2020 Ed Dilution Protocol

DILUTION
PROTOCOL FOR EMERGENCY

DEPARTMENT

HOSPITAL TENGKU AMPUAN AFZAN
2ND EDITION
| ED HTAA DILUTION PROTOCOL 2020

This dilution protocol is a general guide for the use of drugs in Emergency & Trauma
department, HTAA. It was prepared to facilitate doctors, nurses & medical assistants in
general dosing recommendations, preparing the dilutions & the administration of
frequently used medications in Emergency & Trauma department, HTAA.
Each drug is listed with information on the most commonly used dosing, dilution &
administration based on few references as stated on the bottom page of each drug
discussed.
You are also advised to check the most current product information provided by the
manufacturer of each drug to be administered or consult pharmacist for latest info if
there is change of brand/product later than the date this guideline was being prepared.
If, after reviewing the information in this protocol you still have any questions about the
order placed before you, please clarify it with your senior physician, consult your
pharmacist or seek advice from your supervisor.
Compiled by
Shamsiah binti Salim

Pegawai Farmasi Wad Kecemasan,
Jabatan Farmasi,
Hospital Tengku Ampuan Afzan.
Reviewers (Alphabetical order)
Dr Badrul Hisham B. Md Supian

Pakar Perubatan Kecemasan & Trauma,
Dr Norizan Bt. Mustafa

Dr Yip Yat Keong

Dr Zainal Abidin B. Mohamed @ Ismail

Ketua Perkhidmatan Jab. Kecemasan & Trauma Negeri Pahang.
Shamsiah Salim, Ward Pharmacist, Updated July 2020
Contents
DRUGS PAGE
Acetylcysteine 2g/10ml 4-5
Adrenaline 1mg/ml 6
Adenosine 6mg/2ml 7
Alteplase 50mg/ml 8-9
Amiodarone 150mg/2ml 10
Aminophylline 250mg/10ml 11
Atropine 1mg/ml 12
Calcium Gluconate 10% 13
Charcoal Activated 50g (Powder) 14
Dexamethasone 8mg/2ml 15
Diazepam 10mg/2ml 16
Digoxin 0.5mg/2ml 17
Dobutamine 250mg/20ml 18
Dopamine 200mg/5ml 19
Fentanyl 100mcg/2ml 20
Flumazenil 0.5mg/5ml 21
Furosemide 20mg/2ml 22
Fuller’s Erath 60g (Powder) 23
Glyceryl Trinitrate 50mg/10ml 24
Heparin Inj 25000 unit/5ml 25
Hydralazine 20mg/ml 26
Insulin Inj (Actrapid) 27
Isosorbide Dinitrate 10mg/10ml 28
Ketamine 200mg/20ml 29
Labetalol 25mg/5ml 30
Lignocaine 10% 500mg/5ml 31
Lytic Cocktail Regime 32
Magnesium Sulphate 2.47g/5ml 33
Midazolam 5mg/ml 34-35
Morphine 10mg/ml 36
Naloxone Hcl 0.4mg/ml 37-38
Noradrenaline 4mg/4ml 39
Potassium Chloride 1g/10ml 40
Potassium Dihydrogen Phosphate 1.3g/10ml 41
Phenytoin 250mg/5ml 42
Phenobarbitone 200mg/ml 43
Proton Pump Inhibitors 44
Salbutamol 0.5mg/ml 45
Sodium Valproate 400mg/vial 46
Sodium Bicarbonate 8.4% 10ml 47-48
Streptokinase 1.5MU/vial 49

3

Tenecteplase 10,000 u (50mg) / vial 50
Tramadol 50mg/ml 51
Verapamil 5mg/ml 52
Cyanide Antidote 53
Sodium Nitrite 300mg/10ml 54 -55
Sodium Thiosulphate 12.5g/50ml 56-57
Hydroxocobalamin 5g/vial 58-59
APPENDIX
Medications for Procedural Sedation & Analgesia 60-62
Sedative Agents in Mechanically Ventilated Patients 63-64
Analgesic Agents in Mechanically Ventilated Patients 65
Dopamine Infusion Chart (Single Strength) 66
Dopamine Infusion Chart (Double Strength) 67
Dobutamine Infusion Chart (Single Strength) 68
Dobutamine Infusion Chart (Double Strength) 69
Noradrenaline Infusion Chart (Single Strength) 70
Noradrenaline Infusion Chart (Double Strength) 71
ACETYLCYSTEINE 2g/10ml
(i) Paracetamol Poisoning regimen:

IV NAC: (a) 150mg/kg in 200ml D5% over 15 mins, then
(b) 50mg/kg in 500ml D5% over 4 hours, then
(c) 100mg/kg in 1000ml D5% over 16 hours
Oral NAC: (a) 140mg/kg by mouth or nasogastric tube diluted to 5% solution,

then (b) 70mg/kg by mouth q4h x 17 doses
PARACETAMOL POISONING IN CHILDREN:

Refer to adult dosing, however fluid volume should be reduce as below:
Dilution Volume of D5%

Body Weight Loading Dose: 2nd Dose: 3rd Dose:
(Kg) 150mg/kg over 15 50mg/kg Over 4 100mg/kg over 16
mins hours (in 7ml/kg hours (in 14ml/kg
(in 3ml/kg D5%) D5%) D5%)
10 30 70 140
15 45 105 210
20 60 140 280
25 75 175 350
30 90 210 420
(ii) Acute Liver Failure (non acetaminophen related) regimen: (Gastro)
IV NAC: (a) 150mg/kg in 200ml D5% over 1 hour, then

(b) 12.5mg/kg/hour in 500ml D5% over 4 hours, then
(c) 6.25mg/kg/hour in 1000ml D5% over 67 hours
Note for Dose & Administration:

1. For (b) & (c), remember to multiply the dose to the number of HOURS to get
the total dose for 4 hours and 67 hours respectively.
2. For (c), due to the stability of the diluted NAC to be 24 hours only, the
administration of the total dose in 1000ml over 67 hours is divided into 4:4:2 ratio
as follows:
(i) 4 parts of 10 of total dose in 400ml over 24 hrs
(ii) 4 parts of 10 of total dose in 400ml over next 24 hrs total 67 hours
(iii) 2 parts of 10 of total dose in 200ml over remaining 19 hrs
(iii) CT Scan regimen:
IV NAC: (a) 2 hours before scan: 150mg/kg in 500ml D5% over 2 hours, then
(b) 4-6 hours after scan: 50mg/kg in 500ml D5% over 2 hours
Oral NAC: (a) 1 day before scan: 600-1200mg BD, then

(b) On the day of scan: 600-1200mg BD, then
(c) 1 day after scan: 600-1200mg BD
*normally prescribed as T. NAC 600mg or 1200mg BD x3/7*
References:
1. Paracetamol poisoning in adults: Treatment, Uptodate, Feb 2020
2. Acute Liver Failure in adults: Management and prognosis, Uptodate, April 2020
3. Julie Polson & William M. Lee. AASLD: The management of acute liver failure.
Hepatology, May 2005.
4. William M. Lee et al. Intravenous N-Acetylcysteine improves transplant-free
survival in early stage nonacetaminophen acute liver failure. Gastroenterology
2009.
5. Paediatric Protocol for Malaysian Hospitals, 4th Edition 2019.
Adrenaline 1MG/ML (1ml=1mg or 1:1000) inj

1. Asystole/pulseless cardiac arrest (During CPR) (1:1000)
§ Intravenous / Intraosseous: 1mg every 3-5 mins followed by 20ml flush
§ Endotracheal: 2 – 2.5mg dilute in 5 – 10ml NS / sterile water every 3 – 5 mins
2. Bradycardia (symptomatic, unresponsive to atropine or pacing)

§ IV continuous infusion 0.1 – 0.5 mcg/kg/min.
3. Asthma, acute severe, unresponsive to inhaled beta-agonist:

§ IM, SC (1:1000): 0.3 – 0.5 mg every 20 minutes (3 doses)
4. Hypersensitivity reaction (anaphylaxis):

§ Endotracheal (ET)
§ 2 – 2.5 mg dilute in 5 – 10ml NS/sterile water every 3-5 minutes
§ Intramuscular, IM (1: 1000)

§ 0.2 – 0.5mg or 0.01mg/kg (max 0.5mg)
§ Repeat at 5 – 15 mins interval if needed to max of 3 doses.
§ Intravenous, IV (1: 10 000)

§ In patients unresponsive to repeated doses of IM and fluid
§ Slow IV Bolus: 0.05 – 0.1 mg give slowly over 5 to 10 minutes
§ Continuous Infusion: 1 – 15 mcg/min
5. Hypotension/shock:
§ Anaphylactic Shock: 1 – 15 mcg/min
§ Cardiogenic Shock: 0.01 – 0.5 mcg/kg/min or 1 – 35mcg/min
§ Septic Shock: 0.01– 2 mcg/kg/min or 1 – 140mcg/min
Dilution for Continuous Infusion:

3mg (3amp) + NS = 50ml àStrength: 60mcg/ml
Infusion rate: According to dose ordered

(e.g: 1mcg/min = 1ml/hr)
(e.g: 2mcg/min = 2ml/hr)
Precaution/ Remarks:
§ 1:10 0000 = 0.1mg/ml, 1:1 000 = 1mg/ml
§ Deep IM in anterolateral aspect in the middle third of thigh is preferred in setting of
anaphylaxis.
§ Rapid IV bolus administration is associated with cardiac arrythmias, only use if
absolutely necessary.
§ Inotropic actions predominates at lower doses, while vasoconstrictive actions
predominates at higher doses.
Reference:
1. Drug Info, Lexicomp, Uptodate 2020.

7

Adenosine 6MG/2ML Inj
Indication: Stable Narrow complex SVT
Dose:
Initial dose: 6mg 12mg (1-2 vial)
(If not revert after in1-2 minutes of initial dose)
Second dose: 12mg (2 vials)
(If still not revert in 1-2 minutes after 2nd dose)
Third dose: 12mg (2 vials)
Administration:
Place patient in mild reverse Trendelenburgh position
Prepare IV Adenosine & 20ml flush in 2 separate syringe
Attached both syringes to IV injection port closest to patient
Push IV adenosine as quickly as possible (in 1-3 seconds)
While maintaining pressure on IV Adenosine plunger, push 20ml NS flush as rapidly

as possible after IV Adenosine.
Elevate arm (above heart) for 10-20 seconds.
Precautions/Remarks:
• Should be given in large bore line (i.e: brachial region)
• Prior to administration, remind patient about the side effects, chest
discomfort, dyspnea, flushing. Give reassurance that effect is brief.
• Perform continuous ECG monitoring during administration.
• Reduce initial dose to 3mg if patient on Dipyridamole, Carbamazepine,
heart transplant or if given by central IV access.
• Less effective in patients taking theophylline, caffeine (might need larger
dose of 18mg)
• Contraindicated in patients with asthma, poison/drug-induce tachycardia,
or 2nd or 3rd degree heart block.
• If conversion attempts fail, initiate rate control with either intravenous CCB
or beta-blocker.
Reference:
1. ACLS 2015, American Heart Association.
2. Drug Info, Lexicomp, uptodate 2020.
3. Dilution Guide for High Alert Medication, Pharmaceutical Service Division, MOH 2011

8

Alteplase 50 MG/ML Inj (ACTILYSE)
Indication:
1. Thrombolytic treatment in acute ischemic stroke

§ Treatment must be started as early as possible (within 4.5 hours after
onset of stroke)
§ Treatment effect is time-dependent; earlier treatment increases
probability of favorable outcome.
2. Thrombolytic treatment in acute myocardial infarction

§ 90 minutes (accelerated) dose regimen; treatment that can be
started within 6 hours after symptoms onset.
§ 3 hours dose regimen; treatment that can be started between 6-12 hrs
after symptoms onset.
3. Thrombolytic treatment in acute massive pulmonary embolism with

hemodynamic instability.
§ Diagnosis confirmed with pulmonary angiography or lung scanning.
Dose:
1. Acute Ischemic Stroke

§ 0.9 mg/kg (maximum 90 mg) infused over 1 hour.
§ 10% of total dose administer as initial bolus dose, and then infused the
balance of 90% over 1 hour.
Total dose Total Volume Volume to be administer

Weight (mg) (ml) (Conc: 1 mg/ml Alteplase)
(kg)
10% Bolus dose 90% remaining dose over
[0.9 mg/kg] 1 hr
50 45 45 4.5 ml 40.5 ml
55 49.5 49.5 5 ml 44.5 ml
60 54 54 5.4 ml 48.6 ml
65 58.5 58.5 5.9 ml 52.6 ml
70 63 63 6.3 ml 56.7 ml
75 67.5 67.5 6.8 ml 60.7 ml
80 72 72 7.2 ml 64.8 ml
85 76.5 76.5 7.7 ml 68.8 ml
90 81 81 8.1 ml 72.9 ml
95 85.5 85.5 8.6 ml 76.9 ml
100 90 90 9 ml 81 ml
* Max dose: 90 mg
2. Acute Myocardial Infarction

