Give me a generalized rule or formula ( easy to remember and short way or trick ) to calculate the drop rate or rate of infusion of any drugs given ((with it's formulation (mg/ml))) in given time at required rate ( mg/hr or mg / min) ..and how many ampules of that drug to are required for easy and accurate infusion rate .. for example lasix 20mg/2ml .. dilute in 100cc burrete required at rate of 10mg / hour .. or similar way adrenaline ( 1mg/1ml 1:1000) , noradrenaline (4mg/4ml) , isosorbide dinitirite (10mg/10ml), dopamine (200mg/5ml) , labetalol (50mgl/10ml) .. Also give answer for sandostatin (octreotide) (0.1mg/ml) , insulin , midazolam( 5mg/5ml), dobutamine (250ml/5ml) , amiodarone (150ml/3ml) , lidocaine (2%, 10ml), heparin (5000IU/ml), magnesium sulphate (500mg/ml), phenytoin (250mg/5ml) laviteracetam (500mg/5ml) , vasopressin (20U/ml) , terlipressin (1mg/1ml). Diazepam (10mg/2ml). give answer according to the formulations present in Pakistani market .. according to the latest litreture and guidelines followed in ICU and ER , and wards. Take text from the PDF and reconsider and enhance the notes by taking references from the latest literature, guidelines, and textbooks and making the content easy for me to digest and palatable. Make the drugs' ICU dosing protocols by taking references from the latest ICU guidelines, ER guidelines, and ER textbooks and literature. Also consider the formulations for each rug that are present in the Pakistani market and calculate the rates according to them. The notes should be easy to understand, in such a way so that I can take reference from them whenever I am in a hurry or I am treating the patient in the ward or emergency. The dosing and the rates calculation should be accurate according to the guidelines .....i have uploaded the formulations of the drugs that are present in Pakistani market .. so adjust the doses ad. Formulas according to them..
Asking for Preferences
Reading File
Searching the Web
ICU drug infusion rates protocols 2024 guidelines Pakistan vasopressors sedation
Searching PubMed
ICU drug infusion protocols vasopressors sedation 2024
Finding Sources
Finding Sources
Finding Sources
Finding Sources
Finding Sources
Finding Sources
Finding Sources
Finding Sources
Finding Sources
Finding Sources
ICU/ER DRUG INFUSION REFERENCE GUIDE
For Pakistan - Ward, ER & ICU Use
Based on Pakistani market formulations | Guidelines: Surviving Sepsis 2021, AHA 2022-2024, ACCP, ESICM, Tintinalli EM, Goldman-Cecil Medicine, Braunwald's Heart Disease
THE MASTER FORMULA (Memorize This One)
┌─────────────────────────────────────────────────────────────────┐
│ │
│ Rate (ml/hr) = Required Dose (mg/hr or mcg/hr) │
│ ───────────────────────────── │
│ Concentration (mg/ml or mcg/ml) │
│ │
│ Concentration = Total drug added (mg) ÷ Total volume (ml) │
│ │
└─────────────────────────────────────────────────────────────────┘
Weight-based trick (mcg/kg/min drugs like dopamine, dobutamine):
Rate (ml/hr) = Dose (mcg/kg/min) × Weight (kg) × 60
────────────────────────────────────
Concentration (mcg/ml)
Ampules needed:
Ampules = Total dose to put in bag (mg) ÷ Dose per ampule (mg)
The "Easy Concentration" Trick:
- If you dilute drug in 100 ml total: concentration = mg added ÷ 100
- Example: 20 mg Lasix in 100 ml → concentration = 0.2 mg/ml → for 10 mg/hr → run at 50 ml/hr
HOW TO USE THIS GUIDE (Reading each drug entry)
Each drug below has:
- Pakistani formulation available
- Standard ICU/ER dilution recipe
- Resulting concentration
- How to run at commonly used doses
- Ampules required
- Key clinical notes
SECTION 1 - DIURETICS
1. FUROSEMIDE (LASIX)
Pakistani Formulation: 20 mg/2 ml ampoule (10 mg/ml)
Dilution for Continuous Infusion (Burette Method):
| Preparation | How |
|---|---|
| Standard | Add 2 ampoules (40 mg / 4 ml) into 96 ml NS = 100 ml total |
