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.

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.

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.

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.