Intravenous Medication Administration Guidelines Drug  Usual Dose Range* Standard Dilution Maximum Concentration Adjust for Renal or Hepatic Failure Infusion Times/ Comments/ Drug Interactions Central Nervous System Agents Anticonvulsants Fosphenytoin Status epilepticus loading dose:   Nonemergent loading and maintenance dose:   Initial daily maintenance dose:   IM/IV substitution for oral phenytoin therapy:      15-20 mg PE/kg   10-20 mg PE/kg       4-6 mg PE/kg/d     Substitute with same total daily dose Dilute to a final concentration from 1.5 to 25 mg PE/ml with D5W or 0.9% NaCl 25 mg PE/ml Renal: no Hepatic: no Fosphenytoin 75 mg/ml = phenytoin 50 mg/ml Infusion rate 100-150 mg PE/min Continuous monitoring of ECG, BP, respiration Peak phenytoin levels occur approximately 2 h after end of infusion Should not be administered IM for the treatment of status epilepticus. Pentobarbital Bolus dose: 20 mg/kg 100 ml (0.9% NaCl) 20 mg/ml Renal: no Hepatic: no Infuse over 2 h Infusion dose: 1 mg/kg/h initially, then 0.5-3.5 mg/kg/h 250 ml (0.9% NaCl) 10 mg/ml Renal: no Hepatic: yes Therapeutic levels: 20-50 mg/L Phenobarbital 20 mg/kg Undiluted 130 mg/ml Renal: no Hepatic: yes Maximum infusion rate 50 mg/min Therapeutic levels: 15-40 mg/L Phenytoin 15-20 mg/kg Undiluted 50 mg/ml Renal: no Hepatic: yes Maximum infusion rate 25 to 25 mg/min. Doses greater than 300mg and/or rate of 50 mg/min require continuous monitoring of ECG, BP, respiration. Therapeutic levels: 10-20 mg/L. Benzodiazepines Diazepam 2.5-10 mg q2-4h Undiluted 5 mg/ml Renal: no Hepatic: yes Inject at 2-5 mg/min Lorazepam Bolus dose: 0.5-2 mg q1-4h Undiluted 1 mg/ml Renal: no Hepatic: no Inject 2 mg/min Dilute 1:1 with 0.9% NaCl before administration Infusion dose: 0.02-0.1 mg/kg/h 20-40 mg in 250 ml (D5W) 2 mg/ml Dilute 1:1 with 0.9% NaCl before administration Renal: no Hepatic: no Continuous infusion lorazepam should be diluted in glass IV containers because it may be adsorbed onto plastic IV containers Midazolam Bolus dose: 0.025-0.35 mg/kg q1-2h Undiluted   5 mg/ml Renal: no Hepatic: yes Inject 0.5 mg/min   Infusion dose: 0.5-5 µg/kg/min 50 mg in 100 ml (D5W) 5 mg/ml Renal: yes Hepatic: yes Continuous infusion Unpredictable clearance in critically ill patients. Active metabolites accumulate and contribute to pharmacologic effect. Drug interaction: cimetidine (6) Benzodiazepine Antagonist Flumazenil Reversal of conscious sedation: 0.2 mg initially, then 0.2 mg q1min to a total of 1 mg Undiluted 0.1 mg/ml Renal: no Hepatic: no Inject over 15 sec Maximum dose of 3 mg in any 1 h period Benzodiazepine overdose: 0.2 mg initially, then 0.3 mg x 1 dose, then 0.5 mg q30sec up to a total of 3 mg Undiluted 0.1 mg/ml Renal: no Hepatic: no Maximum dose of 3 mg in any 1 h period Infusion dose: 0.1-0.5 mg/h 5 mg in 1000 ml (D5W ) 0.1 mg/ml Renal: no Hepatic: no Continuous infusion Narcotic Analgesic Agents Fentanyl Bolus dose: 25-75 µg q1-2h Undiluted   50 50µg/ml Renal: no Hepatic: no Inject over 5-10 sec Infusion dose: 50-100 µg/hr 50 µg/ml 50 µg/ml Renal: no Hepatic: no Continuous infusion