| Concentration | 40 mg ÷ 100 ml = 0.4 mg/ml |
Rate Calculation:
| Required Dose | Rate |
|---|---|
| 5 mg/hr | 5 ÷ 0.4 = 12.5 ml/hr |
| 10 mg/hr | 10 ÷ 0.4 = 25 ml/hr |
| 20 mg/hr | 20 ÷ 0.4 = 50 ml/hr |
| 40 mg/hr | 40 ÷ 0.4 = 100 ml/hr |
Simple trick: 1 ampoule (20 mg) in 100 ml = 0.2 mg/ml → 10 mg/hr = 50 ml/hr
ICU/ER Protocol:
- Acute decompensated heart failure: Start at 10-20 mg/hr continuous infusion
- Dose = 2.5× the patient's home oral daily dose as IV continuous/24 hr (DOSE trial)
- Bolus option: 40-80 mg IV push (preferred in wards), repeat q6-8h
- Maximum: 4 mg/min for IV bolus to avoid ototoxicity
- Monitor urine output hourly, electrolytes q12h
SECTION 2 - VASOPRESSORS & INOTROPES
2. ADRENALINE (EPINEPHRINE)
Pakistani Formulation: 1 mg/1 ml (1:1000) ampoule
Dilution for ICU Infusion:
| Preparation | How |
|---|---|
| Standard | Add 5 ampoules (5 mg / 5 ml) into 45 ml NS = 50 ml total |
| Concentration | 5 mg ÷ 50 ml = 0.1 mg/ml = 100 mcg/ml |
Alternative (less concentrated):
| Add 1 ampoule (1 mg) into 49 ml NS = 50 ml total → 0.02 mg/ml = 20 mcg/ml |
Rate Calculation (for 70 kg patient):
| Dose | Calculation | Rate |
|---|---|---|
| 0.05 mcg/kg/min | 0.05 × 70 × 60 ÷ 100 mcg/ml | 2.1 ml/hr |
| 0.1 mcg/kg/min | 0.1 × 70 × 60 ÷ 100 | 4.2 ml/hr |
| 0.3 mcg/kg/min | 0.3 × 70 × 60 ÷ 100 | 12.6 ml/hr |
ICU/ER Protocol (Surviving Sepsis 2021 / AHA):
- Anaphylaxis: 0.5 mg IM (thigh) first - then IV infusion if refractory
- Septic shock (add-on after noradrenaline): 0.01-0.3 mcg/kg/min IV infusion
- Cardiac arrest (ACLS): 1 mg IV push q3-5 min (no infusion in arrest)
- Start low (0.05 mcg/kg/min), titrate every 5-10 min
- Must use CVC - peripheral use only in emergency until central access obtained
3. NORADRENALINE (NOREPINEPHRINE)
Pakistani Formulation: 4 mg/4 ml ampoule (1 mg/ml)
Dilution for ICU Infusion:
| Preparation | How |
|---|---|
| Standard | Add 4 ampoules (16 mg) into 84 ml D5W or NS = 100 ml total |
| Concentration | 16 mg ÷ 100 ml = 0.16 mg/ml = 160 mcg/ml |
| Simple (2 amp) | Add 2 ampoules (8 mg) into 42 ml → 50 ml = 0.16 mg/ml |
Rate Calculation (for 70 kg patient):
| Dose | Calculation | Rate |
|---|---|---|
| 0.05 mcg/kg/min | 0.05 × 70 × 60 ÷ 160 | 1.3 ml/hr |
| 0.1 mcg/kg/min | 0.1 × 70 × 60 ÷ 160 | 2.6 ml/hr |
| 0.2 mcg/kg/min | 0.2 × 70 × 60 ÷ 160 | 5.3 ml/hr |
| 0.5 mcg/kg/min | 0.5 × 70 × 60 ÷ 160 | 13 ml/hr |
| 1.0 mcg/kg/min | 1.0 × 70 × 60 ÷ 160 | 26 ml/hr |
ICU Protocol (Surviving Sepsis 2021 - First-line vasopressor):
- Start: 0.01-0.05 mcg/kg/min
- Target MAP ≥65 mmHg (or ≥80 in chronic hypertensives)
- Range: 0.01-2 mcg/kg/min (if >0.5 = high dose, add vasopressin)
- Preferred over dopamine (less arrhythmia, better outcomes in septic shock)
- Must use CVC - peripheral line acceptable only for <2 hr while awaiting access
- Vesicant - extravasation → phentolamine 5 mg in 10 ml NS injected locally
4. DOPAMINE
Pakistani Formulation: 200 mg/5 ml ampoule (40 mg/ml)
Dilution for ICU Infusion:
| Preparation | How |
|---|---|
| Standard | Add 1 ampoule (200 mg / 5 ml) into 245 ml NS = 250 ml total |
| Concentration | 200 mg ÷ 250 ml = 0.8 mg/ml = 800 mcg/ml |
| Simple (syringe pump) | Add 1 amp (200 mg) into 45 ml NS = 50 ml → 4 mg/ml = 4000 mcg/ml |
Rate Calculation - 250 ml bag (800 mcg/ml), 70 kg patient:
| Dose | Calculation | Rate |
|---|---|---|
| 2 mcg/kg/min (renal) | 2 × 70 × 60 ÷ 800 | 10.5 ml/hr |
| 5 mcg/kg/min (cardiac) | 5 × 70 × 60 ÷ 800 | 26.3 ml/hr |
| 10 mcg/kg/min (vasopressor) | 10 × 70 × 60 ÷ 800 | 52.5 ml/hr |
| 15 mcg/kg/min | 15 × 70 × 60 ÷ 800 | 78.8 ml/hr |
| 20 mcg/kg/min | 20 × 70 × 60 ÷ 800 | 105 ml/hr |
ICU/ER Protocol:
- Low dose (1-3 mcg/kg/min): "Renal dose" - NOT recommended (no evidence of renoprotection per current guidelines)
- Moderate (3-10 mcg/kg/min): Inotropic effect - use in cardiogenic shock, low CO
