Anaphylaxis

Epinephrine

IM: 0.3 or 0.5 mg . 0.5 mg in patients >50 kg

Children: 0.01 mL/kg

Use a 1 mg/mL solution.

IM, in the anterolateral aspect of the middle third of the thigh

May repeat q 5 -15 minutes or sooner if patient does not adequately respond.

Glucagon

1-mg bolus followed by 1-mg/hour infusion

Children dose: 20 to 30 mcg/kg

In patients taking oral beta-blockers

Diphenhydramine (Benadryl): 25 to 50 mg PO or IV

May need Inhaled beta-agonists, IV fluids, intubation and vasopressors.

Insomnia

Melatonin: 0.1 - 0.5 mg PO

Trazodone

Immediate release: 50 to 100 mg, PO, at bedtime

Zolpidem (Ambien): 5 mg PO q.h.s, PRN

Sore throat

Chloraseptic spray: 2 sprays q 2hrs PRN

Acute asthma attack

Albuterol (Ventolin, ProAir)

Metered-dose inhaler: Initial-90 mcg/actuation: 2 inhalations qid, PRN

Fluticasone (Flovent)

Metered-dose inhaler: Initial: 88 mcg bid

Appetite Stimulant

Dronabinol (Marinol)

2.5 mg, PO, once or twice daily

Nausea and vomiting

Ondansetron (Zofran)

4 mg IV / PO q 6 hrs PRN

Prochlorperazine (Compazine)

5 to 10 mg, PO, q 6- 8 hrs PRN

2.5 to 10 mg, IV q 3-4 hrs PRN

Maximum: 40 mg/day

Promethazine (Phenergan)

12.5 mg IV q 4-6 hrs PRN

Metoclopramide (Reglan)

10 mg IV /PO q 6 hrs PRN

Hiccups

Baclofen

Initial: 5 to 10 mg, PO, 3 times daily

Metoclopramide, Pantoprazole , and Gabapentin may also be tried.

Reflux

Famotidine (Pepcid)

20 mg, IV / PO, bid

Pantoprazole (Protonix)

40 mg IV / PO daily or bid

Calcium carbonate (Tums)

Chewable Tablets- 1000 mg orally up to 4 times a day

Ileus

Chewing gum: helps to prevent ileus

Methylnaltrexone

38-62 kg: 8 mg/dose SC every other day

62-114 kg: 12 mg/dose SC every other day

<38 kg or >114 kg: 0.15 mg/kg/dose SC every other day

Constipation

Docusate (Colace)

50 to 300 mg PO daily divided in 1 to 4 doses

Bisacodyl (Dulcolax)

Suppository:10 mg daily, PO : 5 to 15 mg daily

Senna

2 tablets once a day. Tablets are 8.6 mg

MiraLAX (polyethylene glycol)

17 g (diluted in 8 ounces of water or juice, or soda) orally once a day

Fleet enema (sodium phosphates)

120 mL, rectally as a single dose

Diarrhea- None- infectious

Loperamide (Imodium)

Oral: Initial: 4 mg, followed by 2 mg after each loose stool (maximum: 16 mg/day)

Diphenoxylate/ atropine (Lomotil)

5 mg diphenoxylate/0.05 mg atropine (2 tablets) PO q6hr

Opium tincture

Oral: 6 mg (0.6 mL) of undiluted opium tincture (10 mg/mL) 4 times daily

C- Diff Infection

Initial episode:

Vancomycin

125 mg orally 4 times per day for 10 days

Fidaxomicin

200 mg twice daily for 10 days

Metronidazole

500 mg orally 3 times per day for 10 days.

GI Fistulas- High Output

Octreotide

100 mcg, SC, tid

Reserve use for patients with fistula output >1 to 1.5 L/day.

Bladder spasm

Oxybutynin (Ditropan)

Immediate release: 5 mg 2 to 3 times daily

Itching

Diphenhydramine (Benadryl)

25 to 50 mg orally or IV

Hypertension

Amlodipine (Norvasc)

Initial: 2.5 to 5 mg, PO, once daily. Max: 10 mg/day

Carvedilol (Coreg)

Immediate release. Initial: 6.25 mg, PO, bid

Usual : 6.25 to 25 mg, PO, twice daily

Metoprolol

Immediate release.

Initial: 50 mg, PO, bid

Usual: 100 to 200 mg/day, PO, in 2 divided doses

Clonidine

Immediate release

Initial: 0.1 mg, PO, bid

Usual dose range: 0.2 to 0.6 mg PO/day in 2 divided doses.

Orthostatic Hypotension

Notice- Make sure there is no bleeding, and patient is not volume depleted.

