ED Drugs Dilution PDF

2016
DILUTION PROTOCOL FOR

DRUGS AVAILABLE IN
EMERGENCY DEPARTMENT
Hospital Sultan Haji Ahmad Shah
Compiled by: Izyan Liyana Rosman (ED Pharmacist)

Updated on: 21 Sept 2016
HoSHAS Drug Dilution Protocol 2016 ii
TABLE OF CONTENTS
DRUGS PAGE
ACETYLCYSTEINE INJ 2000MG/10ML INJ 1
ADENOSINE 6MG/2ML INJ (ADENOCOR) 3
ADRENALINE SOLUTION 1MG/ML INJ (CCM) 4
AMINOPHYLLINE SOL BP 250 MG/10ML INJ (DBL) 5
AMIODARONE 150MG/3ML INJ (CORDARON) 6
ANTIVENENE INJ. 7
ARTESUNATE 60MG INJ. 9
ATRACURIUM BESYLATE 50MG/5ML INJ (ATRALEX) 10
ATROPINE SULPHATE 1MG/1ML INJ (ACIPAN) 11
CALCIUM GLUCONATE 10% INJ. 12
CHARCOAL, ACTIVATED 50GM 13
CHLORPHENIRAMINE MALEATE 10MG/ML INJ 14
DEXAMETHASONE 8MG/2ML INJ (PENATONE) 15
DIAZEPAM 10 MG/2ML INJ (DBL) 16
DICLOFENAC SODIUM 75MG/3ML INJ 17
DIGOXIN 500MCG/2ML INJ (LANOXIN) 18
DOBUTAMINE HCL 250MG/20ML INJ (MOBITIL) 19
DOPAMINE 200MG/5ML INJ (LOXIN) 20
EPHEDRINE HCL 30MG/ML INJ 21
ESMOLOL 100MG/10ML INJ (ESOCARD) 22
FENTANYL 0.1MG/2ML INJ (TALGESIL) 23
FLUMAZENIL 0.5MG/5ML INJ (HAMEIN) 24
FLUPHENAZINE DECANOATE 25MG/ML (MONASAN) 25
FRUSEMIDE 20MG/2ML INJ (ASOKET) 26
FULLER’S EARTH 60GM 27
HALOPERIDOL 5MG/ML INJ (MANACE) 28
HEPARIN SODIUM 1000IU/ML AND 5000IU/ML INJ (HEPARINOL) 29
HYDROCORTISONE SODIUM 100MG INJ 30
HYOSCINE BUTYLBROMIDE 20MG/ML INJ 31
INSULIN REGULAR (ACTRAPID OR HUMULIN R) 1000U/10ML INJ 32
ISOSORBIDE DINITRATE 10MG/10ML INJ (ISOKET) 33
KETAMINE HCL 200MG/20ML INJ (FRESENIUS) 34
LABETALOL HCL 25MG/5ML INJ (TRANDATE) 35
LIGNOCAINE HCL 2% 100MG/5ML INJ. 36
LIGNOCAINE HCL 10% 500MG/5ML INJ. 37
LIGNOCAINE HCL 200MG/10ML INJ. (NOT FOR IV USE) 38
LYTIC COCKTAIL 39
MAGNESIUM SULPHATE 2.465GM/5ML (10MMOL MAGNESIUM IONS) INJ 40
METHYLPREDNISOLONE SODIUM SUCCINATE 500MG INJ (SOLU. MEDROL) 41
METOCLOPRAMIDE 10MG/2ML INJ (PULIN) 42
MIDAZOLAM 5MG/ML AND 15MG/3ML INJ (HAMEIN) 43
MORPHINE SULPHATE 10MG/ML INJ (DUOPHARMA) 44
NALOXONE HCL 0.4MG/ML INJ (MAPIN) 45
HoSHAS Drug Dilution Protocol 2016 iii
NEOSTIGMINE METHYLSULPHATE 2.5MG/ML INJ. 46

NORADRENALINE BITARTRATE 4MG/4ML INJ (CARDIAMED) 47
OMEPRAZOLE 40MG INJ (OMEZOL) 48
OXYTOCIN 5U + ERGOMETRINE 0.5MG/ML INJ. (SYNTOMETRINE) 49
PANTOPRAZOLE 40MG INJ (PANTOSEC) 50
PETHIDINE HCL 50MG/ML OR 100MG/2ML INJ (DUOPHARMA) 51
PHENOBARBITONE SODIUM 200MG/ML INJ (MARTINDALE ) 52
PHENYTOIN SODIUM 250MG/5ML INJ (DILANTIN) 53
PHYTOMENADIONE 10MG/ML INJ (VIT.K) 54
POTASSIUM CHLORIDE 1GM/10ML INJ 55
PRALIDOXIME 500MG/20ML INJ. 56
PROCHLORPERAZINE 12.5MG/ML INJ (LARTIL) 57
PROCYCLIDINE HCL 10MG/2ML INJ (KEMADRIN) 58
PROMETHAZINE HCL 50MG/2ML INJ 59
PROPOFOL 1% 200MG/20ML INJ (FRESOFOL) 60
PROTAMINE SULPHATE 50MG/5ML INJ. 61
RANITIDINE 50MG/2ML INJ. 62
ROCURONIUM 50MG/5ML INJ (ESMERON) 63
SALBUTAMOL 0.5MG/ML INJ (YUNG SHIN) 64
STREPTOKINASE 1,500,000 IU INJ (STREPTASE) 65
SODIUM BICARBONATE 8.4% 10ML INJ 66
SUXAMETHONIUM CHLORIDE 100MG/2ML (FRESENIUS) 67
TENECTEPLASE 10,000UNITS (50MG) INJ (METALYSE) 68
TERBUTALIN SULPHATE 0.5MG/ML INJ (BALTIC) 69
TRAMADOL HCL 50MG/ML INJ. 70
TRANEXAMIC ACID 500MG/5ML INJ 71
VERAPAMIL HCL 5MG/2ML INJ (VERPAMIL) 72
THYROID STORM 73
FLUID THERAPY IN DKA 74
ACETYLCYSTEINE INJ 2000MG/10ML INJ
(DBL HOSPIRA)
RECONSTITUTION Not required
FURTHER DILUTION See administration.
ADMINISTRATION 1. PARACETAMOL POISONING

150 mg/kg IV in 200 ml of D5 over 1H,
then 50 mg/kg IV in 500 ml of D5 over 4H,
then 100 mg/kg IV in 1000ml of D5 over 16H.
2. ACUTE LIVER FAILURE (non PCM related)

*Give undiluted
150 mg/kg IV over 1H,
then 50mg/kg IV over 4H,
then 6.25mg/kg/Hr IV (duration depends on liver profile).
3. CT SCAN REGIMEN
Oral NAC: 600mg BD on a day before scan, and a day after
scan. (For 2 days)
For unplanned scan; IV NAC (*give undiluted)
Run to a total 10g IV NAC.
Run 10ml/hr (2g) for 1st hour
Then 2.5ml/hour (500mg) until finish.
STORAGE & STABILITY Intact Vials: Store below 25°C.

Reconstituted solution: 24hours at 25°C.
REMARKS Anaphylactic reaction with high dose & rapid rate.
References:
1. Product Leaftlet- DBL Hospira
2. Julie Polson & William M Lee. AASLD: The Management of acute liver failure. Hepatology, May 2005.
3. Ministry of Health Malaysia. Critical Care Pharmacy Handbook. Pharmaceutical Service Division 2013.
HoSHAS Drug Dilution Protocol 2016 2
PARACETAMOL POISONING IN CHILDREN:

Refer to adult dosing, however fluid volume should be reduced if pt <40kg as follows:
DILUTION VOLUME OF D5% (ml)
BODY WEIGHT (KG) LD: 150mg/kg over 2nd dose: 50mg/kg 3rd dose: 100mg/kg
60mins over 4H over 16H
30 100 250 500
25 100 250 500
20 60 140 280
15 45 105 210
10 30 70 140
ADENOSINE 6MG/2ML INJ (ADENOCOR)

FURTHER DILUTION Not required
ADMINISTRATION IV Bolus:
Initial dose: 6mg
Second dose: If SVT not subside in 1-2mins, give 12mg.
Third dose: If not subside in 1-2mins, add 12mg.
Higher or additional dose not recommended.
Place patient in mild reverse Tredenleburgh position
Prepare IV Adenosine & 20ml flush in 2 separate syringes
Attach both syringes to IV injection port closest to patient.
Push IV adenosine as quickly as possible (in 1-3 seconds)
While maintaining pressure on IV Adenosine plunger, push

20ml NS flush as rapidly as possible after IV Adenosine.
STORAGE & Intact Vials: Store below 30°C.Do not refrigerate. Discard unused portion.
STABILITY
REMARKS 1. Should be given in large bore line (i.e: brachial region)
2. Prior to administration, kindly remind patient that he will feel his heart stop/heaviness on his chest.
3. Attached cardiac monitoring.
4. Reduce initial dose to 3mg if patient on Dipyridamole, Carbamazepine, heart transplant or if given by
central IV access.
5. Less effective in patients taking theophylline, caffeine (might need larger dose)
6. Contraindicated in patients with asthma, poison/drug-induce tachycardia, or 2nd or 3rd degree heart block.
References:
1. ACLS 2010, AHA

2. Drug Information Handbook 19TH Edition
3. Product Leaftlet - Adenocor
ADRENALINE SOLUTION 1MG/ML INJ (CCM)

FURTHER DILUTION See administration
ADMINISTRATION 1. CARDIAC ARREST (DURING CPR)