Hydromorphone 1-4 mg q4-6h Undiluted 4 mg/ml Renal: no Hepatic: no Inject over 60 sec Dilaudid-HP available as 10 mg/ml Meperidine 25-100 mg q2-4h Undiluted 100 mg/ml Renal: yes Hepatic: yes Inject over 60 sec Avoid in renal failure Neurotoxic metabolite, normeperidine causes seizures Methadone 5-20 mg qd Undiluted 10 mg/ml Renal: yes Hepatic: yes Inject over 3-5 min Accumulation with repetitive dosing Morphine Bolus dose: 2-10 mg q1-2h Undiluted 15 mg/ml Renal: no Hepatic: no Inject over 60 sec Infusion dose: 2-5 mg/h 100 mg in 100 ml (D5W) 15 mg/ml Renal: no Hepatic: no Continuous infusion Active metabolites contribute to pharmacologic effect Remifentanil Continuation in the immediate postoperative period 0.0125-0.025 µg/kg/min 2 mg in 80 ml (D5W) 50 µg/ml Renal: no Hepatic: no Continuous infusion Bolus doses to treat post operative pain are not recommended Infusion rates should not exceed 0.025 µg/kg/min Failure to clear IV tubing of residual drug has been associated with respiratory depression, apnea, and muscle rigidity upon administration of additional fluids through the same IV tubing Narcotic Antagonist Naloxone Bolus dose: 0.4-2 mg (maximum 10 mg) Undiluted   1 mg/ml Renal: no Hepatic: no Inject over 60 sec Infusion dose: 4-5 µg/kg/h 2 mg in 250 ml (D5W) 1 mg/ml Renal: no Hepatic: no Continuous infusion Neuroleptic Agents Chlorpromazine 10-50 mg q4-6h Dilute with NS to a final concentration of 1 mg/ml 1 mg/ml Renal: no Hepatic: yes Infuse at 1 mg/min Droperidol Bolus dose: 0.625-10 mg q1-4h Undiluted 2.5 mg/ml Renal: no Hepatic: yes Inject over 60 sec Infusion dose: 1-20 mg/h 50 mg in 100 ml (D5W) 2.5 mg/ml Renal: no Hepatic: yes Continuous infusion Monitor QT interval and electrolytes Haloperidol lactate Bolus dose: 1-10 mg q2-4 h Undiluted 5 mg/ml Renal: no Hepatic: no Inject over 3-5 min In urgent situations the dose may be doubled every 20-30 min until an effect is obtained Decanoate salt is only for IM administration Infusion dose: 10 mg/h 200 mg in 160 ml (D5W) (1 mg/ml) Pure drug 5 mg/ml; D5W: 3 mg/ml; 0.9% NaCl: 0.75 mg/ml Renal: no Hepatic: no Continuous infusion Monitor QT interval and electrolytes Pulmonary Bronchodilators Aminophylline Loading dose: 6 mg/kg 50 ml (D5W) 25 mg/ml Renal: no Hepatic: no Infuse loading dose over 30 minutes Maximum loading infusion rate 25 mg/min Theophylline dose = 80% of aminophylline dose Drug interactions: cimetidine, ciprofloxacin, erythromycin, clarithromycin (4) Infusion dose:   500 mg in 500 ml (D5W) 10 mg/ml Renal: no Hepatic: yes Continuous infusion Therapeutic levels: 10-20 mg/L CHF normal smoker 0.3 mg/kg/h 0.6 mg/kg/h 0.9 mg/kg/h         Cardiology Antiarrhythmic Agents Adenosine 6 mg initially, then 9 mg, then 12 mg Undiluted 3 mg/ml Renal: no Hepatic: no Inject over 1-2 sec Drug interactions: theophylline (1), dipyridamole (2) Amiodarone First rapid loading infusion: 15 mg/min over first 10 minutes 150 mg in 100 ml (D5W) 1.5 mg/ml Renal: no Hepatic: no Infuse over 10 minutes Followed by slow loading infusion: 1 mg/min over next 6 h 900 mg in 500 ml (D5W) 1.8 mg/ml Renal: