IV infusions — reference & ordering sequence

Order an IV the way pharmacy reads it.

An IV order isn't a fluid — it's a fluid plus a rate, a duration, a route, and a monitoring plan. This page walks the correct ordering sequence and gives you a dense, scannable reference for every solution you'll meet on the inpatient ward.

01 — The 9-step sequence

What every complete IV order contains

1
Indication
Start with WHY. Resuscitation, maintenance, replacement of ongoing losses, KVO (keep-vein-open), drug-delivery vehicle, blood-product replacement — each has different rates and end-points.
2
Solution + additives
Generic name of the bag (0.9% NaCl, LR, D5W, etc.) plus every additive in mEq or mg. Never abbreviate KCl as 'K' — always write 'potassium chloride' and the mEq.
3
Volume
Total volume per bag (e.g., 1000 mL) — separate from the rate. Pharmacy needs this to dispense the right size bag.
4
Rate
mL/hr for continuous infusions OR total mL over total time for bolus / replacement (e.g., '1 L over 1 h'). Drips dosed per kg/min get a calculated mL/hr.
5
Duration / endpoint
Defined stop criterion: 'x 24 h', 'until MAP ≥ 65', 'until UOP ≥ 0.5 mL/kg/hr', '× 3 boluses then reassess', or 'until d/c'. Never open-ended.
6
Line / compatibility
Peripheral vs central. Some drips (NE > 10 mcg/min sustained, K+ > 10 mEq/hr, vesicants, hyperosmolar TPN) require a central line. Check Y-site compatibility against existing infusions.
7
Monitoring
Specify frequency: VS q15min × 4 then q1h, BMP q6h, ECG continuous, MAP/CVP targets. Without a frequency, nursing won't capture data — and you won't titrate appropriately.
8
Hold / titration parameters
For drips: titrate to MAP / HR / RASS / aPTT / glucose; specify the increments and the maximum dose. For boluses: hold for SBP > 160, S3 gallop, rales, etc.
9
Adjuncts / orders linked to the fluid
Foley for strict I&Os, daily weights, baseline + scheduled labs, the antidote / reversal agent if applicable (calcium for hyperK, glucagon for β-blocker drips, naloxone for opioids).

02 — Crystalloids

Every bag on the floor — composition, indication, contraindication

Solution	Osm	Na	K	Cl	Other	Tonicity
0.9% NaCl (NS)	308	154	0	154	—	Isotonic
Lactated Ringer's (LR)	273	130	4	109	Ca 3, lactate 28	Isotonic
Plasma-Lyte A	294	140	5	98	Mg 3, acetate 27, gluconate 23	Isotonic
0.45% NaCl (½ NS)	154	77	0	77	—	Hypotonic
3% NaCl	1027	513	0	513	—	Hypertonic
D5W (5% dextrose in water)	252	0	0	0	Dextrose 50 g/L	Isotonic in bag → hypotonic in body
D5 ½ NS	406	77	0	77	Dextrose 50 g/L	Hypertonic in bag, ~isotonic effect
D5 NS	560	154	0	154	Dextrose 50 g/L	Hypertonic
D10W	505	0	0	0	Dextrose 100 g/L	Hypertonic

Units: osmolarity mOsm/L · electrolytes mEq/L. Dextrose where present 50 g/L (D5) or 100 g/L (D10).

0.9% NaCl (NS)

UseResuscitation, vehicle for blood products, hyponatremia (slow), DKA after initial bolus.

AvoidLarge-volume → hyperchloremic acidosis. CHF/edema. ESRD with hyperkalemia: actually fine (no K).

Lactated Ringer's (LR)

UseResuscitation, surgical / trauma, balanced fluid of choice for most adult resuscitation per recent trials.

AvoidSevere liver failure (impaired lactate metabolism). Hypercalcemia. With ceftriaxone (Ca precipitation) — never co-infuse.

Plasma-Lyte A

UseBalanced crystalloid; lactate-free (use when LR is contraindicated, e.g., liver failure).

AvoidHyperkalemia. Hypermagnesemia (rare).

0.45% NaCl (½ NS)

UseHypernatremia correction (slowly), maintenance fluid in some peds protocols.

AvoidResuscitation (will not stay in vascular space). Hyponatremia. Suspected raised ICP — can worsen cerebral edema.

3% NaCl

UseSymptomatic severe hyponatremia (Na <120 with seizures / obtundation). Refractory raised ICP.

