SOUTH GEORGIA MEDICAL CENTER
PATIENT CARE
POLICY & PROCEDURE
TITLE: High Alert-Specialty Medication & Critical Drip
Medication Administration: Initiation, Maintenance &
Weaning
PREPARED/COORD BY: Clinical Practice Council & Critical
Care Committee
APPROVED BY:
NUMBER: IV-A-80
EFFECTIVE: 9/98
REVIEWED: 3/12
REVISED: 3/99, 4/00, 9/01
REVISED: 4/04, 11/05, 8/08
REVISED: 03/09, 12/12
POLICY STATEMENT & PURPOSE
This policy serves as a resource for the initiation, maintenance and weaning of specialty medications
including calculation for appropriate dosing.
Introduction
Specialty medications include but are not limited to vasoactive, antiarrhythmic, anticoagulant, and insulin
as listed in this policy. The medications included in this policy are considered to be ‘high alert’
medications or medications which may carry a higher risk for adverse outcomes. Patients receiving Nontitrated specialty medications may be located outside the Critical Care units; Patients receiving specialty
medications which will be titrated should have an order to admit/transfer to a critical care unit.
Definition for High alert medication: Medications that have the highest risk of causing injury when misused.
(Cohen, M.R. Medication Errors. 1999. p 5.1).
This policy outlines recommendations for administration and monitoring of listed medications.
Development of this list was based on information in professional literature from the Institute for Safe
Medication Practice (ISMP), Joint Commission on Accreditation of Healthcare Organizations (JCAHO),
American Society of Health-System Pharmacists (AHSP), etc. and from concepts drawn from humanfactors knowledge of principles of error reduction. These guidelines for administering and monitoring
medications known as “high alert medications” (as defined by South Georgia Medical Center’s Medication
Safety Team) should be provided for clinical practitioners to use in the care and treatment of the patient. In
addition to this policy, resources such as the Electronic Drug Reference and Pharmacists are available
and should be consulted when questions arise.
Note: The automated dispensing medication cabinet provides special notations in the message field
screen (alert/message/ reminder) for some medications.
PROCEDURE
Refer to Guidelines for Practice Prior to Treatment and Procedures (XVI-D40)
I.
GENERAL GUIDELINES
A. Specialty drip medications should be initiated by a Registered Nurse (RN).
B. Specialty drip medications should be maintained on an IV pump at all times including during
transport of the patient
C. Prior to initiation of a specialty drip, two (2) nurses, one of which must be a RN, (a Pharmacist
or physician may substitute for one nurse) should validate concentration, dosages, and infusion
pump rates. At each change of shift, transfer from one area to another and/or when a new
bag is administered, the off-going and on-coming nurse should verify concentration by
visually inspecting the bag, calculate the desired dose rate, and verify the pump is infusing at
the calculated rate.
 Two (2) RNs (one may be a pharmacist/MD) verifying the drip should Co-Sign in the
patient’s medical record.
Specialty Medication Administration, PCS IV-A-80
D. Highly concentrated drips are to be administered through a central line only. Standard
concentrations drips listed in appendix A & B may be administered peripherally if a central
line is not available; however a central line is preferred. Changes in recommended drip
concentration will require a physician’s order and consultation with Pharmacy.
E. Compatible drips may be attached to stopcocks connected to the individual ports of the central
venous catheter with compatible IV fluids as the primary line.
F. For adult patients, the minimum rate to any IV site is 10 ml per hour. If the specialty drip
medication is to run at less than 10 ml per hour, primary IV tubing with ordered fluids should be
added to equal a rate of 10 ml per hour. The specialty drip medication should infuse through
the first port closest to the IV site of the primary IV fluids. If the specialty drip is more than 10
ml per hour the drip may infuse without primary fluid infusing.
G. An additional IV site should be maintained for administration of other IV medications and/or IV
fluids by IV route. A peripheral saline lock may be used for this purpose.
H. Telemetry should be maintained on patients receiving antiarrhythmic. The Monitor Bank
should be notified when patient is receiving IV administration of antiarrhythmic.
I. Orders that vary from recommended dosages should be verified with the Physician. If, after
clarifying with the Physician and Pharmacy, the dosage still exceeds the recommendation
below, the nurse should notify the Administrative Coordinator.
J. Non-titrated specialty drip medications may be administered in Non-Intensive Care areas
when patient monitoring is ordered as no greater than every 4 to 8 hours.
