Module Name - Medication

Injections in ICU
 Medication Administration Safety and Policy

Hospital has a medication safety policy and should follow it strictly

Five rights of medication safety:

The right Patient

The right Drug

The right Dose

The right Route

The right Time

 Route of Medication administration

• Oral route

• Per rectal route

• Vaginal route

• Inhaled route

• Injectable medications: it can be either-

• Intravenous route:
Bolus
Infusion
• Intramuscular route or

• Subcutaneous route
 Policy of procurement and storage of medicines before
administration
Prescription is written by doctors in medicine card

Prescription appropriateness is checked by Clinical pharmacists /nursing staffs

Prescription corrections are done by the doctors.

Medicines are ordered/indented by nursing staffs to the concern Pharmacy through ATHMA application

Medicines are received at ward from pharmacy.

Medicines received are checked by the Nursing staffs for appropriateness as per the orders placed by them.

Normal medicine are stored in the appropriate box bearing the patient identification inside the medicine preparation area.

High Alert medicines are stored in the appropriate box with High Alert label and patient identification inside medicine preparation area.

Concentrated electrolytes are stored in an appropriate box with proper label and patient identification inside a cupboard bearing the label
‘Concentrated Electrolytes - “Dilute before administration”. Nursstaff t

Nursing staffs prepare the medicines inside medicine preparation area on Medicine Preparation Trolley for reconstitution and dilution of injectables.
 Intravenous Infusions and its Titration

• Inotropes: Epinephrine (Adrenaline), Dobutamine, Dopamine, Milrinone

• Vasopressors: Norepinephrine, Vasopressin
• Anti-hypertensives : Glyceryl Trinitrate (GTN), Labetalol
• Antiarrhythmic
• Analgesics: Fentanyl
• Sedatives: Propofol, Dexmedetomidine
• Insulin: Human insulin , insulin Glargine
• Heparin: Unfractionated Heparin
• Concentrated electrolytes: Potassium Chloride (KCl)
Potassium Phosphate
Magnesium Sulphate
3% Sodium Chloride
Sodium bicarbonate
Calcium Gluconate
Inotropes: These are agents that alter the force and strength of myocardial contractility.
Vasopressors: These are sympathomimetic drugs that mimic the effects of the sympathetic nervous system.
They cause vascular smooth muscle vasoconstriction.
Drug Receptor
Adrenaline Sympathomimetic amine with high affinity for β1, β2 and α1. β effects are more pronounced at a small dose
and α1 effects at a higher dose.
Noradrenaline Sympathomimetic amine with potent α1 effects and modest β-agonist activity.

Dobutamine Synthetic catecholamine with strong β1 and β2 effects. Its cardiac β1 effect makes it a potent inotrope,
however it has weak chronotropic activity. Vascular smooth muscle binding results in combined α1 adrenergic
agonism and antagonism as well as β2 stimulation with a net vascular effect of mild vasodilation.

Milrinone Phosphodiesterase inhibitor (PDI).Phosphodiesterase 3 is an intracellular enzyme associated with the

sarcoplasmic reticulum in cardiac myocytes and vascular smooth muscle that breaks down cAMP into AMP.
Milrinone is a PDI that increases the
level of cAMP by inhibiting its breakdown. This leads to increased myocardial contractility. It is also a potent
inotrope and vasodilator

Vasopressin Exerts its circulatory effect on V1 receptors causing constriction of vascular smooth muscle. Its V2 effects
increase renal collecting duct permeability and mediate water reabsorption.
 Inotropes , Adrenaline or Epinephrine
Titration order
Medication Name: Adrenaline
Medication Route: Intravenous Infusion via Syringe Pump; central line only
Concentration: 2mg/50ml, 4mg/50ml
Supplied as: 1 ml ampoule contains 1 mg Adrenaline
Dilution : For 2mg/50ml- take 48 ml NS add 2 ampoule adrenaline; for 4mg/50ml take 46 ml NS add 4 ampoule adrenaline
Indication: Inotrope
Scope: Cardiac Surgical Patients ( Adult)

Initial or staring rate of infusion 0.03mcg/kg/min or more

Rate of infusion increased 0.01mcg/kg/min
How often rate of infusion can be increased Every 15 minutes