AvoidPeripheral line (vesicant — central preferred for sustained infusion). Heart failure. Correct Na ≤ 8–10 mEq/L per 24 h to avoid osmotic demyelination.

D5W (5% dextrose in water)

UseFree-water replacement for hypernatremia. Vehicle for some drips (amiodarone, nicardipine).

AvoidResuscitation (no Na, distributes to total body water). Hyperglycemia. Active CVA / TBI.

D5 ½ NS

UseStandard maintenance fluid in adults without contraindications.

AvoidHyperglycemia, hypernatremia. Add K (typically 20 mEq/L) if patient is NPO and making urine.

D5 NS

UseSpecific replacement strategies; rarely first-line maintenance.

AvoidHeart failure, hypernatremia, hyperglycemia.

D10W

UseHypoglycemia in continuous infusion (esp. neonates, sulfonylurea overdose). Insulin overdose.

AvoidPeripheral line for prolonged infusion (irritant). Hyperglycemia.

03 — Colloids & albumin

When the bag needs to be more than salt + water

Albumin 5%

UseIntravascular volume expansion in SBP/large-volume paracentesis, hepatorenal syndrome, post-liver transplant, sepsis (selective).

DoseTypical bolus 250–500 mL. SBP: 1.5 g/kg D1, 1 g/kg D3.

AvoidSevere heart failure, fluid overload, prior reaction.

Albumin 25%

UseOncotic support without large volume. Cerebral edema (selective), refractory ascites + diuretic resistance.

Dose50–100 mL slow IV; aliquots driven by oncotic / volume target.

AvoidPulmonary edema (volume shift into vascular space). Anemic patients without volume need.

Packed RBCs

UseSymptomatic anemia or Hb < 7 (or < 8 in active cardiac ischemia). Hemorrhage with hemodynamic instability.

Dose1 unit ~ 250–300 mL, raises Hb ~1 g/dL. Infuse over 1.5–4 h; faster only in active hemorrhage.

AvoidY-site with anything other than 0.9% NaCl (calcium-containing fluids → clotting; D5W → hemolysis).

Fresh frozen plasma (FFP)

UseActive bleeding with coagulopathy (INR > 1.5), warfarin reversal when 4-factor PCC unavailable, massive-transfusion protocol.

Dose10–15 mL/kg. ABO compatibility required. Thaw 20–30 min lead time.

AvoidAsymptomatic INR elevation — not a vitamin K replacement. TRALI/TACO risk.

Platelets

UsePlt < 10 prophylactic, < 20 with fever/sepsis, < 50 with active bleeding or pre-procedure, < 100 with CNS bleed or neurosurgery.

Dose1 apheresis unit raises plt ~30–50 K. Infuse over 30–60 min.

AvoidTTP / HIT — platelets are contraindicated (worsen microvascular thrombosis).

Cryoprecipitate

UseFibrinogen replacement (< 150 in active bleed, < 100 with DIC), hemophilia A / vWD when factor concentrates unavailable.

Dose1 unit per 10 kg raises fibrinogen ~50 mg/dL.

AvoidGeneric 'INR correction' — cryo is fibrinogen-specific.

04 — Blood products

Correct summarized sequence for ordering blood products

Every unit is 1 patient × 1 bag × 1 nurse × 1 provider — the whole safety net rides on identity checks and threshold discipline. Follow these 8 steps in order for every transfusion, whether it's prophylactic platelets or a massive-transfusion protocol.

