Latest Intravenous Dilution Guidelines

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*Preferred solution is listed first.
Dilution List     [ P ]
This document Copyright © 2005-06  D.McAuley, GlobalRPh Inc. All Rights Reserved.
Pamridonate (Aredia)
Pancuronium (Pavulon)
Pantoprazole (Protonix)
Penicillin G
Pentobarbital (Nembutal)
Phenylephrine (Neosynephrine)
Phenytoin (Dilantin)
Phytonadione (Vitamin K)
Piperacillin/Tazo (Zosyn)
Potassium Chloride
Potassium Phosphate
Procainamide (Pronestyl)
Prochlorperazine (Compazine)
Propofol (Diprivan)
Propranolol (Inderal)
Drug Standard  Dilution Infusion Rate Diluents*
PAMIDRONATE (AREDIA) 60 - 90 mg/ 1000 ml
Minimum dilution: 60-90mg/500ml
(Usually over 4 hours)
24 hours
2 to 24 hours)
NS / D5W

Restricted to oncology. Serum calcium levels should be corrected for serum albumin before determining dose. Corrected calcium= serum calcium + 0.8 (4 - serum albumin).   Dosage: Moderate hypercalcemia (12- 13.5 mg/dl): 60 to 90 mg. Severe hypercalcemia (> 13.5 mg/dl): 90 mg. The manufacturer recommends that the repeat dose not be given sooner than 7 days after the initial dose in order to allow full response to this dose. MOA: biphosphonate compound-inhibits bone resorption (anti-osteoclast activity). Has little effect on bone remineralization. Relative potency of biphosphonate agents: Risedronate (Actonel)>> (pamidronate & alendronate(Fosamax)) >> Etidronate(Didronel)
PANCURONIUM (PAVULON) 12.5 to 25 mg/ 250 ml
50 mg/ 50 ml (Undiluted-viaflex)
(Note: Strongly suggest intermittent
dosing. This is the preferred regimen. The half-life of Pavulon is @ 110 minutes.) Neuromuscular blockade reversal: Neostigmine: 0.03 to 0.08 mg/kg
Titrate D5W / NS

EXP: 48 hours (REF or RT)    [Supplied: 1 mg/ml (10 ml vial); 2mg/ml (2 &5ml vial/amp); Refrigerate]   Nondepolarizing skeletal muscle blocker-competes with acetylcholine at the neuromuscular junction. Intermittent dosing: 0.1 to 0.2 mg/kg (usually 0.1) q1-3h (range: 0.04 to 0.2) Continuous infusion: Loading dose: 0.04 to 0.10 mg/kg , f/b 1 to 1.7 mcg/kg/min or 0.06 to 0.1 mg/kg/hr.   Onset: 2-3 minutes.   Incremental doses slightly increase magnitude of blockade and significantly increase the duration of action.  Cautions: Increases in HR, BP and excessive salivation and sweating may occur. Concurrent use of corticosteroids will decrease pancuronium effectiveness and may increase risk and severity of myopathy resulting in prolonged flaccid paralysis following discontinuation of neuromuscular blocking agent. 
Usual Diluents
NS ,  D5W ,   LR
Standard Dilutions   [Amount of drug]  [Infusion volume]  [Infusion rate]
[40 mg] [100 ml] [15-30 min]

Bolus dose:
[80 mg] [80 ml] [5 minutes]
(Total volume = 100ml)

Continuous infusion (8 mg/hr)
[80 mg] [80 ml] [ 10 ml/hr]
(Total volume = 100ml)

Minimum dilution: Diluted vial (4 mg/ml) can be administered over at least 2 minutes.

Stability: The reconstituted solution may be stored for up to 2 hours at room temperature prior to further dilution; the admixed solution may be stored for up to 24 hours at room temperature prior to intravenous infusion. Both the reconstituted solution and the admixed solution do not need to be protected from light.  Reconstitution: dilute 40 mg vial with 10 ml normal saline. 
Maximum rate
: 3 mg/min.   

