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Latest Intravenous Dilution Guidelines


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*Preferred solution is listed first.
Dilution List     [ H - I ]
This document Copyright © 2005-06  D.McAuley, GlobalRPh Inc. All Rights Reserved.
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Haloperidol (Haldol)
Hematin
Heparin
Hydralazine
Hydrocortisone (Solu Cortef)
HYDROMORPHONE (DILAUDID)
Ibutilide (Corvert)
Immune Globulin
Imipenem (Primaxin)
Infliximab  (Remicade)
Insulin
Inamrinone
Iron Dextran (Imferon)
Isoproterenol (Isuprel)
Drug Standard  Dilution Infusion Rate Diluents*
HALOPERIDOL LACTATE (HALDOL) 0 to 50 mg/ 50 ml
51 to 100 mg/ 100 ml
200 mg/ 160 ml (1 mg/ml)
(may dilute all doses to 1 mg/ml)
See warning below
As directed D5W
Stability/Misc.

EXP: 7 DAYS (RT) Label: Do not Refrigerate.   Haldol may be given IV push. Max IV rate (usual): 5 mg/min. Oral to IV conversion (approximate): oral dose x 0.625 = daily IV dose.   
Package Insert - WARNING:
Cardiovascular Effects
Cases of sudden death, QT-prolongation, and Torsades de Pointes have been reported in patients receiving HALDOL. Higher than recommended doses of any formulation and intravenous administration of HALDOL appear to be associated with a higher risk of QT-prolongation and Torsades de Pointes. Although cases have been reported even in the absence of predisposing factors, particular caution is advised in treating patients with other QT-prolonging conditions (including electrolyte imbalance [particularly hypokalemia and hypomagnesemia], drugs known to prolong QT, underlying cardiac abnormalities, hypothyroidism, and familial long QT-syndrome). HALDOL INJECTION IS NOT APPROVED FOR INTRAVENOUS ADMINISTRATION. If HALDOL is administered intravenously, the ECG should be monitored for QT prolongation and arrhythmias.
Micromedex: 1) An initial bolus dose of 10 milligrams followed by continuous infusion beginning as 10 milligrams per hour is recommended. If control is not achieved, the bolus is repeated every 30 minutes, as well as increasing the infusion rate by 5 milligrams per hour. Adjunctive sedative (benzodiazepines) doses should be adjusted as needed or discontinued if possible. After achieving control, infusion rates should be titrated downward by 50% at each interval, seeking eventual return to bolus dosing. Continuous infusion haloperidol should be considered for patients receiving 80 mg of haloperidol daily (given in 8 or more bolus doses) or who receive more than 10 mg/hour over 5 or more consecutive hours. Continuous dosing is also warranted in patients not effectively managed on other sedatives and in those in whom attempted reversal of the cause of agitation has been unsuccessful (Riker et al, 1994a).
2) Initial infusion doses of 2 to 25 milligrams per hour haloperidol by continuous infusion have been cited in individual cases (Seneff & Mathews, 1995); (Dixon & Craven, 1993)(Fernandez et al, 1988).
HEMATIN (PANHEMATIN) 313 mg vial/ 43 ml 10-15 min Sterile water
Stability/Misc.


Mix just before use / Must use 0.22 micron filter.  Final concentration: 7 mg/ml or @ 301 mg/ 43 ml per manufacturer. Remove entire volume with a syringe and add the "amount ordered" back into the vial. Mix just before use (undergoes rapid decomposition). Usual dose: 1 to 4 mg/kg/day. Maximum dose: 6 mg/kg. Mechanism of action: Heme acts to limit the hepatic and/or marrow synthesis of porphyrin (likely due to inhibition of aminolevulonic acid synthetase-the enzyme which limits the rate of porphyrin synthesis.)   Nursing instruction: (1) flush the line with normal saline (2) Add a 0.22 micron filter to the line-must be used because the solution is not transparent and any undissolved particulate matter is difficult to see. (3) Infuse Hematin over 10 to 15 minutes. (4) Use normal saline as a backflush to complete the infusion. Note: the filter will be stained dark brown.
HEPARIN Standard dilution:
25,000 units/ 250 ml
Loading dose: Give IV push or add to 50 ml D5W.
Titrate D5W / NS
Stability/Misc.




