CCS Drug Infusions v5.0

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CRITICAL CARE PRESCRIBING
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INFUSION
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GUIDELINES
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GENERAL CRITICAL CARE
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The James Cook University Hospital
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General Critical Care 2021
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Critical Care Prescribing: Infusions Guidelines v4.0
General Critical Care 2021 - Version 4.0

Review date January 2022
The James Cook University Hospital
South Tees Hospitals NHS FT
General Critical Care / July 2021 1

Table of Contents
Introduction .......................................................................................................... 5
A – Z of Drug Infusions in Critical Care ................................................................. 6
n-ACETYL CYSTEINE INFUSION ............................................................................................ 7
ADRENALINE (EPINEPHRINE) INFUSION .............................................................................. 8
ADRENALINE (EPINEPHRINE) INFUSION DILUTIONS ........................................................... 9
ALFENTANIL INFUSION ....................................................................................................... 10
ALTEPLASE INFUSION ......................................................................................................... 11
AMINOPHYLLINE INFUSION (Central line) .......................................................................... 12
AMINOPHYLLINE INFUSION (Peripheral) ............................................................................. 13
AMIODARONE INFUSION.................................................................................................... 14
CALCIUM GLUCONATE INFUSION ..................................................................................... 15
CISATRACURIUM INFUSION ................................................................................................ 17
CLONIDINE INFUSION ......................................................................................................... 18
DEXMEDETOMIDINE ........................................................................................................... 19
DESFERRIOXAMINE INFUSION ........................................................................................... 22
DIGOXIN INFUSION ............................................................................................................. 23
DOBUTAMINE INFUSION .................................................................................................... 24
DOBUTAMINE INFUSION DILUTIONS ................................................................................. 25
DOPAMINE INFUSION ......................................................................................................... 26
DOPAMINE INFUSION DILUTIONS ..................................................................................... 27
DOPEXAMINE INFUSION ..................................................................................................... 28
DOXAPRAM INFUSION ........................................................................................................ 29
EPHEDRINE INFUSION ......................................................................................................... 30
EPOPROSTENOL (PROSTACYCLIN) INFUSION ................................................................... 31
EPOPROSTENOL INFUSION DILUTIONS ............................................................................ 32
ESMOLOL INFUSION ........................................................................................................... 33
FENTANYL INFUSION .......................................................................................................... 34
FLECAINIDE INFUSION ........................................................................................................ 35
FLUMAZENIL INFUSION ....................................................................................................... 36
FOMEPIZOLE INFUSION ...................................................................................................... 37
FUROSEMIDE INFUSION ...................................................................................................... 38
GLUCAGON INFUSION ........................................................................................................ 39
GLYCERYL TRINITRATE INFUSION ...................................................................................... 40
HEPARIN INFUSION ............................................................................................................. 41
HYDRALAZINE INFUSION .................................................................................................... 42
HYDROCORTISONE INFUSION ........................................................................................... 43
HYPERTONIC SALINE INFUSION ......................................................................................... 44

INSULIN (ACTRAPID) INFUSION .......................................................................................... 45
ISOPRENALINE INFUSION ................................................................................................... 47
KETAMINE INFUSION .......................................................................................................... 48
LABETALOL INFUSION......................................................................................................... 49
MAGNESIUM INFUSION (Central) ........................................................................................ 50
MAGNESIUM INFUSION (Peripheral) ................................................................................... 51
MANNITOL INFUSION ......................................................................................................... 52
METARAMINOL INFUSION .................................................................................................. 53
METHYLENE BLUE INFUSION .............................................................................................. 54
MILRINONE INFUSION......................................................................................................... 55
MIDAZOLAM INFUSION ....................................................................................................... 56
MORPHINE INFUSION ......................................................................................................... 57
NALOXONE INFUSION ........................................................................................................ 58
NEOSTIGMINE INFUSION.................................................................................................... 59
NIMODIPINE INFUSION ....................................................................................................... 60
NORADRENALINE (NOREPINEPHRINE) INFUSION............................................................. 61
OCTREOTIDE INFUSION ...................................................................................................... 63
OMEPRAZOLE INFUSION .................................................................................................... 64
PAMIDRONATE INFUSION .................................................................................................. 65
PANTOPRAZOLE INFUSION ................................................................................................ 66
PHENOXYBENZAMINE INFUSION ....................................................................................... 67
PHENYLEPHRINE INFUSION ................................................................................................ 68
PHENYTOIN INFUSION ........................................................................................................ 69
PHOSPHATE POLYFUSOR INFUSION .................................................................................. 70
POTASSIUM ACID PHOSPHATE INFUSION......................................................................... 71
PIPERACILLIN-TAZOBACTAM INFUSION ............................................................................ 72
POTASSIUM CHLORIDE INFUSION ..................................................................................... 74
PROPOFOL INFUSION ......................................................................................................... 75
REMIFENTANIL INFUSION ................................................................................................... 76
SALBUTAMOL INFUSION ..................................................................................................... 79
SARILUMAB INFUSION ......................................................................................................... 80
SODIUM BICARBONATE INFUSION .................................................................................... 82
THIOPENTONE INFUSION ................................................................................................... 83
VASOPRESSIN INFUSION ..................................................................................................... 84
ZANAMIVIR INFUSION ......................................................................................................... 85
APPENDICES ...................................................................................................... 86

APPENDIX A: Peripheral Intravenous Infusion of Vasopressor Drugs in Adult

Critical Care Patients ........................................................................................... 87
APPENDIX B: Serum drug concentrations and therapeutic ranges .................... 89
APPENDIX C: Creatinine clearance..................................................................... 90
APPENDIX D: Weight conversion ....................................................................... 91
APPENDIX E: Body Mass Index calculator .......................................................... 92
APPENDIX F: Infusion rate and dose calculator .................................................. 93

Introduction
The Critical Care Prescribing Infusion Guidelines has been developed for the benefit of all
working in the Critical care areas at South Tees. It comprises a list of drugs used in critical care
as infusions and complements the handbook of IV drugs boluses in critical care produced by
another group of critical care practitioners. The drugs protocols on this handbook are adapted
for its use in critical care areas at South Tees after been agreed by the senior critical care staff
at South Tees.
The use of the infusions protocols in this handbook should be only limited to critical care areas
and its use outside these areas should only be after following senior advice.
While every effort has been made to check drug dosage and information about every drug it is
still possible that there could be errors. We will encourage any user of this handbook to check
the information if it seems wrong. In addition, we would be grateful to hear from anybody with
suggestions or corrections about the contents of this handbook.
DRUG INFORMATION RESOURCES
• British National Formulary: www.bnf.org (access via Athens)

• Medusa: www.injguide.nhs.uk (intranet south tees)
• TOXBASE: www.toxbase.org (username: H1944, password: ICU3BW)
• Extravasation database: www.extravasation.org.uk
SUGGESTIONS / CORRECTIONS
Please contact:
isabel.gonzalez@nhs.net
steven.lockwood@.nhs.net

A – Z of Drug Infusions in Critical Care

n-ACETYL CYSTEINE INFUSION

Review January 2022
Date Drug Dose Route
dd/mm/yy N-ACETYL CYSTEINE *Various IV
TOTAL VOLUME Rate (mL/h) Other Directions
mL *100 mL–1000 mL * As per weight
(final dilution) * Dose adjusted as
and indication
per weight and
DILUENT 5% Glucose indication
Minimum - Maximum Check overleaf
Prescriber’s signature A Prescriber Pharmacy

Print Name A Prescriber P
Professional Reg No. 999999
USES: Paracetamol overdose

Liver failure
Antioxidant
MODE: Sulfhydryl group donor

Oxygen free radical scavenger
ACTIONS: Protects the liver by restoring depleted hepatic reduced glutathione.

Cytoprotective. Glutathione (endogenous antioxidant) precursor.
CAUTIONS: Anaphylactoid reactions
DOSES: Liver failure: 150 mg/kg in 200 mL Glucose 5% over 60 min followed by
12.5 mg/kg/hour continuous infusion
Paracetamol overdose (if more than 7.5 g Paracetamol OD or levels
>100 microgram/mL at 4 h-see treatment reference line): 150 mg/kg in
200 mL Glucose 5% over 60 min, followed by 50 mg/kg in 500 mL of
Glucose 5% over next 4 hours, then 100 mg/kg in 1000 mL of Glucose
5% over next 16 hours
NOTES: Hypersensitivity has been removed as a contra-indication to treatment

with acetylcysteine. Sodium Chloride 0.9% can be used if glucose
unsuitable.

ADRENALINE (EPINEPHRINE) INFUSION

Review January 2022
4 mg
dd/mm/yy ADRENALINE IV Central
(single dilution)
Rate (mL/h) Other
TOTAL VOLUME 50 mL
mL (80 microgram/mL,
Directions
Start 1 mL/hour For other dilutions
(final dilution) single dilution) Titrate to MAP see adrenaline
DILUENT dilution tables
5% Glucose Minimum - Maximum

USES: Inotrope and vasopressor
MODE: α and β stimulation. More β effect at low doses (positive

inotrope/chronotrope). More α effect at higher doses (vasoconstriction)
ACTIONS: Increases rate and force of heart contractions (β1), peripheral

vasoconstriction (α1), bronchodilatation (β2), vasodilatation in skeletal
muscle bed (β2), stimulates gluconeogenesis
CAUTIONS: Low dose: β2 > β1 may initially drop BP by preferential vasodilatation in

skeletal muscle
Hyperthyroidism, diabetes mellitus, ischaemic heart disease
Arrhythmias more common with hypercapnia and hypoxia
DOSES: 0.01 – 0.5 microgram/kg/min initially = 0.5 – 24 mL/h for 80 kg adult

Titrate to effect (MAP, HR, CO).
Adrenaline boluses are given only during treatment of cardiac arrest or
anaphylaxis
NOTES: Central line administration is recommended. No flushing. Dilution:

• single 4 mg in 50 mL (80 microgram/mL) (Ready-made vial
available)
• double dilution of 8 mg in 50 mL (160 microgram/mL)
• quadruple dilution of 16 mg in 50 mL (320 microgram/mL)
• neat 40 mg in 40 mL (1 mg/mL) in extreme situations
Peripheral line administration is not recommended, only use in
emergency situation and for short term. Dilution for peripheral
administration is the single one of 80 microgram/mL. Start 0.5 mL/h of
the 80 microgram/mL concentration (approx. 0.01 microgram/kg/min
for a 70kg patient). Titrate to desire effect.
More information: Peripheral Vasopressor Administration Appendix

ADRENALINE (EPINEPHRINE) INFUSION DILUTIONS

SINGLE strengthÞ 4 mg in 50mL (80 micrograms in 1mL) Adrenaline (epinephrine)
Infusion rate (in mL / hour) as per dose and patient body weight
Dosage Patient’s body weight Kg

40 50 60 70 75 80 90 100 110 120
0.01 microgram/kg/min 0.3 0.37 0.45 0.52 0.56 0.6 0.67 0.75 0.82 0.9
0.02 microgram/kg/min 0.6 0.75 0.9 1.05 1.12 1.2 1.35 1.5 1.65 1.8
0.05 microgram/kg/min 1.5 1.87 2.25 2.62 2.81 3 3.37 3.75 4.12 4.5
0.1 microgram/kg/min 3 3.75 4.5 5.25 5.62 6 6.75 7.5 8.25 9
0.2 microgram/kg/min 6 7.5 9 10.5* 11.25* 12* 13.5* 15* 16.5* 18*
0.5 microgram/kg/min 15* 18.75* 22.5* 26.25* 28.12* 30* 33.75* 37.5* 41.25* 45*
*consider using a more concentrated solution
DOUBLE strengthÞ 8 mg in 50mL (160 micrograms in 1mL) Adrenaline (epinephrine)


40 50 60 70 75 80 90 100 110 120
0.05 microgram/kg/min ^0.75 ^0.94 ^1.12 ^1.31 ^1.41 ^1.5 ^1.69 ^1.87 2.06 2.25
0.1 microgram/kg/min ^1.5 ^1.87 2.25 2.62 2.81 3 3.37 3.75 4.12 4.5
0.2 microgram/kg/min 3 3.75 4.5 5.25 5.62 6 6.75 7.5 8.25 9
0.5 microgram/kg/min 7.5 9.37 11.25* 13.12* 14.06* 15* 16.87* 18.75* 20.62* 22.5*
QUAD strengthÞ 16 mg in 50mL (320 micrograms in 1mL) Adrenaline (epinephrine)


40 50 60 70 75 80 90 100 110 120
0.1 microgram/kg/min 0.75^ 0.94^ 1.12^ 1.31^ 1.40^ 1.5^ 1.69^ 1.87^ 2.06 2.25
0.2 microgram/kg/min 1.5^ 1.87^ 2.25 2.62 2.81 3 3.37 3.75 4.12 4.5
0.5 microgram/kg/min 3.75 4.69 5.62 6.56 7.03 7.5 8.44 9.37 10.31* 11.25*
1 microgram/kg/min 7.5 9.37 11.25* 13.12* 14.06* 15* 16.87* 18.75* 20.62* 22.5*
NEATÞ 40 mg in 40mL (1000 micrograms in 1mL) Adrenaline (epinephrine)


40 50 60 70 75 80 90 100 110 120
0.5 microgram/kg/min 1.2 1.5 1.8 2.1 2.25 2.4 2.7 3 3.3 3.6
1 microgram/kg/min 2.4 3 3.6 4.2 4.5 4.8 5.4 6 6.6 7.2

ALFENTANIL INFUSION
Review January 2022
dd/mm/yy ALFENTANIL 25 mg IV
Rate (mL/h) Other
TOTAL VOLUME
50 mL Directions
mL Usually 1-10 mL/hour
(final dilution) (0.5 mg/mL) Titrate to effect
DILUENT Ready-made or dilute with

Minimum - Maximum
Sodium Chloride 0.9%
USES: Alfentanil is a short-acting synthetic opioid analgesic useful both as an

analgesic and as a respiratory depressant in for patients on assisted
ventilation
MODE: Rapid onset of action with short duration

It has relatively few cardiovascular effects
It is relatively non-sedating
ACTIONS: Causes significant respiratory depression
May cause some nausea and vomiting and constipation
Higher doses may cause skeletal muscle rigidity (especially neck, chest
wall and extremities)
Erythromycin and cimetidine will prolong the plasma clearance of
alfentanil
CAUTIONS: 0.5 – 5 mg/hour (1-10 mL/hour of single dilution)

up to 1 microgram/kg/min (= 9.6 mL/hour in 80kg patient)
DOSES: Alfentanil has no active metabolites and accumulates very little in renal
failure. In hepatic failure elimination half-life is markedly increased
Usual dilution is single 25 mg in 50 mL, 0.5 mg/mL, occasionally used
as double strength 50 mg in 50 mL, 1 mg/mL (use 5 mg/mL vials)
NOTES: Alfentanil is a short-acting synthetic opioid analgesic useful both as an

analgesic and as a respiratory depressant in for patients on assisted
ventilation

ALTEPLASE INFUSION
Review January 2022
dd/mm/yy ALTEPLASE 100 mg IV
Rate (mL/h) Other
TOTAL VOLUME
100 mL Directions
mL 10-50 mL/hour
(final dilution) (1 mg/mL) (as per indication, see below)
DILUENT Water for

Minimum - Maximum
injections
USES: Thrombolysis for acute myocardial infarction, pulmonary embolism and

acute ischaemic stroke
MODE/ Thrombolysis
Alteplase binds to clots and selectively converts fibrin-bound
ACTIONS: plasminogen to plasmin, which then acts to lyse the fibrin clot
CAUTIONS: It is usually well-tolerated

