. These events may be more pronounced in patients with hypovolemia, diabetes mellitus, or chronic hypertension, and in the elderly. Treatment may include decreasing/stopping dexmedetomidine, IV fluid, elevation of lower extremities, pressors, or IV anticholinergic agents (e.g. glycopyrrolate or atropine) to modify vagal tone. 4. Use caution in patients with advanced heart block or severe ventricular dysfunction. 5. Co-administration with other vasodlators or negative chronotropic agents can have additive pharmacodynamic effects. 6. Transient hypertension has been observed primarily during the loading dose. Consider reducing the loading dose if this is an issue. 7. Patients can become aroused/alert with stimulation. This should not be considered lack of clinical efficacy. 8. Withdrawal symptoms such as nervousness, agitation, and headache followed by a rapid rise in blood pressure can occur after abrupt withdrawal of dexmedetomidine, especially if the infusion has continued longer than 24 hours. These symptoms may not abate for up to 48 hours after cessation of dexmedetomidine infusion. The most common adverse reactions (>2%) are hypotension, bradycardia, and dry mouth. Blood, Plasma, Amphotericin B, diazepam Compatibility Numerous. See package insert or call Pharmacy. 9/09

Nursing Considerations 1. Use administration components made with synthetic or coated natural rubber gaskets. Dexmedetomidine can bind to natural rubber. 2. Products should be inspected visually for particulate matter and discoloration before administration. Consult the dexmedetomidine drip rate calculation chart to determine the drip rate. 3. Safety and effectiveness of dexmedetomidine has not been formally evaluated in infusions over 24 hours; however, it has been used for up to 9 days in some patients. Dexmedetomidine (Precedex) Drip Rate Calculation Chart Dexmedetomidine 200 mcg in 50 ml (Concentration: 4 mcg/ml) Weight (kg) 0.2 mcg/kg/hr 0.3 mcg/kg/hr 0.4 mcg/kg/hr 0.5 mcg/kg/hr 0.6 mcg/kg/hr 0.7 mcg/kg/hr 50 2 ml/hr 4 ml/hr 5 ml/hr 6 ml/hr 8 ml/hr 9 ml/hr 60 3 ml/hr 5 ml/hr 6 ml/hr 8 ml/hr 9 ml/hr 11 ml/hr 70 4 ml/hr 5 ml/hr 7 ml/hr 9 ml/hr 11 ml/hr 12 ml/hr 80 4 ml/hr 6 ml/hr 8 ml/hr 10 ml/hr 12 ml/hr 14 ml/hr 90 5 ml/hr 7 ml/hr 9 ml/hr 11 ml/hr 14 ml/hr 16 ml/hr 100 5 ml/hr 8 ml/hr 10 ml/hr 13 ml/hr 15 ml/hr 18 ml/hr

Date: September 2004; Revised: December 2014 Drug: Diltiazem (Cardizem) 1. Paroxysmal supraventricular tachycardia. 2. Atrial flutter or fibrillation; temporary control of rapid ventricular rate. Standard: A diltiazem infusion is prepared by adding 100 mg add-vantage vial to 100 ml D5W or 0.9% NaCl for a final concentration of 1mg/ml and a total volume of 100ml. (note: there may be occasions due to shortages when we will need to add a 125mg (25ml) diltiazem vial to a 100 ml bag of D5W or 0.9% NaCl to give a final volume of 125 ml. This will give us the same concentration of 1mg/ml, just a different total volume.) Extreme Fluid Restriction: A diltiazem infusion is prepared by adding 500 mg (100ml) to 250 ml D5W or 0.9% NaCl. Final volume: 350 ml. Final concentration: 1.4 mg/ml. 1. Bolus dose a. Initial dose of 0.25 mg/kg (average: 20 mg) given over 2 minutes. b. If inadequate results after 15 minutes, addi tional bolus of 0.35 mg/kg (average: 25 mg) may be given. 