no Hepatic: no Infuse at 33.3 ml/h Maintenance infusion: 0.5 mg/min over next 18 h 900 mg in 500 ml (D5W) 1.8 mg/ml Renal: no Hepatic: no Infuse at 16.6 ml/h Supplemental infusion: 15 mg/min over 10 minutes 150 mg in 100 ml (D5W) 1.5 mg/ml Renal: no Hepatic: no Infuse over 10 minutes Bretylium           Bolus dose: 5-10 mg/kg Undiluted 50 mg/ml Renal: no Hepatic: no Infuse over 5-10 sec Infusion dose: 1-5 mg/min 2 g in 500 ml (D5W) 10 mg/ml Renal: yes Hepatic: no Continuous infusion Digoxin           Loading dose: 1-1.25 mg over 8-24 h Undiluted   0.25 mg/ml Renal: no Hepatic: no Inject over 3-5 min Maintenance dose: 0.125-0.375 mg q24h Undiluted 0.25 mg/ml Renal: yes Hepatic: no Inject over 3-5 min Drug interactions: amiodarone, cyclosporine, quinidine, verapamil (8) Therapeutic levels: 0.5-2 ng/ml Diltiazem           Bolus dose: 0.25-0.35 mg/kg Undiluted 5 mg/ml Renal: no Hepatic: no Inject over 2 min Infusion dose: 5-15 mg/h 125 mg in 100 ml (D5W ) 1 mg/ml Renal: no Hepatic: no Continuous infusion Lidocaine           Bolus dose: 1 mg/kg Undiluted   10 mg/ml Renal: no Hepatic: yes Inject over 60 sec Drug interaction: cimetidine (6) Infusion dose: 1-4 mg/min 2 g in 500 ml (D5W) 8 mg/ml Renal: no Hepatic: yes Therapeutic levels: 1.5-5.0 mg/L Procainamide           Loading dose: 15 mg/kg 50 ml (D5W) 100 mg/ml Renal: no Hepatic no Maximum infusion rate 25-50 mg/min Infusion dose: 1-4 mg/min 2 g in 500 ml (D5W) 8 mg/ml Renal: yes Hepatic: no Therapeutic levels: Procainamide, 4-10 mg/L, NAPA, 10-20 mg/L Quinidine gluconate 600 mg initially, then 400 mg q2h Maintenance 200-300 mg q6h 800 mg in 50 ml (D5W) 16 mg/ml Renal: no Hepatic: yes Infusion rate 1 mg/min Therapeutic levels: 1.5-5 mg/L Verapamil           Bolus dose: 5-10 mg Undiluted   2.5 mg/ml Renal: no Hepatic: no Inject over 1-2 min Drug interaction: digoxin (8) Infusion dose: 0.1-5 µg/kg/min 40 mg in 250 ml (D5W) 2.5 mg/ml Renal: no Hepatic: yes Continuous infusion. Active metabolite accumulates in renal failure and contributes to pharmacologic effect. Monitor train-of-four stimulation Drug interactions: aminoglycosides (3), anticonvulsants (5) Vasoactive Agents Dobutamine 2.5-20 µg/kg/min 500 mg in 250 ml (D5W) 8 mg/ml Renal: no Hepatic: no Continuous infusion Dopamine           Renal range: <4 µg/kg/min 400 mg in 250 ml (D5W) 8 mg/ml Renal: no Hepatic: no Continuous infusion Inotropic range: 4-8 µg/kg/min 400 mg in 250 ml (D5W) 8 mg/ml Renal: no Hepatic: no Continuous infusion Vasoconstrict-or range: >8 µg/kg/min 400 mg in 250 ml (D5W) 8 mg/ml Renal: no Hepatic: no Continuous infusion Epinephrine 1-4 µg/min 1 mg in 250 ml (D5W) 0.05 mg/ml Renal: no Hepatic: no Continuous infusion Isoproterenol 1-10 µg/min 2 mg in 500 ml (D5W) 0.2 mg/ml Renal: no Hepatic: no Continuous infusion Nitroglycerin 20-200 µg/min 50 mg in 250 ml (D5W) 0.8 mg/ml Renal: no Hepatic: no Drug interaction: heparin (11) Nitroprusside 0.5-10 µg/kg/min 50 mg in 250 ml (D5W) 0.8 mg/ml Renal: no Hepatic: no Maintain thiocyanate <10 mg/dl Norepinephrine 4-10 µg/min 4 mg in 250 ml (D5W) 0.08 mg/ml Renal: no Hepatic: no