1
Confirm the trigger
Transfuse to a threshold + clinical picture — not to a lab number. pRBC: Hb < 7 (< 8 if active cardiac ischemia or symptomatic). Platelets: < 10 prophylactic, < 20 with fever/sepsis, < 50 with active bleed or pre-procedure, < 100 for CNS bleed / neurosurgery. FFP: INR > 1.5 with active bleeding (NOT for asymptomatic INR). Cryo: fibrinogen < 150 with active bleed, < 100 in DIC.
2
Consent + advance-directive check
Signed blood-product consent (one consent typically covers the admission unless revoked). Verify no Jehovah's Witness or other refusal in the chart. Discuss risks (reactions ~1:50–100, viral infection ~1:1M, TRALI/TACO), benefits, and alternatives (iron, EPO, cell salvage).
3
Type & screen / Type & crossmatch
Draw the tube at the bedside with 2 patient identifiers (name + DOB or MRN) and label BEFORE leaving the room — the #1 cause of ABO-mismatch is mislabelled specimens. T&S ~30 min (antibody screen only). T&C 45–60 min (specific units reserved). Emergency: uncrossmatched O-negative for women of childbearing age / O-positive otherwise — should be at bedside within 5–10 min of a massive transfusion protocol call.
4
Access + carrier fluid
18-gauge peripheral minimum (16 g preferred for rapid transfusion or trauma). NS is the ONLY compatible carrier. Never LR (calcium precipitates + clots in the tubing). Never D5W (hemolyses the RBCs). Never co-infuse medications through the same line.
5
Pre-medications — only if indicated
Routine pre-medication is NOT recommended. Acetaminophen 650 mg PO 30 min before ONLY if documented febrile non-hemolytic reaction to prior transfusion. Diphenhydramine 25–50 mg IV/PO ONLY for prior mild allergic reaction. Furosemide 20–40 mg IV before a slow-transfusion in high TACO risk (CHF, ESRD, elderly).
6
Write the order — 6 required elements
Product · # units · indication · rate · duration cap · monitoring plan. Every unit must be infused within 4 hours of leaving the blood bank (bacterial growth risk). pRBC typical rate: 2–4 h/unit stable (start slow), or wide-open in active hemorrhage.
7
Bedside 2-person verification
Two licensed staff at the bedside verify: patient name + DOB + MRN (patient wristband) ↔ blood-band ↔ unit label ↔ ABO/Rh ↔ expiration ↔ cross-match slip. This is the single most important safety step — the majority of transfusion-related deaths from ABO incompatibility trace to identity errors, not lab errors.
8
Slow start + reaction monitoring + post-transfusion re-check
First 15 minutes at 50 mL/hr with a provider at bedside. Baseline VS → q15min × 4 → q1h until complete. STOP the transfusion for temperature ↑ ≥ 1 °C, hives, dyspnea, hypotension, back / flank pain, or hemoglobinuria — see reaction protocol below. When complete: recheck CBC 15–60 min later (expect Hb ↑ ~1 g/dL per unit, platelets ↑ ~30–50 K per apheresis unit, fibrinogen ↑ ~50 mg/dL per 10 kg of cryo). Document product number, volumes, times, VS, tolerance.

Threshold · dose · rate — quick reference

Product	Transfusion trigger	Typical dose / effect	Rate
pRBC	Hb < 7 general · < 8 cardiac ischemia / symptomatic · rising in active hemorrhage	1 unit ~ 250–300 mL, raises Hb ~ 1 g/dL	1.5–4 h stable · wide-open in shock
Platelets	< 10 prophylactic · < 20 fever/sepsis · < 50 procedure/bleed · < 100 CNS/neuroSx	1 apheresis unit raises plt ~ 30–50 K	Over 30–60 min
FFP	INR > 1.5 with active bleeding · warfarin reversal when 4F-PCC unavailable · MTP	10–15 mL/kg (~ 4 units for 70 kg)	As tolerated, typically over 30–60 min per unit
Cryoprecipitate	Fibrinogen < 150 with bleed · < 100 in DIC · hemophilia A / vWD if factor unavailable	1 unit per 10 kg raises fibrinogen ~ 50 mg/dL	Over 15–30 min

Complete every unit within 4 hours of leaving the blood bank (bacterial growth risk). Never through the same line as calcium-containing fluids (LR) or dextrose (D5W).

Massive transfusion protocol (MTP) · 1 : 1 : 1 · TXA within 3 h

Activate when

ABC score ≥ 2 (penetrating mechanism · SBP ≤ 90 · HR ≥ 120 · positive FAST) — predicts MT need.
Ongoing hemorrhage requiring ≥ 4 units pRBC in 1 h, or anticipated ≥ 10 units in 24 h.
Hemodynamic instability that does NOT respond to initial resuscitation.

The 1 : 1 : 1 ratio

Approximate whole blood with balanced components. PROPPR trial showed 1:1:1 improves hemostasis and 24-h mortality vs. 1:1:2.

Per MTP pack	Units
pRBC	6
FFP	6
Platelets (apheresis)	1
Cryoprecipitate (add every 2nd pack)	10

TXA + adjuncts

TXA 1 g IV over 10 min within 3 h of injury, then 1 g IV over 8 h (CRASH-2). No benefit — and possible harm — if started > 3 h from injury.
Calcium: 1 g CaCl₂ IV per 4 units pRBC transfused (citrate chelation → hypocalcemia → coagulopathy + arrhythmia).
Warm everything: rapid-transfuser warmer, warm room, warm blankets. Break the "lethal triad" — hypothermia + acidosis + coagulopathy.
Repeat labs every pack: CBC, coags, fibrinogen, ionized Ca, ABG, lactate.