Maximum rate of infusion 0.2mcg/kg/min

Rate of infusion is decreased For 2/50 dilution @ 0.3 ml/hour; for 4/50 dilution @ 0.2 ml /hour
How often rate of infusion can be decreased Every 1 hour
Objective clinical end point MBP 65 –80 mmHg
 Inotropes… Dobutamine
Titration order
Medication Name: Dobutamine
Medication Route: Intravenous Infusion via syringe pump; central line or peripheral line
Concentration: 250mg/50ml
Supplied as 5 ml ampoule contains 250 mg Dobutamine
Dilution: take 45 ml NS add 1 ampoule Dobutamine
Indication: Inotropes
Scope: Post-operative Cardiac Surgical Patients and decompensated heart failure

Initial or starting rate of infusion 5mcg/kg/min

Rate of infusion increased 2.5mcg/kg/min
How often rate of infusion can be increased Every 15 minutes
Maximum rate of infusion 10mcg/kg/min
Objective clinical end point while increasing dose MBP > 65mmHg, urine output improved and signs
of shock absent
Rate of infusion is decreased 0.3 ml/hour
How often rate of infusion can be decreased Every 1 hour
 Inotropes….Dopamine
Titration order
Medication Name: Dopamine
Medication Route: Intravenous Infusion via syringe pump; central line or peripheral line
Concentration : 200mg/50ml
Supplied in 5 ml ampoule containing 200 mg Dopamine
Dilution: take 45 ml NS add 1 ampoule (5 ml) Dopamine
Indication: inotropes , vasopressors
Scope: Post-operative Cardiac Surgical Patients and decompensated heart failure, cardiogenic and vasodilatory shock
Initial or starting rate of infusion 2mcg/kg/min

Rate of infusion increased 2mcg/kg/min

How often rate of infusion can be increased Every 15 minutes

Maximum rate of infusion 20mcg/kg/min

Objective clinical end point while increasing dose MBP > 65mmHg

Rate of infusion is decreased 0.3 ml/hour

How often rate of infusion can be decreased Every 1 hour
 Inotropes….Milrinone
Titration order
Medication Name: Milrinone

Medication Route: Intravenous Infusion through central line via syringe pump
Concentration: 10mg/50 ml
Supplied as 10 ml vial contains 10 mg milrinone
Dilution : take 40 ml NS add 1 ampoule (10 ml) Milrinone
Indication: Inotrope and vasodilator
Scope: Post-operative Cardiac Surgical Patients and decompensated heart failure, cardiogenic shock

Initial or starting rate of infusion 2 ml/hour

Rate of infusion increased As per doctor's instruction
How often rate of infusion can be increased Every 15 minutes
Maximum rate of infusion 0.75mcg/kg/min; reduce dose in renal failure
Objective clinical end point while increasing dose MBP > 65mmHg, signs of low cardiac output not present
Rate of infusion is decreased 0.3 ml/hour
How often rate of infusion can be decreased Every 1 hour
Stop tapering Milrinone MBP <65mmHg or mixed venous oxygen saturation <60%, other
signs of shock re appears
 Vasopressors……Noradrenaline
Titration order
Medication Name: Noradrenaline
Medication Route: Intravenous Infusion via syringe pump; central line only
Concentration: 2mg/50 ml,4mg/50ml or 8mg/50ml
Available as: 2 ml ampoule contains 2 mg Noradrenaline
Dilution: for 2/50 take 48 lm NS ADD 2 ml Noradrenaline; for 4/50 take 46 ml NS add 4 ml noradrenaline
Indication: Vasopressor
Scope: Cardiac Surgical Patients ( Adult) with hypotension, Septic Shock, Vasoplegic shock
Initial or starting rate of infusion 0.01mcg/kg/min
Rate of infusion increased 0.05mcg/kg/min
How often rate of infusion can be increased Every 15 minutes
Maximum rate of infusion 3mcg/kg/min
Stop increasing dose when MBP > 65mmHg
Infusion is decreased at a rate For 2/50 dilution @ 0.3 ml/hour; for 4/50 dilution
@ 0.2 ml /hour
How often rate of infusion can be decreased Every 1 hour
Stop tapering noradrenaline when MBP <65mmHg
Medication name: Vasopressin
Medication route: Intravenous via syringe pump only
Available as: 1 ml ampoule contains 20 units Vasopressin
Concentration: 1unit/ml; take 48 ml 0.9% NS add 2 ampoule Vasopressin
Indication: Septic shock when noradrenaline dose is high at a range 0.25mcg/kg/min to 0.5 mcg/kg/min
Scope: all critically ill patients in ICU
Use vasopressin in septic shock as second line of vasopressor after noradrenaline.