§ 90 mins accelerated dose regimen: 15 mg as bolus, 50 mg as infusion
over 60 mins, & 35 mg as infusion over 30 mins.
§ 3 hrs dose regimen: 10 mg as bolus, 50 mg as infusion over 1 hour,
then 40 mg over 2 hours.
3. Pulmonary Embolism
§ 100 mg over 2 hours
§ 10 mg as bolus, 90 mg as infusion over 2 hours.
§ For body weight < 65 kg: total dose should not exceed 1.5 mg/kg
Dilution & Administration:
§ 50 mg Alteplase, diluted with 50 ml sterile water for injection

§ Final concentration: 1 mg/ml
Storage & Stability:

§ Reconstituted solution
Precautions / Special Warning:

§ Arrythmias: Coronary thrombolysis may result in reperfusion arrythmia
§ Bleeding, doses > 150mg associated with significantly increased risk of
intracranial hemorrhage.
References:
1. Product Leaftlet ACTYLYSE, Boehringer Ingelheim 2020
2. Drug Information Handbook, Lexicomp

10

Amiodarone 150MG/3ML Inj

1) VF/VT Cardiac Arrest
§ First dose: 300mg IV push
§ Second dose (if needed): 150mg IV push
§ Upon ROSC: IV 1mg/min for 6 hours, then 0.5mg/min for 18hrs.
2) Life-threatening Arrhythmias
(Maximum cumulative dose: 2.2 g over 24 hours)
ACLS 2010, AHA Guideline

Initial dose: 150mg over 15mins
Dilute 150mg (1amp) in 50ml D5% run 200ml/Hr
Then; 300mg over 6 hours

Dilute 300mg (2amp) in 100ml D5% run 17ml/hr
Then; 600mg over 18 hours

OR
British Resuscitation Guideline, 2010

Initial dose: 300mg over 1 hour
Then; 900mg over 23hours

Precautions:
• Administer via large peripheral vein or central vein whenever possible.
• Attached cardiac monitoring.
• Rapid infusion may lead to hypotension.
• Terminal elimination is extremely long (half life lasts up to 40 days)
Reference:
1. ACLS 2015, AHA
2. British Resuscitation Guidelines 2010.
3. Drug Info, Lexicomp, Uptodate 2020

11

Aminophylline 250MG/10ML Inj
Indication: Prevention & treatment of bronchospasm.
Loading dose: (6mg/kg); 250mg (1amp) + NS = 100ml run over 1hour

Maintenance dose: Non-smoker: 0.5mg/kg/hr
• Smoker: 0.8mg/kg/hr
• Elderly: 0.3mg/kg/hr
* Reduce dose by 50% in heart failure & hepatic problem (prolonged half life)
Dilution for Maintenance dose:

250mg (1amp) + NS/D5%= 50ml àStrength: 5mg/ml
Infusion rate: Calculate according to dose & body weight
Aminophylline Dose
Weight (kg) ( ml/hour)
Non-Smoker Smoker Elderly
(0.5mg/kg/hr) (0.8mg/kg/hr) (0.3mg/kg/hr)
60 6 ml/hr 9.6 ml/hr 3.6 ml/hr
70 7 ml/hr 11.2 ml/hr 4.2 ml/hr
80 8 ml/hr 12.8 ml/hr 4.8 ml/hr
90 9 ml/hr 14.4 ml/hr 5.4 ml/hr
100 10 ml/hr 16.0 ml/hr 6.0 ml/hr
110 11 ml/hr 17.6 ml/hr 6.6 ml/hr
120 12 ml/hr 19.2 ml/hr 7.2 ml/hr
130 13 ml/hr 20.8 ml/hr 7.8 ml/hr
OR
250mg (1amp) + NS/D5%= 500ml Strength: 0.5mg/ml
à
Infusion rate: Run over 8 hours *(Dose administer = 31.25mg/hour;
if BW 60kg dose given is 0.52mg/kg/hr)
Precautions
1. Contraindication: Uncontrolled arrhythmias, hyperthyroidism.
2. Toxicity: Life threatening ventricular arrhythmias, seizure.
3. Early signs of toxicity: Nausea, vomiting, abdominal pain, diarrhea, insomnia,
irritability, headache, palpitations, confusion, agitated or manic behavior.
Remarks:
1. GOLD 2014 à Weak bronchodilator, 2nd line therapy in AECOAD (use when
insufficient response to short acting bronchodilators)
2. GOLD 2019 à Not recommended due to increased side effects profiles
3. GINA 2019 à No role in asthma, poor efficacy & safety profile. Greater effectiveness
& safety of SABA.
4. Narrow therapeutic index. Target therapeutic range: 10-20mcg/ml
5. Monitor level 12 - 24hours after loading dose
6. The infusion rate for maintenance dose is only for reference. Please follow TDM
suggestion for further dosing.
Reference:
1. GOLD Report 2019

12

Atropine Sulphate 1MG/ML Inj
Indication & Dose:
1. Bradycardia
Adult: IV 0.5mg every 3-5 mins. Not to exceed total of 3mg or 0.04mg/kg.
*Dose <0.5mg result in paradoxical bradycardia
Child: IV 0.02mg/kg every 3-5 mins (Max single dose is 0.5mg).

Not to exceed total dose of 1mg.
*Dose <0.1mg result in paradoxical bradycardia
Reconstitution: Not required

Further dilution: Not required
Administration: Administer undiluted by rapid IV injection (slow injection
may result on paradoxical bradycardia).
2. Organophosphate Poisoning
Loading: IV Bolus, 1-5mg q3-5mins until fully atropinised.
Double the dose if previous dose does not induce atropinisation.
Administration: Give undiluted over 15-30sec.

Maintenance: IV Infusion,
Give undiluted, run 0.5-1mg/hr OR 10-20% of total LD/hr.
3. Muscle Relaxant Antagonist

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

Intact Vials: Store below 25°C Protect from light.
References:
1. ACLS 2015, AHA.
2. Product Leaftlet – Acipan
3. Ministry of Health Malaysia. Critical Care Pharmacy Handbook. Pharmaceutical
Service Division 2013.
4. Drug Information, Lexicomp, Uptodate 2020.

13

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

Preparation: 1 vial 10% (1g in10 ml) = 2.3 mmol calcium ion.
Dose:
Hypocalcemia:
§ Mild: 1-2 g over 2 hours
§ Moderate to severe: 4g over 4 hours
§ Severe symptomatic (seizure, tetany): 1-2 g over 10 minutes, repeat every
60 minutes until symptoms resolve
Beta-Blocker or Calcium Channel Blocker Overdose

§ Initial: 60mg/kg over 5 – 10 minutes (max 3 – 6 g/dose)
§ May repeat every 10-20 minutes for 3-4 additional doses
§ OR initiate continuous infusion of 60 – 120 mg/kg/hr titrated to improve
hemodynamic response.
Cardiac Arrest or Cardiotoxicity in the presence of Hyperkalemia, Hypocalcemia

& Hypermagnesemia:
§ IV 1.5 – 3 g over 2 – 5 minutes.
§ Routine use in cardiac arrest is not recommended.
Administration: Undiluted
Rate: not exceed 200mg/min
Stability:
§ Used immediately and to be completed within 24 hours.
§ Discard unused portion.
Precautions:
§ Vesicant, ensure proper needle or catheter placement prior to and during IV
infusion.
§ Do not inject IM or SC since severe necrosis and sloughing may occur.
§ Avoid extravasation, may result in severe tissue necrosis and tissue sloughing.
§ If extravasation occurs stop infusion immediately and disconnect (leave
needle/canula in place), gently aspirate extravasated solution (do NOT flush the
line).
Reference:
1. Drug Formulary, MOH, 2019.
2. Drug Info, Lexicomp, Uptodate 2020.

14

Charcoal Activated 50g (Powder)

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

Adult: 25-100gm
Child 1-12yo: 25-50gm OR 0.5-1g/kg
Child < 1yo: 0.5-1g/kg
§ Repeat dose if necessary.

§ Most effective given within 1 hour.
Remarks :
• Contraindicated in unprotected airway, non functioning GI tract and

uncontrolled vomiting, ingestion of most hydrocarbons, intestinal
obstruction, pt at risk of GI perforation or hemorrhage.
• 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. Tintinalli’s Emergency Medicine, 7th Edition.
2. Ministry of Health Malaysia. Critical Care Pharmacy Handbook.
Pharmaceutical Service Division 2013.

15

Dexamethasone 8MG/2ML Inj
Further Dilution: See Indication & Dose
Indication & Dose:
1. Meningitis
IV 10mg 6hourly for up to 4 days.
2. Cerebral Oedema
IV 10mg stat, then IV/IM 4mg
3. Viral Croup in Paediatrics

Dose IV/IM: 0.3-0.6mg/kg
IM: Administer undiluted
Slow IV: Administer undiluted solution slowly over 3-5 minutes.
IV Infusion: Further dilute in 50-100ml NS or D5, run over 15-30mins.
Remarks
• In shock use only IV route
• In meningitis, to give dexamethasone 15-20mins before or during the first
dose of antibiotics.
Storage & Stability

Intact Vials: Store at 15-25°C. Protect from light. Diluted solution: 24hours at
room temperature.
References:
1. Product Leaftlet – Penatone
2. HUKM Drug Formulary 2010, 5th Edition
3. Ministry of Health Malaysia. Paediatric Protocol 4th edition. 2019.
4. Drug Information Lexicomp, Uptodate 2020
5. Ministry of Health Malaysia. National Antibiotic Guideline 2nd edition. 2014.
Pharmaceutical Services Division

16

Diazepam 10MG/2ML inj

Indication: Status Epilepticus
Loading dose:
Intravenous (IV): 0.15 mg/kg IV up to 10 mg per dose,
May repeat in 5 min (Max: 30mg)
Per Rectal (PR):

2–5 years: 0.5 mg/kg
6–11 years: 0.3 mg/kg
> 12 years: 0.2 mg/kg
(Max: 20mg in children)
Dilution: Undiluted
Given as slow IV bolus over 1-2 minutes (rate ≤ 5mg/min)
Anti-convulsant for Eclampsia (severe PE)

• Dose: 10mg IV Bolus, followed by 40mg in D5% slow infusion
• Given only when magnesium sulphate is contraindicated or not available.
Precautions/remarks:
• Rapid redistribution (short duration), active metabolite
• IV contains propylene glycol
• Time to effect: 1-3 minutes
• May consider IM administration into deep muscle, but absorption is slow &
erratic
• Avoid dilution, may precipitate diazepam and adsorb onto IV bag and
tubing.
• Contains Benzyl alcohol, should be avoided in children under 2y.o. &
neonates.
Serious Adverse effects:

• Hypotension
• Respiratory depression
Reference:
1. Brophy G.M., et al; Guidelines for the Evaluation and Management of Status Epilepticus,
Neurocrit Care, April 2012.
2. Product leaflet, Sanofi
4. CPG Hypertension, 2018 MOH.