Endpoint: hemodynamic stability + fibrinogen ≥ 150 + platelets ≥ 50 + INR < 1.5 + ionized Ca ≥ 1.1 + temperature ≥ 36 °C + no ongoing surgical bleeding. Then de-activate the protocol.

Stop-transfusion protocol · what to do if the patient reacts

Reaction

Acute hemolytic (ABO)

SignsFever, hypotension, back / flank pain, hemoglobinuria, DIC — usually in the first 15 minutes.

ActionSTOP. Keep IV open with NS. Send bag + tubing + fresh CBC, DAT, LDH, haptoglobin, bilirubin, coags, UA to blood bank. Aggressive IVF, furosemide 20–40 mg IV to maintain UOP ≥ 100 mL/hr, pressors PRN, ICU.

Reaction

Febrile non-hemolytic

SignsTemp ↑ ≥ 1 °C, chills; no hemolysis. Diagnosis of exclusion after ruling out hemolysis / bacterial.

ActionSTOP. Rule out hemolytic (DAT, hemoglobinuria) + bacterial (cultures from bag + patient). Acetaminophen 650 mg. May restart the same or a new unit slowly once labs clear.

Reaction

Allergic (mild)

SignsHives, pruritus, flushing. No respiratory / hemodynamic compromise.

ActionSTOP transiently. Diphenhydramine 25–50 mg IV. Restart at slower rate once symptoms resolve. Pre-medicate future transfusions.

Reaction

Anaphylaxis

SignsHypotension, wheezing, angioedema, stridor. Consider IgA-deficient recipients (need washed products).

ActionSTOP. Epinephrine 0.3 mg IM (0.5 mg for severe). IVF bolus. IV steroids + antihistamines. Airway support / ICU. Future transfusions: washed cellular products.

Reaction

TRALI

SignsHypoxia + bilateral infiltrates on CXR within 6 h of transfusion. Normal LV filling pressures.

ActionSTOP. Supportive: O2, low tidal volume (6 mL/kg IBW) if intubated, PEEP per ARDSnet. Do NOT diurese (this is not TACO). Report to blood bank — implicated donor unit is quarantined.

Reaction

TACO

SignsDyspnea, HTN, ↑ JVP, S3, bilateral infiltrates within 6 h. Elderly, CHF, or rapid infusion.

ActionSTOP. Sit upright, O2, furosemide 20–40 mg IV. Non-invasive ventilation if needed. Prevent: pre-transfusion furosemide + slower rate (over 4 h) in high-risk patients.

Reaction

Bacterial contamination / sepsis

SignsRigors, high fever, hypotension within minutes to hours — platelets highest risk (room-temp storage).

ActionSTOP. Cultures from bag + patient. Broad-spectrum antibiotics IV within 1 h. Full sepsis resuscitation, ICU.

First 4 actions for ANY reaction — memorise these

STOP the transfusion immediately.
Keep IV open with 0.9% NS (new tubing) — do not flush the current line.
Notify blood bank + physician; do NOT return the bag/tubing to the bank without instructions.
Verify identity at the bedside again — patient wristband ↔ unit label ↔ paperwork.

05 — Reversal agents

How to reverse this drug — bedside reference

Every drug that can cause life-threatening bleeding, cardiotoxicity, or respiratory depression has an antidote or a reversal strategy — many are one-shot IV pushes, others (like NAC, HIE, fomepizole) buy time while the toxin clears. Know which drug maps to which antidote before the code is called.

Offending drug

Warfarin

Reversal

Vitamin K + 4-factor PCC (Kcentra)

Dose

Vit K 10 mg IV over 30 min (slow — anaphylaxis risk) · 4F-PCC 25–50 units/kg IV based on INR (25 for INR 2–4 · 35 for 4–6 · 50 for > 6)

Onset

PCC: minutes · Vit K PO 24 h / IV 4–6 h

Notes

Preferred over FFP for major/CNS bleed. FFP only if PCC unavailable — needs ~15 mL/kg. Also give vitamin K to sustain reversal.

Offending drug

Heparin (UFH)

Reversal

Protamine sulfate

Dose

1 mg IV per 100 units of heparin given in the last 2–3 h (max 50 mg per dose). Give slowly ≤ 5 mg/min.

Onset

5 min

Notes

Hypotension + anaphylaxis risk (fish-allergy, NPH-insulin, vasectomy). Watch for rebound anticoagulation.