Intracerebral haemorrhage occurs in 0.5%
Occasionally causes nausea and vomiting
DOSES: Pulmonary embolism: 10 mg as an IV bolus over 1 to 2 minutes, then 90

mg as an IV infusion over 2 hours (total dose 100 mg over 2 hours). If <65
kg bodyweight the total dose should not exceed 1.5 mg/kg
Acute ischaemic stroke: 0.9 mg/kg (max 90 mg) IV infusion over 60

minutes with 10% of the total dose given as an initial IV bolus over 3 to 5
minutes. Refer to Stroke team and/or Trust guidelines
Myocardial infarction: no longer used. Refer to cardiology.
NOTES: Not to be used after traumatic cardiopulmonary resuscitation or within

10 days of major surgery

AMINOPHYLLINE INFUSION (Central line)

Review January 2022
dd/mm/yy AMINOPHYLLINE 250 mg IV central
Rate (mL/h) Other
(0.5mg/kg/hour)
Directions
TOTAL VOLUME
50 mL 60 kg____30 mg/h_____6 mL/hour
mL Refer to
(final dilution) (5 mg/mL) 70 kg____35 mg/h_____7 mL/hour
80 kg____40 mg/h_____8 mL/hour Trust
90 kg____45 mg/h_____9 mL/hour guidelines
for advice
DILUENT Glucose 5% Minimum - Maximum

USES: Treatment of acute asthma and acute exacerbation of chronic

obstructive lung disease
MODE: Aminophylline is a methylxanthine. Its effects may be mediated by

inhibition of cyclic nucleotide phosphodiesterase resulting in increased
concentrations of intracellular cAMP
ACTIONS: Relaxes the smooth muscle of the respiratory tract producing

bronchodilatation
Increases blood pressure, heart rate and force of contraction
Increases gastric acid output
CAUTIONS: May potentiate hypokalaemic effects of β2 agonists

Cardiac or neurotoxicity with high doses
DOSES: Loading dose: 5mg/kg (usually 250-500 mg) over 20-30 minutes
DO NOT GIVE LOADING DOSE IF ALREADY ON Theophylline/
Aminophylline
Adult maintenance dose: 0.5 mg/kg/hour
Increase dose in young children, reduce dose in elderly or with history
of heart failure or hepatic dysfunction
NOTES: Narrow therapeutic window. Monitor plasma levels regularly with target
= 10 – 20 mg/L

AMINOPHYLLINE INFUSION (Peripheral)

Review January 2022
dd/mm/yy AMINOPHYLLINE 1000 mg IV
Rate (mL/h) Other
Directions
(0.5mg/kg/hour)
TOTAL VOLUME
1000 mL 60 kg____30 mg/h_____30 mL/hour Refer to
mL
(final dilution) (1 mg/mL) 70 kg____35 mg/h_____35 mL/hour Trust
80 kg____40 mg/h_____40 mL/hour
guidelines
90 kg____45 mg/h_____45 mL/hour
for advice
DILUENT Sodium Chloride 0.9% Minimum - Maximum
USES: Treatment of acute asthma and acute exacerbation of chronic

obstructive lung disease
MODE: Aminophylline is a methylxanthine. Its effects may be mediated by

inhibition of cyclic nucleotide phosphodiesterase resulting in increased
concentrations of intracellular cAMP
ACTIONS: Relaxes the smooth muscle of the respiratory tract producing

bronchodilatation
Also increases blood pressure, heart rate and force of contraction, and
increases gastric acid output
CAUTIONS: May potentiate hypokalaemic effects of β2 agonists

Cardiac or neurotoxicity with high doses
DOSES: Loading dose: 5 mg/kg (usually 250-500 mg) over 20-30 minutes
DO NOT GIVE LOADING DOSE IF ALREADY ON Theophylline/
Aminophylline
Adult maintenance dose: 0.5 mg/kg/hour
Increase dose in young children, reduce dose in elderly or with history of
heart failure or hepatic dysfunction
NOTES: Narrow therapeutic window. Monitor plasma levels regularly with target
= 10 – 20 mg/L

AMIODARONE INFUSION
Review January 2022
300 mg (loading)
IV
dd/mm/yy AMIODARONE 900 mg (24 h loading)
central
600 mg (maintenance)
Rate (mL/h) Other
TOTAL VOLUME 50 mL
Directions
mL 50 mL/hour (300 mg loading)
6 mg/mL if 300 mg
(final dilution) 12 mg/mL if 600 mg 50 mL/24 hour (900 mg 24 h loading)
18 mg/mL if 900 mg
50 mL/24 hour (600 mg maintenance)

USES: Ventricular and supraventricular arrhythmias including those associated

with WPW
MODE: Partial antagonist of a and b agonists

Decreases the delayed slow outward potassium current and in high
doses depresses the fast and slow inward currents, due to Sodium and
calcium respectively
ACTIONS: Class III antiarrhythmic

Minimum myocardiac depression
CAUTIONS: Heart block, sinus bradycardia. Iodine sensitivity
DOSES: Loading dose: 300 mg in 50 mL over 1 h then 900 mg in 50 mL over 24 h

Maintenance dose: 600 mg in 50 mL over 24h for 7 days, then decrease
to 400 mg/24hour for 7 days, then 200 mg/24hour (can be converted to
NG/oral at any point)
NOTES: Incompatible with Sodium Chloride 0.9%

Liver metabolised. Safe in renal failure,
Potentiates other drugs (digoxin, calcium antagonists)
Adverse effects:
- Short term: skin reactions, corneal microdeposits
- Long term: pulmonary fibrosis, thyroid dysfunction, liver dysfunction

CALCIUM GLUCONATE INFUSION

Review January 2022
dd/mm/yy CALCIUM GLUCONATE 10% 100 mL IV
TOTAL VOLUME Rate (mL/h) Other
1100 mL
mL Directions
(final dilution) (5 mg/mL) 50 mL/hour
DILUENT Sodium Chloride 0.9% or
Minimum - Maximum
Glucose 5%
USES: Treatment of acute hypocalcemia
MODE: Replacement of Calcium ions
ACTIONS: Cardiopulmonary resuscitation where there is also hyperkalaemia or

hypocalcaemia or calcium channel block toxicity (use Calcium Chloride
10% = 1gr)
CAUTIONS: Highly irritant, ideally administered into a large vein to avoid

extravasation.
Rapid administration of calcium gluconate may result in hot flushes,
hypotension, bradycardia, arrhythmias and cardiac arrest.
Calcium enhances the effects of digoxin on the heart and may
precipitate digitalis intoxication.
Any underlying cause of hypocalcaemia should be investigated and
corrected. Parathyroid hormone and vitamin D levels should ideally be
checked before initiating treatment for hypocalcaemia.
Low magnesium levels should be corrected first. Without replenishing
magnesium first any increase in calcium will be transient.
Monitor serum calcium levels 4 -6 hourly.
DOSES: 100ml of calcium gluconate 10% diluted in 1000ml sodium chloride

0.9% or glucose 5% and start at 50ml/hr (10ml/kg of this preparation
will increase serum calcium by 0.3-0.5 mmol/L)
10ml calcium gluconate 10% solution in 100mls sodium chloride 0.9%

or glucose 5% over 10-20 mins depending on urgency. It can be given
neat by slow IV injection over at least 3 minutes in an emergency (e.g.

tetany) but ECG monitoring is recommended especially in those at risk

of arrhythmias or with cardiac disease.

CISATRACURIUM INFUSION
Review January 2022
dd/mm/yy CISATRACURIUM 300 mg IV
Rate (mL/h) Other
Directions
TOTAL VOLUME 60 mL 3 mL/hour
mL
(5 mg/mL) see below
(final dilution)
(80 kg patient)
DILUENT Neat Minimum - Maximum

USES: Non-depolarising neuromuscular blocking drug (NMBD) for skeletal

muscle relaxation
MODE: Isomer of atracurium and four times more potent with a longer duration
of action
It is metabolised by Hofmann degradation and does not accumulate in
hepatic or renal failure
ACTIONS: Competitive antagonist of acetylcholine at the postsynaptic nicotinic

receptor
Non-depolarizing NMBDs are not metabolised at the neuromuscular
junction - resolution of block is due to a dilutional effect of the drug
with time
Does not result in histamine release (unlike atracurium)
CAUTIONS: Activity prolonged in myasthenia gravis and hypothermia

Resistance may develop with severe burns requiring larger doses
DOSES: Bolus use: 0.1 - 0.15 mg/kg (duration around 30min)
Infusion: Start at 0.18 mg/kg/hour (usual range 0.03-0.6 mg/kg/min) and

adjust according to level of neuromuscular blockade

CLONIDINE INFUSION
Review January 2022
1500
dd/mm/yy CLONIDINE IV
microgram
Rate (mL/h) Other
TOTAL VOLUME Directions
50 mL Titrate to response or
mL
(final dilution) (30 microgram/mL) reduce/stop if side-
effects

USES: Opiate, benzodiazepine and alcohol withdrawal. Agitation.

Hypertensive crisis
MODE: Stimulates a2 (presynaptic) adrenoceptors, decreasing noradrenaline

release from sympathetic nerves, decreasing sympathetic tone and
increasing vagal tone
Activates a2 adrenoceptors in the dorsal horn of spinal cord (analgesic
effect)
ACTIONS: Decrease blood pressure

Decrease cerebral blood flow and intraocular pressure
Depressant effect on spontaneous sympathetic outflow and somato
sympathetic reflexes (Ad and C fibre mediated)
CAUTIONS: Rapid administration may produce transient hypertension then

hypotension.
Stopping clonidine suddenly may cause rebound hypertension,
tachycardia, headaches and irritability
DOSES: 100 - 300 microgram 8 hourly as IV bolus or oral

100 - 150 microgram/h as infusion
NOTES: Side effects include bradycardia, nausea and vomiting, headache,

peripheral vasoconstriction, ECG abnormalities and abnormal liver
function tests

DEXMEDETOMIDINE
Review January 2022
dd/mm/yy DEXMEDETOMIDINE 400 micrograms IV
Rate (mL/h) Other
Directions
Start 7 mL/hour
TOTAL VOLUME 50 mL (80 kg patient)
mL
(final dilution) (8 microgram/mL) (range 1-14 mL/hour)
Adjust per weight
(see table)
DILUENT Sodium Chloride 0.9% Minimum – Maximum

USES: Facilitate weaning of sedation in patients at high risk of developing

agitation or delirium (especially those with midazolam and/or opioid
based regimes)
NOT TO BE USED INSTEAD OF/OR AFTER CLONIDINE as this drug is
many more times expensive and generally if clonidine does not work
dexmedetomidine is unlikely to as well
MODE: Selective α-2 adrenergic receptor agonist (especially

selective for 2A subtype)
ACTIONS: Sedation, free from respiratory depressive effects, does not

require cessation to allow for extubation.
Some analgesic and anaesthetic/analgesic-sparing effects
CAUTIONS: Liver failure (dose adjustment) Severe liver disease (Child Pugh C)
Traumatic brain injury SAH
Cerebrovascular disease Uncontrolled seizures
Microvascular free flap surgery Uncontrolled haemodynamic instability
Pregnancy/ breastfeeding
DOSES: Initial infusion rate of 0.7 microgram/kg/hour (follow algorithm)

adjusted stepwise within the dose range 0.2 to 1.4 microgram/kg/hour.
NOTES: CAUTION if use as BOLUS as will cause transient HYPERTENSION

Most common side effects bradycardia and hypotension.
Elimination half-life 90 minutes. Ensure appropriate analgesia.



DESFERRIOXAMINE INFUSION
Review January 2022
IV
dd/mm/yy DESFERRIOXAMINE 2000 mg
Central
TOTAL Rate (mL/h) Other
VOLUME 50 mL Directions
mL 10 – 30 mL/hour
(40 mg/mL)
(final dilution) (80 kg patient)

USES: Acute iron poisoning (if serum iron >500 microgram/dl)

For chronic iron overload
For aluminium overload in ESRF
MODE/ Binds iron in the blood

ACTIONS:
CAUTIONS: Rapid intravenous infusion may cause flushing, tachycardia, urticaria,

hypotension, and shock, always give slowly.
DOSES: For acute iron poisoning IV infusion: 15 mg/kg/hour and should be

reduced as soon as the situation permits (usually for 4 - 6 h) so that the
total IV dose does not exceed a recommended 80 mg/kg in any 24 h
period.
For chronic iron overload: subcutaneous infusion is the preferred
method. Administer the recommended dose over 8-12 h or
continuously over 24 h.
For treatment of aluminium overload in patients with ESRF, IV infusion:
Administer at a rate of 5 mg/kg/h (follow renal physician advice as given
towards the end of haemodialysis)
NOTES: CONSULT TOXBASE FOR THE MOST UP TO DATE INFORMATION

Pain, swelling, induration, erythema, burning, pruritus, wheals and rash
may occur at the infusion site. Occasionally accompanied by fever,
chills, malaise, arthralgia, myalgia, headache, nausea, vomiting,
abdominal pain and asthma.
Anaphylaxis and angioneurotic oedema have very rarely been reported

DIGOXIN INFUSION
Review January 2022
500 microgram
dd/mm/yy DIGOXIN IV
(loading dose)
Rate (mL/h) Other
TOTAL VOLUME 100 mL Directions
mL 50 mL/hour
(final dilution) (5 microgram/mL)

USES: Atrial fibrillation and flutter

Heart failure
MODE: Inhibits Na+/K+-ATPase, increasing Na+ and decreasing K+

intracellularly (slow AV node conduction), displacing intracellular bound
Ca++ which makes it more available (inotropic action)
Increases efferent vagal activity
ACTIONS: Slows ventricular rate, depresses sinus node discharge and slows AV
node conduction
Positive inotropism, increases force of cardiac contraction
CAUTIONS: Contraindicated in intermittent 2nd and complete heart block, WPW
syndrome, HOCM, constrictive pericarditis
Caution in renal failure
Side effects: gastrointestinal, visual disturbances and dysrhythmias
DOSES: Loading dose 500 - 1500 microgram in 2 - 3 divided doses 6 hourly until
effect (i.e., 500 microgram in 100 mL over 2 h-repeat if required)
Maintenance dose 62.5 – 500 microgram / 24 h (oral or IV)
NOTES: Therapeutic range 1-2 nanogram/mL. Toxicity increased by

hypokalaemia and other drugs
Digoxin-specific antibody fragments (Digifab) available for digoxin
toxicity

DOBUTAMINE INFUSION
Review January 2022
IV
dd/mm/yy DOBUTAMINE 250 mg
central
Rate (mL/h) Other
mL 1 mL/hour
(final dilution) (5 mg/mL)
Titrate to effect

USES: Inotrope and peripheral vasodilator used in cardiogenic and septic shock
MODE: β1 and β2 stimulation

Minimal action on α1 receptors
ACTIONS: Increases cardiac output and reduces afterload (β2 effects on skeletal
muscle).
CAUTIONS: Increased risk of developing an exaggerated pressor response in patients

with pre-existing hypertension and may exacerbate or precipitate
ventricular ectopic activity
Hyperthyroidism
DOSES: Usual dose is 1 - 20 microgram/kg/min

(See table)
NOTES: Hypovolaemia should be corrected with suitable volume expanders

and/or blood products prior to the initiation of treatment with
dobutamine
As a rule, the use of dobutamine in septic shock is generally limited to
patients with mixed venous oxygen levels (SvO2) outside the normal
range 55-75%
Single dilution 250 mg in 50 mL (5 mg/mL).

