The Hitchhikers Guide to Parenteral Nutrition Management for Adult
Must maintain guidelines for peripheral lines when Adjusting dextrose concentration in intravenous ... Limit dextrose in TPN to 150 g/day initially.
Dextrose
In peripheral parenteral nutrition solutions the dextrose concentration is centrated dextrose becomes nonfunctional
What is Too Much? A Survey of Pediatric and Neonatal Parenteral
recommends a maximum of 900 mOsm/L for a peripheral line parenteral There was no maximum dextrose concentration for central PNs for 12 hospitals.
Neonatal Parenteral Nutrition
Peripheral PN solutions cannot exceed 12.5% dextrose Maximum is 3 g/kg/d in term infants and 3.5 g/kg/d in preterm infants.
A.S.P.E.N. Clinical Guidelines: Parenteral Nutrition Ordering Order
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Parenteral Nutrition Consultation and Monitoring Service for Adults
MAXIMUM concentration of dextrose will be 10% peripherally and. 35% centrally. 4. At the time of TPN initiation if the patient is not currently on.
Administration of Intravenous Potassium Chloride (KCL) Replacement
normal saline (0.9% sodium chloride) 5% dextrose
Pediatric Guidelines for IV Medication Administration
For peripheral venous administration dilute dextrose to MAX concentration of 12.5%. (1:1 with. NS)preferred. Monitor blood and urine sugar
DEXTROSE injection for intravenous use
Peripheral vein if final dextrose concentration 5% or less and osmolality is less than 900 mOsm/L Limit aluminum to less than 4 mcg/kg/day (5.8
Adult Intravenous Medications Standard and Maximum Allowable
Amiodarone will leach plastic from PVC bag. Maximum daily dose: 2.1 g/day. Peripheral line: Up to 2 mg/mL. (Concentrations over 2 mg/mL administered for.
[PDF] Dextrose - Ashp Publications
Concentrated dextrose should be diluted in compatible parenteral fluids including PN Maximum concentration Peripheral: 12 5 dextrose (except for emergency
[PDF] DEXTROSE injection for intravenous use - Accessdatafdagov
Peripheral vein if final dextrose concentration 5 or less and osmolality is less than 900 mOsm/L Limit aluminum to less than 4 mcg/kg/day (5 8 8 4)
[PDF] 10% Dextrose Injection USP
DESCRIPTION 10 Dextrose Injection USP (concentrated dextrose in water) is a sterile nonpyrogenic hypertonic solution of Dextrose USP in water for
[PDF] What is Too Much? A Survey of Pediatric and Neonatal Parenteral
The maximum dextrose concentration for a central PN ranged from 20- 35 for the other 19 (61 ) hospitals ? Only 12 9 (4/31) of hospitals allow for albumin
Re-evaluating Safe Osmolarity for Peripheral Parenteral Nutrition in
16 août 2021 · Although the accepted maximum glucose concentration for peripheral IV catheters is 12 5 perhaps according to our study results
Glucose infusions into peripheral veins in the - ResearchGate
Recent evidence supports the integrity of peripheral veins with dextrose concentrations as high as 20 No difference in rate of IV loss was noted for infants
[PDF] The Hitchhikers Guide to Parenteral Nutrition Management for Adult
These include the use of Central PN or provision of peripheral protein-sparing IV fluids containing 5 dextrose The anticipated duration of parenteral support
Glucose infusions into peripheral veins in the - Wiley Online Library
1 fév 2010 · A glucose concentration of 15 has generally been regarded as the highest acceptable for use in solutions infused into peripheral veins in
[PDF] ADULT INTRAVENOUS MEDICATIONS
STANDARD AND MAXIMUM ALLOWABLE CONCENTRATIONS GUIDELINES FOR CONTINUOUS OR Peripheral line: Up to 2 mg/mL (Concentrations over 2 BUN glucose
What is the maximum dextrose through a peripheral line?
This requirement means that peripheral PN formulas should contain no more than 5–10% dextrose and 3.5–5% amino acids. Potential complications of peripheral PN include phlebitis, infiltration, or fluid-overload issues.What is the maximum glucose concentration in a peripheral line?
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Use increased volume with caution in infants where volume overload is a concern. Maximal concentration of glucose in peripheral IV is D12. 5. -If infant requires IV dextrose concentrations >12.5%, insert central venous catheter.Can dextrose 20% be given peripherally?
The solution should not be infused into peripheral veins. Prolonged intravenous infusion of this solution may cause thrombophlebitis extending from the site of infusion.- 50% glucose solution is hypertonic and can cause significant irritation to vessels. Initial boluses can be given via large bore peripheral line however if an ongoing infusion is required a central venous line should be placed.
