Reference Cards
Medicine Drips

Aminophylline bronchodilator; therapeutic level: 10-20 mg/l or ug/ml.

Indications: COPD exacerbation; Status Asthmaticus
Loading Dose (LD): 5.7 mg/kg IVPB over 30 min
Maintenance Dose: 1) Adult-smokers, 0.9 mg/kg/hr; 2) Adult-non smokers, 0.6 mg/kg/hr; 3) CHF, cirrhosis, ascites, cor pulmonale, 0.3 mg/kg/hr; (rate, cc/hr = 0.6 x body weight (kg), for 0.6 mg/kg/hr with 500 mg/500cc)
Complications: nausea, vomiting, anorexia, abd. cramps, dizziness, headaches, agitation, tremors, tachycardia, ventricular arrhythmias, palpitations, hypoxemia 2° V/Q mismatch; overdosage-hyperreflexia, convulsions, hypotension, tachypnea

Amrinone (Inocor) cardiac inotrope, vasodilator, phosphodiesterase inhibitor

Indications: Unresponsive CHF to conventional therapy
Loading Dose: 0.75 mg/kg IVP over 2-4 min and repeat in 30 min if necessary
Maintenance Dose: 5-15 ug/kg/min.*1, not exceeding 10 mg/kg daily including LD Concentration: 400 mg/250cc, NS or 1/2 NS
Complications: thrombocytopenia, hypotension, arrhythmias, nausea, vomiting, hepatotoxicity, don't administer in same line with Lasix, don't dilute with glucose solutions, hypersensitivity to bisulfites; Avoid concurrent use with disopyramide.

Footnote *1 Drip rate (cc/hr) = (wt, kg) (60) (dose)/ (conc) (1000); dose = ug/kg/min; conc = mg/cc or mg/ml

Atracurium (Tracurium) nondepolarizing skeletal muscle relaxant; NMBA; t1/2 = 21 min

Indications: aid to intubation and mechanical ventilatory support in the ICU
Loading Dose: 0.4-0.5 mg/kg IVP bolus over 1 min or if already intubated 0.2 -0.3 mg/kg IVP bolus over 1 min. Use narcotics and/or sedatives beforehand.
Maintenance: 1000 mg tracrium (100 cc) to be mixed in 25Occ bag NS or D5W (4 mg/ml) after the initial removal of 100cc. Begin continuous infusion only after first evidence of spontaneous recovery from LD bolus. The initial infusion rate is 9-10 ug/kg/min*1. Subsequent infusion rates of 5-9 ug/kg/min*1 should be sufficient and titrated prn Monitor patient with periodic peripheral nerve stimulation. Tracrium should not be given IM or mixed in alkaline solutions. Also consider 20-35 mg/hr for a 70 kg adult.
Complications: "histamine release" (may worsen cardiovascular disease, asthma or anaphylaxis) - itching, skin flushing, erythema, urticaria, bronchospasm, bronchial secretions, (dec)BP, tachycardia
NOTE: Avoid problems with NMBA that include decubitus ulcers, corneal ulcers, DVT - PE, peripheral nerve injury, inadequate bronchopulmonary toilet due to poor cough (retained secretions, pneumonia, atelectasis); unrecognized hypoglycemia, seizures, extubation, CVA, and pharmacological persistent paralysis. May potentiate Tracrium include: procainamides, magnesium, patients with neuromuscular disorders. May antagonize Tracrium - corticosteroids, phenytoin, ranitidine, aminopylline. Tracrium reversal can be achieved with the use of an anticholinesterase (neostigmine, phridostigmine or edrophonium) plus an anticholinergic (atropine). Elimination unaltered by hepatic or renal dysfunction.