EXP: 1 DAY (RT).    Heparin nomogram: Bolus dose: 80 units/kg      
I
nitial infusion rate:
18 units/kg/hr.                                               
RESULTS
: [PTT < 37]: 80 units/kg bolus, then increase drip by 4 units/kg/hr    
[37 to 47]:
40 units/kg bolus, then increase drip by 2 units/kg/hr                      
[PTT: 48 to 71]
No change
[PTT: 72 to 93]: Decrease drip by 2 units/kg/hr
[PTT > 93]: Hold infusion 1 hour, then decrease drip by 3 units/kg/hr.  Round all estimations to the nearest 100 units. Maximum initial bolus dose is 10,000 units. Maximum initial continuous infusion rate is 2300 units/hr. Use the patients total body weight for all calculations. Cautions: active hemorrhage, acute CVA, History of thrombocytopenia, baseline labs: PT > 15 ; PTT >48; or Platelets < 100,000 Monitoring: PTT q6 to 8 hours following heparin therapy initiation or change in infusion until 2 consecutive therapeutic PTT levels are achieved at a consistent rate of infusion. Once the patient is stabilized, a PTT level should be checked qam. If a patient's PTT does not change significantly from baseline after 2 legitimate attempts to increase dose, consider heparin resistance (antithrombin III deficiency). Baseline labs: PT, PTT, CBC (Hgb, Hct, platelet count). QOD labs: Hgb, Hct, Platelets. Labwork requiring phys attention: (1) PTT > 100 sec (2) Platelet count < 100,000 or 40% decrease (3) INR > 3.5 (4) Hemoglobin decrease > 2 gm/dl. Remember: The most significant factor in reducing recurrent thromboembolism is reaching a therapeutic PTT in < 24 hours. 
Heparin induced thrombocytopenia:
Consider changing to a direct thrombin inhibitor such as Lepirudin,  or Argatroban. Danaparoid has been discontinued by the manufacturer.
HYDRALAZINE 0 to 20 mg/ 50 ml
21 to 40 mg/ 100 ml
> 40 mg/ 250 ml
30 min
30 min
1 hour
NS
Stability/Misc.


Manufacturer recommends IM or IV push. Monitor BP q5min during initial infusion. Usual dosage: 10 to 40 mg IV q4-6h as needed. May be given q20-30min (until adequate response) for the treatment of severe hypertension. IV push (rate): 10 mg/min.
HYDROCORTISONE (SOLU CORTEF) 0 to 100mg/ 100 ml
101 to 150 mg/ 150 ml
151 to 250 mg/ 250 ml
Minimum dilution:0 to 3000 mg/ 50 ml (4hr stability)
30 min
30 min
60 min
D5W / NS
Stability/Misc.

EXP: 1 DAY (RT) for concentration  of 1 mg/ml.
HYDROMORPHONE (DILAUDID)
Usual Diluents
D5W,  NS
Standard Dilutions   [Amount of drug]  [Infusion volume]  [Infusion rate]
[0 - 100 mg] [100 ml] [Titrate]
Stability/Misc.

EXP: 24 hours RT/REF. 
Some studies indicate stability up to 42 days. Usual rate: 0.2 to 2 mg/hr. 
IBUTILIDE (CORVERT) 0 to 1 mg/ 50 ml 10 min D5W / NS
Stability/Misc.

EXP: 1 DAY (RT) / 2 DAYS (REF). May be administered undiluted as well. Indications: rapid conversion of A-fib/flutter of recent onset. Dosing: patient wt >60kg: 1 mg over 10 minutes.   If < 60kg: 0.01 mg/kg over 10 minutes. If the arrhythmia does not terminate within 10 minutes after the 1st dose, a 2nd dose may be given 10 minutes after the completion of the first infusion. MOA : prolongs action potential duration and increases both atrial & ventricular refractoriness (class III agent).
IMMUNE GLOBULIN Dilute with diluent provided.  Initial rate: 0.5 ml/kg/hr. Max 4ml/kg/hr  
Stability/Misc.