Midodrine

Initial: 5 to 10 mg, PO, q8 hours

Usual dose: 10 to 20 mg, PO, q8 hours

Fludrocortisone (Florinef)

0.1- 0.3 mg, PO, daily

Hypocalcemia

Calcium gluconate

Mild -ionized calcium: 4 to 5 mg/dL (1 to 1.2 mmol/L): 1 to 2 g, IV, over 2 hours

Moderate to severe- ionized calcium: <4 mg/dL (<1 mmol/L): 4 g, IV, over 4 hours

Severe symptomatic (seizure, tetany): 1 to 2 g, IV, over 10 minutes; repeat every 60 minutes until symptoms resolve

Hypomagnesemia

Magnesium sulfate

Mild deficiency (>1.5 to 1.9 mg/dL): 1 to 2 g, IV, over 1 to 2 hours

.

Moderate deficiency (1 to 1.5 mg/dL): 2 to 4 g, IV, over 2 to 12 hours

Severe deficiency (<1 mg/dL): 4 to 8 g, IV, over 4 to 24 hours

Hypophosphatemia

Sodium phosphate

Dose for Critically-ill adult patients receiving concurrent enteral/parenteral nutrition.

Low dose for serum phosphorus level 2.3-3 mg/dL (0.74-0.96 mmol/L): 0.16-0.32 mmol/kg over 4-6 hours

Intermediate dose for serum phosphorus level 1.6-2.2 mg/dL (0.51-0.71 mmol/L): 0.32-0.64 mmol/kg over 4-6 hours

High dose for serum phosphorus <1.5 mg/dL (<0.5 mmol/L): 0.64-1 mmol/kg over 8-12 hours

Hyperphosphatemia

Sevelamer

Initial: 800 to 1,600 mg, PO, 3 times daily with meals

Hypokalemia

Per Lexicomp:

Serum potassium 3 -3.4 mEq/L

Oral: 10 to 20 mEq 2 to 4 times daily.

IV: when patient can not tolerate PO.

20 mEq q 2-3 hours. Maximum infusion rate 10 to 20 mEq/hour. Central-line infusion & continuous ECG monitoring highly recommended for >10 mEq/hour.

Usual initial dose: 20 to 60 mEq. Decide about next doses based on serum potassium.

Serum potassium 2.5 to 3 mEq/L:

IV: Initial: 10 to 20 mEq/hour

Maximum infusion rate: 20 mEq/hour with continuous ECG monitoring

Adjust based on frequent serum potassium monitoring.

Serum potassium <2.5 mEq/L

IV: Initial: 10 to 40 mEq/hour

Maximum infusion rate (central line only): 40 mEq/hour with continuous ECG monitoring;

Adjust based on frequent serum potassium monitoring.

Hyperkalemia

Click here.

Hypo- Hypernatremia

Click here.

Iron Deficiency

Ferrous Sulfate: 325 mg (65 mg of elemental iron), PO, daily or every other day.

Low Molecular Weight Iron Dextran (INFeD)

To calculate total dose, click here.

Prior to the first intravenous INFeD therapeutic dose, administer an intravenous test dose of 0.5 ml.

Administer the test dose at a gradual rate over at least 30 seconds.

Individual doses of 2 mL or less may be given on a daily basis until the calculated total amount required has been reached. INFeD is given undiluted at a slow gradual rate not to exceed 50 mg (1 mL) per minute.

In patients with asthma or more than one drug allergy, we premedicate with Methylprednisolone (125 mg) and Famotidine.

Diabetes

Insulin Algorithm for Type 2 Diabetes

Click here .

Insulin Algorithm for Type 1 Diabetes

Click here.

Iv Insulin Infusion

Iv Insulin Infusion Protocol for Critically-Ill Adult Patients

ICU Insulin Orders

DKA

Management of DKA in Adults

Management of DKA in Persons Younger than 20 Years

Orders for Adults with DKA and Hyperglycemic Hyperosmolar State

Transition from I.V. to S.Q. Insulin

Inpatient Protocol for Transition from I.V. to Basal/Bolus S.Q. Insulin

Transition from I.V. to S.Q. Insulin Order Set TPN or Enteral (Tube) Nutrition

Click here and refer to the corresponding section in the document.

Hypoglycemia

IV: 10-25 g (20-50 mL 50% solution or 40-100 mL of 25% solution).

