Adults parenteral dilution manual

Microsoft Word Adult IV See discussions, stats, and author profiles for this publication at https www researchgate netpublication281710454 Adults Parenteral Dilution Manual Book March 2015 CITATIO.Microsoft Word Adult IV See discussions, stats, and author profiles for this publication at https www researchgate netpublication281710454 Adults Parenteral Dilution Manual Book March 2015 CITATIO.

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Dilution Manual

dedicated to

Humanity as inspired by Allah This story of success speaks a lot about the integrity of the

pharmacy profession As the world of pharmacy is not excused to the constant occurrence

of changes, our pursuit to give top priority to patient care and safety prevails.

Congratulations on the success of the Task Force to imitate, Review, Update and

Standardize the IV Admixture Manual comprised of Pharmaceutical Care Services in the

different regions.

Deputy Minister of Health for Curative Service

Dr.Abdulaziz bin Muhammad Al-Hemaidi

In the daily management of patients, clinicians are often faced with the need to access

drug information quickly in order to make swift therapeutic decisions It is hoped that this

manual may be a readily accessible source of clinically important drug information for

parenteral drug therapy.

Additionally, it is meant to provide a quick and reliable

source of information for nursing staff At a time when worldwide attention is being.

Assistant Deputy Minister for Supportive Medical Services

DR Munira Hemdan Al-esseimi

pharmaceutical preparation services nationwide, it is very timely and essential that the

Pharmaceutical Services Division, Ministry of Health develops and publishes this manual

The contents of this manual will be able to serve as a standard reference for all hospital

pharmacists in handling and managing sterile preparation activities.

I am confident that this manual will also provide useful information on ensuring quality,

safety and efficacy of products.

Director of General Administration of Pharmaceutical care at Ministry of Health

DR YOUSEF AHAMED YOUSEF ALOMI

DR YOUSEF AHAMED ALOMI

DR Somaiya Mohammed Aljudaibi DR Hajer Yousef Almudaiheem

DR Norah Abdulaziz Aljohany DR Samia Zaben Atallah Almurshadi

Reviewers

DR Wajed Awad AL-Shammari DR AMANI ABDULLAH BAHDEALAH

DR.Hind Kh Al Mutairi

KG)

LD 150 mg/kg over 1hr

2ed dose50 mg/kg over 4hrs

3ed dose100 mg/kg Over 16 hrs Aceta

-dote (ml)

D5W (ml)

Aceta -dote (ml)

D5W (ml)

Aceta -dote (ml)

D5W (ml)

24 hrs after spiking

Administer dose within

6 hours of opening vial

Do not refrigerate

or refreeze

Fever reduction Pain relief

<500mg

250mg/ 50ml D5W 250mg/ 50ml NS

10mg/ml

500mg/ 50ml D5W premixed 500mg/ 50ml NS premixed

24 hrs

IVP

IM administration

is not recommended

Intraocul ar pressure Serum electrolyte CBC

patients

Loading Dose 15 min Dose 2

4hrs Dose316h rs

Acolor change may occure in opend vials(light purple)and does not affect the safety or efficacy

Allergic reaction -LFT -KFT Serum level of acetamino phen Serum electolyte

ml D5W

7mg/ ml

600-1750mg/ 250ml D5W 600-1750mg/ 250ml

NS

-Rapid infusion can cause renal damage -Do not use bacteriostatic diluents -Doses less than 500mg diluted it

in 100 cc ,doses greater than 500mg diluted in

250 cc

CBC LFT KFT

[12.5 gm] [50

ml vial]

[ 25 gm]

[100ml ] Admixture:

4 hrs after opening the vial.

Use inline filter

Albumin 5% 2-4 ml/mint in

pt with normal plasma volume, 5-

10 ml/mint

in pt with hypoprotei nemia Albumin 20% 1- 2ml/mint

Do not dilute 5%

vital sign pulmonar

y oedema hypervole mia Resp function BP Hemato crit

solution.