Double dilution 500 mg in 50 mL (10 mg/mL).

DOBUTAMINE INFUSION DILUTIONS
SINGLE strengthÞ 250 mg in 50 mL (5 mg in 1 mL) Dobutamine


40 50 60 70 75 80 90 100 110 120
1 microgram/kg/min 0.48 0.6 0.72 0.84 0.9 0.96 1.08 1.2 1.32 1.44
2.5 microgram/kg/min 1.2 1.5 1.8 2.1 2.25 2.4 2.7 3 3.3 3.6
5 microgram/kg/min 2.4 3 3.6 4.2 4.5 4.8 5.4 6 6.6 7.2
10 microgram/kg/min 4.8 6 7.2 8.4 9 9.6 10.8 12 13.2 14.4
15 microgram/kg/min 7.2 9 10.8 12.6 13.5 14.4 16.2 18 19.8 21.6
20 microgram/kg/min 9.6 12 14.4 16.8 18 19.2 21.6 24 26.4 28.8
DOUBLE strengthÞ 500 mg in 50 mL (10 mg in 1 mL) Dobutamine


40 50 60 70 75 80 90 100 110 120
1 microgram/kg/min 0.24 0.3 0.36 0.42 0.45 0.48 0.54 0.6 0.66 0.72
2.5 microgram/kg/min 0.6 0.75 0.9 1.05 1.12 1.2 1.35 1.5 1.65 1.8
5 microgram/kg/min 1.2 1.5 1.8 2.1 2.25 2.4 2.7 3 3.3 3.6
10 microgram/kg/min 2.4 3 3.6 4.2 4.5 4.8 5.4 6 6.6 7.2
15 microgram/kg/min 3.6 4.5 5.4 6.3 6.75 7.2 8.1 9 9.9 10.8
20 microgram/kg/min 4.8 6 7.2 8.4 9 9.6 10.8 12 13.2 14.4

DOPAMINE INFUSION
Review January 2022
dd/mm/yy DOPAMINE 200 mg IV central
Rate (mL/h) Other
mL 2 mL/hour
(final dilution) (4 mg/mL) Titrate to MAP

USES: Inotrope, chronotrope and vasoconstrictor used in cardiogenic and

septic shock
MODE/ Predominantly dopaminergic effects at low doses (0.5 - 2

ACTIONS: microgram/kg/min) which results in reduced peripheral vascular
resistance and a reduction in afterload
Higher doses (2 – 10 microgram/kg/min) begin to stimulate β1 effects
therefore increasing cardiac output
Doses above 10 microgram/kg/min start to produce α effects with
vasoconstriction and a subsequent increase in peripheral vascular
resistance
CAUTIONS: Arrhythmias may occur at high doses
DOSES: 1 – 20 microgram/kg/min
(See table)
NOTES: Hypovolaemia should be corrected prior to the initiation of treatment

with dopamine.
Dose range may not correlate fully with effect in critically ill patients
So called ‘renal-dose’ or ‘low-dose’ dopamine therapy is no longer
recommended in an attempt to preserve renal blood flow in critically ill
patients

DOPAMINE INFUSION DILUTIONS

SINGLE strengthÞ 200 mg in 50 mL (4 mg in 1mL) Dopamine

40 50 60 70 75 80 90 100 110 120
1 microgram/kg/min 0.6 0.75 0.9 1.05 1.12 1.2 1.35 1.5 1.65 1.8
2.5 microgram/kg/min 1.5 1.87 2.25 2.62 2.81 3 3.37 3.75 4.12 4.5
5 microgram/kg/min 3 3.75 4.5 5.25 5.62 6 6.75 7.5 8.25 9
10 microgram/kg/min 6 7.5 9 10.5 11.2 12 13.5 15 16.5 18
15 microgram/kg/min 9 11.2 13.5 15.7 16.8 18 20.2 22.5 24.7 27
20 microgram/kg/min 12 15 18 21 22.5 24 27 30 33 36
DOUBLE strengthÞ 400 mg in 50mL (8 mg in 1mL) Dopamine


40 50 60 70 75 80 90 100 110 120
1 microgram/kg/min 0.3 0.37 0.45 0.52 0.56 0.6 0.67 0.75 0.82 0.9
2.5 microgram/kg/min 0.75 0.93 1.12 1.31 1.40 1.5 1.68 1.87 2.06 2.25
5 microgram/kg/min 1.5 1.87 2.25 2.62 2.81 3 3.37 3.75 4.12 4.5
10 microgram/kg/min 3 3.75 4.5 5.25 5.62 6 6.75 7.5 8.25 9
15 microgram/kg/min 4.5 5.62 6.75 7.87 8.43 9 10.1 11.2 12.3 13.5
20 microgram/kg/min 6 7.5 9 10.5 11.5 12 13.5 15 16.5 18

DOPEXAMINE INFUSION
Review January 2022
dd/mm/yy DOPEXAMINE 100 mg IV Central
Rate (mL/h) Other
TOTAL Directions
VOLUME 50 mL 1 -12 mL/hour
mL (2 mg/mL)
(final dilution) Titrate to effect
(for 70kg patient)

USES: Inotrope and afterload reduction for short term use
MODE: Acts predominantly on β2 receptors and peripheral dopaminergic

receptors
Indirect sympathomimetic action by inhibition of endogenous
catecholamine uptake
ACTIONS: Increases cardiac output and reduces SVR (afterload)
CAUTIONS: May exacerbate myocardial ischaemia
DOSES: Usual dose is 0.5 – 6 microgram/kg/min
NOTES: Hypovolaemia should be corrected with suitable volume expanders

and/or blood products prior to the initiation of treatment with
dopexamine
Infusion should begin at a dose of 0.5 microgram/kg/min and increased
to 1 microgram/kg/min and then in increments of 0.5microgram/kg/min
up to a maximum of 6 microgram/kg/min at intervals of not less than 15
minutes
There is some evidence to show benefit in critically ill patients when used
to protect renal or hepato-splanchnic perfusion

DOXAPRAM INFUSION
Review January 2022
dd/mm/yy DOXAPRAM 1g IV
Rate (mL/h) Other
TOTAL VOLUME
500 mL Directions
mL 30-120mL/hour Ready-made
(final dilution) (2 mg/mL)
bag
available

USES: Respiratory stimulant for the treatment of post-operative respiratory

depression and acute on chronic respiratory failure
MODE: Stimulates peripheral chemoreceptors and by direct action on the

respiratory centre
ACTIONS: Increases tidal volume and at higher dosage increases respiratory rate
Increases cardiac output, cerebral blood flow and increases
catecholamine and steroid secretion
CAUTIONS: Contraindicated in coronary artery disease and epilepsy

Can cause hypertension, panic attacks, restlessness, hallucinations,
convulsions, dizziness and excessive sweating
DOSES: 1 – 4 mg/min (30 -120 mL/hour of 2mg/mL ready to use infusion) titrating
to response
As a bolus over 30 sec max 1.5 mg/kg
NOTES: Not used routinely. A ready-made bag of 1g in 500 mL is available.

EPHEDRINE INFUSION
Review January 2022
dd/mm/yy EPHEDRINE 60 mg IV
Rate (mL/h) Other
60 mL 6 mL/hour
mL
(final dilution) (1 mg/mL) Titrate to effect
(see notes below)

USES: Inotrope and vasopressor used generally as bolus therapy, especially

following spinal or epidural anaesthesia
MODE: Acts directly on β1 and β2 receptors

Indirect action on α receptors by noradrenaline release
ACTIONS: Increases blood pressure and heart rate

Has some bronchodilation effects
CAUTIONS: May cause inadvertent tachycardia and hypertension
DOSES: Usual bolus dose is 3 – 10 mg repeated as required up to a maximum of

60 mg
Length of action is around 5 – 15 min
Mix 30 mg vial in a total volume of 10 mL Sodium Chloride 0.9% and use
in 1 mL (3 mg) aliquots titrated to effect
Can also be made up as an infusion for peripheral infusion

Very rarely used this way
NOTES: Popular use as a vasopressor in pregnancy as it has minimal effects on

placental blood flow

EPOPROSTENOL (PROSTACYCLIN) INFUSION

Review January 2022
EPOPROSTENOL 100 IV
dd/mm/yy
(PROSTACYCLIN) microgram central
Rate (mL/h) Other
10.5 mL/hour
mL (2 microgram/mL) (70 kg patient at
(final dilution)
(see notes below) 5 nanogram/mL/min,
see table)

USES: Anticoagulant during renal replacement therapy

Pulmonary hypertension
MODE: Stimulates adenyl-cyclase, increasing c-AMP concentration in platelets
ACTIONS: Inhibits platelet aggregation and vasodilatation
CAUTIONS: Causes hypotension, headaches and flushing
DOSES: Dose of 2 - 10 nanogram/kg/min, starting at 0.5 - 1 hour before

haemofiltration
Instructions for reconstitution:
1. Withdraw 10 mL of the glycine diluent into a syringe.
2. Inject the contents of the syringe into the vial of Epoprostenol and
dissolve completely, shaking gently.
3. Draw up all Epoprostenol solution into syringe.
4. Re-inject the entire contents into the residue of the original 50 mL
vial of glycine diluent. Mix well. This is the 'concentrated solution'
and contains 10,000 nanogram in 1 mL (10 microgram in 1 mL).
5. Take 10 mL of this concentrated (10 microgram/mL) solution and
further diluted with 40 mL of Sodium Chloride 0.9% to 2000
nanog/mL (2 microgram/mL)
NOTES: Refer to CVVH guidelines

The 'concentrated solution' must be filtered prior to administration or, if
further diluted, prior dilution, using the filter in the pack.

EPOPROSTENOL INFUSION DILUTIONS

Table 1
Using concentrated solution, i.e., 10000 nanogram/mL Epoprostenol.
Concentration of solution = 10000 nanogram/mL Epoprostenol

Dosage Bodyweight (kilograms)
(nanogram/kg/min)
30 40 50 60 70 80 90 100
1 0.18 0.24 0.30 0.36 0.42 0.48 0.54 0.60
2 0.36 0.48 0.60 0.72 0.84 0.96 1.08 1.20
3 0.54 0.72 0.90 1.08 1.26 1.44 1.62 1.80
4 0.72 0.96 1.20 l.44 1.68 1.92 2.16 2.40
5 0.90 1.20 1.50 1.80 2.10 2.40 2.70 3.00
Flow rates in mL/hour
Table 2
Using diluted solution 10 mL concentrated solution + 40 mL 0.9% saline to give a final total volume of 50 mL.
Resultant concentration = 2000 nanogram/mL Epoprostenol
Concentration of solution = 2000 nanogram/mL Epoprostenol

Dosage Bodyweight (kilograms)
(nanogram/kg/min)
30 40 50 60 70 80 90 100
1 0.90 1.20 1.50 1.80 2.10 2.40 2.70 3.00
2 1.80 2.40 3.00 3.60 4.20 4.80 5.40 6.00
3 2.70 3.60 4.50 5.40 6.30 7.20 8.10 9.00
4 3.60 4.80 6.00 7.20 8.40 9.60 10.80 12.00
5 4.50 6.00 7.50 9.00 10.50 12.00 13.50 15.00
Flow rates in mL/hour

ESMOLOL INFUSION
Review January 2022
dd/mm/yy ESMOLOL 1g IV
100 mL Rate (mL/h) Other Directions
TOTAL VOLUME
Also available as
mL (10 mg/mL) 23 – 90 mL/hour ready-made infusion
(final dilution) bag with 2.5 g in
(75 kg patient)
250mL (10 mg/mL)

USES: AF, Atrial flutter, sinus tachycardia, hypertension
MODE: Competitive blockade of b-adrenoceptors

Relatively cardioselective b1-blocker with rapid onset and very short
duration of action.
ACTIONS: Negative inotropism and chronotropism.

Hypotension and dose dependent fall in heart rate; the cardiac output falls
by about 20%
CAUTIONS: Contraindicated in unstable asthma, sick sinus, AV block, uncontrolled

heart failure and hypotension
DOSES: Loading dose infusion of 500 microgram/kg/min for 1 minute,

followed by 50 microgram/kg/min for 4 minutes.
- If adequate response maintain infusion at 50 microgram/kg/min.
- If inadequate response within 5 minutes, repeat 500 microgram/kg/min
for 1 minute and increase maintenance to 100 microgram/kg/min.
- If adequate response maintain at 100 microgram/kg/min.
- If inadequate response within 5 minutes repeat 500 microgram/kg/min for
1 minute and increase maintenance to 150 microgram/kg/min.
- If adequate response maintain at 150 microgram/kg/min.
- If inadequate response within 5 minutes, repeat 500 microgram/kg/min
over 1 minute and increase maintenance to 200 microgram/kg/min and
maintain.
NOTES: Metabolized by red blood cells esterases, elimination half-life is 9 min

Non compatible with Sodium Bicarbonate
Increases recovery time from suxamethonium from 5 to 8 min approx.
Doses as high as 300 microgram/kg/min have been used.

FENTANYL INFUSION
Review January 2022
dd/mm/yy FENTANYL 2.5 mg IV
Rate (mL/h) Other Directions
TOTAL VOLUME
50 mL
mL Titrate to effect Can be used as PCA
(final dilution) (50 microgram/mL) (see intranet PCA
guidelines))

USES: Analgesic for moderate to severe pain
MODE: Synthetic opioid

Direct effect on opiate receptors throughout body
ACTIONS: Analgesic, CNS and cardio-respiratory depression
CAUTIONS: Respiratory depression

Active metabolites may accumulate in renal and hepatic impairment and
in critically ill following lengthy infusion
Effects on pupillary response may interfere with the monitoring of brain
injury / intracranial pressure
Nausea and vomiting especially with large bolus doses, constipation,
ureteric and biliary spasm
Reduce dose in elderly
DOSES: Bolus dose for acute pain: 1 - 2 microgram/kg
Infusion 2 - 4 microgram/kg/hour
A background low-dose intravenous infusion of fentanyl may be
combined with PCA to provide satisfactory analgesia
NOTES: Effects of fentanyl can be reversed with naloxone

FLECAINIDE INFUSION
Review January 2022
dd/mm/yy FLECAINIDE 150 mg IV
Rate (mL/h) Other
50 mL 75 kg patient:
mL 25 mL/hour 1st 30 min
(final dilution) (3 mg/mL) 37 mL/hour next hour
2.5 – 6 mL/hour next hours
DILUENT GLUCOSE 5% Minimum - Maximum

USES: Anti-arrhythmic agent for suppression of irritable foci (VT and ventricular
ectopics) and for management of re-entry arrhythmias (Wolf-Parkinson-
White syndrome)
MODE: Class IC antiarrhythmic agent.

