Adult IV Push/Infusion Guidelines for Select Medications

ADULT IV PUSH/INFUSION GUIDELINES FOR SELECT MEDICATIONS

Approved by P&T: 4/25/2019

The ADULT IV Administration Guidelines are for commonly administered parenteral medications used in the Clinical Center (CC). These guidelines are not inclusive of all medications used in the CC and are meant to be used as a guide only. Nursing judgment and physician orders should be followed.

MONITORING PARAMETERS (medications may require one or more types of monitoring listed below):

No special monitoring required

Vital sign monitoring: blood pressure, oxygen saturation, heart rate, and/or respiratory rate Vital sign recommendations are guidelines only. Nursing judgment and LIP orders should be followed

Cardiac monitoring in the form of: Telemetry ? central cardiac monitoring with oversight provided by a registered nurse o Units with telemetry: 1NW, 3NW, 5SES, 5NES, 3SWS, 3SWN-IMC o Note, staff with knowledge of using telemetry equipment must be present on the unit. If staff are not available, the patient may need to be relocated to a unit with both monitoring equipment and staff with expertise. Bedside ? direct observation of cardiac rhythm is made by a nurse and/or LIP while a drug is being administered o Bedside monitoring capability is available on 1NW, 5NES, 5SE, 3SWS, and 3SWN-IMC Critical Care Monitoring ? direct intensive observation by Nursing or LIP

Ventilatory support ? authorization to administer these drugs is restricted to credentialed anesthesiologists and CCMD physicians

DEFINITIONS:

Ordered by: Refers to order entered in electronic health record by the individual specified in the guidelines. Course of therapy: A course of therapy is defined as a continuous use of the drug without any breaks in therapy. Unit: location in which drug can be administered.

NOTE:

ACLS medications may be administered in all hospital locations by Code Team members. Even if not specifically denoted below, medications may be administered in the OR pursuant to LIP directives. When the Special Clinical Studies Unit (SCSU)/5NES is under special respiratory isolation (SRI) precautions, this unit may function as an ICU and, therefore, all ICU medications may be given per these guidelines.

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ADULT IV PUSH/INFUSION GUIDELINES FOR SELECT MEDICATIONS

Drug Name

Location(s)

Dosing

Administration Guidelines

Abciximab

ICU, 5SE PCI dosing

Bolus dose

Bolus dose

IV push rate: over 1 minute

0.25 mg/kg IV push 10 - 60 minutes before start of PCI

Maintenance dose

0.125 mcg/kg/min continuous IV infusion (maximum: 10 mcg/min) for 12 ? 24 hours

AcetaZOLAMIDE Adenosine

All units All units

Edema: 250 ? 375 mg or 5 mg/kg daily x 1-2 days

Urinary alkalinization (adults): 5 mg/kg/dose q 812 hours Initial dose: 6 mg IV push *initial dose should be reduced to 3 mg if patient is on carbamazepine or dipyridamole, has a transplanted heart, or if adenosine is given via central line

Repeat dose: 12 mg IV push if SVT not eliminated within 1 - 2 minutes. May repeat 12 mg IV push x 1.

Maximum single recommended dose: 12 mg Higher doses may be used if situation warrants

IV Push: Administer as a direct bolus over at least 1 minute (100-500 mg/min).

IV Infusion: administer over 15-30 minutes. IV push rate: over 1 ? 2 seconds

Administer in closest port to insertion site of IV line.

Flush each dose rapidly with 20 mL NS

Monitoring Parameters Vital signs every 15 minutes x 4, every 30 minutes x 2, then every 1 hour or per patient's condition

AND Telemetry

No special monitoring required

Approved by P&T: 4/25/2019

Comments/Precautions

Ordered by NIH cardiovascular catheterization laboratory and maintained per post procedure orders

Do not use in unstable angina / non ST elevation MI when early invasive management strategy not planned (Anderson, 2011)

Do not shake Inspect drug for particles before administering Filter with nonpyrogenic low protein binding 0.2 or