Note: In-line filter is NOT required with the revised formulation currently being offered by the manufacturer. 

Usual dosage:  
Gastroesophageal Reflux Disease with history of Erosive Esophagitis:
40 mg IV once daily for 7 to 10 days. 

Continuous infusion: Prevention of peptic ulcer rebleeding  in high-risk patients or endoscopic evidence of active bleeding: 80 mg IV bolus over 5-15 minutes, followed by 8 mg/hr x 72 hours (maximum). No additional benefit found for tx > 72 hrs.

Zollinger-Ellison Syndrome: 80 mg q 8-12 hrs daily. Starting dose: 80 mg IV q12h.

Two Minute Infusion:
PROTONIX I.V. for Injection should be reconstituted with 10 mL of 0.9% Sodium Chloride Injection, USP, per vial to a final concentration of approximately 4 mg/mL. The reconstituted solution may be stored for up to 2 hours at room temperature prior to intravenous infusion and does not need to be protected from light. The total volume should be administered intravenously over a period of at least 2 minutes. Note: 80 mg (2 vials - each with a concentration of  4 mg/ml) may also be given over at least  2 minutes.
PENICILLIN G 0 to 4 MU/ 50 ml
Over 4 MU/ 100 ml
Pre-pack :  2 MU/ 50 ml iso D5W
30 min D5W / NS

EXP: 1 DAY (RT) / 3 DAYS (REF).  Label: Refrigerate. Usual dose: 0.5 to 4 mu q4-6h. Severe infection: Dosing interval q2-3h (i.e. 3mu q3h). Max dose per day: up to 80 million units.  Renal dosing: >50/ Usual dose || 10-50/ 75% of usual dose || <10/ 20-50% of usual dose. || Hemodialysis/PD: 20-50% of dose usually q6h. Max dose in ESRD: 6 mu/day.
PENTAMIDINE 0 to 350 mg/ 250 ml 60 min D5W

EXP: 1 DAY (RT) .   Label: Protect from light.    Dosing: PCP: 3 to 4 mg/kg IV qd x 14 - 21 day
500 mg/ 250 ml
2000 mg/ 250 ml
(Concentrations from 0.5 to 8 mg/ml appear to be stable)
Max rate: 50 mg/min
D5W / NS

EXP: 12 to 24 hrs (RT). Label: Do not refrigerate.     Onset: 15-60 min Duration: (Oral): 1-4 hrs (IV): 15 min May be given deep IM (max 250mg per site) or by slow IV injection. Note: can be given IV undiluted. Dosing: Hypnotic (Adult): Oral: 100-200mg qhs.  IM: 150-200mg.   IV: Initially 100mg, may repeat q1-3min up to 200-500mg total dose. Rectal: 120-200mg at bedtime. Preoperative sedation: IM: 150-200 mg. Barbiturate coma in head injury patients: IV loading dose of 5-10 mg/kg over 1 to 2 hours. Maintenance: Initial: 1 mg/kg/hr; may increase to 2-3 mg/kg/hr. Monitor for dose-dependent cardiovascular and respiratory depression. Maintain serum concentration at 2-4 mg/dl. Supplied: 50mg/ml-1ml, 2 ml, 20ml, 50ml. (C-II)
PHENOBARBITAL 0 to 100 mg/ 50 ml
Over 100 mg/ 100 ml
30 min

Maximum rate: 100 mg/min. Recommended routes: IV push, IM. Preventative management of status epilepticus: 15 to 20 mg/kg IV; alternatively, 10 mg/kg followed by another 10 mg/kg if needed. Alcohol withdrawal: 260 mg IV initially, followed by 130mg q30min to achieve light sedation.
(10 to 40 mg/ 250 ml)
Titrate D5W / NS

