Patient wt in kg: ____________
• Titrate for target: ☐SBP ≥_____mmHg &/OR ☐ MAP ≥_____mmHg
• Initiate in the following order:______________________________________
☐if no central line, use peripheral line (note: peripheral line can be use for 2-6 hours, it is suggested to install a central line thereafter)
☐if no peripheral line, use intra-osseous line
• Vital Signs
☐q 15 minutes
☐q 1 hour
☐as following order: take vital signs every ________________
☐ Norepinephrine (Levophed) 8 mg/250 mL (32 mcg/mL) D5W (suggested range 0-50 mL/h)
☐ infuse @ ____to ____mcg/kg/min
(Equivalent to: ____to ____mL/h)
or
☐ infuse @____to____mL/h
*see phentolamine protocol for peripheral IV extravasation
☐ Vasopressin 40 units/100 mL NS (suggested range 2-6 mL/h)
☐ infuse @____ to____mL/h
☐ Phenylephrine(Neosynephrine) 20 mg/250 mL(80 mcg/mL) D5W (suggest range 0-60 mL/h)
☐ infuse @ ____to ____mcg/kg/min.
(Equivalent to: ____to ____mL/h)
or
☐ infuse @____to____mL/h
☐
Epinephrine (Adrenalin) – 4 mg/250 mL NS (16 mcg/mL) (suggest range 0-40 mL/h)
☐ infuse @ ____to ____mcg/kg/min.
(Equivalent to: ____to ____mL/h)
or
☐ infuse @____to____mL/h
☐________________________________________________________________________
☐stop infusion, withdraw drug from catheter and D/C IV. Immediately restart another intravenous.
☐For interstitial Norepinephrine, follow Phentolamine Protocol
• Mix 10 mg Phentolamine in 10 mL NS and inject SQ in multiple areas of surrounding tissue to the interstitial IV site using a 25-29 gauge needle.
• Change needle between each skin entry. Monitor area by marking borders of discolored tissue with indelible marker
• Advise Most Responsible Physician (MRP) of extravasation