Rapid infusion can cause vascular overload.

albumin 25% can

be given undiluted

or diluted in normal saline or D5W infusion of large amounts of albumin diluted with D5W can result in hyponatremia;

therefore, when using large volumes of albumin, dilution

in NS is preferred CAUTION:

Substantial reduction in tonicity, creating the potential for fatal hemolysis and acute renal failure, may result from the use of sterile water as a diluents

1mcg/day to be added to the return line from the HD machine at the end of HD

1mcg/day

to be added to the return line from the HD machine

at the end

of HD

1mcg/day to be added to the return line from the HD machine at the end

of HD

Origi nal back ae

IV bolus

30

- protect from light

- shake injection solution well prior

to use

Electrolyt

e level -KFTS -LFTs

250ml D5W 500mcg/

100ml NS 500mcg/

100ml D5W 500mcg/

50ml NS premixed 500mcg/

50ml D5W

20mcg/ml

500mcg/

25ml NA 500mcg/25ml D5W

Origi nal back ae

0.1mcg/

0.01-kg/ mint

Undiluted alprostadil may interact with plastic volumetric infusion chambers changing their appearance so, the infusion solution should be added

to the volumetric chamber first with the alprostadil added into the solution avoiding contact with the chamber walls.

Arterial pressure respirator

y rate HR Temperat ure Degree of penile pain -length of erection -signs of infection

D5W NS

500mg/ 100ml

NS premixed 500mg/100ml D5W premixed

premixed 500mg/100ml D5W premixed

30–60 minutes

If used in combination with

a penicillin or cephalosporin, administer at a different site If this is not possible then flush the line thoroughly with a compatible solution between drugs.

RFT Level befor 4th dose and 30-60 min after Auditory test if possible

250ml) (6-10gm /500ml) (11-20gm /1000 ml)

8 hrs

It contain benzyl alcohol if given with athor drug contain bezyl alcohol Couse gasping syndrome symptom respiratory depression Metabolic acidosis

IM not recommended

KFT Coagulati

500mg/ 500ml D5W 500mg/ 500ml NS (loading dose) [0 - 250mg]/50ml (30 minutes) or [251-500 mg]/

100 ml-(30 minutes) Continuous

hrs

Loading dose: 30 mint Maintenanc

e dose:

0.36 mg/kg/mint Not greater than : 25mg/

mint

Equivalent to 80% Theophylline Protect from light

Do not administer

as IM

HR Respirato

ry rate CNS effects Serum theophylli n

500 mg/500 ml [Titrate]

Fluid Restricted:

500 mg/250 ml [Titrate]

m and chloride 5mEq/ml (20)ml

D5W

100 – 200 meq / 500-1000 ml NS

100 – 200 meq / 500-1000 ml NS

100 – 200 meq / 500-1000 ml NS

100 – 200 meq / 500-1000 ml NS

be warmed to room temperature

in a water bath prior to use.

-Do not exceed a concentration of 1–2% ammonium chloride.

-Monitor for symptoms of ammonia toxicity (pallor, sweating, retching, bradycar dia, arrhythmi as, hypervent ilation, local and general twitching, tonic convulsio

ns, coma) -Monitor serum bicarbona te -Monitor arterial blood gases -LFT

100mg/ml For IM use

200mg/ml

D5W NS SWFI

5 ml SWFI For IV use

5ml SWFI For IM use

2.5ml SWFI

-Rotate the ampoule to facilitate solution and must not be shaken

- IM :a solution containing 200 mg/mL (20%)

500 mg of the sterile powder for injection should

be dissolved in 2.5

mL of SWFI -IM dose should not exceed 5ml at

-vital signs -BP - respiratio n -cardiac function -KFT -LFT hematolog ic paramete rs

any one site -Do not use if solution does not become absolutely clear within 5 min after reconstitution Amoxacillin/

20ml SWFI

Premixed 600mg/50ml 1.2gm/100 ml NS

12mg/ml

Premixed 600mg/50ml NS

Use immedia tly

Im not recommend

KFT RFT Hematologic function

mg vial.

9.2ml SWFI1g vial

Premixed:

1g/50ml NS 1g/50ml D5W

1 hr

- if D5W used as a diluent the resulting solution stable for 2 hours vs.

8 hours if prepare

d with NS (D5W has limited stability)

2 g

30-60 min

-Intraoeritoneal injection

dissolve 500mg with 10 ml SWFI -Intrapleural Injection

500mg with 5-10

ml SWFI -Intra-articular use500mg in 5

ml SWFI -NS is the diluents

of choice

- IMdissolve 500mg with 1.8

mL SWFI shake vigorously to give

250 mg/mL

- IM ,IVP stable for 1hrr -Rapid infusion may cause seizure

CBC LFT KFT Allergic reactio n

25mg/50 ml NS 25mg/50 ml D5W

immedi atly

6 hrs for first infusion

4 hrs subsequent infusion

- Mix diluted solution by gently inverting infusion bag only once or twice.