EXP: 1 DAY (REF) Label: Do not shake/ Refrigerate.       
Immune globulins with high concentrations of IgA: (1) Venoglobulin-S (2) Gamimune-N (3) Gammar-P IV (4) Sandoglobulin (5) Panglobulin  
Immune globulins with low concentrations of IgA: (1) Polygam S/D (2) Gammagard S/D
Before dispensing
, determine if the patient has an IgA deficiency: In patients with IgA deficiency, IgA can be antigenic and anti-IgA antibodies can develop rapidly leading to anaphylaxis when a product containing significant concentrations of IgA is administered. Therefore, use Polygam S/D or Gammagard S/D for IgA deficient patients. Overview: IgG is comprised of 4 subclasses c a distribution similar to normal serum (IgG1 thru IgG4). IgG1 is the major component in IGIV preparations. IgG1 is involved in tissue protection, complement activation and virus inactivation. Bacterial cells are opsonized by IgG1, making them more prone to phagocytosis. Treatment of immune deficient states probably depends on straightforward replacement of missing antibodies. Immunomodulatory doses of IVIG for autoimmune conditions are considerably larger & are thought to promote blockade of Fc receptors in macrophages (preventing phagocytosis of circulating opsonized platelets or cells tagged c autoantibodies). IVIG may also neutralize pathogenic auto-antibodies, and possibly down regulate IgG production. According to the National Institutes of Health, the commercially available products are equally effective and they may be used interchangeably. (Exception: IgA deficient patients).
IMIPENEM/CILIST. (PRIMAXIN) 0 to 500 mg/ 100 ml
up to 1 gram/ 250 ml
30 min
60 min
NS
Stability/Misc.

EXP: 4 HRS (RT) / 24 HRS (REF). Label: Refrigerate.    Usually restricted to one of the following: (1) Serious nosocomial infections, especially those involving resistant organisms; polymicrobial infections (mixed gram pos/negative + anaerobes). (2) As an alternative to combination therapy for serious intra-abdominal infections. It is used alone, thus avoiding the ototoxic & nephrotoxic effects of amino-glycosides. (3) Pseudomonas infections caused by organisms resistant to both piperacillin & Fortaz.   IM injection: 500 mg/ 2ml (1% lidocaine) forms a suspension-shake well. Dosing: Mild to moderate infection: 250-500mg ivpb q6-8h. Severe infection: 500mg to 1g ivpb q6-8h. Max dose/day= 50mg/kg/day or 4g/day.  Renal dosing: 31-70/ 500mg q6-8h || 21-30/ 500mg q8-12h max || 0-20/ 250-500mg q12h max. || HD: 250 mg AD + q12h. || PD: max dose= 1gram/day i.e. 500mg ivpb q12h.
INAMRINONE (INOCOR) 300 mg/ 240 ml (total volume =300ml)
Minimum dilution: 300mg/60 ml
Conc= 2.5 mg/ml   Total volume=120ml
Titrate NS
Stability/Misc.

EXP: 1 Day (RT). Label: Do not refrigerate/ Protect from light. Supplied: [100mg/20 ml ampule] Dosing: initially 0.75 mg/kg IV bolus over 2-3 min, then start maintenance infusion 5 - 10 mcg/kg/min. Additional bolus of 0.75 mg/kg may be given 30 minutes after treatment starts. Max dose/day: 10 mg/kg. Mechanism of Action: Phosphodiesterase inhibitor with positive inotropic and vasodilator activity.   Renal failure: Clcr<10 mL/minute: Administer 50% to 75% of dose.  ADMINISTRATION — May be administered undiluted for I.V. bolus doses. For continuous infusion: Dilute with 0.45% or 0.9% sodium chloride to final concentration of 1-3 mg/mL. 
INFLIXIMAB (REMICADE) Prescribed dose/ 250 ml
Recommended concentration (0.4 to 4 mg/ml)
2 hours
 Infusions < 2 hours are not recommended.
NS
Stability/Misc.

