‌DILUTION PROTOCOL FOR EMERGENCY‌

DEPARTMENT

HOSPITAL TENGKU AMPUAN AFZAN 2ND EDITION


| ED HTAA DILUTION PROTOCOL 2020


This dilution protocol is a general guide for the use of drugs in Emergency & Trauma department, HTAA. It was prepared to facilitate doctors, nurses & medical assistants in general dosing recommendations, preparing the dilutions & the administration of frequently used medications in Emergency & Trauma department, HTAA.


Each drug is listed with information on the most commonly used dosing, dilution & administration based on few references as stated on the bottom page of each drug discussed.

You are also advised to check the most current product information provided by the manufacturer of each drug to be administered or consult pharmacist for latest info if there is change of brand/product later than the date this guideline was being prepared.


If, after reviewing the information in this protocol you still have any questions about the order placed before you, please clarify it with your senior physician, consult your pharmacist or seek advice from your supervisor.


Compiled by

Shamsiah binti Salim

Pegawai Farmasi Wad Kecemasan, Jabatan Farmasi,

Hospital Tengku Ampuan Afzan.


Reviewers (Alphabetical order)


Dr Badrul Hisham B. Md Supian

Pakar Perubatan Kecemasan & Trauma, Hospital Tengku Ampuan Afzan.

Dr Norizan Bt. Mustafa

Pakar Perubatan Kecemasan & Trauma, Hospital Tengku Ampuan Afzan.

Dr Yip Yat Keong

Pakar Perubatan Kecemasan & Trauma, Hospital Tengku Ampuan Afzan.

Dr Zainal Abidin B. Mohamed @ Ismail Pakar Perubatan Kecemasan & Trauma,

Ketua Perkhidmatan Jab. Kecemasan & Trauma Negeri Pahang.


Contents


DRUGS

PAGE

Acetylcysteine 2g/10ml

4-5

Adrenaline 1mg/ml

6

Adenosine 6mg/2ml

7

Alteplase 50mg/ml

8-9

Amiodarone 150mg/2ml

10

Aminophylline 250mg/10ml

11

Atropine 1mg/ml

12

Calcium Gluconate 10%

13

Charcoal Activated 50g (Powder)

14

Dexamethasone 8mg/2ml

15

Diazepam 10mg/2ml

16

Digoxin 0.5mg/2ml

17

Dobutamine 250mg/20ml

18

Dopamine 200mg/5ml

19

Fentanyl 100mcg/2ml

20

Flumazenil 0.5mg/5ml

21

Furosemide 20mg/2ml

22

Fuller’s Erath 60g (Powder)

23

Glyceryl Trinitrate 50mg/10ml

24

Heparin Inj 25000 unit/5ml

25

Hydralazine 20mg/ml

26

Insulin Inj (Actrapid)

27

Isosorbide Dinitrate 10mg/10ml

28

Ketamine 200mg/20ml

29

Labetalol 25mg/5ml

30

Lignocaine 10% 500mg/5ml

31

Lytic Cocktail Regime

32

Magnesium Sulphate 2.47g/5ml

33

Midazolam 5mg/ml

34-35

Morphine 10mg/ml

36

Naloxone Hcl 0.4mg/ml

37-38

Noradrenaline 4mg/4ml

39

Potassium Chloride 1g/10ml

40

Potassium Dihydrogen Phosphate 1.3g/10ml

41

Phenytoin 250mg/5ml

42

Phenobarbitone 200mg/ml

43

Proton Pump Inhibitors

44

Salbutamol 0.5mg/ml

45

Sodium Valproate 400mg/vial

46

Sodium Bicarbonate 8.4% 10ml

47-48

Streptokinase 1.5MU/vial

49


Tenecteplase 10,000 u (50mg) / vial

50

Tramadol 50mg/ml

51

Verapamil 5mg/ml

52

Cyanide Antidote

Sodium Nitrite 300mg/10ml Sodium Thiosulphate 12.5g/50ml

Hydroxocobalamin 5g/vial

53

54 -55

56-57

58-59

APPENDIX

Medications for Procedural Sedation & Analgesia Sedative Agents in Mechanically Ventilated Patients Analgesic Agents in Mechanically Ventilated Patients Dopamine Infusion Chart (Single Strength)

Dopamine Infusion Chart (Double Strength) Dobutamine Infusion Chart (Single Strength) Dobutamine Infusion Chart (Double Strength) Noradrenaline Infusion Chart (Single Strength) Noradrenaline Infusion Chart (Double Strength)


60-62

63-64

65

66

67

68

69

70

71


‌NEWLY ADDED DRUG (2022 ONWARDS)

Esmolol Hcl 100mg/10ml Inj…………………………………………………… Human Albumin 5% (12.5g In 250ml) Inj……………………………… Vasopressin 20 Iu/Ml Inj…………………………………………………………. Nicardipine 1mg/Ml Inj…………………………………………………………….


72

73

74

75


‌ACETYLCYSTEINE 2g/10ml‌


(i) Paracetamol Poisoning regimen:

IV NAC: (a) 150mg/kg in 200ml D5% over 15 mins, then

  1. 50mg/kg in 500ml D5% over 4 hours, then

  2. 100mg/kg in 1000ml D5% over 16 hours


Oral NAC: (a) 140mg/kg by mouth or nasogastric tube diluted to 5% solution, then (b) 70mg/kg by mouth q4h x 17 doses


PARACETAMOL POISONING IN CHILDREN:

Refer to adult dosing, however fluid volume should be reduce as below:

Dilution Volume of D5%

Body Weight (Kg)

Loading Dose: 150mg/kg over 15 mins

(in 3ml/kg D5%)

2nd Dose:

50mg/kg Over 4 hours (in 7ml/kg D5%)

3rd Dose:

100mg/kg over 16 hours (in 14ml/kg D5%)

10

30

70

140

15

45

105

210

20

60

140

280

25

75

175

350

30

90

210

420


(ii) Acute Liver Failure (non acetaminophen related) regimen: (Gastro)


IV NAC: (a) 150mg/kg in 200ml D5% over 1 hour, then

  1. 12.5mg/kg/hour in 500ml D5% over 4 hours, then

  2. 6.25mg/kg/hour in 1000ml D5% over 67 hours


Note for Dose & Administration:

  1. For (b) & (c), remember to multiply the dose to the number of HOURS to get the total dose for 4 hours and 67 hours respectively.

  2. For (c), due to the stability of the diluted NAC to be 24 hours only, the administration of the total dose in 1000ml over 67 hours is divided into 4:4:2 ratio as follows:

    1. 4 parts of 10 of total dose in 400ml over 24 hrs

    2. 4 parts of 10 of total dose in 400ml over next 24 hrs total 67 hours

    3. 2 parts of 10 of total dose in 200ml over remaining 19 hrs


(iii) CT Scan regimen:


IV NAC: (a) 2 hours before scan: 150mg/kg in 500ml D5% over 2 hours, then

(b) 4-6 hours after scan: 50mg/kg in 500ml D5% over 2 hours


Oral NAC: (a) 1 day before scan: 600-1200mg BD, then

(b) On the day of scan: 600-1200mg BD, then

(c) 1 day after scan: 600-1200mg BD

*normally prescribed as T. NAC 600mg or 1200mg BD x3/7*


References:

  1. Paracetamol poisoning in adults: Treatment, Uptodate, Feb 2020

  2. Acute Liver Failure in adults: Management and prognosis, Uptodate, April 2020

  3. Julie Polson & William M. Lee. AASLD: The management of acute liver failure. Hepatology, May 2005.

  4. William M. Lee et al. Intravenous N-Acetylcysteine improves transplant-free survival in early stage nonacetaminophen acute liver failure. Gastroenterology 2009.

  5. Paediatric Protocol for Malaysian Hospitals, 4th Edition 2019.


Adrenaline 1MG/ML (1ml=1mg or 1:1000) inj


  1. Asystole/pulseless cardiac arrest (During CPR) (1:1000)

    • Intravenous / Intraosseous: 1mg every 3-5 mins followed by 20ml flush

    • Endotracheal: 2 – 2.5mg dilute in 5 – 10ml NS / sterile water every 3 – 5 mins


  2. Bradycardia (symptomatic, unresponsive to atropine or pacing)

    • IV continuous infusion 0.1 – 0.5 mcg/kg/min.

  3. Asthma, acute severe, unresponsive to inhaled beta-agonist:

    • IM, SC (1:1000): 0.3 – 0.5 mg every 20 minutes (3 doses)

  4. Hypersensitivity reaction (anaphylaxis):

    • Endotracheal (ET)

      • 2 – 2.5 mg dilute in 5 – 10ml NS/sterile water every 3-5 minutes


    • Intramuscular, IM (1: 1000)

      • 0.2 – 0.5mg or 0.01mg/kg (max 0.5mg)

      • Repeat at 5 – 15 mins interval if needed to max of 3 doses.


    • Intravenous, IV (1: 10 000)

      • In patients unresponsive to repeated doses of IM and fluid

      • Slow IV Bolus: 0.05 – 0.1 mg give slowly over 5 to 10 minutes

      • Continuous Infusion: 1 – 15 mcg/min


  5. Hypotension/shock:

    • Anaphylactic Shock: 1 – 15 mcg/min

    • Cardiogenic Shock: 0.01 – 0.5 mcg/kg/min or 1 – 35mcg/min

    • Septic Shock: 0.01– 2 mcg/kg/min or 1 – 140mcg/min


      Dilution for Continuous Infusion:

      3mg (3amp) + NS = 50ml Strength: 60mcg/ml


      Infusion rate: According to dose ordered

      (e.g: 1mcg/min = 1ml/hr) (e.g: 2mcg/min = 2ml/hr)

      Precaution/ Remarks:

    • 1:10 0000 = 0.1mg/ml, 1:1 000 = 1mg/ml

    • Deep IM in anterolateral aspect in the middle third of thigh is preferred in setting of anaphylaxis.

    • Rapid IV bolus administration is associated with cardiac arrythmias, only use if absolutely necessary.

    • Inotropic actions predominates at lower doses, while vasoconstrictive actions predominates at higher doses.

Reference:

  1. Drug Info, Lexicomp, Uptodate 2020.

    Adenosine 6MG/2ML Inj

    Indication: Stable Narrow complex SVT


    Dose:

    Initial dose: 6mg 12mg (1-2 vial)

    (If not revert after in1-2 minutes of initial dose)

    Second dose: 12mg (2 vials)

    (If still not revert in 1-2 minutes after 2nd dose)

    Third dose: 12mg (2 vials)


    Administration:

    Place patient in mild reverse Trendelenburgh position Prepare IV Adenosine & 20ml flush in 2 separate syringe Attached both syringes to IV injection port closest to patient Push IV adenosine as quickly as possible (in 1-3 seconds)

    While maintaining pressure on IV Adenosine plunger, push 20ml NS flush as rapidly as possible after IV Adenosine.

    Elevate arm (above heart) for 10-20 seconds.


    Precautions/Remarks:

    • Should be given in large bore line (i.e: brachial region)

    • Prior to administration, remind patient about the side effects, chest discomfort, dyspnea, flushing. Give reassurance that effect is brief.

    • Perform continuous ECG monitoring during administration.

    • Reduce initial dose to 3mg if patient on Dipyridamole, Carbamazepine, heart transplant or if given by central IV access.

    • Less effective in patients taking theophylline, caffeine (might need larger dose of 18mg)

    • Contraindicated in patients with asthma, poison/drug-induce tachycardia, or 2nd or 3rd degree heart block.

    • If conversion attempts fail, initiate rate control with either intravenous CCB or beta-blocker.