- High (>10 mcg/kg/min): Vasopressor effect - alternative if noradrenaline unavailable
- NOT first-line in septic shock (increased arrhythmia vs. noradrenaline - SOAP II trial)
- Max dose: 20 mcg/kg/min; CVC preferred, peripheral acceptable short-term
5. DOBUTAMINE
Pakistani Formulation: 250 mg/5 ml ampoule (50 mg/ml)
Dilution for ICU Infusion:
| Preparation | How |
|---|---|
| Standard | Add 1 ampoule (250 mg / 5 ml) into 245 ml NS or D5W = 250 ml total |
| Concentration | 250 mg ÷ 250 ml = 1 mg/ml = 1000 mcg/ml |
| Syringe pump | Add 1 amp into 45 ml = 50 ml → 5000 mcg/ml |
Rate Calculation - 250 ml bag (1000 mcg/ml), 70 kg patient:
| Dose | Calculation | Rate |
|---|---|---|
| 2.5 mcg/kg/min | 2.5 × 70 × 60 ÷ 1000 | 10.5 ml/hr |
| 5 mcg/kg/min | 5 × 70 × 60 ÷ 1000 | 21 ml/hr |
| 10 mcg/kg/min | 10 × 70 × 60 ÷ 1000 | 42 ml/hr |
| 15 mcg/kg/min | 15 × 70 × 60 ÷ 1000 | 63 ml/hr |
| 20 mcg/kg/min | 20 × 70 × 60 ÷ 1000 | 84 ml/hr |
ICU Protocol:
- Cardiogenic shock, acute decompensated HF with low output
- Start: 2.5 mcg/kg/min; Target: 5-10 mcg/kg/min
- Max: 20 mcg/kg/min
- Causes tachycardia and vasodilation - monitor HR closely
- Can be given peripherally (not a vesicant)
- Titrate based on clinical response (CI, urine output, lactate)
SECTION 3 - ANTIHYPERTENSIVES
6. ISOSORBIDE DINITRATE (ISDN)
Pakistani Formulation: 10 mg/10 ml ampoule (1 mg/ml) - Isoket, Sorbidilat
Dilution for Infusion:
| Preparation | How |
|---|---|
| Standard | Add 5 ampoules (50 mg) into 50 ml NS = 100 ml total (or use undiluted via syringe pump) |
| Concentration | 50 mg ÷ 100 ml = 0.5 mg/ml = 500 mcg/ml |
| Simple (undiluted via syringe pump) | 10 mg/10 ml ampoule = 1 mg/ml = 1000 mcg/ml directly |
Rate Calculation (undiluted, 1 mg/ml via syringe pump):
| Dose | Rate |
|---|---|
| 1 mg/hr | 1 ÷ 1 = 1 ml/hr |
| 2 mg/hr | 2 ml/hr |
| 5 mg/hr | 5 ml/hr |
| 10 mg/hr | 10 ml/hr |
Rate Calculation (0.5 mg/ml diluted):
| Dose | Rate |
|---|---|
| 1 mg/hr | 1 ÷ 0.5 = 2 ml/hr |
| 5 mg/hr | 10 ml/hr |
| 10 mg/hr | 20 ml/hr |
ICU/ER Protocol:
- Acute pulmonary edema / hypertensive urgency: Start 1-2 mg/hr, titrate to 10-20 mg/hr
- STEMI/Unstable angina: Start at 2 mg/hr, titrate by 1 mg/hr q5-10 min for symptom/BP control
- Target: SBP reduction ~25% or SBP 100-110 mmHg
- Contraindication: SBP <90 mmHg, use of PDE5 inhibitors (sildenafil, tadalafil)
- Tolerance develops at 24-48 hr - provide 8-10 hr nitrate-free interval
- Adsorbs to PVC tubing - use glass or polyethylene tubing where possible
7. LABETALOL
Pakistani Formulation: 50 mg/10 ml ampoule (5 mg/ml) - Trandate
Dilution for Infusion:
| Preparation | How |
|---|---|
| Standard | Add 4 ampoules (200 mg / 40 ml) into 160 ml NS = 200 ml total |
| Concentration | 200 mg ÷ 200 ml = 1 mg/ml |
| Simple | Add 2 ampoules (100 mg) into 100 ml NS = 1 mg/ml |
Rate Calculation (1 mg/ml):
| Dose | Rate |
|---|---|
| 1 mg/min (start) | 1 ÷ 1 = 1 ml/min = 60 ml/hr |
| 2 mg/min | 120 ml/hr |
IV Bolus Method (most common in ER):
| Sequence | Dose | Wait |
|---|---|---|
| 1st bolus | 20 mg IV over 2 min | Wait 10 min, check BP |
| 2nd bolus | 40 mg IV over 2 min | Wait 10 min |
| 3rd bolus | 80 mg IV over 2 min | Wait 10 min |
| Max total bolus | 220-300 mg | Stop if SBP <90 |
ICU/ER Protocol (Hypertensive Emergency, Tintinalli / Goldman-Cecil):
- First choice for hypertensive emergency, especially in stroke (avoid excess BP drop)
- Also used in aortic dissection (combined alpha+beta block), eclampsia
- IV infusion: Start 1-2 mg/min, titrate; usual max 2-4 mg/min total
- Contraindications: Asthma, COPD (severe), AV block, decompensated HF, bradycardia
SECTION 4 - ANTIARRHYTHMICS
8. AMIODARONE
Pakistani Formulation: 150 mg/3 ml ampoule (50 mg/ml) - Cordarone, Amipace
Loading Dose (Acute AF / VT):
| Preparation | How |
|---|---|