Footnote *1 Drip rate (cc/hr) = (wt, kg) (60) (dose)/ (conc) (1000); dose = ug/kg/min; conc = mg/cc or mg/ml

Diltiazem (Cardizem) calcium channel blocker

Indications: rapid ventricular response with A Fib. or A Flutter; PSVT Loading Dose: 0.25 mg/kg IVP over 2 minutes; may repeat bolus in 15 minutes if necessary with 0.35 mg/kg over 2 minutes.
Maintenance: 125 mg in 100cc D5W or NS (1.0 mg/ml); 250 mg in 250cc D5W or NS (0.8 mg/ml). Infusion to range from 5 -15 mg/hr - titrate as needed for desired HR. Continuous infusions greater than 24 hrs should be used cautiously. Taper 2.5 mg/hr over 6-8 hrs as tolerated
Contraindications: sick sinus syndrome, VT, 2nd or 3rd degree heat block, WPW, hypotension, shock, concurrent use with IV beta-blocker, hypersensitivity
Complications: hypotension, bc, junctional rhythm, edema, headache, nausea

Dobutamine (Dobutrex) B1 agonist- +inotrope > +chronotrope, B2 agonist, (alpha)1 agonist

Indications: cardiogenic shock, severe CHF, S/P MI with low CO, low CO Standard
Concentration: 250 mg/250cc D5W; (conc = 1.0) Dosage Range: 5-15 ug/kg/min*1
Complications: tachycardia (less than Dopamine), minimal ventricular ectopy, tachyarrhythmias, sinus tc, hypotension 2° vasodilation (B2), IV infiltration tissue necrosis, sloughing, inflammation; hypokalemia (uncommon)

Footnote *1 Drip rate (cc/hr) = (wt, kg) (60) (dose)/ (conc) (1000); dose = ug/kg/min; conc = mg/cc or mg/ml

Dopamine (Intropin) variable agonist to dopaminergic, B1 and alpha receptors

Indications: shock, poor perfusion of vital organs,splanchnic perfusion, low CO Standard
Concentration: 200 mg/250cc D5W, (conc = 0.8)
Dosage Range: 2-4 ug/kg/min*1, +dopamine receptors (increase renal and splanchnic perfusion), minimal B1 agonism; 5-10 ug/kg/min*1; B1 > alpha; 10-15 ug/kg/min*1, alpha > B1; >15 ug/kg/min*1, alpha agonist (increased peripheral vasoconstriction, increased SVR, increased afterload, may decrease CO)
Complications: tachycardia, tachyarrhythmias, sinus tc, arrhythmias S/P MI, myocardial ischemia, IV infiltration may cause tissue necrosis/sloughing, hypoxemia 2° V/Q mismatching, distal extremity ischemia with high dose infusion, hyperglycemia

Footnote *1 Drip rate (cc/hr) = (wt, kg) (60) (dose)/ (conc) (1000); dose = ug/kg/min; conc = mg/cc or mg/ml

Epinephrine (Adrenaline) sympathomimetic agent; B2 (1-3 ug/min), B1 and (alpha) adrenergic agent; (B1-inotrope/chronotrope, (alpha)-vasoconstriction, B2-vasodilatation)

Indications: shock-anaphylactic, septic, cardiogenic, S/P cardiopulmonary arrest
Concentration: 1 mg/250cc D5W = 4 ug/ml
Range: 1-20 ug/min where 1 ug/min = 15 ml/hr (for 1 mg/250 ml) Note - titrate to desired effect. Can dilute 5 mg/500cc D5W (10 ug/ml) where 1 ug/min = 6 cc/hr.
Complications: ventricular ectopy, myocardial ischemia, hyperglycemia, WBC