Reduces maximum rate of depolarisation of heart muscle slowing
conduction particularly in His-Purkinje system.
It has profound effect on accessory pathways especially on retrograde
conduction
ACTIONS: Supresses ventricular ectopic foci

Negative inotropic potential
CAUTIONS: Reversible liver damage

May cause dizziness and visual disturbances
DOSES: Bolus dose of 2 mg/kg (max 150 mg) over 30 min, followed by infusion of
1.5 mg/kg/hour for 1 hour, followed by infusion of 0.1 – 0.25 mg/kg/hour
until arrhythmia control (maximum cumulative dose 600 mg/24hours)
NOTES: Increases plasma digoxin level by 15%

If diluted in small Sodium Chloride 0.9% volume it may precipitate
Not removed by haemodialysis. Reduce dose in renal or hepatic failure

FLUMAZENIL INFUSION
Review January 2022
500 IV
dd/mm/yy FLUMAZENIL
microgram Central
TOTAL VOLUME
50 mL Rate (mL/h) Other
Directions
mL (10 10 - 40 mL/hour
(final dilution) (see below)
microgram/mL)

Reverse over sedation with benzodiazepines

USES: Management of benzodiazepine overdose
MODE: Competitive antagonist at central benzodiazepine receptors
ACTIONS: Reverse of actions of benzodiazepines
CAUTIONS: May cause hypertension, dysrhythmias, convulsions, dizziness, nausea,

vomiting, anxiety and headaches
Re-sedation may occur as short half-life. It acts in 30 – 60 seconds and
lasts 15 – 140 min
DOSES: As IV boluses in 100 microgram increments up to a total of 2 mg for adults

(recommended initial dose of 300 microgram). If drowsiness recurs, a
second bolus injection may be administered.
If IV infusion desired infuse at 100 – 400 microgram/hour. Stop infusion
every 6 hours to see if re-sedation occurs
NOTES: Contraindicated in tricyclic overdose (fits), epileptics on benzodiazepines

(fits), long term benzodiazepine treatment (withdrawal) and raised
intracranial pressure
Very irritant peripherally.
For boluses, administered to freely running established IV drip.
As infusion, administered preferably via central line.

FOMEPIZOLE INFUSION
Review January 2022
dd/mm/yy FOMEPIZOLE See below IV
mL 250 mL Directions
(final dilution) 500 mL/hour
DILUENT Sodium Chloride 0.9%
Minimum - Maximum
or Glucose 5%
PROF REG No. 999999
USES: Ethylene glycol or methanol poisoning (check TOXBASE, this is now

preferred over IV Alcohol)
MODE/ Competes with alcohol dehydrogenase to reduce the production of toxic

metabolites in overdose of ethylene glycol or methanol
ACTIONS:
CAUTIONS: NPIS advises for any patient weighing more than 110 kg the antidote
dose should be calculated using a maximum of 110 kg, rather than the
patient’s actual weight.
DOSES: Loading dose of 15 mg/kg given over 30 minutes (this loading dose
should be given even if ethanol has been administered). Maintenance
dose of 10 mg/kg over 30 minutes every 12 hours for a maximum of 4
doses; followed by 15 mg/kg over 30 minutes every 12 hours thereafter
(see cautions above).

Fomepizole is generally kept at our trust in the Emergency Department.

FUROSEMIDE INFUSION
Review January 2022
dd/mm/yy FUROSEMIDE 250 mg IV
50 mL
mL Directions
(final dilution) (5 mg/mL)* 1 - 2 mL/h *This is the
DILUENT recommended
Minimum - Maximum dilution in
or Neat critical care.
USES: Oedema of cardiac, renal or hepatic origin

Hypertension
Symptomatic hypocalcaemia
Raised intracranial pressure
MODE: Inhibits active Chloride re-absorption in proximal tubule and ascending

limb of loop of Henle, reducing tonicity of renal medulla, a
hypotonic/isotonic urine is produced. At cellular level it is due to an
inhibition of Na+/K+ -ATPase or by inhibition of glycolysis
ACTIONS: Loop diuretic
CAUTIONS: Causes hypokalaemia, hypocalcaemia and hypomagnesaemia, transient

auditory nerve damage, and rarely pancreatitis and bone marrow
depression.
In high dose may cause interstitial nephritis and deafness especially if co-
administered with aminoglycoside
DOSES: As IV infusion 5-10 mg/hour.

Occasionally used as high dose therapy at 3 mg/Kg/day maximum.
Not to be given faster than 240 mg/h otherwise risk of transient deafness.
NOTES: Precipitates if diluted in Glucose 5%. Incompatible with several drugs,

administered separately. Often given as bolus rather than infusion.

GLUCAGON INFUSION
Review January 2022
dd/mm/yy GLUCAGON 50 mg IV central
Rate (mL/h) Other
50 mL 4 mL/hour
mL
(final dilution) (1 mg/mL) for 80 kg patient
(See below)

USES: For the treatment of hypoglycaemia

For the treatment of ß-blocker overdose
MODE: A peptide hormone produced by the alpha cells in the pancreas that
mobilizes glycogen in the liver to convert stored glycogen to glucose.
ACTIONS: Within the treatment of hypoglycaemia it release glycogen from the liver
as glucose.
For the treatment of beta-blockers its main mode of action is the release
of catecholamines or possibly increase of cAMP in the myocardium.
CAUTIONS: Beware of the risk of vomiting and aspiration following the first intial bolus
dose when used for beta-blocker overdose.
Can cause hyperglycaemia, hypokalaemia and hypocalcaemia
Can release catecholamines and in the presence of phaeochromocytoma
can cause the tumour to release large amounts.
DOSES: Beta-blocker overdose: 5-10 mg over 1-2 minutes as IV bolus followed by

an infusion initially of 50 microgram/kg/hour (2.5 mL/hour for 50 kg or 4
mL/hour for weight of 80 kg) and titrate to response.
Hypoglycaemia-consult Trust guidelines for management.
NOTES: CONSULT TOXBASE FOR THE MOST UP TO DATE INFORMATION ON

ß-BLOCKER OVERDOSE

GLYCERYL TRINITRATE INFUSION

Review January 2022
GLYCERYL TRINITRATE
dd/mm/yy 50 mg IV
(NITRONAL-5)
Rate (mL/h) Other
TOTAL VOLUME
Directions
mL 50 mL 1 mL/hour
(final dilution) A 50 mg
Titrate to effect in 50 mL
DILUENT Neat vial is
Minimum - Maximum
available
USES: Vasodilator with myocardial ischaemia, cardiac failure and severe

hypertension
MODE: Direct action on vascular smooth muscle
ACTIONS: Reduces preload by reduction in (mainly venous) systemic vascular

resistance
Reduces pulmonary vascular resistance
Increases coronary blood flow
CAUTIONS: Hypothyroidism, severe liver and renal disease

Contraindicated in hypotension from cardiogenic shock, trauma and
cerebral haemorrhage
DOSES: Usual dose range 0.2 – 5.0 microgram/kg/min

Preferable solution in critical care of 1 mg/mL
Start at 1mL/hour and titrate to effect
NOTES: Monitor blood pressure / CVP carefully.

HEPARIN INFUSION
Review January 2022
20,000
dd/mm/yy HEPARIN (Unfractionated) IV
units
Rate (mL/h) Other
20 mL See protocol on
There is a
mL
prescription chart and
(final dilution) (1,000 units/mL) ready-
see below
made vial
DILUENT available
Sodium Chloride 0.9% Minimum - Maximum

USES: Prevention and treatment of venous thrombosis and pulmonary

embolism, in extracorporeal circuit during renal replacement therapy
MODE: Heparin is a naturally occurring glycosaminoglycan that indirectly inhibits

many of the active forms of the coagulation factors
ACTIONS: Activates antithrombin III, a protease inhibitor which inhibits activated

coagulation factors (especially thrombin and factor Xa)
CAUTIONS: Uncorrected major haemorrhage or uncontrolled severe hypertension,

potential bleeding lesions
Large inter subject variability with dosage and response
Heparin induced thrombocytopenia (HIT)
DOSES: IV bolus dose: 75 units/kg (max 5,000 units) if required

Maintenance intravenous infusion: 700 units – 1,250 units/ hour (initial
rate based on patient’s weight)
= 0.7 – 1.25 mL/hour initially then adjusted as per APTT.
Please refer to local pre-printed prescription for more details.
NOTES: Monitor effects by regular measurement of APTT to the required target

range as per local protocol

HYDRALAZINE INFUSION
Review January 2022
IV
dd/mm/yy HYDRALAZINE 60 mg
Central
Rate (mL/h) Other
TOTAL 60 mL Directions
VOLUME mL 6 mL/hour
(final dilution) (1 mg/mL) then adjust

USES: Hypertensive emergencies, especially if associated with pre-eclampsia

and renal complications
MODE: Precise mode of action unknown
ACTIONS: Vasodilator, principally on arterioles
Decrease in arterial BP and SVR
Produces tachycardia, headache, flushing, increases fluid retention
CAUTIONS: Coronary vascular disease, cerebrovascular disease, hepatic and renal

failure
Severe tachycardia (use β-blockers), hypovolaemia, Cor-pulmonale
DOSES: Bolus doses: 5 mg IV every 15 minutes
Infusion: Start at 6 mg/hour (6 mL/hour) and titrate infusion rate to effect

(or side-effects)
NOTES: Use not recommended in children

HYDROCORTISONE INFUSION
Review January 2022
HYDROCORTISONE
dd/mm/yy 200 mg IV
(Sodium succinate)
TOTAL VOLUME
48 mL For septic shock
mL
(4.16 mg/mL) 2 mL/hour protocol only.
(final dilution)
Other uses tend to
DILUENT Sodium Chloride 0.9% Minimum - Maximum use bolus regimes.
USES: Anti-inflammatory agent

Medical emergencies of shock secondary to adrenocortical
insufficiency.
MODE: Many modes of action but at therapeutic doses it activates

anti-inflammatory pathways.
It inhibits IL12, IFN-alpha, TNF-alpha and TH1 cells, but
stimulates IL4, IL10, IL13 by TH2 cells.
ACTIONS: Glucocorticoid steroid
CAUTIONS: Can weaken the immune system and new infections may
appear during their use. Use the minimum dose for the
minimum amount of time
DOSES: For severe sepsis 200 mg infused over 24 hours.

For inflammation and other indications 100-200 mg as an IV
bolus up to four times a day
NOTES: The use of hydrocortisone in septic shock is still under review.

Used mainly in severe sepsis with high noradrenaline
requirements.

HYPERTONIC SALINE INFUSION

Review January 2022
HYPERTONIC SALINE
dd/mm/yy 3g IV
(SODIUM CHLORIDE 5%)
TOTAL VOLUME
60 mL 1 – 2 mL/Kg/h
mL
(final dilution) 50 mg/mL (maximum to be
given 350 mL)
MIXTURE 50 mL Water for Injections mixed
Minimum - Maximum
with 10 mL of Sodium Chloride 30%
USES: Cerebral oedema and raised ICP in head injury

Hyponatraemic seizures
MODE/ Increases plasma Sodium and creates an osmotic gradient

Induces a shift of fluid from the intracellular to the extracellular space
ACTIONS: Reduces brain water
Increases effective circulating volume
CAUTIONS: Can cause local vascular irritation. Use large vein and at least well-
secured 18G cannula.
DOSES: For raised intracranial pressure use Sodium Chloride 5% 2 mL/Kg over 60
minutes.
For seizures due to hyponatremia use Sodium Chloride 5% 1 mL/Kg to
raise Na >125 mmol/L
NOTES: To make Sodium Chloride 5% mix 10 mL Sodium Chloride 30% with 50

mL sterile water to a total volume of 60 mL.
A ready-made Sodium Chloride 2.7% Polyfusor may be available. In that

case, the dose is 3-5 mL/Kg over 30 minutes.
Hypertonic saline will increase plasma Na+ by approximately 2-3 mmol/L.

The increase may be greater if large diuresis occurs.
Monitor plasma sodium and other electrolytes closely, initially hourly.

INSULIN (ACTRAPID) INFUSION

Review January 2022
dd/mm/yy INSULIN (ACTRAPID) 50 units IV
Rate (mL/h) Other
TOTAL VOLUME 50 mL
mL
Directions
Titrate to blood
(final dilution) (1 unit/mL)
glucose

USES: General glucose control, diabetic ketoacidosis
MODE: Direct hormonal effect on cells
ACTIONS: Regulate carbohydrate, fat and protein metabolism.

Rapid onset IV although short acting, effects usually disappear
after 30 minutes
CAUTIONS: Hypoglycaemia
Alcohol enhances hypoglycaemic effect
DOSES: Rate of insulin infusion is adjusted according to blood glucose

level (see algorithm for insulin in critically ill patients)
Usually started at 1 mL/hour (1.0 unit/hour)
NOTES: Blood glucose levels should be monitored appropriately
Severely ill or shocked patients, or those receiving

corticosteroids or sympathomimetics, may be highly resistant
to insulin and will require relatively large dose infusions initially


ISOPRENALINE INFUSION
Review January 2022
dd/mm/yy ISOPRENALINE 2 mg IV
Rate (mL/h) Other
TOTAL VOLUME
50 mL Directions
mL (40 1-6 mL/hour
(final dilution) (see below)
microgram/mL) Titrate to effect

USES: Used in complete heart block, beta blocker overdose and

severe bradycardia unresponsive to atropine
Can also be used to treat asthma, but less suitable than
specific β2 agonists, e.g., salbutamol
MODE: β1 and β2 stimulation
ACTIONS: Positive inotrope and chronotrope

Bronchodilation
CAUTIONS: Ischaemic heart disease, Diabetes, Hyperthyroidism.

Cardiac arrhythmias may occur, especially ventricular
DOSES: Bolus use: 5 – 20 microgram IV aliquots

Infusion: Commence rate at 1mL/hour and titrate to response.
Usual range for bradycardia is 1-4 microgram/min (approx. 1-6
mL/hour)
NOTES: May cause sweating, headaches, palpitations, tremor

Ideally given centrally, may cause damage to tissues with
extravasation from peripheral administration.
Isoprenaline sulphate is equivalent to 1 mg isoprenaline
hydroChloride

KETAMINE INFUSION
Review January 2022
dd/mm/yy KETAMINE 500 mg IV
Rate (mL/h) Other
mL 4.5-22.5 mL/hour
(final dilution) (10 mg/mL) (75 kg patient)

USES: Intravenous anaesthetic agent, sedative and analgesic at sub-anaesthetic

doses
Additional role in asthma due to bronchodilator effects
MODE: Direct action on NDMA receptors
ACTIONS: Dissociative sedation and analgesia

Increases pulse rate and blood pressure
Increases secretions/salivation
CAUTIONS: Rise in intracranial pressure is a concern in head injured patients,

although this effect is not clear when associated with hypotension from
other causes
Emergence phenomena, hallucinations
DOSES: Bolus dose analgesia: 0.1 - 0.2 mg/kg (usually 5 – 10 mg)

Bolus dose anaesthesia: 1 – 2 mg/kg (maintenance with intermittent 0.5
mg/kg boluses)
Infusion: 0.6 – 3 mg/kg/hour = 4.25 – 22.5 mL/hour (75 kg patient)
NOTES: Appears not to accumulate with prolonged use

LABETALOL INFUSION
Review January 2022
IV
dd/mm/yy LABETALOL 200 mg
Central
TOTAL VOLUME
Rate (mL/h) Other
40 mL Directions
mL
(5 mg/mL) 8-32 mL/hour
(final dilution)

USES: Hypertensive emergencies, controlled hypotension
MODE: Selective effects on α1, β1 and β2 receptors
ACTIONS: Vasodilation
CAUTIONS: Asthma, COPD, cardiogenic shock, heart failure, late pregnancy, hepatic
impairment
DOSES: Bolus dose 20 mg IV every 10 minutes
Infusion: Start at 40 mg/hour (8 mL/hour) and double every 30 min until

satisfactory response or dosage of 160 mg/h (32 mL/h) has been
reached. If the maximum dose is not achieving desired effect, consider
additional or alternative therapies
NOTES: Labetalol 5mg/mL concentration can be used for peripheral bolus

administration but is not suitable for continuous infusion through
peripheral lines.
For peripheral use consider a diluted solution of Labetalol of 1 mg/mL,
i.e., 200 mg (2 ampoules of 20 mL) diluted to 200 ml Sodium Chloride
0.9% or glucose 5%, at a rate of 50 -160 mL/h. Large amounts of fluid
may be administered if using the diluted solution.