| Loading | Add 2 ampoules (300 mg / 6 ml) into 94 ml D5W = 100 ml |
| Concentration | 300 mg ÷ 100 ml = 3 mg/ml |
| Run at | 100 ml over 60 min = 100 ml/hr (= 300 mg over 1 hr) |
Maintenance Infusion:
| Preparation | How |
|---|---|
| Standard 24-hr bag | Add 6 ampoules (900 mg / 18 ml) into 482 ml D5W = 500 ml |
| Concentration | 900 mg ÷ 500 ml = 1.8 mg/ml |
| Run at 1 mg/min (6 hr) | 1 ÷ 1.8 × 60 = 33 ml/hr for 6 hours |
| Then 0.5 mg/min (18 hr) | 0.5 ÷ 1.8 × 60 = 17 ml/hr for 18 hours |
Standard AHA/Tintinalli Protocol:
| Phase | Dose | Rate |
|---|---|---|
| Rapid load | 150 mg over 10 min (in D5W) | Run 2 amp (300 mg) in 100 ml D5W at 300 ml/hr for 10 min = 150 mg in 10 min |
| Slow load | 360 mg over 6 hr (1 mg/min) | 33 ml/hr (using 500 ml bag above) |
| Maintenance | 540 mg over 18 hr (0.5 mg/min) | 17 ml/hr |
| Supplemental | 150 mg PRN for breakthrough VT | |
| Total 24-hr dose | 900-1200 mg |
Key Notes:
- Always use D5W (not NS - precipitates)
- Use CVC or large peripheral vein (phlebitis risk)
- Monitor for hypotension (slow bolus), bradycardia, QT prolongation
- Oral loading: 200 mg TDS × 7-10 days then 200 mg OD maintenance
9. LIDOCAINE (LIGNOCAINE)
Pakistani Formulation: 2% solution, 10 ml ampoule = 200 mg/10 ml (20 mg/ml)
Dilution for Maintenance Infusion:
| Preparation | How |
|---|---|
| Standard | Add 5 ampoules (1000 mg / 50 ml) into 450 ml NS = 500 ml total |
| Concentration | 1000 mg ÷ 500 ml = 2 mg/ml |
| Simple (syringe pump) | 1 ampoule (200 mg in 10 ml) + 40 ml NS = 50 ml → 4 mg/ml |
Rate Calculation (2 mg/ml, standard bag):
| Dose | Rate |
|---|---|
| 1 mg/min | 1 × 60 ÷ 2 = 30 ml/hr |
| 2 mg/min | 60 ml/hr |
| 3 mg/min | 90 ml/hr |
| 4 mg/min | 120 ml/hr |
ICU/ER Protocol (VT, Wide-complex tachycardia - Tintinalli):
- Loading bolus: 1-1.5 mg/kg IV over 2-3 min (max 3 mg/kg total loading)
- For 70 kg: 100 mg (5 ml of 2% ampoule) over 2-3 min
- Repeat 0.5-0.75 mg/kg if needed q5 min
- Maintenance infusion: 1-4 mg/min
- Start with 2 mg/min, reduce to 1 mg/min after 24 hr
- Max: 4 mg/min; reduce in hepatic failure and elderly (0.5-1 mg/min)
- Toxicity signs: tinnitus, circumoral numbness, confusion, seizures
- Not for VF arrest (amiodarone preferred per ACLS 2020)
SECTION 5 - SEDATION & SEIZURE DRUGS
10. MIDAZOLAM
Pakistani Formulation: 5 mg/5 ml ampoule (1 mg/ml) also 5 mg/1 ml (5 mg/ml) available - Dormicum
Dilution for ICU Infusion:
| Preparation | How |
|---|---|
| Using 5 mg/5 ml (1 mg/ml) | Draw 10 ampoules (50 mg / 50 ml) - use undiluted or add to 50 ml syringe |
| Concentration | 1 mg/ml (undiluted) or dilute 10 ampoules in 50 ml NS = 50 mg in 50 ml = 1 mg/ml |
| Using 5 mg/1 ml (5 mg/ml) | Add 10 ampoules (50 mg / 10 ml) into 40 ml NS = 50 ml → 1 mg/ml |
Rate Calculation (1 mg/ml, 70 kg patient):
| Dose | Calculation | Rate |
|---|---|---|
| 0.02 mg/kg/hr | 0.02 × 70 ÷ 1 | 1.4 ml/hr |
| 0.05 mg/kg/hr | 0.05 × 70 | 3.5 ml/hr |
| 0.1 mg/kg/hr | 0.1 × 70 | 7 ml/hr |
| 0.2 mg/kg/hr | 0.2 × 70 | 14 ml/hr |
ICU/ER Protocol:
- Procedural sedation (ER): 0.05-0.1 mg/kg IV (titrate to effect, slow push over 2 min)
- ICU sedation (continuous): Start 0.02-0.05 mg/kg/hr, titrate to RASS -1 to -2
- Range: 0.01-0.2 mg/kg/hr (max 0.2 mg/kg/hr)
- Status epilepticus: 0.1-0.3 mg/kg IV bolus; then infusion 0.05-0.4 mg/kg/hr
- 2024 ICU guidelines: Benzodiazepines are NOT first-line for sedation (propofol/dexmedetomidine preferred); use midazolam for alcohol withdrawal, seizures, or when propofol unavailable
- Reversal: Flumazenil 0.2 mg IV, repeat q1 min up to 1 mg total
11. DIAZEPAM
Pakistani Formulation: 10 mg/2 ml ampoule (5 mg/ml) - Valium, Diaz
Dilution:
Diazepam should NOT be diluted in burettes - precipitates in aqueous solution. Use undiluted via slow IV push only. For infusion use a glass syringe pump with original ampoule, diluted minimally.
