Medication Prescribing Error Reporting and Prevention Program: A 14-Year Experience

Timothy S. Lesar, PharmD

Disclosures

August 14, 2000

In This Article

Appendix 5

Generic Name
(Trade Name)
Standard IV Dilution and Concentration Provided Suggested Starting Dose Usual Incremental Changes Usual/ Maximum Dosage Range Other Considerations
Norepinephrine
(Levophed®)
Infusion:
4mg in 250ml NS (16mcg/ml)
Load:
Not recommended.

Infusion:
1mcg/min

1mcg/min
every 3-5 min
Usual:
1-10mcg/min

Maximum:
20mcg/min

1. Level I monitoring.

2. Infuse via CVL only.

3. See extravasation/ infiltration protocol.

4. Special High Dose Maximum Concentration should only be used in extreme cases of severely depressed myocardial function (i.e. cardiogenic shock, myocarditis or tamponade) with fluid overload.

5. See AMC Dosing Sheets

16 mg in 250ml NS (64mcg/ml)
Special High Dose Maximum Concentration:
40mg in 40ml (1000mcg/ml)
(provided as undiluted drug in a viaflex bag)
Pancuronium
(Pavulon®)
Load:
Provided as 1mg/ml vial.
Load:
0.15mg/ kg/ dose over 3-5min

Infusion:
0.03mg/ kg/h

Reload:
0.1mg/kg

Infusion:
1mg/h
(See NMB Protocol.)

Usual:
1-3mg/h

Maximum:
4mg/h

1. Level I monitoring.

2. Loading dose may cause tachycardia and hypotension.

1. See neuromuscular blockade protocol.

2. Requires intubation/ mechanical ventilation.

Infusion:
50mg in 250ml D5W (0.2mg/ml)
50mg in 50ml (1mg/ml)
(provide as undiluted drug)
Phenylephrine
(Neosynephrine®)
Infusion:
20mg in 250ml D5W (80mcg/ml)
Load:
Not recommended.

Infusion:
20mcg/min

10mcg/min every 5min. Usual:
20-200mcg/min

Maximum:
400mcg/min

1. Level I monitoring.

2. Infuse via CVL only.

3. Special High Dose Maximum Concentration should only be used in maximum dosing.

4. See AMC Dosing Sheets

30mg/250ml D5W (120mcg/ml)
Special High Dose Maximum Concentration:
100mg in 250ml D5W (0.4mg/ml)
Potassium Chloride
(for electrolyte replacement)
20mEq in 100ml SWFI
(0.2mEq/ml)
Dependent on serum potassium level and hypokalemic symptoms. NONE Usual:
20-40mEq infused no morethan 10mEq/h unless patient has continuing K wasting state or has symptomatic hypokalemia.

Maximum:
40mEq infused up to 20mEq/h in continuing K wasting state or up to 30mEq/hr in symptomatic hypokalemia.

1. Level I, II, or III monitoring for rates up to 10mEq/h.

2. Level I, II or III monitoring for rates greater than 10mEq/h only in patients with continuing K wasting states.

3. Level I monitoring for rates greater than 20mEq/h only in patients with symptomatic hypokalemia.

4. Frequency of serum level monitoring is dependent upon disease state and attainment of desired serum potassium level.

40mEq in 100ml SWFI
(0.4mEq/ml)
(central line only)
Procainamide
(Pronestyl®)
Load:
Provided as minibag.
Load:
17mg/kg in D5W 50ml at 20-30 mg/min

Infusion:
2mg/min

1mg/min Usual:
2-4mg/min

Maximum:
4mg/min

1. Level I monitoring

2. Loading dose may cause hypotension.

3. May be proarrhythmic.

Infusion:
1g in 250ml D5W (4mg/ml)
2g in 250ml D5W (8mg/ml)
Propofol
(Diprivan®)
(Continuous Infusion)
Infusion:
500mg in 50ml (10,000mcg/ml)
(in 10% fat emulsion)
Load:
Not Recommended

Infusion:
5mcg/kg/min

5 mcg/kg/min every
3-10min, titrate to Ramsey score ordered.
Usual:
5-50mcg/kg/min

Maximum:
100mcg/kg/min

1. Level I monitoring.

2. Complete Physician's Order Sheet/Dependent Protocol.

3. Requires mechanical ventilation/intubation

4. May cause hypotension at acceptable sedation levels.

1g in 100ml (10,000mcg/ml)
(in 10% fat emulsion)
Propofol
(Diprivan®)
(Acute Sedation)
200mg in 20ml (ampule)
(10,000mcg/ml)
(in 10% fat emulsion)
Load:
Age< = 60: 40mg IV over 30sec.