MAGNESIUM INFUSION (Central)

Review January 2022
20 mmol IV
dd/mm/yy MAGNESIUM SULPHATE
(5 gr) central
TOTAL VOLUME
Rate (mL/h) Other
50 mL Directions
mL
(0.4 mmol/mL) 10 mL/hour
(final dilution)

USES: Acute asthma

Prevention of seizures in eclampsia
Hypomagnesaemia
Treatment of arrhythmias
MODE: Replacement of magnesium ions

Magnesium is essential for numerous biochemical and cellular function,
particularly muscle and nerve tissues, including all functions involving
ATP
ACTIONS: Cellular membrane transport effects, protein and enzyme function,

improves muscle weakness and nerve function in deficiency states
CAUTIONS: Hepatic and renal impairment
DOSES: Magnesium Sulphate 1 gr = 4 mmol Magnesium2+

For arrhythmias (Torsade de Point): 8 mmol over 2 min
For eclampsia: 16 mmol bolus followed by 4 mmol/h infusion
For acute asthma: 4.8 – 8 mmol slow IV over 20 minutes
For treatment of hypomagnesaemia: infusion of 20 mmol over 5 hours.
Repeat if needed.
NOTES: May be given peripherally but cannot be given in the same line as
Sodium Bicarbonate infusion. A more diluted dose is preferably for
peripheral administration.
Consider oral Magnesium Aspartame 10 mmol sachets if oral route
available as one sachet once or twice a day

MAGNESIUM INFUSION (Peripheral)

Review January 2022
20 mmol IV
dd/mm/yy MAGNESIUM SULPHATE
(5 gr) central
TOTAL VOLUME
Rate (mL/h) Other
250mL Directions
mL
(0.08 mmol/mL) 50 mL/hour
(final dilution)
DILUENT Glucose 5% Minimum – Maximum

USES: Acute asthma

Prevention of seizures in eclampsia
Hypomagnesaemia
Treatment of arrhythmias
MODE: Replacement of magnesium ions

Magnesium is essential for numerous biochemical and cellular function,
particularly muscle and nerve tissues, including all functions involving
ATP
ACTIONS: Cellular membrane transport effects, protein and enzyme function,

improves muscle weakness and nerve function in deficiency states
CAUTIONS: Hepatic and renal impairment
DOSES: Magnesium Sulphate 1 gr = 4 mmol Magnesium2+

For arrhythmias (Torsade de Point): 8 mmol over 2 min
For eclampsia: 16 mmol bolus followed by 4 mmol/h infusion
For acute asthma: 4.8 – 8 mmol slow IV over 20 minutes
For treatment of hypomagnesaemia: infusion of 20 mmol over 5 hours.
Repeat if needed.
NOTES: Do not use the same line as Sodium Bicarbonate infusion.

Use the more concentrated preparation (20 mmol Magnesium Sulphate
in 50 mL at 10 mL/h) if fluid restriction
Consider oral Magnesium Aspartame 10 mmol sachets if oral route
available as one sachet once or twice a day

MANNITOL INFUSION
Review January 2022
dd/mm/yy MANNITOL 20% 100 g IV
Rate (mL/h) Other
Directions
TOTAL VOLUME
500 mL 87.5 - 350 mL
mL
(200 mg/mL) (for 70 Kg patient)
(final dilution)
over 1 hour

USES: Reduction of intracranial pressure and cerebral oedema.

Reduction of elevated intraocular pressure if other means failed.
Promotion of elimination of renally excreted toxic substances in
poisoning.
MODE/ Osmotic diuretic.

Maximum effect 1-1.5 h after infusion
ACTIONS:
CAUTIONS: Contraindicated in pre-existing plasma hyperosmolarity, severe

dehydration, well established anuria, severe heart failure, pulmonary
oedema, active intracranial bleeding and hypersensitivity to mannitol.
Mannitol may be nephrotoxic
DOSES: For reduction of intracranial pressure, cerebral volume and intraocular

pressure:
0.25 – 1 g/kg body weight (1.25 - 5 mL/kg of the 20% Mannitol
solution) over 30 - 60 minutes
Can be repeated 1-2 times after 4-8 hours.
NOTES: For mannitol 20%, an in-line filter is recommended (15-micron filters)
Mannitol for infusion can be found as 10% (100mg/mL), 15%

(150mg/mL) or 20% (200mg/mL), in 250-500 mL bottles.
Mannitol may be nephrotoxic

METARAMINOL INFUSION
Review January 2022
dd/mm/yy METARAMINOL 20 mg IV
Rate (mL/h) Other
40 mL
mL 1 - 20 mL/h
(final dilution) (500 microgram/mL) Titrate to effect

USES: For the treatment of severe hypotension particularly as a complication

of anaesthesia.
MODE: α1 adrenergic receptor agonist with some β effect
ACTIONS: Potent sympathomimetic amine.

The actions of Metaraminol are similar to those of noradrenaline but it
is much less potent and has more prolonged action.
A single dose of Metaraminol lasts from about 20 minutes up to one
hour. Its onset is around one or two minutes.
CAUTIONS: Care in administration as can cause tissue necrosis

After discontinuation, flush the peripheral cannula with Sodium
Chloride 0.9% at the same rate the medicine was infused to avoid
adverse haemodynamic effects.
Use in caution in patients on digoxin since the combination can cause
ectopic arrhythmic activity.
DOSES: Start at 0.125 mL/hour and adjust according to response
NOTES: Monitor cardiac function as can cause sinus or ventricular tachycardia

especially in predisposed patients.
If effect on blood pressure not achieved with maximum rate, consider
change to Noradrenaline via IV central infusion, if appropriate.

METHYLENE BLUE INFUSION

Review January 2022
dd/mm/yy METHYLENE BLUE 1% 500 mg IV
Rate (mL/h) Other
50 mL
mL 8 mL/h
(final dilution) 10 mg/mL (for 80 Kg patient)

USES: Methylene blue is a dye commonly in medical practice.

Use very occasionally in some patients with severe refractory septic
shock.
MODE: Modulation of the nitric oxide system by inhibition of soluble guanylate

cyclase.
Acts as an antioxidant and a pro-oxidant, inhibits prostacyclin synthesis,
and accelerates reductive processes in the cell.
Free radical, nitric oxide and cytokines scavenger.
ACTIONS: Increases arterial blood pressure and systemic vascular resistance in

patients with refractory hypotension associated with severe sepsis,
cardiopulmonary bypass, anaphylaxis, ischaemia–reperfusion syndrome
and haemodialysis.
CAUTIONS: No adverse effects apart from change in urine colour, reported.
DOSES: Bolus loading of 1 mg/kg.

Followed by infusion 1 mg/kg/h for 4-6 hours.
NOTES: Change in urine and skin colour.

MILRINONE INFUSION
Review January 2022
dd/mm/yy MILRINONE 10 mg IV
Rate (mL/h) Other
TOTAL VOLUME
50 mL Directions
mL 8.3 - 16.9 mL/hour
(final dilution) (200 microgram/mL) (for 75 kg patient)
(See notes below)

USES: Short term treatment of severe congestive heart failure unresponsive to

conventional therapy
MODE: A phosphodiesterase-3 inhibitor that decreases the degradation of

cAMP.
ACTIONS: Positive inotrope and vasodilator
CAUTIONS: Accumulates in renal impairment, adjust accordingly.

Improved cardiac output may result in a lower requirement of diuretics
DOSES: Start infusion at 30 microgram/kg/h (11.2 mL/h for 75 Kg patient)

If inadequate response after 48 h, increase to 45 microgram/kg/h.
If patient becomes hypotensive reduce to 22 microgram/kg/h.
Ensure creatinine <265 or eGFR >50mL/min. If patient is not within
these parameters start at 22 microgram/kg/h and if response
inadequate increase to 30microgram/kg/h.
NOTES: Do not use a loading dose.

If systolic BP<80mmHg consider starting at 22 microgram/kg/h

MIDAZOLAM INFUSION
Review January 2022
dd/mm/yy MIDAZOLAM 50 mg IV
TOTAL VOLUME
Rate (mL/h) Other
mL
50 mL Directions
1-10 mL/h
(final dilution) (1mg/mL)
Titrate to effect

USES: Sedation, and premedication prior to general anaesthetic.
MODE: Imidazobenzodiazepine on specific benzodiazepine receptors

throughout central nervous system, mainly cortex and midbrain
ACTIONS: CNS and respiratory depression

Less cardiovascular depression than other IV anaesthetic agents such as
propofol
CAUTIONS: Myasthenia gravis, respiratory disease, renal or hepatic impairment

Contraindicated in acute respiratory failure or respiratory depression
without appropriate respiratory support and monitoring
DOSES: Bolus dose of 0.1 - 0.2 mg/kg for procedural sedation or premedication
(max dose 10 mg) Draw 10 mg in 10mL and give 1mg in a ‘stepwise’
administration.
Infusion titrated to sedation level, usually 1 – 10 mL/hour
NOTES: Midazolam half-life is unreliable and may result in accumulate with renal
impairment and in the critically ill
Effects of midazolam may be reversed in emergency situations by
flumazenil

MORPHINE INFUSION
Review January 2022
dd/mm/yy MORPHINE 60 mg IV
TOTAL VOLUME
60 mL Often used as PCA and
mL Titrate to effect use Sodium Chloride
(final dilution) (1 mg/mL) 0.9% as diluent-see
guidance on intranet

USES: Analgesic for moderate to severe pain, particularly when visceral in

origin
MODE: Direct effect on opiate receptors throughout body
ACTIONS: Analgesic, CNS and cardio-respiratory depression
CAUTIONS: Hypotension, hypothyroidism, decreased respiratory reserve or

respiratory impairment
Active metabolites may accumulate in renal and hepatic impairment and
in critically ill following lengthy infusion
Effects on pupillary response may interfere with the monitoring of brain
injury / intracranial pressure
Nausea and vomiting especially with large bolus doses, constipation,
ureteric and biliary spasm
Reduce dose in elderly
DOSES: Bolus dose for acute pain: 0.1 - 0.2 mg/kg repeated as necessary (max
dose for slow bolus is 10 mg) Draw 10 mg Morphine, dilute up to 10 mL
with Sodium Chloride 0.9% and give 1 mg in a ‘stepwise’ administration
Infusion: Titrate to effect and sedation level, starting at 1 mL/hr
NOTES: Effects of morphine can be reversed with naloxone

NALOXONE INFUSION
Review January 2022
dd/mm/yy NALOXONE 2 mg IV
TOTAL VOLUME
500 mL For fluid restricted or if
mL See notes below higher doses required
(final dilution) (4 microgram/mL) can use 10 mg in 50 mL
of Sodium Chloride
0.9%

USES: Reversal of opioid toxicity
MODE: Opioid antagonist
ACTIONS: Blocks the action of opioids at the mu opioid receptor.
CAUTIONS: Some opioids are only partially reversed e.g. buprenorphine.

Naloxone has a very short half-life compared to many opioids.
DOSES: Aim for reversal of respiratory depression, not full reversal of

consciousness.
IV bolus:
• give initial dose of 400microgram
• If no response after 60 seconds give further 800 microgram
• If still no response (after a total of 2 mg), give a further 2 mg dose
• Large doses (4 mg) may be required in a seriously poisoned patient,
consider continuous infusion
IV infusion:
• Titrate dose and rate of administration in accordance with patient
response to IV bolus and reaction to IV infusion
• An infusion of 60% of the initial dose required for resuscitation per hour
is a useful starting point and adjust according to response
• For fluid restricted or if very high doses required, dilute 10 mg
Naloxone in 50 mL of Sodium Chloride 0.9% (200 microgram/mL final
dilution)

NEOSTIGMINE INFUSION
Review January 2022
dd/mm/yy NEOSTIGMINE 10 mg IV
50 mL Directions
mL
(final dilution) (200 microgram/mL) 2 mL/h

USES: As an infusion for bowel care (unlicensed): Severe constipation in

patients with normal or diminished peristalsis. Neostigmine is a 2nd line
agent, and should not be used without a trial of conventional
techniques, e.g., lactulose, senna, suppositories, enemas etc.
Neostigmine as a bolus is used to reverse neuromuscular blockade, to
treat myasthenia gravis, and to prevent post-operative bladder
distention and urinary retention
MODE: Anticholinesterase by inhibition of acetylcholinesterase, increasing the

concentration of acetylcholine in the synaptic space.
ACTIONS: Enhances motor activity of the digestive and urinary tracts and
increases the secretions of the exocrine glands (sweat, lacrimal,
bronchial, gastric, intestinal and pancreatic acinar)
CAUTIONS: Contraindicated in intestinal or urinary obstruction, signs or symptoms

of an acute abdomen, mechanical ileus or pseudo-obstruction
(diagnosed by physical or radiological examination) and if
gastrointestinal surgery within 10 days
Caution in asthma (extreme caution), bradycardia, arrythmia, recent
myocardial infarction, epilepsy and hypotension
DOSES: 10 mg Neostigmine made up to 50 mL with Sodium Chloride 0.9%.

Delivered at 2 mL per hour for 48 hours maximum.
NOTES: Side effects are increased sweating, excess salivation, abdominal

cramping, nausea, vomiting, bronchospasm, bradycardia and
hypotension
PATIENTS ON NEOSTIGMINE INFUSION MUST HAVE CONTINUOUS
ECG MONITORING.
DISCONTINUE INFUSION IF HEART RATE DROPS BELOW 50 BPM

NIMODIPINE INFUSION
Review January 2022
IV
dd/mm/yy NIMODIPINE 10 mg
Central
mL 50 mL Directions
2.5-10 mL/hour
(final dilution)
DILUENT Ready-made Minimum - Maximum

USES: Treatment of subarachnoid haemorrhage.
MODE: Calcium channel blocker
ACTIONS: Preferential activity on cerebral vessels and increases cerebral perfusion,

particularly in poorly perfused areas, by arterial dilatation
CAUTIONS: Hypotensive patients
DOSES: For the first two hours of treatment 1 mg per hour should be infused (5
mL/hour). If tolerated, increase to 2 mg (10 mL/hour), providing no
severe decrease in blood pressure is observed.
Patients of body weight less than 70kg or with unstable blood pressure
should be started on a dose of 0.5mg per hour (2.5mL/hour), or less if
necessary.
NOTES: Nimodipine is light sensitive and should be kept in the cardboard box
until needed.
Reacts with PVC and must not be mixed with other drugs due to
incompatibilities.