Revised9 8ADULTINTRAVENOUSMEDICATIONSSTANDARDANDMAXIMUMALLOWABLECONCENTRATIONS,GUIDELINESFORCONTINUOUSORTITRATEDINFUSIONSMEDICATIONSTANDARDADMIXTUREMAXIMUMCONC./INFUSIONINSTRUCTIONSDOSINGMONITORING/COMMENTSAdenosine(Adenocard®)SlowsconductiontimethroughtheAVnode,interruptingthere-entrypathwaysthroughtheAVnode,restoringnormalsinusrhythm.Onsetofaction:immediateDuration:seconds6mg 2mLvial(3mg mL)givenundilutedGiveundiluteddirectlyintoveinover1-2seconds.Administerasproximalaspossibletotrunk(i.e.,notinlowerarm,hand,lowerleg,orfoot).IfadministeredthroughIVline,administerasclosetoptsheartaspossible.NSflushmustbegivenrapidly,immediatelyfollowinginjectionofadenosine6mginitially.IfSVTnotresolvedin1-2minutes,mayfollowwith12mgdose.Ifnotresolvedin1-2minutes,mayfollowwithanadditional12mgdose.ECG,heartrate,bloodpressureExtremelyshorthalflife:<1 secondsNoteffectiveforconvertingA.flutter,A.fib,orventriculartachycardia.Contraindicatedifsymptomaticbradycardia,sicksinussyndrome,2ndor3rddegreeAVblock(unlesspt.hasfunctioningpacemaker)Amiodarone(Cordarone®)Antiarrhythmicagentthatdepressesconductionvelocity,slowsAVnodeconduction,raisesthethresholdforVF,andexhibitssomeαandβblockadeactivity.Itpossessesvasodilatoryeffectswhichdecreasecardiacworkloadanddecreasemyocardialoxygendemand.Myocardialuptakeisrapidandanti-arrhythmiceffectsareclinicallyrelevantwithinhours,butfulleffectmaytakedays.Exceptionallylonghalflifeof4 -55daysLoad:Dilute15 mg(3mL)in1 mLD5W(1.5mg mL)(PVCbagsuitableforloadingdose)Maintenanceinfusion:Dilute9 mg(18mL)in5 mLD5W(1.8mg mL)INFUSIONMUSTBEADMIXEDINGLASSBOTTLEORNON-PVCBAG.AmiodaronewillleachplasticfromPVCbagMaximumdailydose:2.1g dayPeripheralline:Upto2mg mL(Concentrationsover2mg mLadministeredforlongerthan1hourmustbeinfusedviacentralline)Centralline:Upto6mg mLLoad:15 mg 1 mLover1 minutes.(Nottoexceed3 mg mL)THENInfusion:1mg minfor6hours(33.3mL hr=36 mg),followedby .5mg minfor18hours(16.6mL hr=54 mg)ACLS:3 mgIVpush,mayrepeatwith15 mgx1.Telemetrymonitoring,BP(hypotensionoccursfrequentlywithinitialrates),HR(arrhythmias:AVblock,bradycardia,VT VF,torsadesdepointes),electrolytesPulmonaryfunctiontestwithin1weekifpossibleThyroidfunctionLiverenzymes(AST ALT)Significantinteractionswithdigoxinandwarfarin(enhanceseffectofeach,↓dose,monitordigoxinlevels,PT INR)*Shadedmedicationsrequireadoublecheck*
MEDICATIONSTANDARDADMIXTUREMAXIMUMCONC./INFUSIONINSTRUCTIONSDOSINGMONITORING/COMMENTSAtropineBlockstheactionofacetylcholineatparasympatheticsitesinsmoothmuscle,secretoryglands,andtheCNS;increasescardiacoutputOnsetofaction:veryrapidDuration:2-3hours1mg 1 mLAbbojectsyringe( .1mg mL)MaybeadministeredwithoutfurtherdilutionAsystole PEA:Nolongerrecommendedper2 1 ACLSguidelinesBradycardia: .5mgIVVitalsignsand orEKGDoses< .5mgmayleadtoparadoxicalbradycardiaBumetanide(Bumex®)Potentloopdiuretic.WorksintheascendingLoopofHenleandproximalrenaltubuletoexcreteH2O,Na+,K+,Cl-Onsetofaction:2-3minutesDuration:4-6hours .25mg mL(2mL,4mL,1 mL)Infusion:12mg 48mL( .25mg mL)PROTECTFROMLIGHTNon-formularyatHHMaybegivenundiluted.NotusuallyaddedtoIVsolutionsbutcompatiblewithD5W,NS,andLRIVpush: .5-1mg doseMayrepeatin2-3hoursInfusion: .25-2mg hrDONOTEXCEED10MG/24HOURS1mgBumex=40mgLasixHR,BP,electrolytes,UOP,CO2,BUN,glucoseRoutineBMPanduricacidchecksnecessaryduringtreatmentCalciumChlorideElectrolyte1g 1 mLAbbojectsyringeMaybeadministeredwithoutfurtherdilution8-16mg kgIVat1 mg min(Typicaldose=1g)Mayrepeatasnecessaryat1 minuteintervalsVitalsignsCentrallinerecommendedCalciumchloridenotrecommendedforusesotherthancardiacresuscitationormanagementofcalciumchannelblockertoxicity.Containsthreetimesmoreelementalcalciumthancalciumgluconate.