17

Inj Digoxin 0.5MG/2ML

Indication:
• Stable, narrow-complex tachycardias if rhythm remains uncontrolled or

unconverted by adenosine or vagal maneuvers or if SVT is recurrent.
• Control ventricular rate in patients with atrial fibrillation or atrial flutter.
Dose:
SVT/AF: 0.25 - 0.5mg IV
May repeat dosing of 0.25mg every 6 hours
To a max of 1.5mg over 24hours.
Dilution: 0.5mg (1 amp) + NS/D5% = 50 ml over 30minutes.
Infusion rate: 100ml/hr
Stability: 48 hours
Precautions:
• Slow onset of action and relative low potency renders it less useful for
treatment of acute arrhythmias
• Onset of actions >1hour & peak effect in 6 hours.
• Arrhythmia may be precipitated by Digoxin toxicity. Monitoring of heart rate
is necessary before, during and after drug administration.
• Narrow therapeutic window, monitor level (Target: 0.8 – 2.5 ng/ml)
• Vesicant, ensure proper needle or catheter placement to avoid
extravasation.
• If extravasation occur, stop administration immediately, leave needed/
cannula in place and slowly aspirate. Do NOT flush the line. Remove
needed/cannula and elevate extremity.
Reference:
1. ACLS 2015, AHA
3. Dilution Guide for High Alert Medication, Pharmaceutical Service Division, MOH
2011

18

Dobutamine 250MG/20ML Inj

Indication:
Hypotension
Decompensated Heart Failure (short term infusion for symptomatic benefit)
Dose: 1 – 20mcg/kg/min
Dilution:
Single Strength 250mg (1amp) + NS = 50ml àStrength: 5mg/ml
Double Strength 500mg (2amp) + NS = 50ml àStrength: 10mg/ml
Infusion Rate: Refer infusion rate chart
Stability: 24 hours
• Must be diluted before use.
• Do not mix with sodium bicarbonate.
• Do not administer in the same IV line as Heparin, hydrocortisone,
Cefazolin,penicillin.
Precautions:
• May cause tachyarrhythmias.
• Decrease dose gradually before discontinuation.
• Administer into a large vein / central line.
Reference:
2. Dilution Guide for High Alert Medication, Pharmaceutical Service Division,
MOH 2011

19

Dopamine 200MG/5ML Inj

Indication: Non-Hypovolemic Hypotension
Dose:
Increase urine output: 1 - 3mcg/kg/min
Inotropic & heart rate effect:3 – 10mcg/kg/min
Vasoconstrictive effect: 10 - 20mcg/kg/min
Dilution:
Single Strength: 200mg (1amp) + NS = 50ml. àStrength: 4mg/ml
Double Strength: 400mg (2amp) + NS = 50ml àStrength: 8mg/ml
Stability: 24 hours
Must be diluted before use.
Do not mix with sodium bicarbonate / strong alkaline solution.
Precautions:
• Correct hypovolemia with volume replacement before initiating Dopamine.
• Use with caution in cardiogenic shock with accompanying CHF.
• May cause tachyarrhythmia’s, excessive vasoconstriction.
• Administer into a large vein / central line.
Reference:
2. Dilution Guide for High Alert Medication, Pharmaceutical Service Division, MOH
2011

20

Fentanyl 100MCG/2ML Inj

Dose & Indication:
1. Minor procedures / analgesia:

• 0.5 – 2mcg/kg/dose (3 mins before procedure, may repeat every 1-2
hours)
2. Premedications (RSI):
• 0.3 – 0.5 mcg/kg
3. Analgesia (Critically ill patients)

• Initial Dose: 0.35 – 1.5mcg/kg every 30-60mins as needed
• Maintenance dose: 0.7 – 10 mcg/kg/hr
Dilution:
1. For IV Bolus:
• 100mcg/ml (1amp) + 10ml NS
• Rate: Slow bolus over 3-5 mins
2. For IV Infusion:
• 200mcg (2amps) + NS/D5% = 20ml à Strength : 10mcg/ml
• Rate: Start at 2ml/hr titrate as needed to max dose of 10mcg/kg/hr
• E.g: maximum infusion rate of 60ml/hr for patient with BW of 60kg
Stability: Use within 24 hours
• Muscle and chest wall rigidity may occur with rapid IV administration.
• Fentanyl is 50-100 times as potent as morphine (10mg IM Morphine =
0.1-0.2mg IM Fentanyl)
• Has less hypotensive effects than Morphine.
• May cause muscle rigidity with high doses.
• Onset of action 2-5 mins, with duration of 0.5 – 1 hour.

• Hypotension
Reference:
1. Drug Info, Lexicomp Uptodate 2020.
2. Critical Care Pharmacy Handbook, Pharmaceutical Service Division, MOH

21

Flumazenil 0.5MG/5ML Inj
Reconstitution: Not Required
Further Dilution: See Dose & Administration
Dose & Administration
1. Reversal of Benzodiazepine
• IV Bolus:
o 0.2mg, undiluted over 15 seconds
o If adequate consciousness not obtained in 45seconds, give 0.2mg
every 1min (Max dose: 1mg)
• Occurrence of re-sedation:
o 1mg at 20mins interval (Max: 3mg in any 1 hour)
2. Benzodiazepine Overdose
• IV Bolus
o 0.2mg, undiluted over 30 seconds
o If adequate consciousness is not obtained in 30 seconds, give
another 0.3mg over 30 seconds
o If needed, give further doses of 0.5mg over 30 seconds at 1 min
intervals to a max of 3mg.
o Patient with only partial respond to 3mg, may require slow
additional titration to a total dose of 5mg.
o If no response 5mins after receiving total dose of 5mg, overdose is
unlikely to be Benzodiazepine & further treatment with Flumazenil
will not help.
• Alternative to repeated bolus:

o IV infusion 0.1-0.4 mg/hr
o Dilute 5mg in 50ml NS/D5% à Strength 0.1mg/ml
o Rate: 1-4ml/hr
• Occurrence of re-sedation: 1mg at 20mins interval (Max: 3mg in any 1

hour)
Storage & Stability

• Administer through a freely running IV infusion into large vein
• Stable for 24hours if drawn into a syringe or mixed with solutions
References:
1. Micromedex Drug Reference Essentials
2. Drug Information Lexicomp, Uptodate 2020.

22

Furosemide 20MG/2ml Inj
Indication: Diuretics
Acute heart failure
Dose:
IV Slow Bolus: 40 - 100mg IV give slowly over 1-2 minutes
IV Infusion: 5 – 20mg/hr
*better than intermittent very high bolus doses
Dilution: Undiluted; 20mg of 2ml (1amp) àStrength: 10mg/ml

(e.g: 1 mg/hr = 0.1 ml/hr)
(e.g: 2 mg/hr = 0.2 ml/hr)
(e.g: 3 mg/hr = 0.3 ml/hr)
(e.g: 4 mg/hr = 0.4 ml/hr)
(e.g: 5 mg/hr = 0.5 ml/hr)
(e.g: 10 mg/hr = 1ml/hr)
• iV administration with rate >4mg/mi increases ther 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)
Reference:
1. Heart Failure CPG 2019, MOH
2. Heart Failure Management, ACC/AHA/HFSA Focus Update 2017

23

Fuller’s Earth 60g (Powder)
Indication: Adsorbent in pesticides poisoning
Dose:
Paraquat poisoning
Adult: 100 – 150g every 2- 4 hours x 3 doses
Child <12yo: 1-2 g/kg
Administration:
100g of Fuller’s Earth is mixed with 200ml water (30% suspension)
Remarks:
• Repeat dose until Fuller’s Earth is seen in stool (normally between 4-6 hours)
• Monitor calcium as Fuller’s Earth can cause hypercalcemia & fecaliths
• Can be given via Ryle’s tube
References:
• Drug Formulary, Ministry of Health Malaysia (Blue Book), Pharmaceutical service
division, Bil 3/2019.

24

GlycerylTrinitrate 50MG/10ML Inj
Indication: Hypertensive Emergencies
Prophylaxis or treatment of angina
Acute decompensated left ventricular failure
Dose:
• Start at 5 mcg/minute;
• Increase by 5 mcg/minute every 3–5 minutes
• If no response at 20mcg/min; then increase by 10 mcg/minute
• Max: 200 mcg/minute
Dilution: 15mg (3ml) + NS/D5% = 50 ml àStrength: 300mcg/ml
Infusion Rate: According to dose ordered

(e.g: 5 mcg/min = 1 ml/hr)
Stability: 40 – 48hours
• Preferred in acute coronary syndrome and acute pulmonary edema.
• Avoid in patients with benign intracranial hypertension / elevated
intracranial pressure.
• Onset of action 2-5 minutes
• Duration of action 3-5 minutes
Reference:
1. Hypertension CPG 2018, MOH
2. Drug Info, Lexicomp, uptodate 2020.

25

Heparin Inj
Available preparations:
1. IV Heparin 5, 000 units of 5ml/vial à Strength: 1000unit/ml (Red)
2. IV Heparin 25,000 units of 5ml/vial à Strength: 5000 unit/ml (Blue)
Dose:
STEMI/ • IV bolus: 60 unit/kg (Max: 4000 unit)
NSTEMI • IV infusion: 12 unit/kg/hr (Max: 1000 unit/hr)
• IV Bolus: 80 unit/kg (Max 5000 unit)

VTE Treatment
• IV Infusion: 18u/kg/hr (Max 1300 unit/hr)
Dilution for Infusion

25,000 unit (Blue - 1 vial) + NS = 50 ml à Strength: 500 unit/ml
Infusion rate: According to dose

(e.g: 1000 unit/hr = 2ml/hr)
*Refer to HTAA heparin protocol for dose adjustment
Precautions/ remarks:
• Omit bolus dose if baseline APTT > 1.5
• Monitor APTT every 6 hours (Aim APTT 1.5 – 2.0)
• Omit heparin infusion if APTT > 2.5
OR
Inj Enoxaparin 40mg syringe @ 60mg syringe
STEMI/NSTEMI:
≤ 75 years: 30mg IV bolus; then SC 1 mg/kg BD
≥ 75 years: no IV bolus; SC 0.75mg/kg BD
VTE Treatment: 1mg/kg BD
OR
Inj Fondaparinux 2.5mg syringe @ 7.5mg syringe
STEMI: IV 2.5mg bolus; then SC 2.5mg OD
NSTEMI: SC 2.5mg OD
VTE Treatment: < 50kg: 5mg OD, 50-100kg: 7.5mg OD, > 100kg: 10mg OD
Reference:
• ST-Elevation MI CPG 2019, MOH
• Drug Information Lexicomp, Uptodate 2020
• Guide for High Alert Medication, Pharmaceutical Service Division, MOH 201

26

Hydralazine 20MG/ML Inj
Dose:
IV bolus: 5 – 10mg slow IV over 2 minutes;
Maybe repeated 5mg after 20–30 minutes, (max 20mg bolus dose)
Dilution for bolus: 20mg (1amp) + NS = 20ml
IV Infusion: 200–300 mcg/min initially,

Maintenance 50–150 mcg/min
Dilution for infusion:

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

(50mcg/min = 3ml/hr)
(100 mcg/min = 6ml/hr)
In pregnancy:
Initial dose: 25 μg/min IV infusion
Dilution: 25 mg in 500 ml normal saline
Infusion rate: 30 ml/hour
Stability: 24 hours
Precautions/side effects:
• Caution in acute coronary syndromes, cerebrovascular accidents and
dissecting aneurysm
• Tachycardia (if pulse rate >120 bpm& blood pressure is still high, consider
alternative antihypertensive.
• Side effects: facial flushing, headache, nausea, vomiting, anxiety, tremor.
• Unpredictable BP lowering effects
• No longer recommended as 1st line treatment for acute hypertensive crisis in
pregnancy.
Reference:

27

Insulin (ACTRAPID) Inj
IV Actrapid1000unit/10ml (Strength: 100unit/ml)
Dose:
Diabetic Ketoacidosis • IV infusion: 0.1 unit/kg/hr
(DKA) • Use Estimated BW
Hyperosmolar • IV infusion: 0.05 unit/kg/hr
Hyperglycemic State (HHS) • Use Estimated BW
Dilution:
50 unit (0.5ml) + NS = 50 ml àStrength: 1unit/ml
Infusion rate:
Insulin dose
Weight (kg) (ml/hour)
DKA HHS
DXT ≥ 15mmol/l Dxt < 14 mmol/l 0.05 u/kg/hr
(0.1 u/kg/hr) (0.05 u/kg/hr)
50 – 59 5 2.5 2.5
60 - 69 6 3 3
70 - 79 7 3.5 3.5
80 - 89 8 4 4
90 – 99 9 4.5 4.5
100 – 109 10 5 5
110 – 119 11 5.5 5.5
120 – 129 12 6 6
130 - 139 13 6.5 6.5
*DXT hourly
Dosing adjustment:
Dxt (mmol/L) Insulin infusion dose IVD
> 15 0.1 unit/kg/hr Normal saline
< 14 0.1 unit/kg/hr Dextrose 10%
0.05 unit/kg/hr Dextrose 5%
<5 Omit D5% or D10%
• Assess resolution of DKA:

à Fall in blood ketone measurement at least 0.5mmol/Hr
à Rise in bicarbonate 3mmol/L/Hr
à Reduction in plasma glucose at least 3mmol/L/Hr
• If above criteria is not achieved, check equipment and syringe pump
• If equipment working but inadequate response to treatment, insulin can be
increase by 1unit/hr increment hourly until target achieved.
• Glucose level should not decrease >5mmol/hr (to prevent cerebral edema).
Reference:
1. CPG Managemrnt of DM 5th Edition, 2016
2. HTAA DKA Management Chart (Adult)

28

Isosorbide Dinitrate 10MG/10ML Inj

Dose: 2- 20 mg/hr
Dilution:
Undiluted:
10mg (1 amp) in 10ml à Strength: 1mg/ml
(e.g: 2 mg/hr = 2 ml/hr)
OR
Dilute:
10mg (1amp) + NS/D% = 20ml à Strength 0.5mg/ml
Stability: 24 hours
• Preferred in acute coronary syndrome and acute pulmonary edema.
• Avoid in patients with benign intracranial hypertension / elevated
intracranial pressure.
• Onset of action: 3 -15 minutes
• Duration of action: 1 hour
Reference:
1. Isoket Product leaflet, GlaxoSmithKline
2. CPG Management of Hypertension, 5th Edition 2018.