    Reference:

    1. ACLS 2015, American Heart Association.

    2. Drug Info, Lexicomp, uptodate 2020.

    3. Dilution Guide for High Alert Medication, Pharmaceutical Service Division, MOH 2011


      Alteplase 50 MG/ML Inj (ACTILYSE)

Indication:

  1. Thrombolytic treatment in acute ischemic stroke

    • Treatment must be started as early as possible (within 4.5 hours after onset of stroke)

    • Treatment effect is time-dependent; earlier treatment increases probability of favorable outcome.

  2. Thrombolytic treatment in acute myocardial infarction

    • 90 minutes (accelerated) dose regimen; treatment that can be started within 6 hours after symptoms onset.

    • 3 hours dose regimen; treatment that can be started between 6-12 hrs after symptoms onset.

  3. Thrombolytic treatment in acute massive pulmonary embolism with hemodynamic instability.

    • Diagnosis confirmed with pulmonary angiography or lung scanning.


Dose:


  1. Acute Ischemic Stroke

    • 0.9 mg/kg (maximum 90 mg) infused over 1 hour.

    • 10% of total dose administer as initial bolus dose, and then infused the balance of 90% over 1 hour.



Weight (kg)

Total dose (mg)

[0.9 mg/kg]

Total Volume (ml)

Volume to be administer (Conc: 1 mg/ml Alteplase)

10% Bolus dose

90% remaining dose over 1 hr

50

45

45

4.5 ml

40.5 ml

55

49.5

49.5

5 ml

44.5 ml

60

54

54

5.4 ml

48.6 ml

65

58.5

58.5

5.9 ml

52.6 ml

70

63

63

6.3 ml

56.7 ml

75

67.5

67.5

6.8 ml

60.7 ml

80

72

72

7.2 ml

64.8 ml

85

76.5

76.5

7.7 ml

68.8 ml

90

81

81

8.1 ml

72.9 ml

95

85.5

85.5

8.6 ml

76.9 ml

100

90

90

9 ml

81 ml

* Max dose: 90 mg

  1. Acute Myocardial Infarction

    • 90 mins accelerated dose regimen: 15 mg as bolus, 50 mg as infusion

      over 60 mins, & 35 mg as infusion over 30 mins.

    • 3 hrs dose regimen: 10 mg as bolus, 50 mg as infusion over 1 hour, then 40 mg over 2 hours.

  2. Pulmonary Embolism

    • 100 mg over 2 hours

    • 10 mp as bolus, 90 mg as infusion over 2 hours.

    • For body weight < 65 kp: total dose should not exceed 1.5 mg/kg


    Dilution & Administration:

    • 50 mp Alteplase, diluted with 50 ml sterile water for injection

    • Final concentration: 1 mp/ml


      Storage & Stability:

    • Reconstituted solution

      Precautions / Special Warning:

      • Arrythmias: Coronary thrombolysis may result in reperfusion arrythmia

      • Bleeding, doses > 150mp associated with significantly increased risk of intracranial hemorrhage.

    References:

    1. Product Leaftlet ACTYLYSE, Boehringer Ingelheim 2020

    2. Drug Information Handbook, Lexicomp


Amiodarone 150MG/3ML Inj

  1. VF/VT Cardiac Arrest

    • First dose: 300mg IV push

    • Second dose (if needed): 150mg IV push

    • Upon ROSC: IV 1mg/min for 6 hours, then 0.5mg/min for 18hrs.


  2. Life-threatening Arrhythmias

(Maximum cumulative dose: 2.2 g over 24 hours)

ACLS 2010, AHA Guideline

Initial dose: 150mg over 15mins

Dilute 150mg (1amp) in 50ml D5% run 200ml/Hr


Then; 300mg over 6 hours

Dilute 300mg (2amp) in 100ml D5% run 17ml/hr

Then; 600mg over 18 hours

Dilute 600mg (4amp) in 500ml D5% run 28ml/hr

OR


British Resuscitation Guideline, 2010

Initial dose: 300mg over 1 hour

Dilute 300mg (2amp) in 50ml D5% run 50ml/hr

Then; 900mg over 23hours

Dilute 900mg (6amp) in 500ml D5% run 21ml/hr


Precautions:


Reference:

  1. ACLS 2015, AHA

  2. British Resuscitation Guidelines 2010.

  3. Drug Info, Lexicomp, Uptodate 2020

  4. Dilution Guide for High Alert Medication, Pharmaceutical Service Division, MOH 2011


    Aminophylline 250MG/10ML Inj

Indication: Prevention & treatment of bronchospasm.

Loading dose: (6mg/kg); 250mg (1amp) + NS = 100ml run over 1hour

Maintenance dose: Non-smoker: 0.5mg/kg/hr

* Reduce dose by 50% in heart failure & hepatic problem (prolonged half life)

Dilution for Maintenance dose:

250mg (1amp) + NS/D5%= 50ml Strength: 5mg/ml

Infusion rate: Calculate according to dose & body weight

Weight (kg)

Aminophylline Dose ( ml/hour)

Non-Smoker (0.5mg/kg/hr)

Smoker (0.8mg/kg/hr)

Elderly (0.3mg/kg/hr)

60

6 ml/hr

9.6 ml/hr

3.6 ml/hr

70

7 ml/hr

11.2 ml/hr

4.2 ml/hr

80

8 ml/hr

12.8 ml/hr

4.8 ml/hr

90

9 ml/hr

14.4 ml/hr

5.4 ml/hr

100

10 ml/hr

16.0 ml/hr

6.0 ml/hr

110

11 ml/hr

17.6 ml/hr

6.6 ml/hr

120

12 ml/hr

19.2 ml/hr

7.2 ml/hr

130

13 ml/hr

20.8 ml/hr

7.8 ml/hr

OR

250mg (1amp) + NS/D5%= 500ml Strength: 0.5mg/ml

Infusion rate: Run over 8 hours *(Dose administer = 31.25mg/hour;

if BW 60kg dose given is 0.52mg/kg/hr)


Precautions

  1. Contraindication: Uncontrolled arrhythmias, hyperthyroidism.

  2. Toxicity: Life threatening ventricular arrhythmias, seizure.

  3. Early signs of toxicity: Nausea, vomiting, abdominal pain, diarrhea, insomnia, irritability, headache, palpitations, confusion, agitated or manic behavior.


Remarks:

  1. GOLD 2014 Weak bronchodilator, 2nd line therapy in AECOAD (use when insufficient response to short acting bronchodilators)

  2. GOLD 2019 Not recommended due to increased side effects profiles

  3. GINA 2019 No role in asthma, poor efficacy & safety profile. Greater effectiveness & safety of SABA.

  4. Narrow therapeutic index. Target therapeutic range: 10-20mcg/ml

  5. Monitor level 12 - 24hours after loading dose

  6. The infusion rate for maintenance dose is only for reference. Please follow TDM suggestion for further dosing.

Reference:

  1. GOLD Report 2019

  2. Drug Info, Lexicomp, Uptodate 2020


Atropine Sulphate 1MG/ML Inj


Indication & Dose:


  1. Bradycardia

    Adult: IV 0.5mg every 3-5 mins. Not to exceed total of 3mg or 0.04mg/kg.

    *Dose <0.5mg result in paradoxical bradycardia


    Child: IV 0.02mg/kg every 3-5 mins (Max single dose is 0.5mg). Not to exceed total dose of 1mg.

    *Dose <0.1mg result in paradoxical bradycardia

    Reconstitution: Not required Further dilution: Not required

    Administration: Administer undiluted by rapid IV injection (slow injection may result on paradoxical bradycardia).


  2. Organophosphate Poisoning

    Loading: IV Bolus, 1-5mg q3-5mins until fully atropinised.

    Double the dose if previous dose does not induce atropinisation.

    Administration: Give undiluted over 15-30sec. Maintenance: IV Infusion,

    Give undiluted, run 0.5-1mg/hr OR 10-20% of total LD/hr.


  3. Muscle Relaxant Antagonist

    Dose: IV 0.6-1.2mg of atropine, for each 0.5-2mg neostigmine, Give in a separate syringe few mins before neostigmine.

    Administration: Give undiluted.


    STORAGE & STABILITY

    Intact Vials: Store below 25°C Protect from light.


    References:

    1. ACLS 2015, AHA.

    2. Product Leaftlet – Acipan

    3. Ministry of Health Malaysia. Critical Care Pharmacy Handbook. Pharmaceutical Service Division 2013.

    4. Drug Information, Lexicomp, Uptodate 2020.


Calcium Gluconate 10% (1g/10ml) (~2.3mmol Ca2+) Inj

Preparation: 1 vial 10% (1g in10 ml) = 2.3 mmol calcium ion.


Dose:

Hypocalcemia:

Reconstitution: 50gm in 400ml water. (1g=8ml)


Dose & Administration: Adult: 25-100gm

Child 1-12yo: 25-50gm OR 0.5-1g/kg

Child < 1yo: 0.5-1g/kg



Remarks :


Reconstitution: Not required

Further Dilution: See Indication & Dose


Indication & Dose:


  1. Meningitis

    IV 10mg 6hourly for up to 4 days.


  2. Cerebral Oedema

    IV 10mg stat, then IV/IM 4mg


  3. Viral Croup in Paediatrics Dose IV/IM: 0.3-0.6mg/kg IM: Administer undiluted

    Slow IV: Administer undiluted solution slowly over 3-5 minutes.

    IV Infusion: Further dilute in 50-100ml NS or D5, run over 15-30mins.


    Remarks

      • In shock use only IV route

      • In meningitis, to give dexamethasone 15-20mins before or during the first dose of antibiotics.


    Storage & Stability

    Intact Vials: Store at 15-25°C. Protect from light. Diluted solution: 24hours at room temperature.


    References:

    1. Product Leaftlet – Penatone

    2. HUKM Drug Formulary 2010, 5th Edition

    3. Ministry of Health Malaysia. Paediatric Protocol 4th edition. 2019.

    4. Drug Information Lexicomp, Uptodate 2020

    5. Ministry of Health Malaysia. National Antibiotic Guideline 2nd edition. 2014. Pharmaceutical Services Division


Diazepam 10MG/2ML inj

Indication: Status Epilepticus


Loading dose:

Intravenous (IV): 0.15 mg/kg IV up to 10 mg per dose,

May repeat in 5 min (Max: 30mg)


Per Rectal (PR):

2–5 years: 0.5 mg/kg

6–11 years: 0.3 mg/kg

> 12 years: 0.2 mg/kg (Max: 20mg in children)

Dilution: Undiluted

Given as slow IV bolus over 1-2 minutes (rate ≤ 5mg/min)


Anti-convulsant for Eclampsia (severe PE)


Reference:

  1. Brophy G.M., et al; Guidelines for the Evaluation and Management of Status Epilepticus, Neurocrit Care, April 2012.

  2. Product leaflet, Sanofi

  3. Drug Info, Lexicomp, Uptodate 2020

  4. CPG Hypertension, 2018 MOH.


    Inj Digoxin 0.5MG/2ML

Indication:


Reference:

  1. ACLS 2015, AHA

  2. Drug Info, Lexicomp, Uptodate 2020

  3. Dilution Guide for High Alert Medication, Pharmaceutical Service Division, MOH 2011


Dobutamine 250MG/20ML Inj

Indication:

Hypotension

Decompensated Heart Failure (short term infusion for symptomatic benefit) Dose: 1 – 20mcg/kg/min

Dilution:

Single Strength 250mg (1amp) + NS = 50ml Strength: 5mg/ml Double Strength 500mg (2amp) + NS = 50ml Strength: 10mg/ml


Infusion Rate: Refer infusion rate chart


Stability: 24 hours


Reference:

  1. Drug Info, Lexicomp, Uptodate 2020

  2. Dilution Guide for High Alert Medication, Pharmaceutical Service Division, MOH 2011


Dopamine 200MG/5ML Inj

Indication: Non-Hypovolemic Hypotension


Dose:

Increase urine output: 1 - 3mcg/kg/min Inotropic & heart rate effect:3 – 10mcg/kg/min Vasoconstrictive effect: 10 - 20mcg/kg/min


Dilution:

Single Strength: 200mg (1amp) + NS = 50ml. Strength: 4mg/ml

Double Strength: 400mg (2amp) + NS = 50ml Strength: 8mg/ml


Infusion Rate: Refer infusion rate chart


Stability: 24 hours

Must be diluted before use.