MEDICATIONSTANDARDADMIXTUREMAXIMUMCONC./INFUSIONINSTRUCTIONSDOSINGMONITORING/COMMENTSCalciumGluconateElectrolyte1g 1 mL(1 %)Maybeadministeredwithoutfurtherdilutionormaybefurtherdilutedinupto1, mLofNSEmergencyelevationofserumcalcium:15-3 mL(7-14mEq).Repeatin1-3daysperpt.responseHyperkalemia:4.1-3 mL(2.25-14mEq).Mayrepeatin1-2minutesifindicatedasperEKG.Donotexceed2mL/minVitalsigns,EKGRapidadministrationmaycausevasodilation,↓BP,arrhythmias,syncope,orcardiacarrest.Diltiazem(Cardizem®)Non-dihydropyridinecalciumchannelblockerthatblocksCa2+ioninfluxduringdepolarizationofcardiacandvascularsmoothmuscle.ItdecreasesSVRandcausesrelaxationofthevascularsmoothmuscleresultingin↓BP.SlowsconductionthroughtheAVnode,prolongstherefractoryperiod,andreducesventricularrate.DecreasesHRby1 %withasingledose.Bolus:5mg mLvialMaybegivenundilutedthroughY-tubeor3-waystopcockoftubingcontainingNS,D5W,orD5½NSInfusion:Add125mg(25mL)to1 mLD5WorNS(1mg mL)Bolus:NodilutionrequiredInfusion:1mg mLBolus: .25mg kgIV(typicaldose=2 mg)Mayrepeatwith .35mg kgifnoresponseafter15min.(typicalrepeatdose(25mg)Infusion:5-15mg hr(5-15mL hr).Initiateat5mg hr.Maxdose:15mg hrMayonlyusefor24hours↓HR,arrhythmias↓BP,flushing,edemaEKGmonitoringduringinfusionpreferredStoredinrefrigeratorDobutamine(Dobutrex®)Syntheticsympathomimeticcatecholaminethatstimulatestheβreceptorsoftheheart.Positiveinotrope(↑CO,↑contractility,↑CI).ProducesminimalincreasesinrateandBP.Providestheextra"squeeze"inpatientswithcardiacdecompensation.Onsetofaction:1-1 minutesInfusion:5 mg 25 mLD5Wpremixedbag(2, mcg mL)[concentrated1 mg 25 mLavailableifnecessary(4, mcg mL)]Vial:25 mg 2 mL(12.5mg mL)MAX:5mg mL(1,25 mg 25 mL)inD5WorNSPreferablygivenviacentrallineInfusion:2-2 mcg kg minGraduallyadjustrateat2to1 minuteintervals.AHAguidelinesrecommendtitratingsothatHRdoesnotincreaseby>1 %frombaseline.Ifrates>2 -3 mcg kg minrequired,shouldconsideralternateinotropicagent↑HR,↑BPor↓BP(typicallyassociatedwithoverdose)Arrhythmia,myocardialischemia,↑CODecreasedeffectseeninprofoundlyacidoticpatients.
MEDICATIONSTANDARDADMIXTUREMAXIMUMCONC./INFUSIONINSTRUCTIONSDOSINGMONITORING/COMMENTSDopamine(Inotropin®)Catecholamineprecursortonorepinephrinethatactivatesα,β,andDAreceptors.5-1 mcg kg min:renal,mesenteric,coronarydilation1 -2 mcg kg min:increasedcontractility,HR>2 mcg kg min:vasoconstriction,increasedHRandBPOnsetofaction:5minutesInfusion:4 mg 25 mLD5Wpremixedbag(1,6 mcg mL)Vial:2 mg 5mLMAX:6.4mg mL(1,6 mg 25 mL)PreferablygivenviacentrallineInfusion:2.5-2 mcg kg minIfmorethan2 mcg kg minisrequiredtomaintainBP,consideruseofnorepinephrineinaddition↑BP,palpitations,arrhythmias,↑HR,peripheralnecrosiswith↑dosesInfuseviacentrallinetoavoidextravasationFluidresuscitatepts.priortovasopressortherapy.Effectdiminishedinacidosis.Donotadministerthroughsamelineassodiumbicarbonate!Epinephrine(Adrenalin®)Naturalsymmpathomimeticcatecholamine,bothanαandβagonist.Can↑SVR,↑BP(viavasoconstriction).Itisapotentcardiacstimulant(↑HR,↑contraction)anddilatesbronchi1mg 1 mL(1:1 , )Abbojectsyringe1mg 1mL(1:1 )vialInfusion:1mg 25 mLNS(4mcg mL)[concentrated2mg/250mLor4mg/250mLavailableifnecessary)10mg/250mLNS(cardiacarrestinfusion)4mg 25 mLNSorD5W(16mcg mL)Someinstitutionsreporthigherconcentrations,ifneeded(Duke=10mg/250mL)(Lit=30mg/250mL)ACLSBolus:1mg 1 mL(1:1 , syringe)q3-5min[1mg mL(1:1, )mustbedilutedin10mLNSbeforeIVadministration]ACLSinfusion:*30mg/250mLat100mL/hourthentitrate*10mg/250mLat.01-1.2mcg/kg/minVasopressorormaintenanceinfusion:1-1 mcg minRates>10mcg/min,shouldconsideralternateoradditionalvasopressor↑HR,↑BP(monitorBPandHRq5min)Arrhythmias,tremor,anxiety,pulmonaryedema,myocardialischemiaMonitorforsignsofperipheralnecrosis*Shadedmedicationsrequireadoublecheck*
