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ICU / ER DRUG INFUSION MASTER REFERENCE GUIDE

Pakistan Formulations - Bedside Ready

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THE UNIVERSAL FORMULA (Learn This Once, Use Forever)

┌────────────────────────────────────────────────────────────────┐
│                                                                │
│   STEP 1: Find your solution concentration                     │
│   Conc (mg/ml) = Total mg added ÷ Total volume (ml)           │
│                                                                │
│   STEP 2: Calculate pump rate                                  │
│   Rate (ml/hr) = Required dose (mg/hr) ÷ Conc (mg/ml)         │
│                                                                │
│   FOR WEIGHT-BASED (mcg/kg/min) DRUGS:                        │
│   Rate (ml/hr) = Dose (mcg/kg/min) × Wt (kg) × 60            │
│                  ──────────────────────────────                │
│                  Conc (mg/ml) × 1000                          │
│                                                                │
│   SHORTCUT: Number of Ampules Rule                             │
│   If you dissolve N ampules in 50 ml NS,                       │
│   your concentration is fixed and predictable                  │
│                                                                │
└────────────────────────────────────────────────────────────────┘

Drops/min = Rate (ml/hr) × Drop factor (gtt/ml)
             ─────────────────────────────────
                          60

Burette standard: 60 gtt/ml → Drops/min = ml/hr (1:1 ratio!)

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CONFIRMED PAKISTANI MARKET FORMULATIONS (from your images)

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DRUG-BY-DRUG PROTOCOLS

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1. FUROSEMIDE (LASIX)

Standard Preparation (100 ml Burette)

Take 5 amps (100 mg) → add to 100 ml NS or D5W
Concentration = 100 mg/100 ml = 1 mg/ml

ICU Protocol

• Bolus: 40-80 mg IV (2-4 amps) over 2-3 min
• Continuous infusion: 5-40 mg/hr
• Refractory edema: Up to 4 mg/min (240 mg/hr) but rarely needed
• Max single dose: 200 mg (avoid rapid >4 mg/min = ototoxicity)
• Monitor: Urine output hourly, K+, Mg2+, creatinine

Evidence: 2022 ADHERE registry and AHA/ACC HF guidelines confirm continuous infusion is superior to intermittent bolus for volume removal in acute decompensated HF.

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2. ADRENALINE / EPINEPHRINE

Preparation A - Cardiac Arrest / Anaphylaxis (NO infusion needed)

1 mg IV push every 3-5 min (ACLS)
IM: 0.5 mg (0.5 ml of 1:1000) into anterolateral thigh

Preparation B - Vasopressor Infusion

Take 5 amps (5 mg) → dilute in 50 ml NS = 0.1 mg/ml = 100 mcg/ml
OR
Take 10 amps (10 mg) → dilute in 100 ml NS = 0.1 mg/ml

• Start 0.05-0.1 mcg/kg/min, titrate to MAP ≥65
• Add to norepinephrine in refractory septic shock (Surviving Sepsis 2021)
• Caution: Causes hyperlactatemia; do not use lactate to monitor resuscitation while on epinephrine

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3. NOREPINEPHRINE (NOR ADRIN)

STANDARD PREP - ICU Gold Standard

Take 4 amps (16 mg) → add to 96 ml NS = 16 mg/100 ml = 0.16 mg/ml = 160 mcg/ml
OR (simpler for 70 kg standard dose):
Take 2 amps (8 mg) → dilute to 50 ml = 160 mcg/ml

• FIRST-LINE vasopressor for septic shock
• Start: 0.05-0.1 mcg/kg/min via peripheral IV (can start peripherally <6 hours while CVC being placed)
• Titrate to MAP ≥65 mmHg
• Add vasopressin when dose reaches 0.25-0.5 mcg/kg/min
• Max: 1-2 mcg/kg/min (beyond this, consider adding vasopressin or epinephrine)
• Must use CVC for infusions >6 hours

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4. ISOSORBIDE DINITRATE - ISDN (ISOKET)

Standard Preparation

Take 5 amps (50 mg) → add to 50 ml NS = 1 mg/ml
(Total = 100 ml including drug volume)