NORADRENALINE (NOREPINEPHRINE) INFUSION

Review January 2022
4 mg
dd/mm/yy NORADRENALINE (single dilution)
IV Central
TOTAL VOLUME
Rate (mL/h) Other
mL
50 mL Directions
(80 microgram/mL, single) Start 1 mL/hour
(final dilution)
Titrate to MAP
DILUENT Ready-made or
Minimum - Maximum
Glucose 5%
USES: Inotrope and vasopressor
MODE/ Sympathetic agent with both a and b adrenergic activity, the former
being predominant at the concentrations used in clinical practice.
ACTIONS: Increases peripheral vascular resistance and therefore raises BP
Improves coronary perfusion and myocardial oxygen demand
May reduce cerebral blood flow and oxygen demand
Reduces renal and mesenteric blood flow despite increase in arterial BP
CAUTIONS: Reflex decrease in heart rate may result due to baroreflexes

Extreme caution in myocardial infarction and pregnancy
Caution with hypercapnia and hypoxia
Its effect on BP ceases 1-2 minutes after discontinuing the infusion
If extravasation may cause necrosis of tissues
DOSES: 0.03 - 0.2 microgram/kg/min initially = 1.6 - 10.5 mL/hour for 70 kg

adult
NOTES: Central line administration is recommended. Dilution:
• single 4 mg in 50 mL (80 microgram/mL)
• double dilution of 8 mg in 50 mL (160 microgram/mL)
• quadruple dilution of 16 mg in 50 mL (320 microgram/mL)
• neat 40 mg in 40 mL (1 mg/mL) in extreme situations
Peripheral line administration is not recommended, only use in
emergency situation and for short term. Dilution for peripheral
administration is 4 mg Noradrenaline (4 mL of 1mg/mL) in 246 mL
Sodium Chloride 0.9% final concentration of 16 microgram/mL. Start 13
mL/h (208 microgram/h = 0.05 microgram/kg/min for 70 Kg patient).
Titrate to desired effect.
More information: Peripheral Vasopressor Administration Appendix
NORADRENALINE (NOREPINEPHRINE) INFUSION DILUTIONS

SINGLE strengthÞ 4 mg in 50mL (80 micrograms in 1mL) Noradrenaline (norepinephrine)
Infusion rate (in mL/hour) as per dose and patient body weight
Patient’s body weight Kg
Dosage
40 50 60 70 75 80 90 100 110 120
0.01 microgram/kg/min 0.3 0.37 0.45 0.52 0.56 0.6 0.67 0.75 0.82 0.9
0.02 microgram/kg/min 0.6 0.75 0.9 1.05 1.12 1.2 1.35 1.5 1.65 1.8
0.05 microgram/kg/min 1.5 1.87 2.25 2.62 2.81 3 3.37 3.75 4.12 4.5
0.1 microgram/kg/min 3 3.75 4.5 5.25 5.62 6 6.75 7.5 8.25 9
0.2 microgram/kg/min 6 7.5 9 10.5* 11.25* 12* 13.5* 15* 16.5* 18*
0.5 microgram/kg/min 15* 18.75* 22.5* 26.25* 28.12* 30* 33.75* 37.5* 41.25* 45*
DOUBLE strengthÞ 8 mg in 50mL (160 micrograms in 1mL) Noradrenaline (norepinephrine)

Dosage
40 50 60 70 75 80 90 100 110 120
0.05 microgram/kg/min ^0.75 ^0.93 ^1.12 ^1.31 ^1.41 ^1.5 ^1.69 ^1.87 2.06 2.25
0.1 microgram/kg/min ^1.5 ^1.87 2.25 2.62 2.81 3 3.37 3.75 4.12 4.5
0.2 microgram/kg/min 3 3.75 4.5 5.25 5.62 6 6.75 7.5 8.25 9
0.5 microgram/kg/min 7.5 9.37 11.25* 13.12* 14.06* 15* 16.87* 18.75* 20.62* 22.5*
*consider using a more concentrated solution ^consider using a less concentrated solution
QUAD strengthÞ 16 mg in 50mL (320 micrograms in 1mL) Noradrenaline (norepinephrine)

Dosage
40 50 60 70 75 80 90 100 110 120
0.1 microgram/kg/min 0.75^ 0.94^ 1.12^ 1.31^ 1.40^ 1.5^ 1.69^ 1.87^ 2.06 2.25
0.2 microgram/kg/min 1.5^ 1.87^ 2.25 2.62 2.81 3 3.37 3.75 4.12 4.5
0.5 microgram/kg/min 3.75 4.69 5.62 6.56 7.03 7.5 8.43 9.37 10.31* 11.25*
1 microgram/kg/min 7.5 9.37 11.25* 13.12* 14.06* 15* 16.87* 18.75* 20.62* 22.5*
*consider using a more concentrated solution ^consider using a less concentrated solution
NEATÞ 40 mg in 40mL (1000 micrograms in 1mL) Noradrenaline (norepinephrine)

Dosage
40 50 60 70 75 80 90 100 110 120
0.5 microgram/kg/min 1.2 1.5 1.8 2.1 2.25 2.4 2.7 3 3.3 3.6
1 microgram/kg/min 2.4 3 3.6 4.2 4.5 4.8 5.4 6 6.6 7.2

OCTREOTIDE INFUSION
Review January 2022
dd/mm/yy OCTREOTIDE 500 micrograms IV
Rate (mL/h) Other
TOTAL VOLUME
50 mL Directions
mL
(final dilution) 10 microgram/mL 2.5 – 5 mL/h

USES: Reduce intestinal secretions.

Emergency management to stop bleeding and to protect from re-
bleeding owing to gastro-oesophageal varices in patients with cirrhosis.
MODE/ Synthetic octapeptide derivative of naturally occurring somatostatin

with similar pharmacological effects, but with a considerably prolonged
ACTIONS: duration of action.
The gastrointestinal effects of octreotide are inhibitory to the azygous
blood flow, gastric secretions, splanchnic haemodynamic, pancreatic
secretions, intestinal motility and all gastroenteropancreatic (GEP)
endocrine secretions.
Octreotide decreases the inflow of blood to portal system by
constricting the splanchnic arterioles and significantly reduces
intravariceal pressure.
CAUTIONS: May cause bradycardia.

May affect glucose regulation.
DOSES: Reduction of intestinal secretions: 25 microgram/hour
Variceal bleeding: 50 microgram intravenous bolus followed by a

continuous infusion of 50 microgram/hour for 48 hours and emergency
sclerotherapy
NOTES:

OMEPRAZOLE INFUSION
Review January 2022
dd/mm/yy OMEPRAZOLE 80 mg IV
Rate (mL/h) Other
TOTAL VOLUME
100 mL 10 mL/hour
mL
(0.8 mg/mL) (for continuous infusion)
(final dilution)

USES: Major peptic ulcer bleeding

Routine prophylaxis
MODE: Reduces gastric acid secretion
ACTIONS: Inhibits the enzyme H+/K+-ATPase (acid pump) within the parietal cell
CAUTIONS:
DOSES: Major peptic ulcer healing: loading dose of 80 mg diluted in 100 mL

Sodium Chloride 0.9% over 40-60 minutes then followed by a
continuous infusion of 8 mg/hour for 72 hours
General prophylaxis: 40 mg once daily infused over 20-30 minutes
NOTES: Expiry of bag is 12 hours when made in Sodium Chloride 0.9%. If

glucose is used as an alternative the expiry is 6 hours

PAMIDRONATE INFUSION
Review January 2022
15-90 mg
dd/mm/yy PAMIDRONATE Dependant on IV
calcium levels
Rate (mL/h) Other
250 mL
mL 50 mL/h
(final dilution) (0.06 – 0.36 mg/mL) (slow infusion, not to
exceed 1 mg/min)

USES: To reduce serum calcium especially those associated with increased

osteoclast activity
MODE: Inhibits osteoclastic bone resorption by binding strongly to

hydroxyapatite crystals
ACTIONS: Inhibits bone resorption
CAUTIONS: Care in patients with severe renal impairment.
DOSES: Dependant according to serum calcium levels

Calcium level Recommended dose
< 3 mmol/L 15 - 30 mg
3 -3.5 mmol/L 30 - 60 mg
3.5-4mmol/L 60 - 90 mg
>4mmol/L 90 mg
The total dose may be administered either as a single infusion or in
multiple infusions over 2 to 4 consecutive days.
NOTES: Patients should be adequately rehydrated prior to and during

administration.
Significant decrease in serum calcium levels generally observed 24 to 48
hours after administration and normalisation normally achieved within 3
to 7 days

PANTOPRAZOLE INFUSION
Review January 2022
dd/mm/yy PANTOPRAZOLE 80 mg IV
Rate (mL/h) Other
TOTAL VOLUME
100 mL 10 mL/hour
mL
(0.8 mg/mL) (for continuous infusion)
(final dilution)

USES: Major peptic ulcer bleeding

Routine prophylaxis
MODE: Reduces gastric acid secretion
ACTIONS: Inhibits the enzyme H+/K+-ATPase (acid pump) within the parietal cell
CAUTIONS:
DOSES: Major peptic ulcer healing: loading dose of 80 mg diluted in 100 mL

Sodium Chloride 0.9% over 40-60 minutes then followed by a
continuous infusion of 8 mg/hour for 72 hours
General prophylaxis: 40 mg once daily infused over 20-30 minutes
NOTES: Expiry of bag is 12 hours when made in Sodium Chloride 0.9%. If

glucose is used as an alternative the expiry is 6 hours

PHENOXYBENZAMINE INFUSION
Review January 2022
70 mg
dd/mm/yy PHENOXYBENZAMINE (1 mg/kg IV
for 70 Kg patient)
mL 200 mL Directions
(final dilution) 100 mL/h

USES: Treatment of hypertension specifically caused by phaeochromocytoma
MODE/ Reduces the vasoconstriction caused by adrenaline and noradrenaline

by permanent binding to receptors
ACTIONS:
Non-competitive long acting α adrenergic receptor antagonist
CAUTIONS: Monitor blood pressure and should be slowed or stopped if there is a

precipitous fall in blood pressure
DOSES: Phaeochromocytoma-titrated on a daily basis: dose of 1 mg/kg body

weight.
Not more than one dose in 24 hours and not more than two doses in
48 hours
NOTES: May cause reflex tachycardia

Long duration of action.
Irritant so avoid contact with skin.
Irritant to muscle tissue so should be preferably administered through
central line.

PHENYLEPHRINE INFUSION
Review January 2022
dd/mm/yy PHENYLEPHRINE 10 mg IV
TOTAL VOLUME
Rate (mL/h) Other
100 mL Directions
mL
(100 microgram/mL) 18-108 mL/h
(final dilution)
(titrate to effect)

USES: Vasopressor useful for peripheral IV administration as bolus therapy or

infusion
MODE/ Acts directly on α1 receptors
ACTIONS: Increases blood pressure by peripheral vasoconstriction and increasing

in SVR
Produces a reflex decrease in heart rate
CAUTIONS: May result in reflex bradycardia

After discontinuation, flush the peripheral cannula with Sodium
Chloride 0.9% at the same rate the medicine was infused to avoid
adverse haemodynamic effects.
Metabolised by monoamine oxidase therefore contraindicated in
patients on monoamine oxidase inhibitors.
DOSES: Bolus use: 100 – 500 micrograms IV (dilute 10 mg in 20 mL = 500

microgram/mL). Duration of action 15-20 minutes.
Infusion: start at 10.8 mg/h (108 mL/h of the 100 microgram/mL

concentration, then decrease down to 18-36 mL/h of the standard 100
microgram/h concentration. Titrate rate to effect
NOTES: Recommended concentration for infusion is 100 microgram/mL as 5 mg

(half ampoule) in 50 mL, 10 mg (1 ampoule) in 100 mL or 50 mg (5
ampoules) in 500 mL.
If effect on blood pressure not achieved with maximum rate, consider
change to Noradrenaline via IV central infusion, if appropriate.

PHENYTOIN INFUSION
Review January 2022
20 mg/Kg
IV
dd/mm/yy PHENYTOIN 1400 mg
(large vein)
(for 70 Kg patient)
Rate (mL/h) Other
TOTAL VOLUME 28 mL neat Directions
mL (for 70 Kg patient) 0.5 – 1 mL/min (neat) Observe infusion
(final dilution) (50 mg/mL) (25 – 50 mg/min as for crystal
formation if using
maximum rate)
diluted.
DILUENT Neat (preferred) or in Needs in line
Minimum - Maximum filter.
USES: Status epilepticus, tonic-clonic seizure and focal seizures

Prevention and treatment of seizures during or following neurosurgery
or severe head injury
MODE/ Interaction with Sodium voltage-dependent channels by preferentially

binding to the Sodium channel in its inactive state
ACTIONS:
CAUTIONS: Narrow therapeutic drug: range 10-20 mg/L
Highly protein bound, if low albumin results may be abnormal
DOSES: DO NOT GIVE LOADING DOSE IF PATIENT ON PHENYTOIN

Loading dose of 20 mg/kg at a rate no faster than 50 mg/min (25
mg/min if frail). Use large vein.
Maintenance dose is 3-5 mg/kg/day in divided dose (3 times a day)
Doses adjusted according to desired level-range 10-20 mg/L
Can be used neat (50 mg/mL) or diluted in 50 - 100 mL Sodium Chloride
0.9%. Phenytoin when dilute is liable to precipitate. If diluted use an in-
line filter and give within 1 hour of preparation.
Top-Up Phenytoin: 20 – [latest measured level (mg/L) x 0.7 x weight (kg)]
NOTES: Time to steady-state is around 7 days.

Follows second order (mixed) pharmacokinetics and will reach a
saturation level, i.e., a small dose increase will lead to a large plasma
concentration.
Caution in increasing dose multiple times in a very short period of time
If subtherapeutic consider reloading with 10 mg/kg (usually 500 mg)

PHOSPHATE POLYFUSOR INFUSION

Review January 2022
dd/mm/yy PHOSPHATE POLYFUSOR 50 mmol IV
500 mL Directions
mL
(final dilution) 50 mL/hour
DILUENT Ready made Minimum - Maximum

USES: Hypophosphataemia
MODE/ Replacement of phosphate ions
ACTIONS:
CAUTIONS: Risk of hyperkalaemia and hyperphosphataemia
Renal impairment
Rapid infusion can lead to rapid changes in serum electrolytes Calcium,

Phosphate, Potassium, Sodium, etc
DOSES: Dependent on requirement but generally no more than 50 mmol of

Phosphate in 24 hours.
Often 50 mmol in 500 mL given over 10 hours, i.e., 50 mL/hour
Phosphate Polyfusor
NOTES: Phosphate Polyfusor does contain a small amount of Potassium (9.5

mmol in 500 mL) and Sodium (81 mmol in 500 mL) within it.

POTASSIUM ACID PHOSPHATE INFUSION

Review January 2022
IV
dd/mm/yy POTASSIUM ACID PHOSPHATE 40 mmol
Central
60 mL Directions
mL
(final dilution)
(0.67 mmol/mL) 10 mL/hour To be used if
phosphate
polyfuser not
appropriate
USES: Treatment of combination of hypophosphataemia and hypokalaemia
MODE: Replacement of phosphate and potassium ions
ACTIONS: Improved cellular membrane stability and homeostasis, muscle strength

and nerve cell activity, cardiac and renal function
CAUTIONS: Risk of hyperkalaemia and hyperphosphataemia
Renal impairment
Rapid infusion can lead to rapid changes in serum electrolytes Calcium,

Phosphate, Potassium, Sodium, etc
DOSES: Dependant on requirements but a total daily dose of 50 mmol of

Phosphate should not be exceeded
NOTES: Each 10 mL ampoule of Potassium Acid Phosphate contains 10 mmol of

Potassium and 10 mmol of Phosphate
Phosphate Polyfusor is the preferred way to administer Phosphate as

has less Potassium

PIPERACILLIN-TAZOBACTAM INFUSION
Review January 2022
4.5g
dd/mm/yy PIPERACILLIN-TAZOBACTAM IV
(4g/0.5g)
Rate (mL/h) Other
mL 50 mL Rate dependent on For
(final dilution) dose regime continuous
(see table) infusion only

USES: Penicillin antibacterial agent with antipseudomonal activity
MODE: Beta-lactam antibiotic
ACTIONS: Bacterial cell wall inhibitor which leads to cell death
CONTRA Hypersensitivity to the active substances, any other penicillin-

antibacterial agent or to any of the excipients listed in section
INDICATIONS: History of acute severe allergic reaction to any other beta-lactam
active substances (e.g., cephalosporin, monobactam or
carbapenem)
DOSES: Range from 2.25-4.5 g, 2-4 times daily dependent on treated

condition, severity, and renal function
Intensive care patients generally require higher doses.