MEDICATIONSTANDARDADMIXTUREMAXIMUMCONC./INFUSIONINSTRUCTIONSDOSINGMONITORING/COMMENTSEptifibatide(Integrilin®)BlocksplateletglycoproteinIIb IIIareceptor,thebindingsiteforfibrinogen,vonWillebrandfactor,andotherligands.Reversiblyblocksplateletaggregationandpreventsthrombosis2 mg 1 mLvial(2, mcg mL)Bolus:Doseadministeredfrom1 mLvial,givenundilutedover1-2minutes***Givewithheparinorlovenox***Bolus:Over1-2minutesInfusion:AdministereddirectlyfromvialMaxbolusdose=22.6mgMaxinfusionrate=15mg hrACSBolus:18 mcg kgadministeredover1-2minutesInfusion:2mcg kg min(maxof15mg hr)RenalDysfunction:IfCrCl<50mL/min,↓infusionto1mcg/kg/min.Platelets,Hgb,SCr,PT aPTTSignsofbleeding-avoidBPcuffs,watchIVsites,monitorforblacktarrystoolsetc.ModifiedCockroft-GaultequationtodetermineCrCl:(140-age/SCr)[x0.85iffemale](thisequationprovidesaroughestimationofCrClinordertodetermineanapproximationofthepatientsrenalfunction)Esmolol(Brevibloc®)Shortactingβ1selectiveadrenergicblocker(mayhavesomeβ2activityathighdoses).Hasantiarrhythmicpropertiesandactsto↓HR,↓BP,and↓contractilityinadose-relatedmanner.UsedforTxofSVTwithRVRorHTNOnsetofaction:2-1 minutes.Durationis1 -3 minutes.Bolus:Maybegivenundiluted***Onlyuse10mg/mLamp***Infusion:2,5 mg 25 mLNSpremixedbag(1 mg mL)2 mg mL(5, mg 25 mL)D5WorNSSVTBolus:5 mcg kgover1minuteInfusion:Startinfusionat5 mcg kg minute.Titratetoresponseq4minuptoamaximumdoseof2 mcg kg minHTNcontrol=upto3 mcg kg min↓HR,↓BP,arrhythmias,CHF,bronchospasm,thrombophlebitisShouldtaperoffslowlyInfuseviacentrallinetopreventextravasationEtomidate(Amidate®)Short-acting,non-barbituratehypnoticwithoutanalgesicactivity.AbletoproducethefullspectrumofCNSdepression,fromlightsleeptocoma.Onsetofaction:6 secondsDuration:~5minutes.2mg mLvialMaybegivenundilutedDosemaybegivenundiluted,administeredover3 -6 seconds .3mg kgPainwithinfusioncommonMyoclonuscommonlyseenMayincreaseEEGactivityinfocalseizuresWillcausetransientadrenalsuppression,usecautioninsepticpatients.*Shadedmedicationsrequireadoublecheck*
MEDICATIONSTANDARDADMIXTUREMAXIMUMCONC./INFUSIONINSTRUCTIONSDOSINGMONITORING/COMMENTSFentanyl(Sublimaze®)OpiumderivednarcoticanalgesicwhichisadescendingCNSdepressant.Approximately1 timesmorepotentthanmorphinemgformg.Hasdefiniterespiratorydepressantactionsthatoutlastitsanalgesiceffects.Onsetofaction:almostimmediateDuration: .5-1hour.Bolus:Smallvolumesmaybegivenundiluted(5 mcg mL)Infusion:1,25 mcg 25 mL(5mcg mL)PCA:1,25 mcg 25mL(5 mcg mL)SeeStandardPCAOrderFormEpidural:2or5mcg mLwithbupivicaine .125%in25 mLNS5 mcg mLundiluteddrugOtherbupivicaineconcentrationsavailableperrequest(e.g., . 625%)TitratetoeffectusingpainscaleorRASSscoreInfusion:25-1 mcg hr↓RR,↓HR,↓BPPainscaleassessmentforanalgesiaRASSscoreforsedationNaloxone(Narcan)isantidoteUsecautioninobesepatients.Fentanyldistributestoadiposetissue,requiringalargerinitialdosetoseeeffect.Durationofeffectwillbegreatlyextendedasdrugisslowlyreleasedfromadiposetissue.Monitorrespiratorystatusclosely.Furosemide(Lasix®)Potentloopdiuretic.WorksintheloopofHenletoexcreteH2 ,Na+,K+,Cl-Onsetofaction:~5minutesDuration:2hoursBolus:1 mg mLundiluteddrugInfusion:1 mg 1 mLNS(1mg mL)ProtectfromlightBolus:1 mg mLMaybefurtherdiluteduponrequestInfusion:1 mg mL(1mg mL)D5WorNS(infusionbagstablefor24hours)TitratetodesiredeffectInfusionrateshouldnotexceed4mg