Age > 60: 20mg IV over 30sec.

Age< = 60:
Repeat 40mg IV over 30sec at 1-2min intervals until patient is asleep.

Age > 60:
Repeat 20mg IV over 30sec at 1-2min intervals until patient is asleep.

Usual:
Age<= 60: 2mg/kg
Age > 60: 1.5mg/kg

Maximum:
Age<= 60: 2.5mg/kg
Age > 60: 2mg/kg

1. Level I monitoring.

2. Requires mechanical ventilation/ intubation.

3. Hemodynamic changes are likely to occur

4. Prescribers unfamiliar with use in acute sedation should not use.

5. Short duration of action (5-10 minutes), may result in need to reload to maintain sedation.

Propranolol
(Inderal®)
Load:
Provided as 1mg/ml vial.
Load:
0.5-1mg IVP over 2min

Infusion:
1-2mg/h

Reload:
Not necessary

Infusion:
1mg/h

Usual:
1-3mg/h

Maximum:
4mg/h

1. Level I monitoring.

2. May cause hypotension, bradycardia, and bronchospasm.

Infusion:
15mg in 250 ml D5W
(0.06mg/ml)
Thiopental
(Pentothal®)
(Intractable Seizures, Elevated ICP)
Load:
Provided as a minibag.
Load:
5mg/kg in 50ml D5W over 30min

Infusion:
3-5mg/kg/h

Reload:
5mg/kg in 50ml D5Wover 30min

Infusion:
1mg/kg/h

Usual:
2-20mg/kg/h

Maximum:
20mg/kg/h

1. Level I monitoring.

2. EEG monitoring for burst suppression.

3. Multiple bolus doses may be necessary.

4. Central line recommended.

5. May cause severe hypotension requiring fluid/pressor support.

Infusion:
4gm in D5W 500ml(6mg/ml)
(total volume= 660 ml)
4gm in 160ml(25mg/ml)
(in sterile H2O)
Tissue Plasminogen Activator (tPA)
(Altepase®)
(acute M.I.)
Load & Infusion:
Provided as 100mg in 100ml (in sterile H2O) (1mg/ml)
Initial Load:
15mg/15ml over 2min

Second Load:
50mg/50ml over 30min x1

Final Infusion:
35mg/35ml over 1 hour.

NONE Usual:
15mg over 2minutes
50mg over 30minutes x1, then 35mg over 1h.
Dosing may by reduced in pt. < 67kg.