IV: 1mg every 3-5 minutes followed by 20ml flush of NS;
Elevate arm 10-20 seconds after each dose.
To dilute 1 ampoule (1mg) in 10mL NS.
2. BRADYCARDIA OR HYPOTENSION
Continuous IV infusion;
Single strength-Dilute 3mg in 50ml of D5 or NS.
Double strength-Dilute 6mg in 50 ml.
Usual rate is up to 2mcg/kg/minute.
3. ANAPHYLAXIS
Deep IM: 0.5mg (adult), 0.3mg (child 6-12yo), 0.15mg (child <6yo).
May repeat 5-15 mins PRN. Give undiluted.
Slow IV: 0.1mg given over 3-5 minute. May repeat as above.
To dilute 1 ampoule (1mg) in 10mL NS, give 1ml.
IV Infusion: 1-4mcg/min. To dilute 3mg in 50ml of D5 or NS.
4. NEBULIZED ADRENALINE FOR CROUP
Paediatric dose: 0.5ml/kg of the 1mg/ml solution, max dose 5mls.
May give undiluted OR diluted in 4ml NS.
STORAGE & STABILITY Intact Vials: Store below 25°C. Protect from light.
REMARKS  Rapid IV administration may cause death from cerebrovascular haemorrhage or cardiac
arrhythmias (however rapid IV administration is necessary in pulseless arrest)
 IV admin for anaphylaxis should only be done in pt who are profoundly hypotensive or in
cardiopulmonary arrest refractory to volume resuscitation and several adrenaline
injections.
References:
1. ACLS 2010, AHA
2. Product Leaftlet –CCM Adrenaline (Duopharma)
3. Drug Information Handbook 19th Edition
4. MOH, 2011, Dilution Guide for High Alert Medications
5. British National Formulary 64th edition. 2012.
6. Ministry of Health Malaysia. Paediatric Protocol 3rd edition. 2012.
AMINOPHYLLINE SOL BP 250 MG/10ML INJ (DBL)

ADMINISTRATION Loading dose (LD): 250mg (6mg/kg) dilute in 100ml of NS and

infuse over 20-30 minutes.
No loading if patient previously on Theophylline.
Maintenance dose (MD):

Non-smoker: 0.5mg/kg/hr
Smoker: 0.8mg/kg/hr
Elderly: 0.3mg/kg/hr
*To dilute 1 amp (250mg) in 50ml NS
Max rate of infusion: 0.36mg/kg/min, and < 25mg/min.
Common practice for MD:

1 amp (250mg) in 500ml NS, run over 8 hours, TDS dosing.
REMARKS 1. Contraindication: Uncontrolled arrhythmias, hyperthyroidism.

2. Toxicity: Life threatening ventricular arrhythmias, seizure.
3. Early signs of toxicity: Nausea, vomiting, abdominal pain, diarrhea, insomnia,
irritability, headache, palpitations, confusion, agitated or manic behavior.
4. Weak bronchodilator, 2nd line therapy in AECOAD (use when insufficient response to
short acting bronchodilators), GOLD report 2014
5. No role in asthma, add-on treatment with aminophylline does not improve outcomes
compared with SABA alone, GINA report 2014.
6. Narrow therapeutic index. Target therapeutic range: 10-20mcg/ml
7. Monitor level 12 - 24hours after loading dose
References:
1. Gold report 2014
2. Product Leaftlet- DBL Aminophylline (Hospira)
3. Drug Information Handbook 19th edition.
AMIODARONE 150MG/3ML INJ (CORDARON)

ADMINISTRATION 1. VF/VT CARDIAC ARREST

First dose: 300mg IV push
Second dose (if needed): 150mg IV push
2. LIFE THREATENING ARRHYTHMIAS (*max cumulative dose: 2.2g/24hr)

Then; IV
Initial dose: IV 150mg Then; IV Infusion
Infusion 300mg
over 15mins. 600mg over 18
over 6 hours.
hours. To dilute
To dilute 150mg (1amp) To dilute 300mg
600mg (4amp) in
in 50ml D5% run (2amp) in 100ml
500ml D5% run
200ml/Hr D 5% run
28ml/hr
17ml/hr
OR
LD: 300mg (2amp) in 50mL D5% over 1 hour (run 50ml/hr).
MD: 900mg (6amp) in 500mL D5% over 23 hours (run 21ml/hr).
STORAGE & Intact Vials: Store below 25°C.

STABILITY
REMARKS 1. Administer via large peripheral vein or central vein whenever possible.
2. Attached cardiac monitoring.
3. Rapid infusion may lead to hypotension.
4. Terminal elimination is extremely long (half life lasts up to 40 days)
References:
1. ACLS 2010, AHA
2. British Resuscitation Guidelines 2010.
3. Product Leaftlet –Cordaron
4. Micromedex 2016
ANTIVENENE INJ.
RECONSTITUTION Reconstitute 1 vial with 10ml WFI or with the solution

provided prior to administration.
FURTHER DILUTION Dilute in 5-10ml/kg of NS or D5 (ie 250-500ml for adult)
ADMINISTRATION Skin test:

1. Dilute 1ml of reconstituted antivenin with 10ml NS or
D5 (1:100 dilution)
2. Syringe out 0.02ml, give IM
Monitor patient for anaphylactic reaction.
IV Infusion: Can run 1-2ml/min over 10-15min, may

increase slowly to 5-10ml/min if no reaction. Finish infusion
over an hour.
*Refer dosing to Appendix 1.
STORAGE & STABILITY Intact Vials: Store at 2-8°C. Protect from light.
Reconstituted solution: Use immediately after
reconstitution.
ANTIVENENE SERUM SNAKE HEMATO POLYVALENT INJ

REMARKS ANTIVENENE SERUM SNAKE NEURO POLYVALENT INJ
ANTIVENENE COBRA INJ
ANTIVENENE MALAYSIAN PIT VIPER INJ
ANTIVENENE GREEN PIT VIPER INJ
(THE THAI RED CROSS SOCIETY)
References:
1. Product Leaftlet –The Thai Red Cross Society
2. Snakebite Management Guide for Healthcare Providers in Malaysia 2014
ARTESUNATE 60MG INJ (ARTESUN)
RECONSTITUTION Reconstitute 1 vial with provided 1ml of 5% sodium

bicarbonate injection IP and shaken until dissolve.
ADMINISTRATION IM: Further dilute in 2ml of provided NS to a final

concentration of 20mg/ml.
Slow IV: Further dilute with 5ml of provided NS to a

final concentration of 10mg/ml and administer at a
rate of 3-4ml/min.
Usual dose: 2.4mg/kg at 0, 12, and 24Hours, then

q24H until oral treatment can be substituted.
STORAGE & STABILITY Intact vial: Store below 25°C

Do not freeze
Protect from light
Diluted solution: Use immediately.
References:
1. Product Leaftlet - Artesun

ATRACURIUM BESYLATE 50MG/5ML INJ (ATRALEX)

ADMINISTRATION 1. ADJUNCT TO ANAESTHESIA (for surgery/ intubation)

Initial IV Bolus:0.3-0.6mg/kg, given undiluted.
Maintenance IV bolus:0.1-0.2mg/kg
OR
IV infusion: 5-10mcg/kg/min.
Note: Do not administer before unconsciousness has been induced.
2. INTENSIVE CARE
Initial IV bolus: 0.3-0.6mg/kg
Maintenance IV Infusion: 4.5-29.5mcg/kg/min
(usual 11-13mcg/kg/min)
Dilution for;
IV bolus: To be given undiluted
IV Infusion: To dilute in NS/ D5 to conc. of 0.2mg/ml or 0.5mg/ml.
# 20 mg (2 mL) diluted in 100 mL → 200 mcg/mL (0.2 mg/mL).
# 50 mg (5 mL) diluted in 100 mL → 500 mcg/mL (0.5 mg/mL).
STORAGE & STABILITY Intact Vials: Store at 2-8°C. Protect from light. Do not freeze
After dilution: Stable in 24H in NS at RT, Stable in 8H in D5 at RT.
REMARKS  When small vein is selected as the injection site, Atracurium should be flushed
through the vein with physiological saline after injection.
 Onset 2-3 mins, duration of action 20-35mins.
 Reduce initial dose and inject slowly over 1-2min in pt in whom substantial histamine
release will be hazardous (pt with clinically important CVD)
 Side effects: bradycardia, flushing, hypotension, tachycardia.
References:
1. Product Leaftlet – Atralex
3. Dilution Guide for High Alert Medications 2011.
ATROPINE SULPHATE 1MG/1ML INJ (ACIPAN)

ADMINISTRATION 1. BRADYCARDIA
IV Bolus: 0.5mg q3-5 mins, max 0.04mg/kg (total 3mg).
Give undiluted.
2. ORGANOPHOSPHATE POISONING
Loading: IV Bolus, 1-5mg q3-5mins until fully atropinised.
Double the dose if previous dose does not induce
atropinisation. Give undiluted over 15-30sec.
Maintenance: IV Infusion, Give undiluted,
run 0.5-1mg/hr OR 10-20% of total LD/hr.
3. MUSCLE RELAXANT ANTAGONIST

IV 0.6-1.2mg of atropine, for each 0.5-2mg neostigmine,
Give in a separate syringe few mins before neostigmine.
Give undiluted.
STORAGE & STABILITY Intact Vials: Store below 25°C

Protect from light.
References:
1. ACLS 2010, AHA.
2. Product Leaftlet – Acipan
4. Drug Information Handbook 23rd edition. 2014
5. Betty LG, Adrienne RN. 2014 Intravenous Medications. 30th edition.
CALCIUM GLUCONATE 10% INJ.

(1 amp of 10ml contains 1g or 2.2mmol Ca2+)
ADMINISTRATION HYPOCALCAEMIA
Slow IV: 10 – 20ml Calcium gluconate 10% over 10 minutes;
Give undiluted.
Then, IV infusion 10-50ml Calcium gluconate 10% in 500ml
D5 or NS over 4-8 hours.
STORAGE & STABILITY Intact Vials: Store at RT.

Used immediately & to be completed within 24hours.
Discard unused portion.
References:
1. Product Leaftlet-B Braun

2. Drug Information Handbook 23rd edition, Lexicomp. 2014.
3. Sarawak Handbook of Medical Emergencies, 3rd Edition.
CHARCOAL, ACTIVATED 50GM
RECONSTITUTION 50gm in 400ml water. (1g=8ml)
ADMINISTRATION Adult: 25-100gm

Child 1-12yo: 25-50gm OR 0.5-1g/kg
Child < 1yo: 0.5-1g/kg
*Repeat dose if necessary.
REMARKS  Most effective given within 1 hour.

 Contraindicated in unprotected airway, non functioning GI tract and
uncontrolled vomiting, ingestion of most hydrocarbons, intestinal
obstruction, pt at risk of GI perforation or haemorrhage.
 These are agents which are poorly adsorbed by charcoal:
o Alcohols
o Cyanide
o Metals and inorganic metals eg lithium, sodium, iron, lead
References:
1. Vale JA et al. 1999. Position Statement and Practice Guidelines on the Use of Multi-Dose Activated Charcoal in the Treatment of
Acute Poisoning. Clinical Toxicology, 37(6), PP. 731–751
2. Chyka PA et al. 2005. Position Paper: Single-Dose Activated Charcoal. Clinical Toxicology 43 pp. 61–87
CHLORPHENIRAMINE MALEATE 10MG/ML INJ

(PIRIMAT)
ADMINISTRATION IM and SC: 10-20mg, given undiluted
Slow IV: 10-20mg, given undiluted over 1 minute.