Initial starting rate of infusion: 0.03 units/min

Dose titration not recommended in septic shock

Maximum rate of infusion: 0.06units/min

( at this dose can cause cardiac, splanchnic and digital ischemia)
Stop vasopressin once targeted MBP attained and maintained for few hours: Target MBP> 65 mm of Hg
 Antihypertensive…..GTN
Titration order
Medication Name: Glyceryl Trinitrate
Medication Route: Intravenous Infusion via syringe pump: both central and peripheral line
Concentration: 25mg/50ml (500mcg/ml)
Supplied in 5 ml ampoule contains 25 mg
Dilution: take 45 ml NS add 1 ampoule (5ml) GTN
Indication: vasodilator, antihypertensive, anti-anginal, heat failure
Scope: Post-operative Cardiac Surgical Patients and decompensated heart failure in CCU, angina
Initial or starting rate of infusion 0.6ml/hour (5mcg/min)
Rate of infusion increased 0.6ml/hour (5 mcg/min)
How often rate of infusion can be increased 3 to 5 minutes
Maximum rate of infusion 10 ml/hour
Objective clinical end point while increasing dose Symptoms relieved, SBP within target limit
Rate of infusion is decreased 0.6 ml/hour
How often rate of infusion can be decreased Every 1 hour
When to stop GTN infusion SBP <90mmHg,
Monitor BP Every 15 minutes initial 1st hour then every hourly and as required
 Antihypertensive……Labetalol
Titration order
Medication Name: Labetalol
Medication Route: Intravenous Infusion via syringe pump: both central and peripheral line
Available as: 4ml ampoule contains 20 mg labetalol (1ml=5mg)
Dilution : Central line: 5mg/ml Peripheral line: 1mg/ml
Diluent : 0.9%NS, 5D
Indication: acute hypertension in aortic dissection, neurogenic hypertension, hypertension of pregnancy and hypertensive crisis
(SBP>180 and DBP>120)
Scope: Cardiac Surgical Unit, CCU, Neuro ITU
Give a bolus dose of 10-20 mg over 2 mins before starting infusion
Initial or starting rate of infusion 30mg/hour (0.5mg/min)
Rate of infusion increased By 6mg/hour up to 60 mg/hour
How often rate of infusion can be increased Every 10 minutes
Maximum rate of infusion 2mg/min (120mg/hour)
Maximum dose of infusion 200mg in 24 hours
Objective clinical end point while increasing dose Target SBP 100-120 mmHg, MAP <80 mmHg
Rate of infusion is decreased Gradually over 1-2 hours before stopping.
When to stop Labetalol infusion If HR<60 or desired BP achieved (SBP 100-120)
Monitor BP Continuous monitoring of BP by an arterial line is mandatory.
References : DRUGS TODAY, UPTODATE.COM, NHS Critical Care Guideline, ESC Guideline,
AHA/ACC Guideline
 Antiarrhythmic
• Antiarrhythmics are medications that prevent and treat a heart rhythm that is too fast or irregular (including AF, AFL,
VT and VF)
• How do antiarrhythmics work

They act on hearts various electrical channels to

- Stop an irregular, extra electrical impulses
- Prevent abnormally fast electrical impulse to travel in heart
Classification of antiarrhythmic: Vaughan Williams (VW)
Class I Sodium channel blockers:
Eg. Quinidine, Lignocaine, Flecainide, Mexiletine
Class2 II Beta blockers:
Eg. Atenolol, Metoprolol, Bisoprolol, Propranalol
Class III Potassium channel blocker:
Eg. Amiodarone, Sotalol, Ibutilide
Class IV Nondihydropyridine calcium channel blockers:
Eg. Diltiazem , Verapamil
Not included in this classifications are: Digoxin, Adenosine
 Antiarrythmics … Lignocaine Hydrochloride
Drug order
Medication Name: 2% Lignocaine Hydrochloride
Medication Route: Intravenous Infusion via syringe pump central line only
Available: 50 ml vial contains 2% lignocaine hydrochloride ( 1ml = 20 mg)
Dilution: further dilution not required
Indication: Antiarrhythmic for VPCs, VT, VF
Scope: Cardiac surgical and medical ICU

Initial bolus dose 1 to 1.5 mg/kg

Repeat dose after 5to 10 minutes 0.5 to 0.75 mg/kg

Maximum bolus dose 3mg/kg

Infusion rate 1 to 4 mg/ min
When to stop infusion As soon as arrhythmia under control or earliest sings of toxicity appears