Use(0.22micron)in line filter -Allow the vials of ATG and diluents

-to warm -to room temp Before

Lymphoc yte profile -CBC -Platelet count -Vital signs during administr ation -KFT Hypersen sitivity

reconstitution -Protected from light and freezing -Should be prepared immediately before use

reaction -Signs and symptoms of infection

5 ampoules diluted in 50ml 0.5 NS

5 ampoules/50

ml 0.5 NS

5 ampoules diluted in 50ml 0.5 NS

5 ampoules/50 ml

-Administer test dose first, injection 0.1 ml antivenom intradermally

If positive use agoat antivenom -may repeat dose

up to 20 amps if necessary -monitor patient closely during and

up to 60 mint Antivenom

Dilute 40 ml antivenom in

5 ml/kg NS

Dilute 40 ml antivenom in 5 ml/kg NS

Dilute 40 ml antiveno

m in 5 ml/kg NS

Dilute 40 ml antivenom in 5 ml/kg NS

IV inf

4 ml/mi nt 30-60 mint

Urine output Pulse, BP, heart rate Urea and electrolyte Atenolol

0.5mg/ml

Premixed:

5mg in 50 ml NS 5mg in 50 ml D5W

Use immedi ately

24 hrs

-ECG -Blood pressure -Heart rate

≤1 mg/m int

NA

-Do not freeze -Administer without further dilution -Slow injection cause paradoxical bradycardia -IV atropine sulfate should be injected rapidly during resuscitative efforts, followed

by a 20-mL flush

of IV fluid and elevation of the extremity for 10–

20 seconds in

-Cardiac monitor -Heart rate -Blood pressure -Pulse -Mental status

order to facilitate drug delivery to the central circulation -Intratracheal:

mL with NaCl 0.9%

after given the dose flush immediately with at least

50 ml NS)

0.5mg/ ml

50mg/ 100ml D5W 50mg/ 100ml NS

CBC Platelet counts Total Bilirubin LFT KFT

250 mg/250 ml D5W

2 mg/ml

500 mg/250ml NS Or

500 mg/250 ml D5W

1 mg/ml conce

rate over 3 hrs Or

2 mg/ml conce

rate over 1 hrs

- Not for IM or Bolus -Do not mix with other drugs

-LFT -CBC

0.8mg/ml

20 mg/25ml NS

20 mg/25ml D5W

- the diluted IV solution should be mixed by gently inverting the bag;

should not be shaken to prevent foaming formatiom

Signs and symptoms

of acute rejection

1ml volume NS

give strength

10 units /0.1ml 2ml volume NS

/0.1ml 4ml volume NS

2.5units/0.1 ml 8ml volume NS

ml NS acute pancreatitis

ately

-serum electrolyte -alkaline phosphata se -24 hrs urine collection for hydroxyp roline excretion (paget's disease)

an IV bolus through the catheter at the end of dialysis -syringe stable at room temperature for 8 hrs -protect from light

-symptom of hypercalc emia -serum electrolyte -serum Albumin

D5W

0.5g/ 100ml D5W 0.5g/ 100ml NS

Do not give by IM

or Subcutaneous -stop the infusion

if patient complains pain or discomfort

- Small veins should not be used for infusion

- 1 gm =6.8 mmol=13.6 meq

=273 mg

BP ECG Serum Ca KFT Heart rate Site of injection

Use immedia tely When reconstit ute with SWFI Stable for 7 day when reconstit ute with bacterio static WFI containi ng benzyl alcohol

immedi ately

24 hrs

IVP

IV inf

160 mg/m inute

2 hr

-protect from light -The drug should

be given parenterally rather than orally

in patients with

GI toxicity, nausea, or vomiting and when individual doses greater than

25 mg -reconstituted with bacteriostatic water containing benzyl alcohol should be used only when parenteral doses

of 10 mg/m2 or lower are required

-serum Ca - Diarrhoea - Creatinin

e and methotrex ate -LFT -KFT -CBC

D5W

Premixed:

1g/ 50ml D5W 1g/ 50ml NS

2ml/mint

-Do not Refrigerate -IM is not recommended -Small veins should not be used for infusion -Should not be infused through

an arterial catheter because

of the potential for vasospasm -IV calcium should be used cautiously in patients receiving cardiac glycosides because of the potential of arrhythmias -Use small needle into large vein

ECG Serum Ca KFT Blood pressure Injection site

For IV Dissolve in 2

ml of NS or SWFI For IM adminstration 2ml NS or SWFI

500mg/

ml conc or 2.15 ml NS or SWFI370m g/ml Conc 2.63ml NS or SWFI310m g/ml Conc 3.3ml NS or SWFI

260mg/

ml conc 4.3ml NS or SWFI

210mg/

ml conc And allow 2-3 mint for dissolution

100ml NS

NS

Use immedia tely

24 hrs

Use immedi ately

24

-can be administer IM

Audiomet ric measurem ents and vestibular function -KFT -LFT -serum K level

100 mL NaCl 0.9%

-CBC, electrolyte -Vital signs -Tissue, blood and

or sputum culture before and after treatment -LFT

Premixed:

1g /50ml NS 1g/50ml D5W

69mg/ml NS 77mg/ml D5W

6.9gm/100ml NS 7.7mg/100ml D5W

30 – 60 mint

-protect from light

- frozen cefazolin injections are stable for 48 hours at room temperature or 30 days when refrigerated

- Iv push 50-100 mg/ml Intermetent infusion 5-20 mg/ml

Hypersen sitivity -KFT -LFT -CBC

160mg/ml

for 2g dose

D5W NS

If the single dose 2g( IV) amount of

l SWFI 1g(IV)10ml 1g(IM)

2.4ml

Premixed:

1g/ 50ml D5W 1g/ 50ml NS

60 mg/mL via peripheral vein Maximum conc for IVP:

147 mg/ml in SWFI

20mg/ ml

Premixed:

1g/ 50ml D5W 1g/ 50ml NS

86 mg/mL in D5W 73 mg/mL in NS

20–60 minutes

Refrigerate -Do not give in severe heart failure and in patients with an un-paced heart block.

-can be given deep IM -Rapid IV push (<1 minute) of a cephalosporin has caused potentially life-threatening arrhythmias.

-Protect from light

CBC KFT LFT Hypersen sitivity

10mg/ ml

Premixed:

1g/ 100ml D5W 1g/ 100ml NS

CBC KFT LFT Hypersen sitivity

For IM : Add 3.6 ml lidocaine 1% to 1gm vial to give

250 mg/ml -IV inf preferred over IVP -Protect from light

CBC KFT LFT Hypersen sitivity

7.2 ml SWFI

(100mg/

ml) Undiluted Maximum:1 00mg/

ml

7.5mg/ ml

Premixed:

750mg/ 100ml D5W 750mg/ 100ml NS

CBC KFT LFT Hypersen sitivity Hematolo gic function

5 ml SWFI

for 500 mg dose

10 ml SWFI

For 1gm dose

1g/ 100ml D5W 1g/ 100ml NS

2g/ 100ml NS

Use fresh

IV irritating -Protect from light Don’t use for lees than 6 month

BP ECG KFT RFT

2mg/ ml

200mg/ 100ml D5W 400mg/ 200ml D5W

-Use with caution

in G6PD deficiency -Patients must be adequately hydrated -Protect from light

CBC KFT RFT

24hr NS 8hr D5W

Hypersen sitivity

ml

NS

Use fresh

24 hrs

IV

60 min

IV push (in patients with a totally implantable venous access device [TIVAD]

only dilute

1 M units in 5 ml SW For continuous IV administration:

Inject one-half the total daily Dose over 3 min, the remainder of the total daily dose should be added to a compatible IV fluid and administered over the next 22 - 23 hrs starting 1 - 2 hrs after the initial dose.