(Max 40mg/24hr)
References:
1. Product Leaftlet – Pirimat

DEXAMETHASONE 8MG/2ML INJ (PENATONE)

ADMINISTRATION 1. MENINGITIS
IV 10mg 6hourly for up to 4 days.
2. CEREBRAL OEDEMA
IV 10mg stat, then IV/IM 4mg
3. VIRAL CROUP IN PAEDIATRICS
IV/IM 0.3-0.6mg/kg
IM: Administer undiluted

Slow IV: Administer undiluted solution slowly over 3-5 minutes.
IV Infusion: Further dilute in 50-100ml NS or D5, run over 15-30mins.
STORAGE & STABILITY Intact Vials: Store at 15-25°C.

Protect from light.
Diluted solution: 24hours at room temperature.
REMARKS  In shock use only IV route

 In meningitis, to give dexamethasone 15-20mins before or during the first dose
of antibiotics.
References:
1. Product Leaftlet – Penatone
2. HUKM Drug Formulary 2010, 5th Edition
4. Drug Information Handbook 23rd edition. 2014. Lexicomp
5. Ministry of Health Malaysia. National Antibiotic Guideline 2nd edition. 2014. Pharmaceutical Services Division
DIAZEPAM 10 MG/2ML INJ (DBL )

ADMINISTRATION STATUS EPILEPTICUS

IV Push: Given undiluted. 0.15 mg/kg IV up to 10 mg per
dose, may repeat in 5 min. Max 30mg over 8 hour period.
Give over 1-2mins, with rate ≤ 5mg/min.

Protect from light
REMARKS 1. Avoid dilution, may precipitate diazepam and adsorb onto

IV bag and tubing.
2. Contains Benzyl alcohol, should be avoided in children under
2y.o. and avoid in neonates.
3. Time to effect: 1-3 minutes
4. May consider IM administration into deep muscle, but
absorption is slow & erratic
5. Serious adverse effects: Hypotension, respiratory
depression
References:
1. Product Leaftlet – DBL (Hospira)
2. Micromedex 2015
3. British National Formulary 2011, 61st Edition
4. Consensus Guideline on Management of Epilepsy 2010, Malaysian Society of Neuroscience.
5. Brophy G.M., et al; Guidelines for the Evaluation and Management of Status Epilepticus, Neurocrit Care, April 2012.
6. Lexicomp, Drug Information Handbook 23rd edition.
7. Medscape
DICLOFENAC 75MG/3ML INJ (LUPIN)
ADMINISTRATION IM: 75mg OD/BD (max 150mg/day)

Deeply into gluteal muscle

Protect from light.
Do not freeze.
REMARKS Should not be given for more than 2 days.

If necessary, treatment can be continued with
oral form.
References:
1. Product Leaftlet- Lupin

DIGOXIN 500MCG/2ML INJ (LANOXIN)

ADMINISTRATION SVT/AF
IV 0.25mg. May repeat every 1-2 hours to a maximum 1.5mg in 24hours.
To dilute 1 amp (0.5mg) in 50ml NS or D5.

Each dose to run over 30 minutes.

Protect from light.
Diluted solution : 48H at RT.
REMARKS 1. Arrhythmias may be precipitated by digoxin toxicity. Monitor heart rate before, during & after
the admin.
2. Rapid injection may cause systemic and coronary arteriolar constriction.
3. Death has occurred in digitalized patient with hypocalcemia when receiving calcium. Give
calcium slowly and in small amounts.
4. Slow onset of action and relative low potency renders it less useful for treatment of acute
arrhythmias
5. Onset of actions >1hour & peak effect in 6 hours.
6. Narrow therapeutic window, monitor level (Target: 0.8 – 2.5 ng/ml)
References:
1. Product Leaftlet – Lanoxin
2. Drug Information Handbook. Lexicomp 23rd edition. 2014.
DOBUTAMINE HCL 250MG/20ML INJ (MOBITIL)
ADMINISTRATION IV infusion
Single strength: Dilute 250mg with 50ml of NS or D5.
Double strength: Dilute 500mg with 50ml of NS or D5.
Usual dosage range: 1-20mcg/kg/min.

Protect from light.
Diluted solution: 24 hours at room temperature
REMARKS  Do not mix with sodium bicarbonate.

 Do not administer in the same IV line as Heparin,
hydrocortisone, cefazolin & penicillin.
 May cause tachyarrhythmias.
 Decrease dose gradually before discontinuation.
References:
1. Product Leaftlet – Mobitil
2. British National Formulary 2010, 60th Edition
3. Hospital Selayang Dilution Protocol. 2nd edition. 2010
DOPAMINE 200MG/5ML INJ (LOXIN)

ADMINISTRATION IV infusion
Single strength: Dilute 200mg with 50ml of NS or D5.
Double strength: Dilute 400mg with 50ml of NS or D5.
Usual dosage range:

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

Protect from light.
Diluted solution : 24 hours at room temperature
REMARKS  Must be diluted before use.

 Do not mix with sodium bicarbonate / strong alkaline solution.
 Correct hypovolemia with volume replacement before initiating Dopamine.
 Use with caution in cardiogenic shock with accompanying CHF.
 May cause tachyarrhythmia’s, excessive vasoconstriction.
 Decrease dose gradually before discontinuation.
 Administer into a large vein / central line.
References:
1. ACLS 2010, AHA
2. Product Leaftlet – Loxin
3. Drug Information Handbook 23rd Edition. 2014.
4. Hospital Selayang Dilution Protocol. 2nd edition. 2010.
EPHEDRINE HCL 30MG/ML INJ (CCMD)
RECONSTITUTION Not required.
ADMINISTRATION 1. HYPOTENSION INDUCED BY ANAESTHESIA

Slow IV bolus: 5-25mg per dose q5-10mins.
Dilute 1 amp (30mg) with 10ml NS to make 3mg/ml.
Administer slowly.
Max dose: 150mg in 24Hr.

Protect from light.
Single use only.
References:
1. Product Leaftlet – CCMD
2. Hospital TuankuAmpuanNajihah Method of Reconstitution & Dilution Protocol for Injections 2013. 3rd edition.
3. Drug Information Handbook 23rd edition. 2014
4. Micromedex 2016.
ESMOLOL 100MG/10ML INJ (ESOCARD)
FURTHER DILUTION Not required. The dosage form is pre diluted to provide a
ready-to-use 10mg/ml concentration.
ADMINISTRATION Peripheral or central IV route.
1. SUPRAVENTRICULAR TACHYCARDIA
Loading Dose: IV Bolus 0.5mg/kg over 1 min
Maintenance: IV Infusion 50mcg/kg/min for 4 min,
If the response is inadequate, titrate upward in 50mcg/kg/min
increments to a max 200mcg/kg/min. Infusion up to 48hours.
*For a more rapid response, may rebolus with another loading dose prior to
increasing the infusion rate. Max loading dose: 3 times
2. HYPERTENSIVE EMERGENCY
Same as SVT dosing, however max of IVI up to 300mcg/kg/min
If by chance needs dilution, stability in NS or D5 is 24 hours at
room temperature
REMARKS Contra indicated in patients with sinus bradycardia, heart block

greater than first degree, cardiogenic shock or overt heart
failure.
References:
1. Product Leaftlet – Esocard
2. Drug Information Handbook, Lexicomp23rd edition. 2014.
3. Medscape
FENTANYL 0.1MG/2ML INJ (TALGESIL)
ADMINISTRATION Slow IV: Undiluted over 1-2min via peripheral or central line.
IV Infusion: Dilute with NS to conc of 10mcg/ml.

Ie 0.3mg (3amp) diluted to 30mL NS.
Epidural: Dilute with NS to conc of 2mcg/ml
Midazolam-Fentanyl infusion:
0.3mg (3amp) Fentanyl + 30mg Midazolam
dilute to 30mL NS

Single use only.
References:
1. Product Leaftlet – Talgesil

2. Drug Information Handbook, Lexicomp23rd edition2014
3. Hospital Tuanku Ampuan Najihah. Method of Reconstitution & Dilution Protocol for Injections 2013. 3rd edition.
FLUMAZENIL 0.5MG/5ML INJ (HAMEIN)
ADMINISTRATION 1. REVERSAL OF CONSCIOUS SEDATION

If adequate
IV Bolus: 0.2mg, consciousness not
undiluted over 15 obtained in 45sec,
seconds. give 0.2mg q1min
(max total dose: 1mg)
2. BENZODIAZEPINE OVERDOSE
Alternative to
If adequate repeated
consciousness Repeat doses: bolus:
IV Bolus:
not obtained 0.5mg q1min
0.2mg, IV Infusion:
in 30sec, up to max
undiluted over 0.1-0.4mg/hr.
total dose
30 seconds. give 0.3mg Dilute the
3mg.
over 30sec. daily dose in
50ml NS or D5.
STORAGE & Intact Vials: Store below 25°C. Protect from light.
STABILITY
REMARKS Benzodiazepine overdose: adult with partial response at 3mg may require up to
total dose of 5mg.
References:
1. Product Leaftlet – Hamein
2. Drug Information Handbook, Lexicomp 23rd Edition. 2014
3. Perak Injectable Drugs Dilution 2014. 2nd edition.
FLUPHENAZINE DECANOATE 25MG/ML

(MONASAN)
FURTHER DILUTION Not required.
ADMINISTRATION IM: Deep IM Injection
STORAGE & STABILITY Store below 25°C. Protect from light
References:
1. Product Leaftlet – Monasan

FRUSEMIDE 20MG/2ML INJ (ASOKET)
ADMINISTRATION Slow IV: 40-100mg given slowly for 1 to 2 minutes.

Max 4mg/min. Give undiluted.
IV Infusion: 5-20mg/hr. May be given undiluted.
STORAGE & STABILITY Intact Vials: Store below 25°C. Protect from light. Once
diluted: Stable for 24 hours at room temperature
REMARKS  IV administration with rate >4mg/min increases the risk of ototoxicity.