29

Ketamine HCL 200MG/20ML Inj
Reconstitution Not Required
Further Dilution See Administration
Indications & Administration:
1. Induction Of Anaesthesia
• Slow IV Bolus: 0.5-2mg/kg. Give undiluted, administer over at least 1 minute.
• IM: 4-10mg/kg.
• If adjuvant drugs are used eg midazolam can give dose lower dose.
2. Procedural Sedation
• Slow IV Bolus: 1mg/kg
• IM: 2-4mg/kg
3. Sedation in critically ill
IV 0.2- Over at
Loading dose Undiluted
0.75mg/kg least 1 min
Dilution: 100mg Rate: For BW

Maintenance Infusion: 2- 70kg: 3.6
(10ml) + NS/D5%=
dose 7mcg/kg/min ml/hr - max
50ml
12.6 ml/hr
Remarks
• Rapid administration may result in respiratory depression and enhanced
pressor response.
• Not to run via the same line as IV Barbiturate and IV Diazepam.
• Dilute to concentration of 1- 2mg/ml.
• Onset for IV: 30 seconds, duration for 5-10mins.
• Onset for IM: 3-4mins, duration12-25 mins.
Storage & Stability

• Intact Vials: Store below 25°C.
References:
1. Product Leaftlet – Fresenius

30

Labetalol HCL 25MG/5ML Inj

Indication: Hypertensive emergency
Dose:
IV bolus1: 20 mg injected slowly over at least 2 minutes
Followed by 40 – 80mg every 10mins, (Max 200mg)
IV infusion: 0.5 - 2mg/min

(Cont infusion may exceed max cumulative dose recommended of 300mg, with
close monitoring) 2,4
Dilution:
1. Diluted (given via peripheral line)

• 50 mg (2amp) + 30ml NS/D5% = 50ml à Strength: 1mg/ml
• Infusion Rate: According to dose ordered
(e.g: 0.5 mg/min = 30 ml/hr)
(e.g: 1.0 mg/min = 60 ml/hr)
(e.g: 1.5 mg/min = 90 ml/hr)
(e.g: 2.0 mg/min = 120 ml/hr)
OR
2. Undiluted
• 100 mg (4amp of 25ml/5ml) = 20ml à Strength: 5mg/ml
• Infusion Rate: According to dose ordered
(e.g: 0.5 mg/min = 6 ml/hr)
(e.g: 1.0 mg/min = 12 ml/hr)
(e.g: 1.5 mg/min = 18 ml/hr)
(e.g: 2.0 mg/min = 24 ml/hr)
Stability: 24 hours, Do not mix with sodium bicarbonate, Diluents NS/D5%
Precautions:
• Excessive administration (>300mg) may result in prolonged hypotension and/or
bradycardia.
• Contraindicated in bronchial asthma, severe bradycardia, cardiogenic shock &
used with cautions in heart failure.
• Titrate dose every 30 minutes to stabilize blood pressure.
• Discontinue by weaning over 1-2 hours when blood pressure is consistently
<155/95mmHg.
Reference:
4. Goldsmith TL, et al. Prolonged labetalol infusion for management of severe hypertension and
tachycardia in a critically ill trauma patient. DICP. 1990;24(3):235-258

31

Lignocaine 2% 100MG/5ML Inj

Indication:
• Alternative to Amiodarone in cardiac arrest from VT/VF
• Hemodynamically stable monomorphic VT
Dose:
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 every 5–10 minutes
(Max: 3 doses or total of 3mg/kg)
Maintenance infusion: 1 – 4mg/min (30 – 50mcg/kg/min)

400mg (4amp) + NS/D5% = 50ml à Strength: 8 mg/ml

(e.g: 1mg/min = 7.5 ml/hr)
(e.g: 2 mg/min =15 ml/hr)
(e.g: 3 mg/min = 22.5 ml/hr)
(e.g: 4 mg/min = 30 ml/hr)
Precautions:
• 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.
Reference:
1. ACLS 2010, AHA
2. Drug Info, Lexicomp

32

Lytic Cocktail Regime
Hyperkalemia (Lytic Cocktail Regime)
10 ml of IV Calcium gluconate 10% over 10 minutes
50ml of IV Dextrose 50% over 15 – 30 minutes
10 units of IV Insulin (Actrapid)
Reference:
1. Sarawak Handbook of Medical Emergencies, 3rd Edition.

33

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

1. Torsades de Pointes / Digitalis toxicity.
Loading dose:1-2g (2 - 4ml) + NS = 20ml run over 20mins
(Infusion rate: 60ml/hr)
Maintenance dose: 0.5 – 1g/hour infusion (until resolves)

Dilution: 2.5g (5ml, 1amp) + NS = 50ml run 20ml/hr
2. Acute Exacerbation of Bronchial Asthma

Dose: 2g (4ml) dilute in 20ml NS run over 20 minutes
3. Pre-Eclampsia:
Loading dose:4g (8ml) in 20ml NS run over 15 minutes
Maintenance dose:
Intravenous route: IV infusion 1g/hr until delivery
2.5g (5ml, 1amp) + NS =50ml run 20ml/hr
Intramuscular route:
Give immediately after giving IV loading dose;
IM 10g, then IM 5g every 4hours in alternate buttock.
Precautions:
• Clinical monitoring is of utmost importance, looking for signs of toxicity
(especially loss of deep tendon reflexes, respiratory depression with
rate <16/minute) and renal impairment (hourly urine output <30
ml/hour).
• Levels >12mEq/L (>6mmol/L) can lead to respiratory paralysis & heart
block.
• Occasional fall in blood pressure with rapid administration.
• IM may cause irritation and pain at injection site.
• Do not mix with calcium salt, bicarbonate or phosphate.
Reference:
1. Hypertension CPG, 2018 MOH.

34

Midazolam 5mg/ml
Dose & Indication: Adult
1. Induction Anesthesia
Unpremedicated Premedicated Maintenance

•0.3-0.35 mg/kg over 20-30 •0.05 to 0.2 •0.05 mg/kg
secs mg/kg •Infusion: 0.015 - 0.06
•Repeat if needed at ~25% mg/kg/hr @ 0.25 - 1
of initial dose every 2 mins mcg/kg/min
•Up to 0.6 mg/kg
2. Sedation/anxiolysis/amnesia (preoperative/procedural):
Unpremedicated Premedicated Maintenance

•IM: 0.07 to 0.08 mg/kg, •Reduce initial dose by •25% of dose used to
30-60mins prior 30%. reach sedative effect
•IV: 0.5-2mg, repeat doses
every 2-3 mins if needed
3. Sedation in mechanically ventilated ICU patients:1
Initial Dose Maintenance infusion

•0.01- 0.05 mg/kg (~0.5 to 4 mg) •0.02 to 0.1 mg/kg/hr @
•Repeat every 10 -15min until adequate •0.3 to 1.7 mcg/kg/min
sedation
4. Prehospital status epilepticus:
Intramuscular (IM) Intranasal Buccal

•0.2mg/kg @ 10mg once •0.2mg/kg •0.5mg/kg
•Use 5mg/ml solution
5. Status epilepticus, refractory 2
• Mechanical ventilation and cardiovascular monitoring required

Loading Dose Continuous infusion
• 0.2 mg/kg • 0.05 - 2 mg/kg/hr @
• 0.83 - 33.2 mcg/kg/min

35

Dilution:
20 mg (4 amp) + NS/D5% = 20m à Strength: 1 mg/ml
Infusion Rate: according to dose ordered
• E.g for patient with body weight 60kg

0.02 mg/kg/hr = 1.2 ml/hr
0.05 mg/kg/hr = 3 ml/hr * Sedation dose
0.1 mg/kg/hr = 6 ml/hr
1 mg/kg/hr = 60 ml/hr * Status epilepticus dose
2 mg/kg/hr = 120 ml/hr
Stability:
• Use within 24 hours
• The dose of midazolam needs to be individualized based on the
patient's age, underlying diseases, and concurrent medications.
• Consider reducing dose by 20% to 50% in elderly, chronically ill, or
debilitated patients and those receiving opioids or other CNS
depressants.
• Titration to maintain a light rather than a deep level of sedation is
recommended unless clinically contraindicated
• Midazolam IM is the preferred treatment in patients without IV
access.
• Buccal and intranasal midazolam administration has also been
used in patients without IV access, although these off-label routes
are less well studied
Reference:
1. Devlin JW, , et al. Clinical practice guidelines for the prevention and
management of pain, agitation/sedation, delirium, immobility, and sleep
disruption in adult patients in the ICU. Crit Care Med. 2018;46(9):e825-e873.
2. Brophy GM, et al; Neurocritical Care Society Status Epilepticus Guideline Writing
Committee. Guidelines for the evaluation and management of status epilepticus.
Neurocrit Care. 2012;17(1):3-23.
3. Drug Info, Lexicomp Uptodate 2020.
4. Critical Care Pharmacy Handbook, Pharmaceutical Service Division, MOH

36

Morphine 10mg/ml
Indication & Dose:
1. Acute coronary syndrome, refractory ischemic chest pain

• IV: 2-4mg, then 2-8 mg every 5 to 15 minutes as needed @
• IV: 1-5 mg, then 1 to 5 mg every 5 to 30 minutes as needed
2. Analgesia for Mechanically Ventilated Patient

• Initial Dose:
o 0.01 – 0.15 mg/kg every 1-2 hours as needed
• Maintenance Dose:
o 0.07 – 0.5 mg/kg/hr
Dilution:
20mg (2 amp) + NS/D5% = 20ml à Strength 1mg/ml
• E.g : Patient with body weight of 60kg

0.07 mg/kg/hr = 4.2 ml/hr
Precautions/Remarks:
• Can accumulate in hepatic or renal dysfunction and prolong effects.
• Histamine release and vagally mediated veno-dilation, hypotension,
and bradycardia.
• Use only in patients with continued ischemic chest pain despite
maximally tolerated anti-ischemic medications
• use in patients with ACS has been associated with worse clinical
outcomes and concomitant use with oral P2Y12 inhibitors may diminish
antiplatelet effects
References:
• Micromedex Drug Reference Essentials
• Drug Information Lexicomp, Uptodate 2020.

37

Naloxone HCL 0.4MG/ML Inj
Indication & Dose:
1. Opioids Overdose/ Intoxication with Respiratory Depression
Indication / Dose Opioids Overdose/ Intoxication

Opioid Naïve Opioids Dependent
Initial Dose • 0.4 – 2 mg every 2- • 0.1– 0.2 mg every 2-3
(IV, IM SC) 3 minutes. minutes
• Lower dose to avoid
acute withdrawal
After Successful • Re-administer at later interval; every 20-60 mins.
Reversal • If no response after total 10mg, consider other
(IV, IM SC) causes of respiratory depression.
Continuous Infusion • Use in exposure to long acting opioids (methadone)
or sustained release products.
• Use 2/3 of initial effective bolus dose on hourly basis
(usually 0.25 – 6.25mg/hr).
• 1/2 of the initial bolus dose should be re-
administered 15 mins after initiation of continuous
infusion to prevent drop in naloxone levels
2. Reversal Respiratory Depression with Therapeutic Opioid Doses
Indication Reversal with Therapeutic Opioid Doses

/ Dose Opioids Naïve Opioids Dependent
(Postoperative Reversal) (Cancer Pain Patient)
Initial Dose • 0.1 – 0.2mg every 2-3 • Dilute 1 amp (0.4mg) + NS =
(IV push) mins 10ml à 0.04mg/ml
• Repeat doses may be • Then give 0.02 – 0.08 mg (0.5
needed within 1-2 hour – 2ml) every 1-2 minutes
interval. • If no symptoms improvement
after 1mg, consider other
causes of respiratory
depression.
Continuous • Use in exposure to long acting opioids (methadone) or
Infusion sustained release products.
• Use 2/3 of initial effective bolus dose on hourly basis (usually
0.2 – 0.6 mg/hr).
• 1/2 of the initial bolus dose should be re-administered 15
mins after initiation of continuous infusion to prevent drop in
naloxone levels

38

Dilution for Continuous IV infusion:

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

(e.g: 0.2 mg/hr = 2.5 ml/hr)
(e.g: 0.4 mg/hr = 5 ml/hr)
(e.g: 0.8 mg/hr = 10 ml/hr)
(e.g: 1.0 mg/hr = 12.5 ml/hr)
(e.g: 2.0 mg/hr = 25 ml/hr)
(e.g: 3.0 mg/hr = 37.5 ml/hr)
(e.g: 4.0 mg/hr = 50 ml/hr)
Storage & Stability:

• Intact vials: Store below 25°C.
• Protect from light. Discard unused portion.
• Diluted Solution: 24hours at room temperature
Precaution:
• Consider lower dose in known or suspected opioid dependent patients to
minimize withdrawal syndrome.
• May be given IM or SC when IV access N/A.
References:
1. Product Leaftlet – Mapin
3. Ministry of Health Malaysia. Critical Care Pharmacy Handbook. Pharmaceutical Service
Division 2013.