minA1gramdoseshouldinfuseoveratleast3hourstopreventototoxicityHR,BP,electrolytes,UOPOver-diuresismayprecipitateacontractionalkalosisHeparinPotentiatestheactionofantithrombinIII,therebyinactivatingthrombin(aswellasfactorsIX,X,XI,XII,andplasmin).PreventsconversionoffibrinogentofibrinOnsetofaction:almostimmediateInfusion:25, units 5 mLD5W(5 units mL)Preprintedweight-basedformsavailableSeepreprintedweightbasedprotocolsPlatelets,Hgb,aPTTSignsofbleeding-watchIVsites,monitorforblacktarrystools,etcAntidote:Protamine-each1mgwillreverse1 unitsofheparin.*Shadedmedicationsrequireadoublecheck*
MEDICATIONSTANDARDADMIXTUREMAXIMUMCONC./INFUSIONINSTRUCTIONSDOSINGMONITORING/COMMENTSInsulin,Regular(NovolinR®)Pancreatichormoneresponsibleforstorage,metabolism,anduptakeofcarbohydrates,fats,andprotein.Facilitatesentryofglucoseintomuscle,adiposeandothertissues.Onsetofaction:3 minutesVial:1 units mLInfusion:1 units 1 mLNS(1unit mL)1unit mLUsuallydilutedinNSor½NS.AlsocompatiblewithD5WMayadheretoIVtubingInfusion:Titratetodesiredbloodglucosegoals-followprotocolIfptinDKA,pleasetitrateIVF's,notinsulindripHypoglycemia(FSBS)ONLYRegularinsulinmaybegivenIVDonotlowerBGby>1 mg dLperhour.RapidloweringmayleadtocerebraledemaIsoproterenol(Isuprel®)Syntheticsympathomimeticthatstimulatesβ1andβ2receptorsresultinginrelaxationofbronchial,GI,anduterinesmoothmuscle,increasedheartrateandcontractility,andvasodilationofperipheralvasculatureOnsetofaction:immediateDuration:1 -15minutes1mg 25 mLD5W(4mcg mL)2 mcg mLD5WorNSInfusion:2-2 mcg min(Upto3 mcg mininsevereshock)↑HR,arrhythmias,↑or↓BP,flushing,HA,pulmonaryedemaLabetalol(Trandate®)Blocksα,β1,andβ2adrenergicreceptorsites.Decreasesheartrateandperipheralvascularresistance.Ratioofalpha-tobeta-blockadedependsupontherouteofadministration(1:3oralversus1:7IV)Onsetofaction:2-5minutesDuration:2-4hoursBolus:5mg mLundilutedInfusion:2 mg 2 mL(Add200mg[40mL]labetalolto160mLD5W,NS,LR,orD5/NS)Finalconcentration:1mg mLIVBolus:2 mgoveratleast2minutesMaxconcentration:5mg mLBolus:2 mgasinitialdose,mayrepeatwithdosesof4 -8 mgq1 minDonotexceedtotaldoseof300mgInfusion:starting2mg min(2mL min)-8mg mintitratedtoresponse.Donotexceedtotaldoseof300mg.BP-before&5-1 minutesafterinjectionorduringinfusion.Keeppatientsupineandassistwithambulation(posturalhypotension)Ascumulativedosenears3 mgIV,durationofactionextendstonearly18hours.*Shadedmedicationsrequireadoublecheck*
MEDICATIONSTANDARDADMIXTUREMAXIMUMCONC./INFUSIONINSTRUCTIONSDOSINGMONITORING/COMMENTSLidocaineLocalanestheticandclassIbantiarrhythmic.Suppressesautomaticityofconductiontissuebyincreasingtheelectricalstimulationthresholdoftheventricle.Withusualtherapeuticdosesdoesnotchangemyocardialcontractility,systemicarterialpressure,orabsoluterefractoryperiod.Onsetofaction:2minutesDuration:1 -2 minutes(halflifeincreaseswithrepeatdosing)Bolus:1 mg 5mLAbbojectsyringe(2%)Infusion:2, mg 5 mLD5W(4mg mL)premadebag(Concentrated4,000mg/500mLavailableifnecessary)8mg mLinD5WBolus:1-1.5mg kg(avg.5 -1 mg)Infuseover2-3minutes.Mayrepeatbolusdosein3-5minutestoamaxof3dosesInfusion:Withreturnofperfusion,initiateat1-4mg min.Donotexceed4mg/min.Decreasedoseby5 %forCHF,impairedliverfunction,elderly,useofdrugsthatmaydecreasehepaticclearanceoflidocaine(e.g.,betablockers),shockMonitorEKGcontinuouslyMonitorHR,BP,CNSeffects(confusion,nervousness,seizure),cardiovascularcollapse,arrhythmiasLidocainelevels(ifmaintainedonlidocainedrip,woulddrawlevel12hoursafterinitiatingdripthenq24hthereafter)ACLSnote:Ifpt.hasreceivedamiodarone,thereisnoevidencesupportingtheuseofconcurrentlidocaine.OnceanantiarrhythmicagenthasbeenchosenpertheACLSalgorithm,needtostaywiththatagent.MagnesiumElectrolyte1gm 