Continuous infusion Phenylephrine 20-30 µg/min 15 mg in 250 ml (D5W) 2.5 mg/ml Renal: no Hepatic: no Continuous infusion Milrinone           Loading dose: 50 µg/kg Undiluted 0.2 mg/ml Renal: no Hepatic: no Infuse over 10 min The loading dose may be given undiluted, but diluting to a rounded total volume of 10 or 20 ml may simplify the visualization of the injection rate Maintenance dose: 0.375-0.75 µg/kg/min Premixed solution 0.2 mg/ml 0.2 mg/ml Renal: yes Hepatic: no Continuous infusion Antihypertensive Agents Diazoxide 50-150 mg/kg q5-15min Undiluted 15 mg/ml Renal: no Hepatic: no Inject over 30 sec Maximum 150 mg/dose Enalaprilat 0.625-5 mg q6h Undiluted 1.25 mg/ml Renal: yes Hepatic: no Inject over 5 min Initial dose for patients on diuretics is 0.625 mg Hydralazine 5-20 mg q4-6h Undiluted 20 mg/ml Renal: no Hepatic: no Inject over 60 sec Labetalol Bolus dose: 20 mg q15min Undiluted   5 mg/ml Renal: no Hepatic: no Inject over 2 min Infusion dose: 1-4 mg/min 200 mg in 160 ml (D5W) 1 mg/ml Renal: no Hepatic: yes Continuous infusion Phentolamine Bolus dose: 5-10 mg Undiluted 5 mg/ml Renal: no Hepatic: no Inject over 3-5 min Infusion dose: 1-5 mg/min 100 ml (D5W) 5 mg/ml Renal: no Hepatic: no Continuous infusion Beta-Adrenergic Blocking Agents Esmolol Bolus dose: 500 µg/kg   Undiluted 10 mg/ml Renal: no Hepatic: no Inject over 60 sec Infusion dose: 50-400 mg/kg/min 5g in 500 ml (D5W) 10 mg/ml Renal: no Hepatic: yes Continuous infusion Metoprolol 5 mg q2min x 3 Undiluted 1 mg/ml Renal: no Hepatic: yes Inject over 3-5 min Propranolol 0.5-1 mg q5-15min Undiluted 1 mg/ml Renal: no Hepatic: yes Inject over 60 sec Infusion dose: 1-3 mg/h 50 mg in 500 ml (D5W) 1 mg/ml Renal: no Hepatic: yes Continuous infusion Diuretics Chlorothiazide 0.5-1 g bid-qd 1 g in 18 ml (sterile water) 1 g in 18 ml (sterile water) Renal: no Hepatic: no Inject over 3-5 min Bumetanide Bolus dose: 0.5-1 mg Undiluted 0.5 mg/ml Renal: no Hepatic: no Infuse over 3-5 min Maximum rate of injection is 1 mg/min Infusion dose: 0.08-0.3 mg/h 2.4 mg in 100 ml (0.9% NaCl) 0.5 mg/ml Renal: no Hepatic: no Continuous infusion Furosemide Bolus dose: 20-40 mg q1-2h Undiluted   10 mg/ml Renal: no Hepatic: no Maximum injection rate 40 mg/min Up to 400-800 mg/dose may be required in some patients Infusion dose: 2-20 mg/hr 100 mg in 100 ml (D5W) 10 mg/ml Renal: no Hepatic: no Continuous infusion Mannitol Diuretic: 12.5-100 g over 1-2 h Undiluted 250 mg/ml Renal: no Hepatic: no Inject over 3-5 min Cerebral edema: 0.25-0.5 g/kg q4h Undiluted 250 mg/ml Renal: no Hepatic: no Inject over 3-5 min Gastroenterology H-2Antagonists Cimetidine         Drug interactions: theophylline, warfarin, phenytoin, lidocaine, benzodiazepines (6) IVPB: 300 mg q6-8h 50 ml (D5W) Dilute to 20 ml (15 mg/ml) IVP Renal: yes Hepatic: no Infuse over 15-30 min IVP dose may be injected over at least 5 min Infusion dose: 37.5 mg/h 900 mg in 250 ml (D5W) 9 mg/ml Renal: no Hepatic: no Continuous infusion Ranitidine IVPB: 50 mg q6-8h 50 ml (D5W) 2.5 mg/ml Renal: yes Hepatic: no Infuse over 15-30 min IVP dose should be injected