Dosing (ER / Ward):
| Indication | Dose | How |
|---|---|---|
| Acute seizure / status epilepticus | 10 mg IV | Slow IV push over 2 min (5 mg/min max); repeat q5-10 min, max 30 mg |
| Alcohol withdrawal | 5-10 mg IV/IM | q30 min PRN (CIWA-guided) |
| Muscle relaxant / procedural | 5-10 mg IV | Slow push |
| Anxiety/pre-procedure | 5 mg IV | Slow push |
ICU Notes:
- Avoid continuous infusion - propylene glycol vehicle causes toxicity in infusions
- If infusion needed (status epilepticus refractory): Use midazolam infusion instead
- Short-acting, but active metabolite (desmethyldiazepam) accumulates - prolonged effect in elderly, liver disease
- Reversal: Flumazenil (same as midazolam)
SECTION 6 - ANTIEPILEPTICS
12. PHENYTOIN
Pakistani Formulation: 250 mg/5 ml ampoule (50 mg/ml) - Dilantin, Eptoin
Dilution for Loading Dose:
| Preparation | How |
|---|---|
| Standard | Add 4 ampoules (1000 mg / 20 ml) into 80 ml NS = 100 ml total |
| Concentration | 1000 mg ÷ 100 ml = 10 mg/ml |
| For 70 kg (1200 mg load) | Add 4.8 ampoules (approx 5 ampoules = 1250 mg) in 100 ml NS = 12.5 mg/ml |
⚠️ NEVER dilute in D5W - precipitates. Use NS only.
Rate Calculation (10 mg/ml):
| Rate | Dose Delivered | Comment |
|---|---|---|
| 5 ml/min = 300 ml/hr | 50 mg/min | Maximum safe rate |
| 3 ml/min = 180 ml/hr | 30 mg/min | Safer rate, less hypotension |
| 1 ml/min = 60 ml/hr | 10 mg/min | For elderly/cardiac patients |
ICU/ER Protocol:
- Loading dose: 15-20 mg/kg IV (for 70 kg = 1000-1400 mg)
- Rate: No faster than 50 mg/min (25 mg/min in elderly/cardiac)
- 1000 mg in 100 ml NS = run at 300 ml/hr (50 mg/min rate), typically over 20-30 min
- Maintenance: 100 mg IV/oral q8h (or 4-7 mg/kg/day in 2-3 divided doses)
- Monitor ECG and BP during infusion (bradycardia, hypotension, arrhythmia)
- Therapeutic level: 10-20 mcg/ml
- Avoid in hepatic failure, SJS history, heart block
13. LEVETIRACETAM (KEPPRA / LEVIPIL)
Pakistani Formulation: 500 mg/5 ml ampoule (100 mg/ml) - Levipil, Keppra concentrate
Dilution for Loading/Infusion:
| Preparation | How |
|---|---|
| Standard | Add 4 ampoules (2000 mg / 20 ml) into 80 ml NS = 100 ml total |
| Concentration | 2000 mg ÷ 100 ml = 20 mg/ml |
| For 70 kg load (60 mg/kg = 4200 mg) | Add 8.4 ampoules (approx 8 ampoules = 4000 mg) in 200 ml NS |
Rate Calculation (20 mg/ml):
| Loading dose | Volume | Rate |
|---|---|---|
| 1000 mg | 50 ml (at 20 mg/ml) | Run over 15 min = 200 ml/hr |
| 2000 mg | 100 ml | Run over 15 min = 400 ml/hr |
| 3000 mg (status) | 150 ml | Run over 15 min = 600 ml/hr |
ICU/ER Protocol:
- Status epilepticus: 60 mg/kg IV (max 4500 mg) over 15 minutes - 2nd line after benzodiazepines
- Standard loading: 20-60 mg/kg (commonly 1000-3000 mg) over 15 min
- Maintenance: 500-1500 mg IV/oral q12h
- Preferred over phenytoin in many centers: safer cardiac profile, no drug interactions, can be used in liver disease
- Dose reduction in renal impairment (CrCl <80 ml/min)
- No monitoring of levels routinely required
SECTION 7 - ANTICOAGULANTS
14. HEPARIN (UNFRACTIONATED)
Pakistani Formulation: 5000 IU/ml, 5 ml ampoule = 25,000 IU/ampoule - Multiparin
Dilution for Infusion (DVT/PE/ACS protocol):
| Preparation | How |
|---|---|
| Standard | Add 1 ampoule (25,000 IU / 5 ml) into 245 ml NS = 250 ml total |
| Concentration | 25,000 IU ÷ 250 ml = 100 IU/ml |
| Syringe pump | 25,000 IU in 50 ml NS = 500 IU/ml |
Rate Calculation (100 IU/ml, weight-based):
| Dose | Calculation (70 kg) | Rate |
|---|---|---|
| 1000 IU/hr | 1000 ÷ 100 | 10 ml/hr |
| 1260 IU/hr (18 IU/kg/hr) | 18 × 70 = 1260 ÷ 100 | 12.6 ml/hr |
| 1500 IU/hr | 1500 ÷ 100 | 15 ml/hr |
ICU/ER Protocol (Weight-Based Nomogram - ACCP):
| Dose | |
|---|---|