5 mLD5W2gm 1 mLD5W4gm 1 mLD5W1gm hrCasebased(suggesteddoses):1.5-2. :give2gTRO2hrs1. -1.5:give4gTRO4hrs<1. :give8gTRO8hrs↓BPMglevelsMidazolam(Versed®)Shortactingbenzodiazepinewithsedative,anxiolytic,andamnesticproperties.Threetofourtimesaspotentasdiazepam.Onsetofaction:1-5minutesDuration:average2hours1 mg mLNSpre-madebag(1mg mL)1mg mLTitratetoeffectusingRASSRSIinduction: .2- .3mg kgInfusion:Initially1-7mg hr,thentitrateaccordingtoRASSUselowerinitialdoseifreceivingconcurrentsedatives analgesics↓RR,↓BP,↓HRDrowsiness,impairedmemoryorcoordination,agitation(paradoxical)Flumazenil(Romazicon)isantidotebutitsuseisstronglydiscouraged,especiallyifpt.hasah obenzouseorSzhistory.MayprecipitateseizuresviairreversiblebindingofBZDreceptors(GABA)-Duration~1hr*Shadedmedicationsrequireadoublecheck*
MEDICATIONSTANDARDADMIXTUREMAXIMUMCONC./INFUSIONINSTRUCTIONSDOSINGMONITORING/COMMENTSMorphineOpium-derivednarcoticanalgesic,CNSdepressant,respiratorydepressant.Relievespulmonarycongestion,reducesmyocardialoxygendemand,andreducesanxiety.Onsetofaction:AlmostimmediateDuration:Averageof2hoursBolus:maybegivenundilutedInfusion:1 mg mLinD5W(1mg mL)PCA:3 mg 3 mL(1mg mL)SeestandardPCAorderformUsually1mg mLBolus:average2.5-15mg.Repeatq2-4hasneededRecommendlowerinitialdoseforrenalorhepaticdysfunctionandinelderly.Infusion:TitratetoeffectusingpainscaleorRASS↓BP,↓RR,HR,GIeffects(constipation)Painscaleassessmentforanalgesia.ActivemetaboliteMorphine-6-Glucuronideaccumulatesinrenaldysfunction.Naloxone(Narcan)isantidoteNaloxone(Narcan®)Pureopioidantagonistthatcompetesanddisplacesnarcoticsatopioidreceptors.Onsetofaction:~2minutesDuration:3 -45minutes(upto2hoursifgivenIM)Maybegivenundiluted,dilutedwithSWforinjection,orfurtherdilutedinNSorD5Wandgivenasaninfusion.Infusion:2mg 5 mLNSorD5W( . 4mcg mL[4mcg mL])1mg mLNarcoticoverdose: .4-2mg.Mayrepeatin2-3minutesifindicated.Typicallystartwithlowerdosethenincreaseasneeded.(Mayinitiatewith .1mginpatientswithknownopioiddependencetopreventwithdrawalreaction)Opioidinducedpruritis: .25mcg kg min.MonitorpaincontroltoensurenaloxoneisnotreversinganalgesiaRR,HR,BP,temp,levelofconsciousness,O2satMonitorforwithdrawalsymptomsIneffectiveagainstrespiratorydepressioncausedbybarbiturates,anesthetics,othernon-narcoticagents,orpathologicalconditionsNesiritide(Natrecor®)RecombinanthumanBNP,dilatesveins&arteries.ProducesdosedependentdecreaseinPCWP&systemicarterialpressure.UsedfortreatmentofacutelydecompensatedCHFinptswithdyspneaatrestorwithminimalactivityOnsetofaction:15minutesDuration:>6 minutes(uptoseveralhours)1.5mgin25 mLD5WorNS(6mcg mL)[reconstitutevialwith5mLgentlyrollingvialinhandtodilute.DONOTSHAKE]6mcg mLBolus:2mcg kgover1minute(withdrawbolusfromthepreparedinfusionbag)Infusion: . 1mcg kg minBP(maylastforhours)UOP,renalfunctionContinuoustelemonitoringPCWP