39

Noradrenaline 4MG/4ML Inj

Indication:
1. Treatment of shock that persist after adequate volume replacement.
2. Severe Hypotension.
Dose: 0.05 – 2mcg/kg/min
Dilution:
Single Strength 4mg (1amp) + D5% = 50ml àStrength: 0.08mg/ml
Double Strength 8mg (2amp) + D5% = 50ml àStrength: 0.16mg/ml
Stability: 24 hours
Do not dilute with NS alone may cause degradation due to oxidation.
Do not administer in the same IV line as Sodium bicarbonate
Precautions:
• Assure adequate circulatory volume to minimize the need for
vasoconstriction.
• Infusion should be through a LARGE VEIN / CENTRAL LINE to prevent
complications, severe ischemic necrosis& gangrene.
Reference:
1. Drug Info, Lexicom, Uptodate 2020

40

Potassium Chloride 1g/10ml (~13.4 mmol K+ ion) inj
Preparation:1 vial (1g in 10ml) = 13.4 mmol = 13.4 mEq/L potassium ion
• Normal daily requirements: Oral, IV: 40 to 80 mmol/day

• Prevention of hypokalemia: Oral: 20 to 40 mmol/day in 1 to 2 divided doses
Treatment of hypokalemia:
• IV intermittent infusion, Fast correction:
o 1g (1amp) in 100ml NS run over 1hour
o 2g (2amp) in 200ml NS run over 2hours
o With continuous cardiac monitoring
• Serum potassium >2.5 to 3.5 mmol/L:

o Maximum infusion rate: 10 mmol/hour
o Maximum concentration: 40 mmol/L
• Serum potassium <2.5 mEq/L or symptomatic hypokalemia:

o Maximum infusion rate (central line only): 40 mmol/hour
o In presence of continuous ECG monitoring & frequent lab
monitoring
Stability: 24 hours
Do not administer undiluted or IV push
Inappropriate dilution & administration may be fatal.
Remarks:
• Peripheral or central line: ≤10 mmol/hour
• Central line infusion and continuous ECG monitoring highly recommended
for infusions >10 mmol/hour.
• When maintaining normal daily requirements, IV doses should be
incorporated into the patient's maintenance IV fluids.
• Intermittent IV potassium administration should be reserved for more severe
depletion situations in patients undergoing ECG monitoring.
• As an estimate, 10 mmol of potassium chloride will roughly increase serum
levels by 0.1 mmol/L.
References:
1. Flurie RW, et al., Disorders of Potassium and Magnesium Homeostasis. New York, NY: McGraw-
Hill Education

41

Potassium Dihydrogen phosphate 1.3g/10ml Inj
Preparation:1 vial (1.3g in 10ml) of IV Potassium Dihydrogen phosphate
1.3g/10ml = 10mmol K+, 10mmol Po4+, 20mmol H+
Dose:
Non-Critically ill Patients Critically Ill Patients Receiving

Nutritional Support
Serum Dose Serum Phosphate Dose

Phosphate
≥ 1.25 mg/dL • 0.08 to 0.24 2.3 - 3.0 mg/dL 0.32 mmol/kg
(0.40 mmol/L) mmol/kg over 6 (0.73 - 0.96 mmol/L
hours
(max 30 mmol)
< 1.25 mg/dL • 0.25 to 0.50 1.6 - 2.2 mg/dL 0.64 mmol/kg
(0.40 mmol/L) mmol/kg over 8 - (0.51 - 0.72
12 hours mmol/L)
(max 80 mmol)
< 1.6 mg/dL (< 1.0 mmol/kg
0.50 mmol/L)
Remarks:
• IV phosphate is potentially dangerous since it can precipitate with calcium
causing:
o hypocalcemia due to binding of calcium
o renal failure due to calcium phosphate precipitation in the kidneys
o possibly fatal arrhythmias.
• Give IV therapy in patients with severe symptomatic hypophosphatemia or
inability to take oral therapy.
• Serum phosphate should be monitored every 6 hours when intravenous
phosphate is given
• Patient should be switched to oral replacement when serum phosphate
reaches 1.5 mg/dL (0.48 mmol/L).
Reference:
1. Drug Information, Lexicomp, Uptodate 2020.

42

Phenytoin 250MG/5ML Inj
Dose:
Loading dose: 15 – 20mg/kg
If seizure persist, give additional dose of 10mg/kg 10 min after
loading infusion
Maintenance dose: 5mg/kg/day
Dilution:
Required dose (15 – 20mg/kg) + NS = 100ml over 1hour

(max infusion rate: 50mg/min)
• Time to effect: 10 – 30 minutes
• Narrow therapeutic window.
• Target range: 10 – 20 mcg/ml
• Monitor level 12-24hours after loading dose
• Toxicity: Comatose, hypotension, respiratory& circulatory depression.
• Initial sign of toxicity: Nystagmus, ataxia, tremor, somnolence, drowsiness,
lethargy, slurred speech, nausea, vomiting.

• Arrhythmias, Hypotension, Purple glove syndrome
Stability:
• Do not dilute in D5%, cause crystallization.
Reference:
2. Product leaflet, Pfizer
3. Consensus Guideline on Management of Epilepsy 2010, Malaysian Society of Neuroscience.

43

Phenobarbital 200MG/ML Inj
Loading dose:
Children: 15 - 20 mg/kg IV (Max 1000mg/dose)
Administration rate: 30mg/min
May repeat dose after 15mins as needed to a maximum total dose of
40mg/kg.
Adult: 10-20mg/kg
Administration rate: 60mg/min
May repeat dose in 20 minutes as needed to a maximum total dose of
30mg/kg.
Continuous infusion (in refractory status epilepticus): 0.5 – 5mg/kg/hr 1
Dilution:
Intramuscular: Undiluted, Inject deep into muscle.
Do not exceed 5 ml per injection site due to potential tissue irritation.
IV Bolus: 200mg (1 vial) + NS/D5% = 10ml

Push over 5 minutes (Infusion rate: 50–100 mg/min)
IV Infusion: 400mg (2 vials) + NS/D5% = 20ml à Strength: 20mg/ml

Rate: according to dose
• Intra-arterial injections is contraindicated
• Avoid subcutaneous administration
• Highly alkaline parenteral solution, avoid extravasation
• Max dilution for IV administration 130mg/ml.

• Hypotension
Reference:
1. Brophy G.M., et al; Guidelines for the Evaluation and Management of Status
Epilepticus, Neurocrit Care, April 2012.
2. Product leaflet, Sanofi & Drug Info, Lexicomp
3. Consensus Guideline on Management of Epilepsy 2010, Malaysian Society of
Neuroscience.

44

Proton Pump Inhibitor (PPI) Inj
Omeprazole 40mg
Pantoprazole 40mg
Esomeprazole 40mg
UGIB
IV bolus: 80mg (2vials) + NS = 20ml slow bolus over 2 minutes
IV infusion: 8mg/hour x 72 hours

40mg (1vial) + NS = 40ml à strength: 1mg/ml
Reference:
1. Drug info, lexicomp.

45

Salbutamol 0.5MG/ML Inj
Indication:
Dose: 0.25mg IV slow bolus; then

IV infusion 5 – 20mcg/min
Dilution: 3mg (6amp) + NS/D5% = 50ml àStrength: 60mcg/ml
Infusion rate: According to dose

1 mcg/min = 1 ml/hr
2 mcg/min = 2 ml/hr
5 mcg/min = 5 ml/hr
7 mcg/min = 7 ml/hr
10 mcg/min = 10 ml/hr
Side effects:
• Palpitations
• Tachycardia
• Tremor
• Lactic acidosis
• Hypokalemia
• Pulmonary edema
• Flushing
• Headache
• Anxiety
Reference:
1. Drug Info, Lexicomp

46

Sodium Valproate 400MG Inj
Dose:
Loading dose:20 - 40mg/kg
If persist, give additional dose of 20mg/kg 10 min after loading
infusion
Maintenance dose: 4-8mg/kg 8 hourly
Dilution:
Required dose (20mg/kg) + NS/D5% = 100ml over 1hour
Infusion rate: maximum infusion rate 20mg/min (1200 mg/1 hr)
• Use with caution in patients with traumatic head injury; may be a
preferred agent in patients with glioblastoma multiforme
• Time to effect 10 – 20 minutes
• Narrow therapeutic window. Target range: 50 – 100mcg/ml (trough)
• Monitor level after 3-5 days

Hyperammonemia
Pancreatitis
Thrombocytopenia
Hepatotoxicity
Reference:
2. Product leaflet, Sanofi& Drug Info, Lexicomp
3. Consensus Guideline on Management of Epilepsy 2010, Malaysian Society of Neuroscience.

47

Sodium Bicarbonate 8.4%/10ml (~10 mmol HCO3 ion) Inj
Preparation: 1 vial 8.4% of 10 ml = 10mmol HCO3- & 10 mmol Na2+.
*1ml NaHco3 = 1mmol HCO3- = 1mEq HCO3-
*1 mEq NaHCO3 is equivalent to 84 mg
Dosing:
1. Cardiac Arrest 1,2
Adult (ACLS 2010) • IV: 1 mmol/kg/dose
Peads (PALS) • IV / Intraosseous: 1 mmol/kg/dose
• Repeat doses should be guided by arterial blood gases, routine use of NaHCO3 is
not recommended.
• May be considered in the setting of prolonged cardiac arrest only after adequate
alveolar ventilation has been established & effective cardiac compressions.
• In some cardiac arrest situations (eg, metabolic acidosis, hyperkalemia, or tricyclic
antidepressant overdose), sodium bicarbonate may be beneficial.
2. Metabolic acidosis:
Dose Acid- base Status Available Acid- base Status

Unavailable
Adult • HCO3-(mEq) = 0.5 x weight • 2 to 5 mEq/kg IV infusion
(Intravenous) (kg) x [24 - serum HCO3- over 4 to 8 hours;
(mEq/L)] • Subsequent doses should be
OR based on patient's acid-
• HCO3-(mEq) = 0.5 x weight base status.
(kg) x [desired increase in
serum HCO3-(mEq/L)]
Pediatric • HCO3-(mEq) = 0.3 x weight • <2 years: 1 to 2
(IV, (kg) x base deficit (mEq/L) mEq/kg/dose
Intraosseous) OR • >2 years: 2 to 5 mEq/kg IV
• HCO3 (mEq) = 0.5 x weight
- infusion over 4 to 8 hours;
(kg) x [24 - serum HCO3- • Subsequent doses should be
(mEq/L)] based on patient's acid-
base status
• Administer 1/2 dose initially, then remaining 1/2 dose over the next 24 hours;
monitor pH, serum HCO3-, & clinical status.
• These equations provide an estimated replacement dose. The underlying cause
and degree of acidosis may result in the need for larger or smaller replacement
doses.
• In most cases, the initial goal of therapy is to target a pH of ~7.2 and a plasma
bicarbonate level of ~10 mEq/L to prevent over alkalization.

48

3. Hyperkalemia
• IV: 50 mEq over 5 minutes

Adult (ACLS 2010) • Consider methods of enhancing potassium
removal/excretion
•1 to 2 mEq/kg/dose has been used to redistribute

Pediatric extracellular potassium into cells
Contraindications
• Alkalosis, hypernatremia, severe pulmonary edema, hypocalcemia,
unknown abdominal pain
Warnings/Precautions
• Extravasation: Vesicant (at concentrations ≥8.4%); ensure proper catheter
or needle position prior to and during infusion.
• Avoid extravasation (tissue necrosis may occur due to hypertonicity).
• Pediatric: Rapid administration in neonates, infants, and children <2 years
of age has led to hypernatremia, decreased CSF pressure, and intracranial
hemorrhage.
Reference:
• Field JM, et al, “Part 1: Executive Summary: 2010 American Heart Association
Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care,”
Circulation, 2010, 122 (Suppl 3):640-56.
• Kleinman ME, et al, "Part 14: Pediatric Advanced Life Support: 2010 American Heart
Association Guidelines for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care," Circulation, 2010, 122(18 Suppl 3):876-908.
• Rosner MH. Prevention of contrast-associated acute kidney injury. N Engl J Med.
2018;378(7):671-672.
• Weisbord SD, Gallagher M, Jneid H, et al; PRESERVE Trial Group. Outcomes after
angiography with sodium bicarbonate and acetylcysteine. N Engl J Med.
2018;378(7):603-614.