K. Heparin may be titrated in non-intensive care areas.
L. For vesicant infiltration/extravasation refer to PC policy IV-C-100, Treatment of Vesicant
Extravasation.
M. For Weight-Based drips, use the weight obtained when the drip was started. If a
subsequent drip is started, use the weight obtained for the first drip. All drips should be
based on the same weight.
 The admission weight appears as the default weight in IV Manage. The default weight
should be manually changed in IV Manage when the drip is started
N. Documentation verification
 Stock Bottles of IV fluids and medicated drips are documented on the IV Manage
screen in HED and the name of RN verifying the information. Verifying nurse utilizes
the Co-Sign feature in HED or document in the patient’s medical record.
O. Vital signs should be monitored prior to initiation and during administration of specialty
medications. For Vital Signs monitoring, see specific drug guidelines:
 Non-titration specialty medication Infusion guidelines (appendix A)
 Titrating specialty medication Infusion guidelines – Critical Care (appendix B) .
II.
HIGH ALERT SPECIALTY MEDICATIONS
High alert specialty drip medications and selected monitoring parameters include but are not
limited to:
1. Immune Globulin Intravenous (IVIG)- See Pediatric policy “Administration of
Intravenous Immune Globulin to Pediatric/Adolescent Patient”
2. Immune Globulin Intravenous (IVIG) - See PC policy IV-E-25 (Adult)
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Specialty Medication Administration, PCS IV-A-80
3. Antidysrhythmics – IV Push
NOTE: For the purpose of this policy, IV antidysrhythimic is defined as a medication listed
below that is administered for the emergent/urgent rhythm management and NOT routine
administration for health maintenance.
A. Antidysrhythmics IV push should be administered by a RN.
B. Licensed Practical Nurses and Paramedics in the Emergency Department setting may
administer IV push antidysrhythmics under the direct supervision of the physician/LIP.
C. The patient should be monitored on telemetry during administration of IV antidysrhythmic
agents.
D. The Monitor Bank should be notified prior to administration of the antidysrhythmic agent.
E. The patient’s vital signs should be monitored as indicated by the patient’s condition until
dysrhythmia is stabilized.
F. Refer to the Electronic Drug Reference or pharmacist for rates of infusion.
G. Examples of antidysrhythmic agents include but are not limited to the following:
1. Adenosine (Adenocard)
2. Diltiazem (Cardizem)
3. Metoprolol tartrate (Lopressor)
4. Xylocaine (Lidocaine)
5. Procainamide (Pronestyl)
6. Verapamil (Isoptin, Calan)
7. Amiodarone (Cordarone)
4. Non-Titrating Specialty Medication Infusion Guidelines – See Appendix A
5. Titrating Specialty Medication Infusion Guidelines Critical Care – See Appendix B
6. Neuromuscular Blocking Agents
For use in the presence of a physician with airway management equipment, oxygen and
reversal agents immediately available. Follow physicians order for dose parameters.
Indications include the following:
A. Adjunct to general anesthesia
B. Facilitate endotracheal intubation
C. Skeletal muscle relaxation during surgery or mechanical ventilation
7. Fibrinolytics
A. Activase (Alteplase)
1. Follow Activase order Set
8. Argatroban
For use to decrease the clotting ability of the blood and to help prevent harmful clots from
forming in the blood vessels. This medicine is used to treat or prevent blood clots in patients
with bleeding problems caused by another medicine called heparin. It may also be used in
patients who are having certain heart and blood vessel procedures, such as coronary
angioplasty.
1. Follow Argatroban order set or physician order
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Specialty Medication Administration, PCS IV-A-80
III.
SUBCUTANEOUS MEDICATIONS
A.
IV.
ORAL MEDICATIONS
A.
V.
Refer to Administration of Chemotherapy Agents policy IV-F- 5
PATIENT CONTROL ANALGESIA (PCA)
A.
VII.
Coumadin (warfarin)
1. Verify PT and/or INR level prior to administration.
CHEMOTHERAPY
A.
VI.
Insulin (See Policy, IV-A-20)
1. Orders containing the use of ‘u’ rather than ‘units’ should be clarified.
2. Dose should be verified with second independent check of physician order, medication
container and syringe containing the insulin prior to administration. The second check
should be by another licensed person (nurse, physician or Pharmacist).
Refer to PCA Administration and Documentation, policy IV-B-5
PEDIATRIC MEDICATIONS
A.
B.
Weight based dosing
1.
Refer to HPP 99, Physician Order, Section M.
Chloral Hydrate (for procedures)
1.