MEDICATIONSTANDARDADMIXTUREMAXIMUMCONC./INFUSIONINSTRUCTIONSDOSINGMONITORING/COMMENTSNicardipine(Cardene®)Dihydropyridinecalciumchannelblocker.Causescoronaryandperipheralbloodvesseldilationleadingto↓SVR,↑CO,↑coronarybloodflow,andmyocardialoxygensupplywithoutincreasingcardiacoxygendemand.Onsetofaction:1 minutesDuration:<8hours25mg 25 mLD5WorNS( .1mg mL)(withdraw1 mLfrom25 mLbagpriortoadditionofnicardipinefor .1mg mLfinalconcentration) .1 mg mLIfinfusedperipherally,changeIVsiteQ12hInfusion:5mg hr(5 mL hr)Increaserateby2.5mg hrevery5-15minutesuptomaxof15mg hrConsiderreducingto3mg hrformaintenanceBP,HRHA,nausea vomitingNitroglycerinCausesrelaxationofsmoothmuscle,producingavasodilatoreffectontheperipheralveinsandarterieswithmoreprominenteffectsontheveins.Primarilyreducescardiacoxygendemandbydecreasingpreload.Maymodestlyreduceafterload.DilatescoronaryarteriesandimprovescollateralflowtoischemicregionsOnsetofaction:ImmediateDuration:3-5minutes5 mg 25 mLD5W(2 mcg mL)Pre-mixedinglassbottleStartwith5mcg minthenincreaseby5mcg minQ3-5minuntildesiredresponseobtained.Ifnotresponseat2 mcg min,mayincreaseby1 mcg min.NofixedmaximumdoseTolerancemaydevelopafter12-24hours,requiringnitratefreeperiodUnstableanginaorCHFassociatedwithMI:1 -2 mcg minandincreaseby1 -2 mcg minuntildesiredeffect.Mayneedbolusof12.5to25mcg.NeednitrofreeperiodforeffecttolastUSEEXTREMECAUTIONINPTSWITHRIGHTVENTRICULARINFARCT(theseptsareextremelysensitivetoeffectsofnitroglycerine.UsemaycauseaprecipitousdropinBP)Monitor:BP,HR,HAFlushing,posturalhypotension,reflextachycardia,dizzinessMethemoglobinemiaAntidote:Decreaserate,elevatefootofbed,IVfluids,oxygen,epinephrineNitroprusside(Nitropress®)Potent,rapidactingantihypertensive.Causesperipheralvasodilationbydirectactiononvenousandarteriolarsmoothmuscle,thusreducingperipheralresistance.DecreasesBPandSVR,butwill↑COandmay↑HR.MetabolizedinRBCstocyanide,theninthelivertothiocyanate.Liverorkidneydysfunctioncanaffectmetabolismandelimination.Onsetofaction:<2minDuration:1-1 minutes5 mg 25 mLD5W(2 mcg mL)PROTECTFROMLIGHTSolutionwillhaveafaintbrownishtint.Discardsolutionifhighlycolored,blue,green,ordarkred1 mg 25 mLD5W(4 mcg mL)Infusion: .1-5mcg kg minAHArecommendsstartingwith .1mcg kg min,thengraduallytitratingevery2-3minutes.SmalladjustmentscanleadtomajorfluctuationsinBP.Doses>3mcg kg minrarelyneeded.Donotexceed10mcg/kg/minHR,↓BP,flushing,HARenalfunctionHepaticFunctionCyanide,thiocyanate,ormethemoglobinlevelsforprolongeduseorsuspectedtoxicity.Donotuseinrenalfailure-RiskofcyanidetoxicityDONOTUSEINNEUROLOGICINJURY(trauma,stroke,etc.).Willleadto↑CBF,causing↑ICPwhichmayleadtosecondaryinfarct*Shadedmedicationsrequireadoublecheck*
MEDICATIONSTANDARDADMIXTUREMAXIMUMCONC./INFUSIONINSTRUCTIONSDOSINGMONITORING/COMMENTSNorepinephrine(Levophed®)Naturalsympathomimeticcatecholamine,α1,andβ1agonist.Causesperipheralvasoconstriction,stimulatescardiaccontractilityanddilatescoronaryarteries.↑HRand↑SVR.Onsetofaction:veryrapidDuration:1-2minutes4mg 25 mLD5W(16mcg mL)NSalonenotrecommendedduetolossofpotencyfromoxidation8-16mg 25 mLD5W(32-64mcg mL)Infuseviacentrallinetoavoidextravasation .5-3 mcg minInitiateatlowerdoses,thentitratetoeffectRates>3 mcg min,shouldconsideradditionaloralternativevasopressor↑HR,arrhythmias,↑BP,HA,↑SVR,↑PCWP,↓renalbloodflowAcidosiswillgreatlydiminisheffect.Octreotide(Sandostatin®)Somatostatinanalog,suppressesserotoninsecretion,growthhormone,andothergastro-pancreaticpeptides(insulin,gastrin,glucagon,etc.).StimulatesfluidandelectrolyteabsorptionfromtheGItractandprolongstransittime.Onsetofaction:6-12hoursBolus:5 mcg mLMaybegivenundilutedInfusion:5 mcg 1 mLNS(5mcg mL)1 mcg mLinNSorD5WbagorglassBolus:5 -1 mcgover3minutes(undiluted)Antidiarrheal(AIDS):initial1 mcg,followedbyinfusionof1 -1 mcg hrGIBleed:Loadingdoseof5 -1 mcgfollowedwithacontinuousinfusionof25-5 mcg hrfor72to96hoursGlucose,GIeffects,HA,LFTsPancuronium(Pavulon®)Nondepolarizingneuromuscularblockingagent.Blocksneuraltransmissionatthemyoneuraljunctionbybindingwithcholinergicreceptorsites.Onsetofaction:2-3minutesDuration:Dosedependent,6 -1 minutesBolus1mg mLMaybegivenundilutedInfusion:1 mg 1 mLundiluted(1mg mL)1mg mLInmanufacturer'sdiluentsBolus: . 4- .1mg kgover1minuteInfusion: . 6- .1mg kg hr(1-1.7mcg kg min)TitratetoeffectTrain-of-four&RASSscalemonitoringbynursing.Vagolytic-willincreaseheartrate.Notrecommendedinptsw cardiovasculardiseaseRenalfunction:IfCreatinineclearance<5 mL min,use5 %ofdose*Shadedmedicationsrequireadoublecheck*