| Bolus | 80 IU/kg IV (for 70 kg = 5600 IU = ~1.1 ml of 5000 IU/ml ampoule) |
| Starting infusion | 18 IU/kg/hr (for 70 kg = 1260 IU/hr) |
| Target aPTT | 60-100 seconds (1.5-2.5× control) |
| Check aPTT | 6 hours after start and after every dose change |
Adjustment Table:
| aPTT | Action |
|---|---|
| <40 sec | Bolus 80 IU/kg + increase rate by 4 IU/kg/hr |
| 40-49 sec | Bolus 40 IU/kg + increase rate by 2 IU/kg/hr |
| 50-70 sec (sub-therapeutic) | Increase rate by 2 IU/kg/hr |
| 60-100 sec (therapeutic) | No change |
| 101-120 sec | Decrease rate by 2 IU/kg/hr |
| >120 sec | Stop 1 hr, then decrease rate by 3 IU/kg/hr |
Reversal: Protamine sulfate 1 mg per 100 IU heparin (given in last 2 hr)
SECTION 8 - MAGNESIUM SULPHATE
15. MAGNESIUM SULPHATE (MgSO4)
Pakistani Formulation: 500 mg/ml = 50% solution, 10 ml ampoule = 5 g/ampoule
(Also available as 2 g/10 ml = 200 mg/ml = 20% in some brands)
⚠️ 50% MgSO4 MUST be diluted before IV use - never give undiluted IV push
Dilution:
| Preparation | How |
|---|---|
| For loading 4 g | Take 8 ml of 50% MgSO4 (4 g) + 92 ml NS = 100 ml total |
| Concentration | 4 g ÷ 100 ml = 40 mg/ml |
| Run at | 100 ml over 20 min = 300 ml/hr |
| For maintenance (1 g/hr) | Take 1 ampoule (5 g) into 40 ml NS = 50 ml → 100 mg/ml = run at 10 ml/hr |
Dosing Protocols:
| Indication | Loading Dose | Maintenance |
|---|---|---|
| Pre-eclampsia/Eclampsia | 4 g IV over 20 min | 1-2 g/hr x 24 hr (Pritchard/Magpie trial) |
| Severe asthma (ICU) | 2 g IV over 20 min | Not routinely continued |
| Hypomagnesemia | 2-4 g IV over 30-60 min | 0.5-1 g/hr × 2-4 hr or oral replacement |
| Torsades de Pointes | 1-2 g IV over 5-15 min | 0.5-1 g/hr if recurrent |
| Refractory VF (ACLS) | 1-2 g IV push over 5 min | - |
Toxicity Monitoring:
| Sign | MgSO4 level |
|---|---|
| Loss of patellar reflex | >7 mEq/L (therapeutic: 4-7) |
| Respiratory depression | >10 mEq/L |
| Cardiac arrest | >15 mEq/L |
| Antidote | Calcium gluconate 1 g IV over 10 min |
SECTION 9 - VASOACTIVE (PORTAL HYPERTENSION)
16. VASOPRESSIN
Pakistani Formulation: 20 IU/ml, 1 ml ampoule - Pitressin
Dilution for Infusion:
| Preparation | How |
|---|---|
| Standard | Add 5 ampoules (100 IU / 5 ml) into 95 ml NS = 100 ml total |
| Concentration | 100 IU ÷ 100 ml = 1 IU/ml |
Rate Calculation (1 IU/ml):
| Dose | Rate |
|---|---|
| 0.01 IU/min (0.6 IU/hr) | 0.6 ÷ 1 = 0.6 ml/hr |
| 0.02 IU/min (1.2 IU/hr) | 1.2 ml/hr |
| 0.03 IU/min (1.8 IU/hr) | 1.8 ml/hr |
| 0.04 IU/min (2.4 IU/hr) | 2.4 ml/hr |
ICU Protocol:
| Indication | Dose |
|---|---|
| Septic shock (add-on vasopressor, Surviving Sepsis 2021) | 0.03 IU/min fixed dose (not titrated) |
| Variceal bleeding | 0.2-0.4 IU/min, max 0.9 IU/min |
| Diabetes insipidus | 5-10 IU SC/IM q6-8h or 0.5-1 IU/hr IV |
- Septic shock dose = 0.03 IU/min = 1.8 IU/hr → at 1 IU/ml = 1.8 ml/hr
- Add vasopressin when noradrenaline ≥0.25-0.5 mcg/kg/min (Surviving Sepsis 2021)
- Must use CVC - vasoconstrictive, high extravasation risk
17. TERLIPRESSIN
Pakistani Formulation: 1 mg/1 ml ampoule - Glypressin, Terlipac
Dosing - Variceal Bleeding (Yamada GI Textbook / EASL 2022):
| Initial bolus | 2 mg IV (2 ampoules) over 5-10 min |
| Maintenance | 1-2 mg IV q4-6h for up to 5 days |
| Active bleeding with hypotension | 1 mg q4h; increase to 2 mg q4h if not controlled |
| Continue until | 24 hr free of bleeding, then taper |
Hepatorenal Syndrome Type 1 (HRS-AKI):
| Starting dose | 0.5-1 mg IV q4-6h |
| Max | 2 mg q4h |
| Duration | Until reversal of HRS or 14 days |
| Combine with | Albumin 20-40 g/day IV |
Terlipressin is a bolus drug, NOT a continuous infusion (unlike vasopressin). Each dose is given as a slow IV push or short infusion over 5-10 min.