Prior to administration, inquire as to whether child has had previous sedation
and if yes, determine time the sedation was given. Notify the physician if
patient received any sedation within past 8 hours.
2.
Consult with Pharmacy to calculate dose
3.
Dose should be verified with second independent check of order, medication
container and syringe.
4.
Monitor patient pre and post administration and document.
DOCUMENTATION:
PC IV-A-20: Medication-Insulin Administration
PC IV-C-55: Medication Administration Documentation
REFERENCES:
Pediatric Standard of Care & Practice policy, Administration of Intravenous Immune Globulin to
Pediatric/Adolescent Patient
PC policy IV-C-100: Treatment of Vesicant Extravasation.
PC policy IV-F-5: Administration of Chemotherapy Agents
PC policy IV-B-5 PCA Administration and Documentation
PC policy IV-A-20: Insulin Administration
HPP 94 Procedural Sedation
9/98-Policies that were consolidated into this policy: Dopamine, Dobutamine, Lidocaine, Recommended Guidelines
for the Administration of IV Potassium Chloride, and IV Pharmacological Intervention for The Non-ICU/Non-ER
Patient Experiencing An Unstable Dysrhythmia.
9/12 Critical Drip Initiation, Maintenance & Weaning consolidated into this policy
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Specialty Medication Administration, PCS IV-A-80
Non-Titrating Specialty Medication Infusion Guidelines – Appendix A
Medication
Brand/Generic
Name
Drip
Concentration
Dosage
Monitoring
1mg/ml
2-5 mcg/kg/min
Intropin
Dopamine
1.6mg/ml
2-5 mcg/kg/min
Lidocaine
4mg/ml
1-4 mg/min
Vital signs are taken when infusion is initiated, dosage
is changed PRN using following schedule:
 VS every 15 minutes X 1 hr THEN
 Every 1 hour X 4 THEN
 Every 4 hours thereafter
Monitor IV site closely for signs or symptoms of
infiltration/extravasation
Vital signs are taken when infusion is initiated, dosage
is changed PRN using following schedule:
 VS every 15 minutes X 1 hr THEN
 Every 1 hour X 4 THEN
 Every 4 hours thereafter
Monitor IV site closely for signs or symptoms of
infiltration/extravasation
Vital signs every 4 hours or as ordered
Peripheral
Max conc:
0.2mEq/ml
Per Physician
order/protocol
Dobutrex
Dobutamine
Potassium
Replacement
Therapy
via IV PB
Central Line
Max conc:
0.4mEq/ml
Calcium Gluconate
Infusion
Refer to Physician
order and/or Refer to
Electronic Drug
Reference
Refer to Physician
order and/or Refer
to Electronic Drug
Reference
Natrecor
Nesititide
6 mcg/ml
Bolus: 2 mcg/kg
over 1 minute
Infusion: 0.01
mcg/kg/min
MAXIMUM infusion rate outside ICU/ER should
not exceed 20 mEq/hr
 Potassium infused as a PRIMARY line
 Pt should be monitored on telemetry
 Recommend K+ serum level monitoring
 Monitor IV site closely for S/S infiltration &
extravasation
 May be administered by a LPN after verification
by RN
 Vital signs every 15 minutes while drug infusing
 Watch for hypotension, bradycardia, arrhythmias
 Use caution in patients receiving digoxin
 Monitor serum calcium as ordered
 Pharmacy should provide as a piggyback
BP prior to and after bolus; every 15 minutes X 4;
then every hour X 4; then every 2 hours thereafter
Special Considerations:
1. Natrecor is not usually titrated
2. Major side effect is hypotension. Notify
physician if systolic BP is less than 90 mmHg
3. Do not give IV push medications through the
line infusing Natrecor
Reference: Electronic Drug Reference; American Heart Association
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Specialty Medication Administration, PCS IV-A-80
Titrating Specialty Medication Infusion Guidelines: Critical Care – Appendix B
Medication
Drip
Brand/Generic Concentration
Name
Dosage
Titration
Weaning
Ativan
Lorazepam
0.24 mg/ml
Very agitated:
1 mg/hr.
Less agitated:
0.25-0.5 mg/hr.
Once adequate
sedation achieved,
titrate to lowest
effective dose
Wean according to MD
order
Breviblock
Esmolol
10 mg/ml
Bolus: 500
mcg/kg over 1
minute; then
50mcg/kg/min
Over 4 minutes
then maintenance
50-200
mcg/kg/min
Varies, but usually
if no satisfactory
response. refer to
MD orders
Cardene
Nicardipine
0.1 mg/ml
5-15 mg/hr
Increase by 2.5
mg/hr. every 15
minutes
After clinical control of
heart rate & patient
stabilization, should be
changed to alternate antiarrhythmic; decrease rate
by 50% 30 minutes after
first dose of other drug.