Esmolol (Brevibloc) cardioselective B1 antagonist, t1/2-9 min

Indications: SVT, intra/post op HTN and/or tc, acute aortic dissection with Nipride
Concentration: 5.0 g in 500cc (D5W, NS, 1/2NS, D51/2NS)-10 mg/ml Dosage: LD-500 ug/kg/min*1 over 1 min followed by a 50 ug/kg/min*1 maintenance infusion x 4 min. If clinical endpoint is not observed, repeat LD (over 1 min), and increase maintenance infusion to 100 ug/kg/min*1. Note - can repeat LD twice and increase maintenance infusion to maximum of 200 ug/kg/min*1 (50 ug/kg/min increases over 4 min intervals). May need dosages of 250-300 ug/kg/min to control post op HTN. DO NOT DISCONTINUE ABRUPTLY.
Complications: AV block, asystole, hypotension, bradycardia, bronchospasm, (delta)MS, CHF, dizziness, nausea, phlebitis, adverse drug reactions (verapamil, digoxin, morphine) Contraindications: sinus bc, heart block > 1°, cardiogenic shock, overt CHF, ?bronchospastic disease, ?DM

Footnote *1 Drip rate (cc/hr) = (wt, kg) (60) (dose)/ (conc) (1000); dose = ug/kg/min; conc = mg/cc or mg/ml

Fentanyl (Sublimaze) opiate for analgesia and sedation

Loading Dose: 2-3 ug/kg
Dosage: 2500 ug/50 mls mixed in D5W or NS (0.9%) for a total volume of 250 cc with maintenance infusion at 50 -200 ug/hr (5 -20 ml/hr)
Complications: minimal cardiovascular dysfunction, vagus - mediated bradycardia, decreased minute ventilation, increased chest wall rigidity proportional to muscle rigidity, physical dependence, biliary colic; Avoid opioid -MAO drug interactions. A prolonged effect of fentanyl may be seen after infusion is discontinued due to tissue acculumlation and then re-entry to plasma.
NOTE - hepatic metabolism, renal excretion

Heparin anticoagulant

Indications: DVT, PE, unstable angina, LA embolism prophylaxis with AFib, AMI
Loading Dose: 5000 units IVP x 1
Maintenace Dose: Start 1000 units/hr (25,000 units/500cc at 20 cc/hr). Titrate drip to PTT 1.5-2.5 x control. Reverse with protamine (1 mg per 100 units of heparin, maximum 50 mg over 10 minutes)
Complications: bleeding, thrombocytopenia

Insulin hormonal glucose regulator serum/urine glucoses

Dosage: 50 units Regular Insulin/500cc NS at 50 cc/hr (5 units/hr)
Complications: hypogylcemia; diaphoresis, tc, (delta)MS, seizures, hypokalemia

Labetalol (Normodune): alpha1 and beta antagonist

Indications: Severe HTN, eclampsia, aortic aneurysm or dissection
Dosage: 2 mg/min up to 300 mg total; or 20 mg IV over 2 minutes, then 40 or 80 mg IV every 10 minutes until target BP achieved or 300 mg max
Contraindications: asthma, severe CHF, 2° and 3° heart block, severe bradycardia
Complications: hypotension, CHF, bradycardia, (delta)MS, bronchospasm, fatigue, urinary retention, dizziness, nausea, hypo-hyperglycemia, adverse drug interactions (halothane, digoxin, thyroid, beta adrenergic bronchodilators, cimetidine)

Lidocaine (Xylocaine) class 1B antiarrhythmic

Indications: V Fib, VT, stable wide complex TC ? type, ventricular ectopy
Loading Dose: 1.0-1.5 mg/kg IVP and repeat 0.5-1.5 mg/kg IVP q 3-5 min until converted or to a total of 30 mg/kg
Maintenance Dose: 2-4 mg/min (2 gms/500cc at 30 cc/hr = 2 mg/min)
Complications: CNS depression, drowsiness, unconsciousness, apprehension, change in vision, vomiting, bradycardia, hypotension, seizures, AV block

Midazolam (Versed) benzodiazepine for ICU sedation, sedative hypnotic, anxiolytic

Loading Dose: 2-5 mg or 25-100 ug/kg IVP
Maintenance Dose: 2-10 mg/hr (40 mg/100cc at 10 cc/hr = 4 mg/hr), or 0.25-1.0 ug/kg/min*1
Complications: respiratory depression, BP, always level of consciousness
NOTE: May need higher maintenance dose when intubated Emergence from sedation may take 2-3 days with prolonged infusion Hepatic dependent metabolism.