49

Streptokinase 1.5 milion units/ vial Inj

Indication & Dose:
1. Acute ST elevation MI
• Dose: 1.5 million units over 1hour
• Dilution: 1.5 MU (1 vial) + NS/D5% = 100ml
• Infusion rate: infusion rate: 100ml/hr (over 1 hour)
2. Arterial Thrombosis/Pulmonary Embolism/Deep Veen Thrombosis

• Loading dose: IV 250, 000 IU over 30 mins
• Maintenance dose: 100 000 IU/hr for 24 hours (72 hours if DVT)
• Dilution: 1.5 IU (1 vial) + NS/D5% = 50ml à 30, 000 IU/ml
• Infusion Rate:
o For Loading Dose: 8.3 ml over 30 mins
o For Maintenance Dose: 3.3ml/hour over 24 hours / 72 hours (DVT)
Stability: Room temperature (15 - 30°C): 8 hours

Refrigerator (2 - 8°C): 24 hours
Reconstitute powder with 5ml WFI by adding WFI slowly alongside wall
then dilute gently to prevent foaming.
• Not necessarily to be given with anticoagulant
• Non fibrin specific and it results in a lower patency rate of the occluded
vessel at 60 minutes than fibrin specific agents.
• Despite having a lower risk of intracranial hemorrhage, the reduction in
mortality is less than with fibrin specific agents.
• Antigenic and promotes the production of antibodies. Thus the utilization of
this agent for reinfarction is less effective if given between 3 days and 1 or
even 4 years after the first administration.
• PCI or fibrin specific agents should then be considered.
Reference:
1. ST-Elevation MI CPG 2014, MOH
2. PAHANG Acute MI management, 2012.

50

Tenecteplase 10,000 units (50MG) / vial Inj
Indication: Allergy or prior exposure to streptokinase.
Extensive Anterior STEMI, < 75 years old.
STEMI with hypotension, < 75 years old. (Delay / unable to do 1° PCI)
Dilution:
10,000 units/50 mg (1 vial) + 10ml solvent àStrength = 5mg/ml
Dose:
Single IV bolus over 10 seconds
Body Weight Dose Vol. to Administer

<60kg 6,000 units = 30mg 6 ml
60 – 69 kg 7,000 units = 35mg 7 ml
70 – 79 kg 8,000 units = 40mg 8 ml
80 – 89 kg 9,000 units = 45mg 9 ml
> 90 kg 10,000 units = 50mg 10 ml
*Max dose: 10,000 units / 50mg

* Aim given within 30mins of presentation (Door to needle time)
* MUST be given with anticoagulants.
Fibrinolysis in Unstable Patient

• Ideally should do primary PCI
• Fibrinolysis with Fibrin specific agent is preferred
• Presence with Hypotension:
§ Risk factors: Relative Hypovolemia, RV infarction, Acute LV failure
§ Treatment: IV fluids as necessary, inotropes (preferably Noradrenaline),
fibrinolysis can be given concomitantly if SBP > 90mmHg
• Presence of LV Failure:
§ Treated with Oxygen, NIPPV, HF nasal cannula or intubation if necessary
§ IV Diuretics
• This is a weight-based regimen and thus there is a risk of bleeding if the
weight has been 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 a duration of 48 hours.
• Alternative: SC Fondaparinux 2.5mg OD for 8 days / until discharge.
Reference:
1. ST-Elevation MI CPG 2019, MOH
2. PAHANG Acute MI management, 2012

51

Tramadol 50MG/ML Inj
Dose:
IV bolus: 50mg-100mg every 4-6 hourly. (Max: 400mg/day)
IV infusion: 5 mg – 16mg/hr (Max: 400mg/day)

50mg (1vial) + NS = 50mlà strength: 1mg/ml
Infusion rate: 5 - 16ml/hr (Max: 16ml/hr)
Reference:
1. Drug Info (Lexicomp)

52

Verapamil 5MG/2ML Inj
Indication:
• Stable, narrow-complex tachycardias if rhythm remains uncontrolled or

unconverted by adenosine or vagal maneuvers or if SVT is recurrent.
• Control ventricular rate in patients with atrial fibrillation or atrial flutter.
Dose:
Supraventricular Tachycardia (SVT): Alternative agent for acute treatment
• IV Bolus: 5 to 10 mg (0.075 – 0.15mg/kg) over ≥2 mins
• If response is insufficient after 15 to 30 mins, 2nd bolus dose of 10 mg over 2
mins may be administered.
• If 2 bolus doses do not terminate the arrhythmia, consider alternative therapy
(Max: 30mg)
Acute ventricular rate control

• IV Bolus: 5 to 10 mg (0.075 – 0.15mg/kg) over ≥2 mins
• If inadequate response, dose may be repeated after 15 to 30 min
• If adequate response after 1 to 2 bolus doses, may begin a continuous
infusion
• Continuous infusion: Initial: 5 mg/hour (0.05 mg/kg/min)
§ Titrate up to a max of 20 mg/hr
Dilution for Continuous Infusion:

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

e.g: 5 mg/hr = 10 ml/hr
Precautions:
• 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
• For SVT, use in hemodynamically stable patients if vagal maneuvers and/or
adenosine are unsuccessful.
§ Do not use in patients with preexcitation associated with an accessory
pathway, as this can lead to ventricular arrhythmias
Reference:
1. January CT, et al. AHA/ACC/HRS guideline 2019
2. Micromedex IBM, Updated June 2020

53

Cyanide Toxicity Antidote

54

Inj. Sodium Nitrite 300mg/10ml
Indication:
• Indicated for sequential use with sodium thiosulfate for treatment of acute cyanide
poisoning that is judge to be life threatening.
• Should only be used to treat acute life-threatening cyanide poisoning, used with caution in
patients where diagnosis of cyanide is uncertain or when patient is not in extremis.
Dose:
For Adult
• Sodium Nitrite – 10ml at rate of 2.5-5ml/minute
•
For Children
• Sodium Nitrite – 0.2ml/kg (6mg/kg or 6-8 ml/m2 BSA) at rate of 2.5 – 5ml/minute. Not to
exceed 10ml.
Dilution
Infusion Rate: Slow intravenous injection @ 2.5 – 5ml /min
Administration:
• Is considered as adjunctive to appropriate supportive therapy.
• Airway, ventilator & circulatory support should not be delayed to administer sodium nitrite
& sodium thiosulfate.
• Should be given as early as possible after diagnosis of acute life-threatening cyanide
poisoning has been established.
• Monitor blood pressure during infusion.
• Decrease rate of infusion if significant hypotension is noted.
Incompatibility Information:
• Chemical incompatibility with Hyrdoxocobalamin, should not be administered
simultaneously via same IV line
• Compatible with sodium thiosulfate (can be administered sequentially through the same IV
line)
Adverse Reaction:
• Cardiovascular: syncope, hypotension, tachycardia, methemoglobinemia, palpitations,
dysrhythmia.
• Hematological: Methemoglobinemia.
• Central nervous system: Headache, dizziness, blurred vision, seizures, confusion, coma.
• Gastrointestinal system: nausea, vomiting, abdominal pain
• Respiratory system: tachypnea, dyspnea
• General: anxiety, diaphoresis, lightheadedness, injection site tingling, cyanosis, acidosis,
fatigue, weakness, urticarial, generalized numbness and tingling.
Recommended Monitoring:
• Patients should be monitored for at least 24-48 hours after administration of sodium
thiosulfate for adequacy of oxygenation and perfusion and for recurrent signs and
symptoms of cyanide toxicity.
• When possible, hemoglobin/hematocrit should be obtained when treatment is initiated.
• Measurement of O2 saturations (using pulse oximetry) and calculated O2 saturation based
on measured PO2 are unreliable in the presence of methemoglobinemia.
• Methemoglobin level:
• Administration of sodium nitrite to achieve higher level of methemoglobin is
unnecessary and potentially hazardous.

55

• It has been reported that level as low as < 10% are associated with clinical
response.
• Thus a second dose of sodium nitrite should be considered only if there is
inadequate clinical response to the first dose.
• It is generally recommended that methemoglobin concentration to be closely
monitored and kept below 30%.
Warning & Precautions:

• Life threatening hypotension and methemoglobin formation
• Can cause serious adverse reaction and death even at doses less than twice the
recommended therapeutic dose.
• Hypotension and methemoglobinemia can occur concurrently or separately.
• Thus, should only be used to treat acute life-threatening cyanide poisoning, used with
caution in patients where diagnosis of cyanide is uncertain or when patient is not in
extremis.
• Patient should be closely monitored to ensure adequate perfusion & oxygenation during
treatment with sodium nitrite.
• Other precautions:
o Used with cautions in patients with known anemia. Optimally, patient should
receive reduced dose of sodium nitrite.
o Potential worsening hypoxia in patients with smoke Inhalation Injury.
o G6PD deficiency patients are at higher risk of hemolytic crisis, alternative
therapeutic approach should be considered in these patients. Monitor for acute
drop in hematocrit, exchange transfusion may be needed in G6PD deficiency
patients receiving sodium nitrite.
o Caution in presence of concomitant medications; antihypertensive medications,
diuretics, PDE5 inhibitors (e.g: sildenafil).
Use in Special Populations

• Pregnancy: Category C. Used during pregnancy only if potential benefit justifies the
potential risk to the fetus.
• Nursing mother: No data to determine when breast-feeding can be safely restarted after
administration of sodium nitrite.
• Renal Disease: Known to be substantially excreted in kidney, thus risk of toxic reaction
maybe greater in patients with impaired renal function.
Overdose:
• Large doses result in severe hypotension and toxic levels of methemoglobin which may
lead to cardiovascular collapse.
• Methemoglobin level as low as 15% might cause anxiety, dyspnea, nausea and
tachycardia.
• Methemoglobin level of 10-20%, cyanosis may become apparent.
• More serious sign and symptoms of toxicity including cardiac dysrhythmias, circulatory
failure and CNS depression as methemoglobin level increase. Levels above 70% are usually
fatal.
• Treatment: Supplemental oxygen and supportive measures such as exchange transfusion.
• Methylene blue can be given to treat severe methemoglobinemia, but it may also cause
release of cyanide bound to methemoglobin.
Stability:
• Store at room temperature between 20°C - 25°C.
• Protect from direct light.
• Do not freeze.
Reference:
• Full prescribing information of Sodium Nitrite Injection, USP, HOPE Pharmaceutical, 2011.
• Tintinalli’s Emergency Medicine, 7th Edition.

56

Inj. Sodium Thiosulfate 12.5g/50ml

Indication: Indicated for sequential use with sodium nitrite for treatment of acute cyanide
poisoning that is judge to be life threatening.
Dose:
For Adult
1. Sodium Thiosulfate – 50ml immediately following administration of sodium nitrite
Repeat sodium thiosulfate once at half dose (25ml) if symptoms persist.
For Children
1. Sodium Thiosulfate – 1ml/kg (250mg/kg or approximately 30-40ml/m2 BSA) immediately
following administration of sodium nitrite. Not to exceed 50ml as total dose.
Repeat sodium thiosulfate once at half dose if symptoms persist.
Dilution
Infusion Rate: Slow intravenous injection @ 2.5 – 5ml /min
Administration:
• Is considered as adjunctive to appropriate supportive therapy.
• Airway, ventilator & circulatory support should not be delayed to administer sodium nitrite
& sodium thiosulfate.
• Should be given as early as possible after diagnosis of acute life-threatening cyanide
poisoning has been established.
• Sodium nitrite should be administered first followed immediately by sodium thiosulfate.
• Monitor blood pressure during infusion.
• Decrease rate of infusion if significant hypotension is noted.
Incompatibility Information:
• Chemical incompatibility with Hyrdoxocobalamin, should not be administered
simultaneously via same IV line
• Compatible with sodium thiosulfate (can be administered sequentially through the
same IV line)
Adverse Reaction:
• Cardiovascular: Hypotension
• Central nervous system: Headache, disorientation.
• Gastrointestinal system: nausea, vomiting
• Hematological: prolonged bleeding time
• Respiratory system: tachypnea, dyspnea
• General: salty taste in mouth, warm sensation over body.
Recommended Monitoring:
• Patients should be monitored for at least 24-48 hours after administration of sodium
thiosulfate for adequacy of oxygenation and perfusion and for recurrent signs and
symptoms of cyanide toxicity.