Stability: Use immediately. Infusion should begin within 3 hours of preparation.   Label: Do not shake.   Reconstitute each vial with 10 ml of sterile water for injection using a syringe with a 21-gauge needle or smaller. Direct stream to sides of vial. Do not use if vacuum not present in vial. Gently swirl solution by rotating vial to dilute; do not shake. May foam upon reconstitution; allow to stand for 5 minutes. Solution is colorless to light yellow and opalescent; a few translucent particles may develop as infliximab is a protein. Do not use if opaque particles, discoloration, or other particles occur. Withdraw volume of total infliximab dose from infusion container containing 250 ml 0.9% NaCl. Slowly add total dose of infliximab for a concentration ranging from 0.4 to 4 mg/ml. Mix gently. Do not reuse or store any portion of infusion. Use an in-line, sterile, non-pyrogenic, low protein-binding filter with 1.2 micron pore size or less.   Dosing: Crohn's disease: 5 milligrams/kilogram (mg/kg) via intravenous (IV) infusion. In patients with fistulizing disease, an initial 5 milligrams/kilogram dose should be followed with additional 5 milligrams/kilogram doses at 2 and 6 weeks after the first infusion. Rheumatoid arthritis: The recommended dose is 3 milligrams/kilogram via intravenous infusion followed with additional doses of 3 milligrams/kilogram at 2 and 6 weeks after the first infusion then every 8 weeks thereafter. Infliximab should be given with methotrexate . Supplied: 100mg vial (refrigerate)
INSULIN
Usual Diluents
NS
Standard Dilutions   [Amount of drug]  [Infusion volume]  [Infusion rate]
Usual final concentrations:
0.5 unit/ml  or  1 unit/ml

(ICU's only) 
[120 units/ 240 ml] [Titrate]
[100 units] [100 ml] [Titrate]
Stability/Misc.

EXP: 1 DAY (RT/REF)
IRON DEXTRAN (IMFERON) (Test dose)
25 mg/ 100 ml normal saline

Prescribed dose/ 250 to 1000ml
(Usually 500 ml normal saline)
Length of infusion: Test dose is infused over 5min. Total dose infusion: infuse Over 2 to 6 hours.
5 minutes


2-6 hours
NS
Stability/Misc.


Parenteral iron treatment should be administered only when iron deficiency is not correctable with oral treatment.  A test dose of 25 mg infused over 5 minutes should be given. Infusion should then be stopped for 1 hour. If there is no reaction after 1 hour continue. Fatal anaphylactic reactions are possible. May also be given IM or slow IVP (1 ml/min x 2 min = 100 mg). Epinephrine should be immediately available. Total amount of iron dextran required in ml (Total dose infusion) = 0.0442 (14.8 - observed Hgb) x IBW + (0.26 x IBW).  Parenterally administered iron does not give a faster response compared to oral administration, therefore, the rate of recovery from anemia should be the same. Reticulocyte count will increase in 3-4 days and peak in 7-10 days. 
ISOPROTERENOL (ISUPREL) 1 mg/ 250 ml
(1 to 2 mg/ 250 to 500 ml)
Titrate D5W / NS
Stability/Misc.

EXP: 1 DAY (RT)      (B1/B2) agonist. IV infusion: 2 to 20 mcg/ min. Usual initial rate: 5 mcg/min. Titrate to HR/BP. May give IV Push (must use 1:50,000 dilution). Calculation of drip rate 1 mg/250 ml (ml/hr) = 15 x mcg/min. eg: 5 mcg/min = 75 ml/hr

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The authors make no claims of the accuracy of the information contained herein; and these suggested doses are not a substitute for clinical judgement. Neither GlobalRPh Inc. nor any other party involved in the preparation of this program shall be liable for any special, consequential, or exemplary damages resulting in whole or part from any user's use of or reliance upon this material.PLEASE READ THE DISCLAIMER CAREFULLY BEFORE ACCESSING OR USING THIS SITE. BY ACCESSING OR USING THIS SITE, YOU AGREE TO BE BOUND BY THE TERMS AND CONDITIONS SET FORTH IN THE DISCLAIMER.   Read the disclaimer
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