A stat dose of 4.5 g over 30 minutes must be given before
continuous infusion commenced
Consideration should be given to reducing the dose for patients

who weigh less than 45kg (seek advice)
For continuous infusion make up required dosage (4.5g in 50mL)

and dependent on daily dose required will depend on the required
infusion rate

PIPERACILLIN-TAZOBACTAM
BOLUS AND CONTINUOUS INFUSION TABLE
Glomerular filtration Bolus Dose in 24 h Rate of Infusion
rate (eGFR) (to be (to be prescribed in antibiotic (4.5 g in 50 mL) for
prescribed on section)* continuous infusion
STAT)
eGFR >40 mL/min 4.5 g 4.5 g Four times a day 8.33 mL/hour
eGFR 20-40 mL/min 4.5 g 4.5 g Three times a day 6.25 mL/hour
eGFR < 20 mL/min 4.5 g 4.5 g Twice a day 4.17 mL/hour
Renal replacement
4.5 g 4.5 g Three times a day 6.25 mL/hour
therapy
*Prescribe 4.5 g with the desired frequency but place in additional information (critical care
chart) or special instructions (general chart) Continuous infusion as per protocol

POTASSIUM CHLORIDE INFUSION

Review January 2022
IV
dd/mm/yy POTASSIUM CHLORIDE 50 mmol
Central
Rate (mL/h) Other
Directions
TOTAL VOLUME 50 mL 10-20mL/hour
mL
(maximum rate
(final dilution) (1 mmol/mL)
20 mmol/hour)
DILUENT Ready-made Minimum - Maximum

USES: Treatment of hypokalaemia
MODE: Replacement of potassium ions

An adequate potassium level is required for the generation of the
resting cell membrane potential and the action potential, maintenance
of acid-base balance
It is the main intracellular ion and is responsible for maintaining
intracellular osmolarity
ACTIONS: Improved cellular membrane stability and homeostasis, muscle

strength and nerve cell activity, cardiac and renal function
CAUTIONS: Risk of hyperkalaemia

Renal impairment
DOSES: Infusion of 50mmol usually over 5 hours (no faster than 3 hours) aiming
for plasma value of 4.5mmol/L
NOTES: STRONG SOLUTIONS OF POTASSIUM CHLORIDE (>20 mmol/L)

MUST BE GIVEN VIA A CENTRAL ACCESS
Hypokalaemia is often associated with hypomagnesaemia

PROPOFOL INFUSION
Review January 2022
dd/mm/yy PROPOFOL 1000 g IV
Rate (mL/h) Other
50 mL 1% neat
mL
(final dilution) (20 mg/mL) Titrate to sedation solution
available if
needed for
DILUENT Neat (2%) Minimum - Maximum
intubation
USES: Intravenous anaesthetic agent, sedation
MODE: GABA receptors (alternative site to benzodiazepines)
ACTIONS: Sedation with rapid onset and rapid recovery due to redistribution,
hepatic and extrahepatic metabolism
CAUTIONS: Cardiorespiratory depression, particularly in elderly, septic or

hypovolaemic patients
Accumulates with prolonged use, particularly in obese patients
Prolonged infusions can lead to increased triglyceride and cholesterol

levels
DOSES: Usually start infusion at 5 mL/hour and titrate according to sedation

level
The theoretical maximum recommended dose is 4mg/kg/hour
NOTES: Preferably given by large or central vein due to thrombophlebitis

Not recommended for long term use in children
Propofol infusions may cause urine to colour green or sometimes bright
pink
1% is still available as 20 mL ampoules for rapid sequence intubation

REMIFENTANIL INFUSION
Review January 2022
2 mg in 40 mL (single)
dd/mm/yy REMIFENTANIL 4 mg in 40 mL (double) IV
5 mg in 50 mL (double)
Rate (mL/h) Other
TOTAL VOLUME 40 or 50 mL Directions
mL (Single dilution 50 microgram/mL)
Titrate to effect
(Double dilution 100
(final dilution)
microgram/mL) (see Remifentanil Protocol)

USES: Opioid for analgesia and sedation
MODE: Direct effect on μ-receptors
ACTIONS: Rapid onset (within 1 minute)
Rapid, organ independent and predictable metabolism blood and

tissue esterases to a biologically inactive carboxylic acid
metabolite (95% excreted in the urine)
CAUTIONS: Produces respiratory depression and bradycardia

Tolerance may develop with prolonged use
Ensure adequate analgesia is on-going before stopping
remifentanil infusion due to rapid offset
DOSES: Dose range for analgesia: 6 - 60 microgram/kg/hour

Sedation in intubated patients: 0.625 – 3.125 mL/hour (double
concentration)
NOTES: See remifentanil sedation protocol for further information

regarding dose regime

REMIFENTANIL IN CRITICAL CARE
INDICATIONS FOR REMIFENTANIL CAUTIONS

• Overnight ventilation • Remifentanil is very potent. Use cautiously in elderly or frail patients
• Difficulty in weaning • Boluses should NOT be given (severe bradycardia / asystole)
• Severe renal / hepatic dysfunction • Observe for bradycardia and hypotension in accidental overdose
• Patients requiring neurological assessment • In event of over-administration halve the rate and review
• Raised intracranial pressure • Use a dedicated cannula for administration (ideally of low internal volume)
• Agitation on stopping other sedatives • Syringe changes should be prompt (within 3 min)
• CVP ports / cannulae should be cleared after administration by aspiration
Ensure adequate alternative analgesia at least 30 min prior to stopping remifentanil
REMIFENTANIL DILUTIONS
Is REMIFENTANIL indicated?
SINGLE strength concentration
50 microg/mL (2mg in 40mL) Discuss with senior doctor
DOUBLE strength concentration

(for critical care areas)
Estimate ideal body weight
100 microg/mL
(4mg in 40mL or 5mg in 50mL) Decide if use single or double
strength and follow instructions on
correct table on left side
REMIFENTANIL SINGLE STRENGTH
Dosage Infusion rate of Remifentanil (50 microg/mL) in Calculate range in mL/hour
required
microg/kg/
mL/hr 0.025 – 0.3 microg/Kg/min
min Patients weight (kg)
50 60 70 80 90 100
Aim to achieve target sedation
0.025 1.5 1.8 2.1 2.4 2.7 3.0
score
0.05 3.0 3.6 4.2 4.8 5.4 6.0
0.075 4.5 5.4 6.3 7.2 8.1 9.0
0.1 6.0 7.2 8.4 9.6 10.8 12.0
0.125 7.5 9.0 10.5 12.0 13.5 15.0 Start remifentanil infusion at
0.15 9.0 10.8 12.6 14.4 16.2 18.0 0.1 microg/Kg/min
0.175 10.5 12.6 14.7 16.8 18.9 21.0
0.2 12.0 14.4 16.8 19.2 21.6 24.0 Stop all other opiates
0.225 13.5 16.2 18.9 21.6 24.3 27.0
0.25 15.0 18.0 21.0 24.0 27.0 30.0
0.275 16.5 19.8 23.1 26.4 29.7 33.0
0.3
Increase remifentanil infusion
18.0 21.6 25.2 28.8 32.4 36.0
gradually up to
REMIFENTANIL DOUBLE STRENGTH 0.2 microg/Kg/min

Dosage Infusion rate of Remifentanil (100 microg/mL) in
required mL/hr
microg/kg/
min Patients weight (kg)
50 60 70 80 90 100 If not settled
0.025 0.75 0.9 1.1 1.2 1.35 1.5 If pain or ventilator intolerant
0.05 1.5 1.8 2.1 2.4 2.7 3.0 increase remifentanil up to
0.075 2.25 2.7 3.15 3.6 4.05 4.5
0.3 microg/Kg/min
0.1 3.0 3.6 4.2 4.8 5.4 6.0
0.125 3.75 4.5 5.25 6.0 6.75 7.5 If anxious or agitated add
propofol or midazolam
0.15 4.5 5.4 6.3 7.2 8.1 9.0
0.175 5.25 6.3 7.35 8.4 9.45 10.5
•
0.2 6.0 7.2 8.4 9.6 10.8 12.0
0.225 6.75 8.1 9.45 10.8 12.15 13.5
0.25 7.5 9.0 10.5 12.0 13.5 15.0 If still not adequate sedated
0.275 8.25 9.9 11.55 13.2 14.85 16.5 seek senior medical advice
0.3 9.0 10.8 12.6 14.4 16.2 18.0


SALBUTAMOL INFUSION
Review January 2022
dd/mm/yy SALBUTAMOL 5 mg IV
Rate (mL/h) Other
50mL
mL
(final dilution) (100microgram/mL) 3-12 mL/hour
DILUENT Sodium Chloride 0.9% or

Minimum - Maximum
Glucose 5%
USES: Acute asthma – by bolus dose or infusion
MODE: Selective β2 agonist
ACTIONS: Maximal therapeutic effect within 15 minutes by inhalational route
Effects on smooth muscle resulting in bronchodilatation and some

degree of vasodilatation
Effects on skeletal muscle (including tremor)
Rise in heart rate (reflex and direct stimulation)

Increases gluconeogenesis, causes hypokalaemia
CAUTIONS: Tachycardia may exacerbate myocardial ischaemia
Hypokalaemia more common with IV administration
DOSES: Bolus dose: 250 microgram (4 microgram/kg)
Infusion: 5 - 20 microgram/min = 3 - 12 mL/hour
NOTES: Effects may be more rapid when salbutamol is given intravenously

compared to inhalational administration

SARILUMAB INFUSION
Review January 2022
dd/mm/yy SARILUMAB 400mg stat IV
Rate (mL/h) Other
TOTAL VOLUME
Directions
mL 100 mL
(final dilution)
100 mL/hour
USES: Investigational compound for Immune modulation therapy as potential

treatment for cytokine storm in COVID-19
MODE: Monoclonal antibody that inhibits interleukin
ACTIONS: Human monoclonal antibody (IgG1 subtype) that specifically binds to

both soluble and membrane-bound IL-6 receptors (IL-6Rα).
Inhibits IL-6-mediated signalling which involves ubiquitous signal-
transducing glycoprotein 130 (gp130) and the Signal Transducer and
Activator of Transcription-3 (STAT-3)
CAUTIONS: Do not prescribe if pregnant or trying to conceive
DOSES: Intravenous infusion of 400mg stat dose. Single dose only
NOTES: Sarilumab comes as a pre-filled syringe and is normally intended to be

given as a subcutaneous injection. It means that the attached needle
may cause some difficulties when piercing the rubber bung on the
sodium chloride bag (may need to be gentle). The needle may be
shorter than you are used to, ensure the tip of the needle is present in
the infusion fluid and not still in the bung.
ITEM IS STORED IN A FRIDGE
PREPARATION 1. Uncap the 200 mg PFS (Pre-Filled Syringe)
2. Inject required number of 200mg PFS (two) into a 100mL 0.9% sodium
chloride bag (caution injecting into the bag as PFS have a very fine needle)
3. Mix gently by inverting 10 times
4. Prime the line with the Sarilumab infusion then administer intravenously
over 60 minutes via a central or peripheral line. Do not mix with other
drugs in the same cannula if using a peripheral line.
5. Flush line at the same rate as the Sarilumab infusion with 10-20 mL of
0.9% sodium chloride

SARILUMAB PROTOCOL FOR COVID 19 (NON-TRIAL USE)
The remap-cap trial interim analysis showed that both tocilizumab and sarilumab offer a significant benefit both in
terms of mortality and ITU stay. Whilst the numbers for sarilumab were smaller the effect was slightly more
pronounced. Tociluzumab has been our preferred IL-6 inhibitor, however, due to supply restriction sarilumab is
potentially the only available IL-6 presently with data for critically ill patients.
It is important to note that the Recovery trial did not include Sarilumab as a potential agent, so there is no data for
its efficacy within general ward patients who would otherwise fulfil the criteria for Tocilizumab within that trial.
The guidance that follows is for use in critical care. Note that inclusion criteria included high flow oxygen as well as
CPAP/NIV and there will therefore be a significant number of patients on the wards that may potentially benefit,
although there is no data to support this.
For the purpose of the protocol – RSU and the wards where CPAP is taking place are effectively surge areas. We
do not feel currently that we have the capacity to admit patients to critical care solely for administration of
Sarilumab.
Following discussion, we have made the decision to use it for the moment as follows:
Inclusion Criteria
1. Adult patient with confirmed covid 19 who have severe disease, defined as:
a. High flow oxygen or CPAP/NIV or invasive ventilation and/or cardiovascular support.
b. In an ICU environment (this can be a surge area).
2. Must be less than 24 hours since initiation of organ support.
Exclusion Criteria
1. Already on an IL-6 inhibitor (common ones include anakinra, tociluzumab, ustekinumab)

2. Immunosuppressed
3. Pregnancy
4. AST or ALT greater than 5 times the upper limit of normal
5. Platelet count of less than 50
6. Neutrophils less than 2
7. Evidence of other infection (or not deemed to be in the patient best interests)
8. Patients who are dying.
9. Known allergy or adverse reaction to the drug
• Record the decision to give it in the notes and where patients have capacity and are well enough obtain verbal
consent.
• Prescribe on the BLUETEQ system (either through IT systems or https://www.blueteq-
secure.co.uk/Trust/default.aspx ). It is under the category of high-cost drugs, then select Sarilumab and then
indication covid-19, you will then be asked to complete the patient details. You do not need to do this before
administering but it is useful as there is a tick box of inclusion criteria. If you need a login, you can request one
from Steve Lockwood, Critical Care Pharmacist.
• The single dose should be prescribed on the drug Kardex within the once only administration section.
• Please record any change in the patient’s condition post administration.
• A 400mg dose will only be given once as per Remap-cap protocol
• The effects last potentially up to 28 days (this may be less for Sarilumab though compared to Tocilizumab) and
during this period the CRP will not be helpful and may be misleading so please black out the CRP line on the
results chart during this period. PCT maybe an alternative marker, although this has not been demonstrated as
surrogate marker for covid patients.

SODIUM BICARBONATE INFUSION

Review January 2022
dd/mm/yy
SODIUM BICARBONATE 16.8 g IV
8.4%
Rate (mL/h) Other
TOTAL VOLUME
200 mL Directions
mL
(final dilution) 84 mg /mL 0.5 - 5 mL/kg

USES: Treatment of metabolic acidosis which may occur in severe renal

disease, uncontrolled diabetes, circulatory insufficiency due to shock or
severe dehydration, extracorporeal circulation of blood, cardiac arrest
and severe primary lactic acidosis.
MODE/
ACTIONS:
CAUTIONS: Renal failure, respiratory or metabolic alkalosis, hypoventilation,

chloride depletion, hypernatraemia, hypertension, oedema, congestive
heart failure, eclampsia, aldosteronism, a history of urinary calculi and
consistent potassium depletion or hypocalcaemia, excessive chloride
loss from vomiting or continuous gastrointestinal suctioning and in
patients at risk of developing diuretic-induced hypochloraemic
alkalosis.
DOSES: Cardiac arrest: rapid intravenous dose of one to two 50 mL syringes

Severe Metabolic acidosis: Sodium bicarbonate 8.4% Polyfusor, 2 - 5
mmol/kg of bodyweight, depending upon the severity of the acidosis
over 6-8 h via central line.
NOTES: 84 mg equals 1 mEq of sodium (23 mg) and 1 mEq bicarbonate (61 mg)
Sodium bicarbonate 8.4% is hypertonic and irritant to veins resulting in
extensive skin necrosis if the solution leaks from the vein in the tissues.