2. Continuous infusion a. Give bolus as described above, immediately followed by a continuous infusion of 5 10 mg/hr. b. Infusion may be increased to 15 mg/hr if further reduction in HR is required. c. Infusions longer than 24 hours or >15 mg/hr are not recommended. 1. Diltiazem may prolong AV node conduction and rarely may cause second or third degree heart block. It is contraindicated in patients with sick sinus syndrome or heart block unless functioning ventricular pacemaker is present. 2. Monitor response and possibly decrease dose in patients with liver failure. Rare instances of acute hepatic injury have occurred with diltiazem injection. 3. May cause hypotension; use with caution in he modynamically compromised patients and those taking drugs that decrease peripheral resistance, intravascular volume, myocardial contractility, or conduction. 1. Cardiovascular: Hypotension treat with saline or Trendelenburg position if required. Vasodilation (flushing) may occur. Atrial flutter, AV block, brady cardia, chest pain, CHF and ventricular arrhythmias have been reported. 2. GI: Constipation, nausea, vomiting, elevated liver function tests. 3. CNS: Dizziness, paresthesia, headache. 4. Other: Amblyopia, dry mouth, dyspnea, edema. Lasix Compatibility Aminophylline Lidocaine Dobutamine Midazolam Dopamine Milrinone Epinephrine Nitroglycerin Esmolol Norepinephrine Heparin Potassium chloride Insulin Theophylline Nursing Considerations 1. Consult the diltiazem drip rate calculation chart to determine the drip rate. 2. Diltiazem should be administered by an IV pump to ensure controlled infusion. 3. Closely monitor and document changes in BP, HR, or in the rhythm strip. Document BP at least every hour.

Diltiazem (Cardizem) Drip Rate Calculation Chart Diltiazem 125 mg Added to 100mL (Concentration: 1 mg/ml) Infusion Rate 5 mg/hr 5 ml/hr 6 mg/hr 6 ml/hr 7 mg/hr 7 ml/hr 8 mg/hr 8 ml/hr 9 mg/hr 9 ml/hr 10 mg/hr 10 ml/hr 11 mg/hr 11 ml/hr 12 mg/hr 12 ml/hr 13 mg/hr 13 ml/hr 14 mg/hr 14 ml/hr 15 mg/hr 15 ml/hr Diltiazem (Cardizem) Drip Rate Calculation Chart Diltiazem 500 mg added to 250 ml (Concentration: 1.4 mg/ml) [Max Concentration] Infusion Rate 5 mg/hr 3.5 ml/hr 6 mg/hr 4 ml/hr 7 mg/hr 5 ml/hr 8 mg/hr 6 ml/hr 9 mg/hr 6.5 ml/hr 10 mg/hr 7 ml/hr 11 mg/hr 8 ml/hr 12 mg/hr 8.5 ml/hr 13 mg/hr 9 ml/hr 14 mg/hr 10 ml/hr 15 mg/hr 10.5 ml/hr

Date: September 2004 Drug: Dobutamine (Dobutrex) 1. To increase cardiac output in the short term treatment of patients with cardiac decompensation resulting from depressed contractility (inotropic support). 2. Cardiogenic shock. Premixed dobutamine 500 mg/250 ml in D5W. Final concentration: 2 mg/ml. Usual dose is 2.5 10 mcg/kg/min; rarely up to 40 mcg/kg/min may be given. Infusion is titrated until optimal response is obtained (dose increased 2 mcg/kg/min at 15 20 minute intervals). Onset of action is usually within 2 minutes, and peak effects usually occur within 10 minutes of initiation. 1. Hypovolemia should be corrected before use. 2. In the presence of atrial fibrillation, digoxin is usu ally given before dobutamine initiation to prevent development of a rapid ventricular response. 