over at least 5 minutes Infusion dose: 6.25 mg/h 150 mg in 150 ml (D5W) 2.5 mg/ml Renal: no Hepatic: no Continuous infusion Antiemetic Agents Granisetron Chemotherapy -induced nausea and vomiting resistant to standard antiemetic therapy IV: 10 µg/kg IVP starting 30 minutes before the emetogenic drug IVP 1 mg/ml Renal: no Hepatic: no Infuse over 60 seconds Post operative nausea and vomiting IV: 20-40 µg/kg as a single dose IVP 1 mg/ml Renal: no Hepatic: no Infuse over 5 minutes Ondansetron 16-32 mg 30 min before chemotherapy 50 ml (D5W) 1 mg/ml Renal: no Hepatic: no Infuse over 15-30 min Post-op nausea and vomiting 4 mg IV x 1 Undiluted 2 mg/ml Renal: no Hepatic: no Infuse over 2-5 min Promotility Agents Metoclopramide For intubation of small intestine: 10 mg x 1 dose Undiluted 5 mg/ml Renal: no Hepatic: no Inject over 3-5 min As antiemetic: 2 mg/kg before chemotherapy then 2 mg/kg q2h x 2, then q3h x 3 50 ml (D5W) 5 mg/ml Renal: yes Hepatic: no Infuse over 15-30 min Miscellaneous Agents Octreotide Continuous infusion 50-100 µg bolus, followed by continuous infusion at 25-100 µg/h for 24-48 h 500 µg in 250 ml (D5W) 1000 µg/ml Renal: no Hepatic: no Continuous infusion Vasopressin 0.2-0.3 U/min 100 U in 250 ml (D5W) 1 U/ml Renal: no Hepatic: no Maximum infusion rate 0.9 U/min Metabolic Disorders Acid-Base Balance Acetazolamide 5 mg/kg/24h or 250 mg qid-qd Undiluted 100 mg/ml Renal: no Hepatic: no Infuse at 500 mg/min Hydrochloric acid H+ deficit in mEq = 0.5 x (body weight in kg) x (103-serum Cl) 1 mEq/10 ml (sterile water) 1 mEq/10 ml Renal: no Hepatic: no Maximum infusion rate = 0.2 mEq/kg/h Sodium bicarbonate HCO3- deficit in mEq = 0.4 x (body weight in kg) x (desired HCO3- -measured HCO3-) Premixed soln 0.6 mEq/ml 150 mEq in 1000 ml SW or D5W Renal: no Hepatic: no Continuous infusion Sodium bicarbonate syringes contain 1 mEq/ml Many incompat- ibilities, flush IV line before and after use Electrolyte Replacement Calcium (elemental) 100-200 mg of elemental calcium IV over 15 min followed by 100 mg/h 1000 mg in 1000 ml (0.9% NaCl) 1.5 mg/ml Renal: no Hepatic: no Ca chloride 1 g = 272 mg (13.6 mEq) of elemental calcium Ca gluconate 1 g = 90 mg (4.65 mEq) of elemental calcium Magnesium (elemental)         Magnesium sulfate 1 g = 8 mEq = elemental magnesium 98 mg Magnesium deficiency: 25 mEq over 24 h followed by 6 mEq over the next 12h 25 mEq in 1000 ml (D5W) 1 mEq/ml Renal: yes Hepatic: no   Ventricular arrhythmias: 16 mEq over 1 h followed by 40 mEq over 6 h 40 mEq in 1000 ml (D5W) 1 mEq/ml Renal: yes Hepatic: no 16 mEq (2 g) may be diluted in 100 ml D5W and infused over 1 h Phosphate (potassium) 0.08-0.24 mmol/kg Function of K+ concentration Function of K+ concentration Renal: yes Hepatic: no Infuse over 6-8 h 1 mmol of PO4 = 31 mg of phosphorus Potassium chloride 5-40 mEq/h 40-80 mEq in 1000 ml (0.9% NaCl, D5W, etc.) 0.4 mEq/ml Renal: yes Hepatic: no Cardiac monitoring should be used with infusion rates >20 mEq/h Hypercalcemia Therapy Gallium nitrate 100-200 mg/M2 qd x 5 d 1000 ml (D5W) Dilute in at least 1000 ml Renal: no Hepatic: no