MEDICATIONSTANDARDADMIXTUREMAXIMUMCONC./INFUSIONINSTRUCTIONSDOSINGMONITORING/COMMENTSPantoprazole(Protonix®)Protonpumpinhibitorthatsuppressesgastricacidproduction.Inhibitsbothbasalandstimulatedgastricacidsecretion.Bolus:8 mg 1 mLNSWithdraw2 mLfrom1 mLNSbag,reconstitutingeach4 mgvialwith1 mL.( .8mg mL)Infusion:4 mg 1 mLNStorunover5hrs(8mg hr)Stablefor12hoursGIbleed:8 mgbolusover15minutes,followedbycontinuousinfusionof8mg hrx72hoursStressulcerprophylaxis GERD:Infuse4 mgover15minutesRash,infusionsitereactionsAnaphylaxishasbeenreported72hourinfusiononlyindicatedforactiveGIbleeds.Notindicatedforvaricealbleed!Converttooraltherapywhen ifappropriatePhenylephrine(Neosynephrine®)Syntheticsympathomimeticactingprimarilyonαadrenergicreceptors.Causespotentvasoconstriction,lackschronotropicorinotropicproperties,↓HR.]1 mg 25 mlinNSorD5W(4 mcg ml)4 mg 25 mlinNSorD5W(16 mcg ml)Someinstitutionsreportupto4 mcg ml(1 mg 25 ml)Infuseviacentrallinetoavoidextravasation.Bolus: .1to .5mg doseevery1 to15minutesInfusion:1 to18 mcg mininitially,then4 to6 mcg minmaintenancerate.↓HR,↑BP,HA,arrhythmiasPotassiumChlorideelectrolyte1 mEq 1 mlUSEPRE-MIXEDIVPBsPERPROTOCOLMAXIMUMINFUSIONRATE:1 mEq hrMAXCONC:4 mEq 1 mlCasebasedRateofInfusion:Notfasterthan1 mEq hrSerumPotassiumLevelTachycardia,arrhythmia,muscleaches,GIupset.RenalfunctionPropofol (Diprivan®) Potent, emulsified, sedative-hypnotic agent. Can provide conscious or unconscious sedation, depending on dose. Onset of action is rapid, as is recovery after discontinuation. Minimal impact on cardiac parameters. 1 mg 1 mlglassbottle(1 mg ml)1 %Lipidemulsion=1.1Kcal ml1 mg mlundiluteddrugInfusion:5-1 mcg kg minTitrateslowlyq5-1 minby5-1 mcg kg minincrementstodesiredsedationInitialRate:5mcg/kg/min↓BP,↓HR,Triglycerides:Q3daysLipidprofileVentilationstatus,RASSscoreMayturnurinegreenDonotexceed75mcg kg hr-increasesriskofpropofolinfusionsyndrome*Shadedmedicationsrequireadoublecheck*
MEDICATION STANDARDADMIXTUREMAXIMUMCONC./INFUSIONINSTRUCTIONSDOSINGMONITORING/COMMENTSVasopressin(Pitressin®)Increasescyclicadenosinemonophosphate(cAMP)whichincreaseswaterpermeabilityattherenaltubuleresultingindecreasedurinevolumeandincreasedosmolality;Atgreaterthanphysiologicdoses,vasopressinhasapressoreffectduetovasoconstrictionandcausescontractionofthesmoothmuscleofthegastrointestinaltractVial:2 units mlInfusion:5 units 5 mlNS(1unit ml)IfgivenperIVInfusion,usecentrallineVasopressor Sepsis: . 4units min(2.4units/hr-DONOTTITRATE)DiabetesInsipidus:5-1 units2-3timesdailySCorIMACLS:4 unitsIVsingledoseBPSerumandUrineOsmolaritySerumandUrineSodiumConcentrationSerumElectrolytesMaintainsgoodeffectinacidosisVecuronium(Norcuron®)Nondepolarizingneuromuscularblockingagentwithrapidonsetandintermediatedurationofaction.Bolus:Diluteto2mg mlwithSterileWaterInfusion:1 mg 1 mlNS(1mg ml) .1-1mg mlinNSorD5WBolus: . 8- .1mg kgInfusion: . 5- .1mg kg hrTitratetoeffectTrain-of-FourandRASSscalemonitoringbynursing.Ptmustbeintubated&sedatedRenalfunctionLiverfunction
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