3. Dobutamine is contraindicated in patients with idiopathic hypertropic subaortic stenosis (IHSS). 4. Dobutamine should he used with extreme caution after Ml or in patients with marked mechanical ob struction (e.g., severe valvular aortic stenosis). 5. Use with caution in patients receiving halothane or cyclopropane anesthesia. 6. Dobutamine effects are antagonized by beta blockers. 7. Extravasation or peripheral ischemia can cause sloughing and necrosis of tissue in the surround ing area. Antidote: The site should be infiltrated with a 10 ml solution containing 5 mg phentol amine (Regitine), within 12 hours of event; a fine hypodermic needle should be used, and a physician s order should he obtained for the antidote. Skin color should return within 1 hour if dose effective. 1. Increased HR, increased BP and ectopic beats. These are usually dose related and may respond to a dosage decrease or a temporary discontinuation of the drug. 2. Increase in AV conduction. 3. Angina, nausea, vomiting, tingling, paresthesia, dyspnea, headache, mild leg cramps. Aminophylline Dilantin Potassium Calcium Heparin Sodium bicarbonate Cefazolin Lasix Valium Digoxin Magnesium sulfate Compatibility Amiodarone Dopamine Labetalol Nitroprusside Amrinone Epinephrine Lidocaine Norepinephrine Atracurium Insulin Milrinone Procainamide Diltiazem Isoproterenol Nitroglycerin Theophylline Nursing Considerations 1. The drip may turn a light pink several hours after mixing, but stability or potency is not altered. 2. An accurate weight shall be obtained before administration of dobutamine. 3. Consult the dobutamine drip rate calculation chart to determine the drip rate. 4. Except in cardiac arrest situations, dobutamine should be administered via an IV pump to ensure controlled infusion. 5. Closely monitor and document changes in BP HR, or the rhythm strip. Document BP at least every hour. Pulmonary wedge pressure and cardiac out put monitoring is desirable. Dobutamine (Dobutrex) Drip Rate Calculation Chart Dobutamine 500 mg in 250 ml (concetration: 2mg/ml)

Drug Delivery Rate (mcg/kg/min) Patient s Weight (kg) 5 10 20 30 40 50 60 70 80 90 100 110 0.5 0.08 0.15 0.3 0.45 0.6 0.75 0.9 1.05 1.2 1.35 1.5 1.65 1 0.15 0.3 0.6 0.9 1.2 1.5 1.8 2.1 2.4 2.7 3 3.3 2.5 0.38 0.75 1.5 2 3 4 4.5 5 6 7 7.5 9 5 0.75 1.5 3 4.5 6 7.5 9 10.5 12 13.5 15 16.5 7.5 1.13 2.26 4.6 7 9 11 13.5 16 18 20 22.5 25 10 1.5 3 6 9 12 15 19 21 24 27 30 33 12.5 1.98 3.75 7.5 11 15 19 22.5 26 30 34 37.5 41 15 2.25 4.5 9 13.5 18 22.5 27 31.5 36 40.5 45 49.5 17.5 2.63 5.25 10.5 15.75 21 26.25 31.5 36.75 42 47.25 52.50 57.75 20 3 6 12 16 24 30 36 42 48 54 60 66 ml/hr

Date: September 2004 Drug: Dopamine (Intropin) Correction of hemodynamic imbalances present in shock syndrome resulting from Ml, trauma, sep ticemia, open heart surgery, renal failure, and chronic cardiac decompensation as in CHF. Premixed bag. 400 mg dopamine/250 ml D5W. Final concentration: 1600 mcg/ml 1. Renal perfusion: Rates of 1 5 mcg/kg/min are administered. 2. Hypotension: An initial dose of 5 mcg/kg/min may be used and increased gradually in 5 10 mcg/kg/min increments up to 20 mcg/kg/min. Contact physician if 20 mcg/kg/min does not maintain BP. 1. Dopamine should not be used in patients with pheochromocytoma. 