5 micron syringe filter when preparing drug Monitor patient for any potential bleeding Platelet counts should be monitored prior to

treatment, two to four hours following the bolus, and at 24 hours or prior to discharge, whichever is first

? Avoid use in patients with a CrCl lessthan10 mL/min (ineffective) ? Monitor baseline and periodic CBC, electrolytes

Vital signs before, 5 minutes and 30 May only be administered by Cardiology or CCMD

minutes after dose

ACLS Provider

May cause several seconds of asystole

AND

Printout of rhythm data at time of conversion is

important diagnostic information. Please make

Bedside monitor during administration

efforts to obtain if feasible.

and for 30 minutes after dose, then

Caution in patients with asthma or obstructive

telemetry.

lung disease

AND

Avoid use in antidromic AVRT and patients with

(If possible) Rhythm strip capture and printing capability (EKG or LifePak) at time of administration to capture conversion.

AF if suspicion of WPW Drug interactions

o methylxanthines (caffeine, theophylline): antagonize effect of adenosine

o dipyridamole: potentiate effect of adenosine

o Carbamazepine: increases degree of heart

block

o Beta blockers, non-dihydropyridine calcium

channel blockers (diltiazem, verapamil),

digoxin , or quinidine: additive or synergistic

depressant effects on SA and AV nodes

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ADULT IV PUSH/INFUSION GUIDELINES FOR SELECT MEDICATIONS

Drug Name

Location(s)

Dosing

Administration Guidelines

Monitoring Parameters

Albumin Alteplase

Aminocaproic acid

All units

Variable dosing, dependent on patient condition

Initial dose: 12.5 to 25 g IV; may repeat in 15 to 30 minutes if needed

Maximum dose: 6 g/kg/24hr

ICU, OR, 5SE Acute Ischemic Stroke: 0.9 mg/kg (max total dose: 90 mg) o Patients 100 kg: o Bolus:9 mg o Maintenance: 81mg

Pulmonary Embolism: o 100 mg IV infusion

STEMI: Accelerated regimen (weight-based) o 100 mg over 1.5 hours

All units

Loading dose: 4 ? 5 g for first hour followed by 1 g/hour for 8 hours (max daily dose: 30 g)

Albumin may be given as rapidly as tolerated in shock

Vital sign monitoring

Non-shock states: Albumin 5%:

o Patients with normal plasma volume: max rate of 4 mL/min

o Patients with hypoproteinemia: max rate of 10 mL/min

Albumin 25%: o Patients with normal plasma volume: max rate of 1 mL/min o Patients with hypoproteinemia: max rate of 3 mL/min Telemetry

Acute Ischemic Stroke: Administer bolus over 1 minute Administer maintenance infusion over 60 min

Pulmonary Embolism: If stable, administer 100mg dose over 2 hours May be administered faster if in cardiac arrest

STEMI: Accelerated IV infusion over 1.5 hours Patients over 67 kg:

15 mg IV bolus over 1-2 minutes, then

50 mg infusion over 30 minutes, then 35 mg infusion over 1 hour Patients under 67 kg 15 mg IV bolus over 1-2 minutes,

then 0.75 mg/kg infusion over 30 min,

then 0.5 mg/kg infusion over 1 hour

IV push: do not administer as IV push

No special monitoring required

Loading Dose: may administer loading dose over 15-60 minutes depending on indication

Approved by P&T: 4/25/2019 Comments/Precautions

Use with caution in patients with hepatic and renal insufficiency

Administration must be completed 4 hours after the vial has been spiked.

For treatment of acute ischemic stroke, perform noncontrast-enhanced CT or MRI prior to administration

Initiation of anticoagulants or antiplatelets within 24 hours after starting alteplase is not recommended

For treatment of PE, resume parenteral anticoagulation near the end of or immediately following the alteplase infusion when the aPTT returns to twice normal or less

Use caution in patients with renal insufficiency; drug may accumulate

Do not co-administer with factor IX complex concentrates or anti-inhibitor coagulant complexes

Monitor CPK; discontinue treatment if increase in CPK occurs

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ADULT IV PUSH/INFUSION GUIDELINES FOR SELECT MEDICATIONS

Approved by P&T: 4/25/2019

Drug Name

Location(s)