D/C one hour after second
dose of other drug if rate
control
Decrease by 2.5mg/hr
every 15 minutes
Cardizem
Diltiazem
1 mg/ml
Bolus 0.25 mg/kg
Over 2 minutes;
then start @ 10
mg/hr.
Decrease as ordered
Cordarone
Amiodarone
Bolus: 1.5 mg/ml
Diprivan
Propofol
10 mg/ml
Bolus: 150 mg
over 10 minutes
then 1mg/min
over 6 hrs.
then 0.5 mg/min
for 18 hrs.
10-70 mcg/kg/min
Increase by 5
mg/hr. up to max
of 15 mg/hr. or
until desired
response
Not usually
titrated
Dose adjustments
as noted in dosage
column
10-20 mcg/kg/min
every 10-15
minutes until
desired effect
Dobutrex
Dobutamine
1 mg/ml
2-20 mcg/kg/min
Titrate to desired
parameter
Avoid abrupt
discontinuation. Decrease
by 10-20mcg/kg/min
increments every 10-15
minutes until patient
reaches a light sedation
level
Decrease by
0.5mcg/kg/min every 15
minutes as long as desired
parameter maintained
Epinephrine
4 mcg/ml
2-10 mcg/min
Start @ 2
mcg/min; Increase
by 0.5 mcg/min to
maintain desired
parameter
Decrease by 0.5mcg/min
to maintain desired
parameter
Heparin
50 units/ml
See Specific
Heparin Protocol
Intropin
Dopamine
1.6 mg/ml
2-20 mcg/kg/min
Increase by
0.5-1 mcg/kg/min
until desired
parameter reached
Decrease by
0.5mcg/kg/min every 15
minutes as long as desired
parameter maintained
Insulin
1 unit/1 ml
Per MD order
or protocol/order
set
Per MD order or
protocol/order set
As ordered
Infusion: 1.8 mg/ml
See Diprivan
order for Intubated
& ventilated
patients
See Weight Based
Heparin Order
See Policy IV-A-20
As ordered by MD;
usually stops with
completion of final 18
hour dose
Monitoring
Vital signs every 5-15 minutes for
first hour and at least every 15
minutes and PRN for drip rate
changes. If not titrating and vital
sign stable document every hour
Vital signs every 5-15 minutes for
first hour and at least every 15
minutes and PRN for drip rate
changes. If not titrating and vital
sign stable document every hour
Vital signs every 5-15 minutes for
first hour and at least every 15
minutes and PRN for drip rate
changes. If not titrating and vital
sign stable document every hour
Vital signs every 5-15 minutes for
first hour and at least every 15
minutes and PRN for drip rate
changes. If not titrating and vital
sign stable document every hour
Vital signs every 5-15 minutes for
first hour and at least every 15
minutes and PRN for drip rate
changes. If not titrating and vital
sign stable document every hour
Vital signs every 5-15 minutes for
first hour and at least every 15
minutes and PRN for drip rate
changes. If not titrating and vital
sign stable document every hour.
Wake daily to assess CNS status
Vital signs every 5-15 minutes for
first hour and at least every 15
minutes and PRN for drip rate
changes. If not titrating and vital
sign stable document every hour
Vital signs every 5-15 minutes for
first hour and at least every 15
minutes and PRN for drip rate
changes. If not titrating and vital
sign stable document every hour
Recommend VS every 4 hours or as
ordered
Recommend PTT monitoring as
ordered: PTT 6 hours after any
dosage change
Vital signs every 5-15 minutes for
first hour and at least every 15
minutes and PRN for drip rate
changes. If not titrating and vital
sign stable document every hour
See Policy IV-A-10
 Blood glucose monitoring per
MD order or protocol
Reference: Electronic Drug Reference; American Heart Association
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Specialty Medication Administration, PCS IV-A-80
Titrating Specialty Medication Infusion Guidelines: Critical Care – Appendix B
Medication
Brand/Generic
Name
Drip
Dosage
Non weight base:
0.5-30 mcg/min
Weight based:
0.04-1 mcg/kg/min
Bolus: 1-1.5
mg/kg IVP
Then 1-4 mg/min
Decrease slowly to
avoid abrupt
hypotension
Start @ 2 mg/min,
increase by 0.5-1
mg/min to control
PVCs
Not usually titrated
Decrease by 0.5
mg/min every hour
as long as PVCs
suppressed
Decrease by 10-20
mcg/hr. as long as
desired parameter is
maintained
0.5-5 mg/min
DO NOT
EXCEED
180MG/HR.