Offending drug

Enoxaparin (LMWH)

Reversal

Protamine (partial)

Dose

1 mg per 1 mg enoxaparin if within 8 h (0.5 mg per 1 mg if 8–12 h; no benefit > 12 h). Max 50 mg.

Onset

5 min

Notes

Only ~60 % reversal of anti-Xa activity. For life-threatening bleed after LMWH, add 4F-PCC and TXA if available.

Offending drug

Apixaban / Rivaroxaban (Factor Xa DOACs)

Reversal

Andexanet alfa (Andexxa)

Dose

Low: 400 mg IV bolus @ 30 mg/min then 4 mg/min × 120 min · High: 800 mg IV bolus @ 30 mg/min then 8 mg/min × 120 min. Dose depends on last dose amount + timing.

Onset

2–5 min

Notes

Only FDA-approved reversal for apixaban / rivaroxaban major bleed. Very expensive (~$30 k). If unavailable → 4F-PCC 50 units/kg (off-label).

Offending drug

Dabigatran (Direct thrombin inhibitor)

Reversal

Idarucizumab (Praxbind)

Dose

5 g IV as two consecutive 2.5 g infusions over 5–10 min each.

Onset

Minutes

Notes

Complete reversal within 4 h. Hemodialysis also removes dabigatran (~60 % / 4 h) — bridge if idarucizumab unavailable.

Offending drug

Opioids (any μ-agonist)

Reversal

Naloxone

Dose

0.04–0.4 mg IV (titrate q2 min to adequate respiration) · IN 4 mg / spray q2–3 min · Continuous 2/3 of effective bolus per h for long-acting opioid.

Onset

1–3 min IV

Notes

Goal is adequate respiration (RR ≥ 12, SpO₂ ≥ 92 %), NOT full alertness. Precipitates severe withdrawal in dependent patients.

Offending drug

Benzodiazepines

Reversal

Flumazenil

Dose

0.2 mg IV over 15 sec, repeat q1 min up to 1 mg (rarely > 3 mg). Continuous 0.1–0.4 mg/hr rarely used.

Onset

1–2 min

Notes

USE SPARINGLY — precipitates seizures in chronic-benzo users, mixed overdoses (TCA, cocaine), and lowers seizure threshold. Almost never indicated in adult overdose care.

Offending drug

Beta-blocker overdose

Reversal

Glucagon + high-dose insulin euglycemia (HIE)

Dose

Glucagon 5–10 mg IV bolus then 2–10 mg/hr infusion · Insulin 1 unit/kg IV bolus then 0.5–1 unit/kg/hr with D25 titrated to euglycemia · Add calcium if CCB overlap.

Onset

1–3 min (glucagon) · 15–30 min (HIE)

Notes

HIE outperforms glucagon in severe toxicity. Lipid emulsion for cardiac arrest / refractory shock (see below).

Offending drug

Calcium-channel blocker overdose

Reversal

Calcium + HIE + lipid emulsion

Dose

Calcium chloride 1 g IV (or gluconate 3 g) q10 min × 3 · Insulin 1 unit/kg bolus then 0.5–1 unit/kg/hr · Lipid 20 % 1.5 mL/kg bolus + 0.25 mL/kg/min for LAST / refractory shock.

Onset

Minutes

Notes

Verapamil + diltiazem are cardiotoxic — refractory shock often requires HIE + pacing + ECMO. Atropine + fluids first for bradycardia.

Offending drug

Acetaminophen (APAP)

Reversal

N-acetylcysteine (NAC)

Dose

IV: 150 mg/kg over 1 h → 50 mg/kg over 4 h → 100 mg/kg over 16 h (total 21 h) · PO: 140 mg/kg load then 70 mg/kg q4h × 17 doses.

Onset

Hours — protective, not neutralizing

Notes

Use Rumack-Matthew nomogram (single acute ingestion, 4–24 h). Start empirically if massive ingestion, staggered / unknown timing, or altered mental status.

Offending drug

Digoxin toxicity

Reversal

Digoxin-immune Fab (DigiFab)

Dose

Acute ingestion: # vials = (dose ingested mg × 0.8) / 0.5. Steady-state level: # vials = (level ng/mL × wt kg) / 100. Empiric: 10–20 vials in unknown massive OD.

Onset

30 min

Notes

Indications: life-threatening arrhythmia (VF, VT, brady with hemodynamic compromise), K ≥ 5 in acute overdose, ingested ≥ 10 mg adult / 4 mg child.