EXP: 2 DAYS (RT).  Label: Do not Refrigerate.   (Alpha agonist). May be given IM,SC, IV push, or by continuous  infusion. Treat mild/moderate hypotension, also PSVT.   IV bolus therapy: usual dose:  0.5 mg [range: 0.1 to 1 mg (max)] repeat q10-15 min as needed. IV infusion: usual initial rate: 0.1 to 0.18 mg/min (100 to 180mcg/min) (titrate). Usual maintenance rate: 40-60 mcg/min.  Maximum rate: infusion rates as high as 9 mcg/kg/min may be required in shock.   [Usual maximum dosing range reported: 0.4 to 9.1 mcg/kg/minute ].
PSVT: 0.5 mg rapid IV push, subsequent doses may be increased in increments of 0.1 to 0.2mg. 
Calculation of drip rate (40 mg/250) (ml/hr) = (mg/min) x 375.
PHENYTOIN (DILANTIN) 100 mg/ 50 ml
200 to 500 mg/ 100 ml
501 to 1500 mg/ 250 ml

Concentrations up to 6.7 mg/ml are stable up to 24 hours (insignificant loss). Ideally, the solution should be infused within 1 hour of mixing. Constantly monitor for precipitate formation. Solution should be filtered with a 0.22 micron filter.
15 minutes
15-30 minutes
See note

EXP: 2 HOURS (RT)    Label: Do not Refrigerate / Use an inline 0.22u filter.     Infusion rates: Max: 50 mg/min Recommended rate for most adults: 40 mg/min.  Elderly (rate): 20 mg/min.  Usual IV loading dose: 15 mg/kg TBW     Maintenance dose (started 18-24h after load): 6 mg/kg ibw IV/PO in divided doses q8 to 12h. (The IV maintenance dose should never be given qd in a single dose). Oral loading: 16 mg/kg TBW (use adjBW if obese) given in 3 to 4 divided doses at q2h intervals (divided doses increase bioavailability as well as decrease potential for Gastrointestinal side effects such as N&V). The maximum single oral dose should not exceed 400mg in order to minimize Gastrointestinal side effects and increase absorption. Sampling: 18 to 24h after loading dose, then q5 to 7 days to assess trend.   Average time to steady state: 10 to 14days.   Half-life: 7-42hrs (average=24h)  . Capsules/injection= 92% phenytoin.    Elixir/tabs=100% pht.   Equation used to estimate the dose req'd to increase current level to normal range if subtherapeutic: = [0.7 x IBW x (15 - current level) ] / 0.92* * (if capsules/injection used) 
Adjusted phenytoin concentration if low serum albumin= measured total concentration / [ (0.2 x albumin) + 0.1]

EXP: Administer shortly after preparation. 
Label: Protect from light// Do not Refrigerate. 

Severe reactions, including fatalities, have occurred during and immediately after INTRAVENOUS injection of phytonadione, even when precautions have been taken to dilute the phytonadione and to avoid rapid infusion. Severe reactions, including fatalities, have also been reported following INTRAMUSCULAR administration. Typically these severe reactions have resembled hypersensitivity or anaphylaxis, including shock and cardiac and/or respiratory arrest. Some patients have exhibited these severe reactions on receiving phytonadione for the first time. Therefore the INTRAVENOUS and INTRAMUSCULAR routes should be restricted to those situations where the subcutaneous route is not feasible and the serious risk involved is considered justified.
Preferred route: SC.
Max IV rate: 1 mg/min. 
ADVERSE REACTIONS-------------------------------------
Deaths have occurred after intravenous and intramuscular administration.

Transient “flushing sensations” and “peculiar” sensations of taste have been observed, as well as rare instances of dizziness, rapid and weak pulse, profuse sweating, brief hypotension, dyspnea, and cyanosis.
Pain, swelling, and tenderness at the injection site may occur.

The possibility of allergic sensitivity including an anaphylactoid reaction, should be kept in mind.

Infrequently, usually after repeated injection, erythematous, indurated, pruritic plaques have occurred; rarely, these have progressed to scleroderma-like lesions that have persisted for long periods. In other cases, these lesions have resembled erythema perstans.