2. Patients who have been treated with MAO in hibitors (e.g., Marplan, Nardil, or Parnate) will re quire a reduced starting dose of dopamine, usually at least 1 /10th of the usual dose. 3. Avoid cyclopropane or halogenated hydrocarbon anesthetics. 4. Extravasation or peripheral ischemia can cause sloughing and necrosis of tissue in the surround ing area. Antidote:The site should be infiltrated with a 10 ml solution containing 5 mg phentol amine (Regitine) within 12 hours of the event; a fine hypodermic needle should be used, obtain a physician s order for the antidote. Skin color should return to normal within one hour if effective. Most common are ectopic beats, nausea, vomiting, tachycardia, anginal pain, palpitation, dyspnea, headache, hypotension, and vasoconstriction. Less common are aberrant conduction, bradycardia, piloerecton, widening QRS complex, azotemia, and elevated, BP Amphotericin B Inferon Ampicillin Keflin Ancef Kefzol Flagyl Penicillin G potassium Gentamicin Sodium bicarbonate Compatibility Aminophylline Heparin Amiodarone Labetalol Amrinone Lidocaine Atracurium Midazolam Bretylium Milrinone Diltiazem Nitroglycerin Dobutamine Norepinephrine Epinephrine Nitroprusside Esmolol Theophylline Nursing Considerations 1. An accurate weight should be obtained before administration of dopamine. 2. Consult the dopamine drip rate calculation chart to determine the drip rate. 3. Except in cardiac arrest situations, dopamine should be administered via an IV pump to ensure controlled infusion. 4. The renal perfusion patient s BP should be monitored and documented hourly. The hypotensive patient s BP should be monitored with each increase in dose while dopamine is being incrementally increased. After the desired results are obtained, monitor BP at least hourly and document. Any dis proportionate rise or fall in BP should be noted immediately to the physician. 5. Closely document changes in skin color or temper ature in the extremities as a monitor for ischemia. Closely document changes in HR, renal output, and signs of reversal of confusion or comatose state as a monitor of drug effectiveness.

Dopamine (Intropin) Drip Rate Calculation Chart Concentration: 1.6 mg/ml (400 mg in 250 ml D5W) Drug Delivery Rate mcg/kg/min lb kg 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 77 35 1 3 4 5 7 8 9 11 12 13 14 16 17 18 20 21 22 24 25 26 88 40 2 3 5 6 8 9 11 12 14 15 17 18 20 21 23 24 26 27 29 30 99 45 2 3 5 7 8 10 12 14 15 17 19 20 22 24 25 27 29 30 32 34 110 50 2 4 6 8 9 11 13 15 17 19 21 23 24 26 28 30 32 34 36 38 121 55 2 4 6 8 10 12 14 17 19 21 23 25 27 29 31 33 35 37 39 41 132 60 2 5 7 9 11 14 16 18 20 23 25 27 29 32 34 36 38 41 43 45 143 65 2 5 7 10 12 15 17 20 22 24 27 29 32 34 37 39 41 44 46 49 154 70 3 5 8 11 13 16 18 21 24 26 29 32 34 37 39 42 45 49 50 53 165 75 3 6 8 11 14 17 20 23 25 28 31 34 37 39 42 45 48 51 53 56 176 80 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60 187 85 3 6 10 13 16 19 22 26 29 32 35 38 41 45 48 51 54 57 61 64 198 90 3 7 10 14 17 20 24 27 30 34 37 41 44 47 51 54 57 61 64 68 208 95 4 7 11 14 18 21 25 29 32 36 39 43 46 50 53 57 61 64 68 71 220 100 4 8 11 15 19 23 26 30 34 38 41 45 49 53 56 60 64 68 71 75 231 105 4 8 12 16 20 24 28 32 35 39 43 47 51 55 59 63 67 71 75 79 240 110 4 8 12 17 21 25 29 33 37 41 45 50 54 58 62 66 70 74 78 83 ml/hr