- Contraindications: Severe IHD, PAD, asthma
- Monitor for hypertension, bradycardia, ischemia (splanchnic, peripheral, cardiac)
SECTION 10 - GI BLEED / ENDOCRINE
18. OCTREOTIDE (SANDOSTATIN)
Pakistani Formulation: 0.1 mg/ml (100 mcg/ml), 1 ml ampoule = 100 mcg ampoule
(Also available: 0.5 mg/ml and 1 mg/ml for LAR injections - NOT for acute use)
Dilution for Continuous Infusion:
| Preparation | How |
|---|---|
| Standard | Add 5 ampoules (500 mcg / 5 ml) into 45 ml NS = 50 ml total |
| Concentration | 500 mcg ÷ 50 ml = 10 mcg/ml |
| Or | Add 2 ampoules (200 mcg) into 38 ml NS = 40 ml → 5 mcg/ml |
Rate Calculation (10 mcg/ml):
| Dose | Rate |
|---|---|
| 25 mcg/hr | 2.5 ml/hr |
| 50 mcg/hr | 5 ml/hr |
| 100 mcg/hr | 10 ml/hr |
ICU/ER Protocol (Variceal Bleeding - AASLD/BSG):
| Bolus | 50 mcg (0.5 ml of 0.1 mg/ml) IV push immediately |
| Infusion | 50 mcg/hr for 2-5 days |
| Duration | Continue until 24 hr after endoscopy and no rebleeding |
| Rate at 10 mcg/ml | 5 ml/hr |
Other Uses:
- Carcinoid crisis/tumor: 100-500 mcg bolus, then 50-500 mcg/hr
- Pancreatitis (severe): 100-200 mcg q8h SC (not infusion typically)
- Dump syndrome / secretory diarrhea: 100-200 mcg SC TDS
SECTION 11 - INSULIN
19. INSULIN (REGULAR / SOLUBLE)
Pakistani Formulations:
- Actrapid (Novo Nordisk): 100 IU/ml, 10 ml vial
- Humulin R: 100 IU/ml, 10 ml vial
- Insuman Rapid: 100 IU/ml, 3 ml cartridges
Standard ICU Infusion Preparation:
| Preparation | How |
|---|---|
| Standard | Take 50 IU (0.5 ml from 100 IU/ml vial) into 49.5 ml NS = 50 ml total |
| Concentration | 50 IU ÷ 50 ml = 1 IU/ml |
| Simplest | 50 units in 50 ml NS via syringe pump = 1 IU/ml |
Rate Calculation (1 IU/ml):
| Dose | Rate |
|---|---|
| 1 IU/hr | 1 ml/hr |
| 2 IU/hr | 2 ml/hr |
| 5 IU/hr | 5 ml/hr |
| 0.1 IU/kg/hr (70 kg = 7 IU/hr) | 7 ml/hr |
DKA Protocol (Miller's Anesthesia / ADA 2024):
| Phase | Dose |
|---|---|
| Fixed rate infusion | 0.1 IU/kg/hr (for 70 kg = 7 IU/hr = 7 ml/hr) |
| No IV bolus (ADA 2024 - bolus no longer recommended unless delayed infusion) | |
| Check glucose | Hourly |
| Target glucose fall | 50-75 mg/dl/hr |
| When glucose <200 | Reduce to 0.02-0.05 IU/kg/hr + add D5 to fluids |
| Continue until | pH >7.3, HCO3 >18, anion gap closed |
Hyperkalemia Protocol:
| Insulin dose | 10 IU regular insulin IV bolus |
| Paired with | 50 ml of 50% dextrose (D50) IV |
| Effect | K+ drops by 0.5-1.5 mEq/L in 15-30 min |
| Duration | 4-6 hours (temporizing measure only) |
Blood Sugar Control (ICU):
- Target BS: 140-180 mg/dl (NICE-SUGAR trial evidence)
- Avoid tight control (<110 mg/dl) - increased hypoglycemia mortality
- Check glucose q1-2h on infusion
SECTION 12 - ANTIARRHYTHMIC / RATE CONTROL
20. ISOSORBIDE DINITRATE (refer to Section 3 above)
QUICK REFERENCE TABLE - All Drugs at a Glance
| Drug | Pakistani Formulation | Standard Dilution | Concentration | Common Dose | Rate |
|---|---|---|---|---|---|
| Furosemide | 20 mg/2 ml | 2 amp in 100 ml NS | 0.4 mg/ml | 10 mg/hr | 25 ml/hr |
| Adrenaline | 1 mg/1 ml | 5 amp in 50 ml NS | 0.1 mg/ml (100 mcg/ml) | 0.1 mcg/kg/min (70 kg) | 4.2 ml/hr |
| Noradrenaline | 4 mg/4 ml | 4 amp in 84 ml D5W | 0.16 mg/ml (160 mcg/ml) | 0.1 mcg/kg/min (70 kg) | 2.6 ml/hr |
| Dopamine | 200 mg/5 ml | 1 amp in 250 ml NS | 800 mcg/ml | 5 mcg/kg/min (70 kg) | 26.3 ml/hr |
| Dobutamine | 250 mg/5 ml | 1 amp in 250 ml NS | 1000 mcg/ml | 5 mcg/kg/min (70 kg) | 21 ml/hr |