Maximum: 100mg

1. Level I monitoring.

2. Complete Physician's Order Sheet/Dependent Protocol.

Generic Name
(Trade Name)
Concentration
Provided
Diluent Suggested Starting Dose Usual Incremental
Changes
Usual/ Maximum
Dosage Range
Other Considerations
Alprostadil 0-5 kg (PINK): D5W Continuous: Continuous: Continuous: 1. Level I monitoring
(Prostin VR) 20 mcg/ml 0.05 mcg/kg/min 0.05-0.1 mcg/kg/min Usual: 0.05-0.2 mcg/kg/min 2. Requires pediatric cardiology
Maximum: 0.4 mcg/kg/min 3. See PROSTAGLANDIN E1
LARGER DOSES REQUIRE PROTOCOL
ATTENDING PHYSICIAN 4. Refer to AMC Dosing Chart
AUTHORIZATION
Cimetidine 6-20 kg (BLUE): D5W Continuous: Continuous: Continuous: 1. Level I, II or III monitoring
(Tagamet) 1mg/ml 1.8 mg/kg/h for > 30 ml/min usually unchanged Usual: 0.9-1.8 mg/kg/h up to 2. Dose depends on renal function
creatinine clearance and 0.9 25-50 mg/hr
mg/kg/h for impaired creatinine Maximum: 40 mg/kg/day up
clearance < 30 ml/min to 25-50 mg/hr
21-50 kg (YELLOW): LARGER DOSES REQUIRE
4mg/ml ATTENDING PHYSICIAN
AUTHORIZATION
Dobutamine 0-5 kg (PINK): D5W Continuous: Continuous: Continuous: 1. Level I or II monitoring
(Dobutrex) 1000 mcg/ml 5 mcg/kg/min 2.5 mcg/kg/min Usual: 5-10 mcg/kg/min 2. Doses of < 5 mcg/kg/min may cause
Maximum: 20 mcg/kg/min hypotension
6-20 kg (BLUE):
2000 mcg/ml
LARGER DOSES REQUIRE 3. Refer to AMC Dosing Chart
ATTENING PHYSICIAN
AUTHORIZATION
21-50 kg (YELLOW):
4000 mcg/ml
Dopamine 0-5 kg (PINK): D5W Continuous: Continuous: Continuous: 1. Level I monitoring for doses >
(Intropin) 1000 mcg/ml Splenic/renal: 1-5 mcg/kg/min 2.5 mcg/kg/min Usual: 3-10 mcg/kg/min 5 mcg/kg/min otherwise <
Inotrope: 6-10 mcg/kg/min Maximum: 20 mcg/kg/min 5 mcg/kg/min are Level I, II, III
Pressor: >10 mcg/kg/min LARGER DOSES REQUIRE monitoring
ATTENDING PHYSICIAN 2. Infuse doses > 5 mcg/kg/min via
6-20 kg (BLUE): AUTHORIZATION CVL, or use large peripheral vein
1600 mcg/ml 3. See INFILTRATION/
EXTRAVASATION PROTOCOL
21-50 kg (YELLOW): 4. Refer to AMC Dosing Chart
3200 mcg/ml
Enalaprilat 0-5 kg (PINK): n/a Intermittent: Intermittent: Intermittent: 1. Level I, II or III monitoring
(Vasotec) 0.125 mg/ml 5 mcg/kg/dose (over 5 min) none Usual: 5-10 mcg/kg/dose q8-24h 2. May cause hypotension, use with
Maximum: 10 mcg/kg/dose up caution in patients on diuretics
to 2.5 mg q 6h and/or who are hypovolemic
6-20 kg (YELLOW): LARGER DOSES REQUIRE 3. All orders should contain BP
1.25 mg/ml ATTENDING PHYSICIAN parameters below which drug is
AUTHORIZATION held
21-50 kg (YELLOW):
1.25 mg/ml
Epinephrine 0-5 kg (PINK): D5W Continuous: Continuous: Continuous: 1. Level I monitoring
(Adrenalin) 25 mcg/ml 0.1 mcg/kg/min 0.2 mcg/kg/min Usual: 0.1-0.7 mcg/kg/min 2. Infuse via CVL only
Maximum: 1 mcg/kg/min up 3. See INFILTRATION/
to 20 mcg/min EXTRAVASATION PROTOCOL
6-20 kg (BLUE): LARGER DOSES REQUIRE 4. Refer to AMC Dosing Chart
250 mcg/ml ATTENDING PHYSICIAN
AUTHORIZATION
21-50 kg (YELLOW):
500 mcg/ml
Esmolol 0-5 kg (PINK): D5W Continuous: Continuous: Continuous: 1. Level I monitoring
(Brevibloc) 10,000 mcg/ml load with 500 mcg/kg (slowly 50 mcg/kg/min q 5-10 min Usual: 100-300 mcg/kg/min 2. Must run "YELLOW"
over 1-2 min, pharmacy to for desired response Maximum: 600 mcg/kg/min concentration in CVL
provide 10 mg/ml vial), then LARGER DOSES REQUIRE 3. Refer to AMC Dosing Chart
6-20 kg (BLUE): start drip at 50 mcg/kg/min ATTENDING PHYSICIAN
10,000 mcg/ml AUTHORIZATION
21-50 kg (YELLOW):
20,000 mcg/ml

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