Toxic signs and symptoms Circumoral numbness, tongue paresthesia, dizziness, blurred vision, tinnitus,
restlessness, agitation, seizure, coma.
 Antiarrhythmic … Amiodarone
Titration order
Medication Name: Amiodarone Hydrochloride
Medication Route: Intravenous Infusion via syringe pump central line only
Available: 3 ml ampoule contains 150 mg amiodarone hydrochloride
Dilution: take 38 ml 5D add 4 ampoule (600mg) Amiodarone.
Concentration : 600mg/50ml (12 mg/ml)
Indication: Antiarrhythmic in AF, AFL, VPCs, VT, VF
Scope: Post-operative Cardiac Surgical Patients and decompensated heart failure

Initial bolus dose 150 mg Amiodarone to be added in 100 ml of 5D in a IV drip set chamber and
infused over 10 minutes. Then….
Initial or starting rate of infusion 5ml/hour ( 60 mg/hour or 1mg/min) for 5 hours. Then ….
After 6 hours continue infusion at a 2.5ml/hour (30 mg/hour or 0.5 mg/min)
rate
If breakthrough arrhythmia 150 mg iv bolus over 10 minutes should be repeated
Maximum total dose in 24 hours 2400mg/ 24 hours

Dose of Amiodarone hydrochloride in cardiac arrest due to Pulseless VT and VF:

First dose : 300mg IV bolus
Second dose :150 mg IV bolus.
If ROSC attained then start infusion as per antiarrhythmic dose discussed above
 Analgesics …..Fentanyl
Titration order
Medication Name: Fentanyl ( it is a narcotic and follow hospital policy on narcotics)
Medication Route: Intravenous Infusion via syringe pump: both central and peripheral line
Concentration : 500mcg /50 ml (10 mcg/ml)
Supplied: 1 ml ampoule contains 100mcg fentanyl, 10 ml ampoule contains 500 mcg fentanyl
Dilution : take 40 ml NS add 10 ml (500mcg) Fentanyl
Indication : analgesic ( Narcotic)
Scope: Cardiac Surgical Unit, CCU
Special precaution: Naloxone should be available to treat narcotic overdose ( 0.4 mg IV/IM/SC, if required repeat every 2-3 minutes .
Maximum total dose 10 mg)

Give a bolus dose of 50 to 100 mcg Fentanyl ( 1-2 mcg/kg)

Initial or starting rate of infusion
Rate of infusion increased
Maximum rate of infusion
Maximum dose of infusion
Stop increasing dose when
2 ml /hour
Every hourly as per CPOT / VAS score @ 1ml/hour
1-2 mcg/kg/hour
200 mcg /hour
CPOT score is 0 on ventilated patient and VAS score 0 in nonventilated patient or when
maximum dose reached; add non opioid analgesic

Rate of infusion is decreased When CPOT score <0 to 1mcg/kg/hour

When to stop infusion When CPOT score<-2, assess hourly and restart if pain recurs with a dose f 1 mcg/kg/hour
Monitor BP, pule SPO2 and Respiration Hourly
References : DRUGS TODAY, UPTODATE.COM, NHS Critical Care Guideline, ESC Guideline,
 Sedation …. Propofol
Targeted dose Titration
Medication Name: Propofol

Medication Route: Intravenous Infusion via syringe pump, central line only
Available : 1% Propofol in 50ml vial, contains 500mg (1ml is equal to 10 mg)
Dilution : no dilution required
Indications: Sedation
Scope: Post-operative Cardiac Surgical Patients and other surgical and medical patients on ventilator
Target RASS score: for ventilated patient -1 to -3( target sedation score should be mentioned in sedation order given
by doctor)

Initial or starting rate of infusion 5 to 10 mcg/kg/min

Assess RASS
Increase infusion at a rate
Maximum rate of infusion
Stop further increment of infusion
How often RASS scoring done
Daily sedation interruption
Every 10 minutes till target RASS achieved
5 to 10 mcg/kg/min every 10 minutes till desired sedation achieved
50mcg/kg/min
As target RASS achieved ( as mentioned in sedation advise)
While titrating dose and there after every shift while taking hand over
Once daily during morning shift
 Sedation… Targeted Dose Titration of
Dexmedetomidine
Medication Name: Dexmedetomidine