Do not mix with sodium bicarbonate / strong alkaline solution.


Precautions:


Reference:

  1. Drug Info, Lexicomp, Uptodate 2020

  2. Dilution Guide for High Alert Medication, Pharmaceutical Service Division, MOH 2011


Fentanyl 100MCG/2ML Inj

Dose & Indication:

  1. Minor procedures / analgesia:

    • 0.5 – 2mcg/kg/dose (3 mins before procedure, may repeat every 1-2 hours)


  2. Premedications (RSI):

    • 0.3 – 0.5 mcg/kg


  3. Analgesia (Critically ill patients)

    • Initial Dose: 0.35 – 1.5mcg/kg every 30-60mins as needed

    • Maintenance dose: 0.7 – 10 mcg/kg/hr


Dilution:


  1. For IV Bolus:

    • 100mcg/ml (1amp) + 10ml NS

    • Rate: Slow bolus over 3-5 mins


  2. For IV Infusion:

    • 200mcg (2amps) + NS/D5% = 20ml Strength : 10mcg/ml

    • Rate: Start at 2ml/hr titrate as needed to max dose of 10mcg/kg/hr

    • E.g: maximum infusion rate of 60ml/hr for patient with BW of 60kg Stability: Use within 24 hours

      Precautions/remarks:

    • Muscle and chest wall rigidity may occur with rapid IV administration.

    • Fentanyl is 50-100 times as potent as morphine (10mg IM Morphine = 0.1-0.2mg IM Fentanyl)

    • Has less hypotensive effects than Morphine.

    • May cause muscle rigidity with high doses.

    • Onset of action 2-5 mins, with duration of 0.5 – 1 hour.


      Serious Adverse effects:

    • Hypotension

    • Respiratory depression


Reference:

  1. Drug Info, Lexicomp Uptodate 2020.

  2. Critical Care Pharmacy Handbook, Pharmaceutical Service Division, MOH


Flumazenil 0.5MG/5ML Inj

Reconstitution: Not Required

Further Dilution: See Dose & Administration

Dose & Administration


  1. Reversal of Benzodiazepine

    • IV Bolus:

      • 0.2mg, undiluted over 15 seconds

      • If adequate consciousness not obtained in 45seconds, give 0.2mg every 1min (Max dose: 1mg)


    • Occurrence of re-sedation:

      • 1mg at 20mins interval (Max: 3mg in any 1 hour)


  2. Benzodiazepine Overdose

    • IV Bolus

      • 0.2mg, undiluted over 30 seconds

      • If adequate consciousness is not obtained in 30 seconds, give another 0.3mg over 30 seconds

      • If needed, give further doses of 0.5mg over 30 seconds at 1 min intervals to a max of 3mg.

      • Patient with only partial respond to 3mg, may require slow additional titration to a total dose of 5mg.

      • If no response 5mins after receiving total dose of 5mg, overdose is unlikely to be Benzodiazepine & further treatment with Flumazenil will not help.


    • Alternative to repeated bolus:

      • IV infusion 0.1-0.4 mg/hr

      • Dilute 5mg in 50ml NS/D5% Strength 0.1mg/ml

      • Rate: 1-4ml/hr

    • Occurrence of re-sedation: 1mg at 20mins interval (Max: 3mg in any 1 hour)


      Storage & Stability

    • Administer through a freely running IV infusion into large vein

    • Stable for 24hours if drawn into a syringe or mixed with solutions


References:

  1. Micromedex Drug Reference Essentials

  2. Drug Information Lexicomp, Uptodate 2020.


Furosemide 20MG/2ml Inj

Indication: Diuretics

Acute heart failure


Dose:

IV Slow Bolus: 40 - 100mg IV give slowly over 1-2 minutes

IV Infusion: 5 – 20mg/hr

*better than intermittent very high bolus doses


Dilution: Undiluted; 20mg of 2ml (1amp) Strength: 10mg/ml

Infusion rate: According to dose ordered

(e.g: 1 mg/hr = 0.1 ml/hr)

(e.g: 2 mg/hr = 0.2 ml/hr)

(e.g: 3 mg/hr = 0.3 ml/hr)

(e.g: 4 mg/hr = 0.4 ml/hr)

(e.g: 5 mg/hr = 0.5 ml/hr) (e.g: 10 mg/hr = 1ml/hr)


Precautions/remarks:


Reference:

  1. Heart Failure CPG 2019, MOH

  2. Heart Failure Management, ACC/AHA/HFSA Focus Update 2017

  3. Drug Information Lexicomp, Uptodate 2020


Fuller’s Earth 60g (Powder)


Indication: Adsorbent in pesticides poisoning


Dose:


Paraquat poisoning

Adult: 100 – 150g every 2- 4 hours x 3 doses

Child <12yo: 1-2 g/kg


Administration:

100g of Fuller’s Earth is mixed with 200ml water (30% suspension)


Remarks:


GlycerylTrinitrate 50MG/10ML Inj

Indication: Hypertensive Emergencies

Prophylaxis or treatment of angina

Acute decompensated left ventricular failure


Dose:


Dilution: 15mg (3ml) + NS/D5% = 50 ml Strength: 300mcg/ml


Infusion Rate: According to dose ordered

(e.g: 5 mcg/min = 1 ml/hr)

(e.g: 10 mcg/min = 2 ml/hr)

(e.g: 15 mcg/min = 3 ml/hr)

(e.g: 20 mcg/min = 4 ml/hr)


Stability: 40 – 48hours

Must be diluted before use.


Precautions/remarks:


Reference:

  1. Hypertension CPG 2018, MOH

  2. Drug Info, Lexicomp, uptodate 2020.

  3. Dilution Guide for High Alert Medication, Pharmaceutical Service Division, MOH 2011


    Heparin Inj

Available preparations:

    1. IV Heparin 5, 000 units of 5ml/vial Strength: 1000unit/ml (Red)

    2. IV Heparin 25,000 units of 5ml/vial Strength: 5000 unit/ml (Blue)


Dose:

STEMI/ NSTEMI

VTE Treatment



OR

Inj Enoxaparin 40mg syringe @ 60mg syringe

STEMI/NSTEMI:

≤ 75 years: 30mg IV bolus; then SC 1 mg/kg BD

≥ 75 years: no IV bolus; SC 0.75mg/kg BD

VTE Treatment: 1mg/kg BD

OR

Inj Fondaparinux 2.5mg syringe @ 7.5mg syringe

STEMI: IV 2.5mg bolus; then SC 2.5mg OD

NSTEMI: SC 2.5mg OD

VTE Treatment: < 50kg: 5mg OD, 50-100kg: 7.5mg OD, > 100kg: 10mg OD


Reference:


Hydralazine 20MG/ML Inj

Indication: Hypertensive Emergencies

Dose:

IV bolus: 5 – 10mg slow IV over 2 minutes;

Maybe repeated 5mg after 20–30 minutes, (max 20mg bolus dose) Dilution for bolus: 20mg (1amp) + NS = 20ml


IV Infusion: 200–300 mcg/min initially, Maintenance 50–150 mcg/min


Dilution for infusion:

20mg (1amp) + NS =20ml Strength: 1000 mcg/ml (1mg/ml)


Infusion Rate: According to dose ordered

(50mcg/min = 3ml/hr) (100 mcg/min = 6ml/hr)


In pregnancy:

Initial dose: 25 μg/min IV infusion Dilution: 25 mg in 500 ml normal saline Infusion rate: 30 ml/hour


Stability: 24 hours

Must be diluted before use.


Precautions/side effects:


Reference:

  1. Hypertension CPG 2018, MOH

  2. Drug Info, Lexicomp, Uptodate 2020

  3. Dilution Guide for High Alert Medication, Pharmaceutical Service Division, MOH 201


Insulin (ACTRAPID) Inj

IV Actrapid1000unit/10ml (Strength: 100unit/ml)

Dose:

Diabetic Ketoacidosis (DKA)

Hyperosmolar Hyperglycemic State (HHS)


Reference:

  1. CPG Managemrnt of DM 5th Edition, 2016

  2. HTAA DKA Management Chart (Adult)


Isosorbide Dinitrate 10MG/10ML Inj

Indication: Hypertensive Emergencies


Dose: 2- 20 mg/hr


Dilution:

Undiluted:

10mg (1 amp) in 10ml Strength: 1mg/ml Infusion Rate: According to dose ordered

(e.g: 2 mg/hr = 2 ml/hr)

(e.g: 3 mg/hr = 3 ml/hr)

(e.g: 4 mg/hr = 4 ml/hr)


OR


Dilute:

10mg (1amp) + NS/D% = 20ml Strength 0.5mg/ml Infusion Rate: According to dose ordered

(e.g: 2 mg/hr = 4 ml/hr)

(e.g: 3 mg/hr = 6 ml/hr)

(e.g: 4 mg/hr = 8 ml/hr)


Stability: 24 hours


Precautions/remarks:


Reference:

  1. Isoket Product leaflet, GlaxoSmithKline

  2. CPG Management of Hypertension, 5th Edition 2018.


    Ketamine HCL 200MG/20ML Inj

Reconstitution Not Required

Further Dilution See Administration


Indications & Administration:


    1. Induction Of Anaesthesia

      • Slow IV Bolus: 0.5-2mg/kg. Give undiluted, administer over at least 1 minute.

      • IM: 4-10mg/kg.

      • If adjuvant drugs are used eg midazolam can give dose lower dose.


    2. Procedural Sedation

      • Slow IV Bolus: 1mg/kg

      • IM: 2-4mg/kg


    3. Sedation in critically ill


      Loading dose

      IV 0.2-

      0.

      75mg/kg

      Undiluted

      Over at least 1 min

      Maintenance dose

      Infusion: 2- 7mcg/kg/min

      Dilution: 100mg (10ml) + NS/D5%=

      50ml

      Rate: For BW 70kg: 3.6

      ml/hr - max

      12.6 ml/hr


      Remarks

      • Rapid administration may result in respiratory depression and enhanced pressor response.

      • Not to run via the same line as IV Barbiturate and IV Diazepam.

      • Dilute to concentration of 1- 2mg/ml.

      • Onset for IV: 30 seconds, duration for 5-10mins.

      • Onset for IM: 3-4mins, duration12-25 mins.

        Storage & Stability

      • Intact Vials: Store below 25°C.


References:

  1. Product Leaftlet – Fresenius

  2. Drug Information Lexicomp, Uptodate 2020.


Labetalol HCL 25MG/5ML Inj

Indication: Hypertensive emergency

Dose:

IV bolus1: 20 mg injected slowly over at least 2 minutes Followed by 40 – 80mg every 10mins, (Max 200mg)

IV infusion: 0.5 - 2mg/min

(Cont infusion may exceed max cumulative dose recommended of 300mg, with close monitoring) 2,4


Dilution:

  1. Diluted (given via peripheral line)

    • 50 mg (2amp) + 30ml NS/D5% = 50ml Strength: 1mg/ml

    • Infusion Rate: According to dose ordered (e.g: 0.5 mg/min = 30 ml/hr)

      (e.g: 1.0 mg/min = 60 ml/hr)

      (e.g: 1.5 mg/min = 90 ml/hr)

      (e.g: 2.0 mg/min = 120 ml/hr)


      OR

  2. Undiluted

    • 100 mg (4amp of 25ml/5ml) = 20ml Strength: 5mg/ml

    • Infusion Rate: According to dose ordered (e.g: 0.5 mg/min = 6 ml/hr)

      (e.g: 1.0 mg/min = 12 ml/hr)

      (e.g: 1.5 mg/min = 18 ml/hr)

      (e.g: 2.0 mg/min = 24 ml/hr)

      Stability: 24 hours, Do not mix with sodium bicarbonate, Diluents NS/D5%


      Precautions:

    • Excessive administration (>300mg) may result in prolonged hypotension and/or bradycardia.