• Acute pulmonary edema / ACS: Start 2-5 mg/hr, titrate up every 15 min
• Hypertensive emergency with HF: 5-10 mg/hr
• Target: Systolic BP drop of 10-15% or symptom relief
• Max: 20 mg/hr
• STOP if: SBP <90 mmHg
• Use non-PVC tubing (ISDN adsorbs onto PVC - use glass or polyethylene)
• Avoid with: Sildenafil/tadalafil (within 24-48 hours)

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5. DOPAMINE

STANDARD PREP - The Classic ICU Protocol

Take 1 amp (200 mg) → dilute to 50 ml NS = 4 mg/ml

Rate (ml/hr) ≈ Dose (mcg/kg/min) × 1.05
(roughly: 10 mcg/kg/min ≈ 10.5 ml/hr)

• LOW dose (1-3 mcg/kg/min): Dopaminergic - renal protection (NOT recommended by current guidelines - no proven benefit)
• MED dose (5-10 mcg/kg/min): Beta1 dominant - increases CO and HR
• HIGH dose (>10 mcg/kg/min): Alpha dominant - vasoconstriction
• Second-line vasopressor (after norepinephrine) - only when bradycardia present or tachyarrhythmia risk is low (Surviving Sepsis 2021)
• More arrhythmogenic than norepinephrine - monitor for AF/tachycardia

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6. LABETALOL

For IV Bolus (Hypertensive Emergency)

Draw up 2-4 ml (10-20 mg) → push over 1-2 min
Repeat every 10 min up to 300 mg total

For Infusion

Take 4 amps (200 mg) → add to 160 ml NS = 1 mg/ml

• Hypertensive emergency (non-aortic):
  • Bolus: 20 mg slow IV push, then 40-80 mg every 10 min (max 300 mg)
  • Or infusion: 0.5-2 mg/min
• Hypertensive emergency in pregnancy (eclampsia/PET):
  • 20 mg IV bolus, repeat 20-80 mg every 10-20 min
• Aortic dissection: Drug of choice - bolus + infusion
  • Bolus: 20 mg, then 2 mg/min infusion, titrate to HR 60-70 and SBP <120
• Avoid: Acute decompensated HF, severe asthma, 2nd/3rd degree AV block

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7. OCTREOTIDE / SANDOSTATIN

Standard Prep for Variceal Bleeding

Take 5 amps of 0.1 mg/ml (0.5 mg total) → dilute to 50 ml NS = 10 mcg/ml
OR
Take 1 amp of 0.5 mg/ml → dilute to 50 ml NS = 10 mcg/ml

• Bolus: 50 mcg (0.5 ml of 0.1 mg/ml amp) IV push
• Continuous infusion: 50 mcg/hr (= 5 ml/hr of standard prep above)
• Duration: 3-5 days (minimum 48-72 hours) alongside banding/sclerotherapy
• Also used for: Carcinoid crisis, pancreatic fistula, acromegaly
• For carcinoid crisis: 500 mcg IV push, then 50-200 mcg/hr

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8. INSULIN (ACTRAPID / HUMULIN R)

Standard Prep - The "Rule of 1" Method

Take 50 IU (0.5 ml) → dilute in 50 ml NS = 1 IU/ml

• DKA: Start 0.1 IU/kg/hr (for 70 kg = 7 IU/hr = 7 ml/hr)
  • Or: 0.14 IU/kg/hr without bolus (preferred in 2023 ADA standards)
  • Target: BG drop of 50-75 mg/dl per hour
  • Switch to subcutaneous when BG <200 and AG normal
• ICU glucose control (Surviving Sepsis 2021):
  • Start infusion when BG >180 mg/dl on 2 consecutive readings
  • Target: 140-180 mg/dl
  • Check BG every 1-2 hours until stable, then every 4 hours
• Always run D5W or D10 alongside to prevent hypoglycemia

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9. MIDAZOLAM (DORMICUM)

Standard Prep

Take 10 amps (50 mg) → use undiluted or add to 50 ml NS = 1 mg/ml
(already 1 mg/ml, so can run directly or dilute further)

Take 20 amps (100 mg) → add to 50 ml NS = 2 mg/ml

• Procedural sedation: 1-2 mg IV push slowly, repeat 0.5-1 mg every 2 min (max 5 mg)
• ICU sedation infusion: 0.02-0.1 mg/kg/hr
  • 70 kg: Start 1.4 mg/hr (= 1.4 ml/hr), max 7 mg/hr
• Status epilepticus (refractory): 0.1-0.2 mg/kg/hr infusion after loading 0.2 mg/kg IV
• RASS target: -1 to -2 (light sedation preferred per PADIS guidelines 2018)
• Caution: Prolonged use causes accumulation in obese/renal failure; switch to propofol if >48-72 hrs