 Combination of a loop diuretic at low doses with nitrates is superior to
high dose diuretic therapy alone. (LOE: I,B)
 Other combination with drugs below are also more effective than
increasing the dose of diuretic alone
- Dopamine (LOE: IIa, B)
- Dobutamine(LOE: IIa, B)
References:
1. Product Leaftlet – Asoket
2. Drug Information Handbook, Lexicomp23rd edition. 2014
3. Heart Failure CPG 2014, MOH
4. Heart Failure Management, ACCF/AHA 2013
FULLER’S EARTH 60GM
RECONSTITUTION Dissolve 60g in 400ml water
ADMINISTRATION PARAQUAT POISONING

300ml Fuller’s Earth via NG tube stat,
Then 20ml every hour until diarrhea and
PR passage of Fuller’s Earth.
References:
1. Product Leaftlet
HALOPERIDOL 5MG/ML INJ (MANACE)
ADMINISTRATION AGITATION ASSOCIATED WITH ACUTE PSYCHOSIS

IM or Slow IV Bolus: 2-10mg initially.
Subsequent doses given every 4-8hr PRN,
may require up to q1h.
Max total dose/day: 18mg
Max rate 5mg/min.
STORAGE & STABILITY Store below 25°C. Protect from light

Single use only.
References:
3. Product Leaftlet – Manace

4. Medscape
5. Formulari Ubat KKM
HEPARIN SODIUM 5000U/5ML AND

25000U/5ML INJ (HEPARINOL)

ADMINISTRATION 1. STEMI / NSTEMI

IV bolus: 60U/kg IV infusion: 12U/kg/hr Refer
protocol
(max: 4000 unit) (Max: 1000 unit/hr).
for dose
Administer undiluted. Dilute 25000units in 50ml NS adjustment
2. TREATMENT OF VTE
IV bolus: 80U/kg Refer
Then IV Infusion: 18U/kg/hr.
(max: 5000 unit) protocol for
(max: 1300unit/hr).
dose
Administer undiluted. Dilute 25000units in 50ml NS
adjustment
3. PROPHYLAXIS OF VTE
SC: 5000u BD. Give undiluted.
Opened Vials: 28 days at room temperature
Diluted Solution : 24 hours at room temperature
REMARKS 1. Omit bolus dose if baseline APTT > 1.5

2. Monitor APTT every 6 hours (Aim APTT 1.5 – 2.0)
3. Omit heparin infusion if APTT > 2.5
References:
1. Product Leaftlet – Heparinol
2. Dilution Guide for High Alert Medications 2011.
3. ST-Elevation MI CPG 2014, MOH
4. PAHANG Acute MI management, 2012.
5. Prevention and Treatment of Venous Thromboembolism CPG.
HYDROCORTISONE SODIUM 100MG INJ

(SM PHARMACEUTICAL)
RECONSTITUTION Reconstitute with 2ml WFI
ADMINISTRATION IM: Undiluted
Slow IV bolus: Undiluted over 1-10min.
IV Infusion: Dilute with 100ml D5 or NS to make

1mg/ml and run over 20-30mins.
Once reconstituted, stable for 3 days at RT or under refrigeration.
Once diluted, stable for 24H at RT or under refrigeration.
References:
1. Product Leaftlet– SM Pharmaceuticals

2. Drug Information Handbook, Lexicomp 23rd edition.2014
HYOSCINE BUTYLBROMIDE 20MG/ML INJ (COPAN)
ADMINISTRATION IM or Slow IV: 20mg run over 3-5mins.

Max 100mg daily.
STORAGE & STABILITY Store below 25°C. Protect from light.
References:
1. Product Leaftlet – Copan

INSULIN REGULAR (ACTRAPID OR HUMULIN R)

1000U/10ML INJ
ADMINISTRATION DIABETIC KETOACIDOSIS (DKA)
Insulin infusion: 0.1unit/kg/hr
*Only give bolus dose of insulin (0.1u/kg) if there is delay in initiating infusion.
To dilute 50 units (O.5ml) with 50 ml NS.

Insulin dose
Weight (kg) (Units/hour = ml/hour)
Dextrostix Dextrostix Dextrostix
> 15mmol/l 5 – 15 mmol/l < 5mmol/L
60 - 69 6 3 Omit
70 - 79 7 3.5 Omit
80 - 89 8 4 Omit
90 – 99 9 4.5 Omit
100 – 109 10 5 Omit
110 – 119 11 5.5 Omit
120 – 129 12 6 Omit
130 - 139 13 6.5 Omit
Dosing adjustment:
Dxt (mmol/L) Insulin infusion IVD
dose
> 15 0.1 unit/kg Normal saline
5 - 15 0.05 unit/kg Dextrose 5% alternate with NS
<5 Omit D5% or D10%
STORAGE & STABILITY Intact vials: Store at 2–8°C.

Protected from light.
 Assess resolution of DKA:
REMARKS  Fall in blood ketone measurement at least 0.5mmol/Hr
or (if blood ketone measurement not available)
 Rise in bicarbonate 3mmol/L/Hr
or alternatively
 Reduction in plasma glucose at least 3mmol/L/Hr
 If above criteria is not achieved, insulin can be increase by 1unit/hr increment hourly until resolution at the above rate is seen.
 Glucose level should not decrease > 5mmol/hr (to prevent cerebral edema).
Reference:
1. ADA DKA guidelines 2009
2. Joint British Diabetes Society 2013
4. Dilution Guide for High Alert Medication, Pharmaceutical Service Division, MOH 2011
ISOSORBIDE DINITRATE 10MG/10ML INJ (ISOKET)
FURTHER DILUTION Give undiluted

OR
Dilute with NS or D5 to a final concentration of
0.1-0.2mg/ml. If fluid restricted, dilute to 0.5mg/ml.
ADMINISTRATION IV infusion: Peripheral or central route.

2-10mg/hour.

Diluted solution : Stable for 24H at RT.
REMARKS  Preferred in acute coronary syndrome and acute pulmonary

edema.
 Avoid in patients with benign intracranial hypertension /
elevated intracranial pressure.
References:
1. Product Leaftlet – Isoket

KETAMINE HCL 200MG/20ML INJ (FRESENIUS)

ADMINISTRATION 1. SEDATION
Loading dose: IV 0.2-0.75mg/kg.
Give undiluted, administer over at least 1 minute.
Maintenance dose: IV Infusion 2-7mcg/kg/min.
To dilute with NS or D5 to a concentration of 1-2mg/ml.
{ie 200mg (1 amp) dilute in 100ml}
Rate of infusion: 0.1-0.5mg/min.
2. INDUCTION OF ANAESTHESIA
Slow IV Bolus: 1-4.5mg/kg.
Give undiluted, administer over at least 1 minute.
IM: 6.5-13mg/kg. Give undiluted.
*If adjuvant drugs are used eg midazolam, give dose as below;
Slow IV bolus: 0.5-2mg/kg.
IM: 4-10mg/kg.
REMARKS  Rapid administration may result in respiratory depression and enhanced pressor response.
 Not to run via the same line as IV Barbiturate and IV Diazepam.
 Onset for IV: 30 seconds, duration for 5-10mins.
 Onset for IM: 3-4 mins, duration 12-25 mins.
References:
1. Product Leaftlet – Fresenius
2. Drug Information Handbook, Lexicomp 23rd edition. 2014
3. Micromedex 2016
LABETALOL HCL 25MG/5ML INJ (TRANDATE)
ADMINISTRATION 1. SEVERE HYPERTENSION

IV Bolus: 20mg over 1 minute OR 50mg over 1 min. May be
repeated every 5-10min until BP is achieved.
Max dose 200mg. Give undiluted.
IV Infusion: 0.5-2mg/minute, max total dose 300mg.

IVI in pregnancy: Start at 20mg/H, double every 30min and
titrate accordingly to max 160mg/H.
 To dilute with NS or D5 to final concentration of
1mg/ml; 200mg (8 ampoules) up to 200ml
OR
 may administer undiluted

Diluted solution : 24 hours at room temperature
 Should not be used in patients with asthma or a history of obstructive airways
REMARKS disease.
 When peripheral vasoconstriction suggests low cardiac output, the use of labetolol
to control hypertensive episodes following acute MI is C/I.
 Incompatible with Sodium Bicarbonate 4.2%.
References:
1. Product Leaftlet – Trandate

2. Ministry of Health Malaysia. Dilution Guide for High Alert Medications 2011
LIGNOCAINE HCL 2% 100MG/5ML INJ

(INJECSOL LIG2) – Preservative Free
FURTHER DILUTION& Please refer Lignocaine HCl 10% 500mg/5ml Inj

ADMINISTRATION (Fresenius)
LIGNOCAINE HCL 10% 500MG/5ML INJ (FRESENIUS)

ADMINISTRATION Indications:
1. ALTERNATIVE TO AMIODARONE IN CARDIAC ARREST FROM VT/VF
2. HEMODYNAMICALLY STABLE MONOMORPHIC VT
Initial dose: 1 – 1.5 mg/kg slow IV bolus over 2 minutes.

For refractory VF:
May give additional 0.5 – 0.75 mg/kg IV push every 5–10 minutes.
(Max: 3 doses or total of 3mg/kg)
Maintenance infusion: 1 – 4mg/min (30 – 50mcg/kg/min).
Dilution:
IV Push: 1 amp (500mg) dilute in 12.5-25ml D5 (conc of 20-40mg/ml)
IV Infusion: 1g (2amp) dilute in 50ml D5%
OR
0.5g (1amp) dilute in 250-500ml D5%.

Protect from light.
After dilution: discard after 24hours
REMARKS  Prophylactic use in AMI is contraindicated.

 Reduce maintenance dose (Not Loading dose) in impaired liver function or LV
dysfunction.
 Side effects: Slurred speech, altered consciousness, seizures, bradycardia.
 Discontinue immediately if signs of toxicity develop.
References:
2. ACLS 2010, AHA
3. Drug Information Handbook, Lexicomp 23rdEdition. 2014
4. HUKM Drug Formulary 2010, 5th Edition
LIGNOCAINE HCL 200MG/10ML INJ

(LAKAN-Not for IV use)
ADMINISTRATION IM or SC: Undiluted

Max dose:
4.5mg/kg, not to exceed 300mg without adrenaline.
OR
7mg/kg, not to exceed 500mg with adrenaline.