Infuse over 24 h Pamidronate 60-90 mg x 1 dose 1000 ml (D5W) Dilute in at least 1000 ml Renal: no Hepatic: no Infuse over 24 h Plicamycin 25 µg/kg qd x 3-4 d 1000 ml (0.9% NaCl) 23.8 mg/ml Renal: yes Hepatic: no Infuse over 4-6 h Miscellaneous Agents Desmopressin 0.3 µg/kg 50 ml (0.9% NaCl) 4 µg/ml Renal: no Hepatic: no Infuse over 15-30 min Hematopoietic Agents Hemostatic Agents Protamine <30 min: 1-1.5 mg/100 U heparin 30-60 min: 0.5-0.75 mg/100 U >120 min: 0.25-0.375 mg/100 U 50 mg in 5 ml sterile water 10 mg/ml Renal: no Hepatic: no Inject over 3-5 min Do not exceed 50 mg in 10 min Aminocaproic acid 4 g initially, then 1 g/h 20 g in 1000 ml (D5W) 250 mg/ml Renal: no Hepatic: no Rapid injection is not recommended, infuse initial dose over 60 minutes Thrombolytic Agents Streptokinase For acute myocardial infarction: 1.5 M U 45 ml (D5W) 30,000 U/ml Renal: no Hepatic: no Infuse over 60 min For deep venous thrombosis or pulmonary embolism: 250,000 U over 30 min, then 100,000 U/h x 24-72 h 90 ml (D5W) 30,000 U/ml Renal: no Hepatic: no Continuous infusion Tissue plasminogen activator (rtPA)           Myocardial infarction: 100 mg 100 mg in 100 ml (sterile water) 1 mg/ml Renal: no Hepatic: no Accelerated infusion: 15 mg bolus, followed by 50 mg over 30 min, then 35 mg over the next 60 min 3 hour infusion: 60 mg in the first hour, 20 mg over the second hour, and 20 mg over the third hour Acute ischemic stroke: 0.9 mg/kg (to maximum 90 mg) Appropriate volume of a 1 mg/ml solution 1 mg/ml Renal: no Hepatic: no Infuse over 60 min with 10% of total dose administered as an initial bolus over 1 min Pulmonary embolism: 100 mg 100 mg in 100 ml (sterile water) 1 mg/ml Renal: no Hepatic: no Infuse over 2 h Urokinase 4,400 U/kg over 10 min, then 4,400 U/kg/h x 12 h 195 ml (D5W) 2500 U/ml Renal: no Hepatic: no Continuous infusion Growth Factors Erythropoietin 50-100 U/kg 3x per wk Undiluted 4000 U/ml Renal: no Hepatic: no Inject over 3-5 min Maintenance doses range between 12.5-525 U/kg 3x/week Filgastrim (G-CSF) 5-10 µg/kg x 2-4 wks Dilute in D5W to a final concentration of 5-15 µg/ml 15 µg/ml Renal: no Hepatic: no Infuse over 15-30 min Preferred route of ad-ministration is SC To protect against adsorption to plastic materials, albumin must be added to a final concentration of 2 mg/ml Do not dilute with saline at any time, product may precipitate Sargramostim (GM-CSF) 250 µg/M2/d x 21 d 50 ml (NS) Should be diluted to >10 µg/ml Renal: no Hepatic: no Infuse over 2 h If final concentration is <10 µg/ml, albumin should be added to a final concentration of 0.1% Miscellaneous Agents RhoD Immune Globulin Intravenous 20-250 µg/kg Undiluted 120 µg/ml Renal: no Hepatic: no Inject over 3-5 min Endocrine Diagnostic Agents Cosyntropin 0.25 mg Undiluted 0.25 mg/ml Renal: no Hepatic: no Inject over 60 sec Glucagon 0.5-3 mg followed by 1-20 mg/h 100 mg in 100 ml (D5W) 10 mg/ml Renal: no Hepatic: no Continuous infusion May cause hypokalemia, hyperglycemia, and tachycardia Glucocorticosteroids Dexamethasone 0.5-20 mg 50 ml (0.9% NaCl) 4 mg/ml Renal: no Hepatic: no May give