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10. DOBUTAMINE

Standard Prep

Take 1 amp (250 mg) → dilute to 50 ml NS = 5 mg/ml = 5000 mcg/ml

• Indication: Low cardiac output state, cardiogenic shock, myocardial dysfunction in sepsis
• Start: 2.5-5 mcg/kg/min
• Max: 20 mcg/kg/min (some guidelines allow 40)
• NOT a vasopressor - does not reliably raise MAP; often used with norepinephrine
• Increases HR - if tachycardia >120 bpm, reduce dose or stop
• Dobutamine + Norepinephrine = standard for cardiogenic shock with hypotension

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11. AMIODARONE (CORDARONE)

CARDIAC ARREST (VF/pVT) - No dilution needed for rapid use

Push 300 mg (2 amps = 6 ml) undiluted IV push
Second dose: 150 mg (1 amp = 3 ml) IV push

Stable Arrhythmia / AF / VT Protocol - Infusion

LOADING DOSE (first 10 min):
2 amps (300 mg) → dilute in 50 ml D5W = 6 mg/ml
Run at 300 ml/hr for 10 min (= 300 mg in 50 ml over 10 min)

MAINTENANCE DOSE:
6 amps (900 mg) → dilute in 500 ml D5W = 1.8 mg/ml
Run at:
- 33 ml/hr for first 6 hours (= ~1 mg/min)
- 17 ml/hr for next 18 hours (= ~0.5 mg/min)

• Loading: 150 mg over 10 min (1 amp in D5W)
• Slow infusion: 1 mg/min for 6 hours
• Maintenance: 0.5 mg/min for 18 hours
• Additional 150 mg bolus if breakthrough arrhythmia

• AF with rapid ventricular response in ICU: 150 mg over 10 min, then infusion
• Hemodynamically stable VT: Same loading
• Dilute ONLY in D5W (precipitates in NS)
• Use central line if possible (causes phlebitis in peripheral)
• Monitor: QTc, LFTs, TFTs (prolonged use), BP during bolus (causes hypotension)
• Oral loading: 200 mg TDS for 1 week, then 200 mg BD, then 200 mg OD for maintenance

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12. LIDOCAINE

Standard Prep for Arrhythmia

Take 5 amps (1000 mg) → add to 250 ml NS = 4 mg/ml = 4000 mcg/ml
OR
Take 2 amps (400 mg) → add to 100 ml NS = 4 mg/ml

• Loading dose: 1-1.5 mg/kg IV push (70 kg: 70-100 mg = 3.5-5 ml of 2%)
  • If no effect, repeat 0.5 mg/kg every 5-10 min (max 3 mg/kg)
• Maintenance infusion: 1-4 mg/min
  • Use only if phenytoin contraindicated or failed
• Used for: VT, VF (second-line after amiodarone in ACLS), VES
• Toxic dose: >6 mg/kg → CNS toxicity (seizures, confusion)
• Monitor: ECG for QRS widening, CNS symptoms

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13. HEPARIN

Standard Prep - Weight-Based Protocol (UFH for PE/DVT/ACS)

Take 5000 IU × needed units ÷ 5000 = number of amps
Mix with NS to desired concentration:
Standard: 25,000 IU in 250 ml NS = 100 IU/ml

• Bolus: 80 IU/kg = 5600 IU (= 1.12 ml of 5000 IU/ml)
• Initial infusion: 18 IU/kg/hr = 1260 IU/hr = 12.6 ml/hr (using 100 IU/ml)

• Bolus amount (ml) = Dose (IU) ÷ 5000
• Infusion rate (ml/hr) = Required IU/hr ÷ 100 (using 100 IU/ml standard)

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14. MAGNESIUM SULPHATE (ZAFA)

ECLAMPSIA / PRE-ECLAMPSIA (Pritchard / Magpie Protocol)

LOADING DOSE:
4 g (4 amps) → dilute in 200 ml NS → run over 20-30 min
= 4000 mg in 200 ml = 20 mg/ml → run at 400 ml/hr for 20 min
(OR: add 4 amps to 100 ml = 40 mg/ml, run at 200 ml/hr for 30 min)