57


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

• Pregnancy: Category C. Used during pregnancy only if potential benefit justifies the
potential risk to the fetus.
• Nursing mother: No data to determine when breast-feeding can be safely restarted after
administration of sodium nitrite.
• Renal Disease: Known to be substantially excreted in kidney, thus risk of toxic reaction
maybe greater in patients with impaired renal function.
Stability:
• Store at room temperature between 20°C - 25°C.
• Protect from direct light.
• Do not freeze.
Reference:

58

Inj. Hydroxocobalamine 5g/ml (Cyanokit)
Indication:
• An antidote indicated for the treatment of known or suspected cyanide poisoning.
• If clinical suspicion of cyanide poisoning is high, hydroxocobalamine should be
administered without delay.
Dose:
For Adult:
• The starting dose 5 g administered as intravenous infusion over 15 minutes (approximately
15 mL/min).
• Depending upon the severity of the poisoning and the clinical response, a second dose of
5 g may be administered by intravenous infusion for a total dose of 10 g.
• The rate of infusion for the second dose may range from 15 minutes (for patients in
extremis) to two hours, as clinically indicated.
For Children: Dose of 70 mg/kg
Reconstitution: Reconstitute with 200 mL of diluent using the supplied sterile transfer spike to
produce 25mg/mL solution of hydroxocobalamine.
Diluent: 0.9% NaCl, Lactated Ringers injection, 5% Dextrose injection (D5W).
Further Dilution: Not required
Infusion rate: 15ml/min
Administration:
• The line on the vial label represents 200 mL volume of diluent. Following the addition of
diluent to the lyophilized powder, the vial should be repeatedly inverted or rocked, not
shaken, for at least 60 seconds prior to infusion.
• Hydroxocobalamin solutions should be visually inspected for particulate matter and color
prior to administration. If the reconstituted solution is not dark red or if particulate matter is
seen after the solution has been appropriately mixed, the solution should be discarded.
Incompatibilities:
• Chemically incompatible with sodium thiosulfate, sodium nitrite and ascorbic acid. Physical
incompatibility (particle formation) and chemical incompatibility with selected drugs that
are frequently used in resuscitation efforts.
• Should not be administered simultaneously with other drugs through the same intravenous
line as.
• Not recommended for simultaneous administration with blood products (whole blood,
packed red cells, platelet concentrate and/or fresh frozen plasma) through the same
intravenous line. Can be administered simultaneously using separate intravenous lines
(preferably on contralateral extremities, if peripheral lines are being used).
Adverse Reaction:
• Serious adverse reactions with hydroxocobalamin include allergic reactions and increases
in blood pressure.
• Cardiovascular: increased blood pressure
• Eye: swelling, irritation, redness
• Gastrointestinal: nausea, dysphagia, abdominal discomfort,vomiting, diarrhea, dyspepsia,
hematochezia
• General: headache, peripheral edema, chest discomfort
• Immune system: allergic reaction
• Nervous system: memory impairment, dizziness
• Psychiatric: restlessness

59

• Respiratory: dyspnea, throat tightness, dry throat
• Skin and subcutaneous tissue: rash, urticaria, pruritus, infusion site reaction, hot flush

• Allergic Reactions:
o Use caution in the management of patients with known anaphylactic reactions to
hydroxocobalamin or cyanocobalamin. Consideration should be given to use of
alternative therapies, if available.
o Allergic reactions may include: anaphylaxis, chest tightness, edema, urticaria,
pruritus, dyspnea, and rash.
o Allergic reactions including angioneurotic edema have also been reported in
postmarketing experience.
• Increase in Blood Pressure
o Increases in blood pressure were noted shortly after the infusions were started; the
maximal increase in blood pressure was observed toward the end of the infusion.
These elevations were generally transient and returned to baseline levels within 4
hours of dosing.
• Interference with Clinical Laboratory Evaluations and Clinical Methods
o Clinical Laboratory Evaluations
o Because of its deep red color, hydroxocobalamin has been found to interfere with
colorimetric determination of certain laboratory parameters (e.g., clinical
chemistry, hematology, coagulation, and urine parameters)
o Interference following a 10 g dose can be expected to last up to an additional 24
hours.
o The extent and duration of interference in cyanide-poisoned patients may differ.
Results may vary substantially from one analyzer to another; therefore, caution
should be used when reporting and interpreting laboratory results.
o Interference with Hemodialysis
o Because of its deep red color, hydroxocobalamin may cause hemodialysis
machines to shut down due to an erroneous detection of a “blood leak”.
• Photosensitivity
o Hydroxocobalamin absorbs visible light in the UV spectrum. It therefore has
potential to cause photosensitivity. Patients should be advised to avoid direct sun
while their skin remains discolored.
Stability:
1. Once reconstituted, hydroxocobalamin is stable for up to 6 hours at temperatures not
exceeding 40°C.
2. Do not freeze.
3. Discard any unused portion after 6 hours.
Reference:

60

Medications for Procedural Sedation & Analgesia
Class Anxiolytic Hypnotic / Sedative Dissociative Analgesia Combinations

Drug Midazolam Propofol Etomidate Ketamine Morphine Fentanyl Fentanyl + Propofol +
Midazolam Ketamine
Dose 0.1mg/kg 1-2 mg/kg 0.1 – 0.3 1 - 1.5 mg/kg 0.1 – 0.3 mg/kg 1-2 mcg/kg Fentanyl: 1- Propofol: 1-
mg/kg 2mcg/kg 2 mg/kg
Midazolam: Ketamine:
0.05 – 0.1 0.5mg/kg
mg/kg.
Onset 1-5 min 30-45 sec 30-60 sec 30 – 40 sec 5-10 min 1-2 min 1-2 min 1 min
Duration ~2 hour 20-75 min 3-5 min 5-10 min 2-4 hour 30-60 min 1-3 hour 15-45 min
Dilution & Slow IV over 2- Lipid emulsion. IV push over IV slow bolus. Slow IV. Slow IV Slow IV Slow IV
Administration 5mins IV slow bolus: 30-60 sec.
undiluted. Rapid Dilute with NS Undiluted Undiluted. Compatible
Concentration: 1- IV infusion: Undiluted. administration or WFI to conc to be mix
5mg/ml dilute with D5% may result in 1-2mg/ml. Compatible together as
to conc of ≥ Highly respiratory with NS. ‘Ketofol’.
Compatible D5% 2mg/ml, stable irritating, depression &
or NS for 8 hours. administer to enhance
large vein or pressor
To reduce pain give response.
during with lignocaine.
administration, Undiluted
use larger veins
or add
lignocaine to
propofol (1:10
ratio).

61

Medications for Procedural Sedation & Analgesia

Midazolam Ketamine
Respiratory Important Important Respiratory Bronchodilator Important Important Important Lesser
Effects depressant effect depressant depressant. effect depressant depressant depressant depressant
effect effect effect effect effect
Cardiac Effects Important Important Minimal Important Important Important Important Lesser
depressant effect depressant cardiovascula stimulant depressant depressant depressant depressant
effect r effects effect effect effect effect effect
Analgesia None None Limited Yes Yes Yes Yes Yes
analgesic
properties.
Advantages Shorter acting if Rapid onset, Rapid onset, Analgesic, Reduces Less Analgesic Decrease
preserved organ short duration. short anesthetic, tachypnea hypotensiv and dosing
function. duration. motionlessnes e than anxiolytic. requirement
Motionlessness, s, respiratory morphine for both
Fast onset muscle Reduce ICP. and agents.
relaxant. cardiovascular
stimulant, Antagonistic
Mild antiemetic bronchodilator side effects
properties. (lessen
Attenuates respiratory
Reduce ICP. development and
of acute cardiovascular
tolerance to depression,
opioids. lessen emesis).

62

Medications for Procedural Sedation

Midazolam Ketamine
Disadvantages No analgesia, Increase serum Adrenocortica May cause Hypotension, Chest wall Respiratory
paradoxical TG (lipid l suppression. hallucinations nausea. rigidity, risk depressant
reaction. emulsion), and increase -
pancreatitis. Myoclonus: psychological with larger
avoid in disturbances. doses.
Eliminated Do not give to patients with Increase Cause
renally as active patient allergic increased intraocular histamine Bradycardi
Disadvantages metabolite, risk to egg or soy tone (e.g: CP). pressure, release/ a.
of accumulations products. intracranial Pruritus.
of active Painful pressure,
metabolites in injection. salivation,
renal failure. emetogenic, &
laryngospasm.
Monitoring Respiratory and Anaphylaxis Cardiac and Heart rate, Respiratory Respiratory Respiratory Anaphylaxis
cardiovascular reaction, blood blood blood pressure and CNS and CNS and reaction.
status, blood pressure, pressure. and cardiac status. Blood status. cardiovascu
pressure. cardio- function. pressure Blood lar status,
respiratory pressure blood
depression. and heart pressure.
rate.
Tintinalli’s Emergency Medicine, 7th Edition.


63

Sedative Agents in Mechanically Ventilated Patients
(Compiled by Ms Izyan Liyana Rosman, for ED pharmacy attachment @ HTAA, 2017)
Drug MIDAZOLAM 5MG PROPOFOL 200MG DEXMEDETOMIDINE 100MCG KETAMINE 200MG ETOMIDATE
Price / vial RM 1.75 RM 3.60 RM 111.10 RM 46.00 RM 27.15
Price of RM 10.08 RM 7.80 RM 333.3 RM 46.00 -
continuous (*lowest dose/bw (*lowest dose/bw 60kg) (*lowest dose/bw 60kg) (*lowest dose/bw
infusion/ day 60kg) 60kg)
Dose Initial dose : Initial dose : Initial dose : Initial dose: Initial dose:
0.01 - 0.05 mg/kg 5 mcg/kg/min (0.3 1 mcg/kg over 10 mins. 0.2 - 0.75mg/kg. 0.2-0.6mg/kg
over several min. mg/kg/h) IV infusion for Maintenance dose : Maintenance dose:
Maintenance dose:
Maintenance dose : 5 min then titrate in 5 - 0.2 – 0.7 mcg/kg/h for a 2 - 7 mcg/kg/min 5-20mcg/kg/min
0.02 – 0.1 mg/kg/h. 10 mcg/kg/min maximum of 24 hours.

Maintenance dose:
5 - 50 mcg/kg/min
Dilution 20mg in 20cc NS Undiluted 200mcg in 50cc NS 200mg in 20cc NS Continuous
(200mg/20ml) infusion not
*Ketofol dilution: recommended,
100mg PROPOFOL due to adrenal
(10ml) + 100mg suppression.
KETAMINE (10ml) in
50cc D5)
Onset 1- 5 min 1-2min 5 - 10min 30 - 40sec 30-60sec
Duration ~ 2 hours 2-8min 60 - 120min 5 - 10min (IV) 3-5min, terminated
by redistribution
Elimination Hepatic Cytochrome Hepatic conjugation Hepatic including Hepatic N- Hepatic and
P450 3A4, active glucuronidation and demethylation plasma esterase
metabolite excreted CYP2A6
renally

64

Drug MIDAZOLAM PROPOFOL DEXMEDETOMIDINE KETAMINE ETOMIDATE
Analgesia None None Yes Yes No

Side effects Resp depression, Resp depression, Hypotension and Increase oral -Adrenal
hypotension hypotension, propofol bradycardia secretions, suppression
infusion syndrome associated with -Some formulation
hallucination and contains propylene
dreaming. glycol which can
cause
hyperosmolarity,
metabolic acidosis.
Advantages Fast onset Rapid onset, Short Very short duration Broncholilatory effect Less associated with
acting Has some analgesic Has analgesic hypotension.
Beneficial effect of properties property.
cerebral
vasoconstriction, reduce
ICP.
Disadvantag Active metabolite -C/I in egg and soy Not approved for use >24 May cause -C/I in soya and
es accumulates in renal allergy, risk of Propofol hour in some countries, hallucinations and peanut allergy
failure. infusion syndrome. some studies are longer. other psychological -Cause adrenal
disturbances. suppression, hence
controversial use in
septic shock, and
not recommended
as continuous
infusion.
Preferred in: - Cause cerebral Preferred in substance Preferred in Not for continuous
vasoconstriction and abuse. hypovolaemic infusion.
lowers ICP thus patients / active
beneficial in patients airway disease.
with TBI.