    • Contraindicated in bronchial asthma, severe bradycardia, cardiogenic shock & used with cautions in heart failure.

    • Titrate dose every 30 minutes to stabilize blood pressure.

    • Discontinue by weaning over 1-2 hours when blood pressure is consistently

<155/95mmHg.

Reference:

  1. Hypertension CPG 2018, MOH

  2. Drug Info, Lexicomp, Uptodate 2020

  3. Dilution Guide for High Alert Medication, Pharmaceutical Service Division, MOH 2011

  4. Goldsmith TL, et al. Prolonged labetalol infusion for management of severe hypertension and tachycardia in a critically ill trauma patient. DICP. 1990;24(3):235-258


    Lignocaine 2% 100MG/5ML Inj

Indication:


Reference:

  1. ACLS 2010, AHA

  2. Drug Info, Lexicomp


Lytic Cocktail Regime


Hyperkalemia (Lytic Cocktail Regime)


10 ml of IV Calcium gluconate 10% over 10 minutes

+

50ml of IV Dextrose 50% over 15 – 30 minutes

+

10 units of IV Insulin (Actrapid)


Reference:

1. Sarawak Handbook of Medical Emergencies, 3rd Edition.


Magnesium Sulphate 2.47g/5ml (10mmol Mg2+ ion) inj

  1. Torsades de Pointes / Digitalis toxicity.

    Loading dose:1-2g (2 - 4ml) + NS = 20ml run over 20mins

    (Infusion rate: 60ml/hr)


    Maintenance dose: 0.5 – 1g/hour infusion (until resolves)

    Dilution: 2.5g (5ml, 1amp) + NS = 50ml run 20ml/hr


  2. Acute Exacerbation of Bronchial Asthma

    Dose: 2g (4ml) dilute in 20ml NS run over 20 minutes

    (Infusion rate: 60ml/hr)


  3. Pre-Eclampsia:

    Loading dose:4g (8ml) in 20ml NS run over 15 minutes

    (Infusion rate: 80ml/hr)


    Maintenance dose:

    Intravenous route: IV infusion 1g/hr until delivery

    2.5g (5ml, 1amp) + NS =50ml run 20ml/hr


    Intramuscular route:

    Give immediately after giving IV loading dose;

    IM 10g, then IM 5g every 4hours in alternate buttock.


    Precautions:

    • Clinical monitoring is of utmost importance, looking for signs of toxicity (especially loss of deep tendon reflexes, respiratory depression with rate <16/minute) and renal impairment (hourly urine output <30 ml/hour).

    • Levels >12mEq/L (>6mmol/L) can lead to respiratory paralysis & heart block.

    • Occasional fall in blood pressure with rapid administration.

    • IM may cause irritation and pain at injection site.

    • Do not mix with calcium salt, bicarbonate or phosphate.


Reference:

  1. Hypertension CPG, 2018 MOH.

  2. Dilution Guide for High Alert Medication, Pharmaceutical Service Division, MOH 2011


Midazolam 5mg/ml

Dose & Indication: Adult

  1. Induction Anesthesia

    Unpremedicated

    • 0.3-0.35 mg/kg over 20-30 secs

    • Repeat if needed at ~25% of initial dose every 2 mins

    • Up to 0.6 mg/kg

      Premedicated

      • 0.05 to 0.2 mg/kg

      Maintenance

      • 0.05 mg/kg

      • Infusion: 0.015 - 0.06

        mg/kg/hr @ 0.25 - 1 mcg/kg/min


  2. Sedation/anxiolysis/amnesia (preoperative/procedural):

    Unpremedicated

    • IM: 0.07 to 0.08 mg/kg, 30-60mins prior

    • IV: 0.5-2mg, repeat doses every 2-3 mins if needed

      Premedicated

        • Reduce initial dose by 30%.

          Maintenance

      • 25% of dose used to reach sedative effect


  3. Sedation in mechanically ventilated ICU patients:1


    Initial Dose

    • 0.01- 0.05 mg/kg (~0.5 to 4 mg)

    • Repeat every 10 -15min until adequate sedation

      Maintenance infusion

      • 0.02 to 0.1 mg/kg/hr @

      • 0.3 to 1.7 mcg/kg/min


  4. Prehospital status epilepticus:


    Intramuscular (IM)

    • 0.2mg/kg @ 10mg once

    Intranasal

    • 0.2mg/kg

    • Use 5mg/ml solution

    Buccal

    • 0.5mg/kg

  5. Status epilepticus, refractory 2



Morphine 10mg/ml

Indication & Dose:

  1. Acute coronary syndrome, refractory ischemic chest pain

    • IV: 2-4mg, then 2-8 mg every 5 to 15 minutes as needed @

    • IV: 1-5 mg, then 1 to 5 mg every 5 to 30 minutes as needed

  2. Analgesia for Mechanically Ventilated Patient

    • Initial Dose:

      • 0.01 – 0.15 mg/kg every 1-2 hours as needed

    • Maintenance Dose:

      • 0.07 – 0.5 mg/kg/hr

        Dilution:


        20mg (2 amp) + NS/D5% = 20ml Strength 1mg/ml Infusion Rate: according to dose ordered

    • E.g : Patient with body weight of 60kg

0.07 mg/kg/hr = 4.2 ml/hr

    1. mg/kg/hr = 6 ml/hr

    2. mg/kg/hr = 12 ml/hr

    3. mg/kg/hr = 18 ml/hr

    4. mg/kg/hr = 24 ml/hr

    5. mg/kg/hr = 30 ml/hr


Precautions/Remarks:


Naloxone HCL 0.4MG/ML Inj

Indication & Dose:

  1. Opioids Overdose/ Intoxication with Respiratory Depression


    Indication / Dose

    Opioids Overdose/ Intoxication

    Opioid Naïve

    Opioids Dependent

    Initial Dose (IV, IM SC)

    3 minutes.

    After Successful Reversal

    (IV, IM SC)

    Continuous Infusion

    • 0.4 – 2 mg every 2-

    • 0.1– 0.2 mg every 2-3 minutes

    • Lower dose to avoid acute withdrawal

    • Re-administer at later interval; every 20-60 mins.

    • If no response after total 10mg, consider other causes of respiratory depression.

    • Use in exposure to long acting opioids (methadone) or sustained release products.

    • Use 2/3 of initial effective bolus dose on hourly basis (usually 0.25 – 6.25mg/hr).

    • 1/2 of the initial bolus dose should be re- administered 15 mins after initiation of continuous infusion to prevent drop in naloxone levels


  2. Reversal Respiratory Depression with Therapeutic Opioid Doses


    Indication

    / Dose

    Reversal with Therapeutic Opioid Doses

    Opioids Naïve (Postoperative Reversal)

    Opioids Dependent (Cancer Pain Patient)

    Initial Dose (IV push)

    depression.

    Continuous Infusion

    • 0.1 – 0.2mg every 2-3 mins

    • Repeat doses may be needed within 1-2 hour interval.

    • Dilute 1 amp (0.4mg) + NS = 10ml 0.04mg/ml

    • Then give 0.02 – 0.08 mg (0.5 – 2ml) every 1-2 minutes

    • If no symptoms improvement after 1mg, consider other causes of respiratory

    • Use in exposure to long acting opioids (methadone) or sustained release products.

    • Use 2/3 of initial effective bolus dose on hourly basis (usually 0.2 – 0.6 mg/hr).

    • 1/2 of the initial bolus dose should be re-administered 15 mins after initiation of continuous infusion to prevent drop in naloxone levels


    Dilution for Continuous IV infusion:

    Dilute 1.6 mg (4amp) + NS/D5% = 20ml Strength 0.08 mg/ml


    Infusion Rate: According to dose ordered

    (e.g: 0.2 mg/hr = 2.5 ml/hr)

    (e.g: 0.4 mg/hr = 5 ml/hr)

    (e.g: 0.8 mg/hr = 10 ml/hr)

    (e.g: 1.0 mg/hr = 12.5 ml/hr)

    (e.g: 2.0 mg/hr = 25 ml/hr)

    (e.g: 3.0 mg/hr = 37.5 ml/hr)

    (e.g: 4.0 mg/hr = 50 ml/hr)


    Storage & Stability:

    • Intact vials: Store below 25°C.

    • Protect from light. Discard unused portion.

    • Diluted Solution: 24hours at room temperature


      Precaution:

    • Consider lower dose in known or suspected opioid dependent patients to minimize withdrawal syndrome.

    • May be given IM or SC when IV access N/A.


    References:

    1. Product Leaftlet – Mapin

    2. Drug Information Lexicomp, Uptodate 2020.

    3. Ministry of Health Malaysia. Critical Care Pharmacy Handbook. Pharmaceutical Service Division 2013.


Noradrenaline 4MG/4ML Inj

Indication:

  1. Treatment of shock that persist after adequate volume replacement.

  2. Severe Hypotension.


Dose: 0.05 – 2mcg/kg/min


Dilution:

Single Strength 4mg (1amp) + D5% = 50ml Strength: 0.08mg/ml

Double Strength 8mg (2amp) + D5% = 50ml Strength: 0.16mg/ml


Infusion Rate: Refer infusion rate chart

Stability: 24 hours

Must be diluted before use.

Do not dilute with NS alone may cause degradation due to oxidation. Do not administer in the same IV line as Sodium bicarbonate


Precautions:


Reference:

  1. Drug Info, Lexicom, Uptodate 2020

  2. Dilution Guide for High Alert Medication, Pharmaceutical Service Division, MOH 2011


    Potassium Chloride 1g/10ml (~13.4 mmol K+ ion) inj

Preparation:1 vial (1g in 10ml) = 13.4 mmol = 13.4 mEq/L potassium ion

References:

  1. Flurie RW, et al., Disorders of Potassium and Magnesium Homeostasis. New York, NY: McGraw- Hill Education

  2. Drug Information Lexicomp, Uptodate 2020

  3. Dilution Guide for High Alert Medication, Pharmaceutical Service Division, MOH 2011


    Potassium Dihydrogen phosphate 1.3g/10ml Inj

Preparation:1 vial (1.3g in 10ml) of IV Potassium Dihydrogen phosphate

1.3g/10ml = 10mmol K+, 10mmol Po4+, 20mmol H+


Dose:


Non-Critically ill Patients

Critically Ill Patients Receiving Nutritional Support

Serum Phosphate

Dose

Serum Phosphate

Dose

≥ 1.25 mg/dL

(0.40 mmol/L)

  • 0.08 to 0.24

mmol/kg over 6 hours

(max 30 mmol)

2.3 - 3.0 mg/dL

(0.73 - 0.96 mmol/L

0.32 mmol/kg

< 1.25 mg/dL

(0.40 mmol/L)

  • 0.25 to 0.50

mmol/kg over 8 - 12 hours

(max 80 mmol)

1.6 - 2.2 mg/dL

(0.51 - 0.72

mmol/L)

0.64 mmol/kg

< 1.6 mg/dL (< 0.50 mmol/L)

1.0 mmol/kg


Remarks:


Reference:

  1. Drug Information, Lexicomp, Uptodate 2020.

  2. Dilution Guide for High Alert Medication, Pharmaceutical Service Division, MOH 2011

    42


    Phenytoin 250MG/5ML Inj

    Indication: Status Epilepticus

    Dose:

    Loading dose: 15 – 20mg/kg

    If seizure persist, give additional dose of 10mg/kg 10 min after loading infusion


    Maintenance dose: 5mg/kg/day


    Dilution:

    Required dose (15 – 20mg/kg) + NS = 100ml over 1hour


    Infusion rate: 100ml/hr

    (max infusion rate: 50mg/min)


    Precautions/remarks:

    • Time to effect: 10 – 30 minutes

    • Narrow therapeutic window.