Medication Route: Intravenous Infusion via syringe pump, peripheral or central line
Available : 1 ml ampoule contains 100mcg Dexmedetomidine
Concentration: 200mcg/50ml (4 mcg/ml)
Dilution: take 48 ml NS and 2 ml(200mg) Dexmedetomidine
Indication: sedation in ICU
Scope: Post-operative Cardiac Surgical Patients and other surgical and medical patients on ventilator
Target RASS score: for ventilated patient -1 to -3( target sedation score should be mentioned in sedation order given by
doctor)

Initial or starting rate of infusion 0.2 mcg/kg/hour

Assess RASS
Increase infusion at a rate
Maximum rate of infusion
Stop further increment of infusion
How often RASS done
Daily sedation interruption
Every 10 minutes till target RAS achieved (as mentioned in sedation advise)
0.2 mcg/kg/hour every 10 minutes till target RASS achieved
0.7 mcg/kg/hour
As target RASS of (-3 to 0) achieved
While titrating dose and there after every shift while taking hand over
Once daily during morning shift
 Insulin Therapy…… Drug Titration order
INSULIN INTRAVENOUS INFUSION SLIDING SCALE INSULIN SUBCUTANEOUS SLIDING SCALE
Medication name Human Insulin Actrapid ( fast acting human insulin) Medication name Human Actrapid (fast acting human insulin)
Available as Each vial contains 10 ml @ 40IU/ml
Available as Each vial contains 10 ml @ 40IU/ml
Dilution 2ml insulin in 48 ml NS
Final Concentration 80 units/ 40 ml ( 2 IU/ ml) Dilution Not required
Medication route Intravenous through central line/ Peripheral line, via a syringe pump Final concentration 40 IU/ml
Medication route Subcutaneous
Indications Hyperglycemia Indications Hyperglycemia
Scope All critical care patients Scope All critically ill patients on oral or tube feed
Maximum rate of Not specified. When rate of infusion > 5ml inform doctor Maximum rate of Not specified
infusion infusion
Target CBG 140 to 180 mg/dl
During dialysis >200mg/dl
Frequency of insulin Before Breakfast, Before Lunch, Before Dinner
dose
TITRATION ORDER FOR INSULIN INFUSION
Target CBG 140 to180 mg/dl
CBG Rate of infusion Check CBG During dialysis > 200mg/dl
TITRATION ORDER FOR SUBCUTANEOUS HUMAN INSULIN
Protocol A Protocol B Protocol C
< 100 0 0 0 Hourly CBG Dose of insulin Check CBG
101 to 125 0 0.5 0.5 Hourly
<90 No insulin Before break fast
126 to 150 1 1.5 1.5 Hourly 90 to 120 2
151 to 200 2 3 4 Hourly Before lunch
121 to 150 4
201 to 250 3 4 5 Hourly
151 to 180 5 Before dinner
251 to 300 4 5 7 Hourly 181 to 210 6
>300 inform inform inform hourly 211 to 240 7 10 pm
Up titration: Start with protocol A, if CBG remains > 200 tow consecutive hours then go to 241 to 270 8
protocol B.
If on protocol B the CBG remains > 200 two consecutive hours go to protocol C 271 to300 9
Down titration: if on any of the above protocol CBG remains <200 in two consecutive hours > 300 Start insulin infusion
come back to the previous protocol ( form C to B or from B to A)
If hypoglycemia < 70 mg STOP insulin infusion and give treatment of hypoglycemia, check CBG Add 80% of total dose of human insulin in 24 hours as basal insulin (Insulin Glargine) at
every 15 minutes till CBG comes to target range. 10 pm
1 vial of Insulin Glargine contains 3ml; each ml contains 100 IU Insulin Glargine.
 Anticoagulation Therapy

Indications of anticoagulation therapy: heart valve replacement surgery,

• Vascular surgery, vascular intervention,
• MI, ACS
• Treatment of DVT and PE
• Prevention of DVT
• Prevention of thromboembolism in AF ( where indicated)
• Patient on ECMO, Ventricular assist device

Following anticoagulation medications are commonly used in ICU:

• ORAL: Warfarin, Acitrom, factor Xa inhibitors (Rivaroxaban, Apixaban), Direct Thrombin Inhibitor (Dabigatran,
Argatroban)
• Injectable: Unfractionated Heparin, LMWH (Enoxaparin, Dalteparin)

Routine Monitoring a patient on anticoagulation:

• Unfractionated heparin infusion: 6 hourly APTT and titrate dose accordingly
• Bolus unfractionated heparin APTT once daily
• Warfarin and Acitrom daily PT and INR
 Check list before starting Heparin
Therapy
Characteristics Yes No
Doctors written advise for heparin therapy is there
Nurse is aware that heparin is a high risk medicine
Indication of antithrombotic therapy
Allergy to heparin
Actual body weight
Most recent pertinent laboratory data (APTT, INR, platelet, Hb)
Any active bleeding present?
Recent trauma or surgery
Bleeding problem experienced while receiving any previous antithrombotic therapy
Any known history of HIT
Liver disease ( chance of bleeding complications are high)
Hypercoagulable state (that would affect the dose requirement of heparin)
Frequency of APTT monitoring advised
Heparin infusion protocol is available and doctors advise is there
A CVP line is present for frequent blood sampling
Nurse is aware of the complication of heparin therapy like bleeding, HIT
Therapeutic goal of antithrombotic therapy written
 Unfractionated Heparin Nomogram

Initial dosing: ACS/ MI DVT/PE/AF

Follow doctor’s Bolus: 60 units/kg IV once (not to exceed 5000 Bolus: 80 units/kg IV once (not to exceed 10000
Instruction, units) units)
about bolus Half Bolus: 30 units/kg IV once Half Bolus: 40 units/kg IV once
Half bolus or no No Bolus: No Bolus
bolus Infusion: starting dose 12 units/kg/hr (not to Infusion: starting dose 18 units/kg/hr (not to
exceed 1000 units/hr); repeat APTT after 6 hours exceed 2250 units/hr); repeat APTT after 6 hr.

Heparin infusion titration order:

use heparin dosing nomogram below for all treatment indications. Mention therapeutic goal of APTT---------------------
Heparin Dosing Nomogram
APTT results in sec. Dose Adjustment Repeat APTT
<35 (1.2) Bolus with 80 units/ kg IV AND increase infusion by 4 units/kg/hr. 6 hours
35- 45(1.2- 1.5) Bolus with 40 units/kg IV AND Increase dose by 2 units/kg/hr. 6 hours
46-70 (1.5- 2.3) No change, therapeutic range Next morning
71-90 (2.3-3) Decrease infusion by 2 units/kg/hr. 6 hours
90 or more(>3) Hold infusion for 1 hr AND decrease infusion by 3 units/kg/h 6hours
•Once two consecutive APTT results are at therapeutic level then check APTT every 24 hours.
•Start warfarin/ acenocoumarol orally after heparinisationimmediately, continue heparin infusion at least 5 days or till INR therapeutic.
•Repeat platelet count every 2to3 days from 4thday of infusion to 14 days or until heparin is stopped, whichever comes first.
•When the APTT values are outside target range contact doctor and modify therapy accordingly
•If platelet count <100,000/<50% of baseline, do 4Ts score to assess possible diagnosis of HIT.
 Concentrated Electrolytes

• Follow hospital policies related to concentrated electrolytes prescription, procurement , storage and administration

Definition: concentrated electrolytes may be described as solution manufactured and distributed with the intension
of being diluted prior to administration.

Example includes but not limited to:

Potassium chloride injection 2 mmol/ml
Magnesium Sulphate 50% injection
3% hypertonic saline
Sodium bicarbonate 8.4%
Calcium Gluconate

When these solutions are available on a patient care unit, the risk is significant that accidental administration may
occur without first diluting , especially during an emergency.
Stocking concentrated electrolytes in clinical areas if needed should be done as per hospital policies.
Appropriate safeguards must be developed to prevent inadvertent administration of these medications without
proper dilution
 Concentrated Electrolytes….Potassium chloride Drug Titration order for Cardiac Sugrical
Critical Care(ITU 789) & Coronary Critical Care Unit (CCU 2,3,4 & CCU 1-Cardiac side )

Medication name Potassium Chloride

Medication route Intravenous through central line, via a syringe pump
Available 10 ml ampoule contains 20 mmol KCl
Concentration Take 40 ml NS add 1 ampoule (10ml) KCl to make a concentration of 20mmol/50ml
Indications Hypokalemia
Scope Cardiac surgery , GI surgery not on enteral feed, cardiac arrhythmia
Maximum rate of infusion 20 mmol/hour via central line
Target potassium GFR>30ml/minute target – 3.8 to 4.5
GFR< 30ml/minute, target 3.6 to 4.0
Serum potassium Infusion rate Check serum potassium in ABG sample
<2 20 mmol/hour After 2 hours
2.0 to 2.5 14 m mol/hour After 2 hours
2.5 to 3.0 8 m mol/hour After 2 hours
3.0 to 3.5 6 After 4 hours
3.5 t0 4 5 After 4 hours
4.0 to 4.5 Calculate predicted loss and replace
 4.5 Stop potassium infusion. Recheck potassium after 4 hours
 Concentrated Electrolytes….Potassium chloride Drug titration order for Medical Critical care &
Surgical Critical Care (CCU 1) & Medical Critical Care units (ITU 4,5,6, ITU 3 & ITU 10)