Hyperbilirubinemia has been observed in the newborn following administration of phytonadione. This has occurred rarely and primarily with doses above those recommended. 
DOSAGE AND ADMINISTRATION--------------------------------
Whenever possible, Vitamin K1 Injection (Phytonadione Injectable Emulsion, USP) should be given by the subcutaneous route.  When intravenous administration is considered unavoidable, the drug should be injected very slowly, not exceeding 1 mg per minute.

Protect from light at all times.

Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit.

Directions for Dilution
Vitamin K1 Injection may be diluted with 0.9% Sodium Chloride Injection, 5% Dextrose Injection, or 5% Dextrose and Sodium Chloride Injection. Benzyl alcohol as a preservative has been associated with toxicity in newborns. Therefore,all of the above diluents should be preservative-free. Other diluents should not be used. When dilutions are indicated, administration should be started immediately after mixture with the diluent, and unused portions of the dilution should be discarded, as well as unused contents of the ampul.

Prophylaxis of Hemorrhagic Disease of the Newborn
The American Academy of Pediatrics recommends that vitamin K1 be given to the newborn. A single intramuscular dose of Vitamin K1 Injection 0.5 to 1 mg within one hour of birth is recommended.
Treatment of Hemorrhagic Disease of the Newborn
Empiric administration of vitamin K1 should not replace proper laboratory evaluation of the coagulation mechanism. A prompt response (shortening of the prothrombin time in 2 to 4 hours) following administration of vitamin K1 is usually diagnostic of hemorrhagic disease of the newborn, and failure to respond indicates another diagnosis or coagulation disorder.
Vitamin K1 Injection 1 mg should be given either subcutaneously or intramuscularly. Higher doses may be necessary if the mother has been receiving oral anticoagulants.
Whole blood or component therapy may be indicated if bleeding is excessive. This therapy, however, does not correct the underlying disorder and Vitamin K1 Injection should be given concurrently.

Anticoagulant-Induced Prothrombin Deficiency in Adults
To correct excessively prolonged prothrombin time caused by oral anticoagulant therapy—2.5 to 10 mg or up to 25 mg initially is recommended. In rare instances 50 mg may be required. Frequency and amount of subsequent doses should be determined by prothrombin time response or clinical condition. If in 6 to 8 hours after parenteral administration the prothrombin time has not been shortened satisfactorily, the dose should be repeated.
INR< 5 (no bleeding): Decrease dose or omit next dose and resume warfarin at lower dosage when INR approaches desired range.
INR >5 but <9 (No bleeding): If no additional risk factors for bleeding: Omit next one or two doses of warfarin and resume warfarin at lower dosage when INR approaches desired range. Or If increased risk of bleeding: Omit next dose of warfarin and give Vitamin K 1-2.5 mg orally.
INR > 9 (no bleeding): Hold warfarin and give Vit K 3-5 mg po, may repeat Vitamin K if INR still elevated at 24-48 hours.
 Serious bleeding or INR > 20: Hold warfarin and Vitamin K 10 mg by slow IV infusion (10-20 minutes) and supplement with fresh plasma or prothrombin complex concentrate. May repeat Vitamin K q12h. Life-threatening bleeding: Hold warfarin and replace with prothrombin complex concentrate supplemented with Vit K 10 mg IV. May repeat Vitamin K depending on INR.
Rapid reversal required for urgent surgery or dental extraction: Hold warfarin and give Vitamin K 2-4 mg orally. May repeat Vitamin K 1-2 mg orally  if INR remains high at 24 hours. [Chest 1998 (suppl), 114: S445-S469]
PIPERACILLIN 0 to 2 grams/ 50 ml
Over 2 grams/ 100 ml
30 min D5W / NS