    • Target range: 10 – 20 mcg/ml

    • Monitor level 12-24hours after loading dose

    • Toxicity: Comatose, hypotension, respiratory& circulatory depression.

    • Initial sign of toxicity: Nystagmus, ataxia, tremor, somnolence, drowsiness, lethargy, slurred speech, nausea, vomiting.


      Serious Adverse effects:

    • Arrhythmias, Hypotension, Purple glove syndrome


    Stability:

    • Do not dilute in D5%, cause crystallization.

    • IV contains propylene glycol


Reference:

  1. Brophy G.M., et al; Guidelines for the Evaluation and Management of Status Epilepticus, Neurocrit Care, April 2012.

  2. Product leaflet, Pfizer

  3. Consensus Guideline on Management of Epilepsy 2010, Malaysian Society of Neuroscience.


Phenobarbital 200MG/ML Inj

Indication: Status Epilepticus


Loading dose:

Children: 15 - 20 mg/kg IV (Max 1000mg/dose) Administration rate: 30mg/min

May repeat dose after 15mins as needed to a maximum total dose of 40mg/kg.

Adult: 10-20mg/kg

Administration rate: 60mg/min

May repeat dose in 20 minutes as needed to a maximum total dose of 30mg/kg.

Continuous infusion (in refractory status epilepticus): 0.5 – 5mg/kg/hr 1


Dilution:

Intramuscular: Undiluted, Inject deep into muscle.

Do not exceed 5 ml per injection site due to potential tissue irritation.


IV Bolus: 200mg (1 vial) + NS/D5% = 10ml

Push over 5 minutes (Infusion rate: 50–100 mg/min)

IV Infusion: 400mg (2 vials) + NS/D5% = 20ml Strength: 20mg/ml

Rate: according to dose

Precautions/remarks:


Reference:

  1. Brophy G.M., et al; Guidelines for the Evaluation and Management of Status Epilepticus, Neurocrit Care, April 2012.

  2. Product leaflet, Sanofi & Drug Info, Lexicomp

  3. Consensus Guideline on Management of Epilepsy 2010, Malaysian Society of Neuroscience.


    Proton Pump Inhibitor (PPI) Inj

Omeprazole 40mg Pantoprazole 40mg Esomeprazole 40mg


UGIB

IV bolus: 80mg (2vials) + NS = 20ml slow bolus over 2 minutes IV infusion: 8mg/hour x 72 hours


Dilution for infusion:

40mg (1vial) + NS = 40ml strength: 1mg/ml Infusion rate: 8ml/hr


Reference:

    1. Drug info, lexicomp.


Salbutamol 0.5MG/ML Inj

Indication:

Dose: 0.25mg IV slow bolus; then IV infusion 5 – 20mcg/min


Dilution: 3mg (6amp) + NS/D5% = 50ml Strength: 60mcg/ml

Infusion rate: According to dose

1 mcg/min = 1 ml/hr

2 mcg/min = 2 ml/hr

5 mcg/min = 5 ml/hr

7 mcg/min = 7 ml/hr

10 mcg/min = 10 ml/hr

15 mcg/min = 15 ml/hr

20 mcg/min = 20 ml/hr


Side effects:


Reference:

1. Drug Info, Lexicomp


Sodium Valproate 400MG Inj

Indication: Status Epilepticus


Dose:

Loading dose:20 - 40mg/kg

If persist, give additional dose of 20mg/kg 10 min after loading infusion


Maintenance dose: 4-8mg/kg 8 hourly


Dilution:

Required dose (20mg/kg) + NS/D5% = 100ml over 1hour Infusion rate: maximum infusion rate 20mg/min (1200 mg/1 hr)


Precautions/remarks:


Serious Adverse effects: Hyperammonemia Pancreatitis Thrombocytopenia Hepatotoxicity


Reference:

  1. Brophy G.M., et al; Guidelines for the Evaluation and Management of Status Epilepticus, Neurocrit Care, April 2012.

  2. Product leaflet, Sanofi& Drug Info, Lexicomp

  3. Consensus Guideline on Management of Epilepsy 2010, Malaysian Society of Neuroscience.

    Sodium Bicarbonate 8.4%/10ml (~10 mmol HCO3 ion) Inj

    Preparation: 1 vial 8.4% of 10 ml = 10mmol HCO3- & 10 mmol Na2+.

    *1ml NaHco3 = 1mmol HCO3- = 1mEq HCO3-

    *1 mEq NaHCO3 is equivalent to 84 mg


    Dosing:

    1. Cardiac Arrest 1,2

      Adult (ACLS 2010)

      • IV: 1 mmol/kg/dose

      Peads (PALS)

      • IV / Intraosseous: 1 mmol/kg/dose

      • Repeat doses should be guided by arterial blood gases, routine use of NaHCO3 is not recommended.

      • May be considered in the setting of prolonged cardiac arrest only after adequate alveolar ventilation has been established & effective cardiac compressions.

      • In some cardiac arrest situations (eg, metabolic acidosis, hyperkalemia, or tricyclic antidepressant overdose), sodium bicarbonate may be beneficial.


    2. Metabolic acidosis:


      Dose

      Acid- base Status Available

      Acid- base Status Unavailable

      Adult (Intravenous)


      Pediatric (IV,

      Intraosseous)

      OR

      OR

      infusion over 4 to 8 hours;

      • HCO3-(mEq) = 0.5 x weight (kg) x [24 - serum HCO3- (mEq/L)]

      • HCO3-(mEq) = 0.5 x weight (kg) x [desired increase in serum HCO3-(mEq/L)]

      • 2 to 5 mEq/kg IV infusion over 4 to 8 hours;

      • Subsequent doses should be based on patient's acid- base status.

      • HCO3-(mEq) = 0.3 x weight (kg) x base deficit (mEq/L)

      • HCO3-(mEq) = 0.5 x weight (kg) x [24 - serum HCO3- (mEq/L)]

      • <2 years: 1 to 2 mEq/kg/dose

      • >2 years: 2 to 5 mEq/kg IV

      • Subsequent doses should be based on patient's acid- base status


      • Administer 1/2 dose initially, then remaining 1/2 dose over the next 24 hours; monitor pH, serum HCO3-, & clinical status.

      • These equations provide an estimated replacement dose. The underlying cause and degree of acidosis may result in the need for larger or smaller replacement doses.

      • In most cases, the initial goal of therapy is to target a pH of ~7.2 and a plasma bicarbonate level of ~10 mEq/L to prevent over alkalization.

    3. Hyperkalemia


Adult (ACLS 2010)



Contraindications

49


Streptokinase 1.5 milion units/ vial Inj

Indication & Dose:


  1. Acute ST elevation MI

    • Dose: 1.5 million units over 1hour

    • Dilution: 1.5 MU (1 vial) + NS/D5% = 100ml

    • Infusion rate: infusion rate: 100ml/hr (over 1 hour)

  2. Arterial Thrombosis/Pulmonary Embolism/Deep Veen Thrombosis

    • Loading dose: IV 250, 000 IU over 30 mins

    • Maintenance dose: 100 000 IU/hr for 24 hours (72 hours if DVT)

    • Dilution: 1.5 IU (1 vial) + NS/D5% = 50ml 30, 000 IU/ml

    • Infusion Rate:

      • For Loading Dose: 8.3 ml over 30 mins

      • For Maintenance Dose: 3.3ml/hour over 24 hours / 72 hours (DVT)


        Stability: Room temperature (15 - 30°C): 8 hours Refrigerator (2 - 8°C): 24 hours

        Reconstitute powder with 5ml WFI by adding WFI slowly alongside wall then dilute gently to prevent foaming.


        Precautions/remarks:

    • Not necessarily to be given with anticoagulant

    • Non fibrin specific and it results in a lower patency rate of the occluded vessel at 60 minutes than fibrin specific agents.

    • Despite having a lower risk of intracranial hemorrhage, the reduction in mortality is less than with fibrin specific agents.

    • Antigenic and promotes the production of antibodies. Thus the utilization of this agent for reinfarction is less effective if given between 3 days and 1 or even 4 years after the first administration.

    • PCI or fibrin specific agents should then be considered.


Reference:

  1. ST-Elevation MI CPG 2014, MOH

  2. PAHANG Acute MI management, 2012.

  3. Dilution Guide for High Alert Medication, Pharmaceutical Service Division, MOH 2011


    Tenecteplase 10,000 units (50MG) / vial Inj

Indication: Allergy or prior exposure to streptokinase.

Extensive Anterior STEMI, < 75 years old.

STEMI with hypotension, < 75 years old. (Delay / unable to do 1° PCI)


Dilution:

10,000 units/50 mg (1 vial) + 10ml solvent Strength = 5mg/ml


Dose:

Single IV bolus over 10 seconds


Body Weight

Dose

Vol. to Administer

<60kg

6,000 units = 30mg

6 ml

60 – 69 kg

7,000 units = 35mg

7 ml

70 – 79 kg

8,000 units = 40mg

8 ml

80 – 89 kg

9,000 units = 45mg

9 ml

> 90 kg

10,000 units = 50mg

10 ml

*Max dose: 10,000 units / 50mg

Fibrinolysis in Unstable Patient


Precautions/remarks:


Dose:

IV bolus: 50mg-100mg every 4-6 hourly. (Max: 400mg/day)


IV infusion: 5 mg – 16mg/hr (Max: 400mg/day)


Dilution for infusion:

50mg (1vial) + NS = 50ml strength: 1mg/ml Infusion rate: 5 - 16ml/hr (Max: 16ml/hr)


Reference:

  1. Drug Info (Lexicomp)


    Verapamil 5MG/2ML Inj

Indication:


Dilution for Continuous Infusion:

10 mg (2amp) + NS/D5% = 20ml Strength 0.5mg/ml


Infusion Rate: according to dose ordered

e.g: 5 mg/hr = 10 ml/hr

e.g: 10 mg/hr = 20 ml/hr

e.g: 15 mg/hr = 30 ml/hr

e.g: 20 mg/hr = 40 ml/hr


Precautions:

Reference:

  1. January CT, et al. AHA/ACC/HRS guideline 2019

  2. Micromedex IBM, Updated June 2020


    Cyanide Toxicity Antidote



Indication:

Inj. Sodium Nitrite 300mg/10ml


Inj. Sodium Thiosulfate 12.5g/50ml


Indication: Indicated for sequential use with sodium nitrite for treatment of acute cyanide poisoning that is judge to be life threatening.


Dose:

For Adult

  1. Sodium Thiosulfate – 50ml immediately following administration of sodium nitrite Repeat sodium thiosulfate once at half dose (25ml) if symptoms persist.


    For Children

    1. Sodium Thiosulfate – 1ml/kg (250mg/kg or approximately 30-40ml/m2 BSA) immediately following administration of sodium nitrite. Not to exceed 50ml as total dose.

      Repeat sodium thiosulfate once at half dose if symptoms persist.

      Dilution

      Reconstitution: Not required Further dilution: Not required

      Infusion Rate: Slow intravenous injection @ 2.5 – 5ml /min


      Administration:

      • Is considered as adjunctive to appropriate supportive therapy.

      • Airway, ventilator & circulatory support should not be delayed to administer sodium nitrite & sodium thiosulfate.

      • Should be given as early as possible after diagnosis of acute life-threatening cyanide poisoning has been established.

      • Sodium nitrite should be administered first followed immediately by sodium thiosulfate.

      • Monitor blood pressure during infusion.

      • Decrease rate of infusion if significant hypotension is noted.