Protect from light.
REMARKS Not for IV use
References:
1. Product Leaftlet –Lakan

3. Medscape
LYTIC COCKTAIL
ADMINISTRATION HYPERKALAEMIA:
• 10ml of IV Calcium Gluconate 10%

1 infused over 10mins.
• 50ml of IV Dextrose 50% infused over

2 15-30min.
• IV Insulin (Actrapid or Humulin R)

3 10 units
References:
1. Sarawak Handbook 2011

MAGNESIUM SULPHATE 2.465GM/5ML INJ (DBL)

(1 amp of 5ml contains 2.47g or 10mmol Mg 2+)

FURTHER DILUTION See Administration.
ADMINISTRATION 1. TORSADES DE POINTES / DIGITALIS TOXICITY.

Loading dose: IV 1-2g (2 - 4ml) in 20ml NS run over 20mins.
Maintenance dose: 0.5 – 1g/hour IV infusion (until resolves), TO DILUTE 2.5g (1amp) in 50ml NS.
2. ACUTE EXACERBATION OF BRONCHIAL ASTHMA

IV 2g (4ml) dilute in 20ml NS run over 20 minutes.
Paeds: IV bolus 0.1 mL/kg (50 mg/kg) run over 20 mins. TO DILUTE 1amp (5ml) in at least 7.5ml
NS or D5.
3. PRE-ECLAMPSIA
Loading dose: IV 4g (8ml) in 20ml NS run over 15 minutes (infusion rate: 80ml/hr)
Maintenance dose: IV infusion 1g/hr until paroxysm cease. TO DILUTE 2.5g (1amp) in 50ml NS,
(infusion rate: 20ml/hr)
OR
Loading Dose: IM 5gm into each buttock (upper outer quadrant)- total 10gm
Maintenance Dose: IM 5g every 4hours in alternate buttock as necessary.
4. HYPOMAGNESEMIA
Usual practice: IV Infusion: 1 amp dilute in 50-100ml NS run over 1hr.
STORAGE & STABILITY Intact vials: Store below 25°C. Once diluted, stable for 24H at <25°C,
REMARKS  Magnesium sulphate is incompatible with Calcium salts.

 Clinical monitoring is of utmost importance, looking for signs of toxicity (especially loss of deep tendon reflexes,
respiratory depression with rate <16/minute) and renal impairment (hourly urine output <30 ml/hour).
 Levels >12mEq/L (>6mmol/L) can lead to respiratory paralysis & heart block.
 Occasional fall in blood pressure with rapid administration.
 IM may cause irritation and pain at injection site.
 Do not mix with calcium salt, bicarbonate or phosphate.
References:
1. Product Leaftlet –DBL
2. ACLS 2010, AHA
3. Minisrty of Health Malaysia. Dilution Guide for High Alert Medications 2011
4. Dilution Protocol Hospital Sultan Abdul Halim. 2016.
5. Drug Information Handbook, Lexicomp 23rd edition. 2014.
6. World Health Organizations. 2006. Integrated Management of Pregnancy and Childbirth – Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice, 2nd edition. Geneva. WHO.
METHYLPREDNISOLONE SODIUM SUCCINATE

500MG INJ (SOLU. MEDROL)
RECONSTITUTION Reconstitute with 7.8ml solvent provided.

ADMINISTRATION 1. ACUTE SPINAL CORD INJURY
Initial bolus dose: 30mg/kg in 50ml D5% over 15 mins
Maintenance dose: 5.4mg/kg/hr x 23hour
Dilution for maintenance dose:

Calculate total dose per kg BW for duration of 23hours
= 5.4mg x BW (kg) X 23hours, Then Dilute in 230ml of
NS/D5% Infuse at 10ml/hr x 23hours
2. OTHER INDICATIONS
Slow IV (for < 250 mg): Administer reconstituted solution over at least 5minutes.
IV infusion: (for >250 mg): Dilute with 50-100 ml of NS or D5 and administer over
30 minutes.
STORAGE & Intact vials: Store below 25°C.

STABILITY Reconstituted solution: 48hours at room temperature.
Diluted solution: Stable for 24H at RT.
REMARKS In Acute spinal cord injury: dose should be initiated within 8 hours of injury
References:
1. Product Leaftlet – Solu Medrol
2. Drug Information Handbook, Lexicomp23rd edition 2014
METOCLOPRAMIDE 10MG/2ML INJ (PULIN)
ADMINISTRATION IM: Give undiluted.
IV Injection:
≤10mg :Undiluted slowly over 1-2 mins
>10mg: Diluted in 50 ml NS(max conc: 5mg/ml)
over 15-30 min (max rate: 5mg/min)
Max total daily dose: 0.5mg/kg/day.
STORAGE & STABILITY Intact vials: Store below 25°C.

Protect from light.
REMARKS 1. Rapid IV admin is associated with transient feeling of

anxiety and restlessness.
2. Not recommended for the first trimester of
pregnancy.
3. Avoided in children < 2 yrs old and not to be used in
neonates, as it contains Benzyl Alcohol.
References:
1. Product Leaftlet – Pulin

2. Drug Information Handbook, Lexicomp23rd Edition.2014
MIDAZOLAM 5MG/ML AND 15MG/3ML INJ

(HAMEIN)
ADMINISTRATION 1. SEDATION
Initial dose: 0.01-0.05mg/kg slow IV.
Administer undiluted over 2 minutes.
Maintenance dose: IV Infusion 0.02-0.1mg/kg/hr.
Dilute with NS or D5 to a final concentration of 1mg/ml.
Usual practice IVI Midamorphine

30mg Midazolam + 30mg Morphine in 30ml NS.
Infuse at rate : 1-2ml/ Hr
2. STATUS EPILEPTICUS
Loading dose: 0.2 mg/kg IM up to maximum of 10 mg. Give undiluted.
Pediatrics:
IM: 10 mg (>40 kg); 5 mg (13–40 kg)
Intranasal: 0.2 mg/kg
Buccal: 0.5 mg/kg

Diluted Solution: 24hours under refrigeration.
REMARKS 1. Agents recommended for continuous infusion in refractory status epilepticus at dose of 0.05 – 2mg/kg/hr.
2. Serious adverse events: Hypotension, Respiratory depression.
3. Onset of action 1-5mins
References:
1. Product Leaftlet – Hamein
2. Drug Information Handbook 23rd Edition. 2014
MORPHINE SULPHATE 10MG/ML INJ (DUOPHARMA)

ADMINISTRATION Slow IV: Undiluted OR Dilute 4-10mg in 4-5ml WFI or NS run over 4-5 min.
IV Infusion: Dilute in NS or D5 to 0.1-1mg/ml.

ie 1 amp (10mg) in 10-100ml NS.
PCA Morphine: Dilute with NS to a final concentration of 1 mg/ml.
Usual practice IVI Midamorphine:

30mg Midazolam + 30mg Morphine in 30ml NS.
Infuse at rate : 1-2ml/ Hr
STORAGE & STABILITY Intact vials: Store below 25°C. Protect from light.
Epidural is stable up to 4H after dilution.
Once diluted for IVI, stable for 7 days at RT and under refrigeration.
REMARKS  SC causes local tissue irritation, and IM is no longer recommended due to variable absorption.Other
routes preferred.
 Contraindicated in respiratory depression, acute or severe bronchial asthma, within 2 weeks of
monoamine oxidase therapy, heart failure due to chronic lung disease,, head injuries, seizure disorders,
raised intracranial pressure, cardiac arrhythmia.
 May cause constipation. Consider preventive measures eg laxatives.
References:
1. Product Leaftlet – Duopharma
2. Drug Information Handbook, Lecicomp 23rdEdition. 2014
4. Medscape 2016
NALOXONE HCL 0.4MG/ML INJ (MAPIN)
RECONSTITUTION Not Required

FURTHER DILUTION See Administration
ADMINISTRATION
Indication Opioids intoxication: Respiratory Post operative
depression reversal
Opioids naive Opioids dependant
Initial dose SC, IM or IV Bolus: SC, IM or IV bolus: IV: 0.1-0.2mg q2-3
0.4-2mg q2-3mins, 0.04-0.4mg, may mins, repeat doses
may need to repeat repeat or escalate may be needed within
q20-60mins up to dose up to 2mg if 1-2hr. IV bolus over
total of 10mg. inadequate reponse. 30secs.
Give undiluted. IV Give undiluted, IV
bolus over 30sec. Bolus over 30sec.
Cont. Infusion 2/3 of the total initial bolus dose on an hourly N/A
(IV) basis (typically 0.25-6.25mg/hr)
*Half of the initial bolus dose should be readministered

15 mins after initiation of cont. infusion to prevent a
drop in naloxone levels.
Dilution for Continuous IV infusion:
Dilute 0.4mg (1amp) in 100mL NS or D5 to a conc. of 0.004mg/ml.
OR
Dilute 4mg (10amp) in 20mL NS or D5, final conc. 200mcg/mL.

Protect from light. Discard unused portion.
Diluted Solution : 24hours at room temperature
REMARKS 1. Consider lower dose in known or suspected opioid dependant patients to minimize
withdrawal syndrome.
2. May be given IM or SC when IV access N/A.
References:
1. Product Leaftlet – Mapin
3. Drug Information Handbook, Lexicomo 23rdEdition. 2014
NEOSTIGMINE 2.5MG/ML INJ (SETISIN)
ADMINISTRATION 1. MUSCLE RELAXANT ANTAGONIST

IV 0.5-2mg.
2. TREATMENT OF MYASTHENIA GRAVIS

IM 0.5mg, titrate carefully.
Dilution;
SC or IM: Undiluted
IV slow bolus: Undiluted over 1 min.
REMARKS In the diagnosis of myasthenia gravis, all anticholinesterase

medications should be discontinued at least 8 hours before
administering Neostigmine.
References:
1. Product Leaftlet –Setisin

2. Drug Information Handbook, Lexicomp23rd Edition. 2014
NORADRENALINE BITARTRATE 4MG/4ML INJ

(CARDIAMED )
RECONSTITUTION Not Required

ADMINISTRATION Single strength: 4mg dilute in 50ml D5

Double strength: 8mg dilute in 50ml D5
IV Infusion: Refer infusion chart rate.

Dose range: 0.05-2mcg/kg/min,

Protect from light.
Discard if there is any discoloration of solution
Diluted Solution: 24hours at room temperature
REMARKS 1. DO NOT dilute in NS alone due to oxidation.