EXP: 1 DAY (RT) / 7 DAYS (REF).   Label: Refrigerate.    IM injection: Dissolve each gram with 2 ml. Maximum of 2 grams per injection site. (May use SW, BS-SW, NS, 0.5 to 1% lido).  Mild infection: 3-4g ivpb q6-8h Serious infection: 3-4g ivpb q4-6h (200-300mg/kg/day) Maximum 24g/day.  Renal dosing:  >40/ No change || 20-40/ 4g q8h || <20/ 4g q12h || HD/PD: 2g q8h. || Alternatively: >50/q4-6h || 10-50/ q6-8h || <10/ q8h
ZOSYN (Piper/Tazobactam) 2.25 grams/ 50 ml
3.375 and 4.5 grams/ 100 ml
30 min D5W / NS

EXP: 1 DAY (RT)  /  7 DAYS (REF).   Label: Refrigerate.  Cannot be given IM. Dosing: Mild infection: 3.375g ivpb q6h.  Moderate to severe: 3.375g ivpb q4h.  Renal dosing: >40/ 3.375g q6h || 20-40/ 2.25g q6h || <20/ 2.25g q8h || HD: Max 2.25g q8h. 0.75g AD. || PD: 2.25g q8h
POTASSIUM CHLORIDE Floors:10 meq/ 100 ml or
 20 meq/250 ml or 40 meq/ 500 ml.
ICU's:20 meq/ 100 ml
(10 meq/hr)
(10-20 meq
NS / D5W

EXP: 1 DAY (RT)   [Normal range: 3.5 to 5 meq/L]  

General guidelines - Review the disclaimer

Treatment of hypokalemia: Level < 2.5: (life-threatening): 
(a) ECG monitoring necessary (transfer to ICU) 
(b) Give KCL at 20 to 40 meq/hr depending on severity 
(c) Monitor K+ levels hourly 
(d) Decrease rate to max of 20 meq/hr when patient is no longer in immediate danger (eg normal ECG, or level > 2.5) 

K+ level: 2.5 to 3.0: 
(a) ECG monitoring recommended 
(b) Infuse K+ at 10-20 meq/hr x 2 hrs (ICU) or 10 meq/hr x 2-4 hrs (floors). 
(c) Order K+ levels q2h (ICU) q4h (floor). 
(d) Repeat infusion as above if K+ < 3.0 
(e) Consider oral replacement if patient is asymptomatic K+ level 

K+ level:  3 to 3.5: Oral therapy recommended unless npo. Give 20 to 40 meq po bid-tid. Follow levels closely.
General info: 
*Dextrose solutions containing K+ may cause transient worsening of hypokalemia and should be avoided if possible. 

*In the majority of cases (not critical) K+ rate of infusion should not exceed 10 meq/hr. 

*The amt of K+ to be replaced is difficult to estimate, therefore, frequent K+ levels should be obtained. 

*Extreme caution should be used in patients with renal failure (reduce rate of administration). 

*Maximum rate without cardiac monitoring: 20 meq/hr 

*The maximum single oral dose should not exceed 50 meq (gastric irritation, potential for cardiac arrest, etc.) 

*hypokalemia potentiates the effects of digoxin. If ischemic heart disease or PVC's are absent and patient not on digoxin, one may elect to withhold replacement of K+ until level< 3.2.

Treatment of hyperkalemia (K+ level > 5): 
Therapeutic approach: 
**Rule out pseudohyperkalemia: (hemolyzed specimen, severe leukocytosis, fist clenching during phlebotomy, lab error.) Obtain ECG or rpt K+ level. 

**Stop all K+ intake (IV/PO) **Check pH, corrent acidosis if present. For every 0.1 decline in pH from 7.4(nml) results in an increase in K+ of 0.6 meq/L. 