        Incompatibility Information:

        • Chemical incompatibility with Hyrdoxocobalamin, should not be administered simultaneously via same IV line

        • Compatible with sodium thiosulfate (can be administered sequentially through the same IV line)


          Adverse Reaction:

      • Cardiovascular: Hypotension

      • Central nervous system: Headache, disorientation.

      • Gastrointestinal system: nausea, vomiting

      • Hematological: prolonged bleeding time

      • Respiratory system: tachypnea, dyspnea

      • General: salty taste in mouth, warm sensation over body.


        Recommended Monitoring:

      • Patients should be monitored for at least 24-48 hours after administration of sodium thiosulfate for adequacy of oxygenation and perfusion and for recurrent signs and symptoms of cyanide toxicity.


        Warning & Precautions:

      • May contain trace impurities of sodium sulfite. Cautions in sulfite-sensitive patients, but should not deter administration of sodium thiosulfate in emergency situations.

        Use in Special Populations

      • Pregnancy: Category C. Used during pregnancy only if potential benefit justifies the potential risk to the fetus.

      • Nursing mother: No data to determine when breast-feeding can be safely restarted after administration of sodium nitrite.

      • Renal Disease: Known to be substantially excreted in kidney, thus risk of toxic reaction maybe greater in patients with impaired renal function.


        Stability:

      • Store at room temperature between 20°C - 25°C.

      • Protect from direct light.

      • Do not freeze.

        Reference:

      • Full prescribing information of Sodium Nitrite Injection, USP, HOPE Pharmaceutical, 2011.

      • Tintinalli’s Emergency Medicine, 7th Edition.

        Inj. Hydroxocobalamine 5g/ml (Cyanokit)


        Indication:

        • An antidote indicated for the treatment of known or suspected cyanide poisoning.

        • If clinical suspicion of cyanide poisoning is high, hydroxocobalamine should be administered without delay.


          Dose:

          For Adult:

        • The starting dose 5 g administered as intravenous infusion over 15 minutes (approximately 15 mL/min).

        • Depending upon the severity of the poisoning and the clinical response, a second dose of 5 g may be administered by intravenous infusion for a total dose of 10 g.

        • The rate of infusion for the second dose may range from 15 minutes (for patients in extremis) to two hours, as clinically indicated.

          For Children: Dose of 70 mg/kg

          Reconstitution: Reconstitute with 200 mL of diluent using the supplied sterile transfer spike to produce 25mg/mL solution of hydroxocobalamine.

          Diluent: 0.9% NaCl, Lactated Ringers injection, 5% Dextrose injection (D5W).

          Further Dilution: Not required

          Infusion rate: 15ml/min

          Administration:

        • The line on the vial label represents 200 mL volume of diluent. Following the addition of diluent to the lyophilized powder, the vial should be repeatedly inverted or rocked, not shaken, for at least 60 seconds prior to infusion.

        • Hydroxocobalamin solutions should be visually inspected for particulate matter and color prior to administration. If the reconstituted solution is not dark red or if particulate matter is seen after the solution has been appropriately mixed, the solution should be discarded.

          Incompatibilities:

        • Chemically incompatible with sodium thiosulfate, sodium nitrite and ascorbic acid. Physical incompatibility (particle formation) and chemical incompatibility with selected drugs that are frequently used in resuscitation efforts.

        • Should not be administered simultaneously with other drugs through the same intravenous line as.

        • Not recommended for simultaneous administration with blood products (whole blood, packed red cells, platelet concentrate and/or fresh frozen plasma) through the same intravenous line. Can be administered simultaneously using separate intravenous lines (preferably on contralateral extremities, if peripheral lines are being used).


          Adverse Reaction:

        • Serious adverse reactions with hydroxocobalamin include allergic reactions and increases in blood pressure.

        • Cardiovascular: increased blood pressure

        • Eye: swelling, irritation, redness

        • Gastrointestinal: nausea, dysphagia, abdominal discomfort,vomiting, diarrhea, dyspepsia, hematochezia

        • General: headache, peripheral edema, chest discomfort

        • Immune system: allergic reaction

        • Nervous system: memory impairment, dizziness

        • Psychiatric: restlessness


        • Respiratory: dyspnea, throat tightness, dry throat

        • Skin and subcutaneous tissue: rash, urticaria, pruritus, infusion site reaction, hot flush

          Warning & Precautions:

        • Allergic Reactions:

          • Use caution in the management of patients with known anaphylactic reactions to hydroxocobalamin or cyanocobalamin. Consideration should be given to use of alternative therapies, if available.

          • Allergic reactions may include: anaphylaxis, chest tightness, edema, urticaria, pruritus, dyspnea, and rash.

          • Allergic reactions including angioneurotic edema have also been reported in postmarketing experience.

        • Increase in Blood Pressure

          • Increases in blood pressure were noted shortly after the infusions were started; the maximal increase in blood pressure was observed toward the end of the infusion. These elevations were generally transient and returned to baseline levels within 4 hours of dosing.

        • Interference with Clinical Laboratory Evaluations and Clinical Methods

          • Clinical Laboratory Evaluations

          • Because of its deep red color, hydroxocobalamin has been found to interfere with colorimetric determination of certain laboratory parameters (e.g., clinical chemistry, hematology, coagulation, and urine parameters)

          • Interference following a 10 g dose can be expected to last up to an additional 24 hours.

          • The extent and duration of interference in cyanide-poisoned patients may differ. Results may vary substantially from one analyzer to another; therefore, caution should be used when reporting and interpreting laboratory results.

          • Interference with Hemodialysis

          • Because of its deep red color, hydroxocobalamin may cause hemodialysis machines to shut down due to an erroneous detection of a “blood leak”.

        • Photosensitivity

          • Hydroxocobalamin absorbs visible light in the UV spectrum. It therefore has potential to cause photosensitivity. Patients should be advised to avoid direct sun while their skin remains discolored.

        Stability:

        1. Once reconstituted, hydroxocobalamin is stable for up to 6 hours at temperatures not exceeding 40°C.

        2. Do not freeze.

        3. Discard any unused portion after 6 hours.


          Reference:

          • Full prescribing information of Sodium Nitrite Injection, USP, HOPE Pharmaceutical, 2011.

          • Tintinalli’s Emergency Medicine, 7th Edition.

        60

        Medications for Procedural Sedation & Analgesia


        Class Drug

        Anxiolytic Midazolam

        Hypnotic / Sedative

        Dissociative Ketamine

        Analgesia

        Combinations

        Propofol

        Etomidate

        Morphine

        Fentanyl

        Fentanyl +

        Midazolam

        Propofol +

        Ketamine

        Dose

        0.1mg/kg

        1-2 mg/kg

        0.1 – 0.3

        mg/kg

        1 - 1.5 mg/kg

        0.1 – 0.3 mg/kg

        1-2 mcg/kg

        Fentanyl: 1- 2mcg/kg

        Midazolam:

        0.05 – 0.1

        mg/kg.

        Propofol: 1-

        2 mg/kg

        Ketamine: 0.5mg/kg

        Onset

        1-5 min

        30-45 sec

        30-60 sec

        30 – 40 sec

        5-10 min

        1-2 min

        1-2 min

        1 min

        Duration

        ~2 hour

        20-75 min

        3-5 min

        5-10 min

        2-4 hour

        30-60 min

        1-3 hour

        15-45 min

        Dilution & Administration

        Slow IV over 2- 5mins

        Concentration: 1- 5mg/ml

        Compatible D5% or NS

        Lipid emulsion. IV slow bolus: undiluted.

        IV infusion: dilute with D5% to conc of ≥ 2mg/ml, stable for 8 hours.

        To reduce pain during with administration, use larger veins or add lignocaine to

        propofol (1:10 ratio).

        IV push over 30-60 sec.

        Undiluted.

        Highly irritating, administer to large vein or give lignocaine.

        IV slow bolus.

        Rapid administration may result in respiratory depression & enhance pressor response.


        Undiluted

        Slow IV.

        Dilute with NS or WFI to conc 1-2mg/ml.

        Slow IV Undiluted

        Slow IV Undiluted.

        Compatible with NS.

        Slow IV

        Compatible to be mix together as ‘Ketofol’.

        Medications for Procedural Sedation & Analgesia


        Class Drug

        Anxiolytic Midazolam

        Hypnotic / Sedative

        Dissociative Ketamine

        Analgesia

        Combinations Fentanyl + Propofol +

        Midazolam Ketamine

        Propofol

        Etomidate

        Morphine

        Fentanyl

        Respiratory Effects

        Important depressant effect

        Important depressant effect

        Respiratory depressant.

        Bronchodilator effect

        Important depressant effect

        Important depressant effect

        Important depressant effect

        Lesser depressant effect

        Cardiac Effects

        Important depressant effect

        Important depressant effect

        Minimal cardiovascula r effects

        Important stimulant effect

        Important depressant effect

        Important depressant effect

        Important depressant effect

        Lesser depressant effect

        Analgesia

        None

        None

        Limited

        analgesic properties.

        Yes

        Yes

        Yes

        Yes

        Yes

        Advantages

        Shorter acting if preserved organ function.

        Fast onset

        Rapid onset, short duration.

        Motionlessness, muscle relaxant.

        Rapid onset, short duration.

        Reduce ICP.

        Analgesic, anesthetic, motionlessnes s, respiratory and cardiovascular stimulant, bronchodilator

        Attenuates development of acute tolerance to opioids.

        Reduces tachypnea

        Less hypotensiv e than morphine

        Analgesic and anxiolytic.

        Decrease dosing requirement for both agents.



        Mild antiemetic properties.

        Reduce ICP.





        Antagonistic side effects (lessen respiratory and cardiovascular depression,

        lessen emesis).


        Medications for Procedural Sedation


        Class Drug

        Anxiolytic Midazolam

        Hypnotic / Sedative

        Dissociative Ketamine

        Analgesia

        Combinations Fentanyl + Propofol +

        Midazolam Ketamine

        Propofol

        Etomidate

        Morphine

        Fentanyl

        Disadvantages


        Disadvantages

        No analgesia, paradoxical reaction.


        Eliminated renally as active metabolite, risk of accumulations of active metabolites in renal failure.

        Increase serum TG (lipid emulsion), pancreatitis.

        Do not give to patient allergic to egg or soy products.

        Adrenocortica l suppression.

        Myoclonus: avoid in patients with increased tone (e.g: CP).


        Painful injection.

        May cause hallucinations and psychological disturbances. Increase intraocular pressure, intracranial pressure, salivation,

        emetogenic, & laryngospasm.

        Hypotension, nausea.


        Cause histamine release/ Pruritus.

        Chest wall rigidity, risk increase with larger doses.

        Bradycardi a.

        Respiratory depressant


        -

        Monitoring

        Respiratory and cardiovascular status, blood pressure.

        Anaphylaxis reaction, blood pressure, cardio- respiratory depression.

        Cardiac and blood pressure.

        Heart rate, blood pressure and cardiac function.

        Respiratory and CNS status. Blood pressure

        Respiratory and CNS status.

        Blood pressure and heart

        rate.

        Respiratory and cardiovascu lar status, blood pressure.

        Anaphylaxis reaction.


        Tintinalli’s Emergency Medicine, 7th Edition.

        Sedative Agents in Mechanically Ventilated Patients

        (Compiled by Ms Izyan Liyana Rosman, for ED pharmacy attachment @ HTAA, 2017)


        Drug

        MIDAZOLAM 5MG

        PROPOFOL 200MG

        DEXMEDETOMIDINE 100MCG

        KETAMINE 200MG

        ETOMIDATE

        Price / vial

        RM 1.75

        RM 3.60

        RM 111.10

        RM 46.00

        RM 27.15

        Price of continuous infusion/ day

        RM 10.08

        (*lowest dose/bw 60kg)

        RM 7.80

        (*lowest dose/bw 60kg)

        RM 333.3

        (*lowest dose/bw 60kg)

        RM 46.00

        (*lowest dose/bw 60kg)

        -

        Dose

        Initial dose :

        Maintenance dose :

        Initial dose :

        5 mcg/kg/min (0.3 mg/kg/h) IV infusion for 5 min then titrate in 5 - 10 mcg/kg/min

        Maintenance dose:

        5 - 50 mcg/kg/min

        Initial dose :

        1 mcg/kg over 10 mins.