2. Do not administer sodium bicarbonate through an IV line
containing Noradrenaline.
3. Assure adequate circulatory volume to minimize the need for
vasoconstriction.
4. Infusion should be through a LARGE VEIN / CENTRAL LINE to
prevent complications, severe ischemic necrosis & gangrene.
5. Decrease dose gradually before discontinuation.
References:
1. Product Leaftlet –Cardiamed
2. Drug Information Handbook 23rdedition. 2014
3. Dilution Protocol Hospital Sultan Abdul Halim. 2016.
OMEPRAZOLE 40MG INJ (OMEZOL)
RECONSTITUTION Reconstitute 40mg vial with provided solvent

(10ml of WFI).
ADMINISTRATION Slow IV: Administer the reconstituted solution at a

period of minimum 2.5min at a max rate of 4ml/min.
STORAGE & STABILITY Intact vial: Store below 25°C.

Protect from light.
Reconstituted solution: 4 hours at room temperature.
References:
1. Product Leaftlet – Omezol

OXYTOCIN 5 UNITS & ERGOMETRINE MALEATE

0.5MG/ML INJ (SYNTOMETRINE)
ADMINISTRATION 1. ACTIVE MANAGEMENT OF THIRD STAGE OF LABOUR

IM: 1ml undiluted
2. PREVENTION AND TREATMENT OF POSTPARTUM

HAEMORRHAGE
IM: 1ml undiluted. May be repeated after interval of no less
than 2 hours. Total dose max 3ml/24hr.
STORAGE & STABILITY Intact ampoule: Store between 2°C -8°C.

Protect from light.
REMARKS IV administration of Syntometrine is possible but not normally

recommended, as IV administration is associated with the risk of sudden
hypertensive or cerebrovascular accident and Syntometrine should
therefore only be given by this route if absolutely necessary.
References:
1. Product Leaftlet –Syntometrine

PANTOPRAZOLE 40MG INJ (PANTOSEC)
RECONSTITUTION Reconstitute 40mg vial with 10ml NS.
ADMINISTRATION Slow IV: Administer the reconstituted solution over

2-5minutes.
Intermittent IV Infusion: Further dilute with 100ml NS or

D5. Administer over 15-30 minutes.
Usual practice for continuous IV Infusion in UGIB:

80mg in 40ml NS or D5. Run 8mg/H for 72H.
STORAGE & STABILITY Intact vial: Store below 25°C. Protect from light.
Reconstituted solution: 12 hours at room temperature.
Discard unused portion
References:
2. Product Leaftlet – Pantosec

PETHIDINE HCL 50MG/ML OR 100MG/2ML INJ

(DUOPHARMA)
ADMINISTRATION IM, SC: Undiluted
Slow IV: Undiluted OR Dilute with NS to 10mg/ml, give

over 4-5min.
IV Infusion: Dilute with NS to 1mg/ml
PCA: Dilute with NS to 10mg/ml
STORAGE & STABILITY Store below 25°C. Protect from light.
References:
1. Product Leaftlet –Duopharma

3. Micromedex 2016
PHENOBARBITONE SODIUM 200MG/ML INJ

(MARTINDALE )
ADMINISTRATION Loading Dose: Slow IV 20mg/kg.

Dilute 1 vial in 10ml NS or D5, push over 3-5 mins.
Max rate: 30mg/min in children.
Max rate: 60mg/min in adults.
*If persist, give additional dose of 5 - 10mg/kg 10 min after loading
infusion.
IM or SC: Undiluted. Do not exceed 5ml per injection to avoid

potential tissue irritation.
STORAGE & STABILITY Store below 25°C.

Protect from light.
REMARKS 1. IV contains propylene glycol

2. Agents recommended for continuous infusion in refractory status
epilepticus at dose of 0.5 – 5mg/kg/hr 1
3. Serious adverse effects: Hypotension, Respiratory depression
References:
1. Brophy G.M., et al; Guidelines for the Evaluation and Management of Status Epilepticus, Neurocrit Care, April
2012.
2. Product Leaftlet – Martindale
3. Drug Information Handbook, Lexicomp 23rd edition 2014
PHENYTOIN SODIUM 250MG/5ML INJ (DILANTIN)

ADMINISTRATION Loading dose: 15-20mg/kg

*If seizure persist, give additional dose of 10mg/kg,
10 min after loading infusion
IV infusion: Further dilute required dose with 100ml NS

(final concentration not exceed 10mg/ml).
Administer over 60 minutes.

Protect from light.
Once diluted: Stable for 2H at RT.
REMARKS 1. Do not dilute in D5, cause crsytallization

2. Time to effect: 10 – 30 minutes
3. Narrow therapeutic window.
4. Target range: 10 – 20 mcg/ml
5. Monitor level 12-24hours after loading dose
6. Toxicity: Comatose, hypotension, respiratory& circulatory depression.
7. Initial sign of toxicity: Nystagmus, ataxia, tremor, somnolence, drowsiness,
lethargy, slurred speech, nausea, vomiting.
8. Serious adverse event: Arrhythmias, Hypotension, Purple glove syndrome
References:
1. Product Leaftlet – Dilantin
PHYTOMENADIONE 10MG/ML INJ (VIT.K-KISAN)

ADMINISTRATION 1. WARFARIN REVERSAL
INR TREATMENT
<5 No bleeding • Lower or omit the next dose
• Monitor frequently and resume at lower dose when INR therapeutic
Rapid reversal • Hold warfarin
• IV infusion vitamin K 1mg or PO 2mg
≥5-<9 No bleeding • Omit next 1 or 2 doses and monitor frequently OR
• Omit dose and Oral vitamin K ≤5mg (if at risk of bleeding)
• IV Infusion vitamin K 1-2mg or PO 2-5mg (expect INR drop within 24Hr)
≥9 No bleeding • Hold warfarin
• PO vitamin K 2.5-5mg or IV nfusion 1-2mg (expect INR drop within 24-48 Hr)
• IV nfusion Vitamin K 1-10mg (may repeat 6-24Hr PRN)
Any Serious beeding • Hold warfarin
• Vitamin K 10mg slow IV infusion (can be repeated q12Hr, supplement with FFP
or PCC
Life threatening • Hold warfarin
bleeding • Give PCC supplement with vitamin K 10mg slow IV infusion. Repeat PRN.
Dilution for IV Infusion:
 Dilute in 50ml NS or D5,infuse for at least 20mins
OR
 Dilute in 10ml NS or D5. run at max rate 1mg/min
2. HYPOPROTHROMBINAEMIA DUE TO DRUGS (OTHER THAN COUMARIN DERIVATIVES) OR

FACTORS LIMITING ABSORPTION OR SYNTHESIS
2.5-10mg IV/IM, may be increased PRN up to 50mg. May be repeated in 12-48 Hours.
If IM, give undiluted. For IV, refer IV Infusion as above.
STORAGE & Store below 25°C. Protect from light.Use immediately after dilution.
STABILITY
REMARKS  Contains Benzyl Alcohol. Its use should be avoided in children under 2y.o. and not to be used in neonate.
 Phytomenadione 1mg/ml is free of benzyl alcohol and safe in children.
 IM should be avoided due to risk of hematoma formation.
 ACCP recommends IV route in patients with major bleeding secondary to use of vitamin K antagonists.
 Ineffective in hereditary hypoprothrombinaemia
 Rapid IV may cause potentially fatal anaphylaxis.
References:
1. Product Leaftlet – Kisan
2. Hospital Selayang Dilution Protocol 2015. 3rd edition.
3. Drug Information Handbook, Lexciomp 23rd edition. 2014
POTASSIUM CHLORIDE 1GM/10ML INJ

(1 amp of 10ml contains 13.4mmol K +)

ADMINISTRATION IV Infusion:
Peripheral line: Dilute with NS or D5 to a maximum concentration
10mmol/100ml & infused with maximum rate not exceeding 10mmol/hour.
Central line: Dilute with NS or D5 to a maximum concentration
20mmol/100ml & infused with maximum rate not exceeding 40mmol/hour.
Fast correction: 1g Kcl in 100ml NS over 1Hr.

: 2g Kcl in 200ml over 2Hr.
Slow correction: 1g Kcl in 500ml NS or D5 over 2-3h.
HYPOKALAEMIA WITH INSULIN THERAPY IN DKA

 Establish adequate renal function (urine output ~ 50ml/hr)
 If potassium is not <3.0 mmol, only start adding potassium after completing the 1st
1liter of fluid replacement.
Potassium level (mmol/L) Action
<3.0 Hold insulin therapy first, give K+ 40 mmol
3.0-4.0 give K+ 30 mmol
4.0-5.0 give K+ 20 mmol
>5.0 Do not give K+ , check serum K+ every 2 hours.
STORAGE & STABILITY Intact vials: Store below 25°C. Protect from light.
Once diluted: Stable for 24H at RT.
REMARKS Must be diluted.
References:
1. Product Leaftlet
2. Minsistry of Health Malaysia. Dilution Guide for High Alert Medications 2011
PRALIDOXIME 500MG/20ML INJ.

ADMINISTRATION 1. ORGANOPHOSPHATE POISONING

Loading dose: IV /IM 1-2g,
then repeat IV bolus 1-2g after 1 hour and every 10-12 hours
OR
Loading dose IV 30mg/kg,
Maintenance dose IV Infusion 8mg/kg/hr.
Dilution;
Loading dose: To dilute 1-2g in 100ml NS (10-20mg/ml),
run over 30mins.
*In fluid restricted: May give undiluted over ≥5mins.
Maintenance: To dilute 1-2g in 100ml NS (10-20mg/ml),
run at ≤200mg/min.
REMARKS  Administer as soon as possible after exposure (ideally within 36hours)

however pt presenting late (2-6 days) may still benefit.
References:
1. Ministry of Health Malaysia. Critical Care Pharmacy Handbook. Pharmaceutical Service Division 2013
2. Lexicomp 23rd edition 2014
3. Product leaflet
PROCHLORPERAZINE MESYLATE
12.5MG/ML INJ (LARTIL)
ADMINISTRATION IM: 12.5mg Undiluted into outer quadrant of buttocks

(preferred)
Slow IV: Undiluted, max rate 5mg/min
IV Infusion: Dilute in 50-100ml NS or D5,

≤5mg/min over 30mins.
STORAGE & STABILITY Intact vials: Store <30°C. Protect from light.
REMARKS Contra indicated in children <2 years old.
References:
1. Product Leaftlet –Lartil

2. Drug Information Handbook, Lexicomp23rd Edition. 2014
PROCYCLIDINE HCL 10MG/2ML INJ (KEMADRIN)
ADMINISTRATION 1. ACUTE TORSION DYSTONIA AND PAROXYSMAL DYSKINESIAS

Slow IV: 5-10mg. Give undiluted over at least 5 minute.
IM: 5-10mg, repeated after 20mins PRN. Give undiluted.
Max 20mg/day.