Dosing

Administration Guidelines

Monitoring Parameters

Comments/Precautions

Amiodarone

Arginine 10% Antithymocyte Globulin (Equine) [ATGAM]

ICU, 5SE

5NW, 1NW, ICU

1NW, 3NW, 3NE, 3SEN, ICU

Atrial arrhythmia and stable ventricular

Loading dose

Vital signs on initiation, every 15

tachycardia dosing Loading dose

Amiodarone 150 mg in 100 mL D5W IV over 10 minutes

150 mg IV bolus

Maintenance dose

Maintenance dose

1 mg/min for 6 hours, then 0.5 mg/min continuous

IV infusion x 18 hours. May continue longer if

clinical situation warrants

Amiodarone 900 mg in 500 mL D5W (Final concentration 1.8 mg/mL) 1 mg/min = 33 mL/h 0.5 mg/min = 16.7 mL/h

minutes x 4, every 30 minutes x 2, every 1 hour x 4 or until stable, then

every 4 hours

Currently infusing: routine vital signs

AND

On initiation of loading dose: bedside

monitoring, then telemetry

Usual dosing: up to 30 g as a single dose

IV Push: Do not administer as IV Push

Vital sign monitoring

IV infusion: Administer over 30 min

*For hyperammonemia associated with urea

cycle disorders, give loading dose over 90-

120 min; maintenance dose should not

exceed 150 mg/kg/h

IV infusion: 5 to 40 mg/kg/dose over a minimum of 4 IV infusion: hours (range 4-24 hours)

First infusion: Vital signs prior to start of infusion, then every 15

Day 1 initial infusion rate: Start at a rate that is 10% or less of total infusion volume per hour for the first 15 minutes. If tolerated, advance rate. (e.g. a 500 mL bottle will start at 50 mL/h)

minutes x 4, then every 30 minutes x

2, then every hour until infusion

completed.

o RN will remain with patient during the first 15 minutes of the initial dose to monitor for

adverse reaction.

o

LIP will remain on the patient care unit during the first 15

minutes of the initial dose.

Subsequent infusions: Vital signs prior to start of infusion, then 30

minutes after initiating infusion, then

every hour until infusion complete.

In non-ICU areas, must be ordered by Cardiology or CCMD LIP If patient is on greater than maintenance dose for extended period of time, consider an ICU consult Hold infusion for symptomatic bradycardia; call LIP Use 0.2 micron in-line filter and PVC tubing Concentrations > 2 mg/mL should be administered through a central line If required for maintenance treatment, consider starting oral amiodarone at least 24 hours before discontinuing infusion

Administer undiluted Drug is a vesicant; if extravasation occurs, stop infusion immediately and notify LIP Used for increased levels of ammonia and for stimulation of growth hormone

Refer to Nursing SOP regarding the care of the patient receiving ATG: Administration through a high-flow central vein is recommended to minimize phlebitis and thrombosis. Prepared dose should be diluted prior to administration with concentrations not to exceed 4 mg/mL. Administer pre-medication (e.g. acetaminophen and diphenhydramine) 30 minutes prior to start of infusion. Infuse through a 0.2 to 1 micron in-line filter Emergency medications should be readily available due to high incidence of infusion-related toxicities. Patient may not leave patient care unit during ATG infusion unless accompanied by RN. Avoid administration within 2 hours (before or after) of blood products or amphotericin B formulations without approval or order from LIP.

Atropine

All units

Bradycardia dosing 0.5 mg IV push every 3 ? 5 minutes Maximum dose 3 mg (0.04 mg/kg)

IV push: administer undiluted by rapid IV push slow injection may cause paradoxical

bradycardia

Vital signs every 15 minutes x 4, every

30 minutes x 2, then every 1 hour until

stable

AND Bedside monitor for first ten minutes then telemetry

Minimum dose is 0.5 mg; lower doses may cause paradoxical bradycardia Caution in patients with acute coronary ischemia or myocardial infarction and heart failure patients

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ADULT IV PUSH/INFUSION GUIDELINES FOR SELECT MEDICATIONS

Drug Name

Location(s)

Dosing

Administration Guidelines

Bumetanide

All units

Usual dose: 0.5 - 1 mg, may be repeated at 2-3 hour IV push: give undiluted over 1-2 minutes. intervals (Max dose: 10 mg/day)

Monitoring Parameters No special monitoring required

Calcitriol Calcium chloride

5NW, ICU All units

Hypocalcemia (dialysis):

IV push: may be given undiluted as a bolus dose No special monitoring required

1 ? 2 mcg three times a week

into the venous line at the end of hemodialysis.