        Maintenance dose :

        0.2 – 0.7 mcg/kg/h for a maximum of 24 hours.

        Initial dose:

        0.2 - 0.75mg/kg.

        Maintenance dose:

        2 - 7 mcg/kg/min

        Initial dose:

        0.2-0.6mg/kg Maintenance dose: 5-20mcg/kg/min

        Dilution

        20mg in 20cc NS

        Undiluted (200mg/20ml)

        200mcg in 50cc NS

        200mg in 20cc NS


        *Ketofol dilution: 100mg PROPOFOL

        (10ml) + 100mg

        KETAMINE (10ml) in 50cc D5)

        Continuous infusion not recommended, due to adrenal suppression.

        Onset

        1- 5 min

        1-2min

        5 - 10min

        30 - 40sec

        30-60sec

        Duration

        ~ 2 hours

        2-8min

        60 - 120min

        5 - 10min (IV)

        3-5min, terminated by redistribution

        Elimination

        Hepatic Cytochrome P450 3A4, active metabolite excreted renally

        Hepatic conjugation

        Hepatic including glucuronidation and CYP2A6

        Hepatic N- demethylation

        Hepatic and plasma esterase

          1. - 0.05 mg/kg over several min.

          2. – 0.1 mg/kg/h.


        Drug

        MIDAZOLAM

        PROPOFOL

        DEXMEDETOMIDINE

        KETAMINE

        ETOMIDATE

        Analgesia

        None

        None

        Yes

        Yes

        No

        Side effects

        Resp depression, hypotension

        Resp depression, hypotension, propofol infusion syndrome

        Hypotension and bradycardia

        Increase oral secretions, associated with hallucination and dreaming.

        -Adrenal suppression

        -Some formulation contains propylene glycol which can cause hyperosmolarity,

        metabolic acidosis.

        Advantages

        Fast onset

        Rapid onset, Short acting

        Beneficial effect of cerebral vasoconstriction, reduce ICP.

        Very short duration

        Has some analgesic properties

        Broncholilatory effect

        Has analgesic property.

        Less associated with hypotension.

        Disadvantag es

        Active metabolite accumulates in renal failure.

        -C/I in egg and soy allergy, risk of Propofol infusion syndrome.

        Not approved for use >24 hour in some countries, some studies are longer.

        May cause hallucinations and other psychological disturbances.

        -C/I in soya and peanut allergy

        -Cause adrenal suppression, hence controversial use in septic shock, and not recommended as continuous infusion.

        Preferred in:

        -

        Cause cerebral vasoconstriction and lowers ICP thus beneficial in patients with TBI.

        Preferred in substance abuse.

        Preferred in hypovolaemic patients / active airway disease.

        Not for continuous infusion.

        Analgesic Agents in Mechanically Ventilated Patients

        (Compiled by Ms Izyan Liyana Rosman, for ED pharmacy attachment @ HTAA, 2017)

        Morphine 10mg/ml

        Fentanyl 100mcg/2ml

        Remifentanyl 5mg/vial

        Dose

        Initial dose:

        0.01-0.15mg/kg

        Maintenance dose: 0.07-0.5mg/kg/hr

        Initial dose:

        0.35-1.5mcg/kg

        Maintenance dose: 0.7-10mcg/kg/hr

        Initial dose:

        1mcg/kg over 30-60sec Maintenance dose:

        0.6-15mcg/kg/hr

        Onset

        5-20 min

        2 - 5 min

        1-3 min

        Dilution

        20mg in 20cc NS

        0.2mg in 20cc NS

        5mg in 20cc NS

        Duration

        2-4 hours

        0.5 – 1 hours

        0.3 – 0.6 hours

        Elimination

        Hepatic conjugation; active metabolite excreted renally.

        Hepatic CYP450 3A4.

        Hydrolysis by esterases.

        Precaution

        Advantages

        Reduces tachypnea.

        Less hypotensive than morphine.

        Has a more rapid offset

        Disadvantages

        -Reduces blood pressure.

        -Respiratory depression.

        -Accumulation in hepatic/ renal failure

        Chest wall rigidity

        -Reduces heart rate and blood pressure.

        -Chest wall rigidity

        Price per day

        RM 1.20

        (RM 0.12/VIAL)

        RM 28.72

        (RM 2.85/vial)

        RM 186.0

        (RM 186.0/vial)

        • May cause CNS depression, hypotension, orthostatic hypotension and syncope.

        • May cause respiratory depression, especially in elderly debilitated patients, hypoxia or hypercapnia.

        • Use with caution in patients with history of drug abuse or acute alcoholism.

        • Use with caution in renal/ hepatic impairment, head trauma, seizure, thyroid dysfunction

        • May cause CNS depression, respiratory depression.

        • Use with caution in patients with history of drug abuse or acute alcoholism.

        • Use with caution in bradycardia, bradyarrhythmias, renal/ hepatic impairment, head trauma.

        • May cause hypotension

        • Use with caution in patient with hypovolemia, cardiovascular disease.

        • Rapid IV infusion may result in skeletal muscle and chest wall rigidity, impaired ventilation or respiratory distress/ arrest


        Shamsiah Salim, Ward Pharmacist, Updated July 2020

        DOPAmine Continuous Infusion Chart (DOUBLE Strength)

        DOUBLE STRENGTH . 400mg (2 ampul) in 50mI Sodium Chloride 0.9% (NS) or Dextrose 5% (D5)



        mcg//kg

        1 ml = = 8 mg

        50 ml

        If run at 1 ml/hr = 8 mg/hr

        convert to mcg/kg/min base on body weight =   8 x 1000mce

        min

        weight (kg) x 60min

        eg: what is the dose given to patient (60kg),run at 5mI/hr? 5 ml = = 40 mg

        50 ml

        5 ml/hr = 40 mg/hr

        convert to mcg/kg/min = 40 x J000 mre = 11.1mcg/kg/min

        60kg x 60min Shamsiah Salim, Ward Pharmacist, Updated July 2020


        DOBUTAmine Continuous Infusion Chart (DOUBLE Strength)


        DOUBLE STRENGTH : 500mg (2 vial) in 50ml Sodium Chloride 0.9% (NS) or Dextrose 5% (D5)


        Weight(kg)

        Infusion rate (ml/hr)


        0.5

        1.0

        1.5

        2.0

        2.5

        3.0

        3.5

        4.0

        4.5

        5.0

        5.5

        6.0

        6.5

        7.0

        7.5

        8.0

        8.5

        9.0

        9.5

        10.0

        10.5

        11.0

        11.5

        12.0

        35

        2.4

        4.8

        7.1

        9.5

        11.9

        14.3

        16.7

        19.0

        21.4
















        40

        2.1

        4.2

        6.3

        8.3

        10.4

        12.5

        14.6

        16.7

        18.8

        20.8















        45

        1.9

        3.7

        5.6

        7.4

        9.3

        11.1

        13.0

        14.8

        16.7

        18.5

        20.4














        50

        1.7

        3.3

        5.0

        6.7

        8.3

        10.0

        11.7

        13.3

        15.0

        16.7

        18.3

        20.0













        55

        1.5

        3.0

        4.5

        6.1

        7.6

        9.1

        10.6

        12.1

        13.6

        15.2

        16.7

        18.2

        19.7

        21.2











        60

        1.4

        2.8

        4.2

        5.6

        6.9

        8.3

        9.7

        11.1

        12.5

        13.9

        15.3

        16.7

        18.1

        19.4

        20.8










        65

        1.3

        2.6

        3.8

        5.1

        6.4

        7.7

        9.0

        10.3

        11.5

        12.8

        14.1

        15.4

        16.7

        17.9

        19.2

        20.5









        70

        1.2

        2.4

        3.6

        4.8

        6.0

        7.1

        8.3

        9.5

        10.7

        11.9

        13.1

        14.3

        15.5

        16.7

        17.9

        19.0

        20.2








        75

        1.1

        2.2

        3.3

        4.4

        5.6

        6.7

        7.8

        8.9

        10.0

        11.1

        12.2

        13.3

        14.4

        15.6

        16.7

        17.8

        18.9

        20.0







        80

        1.0

        2.1

        3.1

        4.2

        5.2

        6.3

        7.3

        8.3

        9.4

        10.4

        11.5

        12.5

        13.5

        14.6

        15.6

        16.7

        17.7

        18.8

        19.8

        20.8





        85

        1.0

        2.0

        2.9

        3.9

        4.9

        5.9

        6.9

        7.8

        8.8

        9.8

        10.8

        11.8

        12.7

        13.7

        14.7

        15.7

        16.7

        17.6

        18.6

        19.6

        20.6




        90

        0.9

        1.9

        2.8

        3.7

        4.6

        5.6

        6.5

        7.4

        8.3

        9.3

        10.2

        11.1

        12.0

        13.0

        13.9

        14.8

        15.7

        16.7

        17.6

        18.5

        19.4

        20.4



        95

        0.9

        1.8

        2.6

        3.5

        4.4

        5.3

        6.1

        7.0

        7.9

        8.8

        9.6

        10.5

        11.4

        12.3

        13.2

        14.0

        14.9

        15.8

        16.7

        17.5

        18.4

        19.3

        20.2


        100

        0.8

        1.7

        2.5

        3.3

        4.2

        5.0

        5.8

        6.7

        7.5

        8.3

        9.2

        10.0

        10.8

        11.7

        12.5

        13.3

        14.2

        15.0

        15.8

        16.7

        17.5

        18.3

        19.2

        20.0


        NORADRENALINE Continuous Infusion Chart (DOUBLE Strength)

        DOUBLE STRENGTH : 8mg (2 ampul) in 50ml Dextrose 5% (D5) OR Dextrose Saline


        Weight(kg)

        Infusion rate (ml/hr)