**Check Ca++, Mg++, BUN/creat. 

**Identify underlying cause if necessary (eg renal failure, mineralocorticoid deficiency etc). 

Emergencies (cardiac toxicity or K+ > 6.1) (Note: the following measures are instituted immediately & f/b kayexalate. Withhold Calcium gluconate if K+ < 6.5. Patient must be on monitor) (1) Give Calcium gluconate 1-2g over 15-30 minutes. Used to counteract the neuromuscular and cardiac effects of hyperkalemia. May give more rapidly if ECG has deteriorated to a sine wave or worse-give 0.5 to 1g Calcium gluconate  over 3 to 5 minutes. 

(2) Administer 50ml (1 amp) Sodium bicarb IV over 5min. Repeat as necessary-especially if patient is acidotic (common in renal failure). Increased risk in patients with CHF. Onset: immediate Duration: 2-3 hr. Normally repeated in 15 minutes if ECG changes persist. ECG changes: Tall thin T-waves, Prolonged PR-interval, widened QRS, loss of P-wave. 

(3) Admin 1 amp of 50% dextrose IVP over 5 min plus 10u insulin IV. Repeat in 15min if serum K+ still toxic. Alternatively, admin 500 ml 10% dext + 10-15u insulin over 1 hr. Glucose is unnecessary if blood sugar is elevated. Onset: 15-45 minutes. Duration: 4-6hrs. (4) Administer 15 to 50g of kayexalate po now. May repeat q6h. (If npo: give 25-50g by rectal retention enema (retain for 1hr).  Oral: 1 gram/ 1 meq K+. Onset: 1-2hrs. Duration: 4-6hrs. Use caution in patients who cannot tolerate even a small increase in sodium load (eg severe CHF; marked edema; etc.) Note: Never administer kayexalate alone for symptomatic hyperkalemia because of the slow onset. 

Patients with K+ < 6 meq/L with no ECG changes: Administer kayexalate as above. Consider lasix 20 to 40mg IVpush in the volume-overloaded patient or when inadequate K+ excretion contributes to hyperkalemia.
POTASSIUM PHOSPHATE Floors:15 mmol / 250 ml
ICU's:15 mmol/ 100 ml
4-8 hours
ICU's: 2 hours

EXP: 1 DAY (RT).   [Supplied: 15 mmol PO4 (and 22 meq K+) / 5 ml vial].  Normal range: 2.5 to 4.5 mg/dl.   
*Mild to moderate hypophosphatemia (1.3 to 2.5 mg/dl): Oral therapy adequate: 2.5 to 5 mg/kg of PO4 bid-tid or approx 1-2 pkts (250 mg=8 mmol/packet) of Neutra-phos bid to tid. Manufacturer recommends: 1-2 packets 4 times daily (after meals and at bedtime)
*Severe hypophosphatemia (PO4 < 1.2 mg/dl): Give 0.16 to 0.25 mmol/kg IVPB q6 to 8 hours until serum level reaches 2 mg/dl. Doses as high as 0.5 mmol/kg may be given if level is below 0.7 mg/dl.
*Alternatively: (level < 2 mg/dl) (ICU  pt): give 15 mmol NaPO4 in 100 ml NS over 2 to 6 hrs; repeat q6h to max of 45 mmol/24 hours. [Crit Care Med 1995;23:1204.]
PROCAINAMIDE (PRONESTYL) Loading dose: 1 gram/ 50 ml
Continuous infusion: 1 to 2 grams/ 250 ml
Titrate D5W

EXP: 1 DAY (RT).   Label: Do not Refrigerate.      (Tx: PVC, VT, A-fib/flutter, PAT) Dosing: Loading: 100mg q5min (max 25 to 50 mg/min) until arrhythmia disappears or adverse effects up to (17 mg/kg max if normal renal function, otherwise max of 12 mg/kg). If arrhythmia disappears, start IV infusion: 2 to 6 mg/min (Usual maintenance dose with renal/cardiac failure: 1 to 2 mg/min) . If arrhythmia reappears, repeat bolus as above. Side effects: Severe hypotension with rapid infusion; bradycardia, AV block, V-fib. Alternate loading regimen: Add 1g/ 50 ml D5W-20 mg/min x 25 to 30 min, wait 10min for distribution, if no response continue with loading. (Note: 20 mg/min= 60 ml/hr-1 g/50ml). If patient responds start maintenance infusion: 2 to 6 mg/min. Stop infusion if QRS widens > 50%. Steady state: 24hrs (IV) / 48 hrs (oral).
Calculation of drip rate
(1 gram/250 ml) ml/hr: = (mg/min) x 15
PROCHLORPERAZINE  (COMPAZINE) 0 to 20mg/ 50 ml 30 min NS / D5W