Adjust dose by 0.5 to 1 mcg at 2 to 4 week

intervals (range: 0.5 to 4 mcg three times weekly)

IV push: 0.5 to 1 g; may repeat as necessary

IV push: maximum rate of 100 mg/min

Telemetry

except in emergency situations IV infusion for beta-blocker or calcium channel

blocker overdose: 20 to 50 mg/kg/h (10% solution) IV infusion: infuse diluted solution over 1

hour or maximum of 90 mg/kg/h

Calcium gluconate Chlorothiazide

IV push IV push: 0.5 to 2 g

only in

5NW and IV infusion:

ICU

o Mild hypocalcemia: 1 to 2 g over 2 hours

Infusion

o Moderate to severe hypocalcemia: 4 g over 4

in all

hours

units

All units

Usual dosing: 0.5 g to 1 g once or twice daily

IV push: maximum rate 200 mg/min in adults Telemetry

IV infusion: adjust rate as needed based on serum calcium levels

AND Beside monitor required on 5NW

Administer by slow IV push or infusion

No special monitoring required

Cisatracurium Dexmedetomidine

DiazePAM Digoxin

ICU, OR ICU, OR

All units All units

Bolus: 0.15 to 0.2 mg/kg IV push

IV push: over 5 to 10 seconds

Ventilatory support

Maintenance: initial rate of 1 to 3 mcg/kg/min continuous IV infusion

Loading infusion dose: 1 mcg/kg Maintenance infusion dose: 0.2 to 1.5 mcg/kg/h

IV infusion: continuous infusion via infusion pump

Loading dose rate: administer over 10 minutes

Vital sign monitoring (may cause bradycardia and hypotension)

Usual dose: 2 to 10 mg; may repeat in 3-4 hours if needed

Maintenance infusion: adjust rate no more than every 30 minutes to desired sedation level

IV push: administer undiluted as slow IV push (max rate of 5 mg/min)

Vital sign monitoring

IV infusion: Do not administer as infusion

Usual loading dose: 0.25 ? 0.5 mg bolus; may repeat IV Push: ICU Only

0.25 mg bolus every 6-8 hours up to maximum of 1

mg/day

IV Infusion (preferred): Administer over 5

to 15 minutes

Usual maintenance dose: 0.0625 - 0.25 mg daily

Vital sign monitoring for infusion Telemetry for IV Push

Approved by P&T: 4/25/2019 Comments/Precautions

1 mg : 40 mg ratio (bumetanide to furosemide) May affect serum electrolytes and renal function Monitor blood pressure and fluid status Monitor serum Ca, PO4

IV push over 2-5 minutes by Code Team ACLS provider during cardiac arrest

IV push over 10 minutes by LIP for emergency treatment of hypocalcemia or hyperkalemia

Administration via central line is preferred Stop the infusion immediately if the patient

complains of pain or discomfort IV push during cardiac arrest by Code Team ACLS

provider or by LIP for emergency treatment of hypocalcemia or hyperkalemia

Monitor serum electrolytes Ineffective with CrCl less than 30 mL/min unless used

in combination with a loop diuretic Do not use if CrCl less than 10 mL/min For infusion, titrate to Train of Four

At recommended doses, dexmedetomidine does not provide adequate and reliable amnesia; therefore, use of additional agents (eg, benzodiazepines) may be necessary

Do not mix or dilute with other solutions or drugs

Short stability once diluted Check product for visible precipitate before

administration; do not use if present Adjust dosing based on renal function

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