65

Analgesic Agents in Mechanically Ventilated Patients
(Compiled by Ms Izyan Liyana Rosman, for ED pharmacy attachment @ HTAA, 2017)
Morphine 10mg/ml Fentanyl 100mcg/2ml Remifentanyl 5mg/vial

Dose Initial dose: Initial dose: Initial dose:
0.01-0.15mg/kg 0.35-1.5mcg/kg 1mcg/kg over 30-60sec
Maintenance dose: Maintenance dose: Maintenance dose:
0.07-0.5mg/kg/hr 0.7-10mcg/kg/hr 0.6-15mcg/kg/hr
Onset 5-20 min 2 - 5 min 1-3 min
Dilution 20mg in 20cc NS 0.2mg in 20cc NS 5mg in 20cc NS
Duration 2-4 hours 0.5 – 1 hours 0.3 – 0.6 hours

Elimination Hepatic conjugation; active metabolite Hepatic CYP450 3A4. Hydrolysis by esterases.
excreted renally.
Precaution • May cause CNS depression, hypotension, • May cause CNS depression, • May cause hypotension
orthostatic hypotension and syncope. respiratory depression. • Use with caution in patient with
• May cause respiratory depression, especially • Use with caution in patients with hypovolemia, cardiovascular
in elderly debilitated patients, hypoxia or history of drug abuse or acute disease.
hypercapnia. alcoholism. • Rapid IV infusion may result in
• Use with caution in patients with history of • Use with caution in bradycardia, skeletal muscle and chest wall
drug abuse or acute alcoholism. bradyarrhythmias, renal/ hepatic rigidity, impaired ventilation or
• Use with caution in renal/ hepatic impairment, head trauma. respiratory distress/ arrest
impairment, head trauma, seizure, thyroid
dysfunction
Advantages Reduces tachypnea. Less hypotensive than morphine. Has a more rapid offset
Disadvantages -Reduces blood pressure. Chest wall rigidity -Reduces heart rate and blood
-Respiratory depression. pressure.
-Accumulation in hepatic/ renal failure -Chest wall rigidity
Price per day RM 1.20 RM 28.72 RM 186.0
(RM 0.12/VIAL) (RM 2.85/vial) (RM 186.0/vial)

66


67


68


69

DOBUTAmine Continuous Infusion Chart (DOUBLE Strength)
DOUBLE STRENGTH : 500mg (2 vial) in 50ml Sodium Chloride 0.9% (NS) or Dextrose 5% (D5)
Infusion rate (ml/hr)

Weight(kg)
0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0 9.5 10.0 10.5 11.0 11.5 12.0
35 2.4 4.8 7.1 9.5 11.9 14.3 16.7 19.0 21.4 23.8 26.2 28.6 31.0 33.3 35.7 38.1 40.5 42.9 45.2 47.6 50.0 52.4 54.8 57.1
40 2.1 4.2 6.3 8.3 10.4 12.5 14.6 16.7 18.8 20.8 22.9 25.0 27.1 29.2 31.3 33.3 35.4 37.5 39.6 41.7 43.8 45.8 47.9 50.0
45 1.9 3.7 5.6 7.4 9.3 11.1 13.0 14.8 16.7 18.5 20.4 22.2 24.1 25.9 27.8 29.6 31.5 33.3 35.2 37.0 38.9 40.7 42.6 44.4
50 1.7 3.3 5.0 6.7 8.3 10.0 11.7 13.3 15.0 16.7 18.3 20.0 21.7 23.3 25.0 26.7 28.3 30.0 31.7 33.3 35.0 36.7 38.3 40.0
55 1.5 3.0 4.5 6.1 7.6 9.1 10.6 12.1 13.6 15.2 16.7 18.2 19.7 21.2 22.7 24.2 25.8 27.3 28.8 30.3 31.8 33.3 34.8 36.4
60 1.4 2.8 4.2 5.6 6.9 8.3 9.7 11.1 12.5 13.9 15.3 16.7 18.1 19.4 20.8 22.2 23.6 25.0 26.4 27.8 29.2 30.6 31.9 33.3
65 1.3 2.6 3.8 5.1 6.4 7.7 9.0 10.3 11.5 12.8 14.1 15.4 16.7 17.9 19.2 20.5 21.8 23.1 24.4 25.6 26.9 28.2 29.5 30.8
70 1.2 2.4 3.6 4.8 6.0 7.1 8.3 9.5 10.7 11.9 13.1 14.3 15.5 16.7 17.9 19.0 20.2 21.4 22.6 23.8 25.0 26.2 27.4 28.6
75 1.1 2.2 3.3 4.4 5.6 6.7 7.8 8.9 10.0 11.1 12.2 13.3 14.4 15.6 16.7 17.8 18.9 20.0 21.1 22.2 23.3 24.4 25.6 26.7
80 1.0 2.1 3.1 4.2 5.2 6.3 7.3 8.3 9.4 10.4 11.5 12.5 13.5 14.6 15.6 16.7 17.7 18.8 19.8 20.8 21.9 22.9 24.0 25.0
85 1.0 2.0 2.9 3.9 4.9 5.9 6.9 7.8 8.8 9.8 10.8 11.8 12.7 13.7 14.7 15.7 16.7 17.6 18.6 19.6 20.6 21.6 22.5 23.5
90 0.9 1.9 2.8 3.7 4.6 5.6 6.5 7.4 8.3 9.3 10.2 11.1 12.0 13.0 13.9 14.8 15.7 16.7 17.6 18.5 19.4 20.4 21.3 22.2
95 0.9 1.8 2.6 3.5 4.4 5.3 6.1 7.0 7.9 8.8 9.6 10.5 11.4 12.3 13.2 14.0 14.9 15.8 16.7 17.5 18.4 19.3 20.2 21.1
100 0.8 1.7 2.5 3.3 4.2 5.0 5.8 6.7 7.5 8.3 9.2 10.0 10.8 11.7 12.5 13.3 14.2 15.0 15.8 16.7 17.5 18.3 19.2 20.0

70


71

NORADRENALINE Continuous Infusion Chart (DOUBLE Strength)
DOUBLE STRENGTH : 8mg (2 ampul) in 50ml Dextrose 5% (D5) OR Dextrose Saline
Infusion rate (ml/hr)

Weight(kg)
1 2 3 4 5 6 7 8 9 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50
30 0.09 0.18 0.27 0.36 0.44 0.53 0.62 0.71 0.80 0.89 1.07 1.24 1.42 1.60 1.78 1.96 2.13 2.31 2.49 2.67 2.84 3.02 3.20 3.38 3.56 3.73 3.91 4.09 4.27 4.44
35 0.08 0.15 0.23 0.30 0.38 0.46 0.53 0.61 0.69 0.76 0.91 1.07 1.22 1.37 1.52 1.68 1.83 1.98 2.13 2.29 2.44 2.59 2.74 2.90 3.05 3.20 3.35 3.50 3.66 3.81
40 0.07 0.13 0.20 0.27 0.33 0.40 0.47 0.53 0.60 0.67 0.80 0.93 1.07 1.20 1.33 1.47 1.60 1.73 1.87 2.00 2.13 2.27 2.40 2.53 2.67 2.80 2.93 3.07 3.20 3.33
45 0.06 0.12 0.18 0.24 0.30 0.36 0.41 0.47 0.53 0.59 0.71 0.83 0.95 1.07 1.19 1.30 1.42 1.54 1.66 1.78 1.90 2.01 2.13 2.25 2.37 2.49 2.61 2.73 2.84 2.96
50 0.05 0.11 0.16 0.21 0.27 0.32 0.37 0.43 0.48 0.53 0.64 0.75 0.85 0.96 1.07 1.17 1.28 1.39 1.49 1.60 1.71 1.81 1.92 2.03 2.13 2.24 2.35 2.45 2.56 2.67
55 0.05 0.10 0.15 0.19 0.24 0.29 0.34 0.39 0.44 0.48 0.58 0.68 0.78 0.87 0.97 1.07 1.16 1.26 1.36 1.45 1.55 1.65 1.75 1.84 1.94 2.04 2.13 2.23 2.33 2.42
60 0.04 0.09 0.13 0.18 0.22 0.27 0.31 0.36 0.40 0.44 0.53 0.62 0.71 0.80 0.89 0.98 1.07 1.16 1.24 1.33 1.42 1.51 1.60 1.69 1.78 1.87 1.96 2.04 2.13 2.22
65 0.04 0.08 0.12 0.16 0.21 0.25 0.29 0.33 0.37 0.41 0.49 0.57 0.66 0.74 0.82 0.90 0.98 1.07 1.15 1.23 1.31 1.39 1.48 1.56 1.64 1.72 1.81 1.89 1.97 2.05
70 0.04 0.08 0.11 0.15 0.19 0.23 0.27 0.30 0.34 0.38 0.46 0.53 0.61 0.69 0.76 0.84 0.91 0.99 1.07 1.14 1.22 1.30 1.37 1.45 1.52 1.60 1.68 1.75 1.83 1.90
75 0.04 0.07 0.11 0.14 0.18 0.21 0.25 0.28 0.32 0.36 0.43 0.50 0.57 0.64 0.71 0.78 0.85 0.92 1.00 1.07 1.14 1.21 1.28 1.35 1.42 1.49 1.56 1.64 1.71 1.78
80 0.03 0.07 0.10 0.13 0.17 0.20 0.23 0.27 0.30 0.33 0.40 0.47 0.53 0.60 0.67 0.73 0.80 0.87 0.93 1.00 1.07 1.13 1.20 1.27 1.33 1.40 1.47 1.53 1.60 1.67
85 0.03 0.06 0.09 0.13 0.16 0.19 0.22 0.25 0.28 0.31 0.38 0.44 0.50 0.56 0.63 0.69 0.75 0.82 0.88 0.94 1.00 1.07 1.13 1.19 1.25 1.32 1.38 1.44 1.51 1.57
90 0.03 0.06 0.09 0.12 0.15 0.18 0.21 0.24 0.27 0.30 0.36 0.41 0.47 0.53 0.59 0.65 0.71 0.77 0.83 0.89 0.95 1.01 1.07 1.13 1.19 1.24 1.30 1.36 1.42 1.48
95 0.03 0.06 0.08 0.11 0.14 0.17 0.20 0.22 0.25 0.28 0.34 0.39 0.45 0.51 0.56 0.62 0.67 0.73 0.79 0.84 0.90 0.95 1.01 1.07 1.12 1.18 1.24 1.29 1.35 1.40
100 0.03 0.05 0.08 0.11 0.13 0.16 0.19 0.21 0.24 0.27 0.32 0.37 0.43 0.48 0.53 0.59 0.64 0.69 0.75 0.80 0.85 0.91 0.96 1.01 1.07 1.12 1.17 1.23 1.28 1.33

2020 Ed Dilution Protocol

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DILUTION

PROTOCOL FOR EMERGENCY

| ED HTAA DILUTION PROTOCOL 2020

Shamsiah binti Salim

Reviewers (Alphabetical order)

Dr Badrul Hisham B. Md Supian

Dr Norizan Bt. Mustafa

Dr Yip Yat Keong

Dr Zainal Abidin B. Mohamed @ Ismail

Shamsiah Salim, Ward Pharmacist, Updated July 2020

Shamsiah Salim, Ward Pharmacist, Updated July 2020

(i) Paracetamol Poisoning regimen:

Oral NAC: (a) 140mg/kg by mouth or nasogastric tube diluted to 5% solution,

PARACETAMOL POISONING IN CHILDREN:

Dilution Volume of D5%

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

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

Note for Dose & Administration:

(iii) CT Scan regimen:

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

Shamsiah Salim, Ward Pharmacist, Updated July 2020

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

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

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

4. Hypersensitivity reaction (anaphylaxis):

§ Intramuscular, IM (1: 1000)

§ Intravenous, IV (1: 10 000)

Dilution for Continuous Infusion:

Infusion rate: According to dose ordered

Shamsiah Salim, Ward Pharmacist, Updated July 2020

Prepare IV Adenosine & 20ml flush in 2 separate syringe

Attached both syringes to IV injection port closest to patient

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

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

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

Shamsiah Salim, Ward Pharmacist, Updated July 2020

1. Thrombolytic treatment in acute ischemic stroke

2. Thrombolytic treatment in acute myocardial infarction

3. Thrombolytic treatment in acute massive pulmonary embolism with

1. Acute Ischemic Stroke

Total dose Total Volume Volume to be administer

Shamsiah Salim, Ward Pharmacist, Updated July 2020

2. Acute Myocardial Infarction

Dilution & Administration:

§ 50 mg Alteplase, diluted with 50 ml sterile water for injection

Storage & Stability:

Precautions / Special Warning:

Shamsiah Salim, Ward Pharmacist, Updated July 2020

Amiodarone 150MG/3ML Inj

ACLS 2010, AHA Guideline

Then; 300mg over 6 hours

Then; 600mg over 18 hours

British Resuscitation Guideline, 2010

Then; 900mg over 23hours

Shamsiah Salim, Ward Pharmacist, Updated July 2020

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

Dilution for Maintenance dose:

Shamsiah Salim, Ward Pharmacist, Updated July 2020

Atropine Sulphate 1MG/ML Inj

Indication & Dose:

Child: IV 0.02mg/kg every 3-5 mins (Max single dose is 0.5mg).

Reconstitution: Not required

Administration: Give undiluted over 15-30sec.