Protect from light
REMARKS  IV are frequently effective in 5-10min, and patient may require up to

half an hour to obtain relief.
 Contra indicated in untreated urinary retention, closed angle
glaucoma and gastro instestinal obstruction.
References:
1. Product Leaftlet – Kemadrin

2. FormulariUbat KKM
PROMETHAZINE HCL 50MG/2ML INJ (FRESENIUS)
ADMINISTRATION ALLERGIC REACTION

25mg IM or IV, may be repeated within 2 hrs if required,
max 100mg.
Dilution;
Deep IM: No dilution required. (preferred)
Slow IV: Further dilute 1 amp into 10 - 20mL NS,
and administer over 10 - 15 minutes.
Max rate: 25mg/min

Protect from light
References:

PROPOFOL 1% 200MG/20ML INJ

(FRESOFOL 1% MCT/LCT EMULSION)
ADMINISTRATION 1. INDUCTION OF GENERAL ANAESTHESIA

Dose should be titrated. Give as Slow IV
<55yo : 2-2.5mg/kg (~40mg q10sec until onset)
>55yo or debilitated or ASA III/IV: 1-1.5mg/kg (~20mg q10sec until onset)
2. MAINTENANCE OF GENERAL ANAESTHESIA

<55yo: 0.1-0.2mg/kg/min
>55yo or debilitated or ASA III/IV: 0.05-0.1mg/kg/min
Give as continuous IV Infusion
3. MONITORED ANAESTHESIA CARE SEDATION

Initial dose: Slow IV Infusion 100-150mcg/kg/min for 3-5mins.
Maintenance: 25-75 mcg/kg/min IV infusion
4. SEDATION FOR MECHANICALLY VENTILATED PATIENT

Initial dose: Continuous IV Infusion 5mcg/kg/min for 5min, then titrate in
5-10mcg/kg/min increments every 5-10min until reaches desired level.
Maintenance: 5-50mcg/kg/min or higher.
Dilution: Slow IV Infusion: Can be administered undiluted.

Continuous IV Infusion: Can be administered undiluted OR
if diluted, in NS or D5 to maximum 2mg/ml. (i.e. 200mg in 100ml NS or D5)
STORAGE & STABILITY Intact vial: Store below 25°C. Do not freeze. Protect from light. .
If used directly from vial, use within 12H. If diluted, stable for 6H at RT.
1. In order to reduce pain, Propofol may be mixed with preservative-free Lidocaine injection 1% (mix 20 parts of Propofol with up
REMARKS to 1 part of Lidocaine injection 1%).
2. Propofol can be administered for a maximum period of 7 days
3. Rapid bolus administration should not be used in elderly; caused cardiopulmonary depression
4. The infusion of Fresofol via one infusion system must not exceed 12hours. After 12 hours, to replace infusion system.
5. Contraindicated in patients allergic to soy or peanut, for <3years old and for the indication of SEDATION in <16years old.
References:
1. Product Leaftlet –Fresofol
3. Micromedex
4. . Ministry of Health Malaysia. Critical Care Pharmacy Handbook. Pharmaceutical Service Division 2013.
5.
PROTAMINE SULPHATE 50MG/5ML INJ.
ADMINISTRATION 1. HEPARIN POISONING

The dose is dependent on the amount of heparin to be
neutralized and the time elapsed since it was last given.
Time elapsed Dose of protamine to
neutralize 100IU heparin
<30mins 1mg
30-60mins 0.5-0.75mg
60-120mins 0.375-0.5mg
>120mins 0.25-0.375mg
*Max dose: 50mg
To give IV infusion over 10mins or ≤5mg/min.

Administer undiluted.
STORAGE & STABILITY Protect from light.
References:
1. Product Leaflet
RANITIDINE HCL 50MG/2ML INJ (AMEKET)
ADMINISTRATION IM: Undiluted
Slow IV Bolus: Dilute 1 amp (50mg) with 20ml NS,

Give over at least 2 mins.
Intermittent IV Infusion: Dilute 1 amp (50mg) in

100ml NS or D5 over 15 -120 minutes
OR
infuse at a rate of 25mg/hr for 2 hours.

Protect from light and do not freeze.
Once diluted stable for 48H at RT
References:
1. Product Leaftlet – Ameket

3. Hospital Selayang Dilution Protocol. 2nd edition. 2010
ROCURONIUM 50MG/5ML INJ (ESMERON)
ADMINISTRATION 1. SURGERY PROCEDURES (INTUBATION)

Initial: IV bolus 0.6mg/kg
Maintenance: IV bolus 0.15mg/kg (elderly: 0.075-0.1mg/kg)
OR
IV Infusion: 0.3-0.6mg/kg/hr (elderly: 0.4mg/kg/hr)
2. INTENSIVE CARE
Initial: IV bolus 0.6mg/kg
Maintenance: IV infusion 0.3-0.6mg/kg/hr for first hour then
adjusted according to response.
Dilution;
IV Bolus: Give undiluted
IV infusion: Dilute to a concentration of 0.5-2mg/ml with NS or D5
(i.e. dilute 1 vial (50mg) in 100mL). Run accordingly.
STORAGE & STABILITY Intact Vials: Store at 2-8°C. Protect from light.
Diluted Solution: 24 hours at room temperature. Discard unused
portion
REMARKS  Onset is 1-2mins, and duration of action is 30 mins.

 Monitor peripheral nerve stimulator measuring twitch response, HR, BP.
 Cautions in patients with valvular heart disease, pulmonary disease, hepatic
impairment; ventilation must be supported during neuromuscular blockade.
 Side effects: transient hyper and hypotension.
References:
1. Product Leaftlet – Esmeron
2. Ministry of Health Malaysia. Dilution Guide for High Alert Medication 2011
SALBUTAMOL 0.5MG/ML INJ (YUNG SHIN)

ADMINISTRATION SC or IM: Undiluted.
Slow IV: Dilute 1 ampoule with 10ml of NS and administer

over 3 – 5 minutes.
IV Infusion:
Dilute to a conc. Up to 200mcg/mL in NS or D5
ie: 3mg (6 amp) dilute in 50ml NS or D5
Status asthmaticus: Run 5-20mcg/min
AEBA in paediatrics
IV Bolus: 5-10mcg/kg over 10mins. Give undiluted.
Continous IV Infusion: 1-5mcg/kg/min, give undiluted
*1mcg/kg/min=0.12ml/kg/hr*
STORAGE & STABILITY Intact Vials: Store below 25°C. Protect from light. Diluted
solution: 24 hours at room temperature.
REMARKS  Side effects: Palpitations, Tachycardia ,Tremor , Lactic acidosis ,

Hypokalemia Pulmonary edema , Flushing, Headache , Anxiety
References:
1. Product Leaftlet – Yung Shin
STREPTOKINASE 1,500,000 IU INJ (STREPTASE)
RECONSTITUTION Reconstitute 1 vial with 5ml NS or D5.
FURTHER DILUTION Further dilute 1 vial (1.5MU) with 100ml of NS or D5
ADMINISTRATION 1. ACUTE STEMI

1.5MU infused over 1 hour.
2.PULMONARY EMBOLISM:
250000u over 30min followed by 100000u/H for up to 12-
72H with monitoring of clotting factors.
STORAGE & STABILITY Intact Vials: Store at 2-8°C.

Reconstituted solution:
Stable for 24H at 2-8°C.
Stable for 8Hr at room temperature.
REMARKS 

Not necessarily to be given with anticoagulant
Non fibrin specific and it results in a lower patency rate of the occluded vessel at 60
minutes than fibrin specific agents.
 Despite having a lower risk of intracranial haemorrhage, the reduction in mortality
is less than with fibrin specific agents.
 Antigenic and promotes the production of antibodies. Thus the utilisation of this
agent for reinfarction is less effective if given between 3 days and 1 or even 4 years
after the first administration.
 PCI or fibrin specific agents should then be considered.
References:
1. Product Leaftlet – Streptase
2. Dilution Guide for High Alert Medications. PSD. MOH 2011
SODIUM BICARBONATE 8.4% 10ML INJ

(PHARMANIAGA)
(contains 10mmol Na + and 10mmol HCO3 - )
ADMINISTRATION SC: Dilute 1ml with 4.6ml of WFI
IV Infusion: Administered undiluted over 4-8H with infusion rate

≤1mEq/kg/min (1mEq=1 ml), OR
can be diluted (15mL or 1.5amp in 100mL NS / D5).
1. USUAL PRACTICE FOR DKA PH <6.9

IV 50ml (5amp) of undiluted solution infused over 30 mins.
2. METABOLIC ACIDOSIS
Dose: 1-2mmol/kg IV

Diluted solution : Discard unused portion
REMARKS  Incompatible with acids, acidic salts, many alkaloidal salts, aspirin, norepinephrine
bitartrate, and dopamine HCl.
 Adverse effects: CO2 generation, hyperosmolarity, hypernatremia, hypoglycemia,
intracellular acidosis, myocardial acidosis, and “over- shoot” alkalosis.
References:
1. Product Leaftlet –Pharmaniaga
3. Hospital TuankuAmpuanNajihah Method of Reconstitution & Dilution Protocol for Injections 2013. 3 rd edition.
SUXAMETHONIUM CHLORIDE 100MG/2ML

-Succinylcholine (FRESENIUS)

ADMINISTRATION 1. MUSCLE RELAXANT AS AN ADJUNCT TO ANAESTHESIA

Initial test dose: IV bolus: 5-10mg may be given.
Usual single dose is 0.6mg/kg (0.3-1.1mg/kg).
Max 100mg. Give undiluted over 10-30 seconds.
OR
IM: Deep into deltoid muscle. Give undiluted
Dose: 2.5-4mg/kg, Max: 150mg
2. FOR LONG SURGICAL PROCEDURES

Continous IV infusion: Further dilute with NS or D5 to provide
solution of up to 2mg/ml (ie. 100mg (1 amp) dilute in 50-100ml),
And infuse at rate of 2.5-4mg/minute.
Total maximum dose 500mg/H.
STORAGE & STABILITY Intact Vials: Store at 2-8°C. Do not freeze. Protect from light.
REMARKS  Use IM only when IV access not available.