Date: September 2004 Drug: Epinephrine (Adrenaline) Injection 1. Adjunct in the management of cardiac arrest to restore cardiac rhythm. 2. Conversion of fine, low amplitude fibrillation to a higher amplitude activity before cardioversion. 3. Emergency treatment of severe acute anaphylactic reactions. An epinephrine drip is prepared by adding 1 mg epinephrine to 250 ml D5W or 0.9% NS. Final concentration: 4 mcg/ml. Note: Solutions of double strength (2 mg/250 ml equal to 8 mcg/ml) and triple strength (3 mg/250 ml equal to 12 mcg/ml) may also be prepared. *The maximal concentration recommended at WMC is 10 mg/250 ml equal to 40 mcg/ml). 1. Cardiac arrest a. As bolus of 1 mg IVP; repeat every 3 5 min utes if needed; each dose should be followed by 20 ml NS to ensure drug delivery. b. Epinephrine bolus may be given via endotracheal tube or intracardiacally if there is difficulty in starting IV c. Epinephrine may be infused as a continuous infusion (after bolus) at a rate of 1 4 mcg/min. 2. Severe anaphylactic reaction a. 0.1 0.5 mg SC or IM; if severe anaphylactic shock, give 0.1 0.25 mg slow IVP. b. IV bolus may be followed by a continuous infu sion at a rate of 1 4 mcg/min, if necessary. 1. Epinephrine increases myocardial oxygen demand and should not be used in cardiogenic shock. 2. Epinephrine should not be used in traumatic or hemorrhagic shock. 3. Intracardiac epinephrine injection runs the risk of coronary artery laceration, cardiac tamponade, pneumothorax, and intramyocardial injection of the drug. 4. Epinephrine may cause potentially fatal ventricular arrhythmias including fibrillation; use with care in patients with organic heart disease or those receiving other drugs that sensitize the heart. 5. Extravasation or peripheral ischemia can cause sloughing and necrosis of tissue in the surround ing area. Antidote:The site should be infiltrated with a 10 ml solution containing 5 mg phentol amine (Regitine) within 12 hours of the event; a fine hypodermic needle should be used, obtain a physician s order for the antidote. Skin color should return to normal within one hour if effective. 1. Cardiovascular: Arrhythmias, increased HR, may precipitate angina pectoris, hypertension. 2. May produce a variety of CNS changes. 3. Nausea, vomiting, sweating and respiratory difficulty. Aminophylline Sodium bicarbonate Compatibility Amrinone Labetalol Atracurium Midazolam Diltiazem Nitroglycerin Dobutamine Norepinephrine Dopamine Potassium chloride Heparin Nursing Considerations 1. Consult the epinephrine drip rate calculation chart to determine the drip rate. 2. Except in cardiac arrest situations, epinephrine should be administered via an IV pump to ensure controlled infusion. 3, The patients BP and HR should be monitored every 2 5 minutes until patient is stabilized, then every 15 minutes. 4. Patient should be closely monitored while receiv ing IV epinephrine. Document BP and HR; ob serve and report rate and character (regularity and force) of the pulse. 5. May use regitine protocol for infiltration.