- 1million = 80 mg

Scr BUN Urine output Signs of neurotoxi city

Prepare in chemo room

Bp Scr Blood level

Do not mix with other solutions

IM not recommended

LFT Body weight

>8mg/50ml

>8mg/50ml D5W

>8mg/50ml NS

Hemoglob in -Serum K -Serum glucose

to precipitation risk -IV slowly to avoid venous thrombosis and phlebitis

- Diazepam emulsion is the preferred preparation for

IV inf because it forms more stable preparation and is also less irritant to veins

- PVC containers and giving sets should not be used – more than 50%

of the dose may be adsorbed Glass

or polyethylene should be used in preference -Protect from light

Cardiovas cular and mental statues Respirato ry function -LFT

- slow administration reduces the antihypertensive response, Use a cannula for administration, taking care to avoid extravasation

- Patients should remain supine at least 1 hour after

IV dosing and also during administration.

-protect from light

Blood pressure -Serum uric acid -KFT -CBC with differenti

al AST -Urine glucose and ketones

CNS depressio n Drowsines s

2.5mg/ml

50mg/20ml NS 50mg/20ml D5W

567 micrograms/kg by

IV infusion over 4 minutes (at approx 142 micrograms/kg/mi nute) Thallium-

201 should be injected within 3–

5 minutes following the 4- minute infusion.

-Aminophylline should be available for emergent use dose

of 50-100 mg IVP over30-60 second

-Heart rate -Blood pressure -ECG

ml

90mg/250ml NS 90mg/250ml D5W

Use immedia tely

NA

Use immedi ately

24

60 mg/hour (1mg/min)

In impaired renal function maximum rate 20 mg/hour.

-The patient must

be adequately hydrated using NaCl 0.9% before dosing for ↑Ca.

Infusion into a relatively large vein minimizes patient discomfort

- should be infused slowly to avoid renal impairment

-Serum Ca, electrolyte -CBC -Serum creatinine

500 mg dose 20ml SWFI

Do not use NS for reconstitution may precipitate

CBC LFT Vital signs

10- 20 mcg/kg/min t

-infusion may lead

to adrenal suppression

Heart rate -blood pressure

Depend on product

Depend on product

Depend on product

Depend on product

Depend on product

3hr depe

nd on prod uct

Depend on product

Depe

nd on prod uct

Depen

d on produc t

Depe

nd on prod uct

Depend on product

Depend on product

Level of factor VII and IX PT PTT

d at 2 to 8

°C and protected from direct sunlight

IV inf

15-30 min

IV inf intermitted 15-60 min

IV inf continues over 24hr

-SC Undiluted -Scinf: add to a suitable volume of Gluc 5%, ensuring that the final concentration is 15 micrograms/mL

or more -Stability is conc.

dependent: if filgrastim concentration is

<15 micrograms/mL then human serum albumin must be added to produce a final albumin conc of 2 mg/mL

IV P

IV inf IM

3–4 minu tes

30-60 min

Intrapleural injection IT

-LFT -RFT -FBC

400 mg /200 mL over 20 minutes (600 mL/hr).In the USA, a maximum infusion rate of

100 mL/hour is recommended.

LFT, Renal function test

100-400 micrograms /hour continuous infusion

Max cumulative dose 3mg/hr -For additional doses,may repeat

at 1min intervals (Max 4 doses) -avoid extravasations,avo

id pain

on inj by using large vein

IM NOT RECOMMENDE

blood pressure -Heart rate -Level of re- sedation and conscious ness

ds) Not to excee

d 0.2 mg/m in.

Premixed 250ml bottle

12mg/ml Periphera

l line 24mg/ml Central line

Premixed

Use immedi ately

not to exceed 60 mg/kg over

1 hour or

120 mg/kg over 2 hours or 1mg/kg/min t -Use 0.22 micron in line filter

-Not for rapid injection -The 24 mg/mL solution may be given without dilution via a central vein -If a peripheral vein is used, the solution must be diluted to give a solution containing 12 mg/mL before administration -some centers piggyback 1 L NaCl 0.9% to run concurrently with the foscarnet dose

CBC Electrolyt e -KFT Ophthalm

NA

suitable for doses ≤80 mg (10mg/ml) undiluted

100ml NS

2mg/ml

100mg/50ml NS

Use immedia tly

IV inf

3-5 mint Or 40mg /mint over 1-2 mint

≤4mg/

minute

In severe renal impairment the rate may be reduced to 2.5 mg/minute

to reduce ototoxicity

-The IV inf either give undiluted using a syringe pump or add to a convenient volume of NaCl 0.9%

-Can be administer IM only for doses ≤50

mg where neither the oral or IV routes are available

- IM use is not suitable for the treatment of acute conditions such as pulmonary oedema -Protect from light

Weight -I & O daily -BP Orthostas is Electrolyt e -KFT -In high doses Monitor hearing

D5W NS

Premixed:

80mg/ 100ml NS 60mg/50ml NS Or 80mg/100ml D5W 60mg/50ml D5W

D5W 400mg/ 100ml NS

Use fresh

Do not give in myasthenia gravis.