EXP: 1 DAY (RT).    Label: Protect from light.    Single doses normally should not exceed 10mg. Maximum rate (IVPush): 5 mg/min (usual: 2.5 mg/min). Usual rate(infusion):  1 mg/min. Maximum recommended  dose/day: 40 mg. Some studies have used high dose Compazine (30-40mg) over 20-30min prior to chemotherapy.
PROPOFOL (DIPRIVAN) 1000 mg/ 100 ml (vial)
500 mg/ 50 ml (vial)
[Concentration: 10 mg/ml]

Label: Do not Refrigerate / Shake well before use/ Replace IV tubing q6-12h.     Dosing: (ICU sedation in intubated/mechanical vent patients): initially  0.3 mg/kg/hr for at least 5min. Then increase by 0.3 to 0.6 mg/kg/hr q5-10min until desired level of sedation. Alternative (initial dosing): 1-3 mg/kg/hr-titrate to effect. Usual dose req'd for maintenance: 1.5 to 4.5 mg/kg/hr.
Calculation of rate (ml/hr) = (mg/kg/hr) x 0.1 (Note: changes in the rate of administration should be made slowly (>5 min) in order to minimize hypotension and avoid acute overdosage. Monitoring: Patients should be monitored for early signs of significant hypotension and/or cardiovascular depression, which may be profound.
15 mg/ 250ml
10-15 min
NS / D5W

EXP: 1 DAY (RT)    [Supplied: 1 mg/ml amp]    Dosing: Life-threatening arrhythmia: usually 1- 3 mg (maximum rate: 1 mg/min)-may dilute in D5W-50ml. After 3 mg infused, may repeat in 2 minutes. Subsequent doses no sooner than 4 hours. May start IV infusion: usual rate: 2 to 3 mg/hr. Titrate to HR/BP. Oral to IV conversion: An equivalent IV dose cannot be predicted with any precision because of the highly variable metabolic and bioavailability characteristics of oral propranolol, as well as significant variability in patient response. Therefore, careful titration of an IV dose is necessary (start continuous infusion: 2 to 3 mg/hr-titrate to HR/BP). Average bioavailability of oral propranolol: (30-40%) ( range: 16-60%). Propranolol is well absorbed, however, there is an extensive first pass metabolism. Variations in metabolism result from differences in hepatic blood flow, intrinsic clearance, genetic makeup, etc.
PROTAMINE Dilute 50 mg vial with 5 ml sterile water (10mg/ml). Normally given undiluted. May add to 25-50 ml  NS / D5W.    

Treatment of  heparin overdose: If immediate, give 1 mg (up to 1.5mg) IV for every 100u of heparin infused in preceding 2 hours. Give by slow IV injection (50mg over 10minutes). Maximum of 50mg in any 10 minute period. May dilute with 25-50ml NS/D5W and infuse over 10-20 minutes. Obtain PTT 5-15min after protamine administration. If 30 minutes to 1 hour have elapsed before starting protamine: use 0.5 to 0.75 mg/100 u of heparin (in preceding 2 hours). If > 2 hours have elapsed: use 0.25 to 0.375mg/ 100units. Symptoms of overdose of protamine include hypertension, and possible hemorrhage due to paradoxical anticoagulation with higher doses (eg > 100mg). [Too rapid administration can cause severe hypotensive and anaphylactoid reactions. Facilities to treat shock should be available.]

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