Epinephrine (Adrenalin) Drip Rate Calculation Chart Epinephrine 1 mg/250 ml (Concentration: 4 mcg/ml) Epinephrine 2 mg/250 ml (Concentration: 8 mcg/ml) Infusion Rate Infusion Rate 1 mcg/min 15 ml/hr 1 mcg/min 7.5 ml/hr 1.5 mcg/min 22 ml/hr 1.5 mcg/min 11 ml/hr 2 mcg/min 30 ml/hr 2 mcg/min 15 ml/hr 2.5 mcg/min 37 ml/hr 2.5 mcg/min 19 ml/hr 3 mcg/min 45 ml/hr 3 mcg/min 23 ml/hr 3.5 mcg/min 52 ml/hr 3.5 mcg/min 26 ml/hr 4 mcg/min 60 ml/hr 4 mcg/min 30 ml/hr 5 mcg/min 75 ml/hr 5 mcg/min 38 ml/hr 6 mcg/min 90 ml/hr 6 mcg/min 45 ml/hr 7 mcg/min 105 ml/hr 7 mcg/min 53 ml/hr 8 mcg/min 120 ml/hr 8 mcg/min 60 ml/hr Epinephrine 3 mg/250 ml (Concentration: 12 mcg/ml) Epinephrine 10 mg/250 ml (Concentration: 40 mcg/ml) Infusion Rate Infusion Rate 1 mcg/min 5 ml/hr 1 mcg/min 1.5 ml/hr 1.5 mcg/min 7.5 ml/hr 1.5 mcg/min 2.25 ml/hr 2 mcg/min 10 ml/hr 2 mcg/min 3 ml/hr 2.5 mcg/min 13 ml/hr 2.5 mcg/min 3.75 ml/hr 3 mcg/min 15 ml/hr 3 mcg/min 4.5 ml/hr 3.5 mcg/min 18 ml/hr 3.5 mcg/min 5.25 ml/hr 4 mcg/min 20 ml/hr 4 mcg/min 6 ml/hr 5 mcg/min 25 ml/hr 5 mcg/min 7.5 ml/hr 6 mcg/min 30 ml/hr 6 mcg/min 9 ml/hr 7 mcg/min 35 ml/hr 7 mcg/min 10.5 ml/hr 8 mcg/min 40 ml/hr 8 mcg/min 12 ml/hr

Date: September 2004 Drug: Eptifibatide (Integrilin) 1. A cyclic heptapeptide antagonist of the platelet glycoprotein (GP) lib/iiia receptor, which inhibits platelet aggregation. 2. Integrilin, in combination with heparin, is indicated for the treatment of acute coronary syndromes (e.g., unstable angina, non Q wave Ml), including those patients who are to be managed medically and those undergoing PTCA. 1. Premix vial containing 200mg of eptifibatide in 100 ml of solution. Final concentration: 2 mg/ml. 2. Bolus doses should be withdrawn from the 100 ml vial into a syringe and given undiluted by IV push over 1-2 min. The continuous infusion should be started undiluted directly from the 100 ml premix vial immediately after bolus is given at recommended rate. (See dosing chart.) 3. Discard solution after 24 hours. 1. Acute coronary syndrome. The recommended dose for patients with normal renal function (i.e., creatinine <2) is 180 mcg/kg bolus as soon as possible, followed by 2 mcg/kg/min infusion up to the time of discharge, CABG surgery, or 72 hours. For patients with renal insufficiency (i.e., creati nine 2 4), use 180 mcg/kg bolus and 1 mcg/kg/min infusion. 2. Percutaneous coronary intervention (PCI):The rec ommended dose for patients with normal renal function (i.e., creatinine <2) is 180 mcg/kg bolus and 2 mcg/kg/min infusion. A second bolus of 180 mcg/kg is given 10 minutes after the first bolus. For patients with renal insufficiency (i.e., creatinine 2 4), use 180 mcg/kg bolus and a 1 mcg/kg/min infusion. A second bolus of 180 mcg/kg is repeated after the first bolus. 1. Bleeding is the most common complication encountered during therapy with eptifibatide. 2. Use with caution in patients with platelet count <150,000/mm 3 3. Use with caution in patients with hemorrhagic retinopathy. 4. Caution should be employed when using with other drugs that affect hemostasis. 5. During therapy with eptifibatide, patients should be monitored for potential bleeding. When bleed ing cannot be controlled with pressure, infusion of eptifibatide and heparin should be discontinued. The most common adverse effect is bleeding. Furosemide Compatibility lntegrilin may be infused in the same IV line as atropine, dobutamine, heparin, lidocaine, meperidine, metoprolol, midazolam, morphine, nitroglycerin, TPA, or verapamil. Integrilin is compatible with NS, D5NS, and up to 60 meq/l of KCI. Nursing Considerations 1. Obtain and use WMC Integrilin Protocol. Eptifibatide (Integrilin) Dosing Chart