Footnote *1 Drip rate (cc/hr) = (wt, kg) (60) (dose)/ (conc) (1000); dose = ug/kg/min; conc = mg/cc or mg/ml

Milrinone (Primacor) inotrope/vasodilator - phosphodiesterase inhibitor

Indications: CHF
Loading Dose: 50 ug/kg IVP over 10 minutes
Maintenance: 50 mg /200cc D5W or NS for final dilution of 50 mg/250 ml (200 ug/ml). Begin at 0.50 ug/kg/min*1 with a range of 0.375 - 0.75 ug/kg/min*1 prn.
Complications: tachyarrhythmias (VEA,SVT), (dec)BP, angina, headache, K+;
NOTE - maintenance infusion rate may be needed in patients with renal insufficiency.

Footnote *1 Drip rate (cc/hr) = (wt, kg) (60) (dose)/ (conc) (1000); dose = ug/kg/min; conc = mg/cc or mg/ml

Morphine Sulfate opioid analgesic, sedative, vasodilator (preload)

Dosage: Start 2 mg/hr and titrate (3-10 mg/hr) to desired sedation or pain relief (ex.- 40 mg/100cc NS at 10 cc/hr = 4 mg/hr); May need loading dose (4-10 mg IVP) prn
Complications: hypotension, respiratory depression, (delta)MS, ileus, urinary retention, nausea, vomiting

Nicardipine (Cardene) calcium channel blocker; selective arterial vasodilator à (dec)SVR

Indications: HTN
Concentration: 25 mg/10 ml ampule + 240 mI lV soln 250 ml dilution (.1 mg/ml)
Dosage: Start IV therapy at 50 ml/hr (5.0 mg/hr). Increase infusion rate 10-20 ml/hr (1-2 mg/hr) every 5-15 min prn to a max of 150 ml/hr (15 mg/hr) Taper as directed.
Complications: hypotension, tachycardia, headache, nausea, vomiting, dizziness, sweating, polyuria, ventricular extrasystoles
Contraindications: known hypersensitivity, advanced aortic stenosis, ?decreased renal or hepatic function, ? in combination with B Blocker with CHF
NOTE: Not compatible with NaHCO3 (5%) or lactated ringers. Change IV site every 12 hours. Cimetidine increases Cardene levels

Nitroglycerin nitrate, vasodilator, venous >> arterial dilation (decrease of preload > decrease of afterload), coronary artery dilation, decreased SVR, decreased PVR

Indications: unstable angina, CHF with MI, CHF -pulm. edema, with vasopressors, HTN with ?cardiac ischemia.
Dosage: 5-100 ug/min; Start 25 mg/250cc D5W at 5-10 cc/hr or 5 ug/min, and advance 3-5 cc/hr every 5 min until chest pain resolved May need to concentrate solution (50 or 100 mg/250 cc D5W) with fiuid restriction.
Complications: hypotension, headaches

Nitroprusside (Nipride) arterial-venous vasodilator, afterload reducing agent

Indications: severe HTN, SVR, hypertensive encephalopathy, aortic dissection, APE, afterload reduction 2° severe L V dysfunction, consider with cerebral infarction or hemorrhage
Dosage Range: 0.5-10 ug/kg/min*1; Start 50 mg/500cc D5W at 20 cc/hr and titrate to BP. Can advance to 100 mg/250cc D5W at 100 cc/hr.
Complications: hypotension, nausea, headaches, restless, cyanide and thiocyanate toxicity, degraded by light; Avoid with renal failure

Footnote *1 Drip rate (cc/hr) = (wt, kg) (60) (dose)/ (conc) (1000); dose = ug/kg/min; conc = mg/cc or mg/ml