doses =10 mg undiluted IV over 60 seconds Hydrocortisone 12.5-100 mg q6-12h Undiluted 50 mg/ml Renal: no Hepatic: no Inject over 60 sec Methylpred- nisolone 10-250 mg q6h Undiluted 62.5 mg/ml Renal: no Hepatic: no Inject over 60 sec Estrogens Conjugated estrogens 0.6 mg/kg/d x 5 d 50 ml (0.9% NaCl) 5 mg/ml Renal: no Hepatic: no Infuse over 30 min Thyroid Hormones Levothyroxine 25-200 µg q24h Undiluted 100 µg/ml Renal: no Hepatic: no Inject over 5-10 sec IV dose = 75% of PO dose Miscellaneous Agents Antihistamines Diphenhydra- mine 25-100 mg q2-4h Undiluted 50 mg/ml Renal: no Hepatic: no Inject over 3-5 minutes Competitive histamine antagonist, doses >1000 mg/24h may be required Anticholinergic Agents Glycopyrrolate 5-15 µg/kg Undiluted 0.4 mg/ml Renal: no Hepatic: no Inject over 60 sec Vitamins Thiamine 100 mg qd x 3 50 ml (D5W) 2 mg/ml Renal: no Hepatic: no Infuse over 15-30 min Immunosuppressive Agents Cyclosporine 5-6 mg/kg q24h 100 ml (D5W) 2.5 mg/ml Renal: no Hepatic: no Infuse over 2-6 h Drug interactions: digoxin (8), erythromycin (9), amphotericin B, nonsteroidal anti- inflammatory drugs (10) IV dose = 1/3 PO dose Infectious Diseases Aminoglycoside Antibiotics Amikacin 7.5 mg/kg q12h 50 ml (D5W) 50 mg/ml Renal: yes Hepatic: no Infuse over 30 min Drug interaction: neuromuscular blocking agents (3) Therapeutic levels: peak, 20-40 mg/L; trough, <8 mg/L High dose extended interval 20 mg/kg 50ml (D5W) 50 mg/ml Renal: yes Hepatic: no Infuse over 60 minutes Trough level 0 mg/L before next dose Peak levels unnecessary Gentamicin Loading dose: 2-3 mg/kg 50 ml (D5W) 40 mg/ml Renal: no Hepatic: no Infuse over 30 min Maintenance dose: 1.5-2.5 mg/kg q8-24h 50 ml (D5W) 40 mg/ml Renal: yes Hepatic: no Infuse over 30 min Critically ill patients have an increased volume of distribution requiring increased doses Drug interaction: neuromuscular blocking agents (3) Therapeutic levels: peak, 4-10 mg/L, trough <2 mg/L High dose extended interval: 5-8 mg/kg 50 ml (D5W) 40 mg/ml Renal: yes Hepatic: no Infuse over 60 min Trough level 0 mg/L before next dose Peak levels unnecessary Tobramycin Loading dose: 2-3 mg/kg 50 ml (D5W) 40 mg/ml Renal: no Hepatic: no Infuse over 30 min Maintenance dose: 1.5-2.5 mg/kg q8-24h 50 ml (D5W) 40 mg/ml Renal: yes Hepatic: no Infuse over 30 min Critically ill patients have an increased volume of distribution requiring increased doses Drug interaction: neuromuscular blocking agents (3) Therapeutic levels: peak, 4-10 mg/L, trough <2 mg/L Penicillins Ampicillin 0.5-3 g q4-6h 100 ml (0.9% NaCl) 50 mg/ml Renal: yes Hepatic: no Infuse over 15-30 min Ampicillin- sulbactam 1.5-3 g q6h 100 ml (0.9% NaCl) 50 mg/ml Renal: yes Hepatic: no Infuse over 15-30 min Nafcillin 0.5-2 g q4-6h 100 ml (D5W) 250 mg/ml Renal: no Hepatic: yes Infuse over 30-60 min Oxacillin 0.5-2 g q4-6h 100 ml (D5W) 250 mg/1.5 ml Renal: no Hepatic: yes Infuse over 30 min Penicillin G 8-24M U divided q4h 100 ml (D5W) 100,000 U/ml Renal: yes Hepatic: no Infuse over 15-30 min Piperacillin 2-4 g q4-6h 100 ml (D5W) 200 mg/ml Renal: yes Hepatic: no Infuse over 15-30 