Start @ 100
mcg/min and
increase by 10
mcg/min to
maintain desired
parameter
Start @ 0.5
mcg/kg/min.
Increase by 0.5
mcg/kg/min q 5
minutes to reach
desired parameter
Increase 0.5 mg/min
every 30 minutes
until desired
response
GI bleed:
0.2-0.8 units/min
GI bleed:
0.2 units/hr
16 mcg/ml
Lidocaine
4 mg/ml
Natrecor
Nesititide
6 mcg/ml
Bolus: 2 mcg/kg
over 1 minute
Infusion: 0.01
mcg/kg/min
Neosynephrine
Phenylephrine
0.04 mg/ml
100-180 mcg/min
Nipride
0.2 mg/ml
0.3-10
mcg/kg/min
1 mg/ml
0.4 units/ml
Nitroprusside Sodium
Trandate
Labetalol
Pitressin
Vasopressin
Weaning
None
Levophed
Norepinephrine
Normodyne
Titration
Monitoring
Concentration
Precedex
Dexmedetomidine
4 mcg/ml
Primacor
Milrinone
0.2 mg/ml
Pronestyl
Procainamide
4 mg/ml
Tridil
Nitroglycerine
0.2 mg/ml
Septic shock:
0.01-0.04
units/min
Loading dose:
1mcg/kg over 10
Minutes
then
0.1-0.7 mcg/kg/hr.
Loading dose:
50 mcg/kg over 10
Minutes
then
0.5 mcg/kg/min
Loading dose
20 mg/min up to 1
Gram
then
2-4 mg/min
Start @ 5-10
mcg/min
Vital signs every 5-15 minutes for first hour
and at least every 15 minutes and PRN for
drip rate changes. If not titrating and vital
sign stable document every hour
Vital signs every 4 hours or as ordered
BP - prior to and after bolus; then q 15
minutes X4; then q hour X4; then q 2 hours
thereafter
Considerations
 Major side effect is hypotension. Notify
MD if systolic BP is less than 90 mmHg
 Do not give IV push medications
through the line infusing Natrecor
Vital signs every 5-15 minutes for first hour
and at least every 15 minutes and PRN for
drip rate changes. If not titrating and vital
sign stable document every hour
Decrease by 0.5
mcg/kg/min q15
minutes as long as
desired parameter
maintained
Vital signs every 5-15 minutes for first hour
and at least every 15 minutes and PRN for
drip rate changes. If not titrating and vital
sign stable document every hour
Decrease by 0.5
mg/min every 30
minutes
Vital signs every 5-15 minutes for first hour
and at least every 15 minutes and PRN for
drip rate changes. If not titrating and vital
sign stable document every hour
GI bleed: If
bleeding controlled
for 12 hours, may
decreased drip by
50% then stop in
12-24 hours
Not usually weaned.
Patients may be
extubated while on
Precedex
Vital signs every 5-15 minutes for first hour
and at least every 15 minutes and PRN for
drip rate changes. If not titrating and vital
sign stable document every hour
May be titrated as
ordered Often not
titrated
Decrease as ordered
Vital signs every 5-15 minutes for first hour
and at least every 15 minutes and PRN for
drip rate changes. If not titrating and vital
sign stable document every hour
Start @ 2 mg/min.
Increase by 0.5-1
mg/min as to
control PVC’s. Do
not exceed 4mg/min
Increase 5-10
mcg/min q 3-5
minutes until chest
Decrease by 0.5
mg/min every hour
as long as PVCs
suppressed
Vital signs every 4 hours or as ordered
Decrease by 5-10
mcg/min every 15
minutes as long as
desired parameters
maintained
Vital signs every 5-15 minutes for first hour
and at least every 15 minutes and PRN for
drip rate changes. If not titrating and vital
sign stable document every hour
Septic shock:
DO NOT
TITRATE
None
discomfort relieved,
highest ordered dose
achieved,
hypotension develops
Vital signs every 5-15 minutes for first hour
and at least every 15 minutes and PRN for
drip rate changes. If not titrating and vital
sign stable document every hour
Reference: Electronic Drug Reference; American Heart Association
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