THIOPENTONE INFUSION
Review January 2022
dd/mm/yy THIOPENTONE 1000 mg IV
Rate (mL/h) Other
40 mL 2.8-28mL/hour
mL
(final dilution) (25 mg/mL) (for 70 kg patient)

USES: Induction of anaesthesia

Critical Care use in status epilepticus and potentially in acute brain
injury
MODE: Rapidly acting barbiturate (loss of consciousness within 15 - 30 seconds)

with redistribution to body tissues
ACTIONS: Reduces cerebral metabolism and cerebral blood flow

Potent anticonvulsant activity
Cardiovascular depression (reduced contractility) with vasodilatation
and subsequent increase in heart rate
Hepatic metabolism, 1% excreted unchanged in urine
CAUTIONS: Hypotension
Renal or hepatic disease
May cause bronchospasm in severe asthma
Cardiac disease
DOSES: Start at 5 mg/kg/hour. Maximum 10 mg/kg/hour. Normal dose range is

in the region of 1-3 mg/kg/hour.
For approx. for a 70 kg patient this equates to 14 mL/hour (titrate to
effect) to a maximum of 28 mL/hour
Normal dose range is 2.8 to 8.4 mL/hour.
NOTES: Thiopentone has no analgesic properties and has a prolonged effect if

used via infusion.

VASOPRESSIN INFUSION
Review January 2022
dd/mm/yy VASOPRESSIN 20 units IV
TOTAL VOLUME
Rate (mL/h) Other
50mL Directions
mL
(0.4 units/mL) 3-6 mL/hour
(final dilution)

USES: Adjunctive therapy in severe sepsis with evidence of ADH depletion or

inhibited production, diabetes insipidus, oesophageal varices
haemorrhage
MODE: Endogenous nonapeptide hormone normally released by posterior

pituitary
Direct effects on vascular smooth muscle and kidneys via vasopressin
receptors
ACTIONS: Increases urinary concentration

Vasoconstriction and potentiates cortisol release
May potentiate splanchnic hypoperfusion
Effect on platelets may exacerbate aggregation
CAUTIONS: Myocardial ischaemia (increased afterload and coronary

vasoconstriction)
May produce bronchoconstriction
DOSES: Infusion for sepsis: 0.01 - 0.04 units/min

Usually started at 3 mL/hour, increased up to max 6 mL/hour
Infusion for oesophageal varices: 0.3 – 0.9 units/min
NOTES:

ZANAMIVIR INFUSION
Review January 2022
dd/mm/yy ZANAMIVIR Variable IV
Rate (mL/h) Other
100 or 250 mL For 100 mL - 50 mL/h
mL
(final dilution) (see notes below) For 250 mL - 125 mL/h
(give volume over 30 min)

USES: Treatment of complicated and potentially life-threatening influenza A or

B virus infection where other agents cannot be used or resistance to
these other agents
MODE/ Inhibitor of influenza virus neuraminidase which is involved with viral

replication
ACTIONS:
CAUTIONS: Should only be used under advice from microbiology/ infectious

diseases
DOSES: 600mg twice a day for 5 to 10 days

In renal failure as below:
ClCr or CLCRRT
Initial Dose Maintenance Dose Maintenance Dose Schedule
(mL/min or mL/min/1.73m2)*
50 - 80 600 mg 400 mg twice daily Begin maintenance dosing 12

30 - 49 600 mg 250 mg twice daily hours after the initial dose
Begin maintenance dosing 24

15 -29 600 mg 150 mg twice daily
hours after the initial dose
Begin maintenance dosing 48

< 15 600 mg 60 mg twice daily
hours after the initial dose
The product is licensed but only for the intravenous route (not
NOTES: nebulisation as previously on compassionate programme).
Vials are for once-only use.
Fluid can be reduced or increased as desired as long as diluted and
concentration must be 200 microgram/mL or greater

APPENDICES

APPENDIX A: Peripheral Intravenous Infusion of

Vasopressor Drugs in Adult Critical Care Patients
The following is based on the ICS Guidelines The use of Vasopressor Agents by Peripheral
Intravenous Infusion in Adult Critical Care Patients (2020).
The critical care units should follow the standards for the administration of vasopressor agents
by peripheral venous cannula (PVC):
• PVC should be at least 20G, be sited proximal to wrist, avoiding flexion sites, should be
easily flushed. A second peripheral venous cannula should be sited as a contingency in
case of a primary site failure.
• Midline catheters inserted in peripheral larger veins can be considered if available.
• Do not use Y-connectors to avoid inadvertent boluses.
• Vasopressor drugs infusions via PVC must be prescribed following the recommendations
of this guideline regarding concentration and rate range. The infusions must be given
via an infusion pump or volumetric.
• The practitioner starting and maintaining the infusions of peripheral vasopressors must
be adequately training.
• Invasive blood pressure monitoring is preferable but if unable or consider not
appropriate, regular frequent non-invasive blood pressure should be monitored.
• Patients on peripheral vasopressor drugs should be looked after in appropriate locations
such as Critical Care or enhanced care areas with adequate training such as Post
Anaesthetic Care Unit, Theatre Recovery, Enhanced Care Maternity Area, Resuscitation
Bays in Emergency Department.
• After discontinuation of the peripheral vasopressor infusion, the PVC should be flushed
with Sodium Chloride 0.9% at the same rate the medicine was infused to avoid adverse
haemodynamic effects.
• Any adverse event related to peripheral administration of vasopressor agent, for
example, extravasation of vasopressor agent, should be reported and investigated using
the DATIX system
• The duration of the infusion of a vasopressor administered peripherally should be
reviewed and monitored in a case-to-case basis by a senior clinician. Potential risks with
peripheral vasopressors will increase with duration. In the case of peripheral infusion of
adrenaline or noradrenaline, the duration should be maintained to a minimum until
central access is achieved.

PERIPHERAL USE OF VASOPRESSORS

Concentration for Rate range Duration
peripheral (for 70 kg patient)
80 microgram/mL 0.5 - 26 mL/h Minimum
Adrenaline
(4 mg in 50 mL Glucose 5%) (0.01 - 0.5 microgram/kg/min) (hours)
16 microgram/mL 2.6 - 26 mL/h Minimum
Noradrenaline
(4 mg in 250 mL Glucose 5%) (0.01 - 0.1 microgram/kg/min) (hours)
500 microgram/mL
Metaraminol (10 mg in 20 mL Sodium 1-20 mL/h Days
Chloride 0.9%)
100 microgram/mL 18 - 36 mL/h
Phenylephrine (10 mg in 100 mL Sodium (starting infusion 108 mL/h Days
Chloride 0.9%) then reduce)
SUGGESTED MANAGEMENT OF EXTRAVASATION OF

PERIPHERAL VASOPRESSOR
1. Stop the infusion immediately and disconnect the line from the PVC.
2. Attempt to aspirate 3-5mL from the PVC if able.
3. Remove the cannula and apply a dressing to the removal site.
4. Mark the extravasation area if possible, in order to allow monitoring of any
developing injury.
5. Elevate the affected limb if able to do so to reduce swelling.
6. Consider application of a topical vasoactive agent to encourage local blood flow
(for example nitroglycerin paste).
7. Administer analgesia if required.
8. Seek advice from a surgeon or your local tissue viability service if concerned.
9. Document the incident and report via local incident reporting system.
FURTHER INFORMATION
Electronic Medicines Compendium available at: www.medicines.org.uk

Medusa Injectable Medicines Guide available at: medusa.wales.nhs.uk
Medicines Complete available at: www.medicinescomplete.com

APPENDIX B: Serum drug concentrations and

therapeutic ranges
The serum drug concentrations should never be interpreted in isolation. The
patient’s clinical condition must be considered. Samples must be taken at the
correct time in relation to the dose interval. The reference range is often quoted
when the results are published. If uncertain contact Pathology Lab.
Sampling times Threshold for Threshold for Notes

DRUG therapeutic toxic effect
effect
Digoxin At least 6 hours
0.8 microgram/l 2 microgram/l
after dose
Gentamicin Consult antimicrobial
Dependant on
guidelines for details on
regime used Hartford regime
Lithium 1-2 mmol/l
12 hours post Moderate toxicity
0.4 mmol/l
dose >2 mmol/l
Severe toxicity
Phenytoin 3.5 hours post
oral dose
10 mg/l 20 mg/l
2-4 hours post IV
dose
Theophylline Random time for
sample if using
Trough: pre-dose 10 mg/l 20 mg/l
continuous
Aminophylline infusion
Sodium Levels do not correlate
Valporate to clinical effect. Only
Trough: pre-dose 50 mg/l 100 mg/l really useful for
assessing compliance or
absorption
Vancomycin NB: these levels are
Trough: pre dose
higher than previously
up to 30 minutes recommended. Also for
before the third serious infections,
5mg/l 20 mg/l
dose; more higher levels are
frequent if associated with better
outcomes. Seek advice
eGFR<50 mL/min
if unsure

APPENDIX C: Creatinine clearance
This can be calculated by using the following formulae:
When serum creatinine is measured in µmol/L:
Where Constant is 1.23 for men and 1.04 for women.
eGFR (estimated Glomerular filtration rate) values are commonly used now and are often
reported with the patients normal biochemistry results. This is a useful estimate but should be
treated with caution with patients at extremes of body weight and when an eGFR value has
been calculated as very low eg eGFR of less than 10.
Patients with very low eGFR should in relation to the elimination of renal excreted drugs as
been non-existent. Carefully consider the dose and monitor for any adverse effects for patients
with very low eGFR.

APPENDIX D: Weight conversion

Stones and pounds to kilogrammes (approx. to 1 decimal place)
POUNDS
0 2 4 6 8 10 12 13
6 38.1 39.0 40 40.8 41.7 42.6 43.5 44
7 44.5 45.4 46.3 47.2 48.1 49 49.9 50.4
8 50.8 51.7 52.6 53.5 54.4 55.3 56.2 56.7
9 57.2 58.1 59 59.9 60.8 61.7 62.6 63.1

STONES
10 63.5 64.4 65.3 66.2 67.1 68 68.9 69.4
11 69.9 70.8 71.7 72.6 73.5 74.4 75.3 75.8
12 76.2 77.1 78 78.9 79.8 80.7 81.6 82.1
13 82.6 83.5 84.4 85.3 86.2 87.1 88 88.5
14 88.9 89.8 90.7 91.6 92.5 93.4 94.3 94.8
15 95.3 96.2 97.1 98 98.9 99.8 100.7 101.2
For example:
Patient weighs 12 stone 6 pounds the approx. conversion is 78.9 kg

APPENDIX E: Body Mass Index calculator

A BMI calculator can be found on the NHS website at the following address:
www.nhs.uk/live-well/healthy-weight/bmi-calculator/
Alternatively, you can use the equation below or the following table:
BMI = weight in Kilograms/(Height in meters x Height in metres)

BMI = weight in pounds/(Height in inches x Height in inches) x 703

APPENDIX F: Infusion rate and dose calculator
UNITS OF MEASUREMENT IN MEDICINE DOSAGE
CONVERTING UNITS OF MEASUREMENT
FORMULAS FOR CALCULATING DOSAGE PER WEIGHT PRESCRIBED PER MINUTE

Critical Care Services

2021
Edited by Mr S Lockwood and Dr I Gonzalez
Acknowledgements
With thanks to all the staff within Critical Care at South Tees Hospitals for
their suggestions and corrections

CCS Drug Infusions v5.0

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General Critical Care 2021 - Version 4.0

General Critical Care / July 2021 1

HYPERTONIC SALINE INFUSION ......................................................................................... 44

General Critical Care / July 2021 3

APPENDIX A: Peripheral Intravenous Infusion of Vasopressor Drugs in Adult

General Critical Care / July 2021 4

DRUG INFORMATION RESOURCES

• British National Formulary: www.bnf.org (access via Athens)

General Critical Care / July 2021 5

A – Z of Drug Infusions in Critical Care

General Critical Care / July 2021 6

n-ACETYL CYSTEINE INFUSION

Prescriber’s signature A Prescriber Pharmacy

USES: Paracetamol overdose

MODE: Sulfhydryl group donor

ACTIONS: Protects the liver by restoring depleted hepatic reduced glutathione.

CAUTIONS: Anaphylactoid reactions

NOTES: Hypersensitivity has been removed as a contra-indication to treatment

General Critical Care / July 2021 7

ADRENALINE (EPINEPHRINE) INFUSION

Prescriber’s signature A Prescriber Pharmacy

USES: Inotrope and vasopressor

MODE: α and β stimulation. More β effect at low doses (positive

ACTIONS: Increases rate and force of heart contractions (β1), peripheral

CAUTIONS: Low dose: β2 > β1 may initially drop BP by preferential vasodilatation in

DOSES: 0.01 – 0.5 microgram/kg/min initially = 0.5 – 24 mL/h for 80 kg adult

NOTES: Central line administration is recommended. No flushing. Dilution:

General Critical Care / July 2021 8

ADRENALINE (EPINEPHRINE) INFUSION DILUTIONS

Dosage Patient’s body weight Kg

DOUBLE strengthÞ 8 mg in 50mL (160 micrograms in 1mL) Adrenaline (epinephrine)

Dosage Patient’s body weight Kg

QUAD strengthÞ 16 mg in 50mL (320 micrograms in 1mL) Adrenaline (epinephrine)

Dosage Patient’s body weight Kg

NEATÞ 40 mg in 40mL (1000 micrograms in 1mL) Adrenaline (epinephrine)

Dosage Patient’s body weight Kg

General Critical Care / July 2021 9

DILUENT Ready-made or dilute with

USES: Alfentanil is a short-acting synthetic opioid analgesic useful both as an

MODE: Rapid onset of action with short duration

CAUTIONS: 0.5 – 5 mg/hour (1-10 mL/hour of single dilution)

NOTES: Alfentanil is a short-acting synthetic opioid analgesic useful both as an

General Critical Care / July 2021 10

DILUENT Water for

USES: Thrombolysis for acute myocardial infarction, pulmonary embolism and

CAUTIONS: It is usually well-tolerated

DOSES: Pulmonary embolism: 10 mg as an IV bolus over 1 to 2 minutes, then 90

Acute ischaemic stroke: 0.9 mg/kg (max 90 mg) IV infusion over 60

Myocardial infarction: no longer used. Refer to cardiology.

NOTES: Not to be used after traumatic cardiopulmonary resuscitation or within

General Critical Care / July 2021 11

AMINOPHYLLINE INFUSION (Central line)

Prescriber’s signature A Prescriber Pharmacy

USES: Treatment of acute asthma and acute exacerbation of chronic

MODE: Aminophylline is a methylxanthine. Its effects may be mediated by

ACTIONS: Relaxes the smooth muscle of the respiratory tract producing

CAUTIONS: May potentiate hypokalaemic effects of β2 agonists

General Critical Care / July 2021 12

AMINOPHYLLINE INFUSION (Peripheral)

USES: Treatment of acute asthma and acute exacerbation of chronic

MODE: Aminophylline is a methylxanthine. Its effects may be mediated by

ACTIONS: Relaxes the smooth muscle of the respiratory tract producing