Offending drug

Iron overdose

Reversal

Deferoxamine

Dose

15 mg/kg/hr IV infusion (max 6 g/24 h in adults). Continue until urine colour normal + level < 350 mcg/dL.

Onset

Chelation begins immediately

Notes

Give if serum Fe > 500 mcg/dL, symptomatic, or metabolic acidosis. Watch for hypotension + ARDS. Whole-bowel irrigation for pill fragments on KUB.

Offending drug

Cyanide (smoke inhalation, nitroprusside)

Reversal

Hydroxocobalamin (Cyanokit)

Dose

5 g IV over 15 min · repeat once for severe toxicity.

Onset

Minutes

Notes

Turns skin, urine, and secretions red-pink. Prefer over cyanide kit (thiosulfate + nitrite) in fire victims (no methemoglobinemia).

Offending drug

Methanol / ethylene glycol

Reversal

Fomepizole (± dialysis)

Dose

15 mg/kg IV load over 30 min → 10 mg/kg q12h × 4 doses → 15 mg/kg q12h until level < 20 mg/dL. Dialysis if severe acidosis or renal failure.

Onset

Blocks alcohol dehydrogenase — protective

Notes

Also give folate (methanol) or thiamine + pyridoxine (ethylene glycol) to shunt metabolism. Ethanol IV is a legacy backup only.

Offending drug

Rocuronium / vecuronium (NMB)

Reversal

Sugammadex

Dose

2 mg/kg IV for T2 recovery · 4 mg/kg for 1–2 post-tetanic counts · 16 mg/kg for immediate reversal of rocuronium (rescue after failed intubation).

Onset

1–3 min

Notes

Superior to neostigmine + glycopyrrolate. No effect on succinylcholine, atracurium, cisatracurium.

Offending drug

Anticholinergic toxidrome

Reversal

Physostigmine

Dose

1–2 mg IV over 5 min (slow — seizure / bradycardia risk).

Onset

5 min

Notes

For pure anticholinergic (Datura, atropine, antihistamines, TCAs with pure anticholinergic picture). AVOID in TCA overdose with QRS widening or bradyarrhythmia — worsens conduction.

Offending drug

TCA overdose (cardiotoxicity)

Reversal

Sodium bicarbonate

Dose

1–2 mEq/kg IV bolus, repeat until QRS < 100 ms and pH 7.45–7.55, then bicarb drip (150 mEq NaHCO₃ in 1 L D5W at 250 mL/h).

Onset

5–10 min

Notes

Also give NS + Mg for torsades, avoid class Ia/Ic/III antiarrhythmics. Lipid emulsion for refractory arrest.

Offending drug

Serotonin syndrome (mod-severe)

Reversal

Cyproheptadine

Dose

12 mg PO/NG load then 2 mg q2h until symptoms resolve (max 32 mg/24 h).

Onset

1–2 h

Notes

First-line: STOP offending agent, cool aggressively, benzos, IVF. Cyproheptadine for moderate/severe. Intubate + paralyze for hyperthermia > 41 °C.

Universal rescue — IV lipid emulsion (ILE)

20 % lipid emulsion is the last-line antidote for local-anesthetic systemic toxicity (LAST) and for cardiac arrest / refractory shock from any lipophilic drug (bupivacaine, verapamil, propranolol, TCA, cocaine, chloroquine).

1.5 mL/kg IV bolus over 1 min → 0.25 mL/kg/min infusion. Repeat bolus q3–5 min for persistent asystole. Continue infusion 10 min after hemodynamic stability. Max total dose ~ 10 mL/kg over 30 min.

06 — Continuous infusions

Drip reference: concentration, dose, line, monitoring

Norepinephrine
Epinephrine
Phenylephrine
Vasopressin
Dobutamine
Nitroglycerin
Nicardipine
Diltiazem
Amiodarone
Heparin (UFH)
Insulin (regular)
Propofol
Dexmedetomidine
Fentanyl
Magnesium sulfate
Potassium chloride

Norepinephrine

Standard concentration

4 mg / 250 mL D5W (16 mcg/mL) or 8 mg / 250 mL (32 mcg/mL) high-concentration

Dose

Start 0.05 mcg/kg/min, titrate q5–15 min to MAP ≥ 65. Typical 0.05–0.5; refractory ≤ 3.

Line

Central preferred for sustained doses > 0.05–0.1 mcg/kg/min; peripheral OK short-term with extravasation plan (phentolamine local infiltration if extrav).