 Onset is 2-3mins, duration of action is 10-30mins.
 Monitor vital signs, serum potassium and calcium, ventilator status.
 Contraindicated in acute phase of injury following major burns.
 Caution in children, recommended that use on children restricted to emergency
intubation or immediate securing of airway is necessary.
 Side effects: arrythymias, bradycardia, hyper/hypotension, excessive salivation,
rhabdomyolysis, resp depression, hyperkalaemia.
References:
2. Micromedex
3. Drug Information Handbook,Lexicomp 23rd edition. 2014.
5. Micromedex
TENECTEPLASE 10,000UNITS (50MG) INJ (METALYSE)
RECONSTITUTION Use the prefilled syringe of solvent (WFI) 10ml provided in the package.
ADMINISTRATION Indicated for:

*Allergy or prior exposure to streptokinase.
*Anterior STEMI, < 75 years old.
*STEMI with hypotension, < 75 years old. (Delay/unable to do 1° PCI)
Single slow IV bolus: Given over 5-10 seconds.

Body weight Dose Volume to
(kg) administer (ml)
<60 6000 units = 30mg 6
60 – 69 7000 units = 35mg 7
70 – 79 8000 units = 40mg 8
80 – 89 9000 units = 45mg 9
> 90 10000 units = 50mg 10
Max dose: 10,000 units (50mg)
*Aim to be given within 30mins of presentation (door to needle time)
*Must be given with anticoagulants.

Reconstituted solution: 24 hours at 2-8°C or
8 hours at room temperature.
REMARKS  May be given into a pre-existing IV line with NS.

 Dextrose containing line must be flushed with NS before and after administration
 This is a weight-based regimen and thus there is a risk of bleeding if the weight is overestimated.
 In patients over the age of 75, the dose should be reduced by 50%.
 Heparin / Enoxaparin should be given immediately after completion of fibrinolysis for f 48hours.
 Alternative: SC Fondaparinux 2.5mg OD for 8 days / until discharge.
References:
1. Product Leaftlet – Metalyse
2. Ministry of Health Malaysoa. Dilution Guide for High Alert Medication 2011
TERBUTALIN SULPHATE 0.5MG/ML INJ (BALTIC)
ADMINISTRATION 1. ACUTE ASTHMA IN PAEDS: SC 5-10mcg/kg.
Dilution;
SC: Administer undiluted.
Slow IV: Dilute 1amp in 10mL NS or D5 over 3-5 mins.
Continuous IV Infusion: Dilute 1.5mg- 2.5mg
(3-5amp) in 500mL NS or D5 to a
final conc. of 3-5mcg/ml.
OR
Other practice: Dilute 3mg (6amp) in 50mL NS.

Single use only
REMARKS Contains Benzyl alcohol, should be avoided in children

under 2 years old and not to be used in neonates.
References:
1. Product Leaftlet – Baltic

2. Hospital TuankuAmpuanNajihah Method of Reconstitution & Dilution Protocol for Injections 2013. 3rd edition.
TRAMADOL 50MG/ML INJ. (ACUGESIC)
ADMINISTRATION USUAL DOSE

IV/IM: 50-100mg q4-6 hourly. Max 400mg/day
IM: Give undiluted

Slow IV Bolus: Give undiluted over 2-3 minutes
IV Infusion:5-16mg/hr (Max 400mg/day)

To Dilute 50mg (1amp) in 50ml NS.
References:
1. Product Leaftlet –Acugesic

2. Drug information Handbook, Lexicomp 23rd edition. 2014.
TRANEXAMIC ACID 500MG/5ML INJ (TREN)
ADMINISTRATION Slow IV: 0.5-1g TDS. Give undiluted over 5-10 minutes.
IV Infusion: 1g in 500ml NS over 8 hours.

Protect from light
REMARKS Do not inject >1mL/min to avoid hypotension.
References:
3. Product Leaftlet – Tren

4. Drug Information Handbook, Lexicomp2014 23rd edition
5. Hospital SultanahAminah Medication Reconstitution and Dilution Reference 2013
VERAPAMIL HCL 5MG/2ML INJ (VERPAMIL)
ADMINISTRATION 1. SVT
IV bolus 2.5-5mg, give over 2 minutes (3 minutes in elderly).
Repeat 5-10mg every 15-30mins if no response (max 30mg).
Give undiluted.
2. ATRIAL FIBRILLATION (rate control)

IV Bolus 0.075 – 0.15mg/kg (max 10mg) given over 2 minutes, undiluted;
Repeat 5 – 10 mg every 15 to 30 minutes if no response;
Then 0.005mg/kg/min IV infusion.
Dilution for infusion:

10mg (2amp) dilute in 50ml NS or D5. Run over 1 hour.
Max total daily dose: 100mg.

Protect from light
REMARKS  Side effects: Hypotension, bradycardia, precipitation of heart failure

 Should only be given to patients with narrow-complex tachycardias (regular or irregular).
 Avoid in patients with heart failure and pre-excited AF or flutter or rhythms consistent with VT
References:
1. Product Leaftlet –Verpamil
2. ACLS 2010, AHA
3. Management of AF 2014, AHA
4. Drug Information Handbook 23rd edition. 2014, Lexicomp
THYROID STORM
1. INHIBITION OF THYROID HORMONE FORMATION

PROPYLTHIOURACIL
CARBIMAZOLE
LD 600mg stat and 900-1200mg/day PO or NG tube in 4-6
divided doses, OR 60-120mg/day in 3-4 divided doses PO or NG tube
PTU is preferable because has additional effect on inhibiting T4 to T3 conversion.

If pt can't take orally, PTU and carbimazole can be suspended in liquid, and give rectally.
2. INHIBITION OF THYROID HORMONE RELEASE

LUGOL’S IODINE PO 10-20 drops 8hourly.
To give iodine at least 1 hour after initial dose of PTU/ carbimazole to ensure iodine not taken up by gland for
synthesis.
3. GIVE STEROIDS
IV DEXAMETHASONE 2mg 6Hourly. (Refer section for IV dexamethasone for dilution)
4. RECEPTOR BLOCKADE
*IV PROPANOLOL 1-2mg slowly 4-6Hourly OR IV DILTIAZEM if B blocker contra indicated.
References:
1. Sarawak Handbook of Medical Emergencies 3rd edition.
FLUID THERAPY IN DKA
1 Liter 1 Hour  1 pint 30mins

 1 pint 30mins
1 Liter 2 Hours  1 pint 1hour

 1 pint 1hour
1 Liter 4 Hours  1 pint 2hours

 1 pint 2hours

 1 pint 3hours

 1 pint 4hours
Selection of fluids:
Dxt (mmol/L) IVD Insulin infusion dose
> 15 Normal saline 0.1unit/kg/hr
5 - 15 Dextrose 5% alternate 0.05 unit/kg/hr
with NS
<5 D5% or D10% Omit
Reference:

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2016

DILUTION PROTOCOL FOR

Compiled by: Izyan Liyana Rosman (ED Pharmacist)

NEOSTIGMINE METHYLSULPHATE 2.5MG/ML INJ. 46

ADMINISTRATION 1. PARACETAMOL POISONING

2. ACUTE LIVER FAILURE (non PCM related)

STORAGE & STABILITY Intact Vials: Store below 25°C.

REMARKS Anaphylactic reaction with high dose & rapid rate.

PARACETAMOL POISONING IN CHILDREN:

ADENOSINE 6MG/2ML INJ (ADENOCOR)

RECONSTITUTION Not required

Prepare IV Adenosine & 20ml flush in 2 separate syringes

Attach both syringes to IV injection port closest to patient.

Push IV adenosine as quickly as possible (in 1-3 seconds)

While maintaining pressure on IV Adenosine plunger, push

1. ACLS 2010, AHA

ADRENALINE SOLUTION 1MG/ML INJ (CCM)

RECONSTITUTION Not required

ADMINISTRATION 1. CARDIAC ARREST (DURING CPR)

AMINOPHYLLINE SOL BP 250 MG/10ML INJ (DBL)

RECONSTITUTION Not required

ADMINISTRATION Loading dose (LD): 250mg (6mg/kg) dilute in 100ml of NS and

Maintenance dose (MD):

Common practice for MD:

STORAGE & STABILITY Intact Vials: Store below 25°C.

REMARKS 1. Contraindication: Uncontrolled arrhythmias, hyperthyroidism.

AMIODARONE 150MG/3ML INJ (CORDARON)

ADMINISTRATION 1. VF/VT CARDIAC ARREST

2. LIFE THREATENING ARRHYTHMIAS (*max cumulative dose: 2.2g/24hr)

STORAGE & Intact Vials: Store below 25°C.

RECONSTITUTION Reconstitute 1 vial with 10ml WFI or with the solution

FURTHER DILUTION Dilute in 5-10ml/kg of NS or D5 (ie 250-500ml for adult)

ADMINISTRATION Skin test:

IV Infusion: Can run 1-2ml/min over 10-15min, may

ANTIVENENE SERUM SNAKE HEMATO POLYVALENT INJ

RECONSTITUTION Reconstitute 1 vial with provided 1ml of 5% sodium

FURTHER DILUTION See administration.

ADMINISTRATION IM: Further dilute in 2ml of provided NS to a final

Slow IV: Further dilute with 5ml of provided NS to a

Usual dose: 2.4mg/kg at 0, 12, and 24Hours, then

STORAGE & STABILITY Intact vial: Store below 25°C

1. Product Leaftlet - Artesun

ATRACURIUM BESYLATE 50MG/5ML INJ (ATRALEX)

RECONSTITUTION Not required

ADMINISTRATION 1. ADJUNCT TO ANAESTHESIA (for surgery/ intubation)

ATROPINE SULPHATE 1MG/1ML INJ (ACIPAN)

RECONSTITUTION Not required

3. MUSCLE RELAXANT ANTAGONIST

STORAGE & STABILITY Intact Vials: Store below 25°C

CALCIUM GLUCONATE 10% INJ.

RECONSTITUTION Not required

FURTHER DILUTION See administration

STORAGE & STABILITY Intact Vials: Store at RT.

1. Product Leaftlet-B Braun

CHARCOAL, ACTIVATED 50GM

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

ADMINISTRATION Adult: 25-100gm

REMARKS  Most effective given within 1 hour.

CHLORPHENIRAMINE MALEATE 10MG/ML INJ

RECONSTITUTION Not required

FURTHER DILUTION Not required

ADMINISTRATION IM and SC: 10-20mg, given undiluted