min Ticarcillin- clavulanic acid 3.1 g q4-6h 100 ml (D5W) 100 mg/ml Renal: yes Hepatic: no Infuse over 15-30 min Cephalosporins First Generation Cefazolin 0.5-1 g q6-8h 50 ml (D5W) 1 g in 10 ml sterile water IVP Renal: yes Hepatic: no Infuse over 15-30 min Second Generation Cefoxitin 1-2 g q4-6h 50 ml (D5W) 1-2 g in 10 ml sterile water IVP Renal: yes Hepatic: no Infuse over 15-30 min Third Generation Ceftazidime 0.5-2 g q8-12h 50 ml (D5W) 1-2 g in 10 ml sterile water IVP Renal: yes Hepatic: no Infuse over 15-30 min Ceftriaxone 0.5-2 g q12-24h 50 ml (D5W) 40 mg/ml Renal: no Hepatic: no Infuse over 15-30 min Fourth Generation Cefepime 0.5-2 g q12h 50 ml (D5W) 2 gm in 50 ml Renal: yes Hepatic: no Infuse over 30 minutes Carbapenem Antibiotics Imipenem 0.5-1 g q6-8h 100 ml (D5W) 5 mg/ml Renal: yes Hepatic: no Infuse over 30-60 min Meropenem 1 g q8h 100 ml (D5W) 1g/30 ml IVP Renal: yes Hepatic: no Infuse over 15-30 min Injection over 3-5 min Macrolide Antibiotics Azithromycin 500 mg qd for 1-2 d, then convert to oral therapy 1 mg/ml 2 mg/ml Renal: no Hepatic: no Infuse the 1 mg/ml final concentration over 3h and the 2 mg/ml final concentration over 1 h Erythromycin 0.5-1 g q6h 250 ml (0.9% NaCl) 20 mg/ml Renal: no Hepatic: yes Infuse over 60 min Drug interactions: theophylline (4), cyclosporine (9) Quinolone Antibiotics Ciprofloxacin 200-400 mg q12h Premixed solution 2 mg/ml 2 mg/ml Renal: yes Hepatic: no Infuse over 60 min Drug interactions: theophylline, warfarin (7) Levofloxacin 250-500 mg qd Premixed solution 5 mg/ml 5 mg/ml Renal: Yes Hepatic: no Infuse over 60 min Antianaerobic Antibiotics Clindamycin 150-900 mg q8h 100 ml (D5W) 12 mg/ml Renal: no Hepatic: yes Infuse over 30-60 min Metronidazole 500 mg q6h Premixed solution 5 mg/ml 5 mg/ml Renal: yes Hepatic: yes Infuse over 30 min Miscellaneous Antibiotics Aztreonam 0.5-2 g q6-12h 100 ml (D5W) 200 mg/ml Renal: yes Hepatic: no Infuse over 15-30 min Chloramphen- icol 0.5-1 g q6h 50 ml (D5W) 100 mg/ml Renal: yes Hepatic: yes Infuse over 30 min Therapeutic levels: peak, 10-25 mg/L; trough, 5-10 mg/L Doxycycline 100-200 mg q12-24h 250 ml (D5W) 1 mg/ml Renal: no Hepatic: yes Infuse over 60 min Pentamidine 4 mg/kg q24h 50 ml (D5W) 100 mg/ml Renal: yes Hepatic: no Infuse over 60 min Trimethoprim-sulfamethoxazole (TMP-SMX) General: 4-5 mg/kg q12h TMP 16 mg-SMX 80 mg per 25 ml (D5W) TMP 16 mg- SMX 80 mg per 10 ml (D5W) Renal: yes Hepatic: yes (SMX) Infuse over 60 min For Pneumocystis carinii: 5 mg/kg q6h TMP 16 mg- SMX 80 mg per 25 ml (D5W) TMP 16 mg- SMX 80 mg per 10 ml (D5W) Renal: yes Hepatic: yes (SMX) Infuse over 60 min Therapeutic levels (SMX): <150 mg/L Vancomycin 1 g q12h 250 ml (D5W) 20 mg/ml Renal: yes Hepatic: no Infuse over at least 1 h to avoid "red-man" syndrome Therapeutic levels: peak, 20-40 mg/L, trough, <10 mg/L Antifungal Agents Amphotericin B 0.5-1.5 mg/kg q24h 250 ml (D5W) 1.4 mg/ml Renal: no Hepatic: no Infuse over 2-6 h Do not mix in electrolyte solutions (e.g., 0.9% NaCl, Ringer's lactate) Amphotericin B Lipid Complex (ABLC) 5 mg/kg/d D5W to a final concentration of 1 mg/ml