Monitoring

Continuous BP/MAP (arterial line if titrating), HR, UOP q1h, lactate q2–6h, glucose.

07 — Septic shock

The Hour-1 bundle (Surviving Sepsis Campaign)

Septic shock is sepsis-induced hypotension persisting despite adequate fluid resuscitation AND lactate ≥ 2 mmol/L. Every step below has a time target. Each hour of delay in antibiotics raises mortality ~7% — start them after cultures but never let cultures delay the dose more than 45 minutes.

Measure lactate

Within 1 h

Initial level — repeat at 2 h if first ≥ 2 mmol/L. Trend guides resuscitation success; failure to clear ≥ 10% suggests ongoing tissue hypoxia.

Lactate STAT, repeat in 2 h

Obtain blood cultures

Before antibiotics (must not delay them > 45 min)

Two sets from two separate sites. If patient already on antibiotics, draw immediately before next dose. Adding fungal / AFB cultures when clinically indicated.

Blood culture × 2 sets (peripheral + line if present), STAT

Broad-spectrum antibiotics

Within 1 h of recognition

Empiric coverage based on suspected source. Each hour of delay increases mortality ~7%. Reassess at 48–72 h with culture data for de-escalation.

Piperacillin-tazobactam 4.5 g IV q8h (extended infusion 4 h) — empiric Gm-neg + anaerobe coverage
+ Vancomycin 25–30 mg/kg IV load, then per pharmacy nomogram — MRSA coverage
± Consider antifungal (e.g., micafungin 100 mg IV q24h) if at-risk host

Rapid crystalloid resuscitation

Within 3 h

30 mL/kg ideal-body-weight balanced crystalloid (LR or Plasma-Lyte preferred over NS) for MAP < 65 or lactate ≥ 4. Reassess after each litre — dynamic measures (PLR, pulse-pressure variation, IVC US) > static (CVP).

Lactated Ringer's 30 mL/kg IV over 1–3 h (= ~2 L for 70 kg)
Reassess MAP, UOP, JVP / IVC, lactate after each bolus

Start vasopressors if MAP < 65

During or after fluid resuscitation

Norepinephrine first-line. Target MAP ≥ 65 (consider 80–85 if chronic HTN). Add vasopressin 0.03 units/min at NE > 0.25 mcg/kg/min as catecholamine-sparing. Epinephrine third-line.

Norepinephrine 4 mg / 250 mL D5W:
   start 0.05 mcg/kg/min, titrate q5 min to MAP ≥ 65
   max 1 mcg/kg/min — call MD if approached
± Vasopressin 0.03 units/min fixed if NE > 0.25 mcg/kg/min
Central line if NE sustained > 0.1 mcg/kg/min for > 1 h
Arterial line for continuous MAP

Resuscitation targets at 6 h

MAP

≥ 65 mmHg

UOP

≥ 0.5 mL/kg/hr

Lactate

↓ ≥ 10% / 2 h or normalising

ScvO₂

≥ 70% (if central access)

Adjuncts (beyond the bundle, often within 24 h)

Steroids

Hydrocortisone 200 mg/day (50 mg IV q6h OR 200 mg/day continuous) if vasopressor-dependent after adequate fluid + NE. Continue until off pressors.

Source control

Imaging within 6 h to identify drainable foci. Drainage / debridement / device removal within 6–12 h if anatomically possible.

Glycemic control

Insulin drip for sustained BG > 180 mg/dL. Target 140–180 (not tight control — increases hypoglycemia + mortality).

Stress-dose & VTE

PPI for stress-ulcer prophylaxis if mechanically ventilated > 48 h or coagulopathic. Mechanical VTE prophylaxis day 1; chemical when bleeding risk acceptable.

Lung-protective vent

If intubated: tidal volume 6 mL/kg IBW, plateau pressure < 30, PEEP titrated to FiO2 / ARDSnet table.

When to re-image / re-culture

Persistent fever or rising lactate at 48–72 h → repeat imaging of suspected source, repeat cultures off antibiotics if possible, infectious-disease consult.

08 — Common pitfalls

Where IV orders go wrong

Pitfall

Ordering a bolus without a rate

'500 mL NS bolus' is incomplete — pharmacy and nursing infer rate, which can mean 30 min or 4 h. Write '500 mL NS over 30 min'.

Pitfall

Co-infusing LR with ceftriaxone

Calcium in LR precipitates with ceftriaxone → fatal pulmonary embolism. Never on the same line, ever. Use NS as carrier for ceftriaxone.