DRUG DOSE DILUTION TITRATION TAPERING

POTASSIUM 20 mEq KCl (10 ml) + 40 ml NS (0.4 20 mEq KCl IV over • How much:100 mEq (andequivalent
CHLORIDE mEq/ml) 40 mEq KCl (20 ml) + 30 ml 4 hrs @12.5 ml/hr fractions) for each 1.0 mmol deficit of K+;
NS (0.8 mEq/ml) NB. ie, 5 mEq/hr half dose for renal dysfunction
40 mEq KCl IV over
If hypernatremia / hyperchloremia is 6 hrs @8.3 ml/hr • How long:Replacement stopped when
a worry, dilution maybe done in ½NS ie, ~7 mEq/hr K+≥4.0 mmol/L
& will be advised by the physician.
All other • Frequency of monitoring: usually 24 hrly,
replacements are unless otherwise specified. In case of
combinations / worsening renal function / post-RRT (HD),
multiples of the monitoring to be done 12 hrly
above 2 – (eg, 60
mEq IV over 10 • Where:IV replacement of KCl should be
hrs, 80 mEq IV always done in a monitored bed (either
over 12 hrs, etc) ICU or HDU)
 Concentrated Electrolyte…50% Magnesium Sulphate Drug order for Cardiac sugrical Critical
Care(ITU 789) & Coronary Critical Care Unit (CCU 2,3,4 & CCU 1-Cardiac side)

Medication name Magnesium Sulphate

Route of administration Intravenous, central line, via a syringe pump
Available 2ml ampoule contains 1gm Magnesium
Dilution 2gm./ 50 ml
Diluent 0.9% NS
Indications Hypomagnesemia, Cardiac Arrhythmia, Torsade’s, Preeclampsia, Eclampsia
Scope Cardiac surgical / medical and maternity ward
Bolus dose Should be prepared separately not along with infusion
Infusion dose and rate
Indications Bolus dose Infusion dose Maximum Rate of Maximum dose Lab Mg test
infusion
Severe symptomatic 1-2 gm. IV over 15 4-8 gm. over 12- 24 hours 0.5gm/hour 1.5meq/kg/day .Daily once.
Hypomagnesemia minutes (1gm=8meq) .If any signs or symptoms of
Torsade’s de pointes 2 gm. iv over 15 4-8 gm. over 12-24 hours 0.5gm/hour 1.5meq/kg/day Hypermagnesaemia
minutes . frequently in renal failure
Eclampsia 4gm iv over 15 min.If 1gm/hour 3gm/hour Continued 24 hours after
recur repeat 2gm birth or more if symptoms
persists
Hypomagnesemia in 1gm IV bolus over 15 4gm in 50 ml NS over 24 Should be used cautiously in renal failure
renal impairment minutes hrs.
Hypermagnesaemia
Symptoms and signs Hypotension, bradycardia, heart block, muscle flaccid paralysis, breathing difficulty, loss of deep tendon reflexes

Treatment Inj calcium gluconate 500 mg over 5 minutes

 Concentrated Electrolyte….Magnesium Sulphate Drug order for Medical Critical care &
Surgical Critical Care (CCU 1) & Medical Critical care units (ITU 4,5,6, ITU 3 & ITU 10)

DRUG DOSE DILUTION TITRATION TAPERING

MAGNESIUM Diluted in NS, to make upto 50
SULPHATE ml; maximum 12 g (12 ampoules
= 24 ml) eg, if 1 g replaced, 2 ml
amp is added to 48 ml NS NB. If
hypernatremia / hyperchloremia
is a worry, dilution maybe done
in ½NS & will be advised by the
physician
For number of grams How much: 1 g (and equivalent fractions; 1 g
of MgSO4replaced, Ξ 2 ml [1 ampoule]) for each 0.1 mg/dl deficit
infusion rate is double of Mg2+; half dose for renal dysfunction
of that, eg, for 1 g
replaced, duration of How long: Replacement stopped when
infusion is 2 hrs Mg2+≥2.0 mg/dl Frequency of monitoring:
Usually 24 hrly, unless otherwise specified. In
case of worsening renal function, monitoring
may be done 12 hourly