| ISDN | 10 mg/10 ml | Undiluted syringe pump | 1 mg/ml | 2-5 mg/hr | 2-5 ml/hr |
| Labetalol | 50 mg/10 ml | 2 amp in 100 ml NS | 1 mg/ml | Bolus 20→40→80 mg OR 1-2 mg/min infusion | 60-120 ml/hr |
| Amiodarone | 150 mg/3 ml | Load: 2 amp in 100 ml D5W; Maint: 6 amp in 500 ml D5W | 3 mg/ml / 1.8 mg/ml | Load 300 mg/hr; Maint 1 mg/min | 100 ml/hr → 33 ml/hr |
| Lidocaine | 200 mg/10 ml (2%) | 5 amp in 500 ml NS | 2 mg/ml | 2 mg/min | 60 ml/hr |
| Midazolam | 5 mg/5 ml (1 mg/ml) | 10 amp in 50 ml NS | 1 mg/ml | 0.1 mg/kg/hr (70 kg) | 7 ml/hr |
| Diazepam | 10 mg/2 ml (5 mg/ml) | Bolus only (no infusion) | - | 10 mg slow IV push | - |
| Phenytoin | 250 mg/5 ml | 4 amp in 80 ml NS | 10 mg/ml | 15-20 mg/kg load | ≤50 mg/min = 300 ml/hr |
| Levetiracetam | 500 mg/5 ml | 4 amp in 80 ml NS | 20 mg/ml | 60 mg/kg over 15 min | ~400-600 ml/hr |
| Heparin | 5000 IU/ml (5 ml amp) | 1 amp in 250 ml NS | 100 IU/ml | 18 IU/kg/hr (70 kg = 1260 IU/hr) | 12.6 ml/hr |
| MgSO4 | 500 mg/ml (50%, 10 ml) | 8 ml (4g) in 92 ml NS | 40 mg/ml | 4g load over 20 min; 1 g/hr maintenance | 300 ml/hr → 25 ml/hr |
| Vasopressin | 20 IU/ml (1 ml) | 5 amp in 95 ml NS | 1 IU/ml | 0.03 IU/min (1.8 IU/hr) | 1.8 ml/hr |
| Terlipressin | 1 mg/1 ml | Bolus (no infusion) | - | 2 mg IV bolus q4-6h | Slow push over 5-10 min |
| Octreotide | 0.1 mg/ml (100 mcg/ml) | 5 amp in 45 ml NS | 10 mcg/ml | 50 mcg/hr | 5 ml/hr |
| Insulin (Regular) | 100 IU/ml (10 ml vial) | 50 IU in 50 ml NS | 1 IU/ml | 0.1 IU/kg/hr (70 kg = 7 IU/hr) | 7 ml/hr |
THE 3-STEP BEDSIDE PROTOCOL (For ANY Drug)
STEP 1 - PREPARE:
Ampules needed = Total dose to put in bag ÷ Dose per ampule
STEP 2 - CALCULATE CONCENTRATION:
Concentration (mg/ml) = Total drug in bag (mg) ÷ Total volume (ml)
STEP 3 - CALCULATE RATE:
Rate (ml/hr) = Required dose (mg/hr) ÷ Concentration (mg/ml)
For weight-based (mcg/kg/min):
Rate (ml/hr) = Dose (mcg/kg/min) × Weight (kg) × 60
────────────────────────────────────
Concentration (mcg/ml)
Memory trick - "The Rule of 6" (for dopamine/dobutamine at weight of 60-70 kg):
- 6 ampoules of 200 mg dopamine in 500 ml → concentration ~2400 mcg/ml
- Running at 6 ml/hr ≈ 1 mcg/kg/min
- So rate (ml/hr) ≈ desired dose (mcg/kg/min) × 6 at this preparation
CRITICAL SAFETY REMINDERS
| ⚠️ Rule | Details |
|---|---|
| Check concentration TWICE | Before starting any infusion |
| Amiodarone → D5W only | Precipitates in NS |
| Phenytoin → NS only | Precipitates in D5W |
| MgSO4 50% → must dilute | Never bolus undiluted IV |
| Diazepam → bolus only | No continuous IV infusion |
| Noradrenaline/Adrenaline → CVC | Peripheral only as bridge |
| Vasopressin → CVC mandatory | High extravasation risk |
| Terlipressin → bolus not infusion | Unlike vasopressin |
| Phenytoin → ECG + BP monitoring | ≤50 mg/min always |
| Insulin → check glucose hourly | Target 140-180 mg/dl (ICU) |
| Heparin → aPTT q6h | Adjust by nomogram |
| MgSO4 → check reflexes + RR | Calcium gluconate at bedside |
Sources: Surviving Sepsis Campaign 2021, AHA/ACC Guidelines 2022-2024, ACLS 2020, AASLD Variceal Bleeding Guidelines 2022, ADA DKA Standards 2024, Tintinalli's Emergency Medicine 9e, Goldman-Cecil Medicine, Braunwald's Heart Disease 12e, Katzung Pharmacology 16e, Miller's Anesthesia 10e, Morgan & Mikhail's Clinical Anesthesiology 7e, Harriet Lane Handbook 23e
This is a shared conversation. Sign in to Orris to start your own chat.