Norepinephrine (Levophed) alpha and B1 agonist, vasopressor

Indications: unresponsive shock with hypotension
Dosage: 4 mg/500cc; start at 10 cc/hr or 5-10 ug/min, and titrate to BP (increase SVR).
Complications: tachyarrhythmias, angina, tissue necrosis/sloughing with infiltration

Pancuronium (Pavulon) non depolarizing neuromuscular blocking agent; t1/2 -2 hrs

Loading Dose: 4-10 mg IVP (0.1 mg/kg over 15 seconds)
Maintenance Dose: 1-4 mg/hr; (2 mg/hr = 20 mg/100cc NS at 10 cc/hr). Reversed by pyridostigmine (cholinesterase inhibitor), 10-20 mg IVP; give with Atropine
Complications: causes temporary paralysis, BP, tachycardia, check neuromuscular blockade with peripheral nerve stimuiation -Train of Four, adjust dose with renal/hepatic dysfunction -primarily renal elimination, persistent muscle weakness of paralysis, myopathy with corticosteroid administration, motor neuropathy, neuromuscular blocker tolerance/tachyphylaxis, active metabolite

Phenylephrine (Neo-Synephrine) alpha-1 agonist, vasopressor Indications: refractory hypotension unresponsive to IV fluid challenges and intotropic agents, i.e. MAP associated with SVR.

Concentration: 50 mg/250cc D5W or NS (0.2 mg/ml) to a max of 250 mg/250 cc (1.0 mg/ml)
Dose Range: Initial continuous IV infusion to begin at 5-10 ug/min, and titrate prn for adequate BP response. Taper IV infusion gradually
Complications: myocardial ischemia, bradycardia, hyperglycemia, IV infiitration tissue necrosis/sloughing, distal extremity ischemia; Avoid use with MAO inhibitors and tricyclic antidepressants, pheochromocytoma, clinically significant heart block

Procainamide (Pronestyl) class 1A antiarrhythmic

Loading Dose: 20-30 mg/min until arrhythmia suppressed, hypotension, QRS widened > 50%, or 17 mg/kg (1.2 g for 70 kg patient) given; BP and QRS complex every 5 min.
Maintenance Dose: 1-4 mg/min (2 gms/500cc D5W at 30 cc/hr = 2 mg/min) Complications: (dec)BP, QRS widening, cardiac arrest, AV block, negative inotrope

Propofol (Diprivan) sedative hypnotic

Indication: ICU sedation for ventilator dependent intubated adult patients.
Maintenance: Use of premixed vials of either 50 ml or 100 ml (10 mg/ml). Begin infusion at 5 ug/kg/min*1 (2 cc/hr for 70 kg adult) and increase rate 5-10 ug/kg/min*1 q 5-10 minutes until sedation achieved. Maintenance infusion rates of 5-50 ug/kg/min*1 (2-21 cc/hr for 70 kg pat.) or greater may be required. Avoid abrupt discontinuation of maintenance infusion. Bolus dosing 10-20 mg IVP slowly to quickly increase depth of sedation for patients not at risk for hypotension.
Contraindications: hypersensitivity to Diprivan or it's components (glycerol, soy bean oil, egg lecithin), pregnant or nursing patients, pediatric patients, patients without intubation - mechanical ventilatory support.
Complications: hypotension, bradycardia, phlebitis, hyperlipidemia, respiratory depression-apnea, arterial desaturation.
NOTE: Use strict aseptic technique. Diprivan solution supports rapid microbial growth. Infusion vial stability is 12 hrs and remaining dose and tubing must be changed. If Diprivan is transferred, discard product and lines after 6 hrs. Daily CNS function and wake up must be performed. Reduce dose in patients receiving large doses of narcotics and sedatives, or >55 years old. Don't mix with other agents. Diprivan is based in a fat emulsion, where 1ml=0.1g fat (1.1 kcal). Adjust nutritional intake prn.