        1

        2

        3

        4

        5

        6

        7

        8

        9

        10

        12

        14

        16

        18

        20

        22

        24

        26

        28

        30

        32

        34

        36

        38

        40

        42

        44

        46

        48

        50

        30

        0.09

        0.18

        0.27

        0.36

        0.44

        0.53

        0.62

        0.71

        0.80

        0.89

        1.07

        1.24

        1.42

        1.60

        1.78

        1.96

        2.13














        35

        0.08

        0.15

        0.23

        0.30

        0.38

        0.46

        0.53

        0.61

        0.69

        0.76

        0.91

        1.07

        1.22

        1.37

        1.52

        1.68

        1.83

        1.98

        2.13












        40

        0.07

        0.13

        0.20

        0.27

        0.33

        0.40

        0.47

        0.53

        0.60

        0.67

        0.80

        0.93

        1.07

        1.20

        1.33

        1.47

        1.60

        1.73

        1.87

        2.00











        45

        0.06

        0.12

        0.18

        0.24

        0.30

        0.36

        0.41

        0.47

        0.53

        0.59

        0.71

        0.83

        0.95

        1.07

        1.19

        1.30

        1.42

        1.54

        1.66

        1.78

        1.90

        2.01









        50

        0.05

        0.11

        0.16

        0.21

        0.27

        0.32

        0.37

        0.43

        0.48

        0.53

        0.64

        0.75

        0.85

        0.96

        1.07

        1.17

        1.28

        1.39

        1.49

        1.60

        1.71

        1.81

        1.92

        2.03







        55

        0.05

        0.10

        0.15

        0.19

        0.24

        0.29

        0.34

        0.39

        0.44

        0.48

        0.58

        0.68

        0.78

        0.87

        0.97

        1.07

        1.16

        1.26

        1.36

        1.45

        1.55

        1.65

        1.75

        1.84

        1.94

        2.04





        60

        0.04

        0.09

        0.13

        0.18

        0.22

        0.27

        0.31

        0.36

        0.40

        0.44

        0.53

        0.62

        0.71

        0.80

        0.89

        0.98

        1.07

        1.16

        1.24

        1.33

        1.42

        1.51

        1.60

        1.69

        1.78

        1.87

        1.96

        2.04



        65

        0.04

        0.08

        0.12

        0.16

        0.21

        0.25

        0.29

        0.33

        0.37

        0.41

        0.49

        0.57

        0.66

        0.74

        0.82

        0.90

        0.98

        1.07

        1.15

        1.23

        1.31

        1.39

        1.48

        1.56

        1.64

        1.72

        1.81

        1.89

        1.97

        2.05

        70

        0.04

        0.08

        0.11

        0.15

        0.19

        0.23

        0.27

        0.30

        0.34

        0.38

        0.46

        0.53

        0.61

        0.69

        0.76

        0.84

        0.91

        0.99

        1.07

        1.14

        1.22

        1.30

        1.37

        1.45

        1.52

        1.60

        1.68

        1.75

        1.83

        1.90

        75

        0.04

        0.07

        0.11

        0.14

        0.18

        0.21

        0.25

        0.28

        0.32

        0.36

        0.43

        0.50

        0.57

        0.64

        0.71

        0.78

        0.85

        0.92

        1.00

        1.07

        1.14

        1.21

        1.28

        1.35

        1.42

        1.49

        1.56

        1.64

        1.71

        1.78

        80

        0.03

        0.07

        0.10

        0.13

        0.17

        0.20

        0.23

        0.27

        0.30

        0.33

        0.40

        0.47

        0.53

        0.60

        0.67

        0.73

        0.80

        0.87

        0.93

        1.00

        1.07

        1.13

        1.20

        1.27

        1.33

        1.40

        1.47

        1.53

        1.60

        1.67

        85

        0.03

        0.06

        0.09

        0.13

        0.16

        0.19

        0.22

        0.25

        0.28

        0.31

        0.38

        0.44

        0.50

        0.56

        0.63

        0.69

        0.75

        0.82

        0.88

        0.94

        1.00

        1.07

        1.13

        1.19

        1.25

        1.32

        1.38

        1.44

        1.51

        1.57

        90

        0.03

        0.06

        0.09

        0.12

        0.15

        0.18

        0.21

        0.24

        0.27

        0.30

        0.36

        0.41

        0.47

        0.53

        0.59

        0.65

        0.71

        0.77

        0.83

        0.89

        0.95

        1.01

        1.07

        1.13

        1.19

        1.24

        1.30

        1.36

        1.42

        1.48

        95

        0.03

        0.06

        0.08

        0.11

        0.14

        0.17

        0.20

        0.22

        0.25

        0.28

        0.34

        0.39

        0.45

        0.51

        0.56

        0.62

        0.67

        0.73

        0.79

        0.84

        0.90

        0.95

        1.01

        1.07

        1.12

        1.18

        1.24

        1.29

        1.35

        1.40

        100

        0.03

        0.05

        0.08

        0.11

        0.13

        0.16

        0.19

        0.21

        0.24

        0.27

        0.32

        0.37

        0.43

        0.48

        0.53

        0.59

        0.64

        0.69

        0.75

        0.80

        0.85

        0.91

        0.96

        1.01

        1.07

        1.12

        1.17

        1.23

        1.28

        1.33


        ESMOLOL HCL 100MG/10ML INJ


        ‌INDICATION: 1. Supraventricular tachycardia 2,5

        DOSE AND Loading dose 500-1000mcg/kg over 1 minute, then 50mcg/kg/min infusion for 4 minutes.

        ADMINISTRATION: For additional BP control, repeat loading dose and increase infusion by 50mcg/kg/min increments up to maximum total dose of 200mcg/kg/min (increase no more frequently than every 4 minutes). (ACC/AHA 2017). Total loading dose up to 3-4 times. May continue the infusions up to 48 hours.


        Indication: 2. Control of heart rate in thyroid storm 1

        DOSE AND Loading dose 250-500mcg/kg (0.025-0.05ml/kg) over 1 minute, then titrated to desired

        ADMINISTRATION: heart rate and BP with range 50-100mcg/kg/min (guideline dosing).1


        DILUTION: Give undiluted. 4



        Dose

        50

        micrograms

        /kg/min

        100

        micrograms

        /kg/min

        150

        micrograms

        /kg/min

        200

        micrograms

        /kg/min

        Body weight (kg)

        Continuous/ Maintenance infusion rate

        mL/hour

        40

        12

        24

        36

        48

        45

        13.5

        27

        40.5

        54

        50

        15

        30

        45

        60

        55

        16.5

        33

        49.5

        66

        60

        18

        36

        54

        72

        65

        19.5

        39

        58.5

        78

        70

        21

        42

        63

        84

        75

        22.5

        45

        67.5

        90

        80

        24

        48

        72

        96

        85

        25.5

        51

        76.5

        102

        90

        27

        54

        81

        108

        95

        28.5

        57

        85.5

        114

        100

        30

        60

        90

        120


        STABILITY: Stable for 24hours at room temperature or under refrigeration. 4


        PRECAUTION/ Avoid infusion into small veins (thrombophlebitis). 2

        REMARKS: Ultra short-acting, cardioselective B-blocker. Onset within 2-10min, duration 10-30mins.2 Avoid use in patient with bradycardia, cardiogenic shock or active bronchospasm or patient receiving IV verapamil / diltiazem. 2

        Caution in patient with asthma, COPD, decompensated heart failure. 2


        REFERENCES: 1. CPG Management of Thyroid Storm 2019.

    2. Esmolol, Drug Info, Lexicomp, Uptodate 2021

    3. Esmolol, MimsGateway 2021.

    4. Gahart, B. L., Nazareno, A. R., & Ortega, M. Q. (2021). Gahart's 2021 intravenous medications.

    5. Product Leaflet (Esocard Injection).


      Date added: 23 Sept 2022


HUMAN ALBUMIN 5% (12.5G in 250ML) INJ


INDICATION: 1. Hypovolemic shock/ Hemorrhagic shock1,2

DOSE AND 25 g (500 mL). Repeat after 15 to 30 minutes as needed (if hemodynamic stability

ADMINISTRATION: is not achieved). 1

Starting infusion rate: 1-2mL/min (60-120ml/H)

Maximum infusion rate:

Maximum 2 g/kg daily recommended by some manufacturers.


DILUTION: Give undiluted. 3

If required/ stock for human albumin 5% not available, human albumin 20% solution can be diluted to become 5%: 300ml of NS or D5 + 100 mL (20g) of human albumin 20%. 3

Must not be diluted with water for injections as this may cause haemolysis in recipients.


STABILITY: Stable for 4hours after opening at room temperature. 2

Do not use if solution is cloudy or have deposits.


PRECAUTION/ Rapid infusion may cause vascular overload with resultant pulmonary edema.2

REMARKS: Sign of cardiovascular overload due to hypervolemia: headache, dyspnea, jugular vein congestion, or increased blood pressure, raised venous pressure and pulmonary edema, the infusion is to be stopped immediately.

Mild reactions such as flush, urticaria, fever, and nausea occur rarely & disappear rapidly when the infusion rate is slowed down or the infusion is stopped.


REFERENCES: 1. Human Albumin, Drug Info, Lexicomp, Uptodate 2021.

  1. Human Albumin, MimsGateway 2021.

  2. Product Leaflet (Albumex 20 Inj.).


Date added: 1 Feb 2023


VASOPRESSIN 20 IU/ML INJ


INDICATION:

Septic shock and other vasodilatory shock states (adjunctive agent)1,2

May be used in patients with refractory shock despite adequate fluid resuscitation, in addition to norepinephrine for raising MAP to target; or to decrease norepinephrine dosage.

DOSE AND ADMINISTRATION:

Dose: 0.01 to 0.04 unit/minute1 (NOT per kg)

TO BE GIVEN VIA CENTRAL LINE


Maximum infusion rate: 0.04 units/minute1

Doses >0.04 unit/minute has potential risk of ischemic complications.


Rate increase: increase by 0.3 unit/H every 10 - 15 minutes.

Ceasing infusion: Wean by decreasing rate by 0.3 unit/H every 30 minutes.1 Weaning may need to be quicker if the patient is hypertensive.


DILUTION:

Usual dilution: 20iu (1 amp) in 50ml NS or D5%

(Final concentration: 0.4iu/ml)

May dilute to a concentration of 0.1 – 1 IU/ml 2


Table: Rate of infusion for dilution of 20iu in 50ml (0.4iu/ml)


Dose

Rate of infusion (ml/H)

unit/minute

unit/H

0.01

0.6

1.5

0.015

0.9

2.3

0.02

1.2

3

0.025

1.5

3.8

0.03

1.8

4.5

0.035

2.1

5.3

0.04

2.4

6


STABILITY:

After dilution: Room temperature (18H), 2-8˚C (24 hours)3

PRECAUTION/ REMARKS:

  • Do not administer on lines where other infusions may be bolused or flushed.

  • Use extreme caution to avoid extravasation because of risk of necrosis and gangrene.

  • Extreme caution when used in patients with vascular disease, especially disease of the coronary arteries (small doses may precipitate anginal pain & for larger doses the possibility of myocardial infarction should be considered).

  • Use cautiously in conditions that may be aggravated by water retention (e.g. cardiac failure, asthma, epilepsy, migraine, preeclampsia, nephritis, coronary thrombosis).


REFERENCES: 1. Vasopressin, Drug Info, Lexicomp, Uptodate 2021.

  1. Health Biotech Ltd: Vasopressin Injection USP 20IU/ml Product Insert. Revised Date

  2. Vasopressin. ASHP Injectable Drug Information.

Date added: 7 Mar 2023


NICARDIPINE 1MG/ML INJ


INDICATION:

Hypertensive emergency1,2

In general, reduce mean arterial blood pressure gradually by ~10% to 20% over the first hour, then by an additional 5% to 15% over the next 23 hours, unless there is a compelling indication (eg, acute aortic dissection, severe preeclampsia, eclampsia) for more rapid blood pressure and heart rate control.

DOSE AND ADMINISTRATION:

Dose: Initially 3-5 mg/hour over 15 minutes1,2,3

Rate increase:

  • Increments of 0.5-2.5 mg/hour every 5- to 15-minute intervals to achieve target blood pressure.

  • When the target pressure is reached, the dose should be reduced progressively, usually to between 2 and 4 mg/h, to maintain the therapeutic efficacy.

Maximum infusion rate: 15 mg/hour

In case of hypotension or tachycardia, discontinue infusion. When blood pressure and heart rate stabilize, restart infusion at low doses such as 30-50 mL/hr (3-5 mg/hr) 3

DILUTION:

Dilute to final concentration of 0.1mg/ml 3

With NS, HS, D5%, NSD5% or HSD5%

Dilution depends on available product, example:

2mg dilute to 20ml or

10mg dilute to 100ml


Table: Rate of infusion for dilution of 0.1mg/ml


Dose (mg/H)

Rate of infusion (ml/H)

3

30

4

40

5

50

6

60

7

70

8

80

Max 15

Max 150


STABILITY:

After dilution: Room temperature (24H)3

PRECAUTION/ REMARKS:

  • Onset: 10 min2

  • Change infusion site every 12 hours if administered via peripheral vein to reduce irritation3

  • Contraindication: Patients with advanced aortic stenosis, unstable angina, cardiogenic shock & acute angina attack. Use within 1 month of MI2


REFERENCES: 1. Nicardipine, Drug Info, Lexicomp, Uptodate 2023.

  1. Nicardipine, MimsGateway 2023

  2. Product Leaflet (Cardene Inj.)

Date added: 8 Aug 2023