MAINTENANCE:
1 g/hr = 1 amp/hr (undiluted via syringe pump)
OR: 4 amps (4 g) in 250 ml NS = 16 mg/ml, run at 62.5 ml/hr = 1 g/hr

4 amps (4 g) in 40 ml NS via syringe pump = 100 mg/ml = 0.1 g/ml
Run at 10 ml/hr = 1 g/hr

SEVERE ASTHMA

• 2 g (2 amps) IV over 20 min (single dose)
• Dilute 2 amps in 100 ml NS, run over 20 min

TORSADES DE POINTES

• 2 g IV push over 5-10 min (undiluted or in 20 ml)

HYPOMAGNESAEMIA

• 1-2 g (1-2 amps) in 100 ml NS over 1-2 hours

• Respiratory rate >12/min ✓
• Knee jerk present ✓
• Urine output >25 ml/hr ✓
• If toxicity: 10 ml of 10% Calcium Gluconate IV push (antidote)

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15. PHENYTOIN / EPIGRAN

Standard Protocol - Status Epilepticus

LOADING DOSE: 20 mg/kg IV
For 70 kg: 1400 mg = 5.6 amps → dilute in 250 ml NS = 5.6 mg/ml
Infuse at NO faster than 50 mg/min (max rate)
For 1400 mg at 50 mg/min = 28 min → set pump at ~535 ml/hr
SAFE RATE: Use 25 mg/min = ~57 min → pump at ~267 ml/hr

2 amps (500 mg) in 100 ml NS = 5 mg/ml
For 25 mg/min rate: 25 ÷ 5 = 5 ml/min = 300 ml/hr
MAXIMUM: 50 mg/min = 600 ml/hr (this is fast - monitor ECG!)

• Loading: 20 mg/kg IV at max 25-50 mg/min (slower in elderly/cardiac patients = 25 mg/min)
• Maintenance: 100 mg IV/PO every 8 hours (1-1.5 amps IV q8h)
• Dilute ONLY in NS (precipitates in D5W - use D5W, rinse with NS before and after)
• Monitor: BP, ECG (QRS widening, bradycardia, hypotension)
• Never push undiluted rapidly - cardiac arrhythmia/arrest risk
• Use non-inline filter (IV sets with 0.22 micron filter)
• Therapeutic level: 10-20 mcg/ml (free: 1-2.5 mcg/ml)

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16. LEVETIRACETAM (KEPPRA)

Loading Dose - Status Epilepticus (ESETT Trial 2019)

LOADING: 60 mg/kg IV (max 4500 mg)
For 70 kg: 4200 mg = 8.4 amps (500 mg) → dilute in 100 ml NS
Run over 10 minutes

500 mg in 100 ml NS = 5 mg/ml
Run 250 ml/hr for 10 min = 500 mg in 10 min
OR: 1000-1500 mg in 100 ml NS, run over 15 min

• First-line for status epilepticus (alongside or alternative to phenytoin - ESETT 2019 showed equal efficacy)
• Loading: 60 mg/kg (max 4500 mg) over 10 min
• Maintenance: 500-1500 mg BD IV/PO (adjust for renal function: CrCl 30-50 → reduce by 50%)
• Advantages: No cardiac monitoring needed, no CYP interactions, safe in liver disease
• Dilute in NS or D5W - both compatible

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17. VASOPRESSIN

Standard Prep for Septic Shock

Take 5 amps (100 IU) → dilute in 95 ml NS = 1 IU/ml

• Add vasopressin to norepinephrine when NE dose reaches 0.25-0.5 mcg/kg/min
• Fixed dose: 0.03-0.04 IU/min (NOT titrated - unlike NE)
• Do NOT use as sole vasopressor
• Reduces NE requirements, reduces AF risk compared to NE alone (VASST trial)
• GI ischemia and digital ischemia are serious risks - watch for signs
• Also used for: Esophageal variceal bleeding (0.2-0.4 IU/min, less preferred than octreotide)

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18. TERLIPRESSIN (NOVAPRESSIN)

Variceal Bleeding Protocol

RECONSTITUTE: 1 mg powder + 5 ml solvent → 0.2 mg/ml solution
Use entire 5 ml vial = 1 mg dose