Footnote *1 Drip rate (cc/hr) = (wt, kg) (60) (dose)/ (conc) (1000); dose = ug/kg/min; conc = mg/cc or mg/ml

Succinylcholine (Anectine) ultra short acting depolarizing skeletal muscle relaxant

Indications: facilitate Intubation, adjunct to anesthesia
Dosages: 1.0-1.5 mg/kg; onset 30 seconds -1 min; duration- 4-6 min
Complications: malignant hyperthermia, hyperkalemia, cardiac arrest, bradycardia (may need Atropine), BP, causes temporary paralysis, IOP, ICP, myoglobinemia

Thrombolytic Agents - *Suggest Cardiology, Pulmonary, Vascular, or Neurology consultation

Indications: Acute MI; acute PE (massive); DVT; Acute ischemic stroke; Arterial embolism or thrombosis not left heart origin; AV cannulae occlusion

A) Acute Myocardial Infarction CCU admission and cardiology consult
B) Acute Pulmonary Embolism (Massive)

1) Activase (Alteplase-t-PA) -100 mg in 100 cc sterile water at 50 mg/hr infused over 2 hrs. Upon completion of Activase infusion, begin heparin infusion, typically without a LD, when aPTT or TT is less than or equal to 1.5 x control.
2) Streptase (Streptokinase-SK) -250,000 IU in 50 cc D5W IVPB over 30 minutes for LD. Maintenance infusion -100,000 IU Streptase/hr for a 24 hr continuous infusion. Upon completion of streptase infusion, begin heparin infusion, typically without a LD, when aPTT or TT is less than or equal to 1.5 x control.
3) Abbokinase (Urokinase-UK) -4,400 IU/kg in 50 cc NS IVPB over 10 minutes for LD. Maintenance infusion of 4,400 IU Urokinase/kg/hr for a 12 hr continuous infusion. Upon completion of the Urokinase infusion, begin heparin infusion, typically without a LD, when aPTT or TT is less than or equal to 1.5 x control.

C) Deep Vein Thrombosis

1) Streptase - Extend maintenance infusion for 48-72 hrs.
2) Abbokinase - Extend maintenance infusion for 24-48 hrs
3) Activase - not used


Absolute: Active internal bleeding, CVA (hemorrhagic), uncontrolled HTN >= 185/110 mmHg, known bleeding diathesis, recent head trauma or intracranial-intraspinal surgery (< 2 months), intracranial neoplasm, aneurysm or AVM, SAH, known severe allergic reaction.
Relative: recent major surgery, OB delivery, organ biopsy, puncture of noncompressible vessel, GU or GI bleeding, trauma, CPR (<10 days), HTN >= 180/110 mmHg, left heart thrombus, SBE, cerebrovascular disease, diabetic hemorrhagic retinopathy, acute pericarditis, hepatic dysfunction, septic thrombophlebitis, hemostatic defects with or without associated hepatic or renal disease, pregnancy and age >= 75.
Note -The risks of thrombolytic therapy should be weighed against the potential benefits.

Complications: bleeding (intracranial with ischemic stroke), reperfusion arryhthmias, hypersensitivity reactions, fever, chills, nausea, vomiting, hypotension, ARDS-SK (rare).

Vasopressin (Pitressin) arterial constriction, mesenteric vasoconstriction, H2O reabsorption in renal tubules

Dosage: GI bleed (esophageal varices) - 0.2-0.8 units/min (200 units/500cc D5W at 30 cc/hr = 0.2 units/min); Diabetes Insipidus -5-10 units IM or SubQ TID/QID
Complications: Avoid patients with significant vascular disease esp. AD; cardiac ischemia, peripheral cyanosis or Ischemia, arrhythmias, oliguria, hyponatremia, H2O intoxication, tremor, vomiting, abdominal cramps

Ramsey Sedation Scoring System

1 - anxious and agitated, restless;
2 -cooperative, oriented, tranquil;
3 -responding to verbal commands, drowsy;
4 - asleep, responsive to light stimulation (loud noise, tapping);
5 - asleep, slow response to stimulation;
6 - no response to stimulation