Pain

Acetaminophen (Tylenol)

650 mg PO or PR q 6 hrs PRN

Acetaminophen (Ofirmev)

≥50 kg: 650 mg IV q4hr OR 1000 mg IV q6hr; Maximum dose: 4 g/day

Ketorolac (Toradol)

Weight ≥50 kg and <65 years of age: 15 to 30 mg, IV, q 6 hr, PRN

Weight <50 kg or ≥65 years of age:

15 mg q 6 hr, IV, PRN

Gabapentin (Neurontin)

Immediate release: Initial: 100 to 300 mg, PO, 1 to 3 times daily

Pregabalin (Lyrica)

Immediate release: Initial: 25 to 150 mg/day, PO, in 2 to 3 divided doses

Tramadol

Immediate release: Initial: 50 mg, PO, every 4 to 6 hours, PRN

The dose may be increased as needed & tolerated to 100 mg q 4 - 6 hours (maximum dose: 400 mg/day)

Lidocaine patch 5% (Lidoderm)

Only once for up to 12 hours. Max : 3 / 24 hours.

Oxycodone/ Acetaminophen (Percocet)

Immediate release: 2.5 to 10 mg (oxycodone),PO, every 4 to 6 hours, PRN

Hydromorphone (Dilaudid)

PO- immediate release: 2 to 4 mg every 4 to 6 hours, PRN

IV- 0.2 to 1 mg every 2 to 3 hours, PRN

PCA- Loading dose: 0.4 mg, demand dose: 0.1 to 0.4 mg. Lockout interval: 10 minutes

Morphine

1 to 4 mg, IV, every 1 to 4 hours, PRN

Fentanyl

To be used in ICU.

Loading dose: 25 to 100 mcg or 1 to 2 mcg/kg, IV

Continuous infusion: 25 to 50 mcg/hour

Titrate every 30 to 60 minutes to achieve your goal.

Usual dosing range: 50 to 200 mcg/hour

Anticoagulant Prophylaxis

Early ambulation

Compression stockings (TED hose)

Pneumatic compression device

Heparin:

5000 units, SC, q8h or q12h . BMI ≥30: 5000 units q8h

Enoxaparin (Lovenox)

40 mg SC daily

If CrCl <30 mL/min: 30 mg SC daily

BMI ≥40: 40 mg twice daily

Anticoagulant Therapy

Notice: you might need to use different dose and therapeutic levels in some transplant patients who are at increased risk for bleeding.

Unfractionated heparin

Bolus: 80 units/kg .Max: 10,000 units

Initial infusion rate: 18 units/kg/hr. Max: 2000 units/hr

Adjust per following link. Click here.

Enoxaparin : 1 mg/kg SC q12hr, OR 1.5 mg/kg SC daily

Warfarin

Starting dose: 5 mg per day

Continue Heparin or LMWH for a minimum of five days and until INR is in the targeted therapeutic range for a minimum of 24 hours.

If INR is high, adjust per following link. Click here.

Erythropoetin Stimulating Agents

Darbepoetin alfa (Aranesp)

0.45 mcg/kg as an IV or SC injection once weekly OR 0.75 mcg/kg as an IV or SC injection once every 2 weeks

Granulocyte CSF

Filgrastim (Neupogen)

Up to 2 courses, 3 doses per week each, has been used by some transplant centers for absolute neutrophil count < 500. Repeat CBC 3 and 7 days after last dose of 1st course. Each dose: 300 mcg, SC

Acute GI bleeding- Liver Failure

Esophageal varices bleeding prophylaxis

Medical options: propranolol, nadolol, and carvedilol

Due to concerns in patients who have ascites, endoscopic variceal ligation is preferred.

Esophageal varices bleeding management

Proceed per guidelines. Medications include:

Octreotide

Initial: 50 mcg bolus, followed by continuous infusion of 50 mcg/hour for 2 to 5 days

Repeat the bolus in first hour if hemorrhage is not controlled.

Other vasoactive agents that maybe used include terlipressin, somatostatin, and vasopressin.

Ceftriaxone : 1 gram bid for 7 days

Hepatorenal Syndrome

Albumin: 10 to 20 grams, IV, per day

Octreotide

S/C: Initial: 100 mcg 3 times daily; may increase to 200 mcg 3 times daily or

IV-preferred: 50 mcg/hour as a continuous infusion

Discontinue after 2 weeks if no response.

Midodrine : up to 12.5 mg, PO, tid

Post-paracentesis albumin

6-8 grams per each liter of removed fluid

May not be necessary for a single tap of < 4 to 5 L

SBP

Cefotaxime, IV, 2 grams every 8 hours for 5 days

Albumin

If serum creatinine >1 mg/dL, BUN >30 mg/dL, or total bilirubin >4 mg/dL:

1.5 gram/kg within 6 hours of detection and 1.0 gram/kg on day 3

Norfloxacin

400 mg, PO, daily. After completion of the treatment and as a long-term prophylaxis after first SBP.