Ensure good hydration status -obese patients dosage should be based on the following equation:Dosing weight = IBW + 0.4 (TBW – IBW)

Audiogra

m if longterm CBC KFT

-1 unit=1mg -Gently roll vial to dissolve glucagon -Continuous infusion may be used in beta- blocker toxicity/over dose 5–10 mg by slow

IV injection over

10 minutes (to reduce the likelihood of vomiting);

followed by an IV infusion of 1–5 mg/hour (50 micrograms/kg/ho ur) titrated to clinical response

- If the solution shows signs of fibril formation (↑viscosity) or insoluble matter it should be discarded

-Blood pressure -ECG -Blood glucose -Heart rate - Mentation

2mcg/ml

0.2mg/100ml NS 0.2mg/100ml D5W

Use immedia tely

IV inf

60sec - 3mint

15–20 minutes

-IM administer undiluted -Glycopyrrolate may be mixed with neostigmine

or pyridostigmine

to minimize cardiac side effects 5–10 mcg/kg (0.2 mg of glycopyrrolate for every 1 mg of neostigmine or 5

mg of pyridostigmine

-Heart rate anticholin ergic effects -Bowel sounds

mg (1 mL) to

5 mL with NaCl 0.9%

in the syringe

0.02mg/ ml

1mg/ 50ml D5W 1mg/ 50ml NS

24 hrs

IVP

IV inf

30 sec (undi luted) or over 2–5 minu tes

5 -30 mint

-Protect from light -40 mcg/kg is the usual maximum dose -Multidose vial stability 30 days

Clinical improvem ent

ECG Electrolyt es: Serum

K, Ca,

Mg LFTs KFT Hydralazine

mL with NaCl 0.9%

0.05mg – 0.2mg/mint

No Special Conditions

BP Pulse KFT LFT

4ml

D5W NS

2 ml SWFI

Premixed:

100mg/ 100ml D5W 100mg/ 100ml NS

60mg/ ml

3000mg/ 50ml D5W 3000mg/ 50 ml NS (4 hrs stability)

hrs

0.1 -1 mg/ ml

24 hrs 2-10 mg/ml

4 hrs

24 hrs

IVP

IV inf

1–10 minu tes 1 mint for doses

< 200 mg 10 mint for doses

≥200 mg

0.4mg/ml

Premixed:

20mg/50ml D5W 20mg/50ml NS

IV inf

1 mg/m int

undiluted

-IOP -HR -Urine output

60 min)

Can be given IM Suspension for IM administration should be reconstituted with 1% lidocaineHCl without epinephrine

CBC KFT RFT

24 hrs

Do not dilute further

Do not use dextros e

-KFT -LFT

e therapy who have tolerated at least three prior 2- hour infusions, a shorter infusion time of a minimum

of 1 hour may be considered

IV infusion through a low- protein-binding filter (pore size 1.2 micron or less) over at least 2 hours

Vital sign Sign of infection, LFT

IVP

IV inf

1 mL/

minu te

Body weight CBC KFT LFT

1mg/1ml

Premixed 100mg/

100ml NS

1mg/1ml

Premixed 100mg/

100ml NS

Use

24 hrs

IVP

IV inf

1 mL/

minu te (i.e 5 minu tes per ampo ule)

Use volumetric infusion device as follows:

give 100 mg over at least

15 minutes;

give 200 mg over at least

30 minutes

Initial test dose (prior to first dose only) -Infusion: dilute 300mg/250ml NS infuse at least 1.5 hrs, 400mg/250ml infuse at least 2.5 hrs, 500mg/250ml infuse at least 3.5 hrs

Hemoglob in Hematocr it -Serum Ferritin Transferr in

0.004mg/

ml

Premixed 2mg/ 500ml D5W

Use

24 hrs

IV inf

-Can be given IM And

ECG Hemodyn