Where: IV replacement of MgSO4may be

done in critical caresetting
 Concentrated electrolytes….3% hypertonic saline 100 ml bottle for Cardiac Sugrical
Critical care(ITU 789) & Coronary Critical Care unit (CCU 2,3,4 & CCU 1-Cardiac side)

Medication Name: 3% Hypertonic Saline

Medication Route: Intravenous Infusion via syringe pump, through central line only
Concentration: 3%
Dilution: not required
Indication: Symptomatic Hyponatremia (Se Na<120), brain edema
Scope: Critical care areas and emergency ward

Initial or staring rate of infusion: 20 ml/hour

Maximum rate of infusion: Not more than 30 ml/hour

How often rate of infusion can be changed: 6 hourly (after checking serum sodium value)

How often to check serum sodium and serum Every 6 hourly till infusion is on.
(osmolarity):
Expected correction: 1 ml /kg 3% saline will increase serum sodium of 1 meq/l

Target rate of increase of serum sodium: Increase of serum sodium of 10-12 meq /day
When to stop 3% saline infusion: Clinical improvement or serum sodium>124
 Concentrated Electrolytes….3% hypertonic saline 100 ml bottle for
Medical Critical Care & Surgical Critical Care (CCU 1)

DRUG DOSE DILUTION TITRATION TAPERING

For raised ICP -

Na+& Cl-sent 12 hrly;
3% SODIUM @10 ml/hr NA Target Na+ level 145- not tapered, but
CHLORIDE 155 mmol/L stopped when target
reached or as directed
by the physician

For symptomatic
hyponatremia -
Na+& Cl-sent 1 hr after
@10 ml/hr NA
completion of
Target level will be
infusion; not tapered,
directed by the
but stopped when
Physician / stopped
target reached or as
when patient
directed by the
becomes
physician
asymptomatic
Target rise not >10-12
mmol/L/d
 Concentrated Electrolytes….Calcium Gluconate for Medical Critical
Care & Surgical Critical Care (CCU 1)

DRUG DOSE DILUTION TITRATION TAPERING

CALCIUM • IV bolus, 10% Ca gluconate • Preferably diluted • NA (bolus) • NA (bolus)

GLUCONATE 10 ml IV slowly over 10 min, in NS or 5%D
preferably through a large • Diluted in either • NA fixed infusion • NA, fixed infusion
vein NS or 5%D – 2 amp rate rate – checked 12-
(when given as • For moderate-to-severe (20 ml) calcium 24 hrly. More
infusion (10% in hypocalcemia, @ 25 ml/hr, gluconate + 30 ml frequently
10 ml) maximum 4 hrs; maximum diluent monitored if
3-4 times/day • Diluted in either • Infusion rate severe
NS or 5%D depends on hypocalcemia /
• For persistent hypocalcemia, patient weight, repeat doses given
5-20 mg/kg/hr (StatPearls) target total fluid
(medacape 0.5-2 mg/kg/hr) delivery & IV
infusion rate
(Each ampoule of 10% calcium
gluconate contains 1 g calcium
gluconate ≡93 mg elemental
calcium)
 Concentrated Electrolytes….Sodium Bi-Carbonate for Medical Critical
care & Surgical Critical Care (CCU 1)
DRUG DOSE DILUTION TITRATION TAPERING

SODIUM BI- Calculation of deficit – 0.3 x (24 • IV (undiluted) bolus, ABG (usually) / Serum Further infusions
CARBONATE – HCO3-) mmol/l x body weight maximum 50 ml (2 amp), HCO3-levels repeated ½-1 stopped after target
(kg) may be given over 5-10 hr after replacement reached – Serum HCO3-
min, in emergencies (eg, >10 mmol/LUrine pH 7.5-
‘Half correction’ done hyperkalemia with 7.55Serum pH not >7.50
(When given as usually(Each ampoule of 8.4% metabolic acidosis)
infusion (8.4% in NaHCO3contains 25 mmol in 25 • Short infusions of upto
25 ml) ml) 100 ml may be ordered by
physicians, over 1-4 hrs.
These are usually infused
undiluted & often follow
the above bolus doses
• For prolonged infusions –
load 250 ml (10 amp)
NaHCO3in 250 ml 5%D &
infuse at IVF running
rate / required rate, as
directed by the physician
THANK YOU