• Bolus (preferred method): 2 mg IV push STAT (= 2 vials/amps), then 1-2 mg every 4-6 hours
  • Reduce to 1 mg every 4-6 hours if body weight <50 kg or if side effects
• Continuous infusion (alternative):
  • 2 mg bolus, then 2 mg in 50 ml NS over 24 hours = 1.7 ml/hr
• Duration: Continue until variceal bleeding controlled + 2-5 days
• Side effects: Hyponatremia, cardiac ischemia, intestinal ischemia, peripheral cyanosis
• Contraindicated in: Known coronary artery disease, PVD, severe hyponatremia (<130 mmol/L)
• Combine with: Antibiotics (ceftriaxone 1g OD) + urgent endoscopy within 12 hours

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19. DIAZEPAM

Acute Seizure/SE Protocol

BOLUS: 10 mg (2 ml) IV push slowly over 2-3 min
        (max rate 5 mg/min)
Repeat every 10-15 min (max 3 doses = 30 mg)

Infusion (where syringe pump available)

Take 5 amps (50 mg) → add to 45 ml NS = 1 mg/ml

• PREFERRED: Midazolam over diazepam for ICU infusions (less lipid accumulation, easier titration)
• Diazepam is INCOMPATIBLE with most IV fluids in large volumes (precipitates)
• Best as bolus doses in acute setting
• Lorazepam (if available) preferred for SE over diazepam for IV infusion
• Use rectal diazepam (0.5 mg/kg) if no IV access

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QUICK REFERENCE CHEAT SHEET

"Rule of 50" for Standard ICU Preparations

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VASOPRESSOR QUICK CHART (70 kg Patient)

FIRST-LINE: Norepinephrine (Nor Adrin)
Standard prep: 8 mg in 50 ml = 160 mcg/ml

0.1 mcg/kg/min = 7 mcg/min = 2.6 ml/hr  ← start here
0.25 mcg/kg/min = 17.5 mcg/min = 6.6 ml/hr ← add vasopressin at this point
0.5 mcg/kg/min = 35 mcg/min = 13 ml/hr   ← consider epinephrine/hydrocortisone

ADD VASOPRESSIN at 0.25-0.5 mcg/kg/min NE:
Fixed 0.03 IU/min = 1.8 IU/hr (using 100 IU in 100 ml = 1 IU/ml → 1.8 ml/hr)

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RAPID MENTAL MATH SHORTCUTS

For weight-based drugs (mcg/kg/min):

Dopamine (4 mg/ml = 4000 mcg/ml):
    Rate (ml/hr) = Dose (mcg/kg/min) × 1.05  (× 70 × 60 ÷ 4000 ≈ ×1.05)

Dobutamine (5 mg/ml = 5000 mcg/ml):
    Rate (ml/hr) = Dose (mcg/kg/min) × 0.84  (× 70 × 60 ÷ 5000 ≈ ×0.84)

Norepinephrine (160 mcg/ml):
    Rate (ml/hr) = Dose (mcg/kg/min) × 26.25  (× 70 × 60 ÷ 160)

For mg/hr drugs (fixed dose, not weight-based):

Concentration (mg/ml) in syringe × Rate (ml/hr) = Dose (mg/hr)
→ Rate (ml/hr) = Desired dose (mg/hr) ÷ Concentration (mg/ml)

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SPECIAL NOTES FOR BURETTE WITHOUT SYRINGE PUMP

Drops/min = ml/hr  (since burette = 60 gtt/ml → drops/min = ml/hr)

Examples:
- Furosemide 10 mg/hr (from 1 mg/ml prep) = 10 ml/hr = 10 drops/min
- ISDN 2 mg/hr (from 1 mg/ml prep) = 2 ml/hr = 2 drops/min  
- Heparin 1000 IU/hr (from 100 IU/ml) = 10 ml/hr = 10 drops/min

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RED FLAGS / NEVER DO LIST

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Sources: Surviving Sepsis Campaign Guidelines 2021, Tintinalli's Emergency Medicine 9e, ACLS 2020, AHA/ACC HF Guidelines 2022, AASLD/EASL Variceal Bleeding Guidelines, Washington Manual of Therapeutics, ESETT Trial 2019, PADIS Guidelines 2018, Medscape IV Drip Rate Formula, local Pakistan formulary (Dyago, DRAP-listed brands).

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