Pitfall

Peripheral KCl > 10 mEq/hr

Severe burning + phlebitis. Central line OR slow the rate. Always order on a pump, never run K wide-open.

Pitfall

Rapid Na correction in chronic hyponatremia

Max 8–10 mEq/L per 24 h. Faster → osmotic demyelination syndrome. Use D5W to slow correction if you're going too fast.

Pitfall

D5W resuscitation

Distributes to total body water — does NOT stay in the vascular space. Useless for shock. Use a balanced crystalloid.

Pitfall

Forgetting compatibility on a single line

When the patient has 2 peripheral IVs and 4 drips, somebody runs them together. Check every Y-site pair against the institutional compatibility tool.

Pitfall

Heparin without baseline labs

Need CBC, aPTT, INR, SCr before starting. HIT requires a baseline platelet count. Renal failure changes anti-Xa monitoring strategy.

Pitfall

Open-ended vasopressor orders

'Titrate to MAP ≥ 65' is necessary but not sufficient — add a max dose, a re-eval interval, and the next-line drug if you exceed it.

09 — Side by side

Septic shock resuscitation, written two ways

A 72-year-old with sepsis, MAP 56 despite 2 L crystalloid, lactate 4.2.

Incorrect

start levo and give some fluids

Brand name 'levo' for norepinephrine.
No fluid type, volume, or rate.
No starting drip rate or titration target.
No line plan, no monitoring frequency, no max dose.

Correct

1) Lactated Ringer's 30 mL/kg IV (= 2 L for 67 kg) over 1 h
2) Norepinephrine 4 mg / 250 mL D5W:
   start 0.05 mcg/kg/min, titrate q5 min to MAP ≥ 65
   max 1 mcg/kg/min — call MD if exceeded
3) Central line if NE > 0.1 mcg/kg/min sustained > 1 h
4) Arterial line for continuous MAP
5) Lactate q2h × 3, BMP q6h, CBC q12h
6) UOP q1h, target ≥ 0.5 mL/kg/hr
7) Indication: septic shock

Bolus dose, type, and rate all specified.
Pressor with concentration, starting dose, titration interval, target, and max.
Line plan + arterial monitoring tied to the drip.
Lab and urine output endpoints make titration possible.
Indication anchors the order to the patient's problem list.

Order an IV the way pharmacy reads it.

What every complete IV order contains

Indication

Solution + additives

Volume

Rate

Duration / endpoint

Line / compatibility

Monitoring

Hold / titration parameters

Adjuncts / orders linked to the fluid

Every bag on the floor — composition, indication, contraindication

When the bag needs to be more than salt + water

Albumin 5%

Albumin 25%

Packed RBCs

Fresh frozen plasma (FFP)

Platelets

Cryoprecipitate

Correct summarized sequence for ordering blood products

Confirm the trigger

Consent + advance-directive check

Type & screen / Type & crossmatch

Access + carrier fluid

Pre-medications — only if indicated

Write the order — 6 required elements

Bedside 2-person verification

Slow start + reaction monitoring + post-transfusion re-check

Acute hemolytic (ABO)

Febrile non-hemolytic

Allergic (mild)

Anaphylaxis

TRALI

TACO

Bacterial contamination / sepsis

How to reverse this drug — bedside reference

Warfarin

Heparin (UFH)

Enoxaparin (LMWH)

Apixaban / Rivaroxaban (Factor Xa DOACs)

Dabigatran (Direct thrombin inhibitor)

Opioids (any μ-agonist)

Benzodiazepines

Beta-blocker overdose

Calcium-channel blocker overdose

Acetaminophen (APAP)

Digoxin toxicity

Iron overdose

Cyanide (smoke inhalation, nitroprusside)

Methanol / ethylene glycol

Rocuronium / vecuronium (NMB)

Anticholinergic toxidrome

TCA overdose (cardiotoxicity)

Serotonin syndrome (mod-severe)

Drip reference: concentration, dose, line, monitoring

Norepinephrine

The Hour-1 bundle (Surviving Sepsis Campaign)

Measure lactate

Obtain blood cultures

Broad-spectrum antibiotics

Rapid crystalloid resuscitation

Start vasopressors if MAP < 65

Steroids

Source control

Glycemic control

Stress-dose & VTE

Lung-protective vent

When to re-image / re-culture

Where IV orders go wrong

Ordering a bolus without a rate

Co-infusing LR with ceftriaxone

Peripheral KCl > 10 mEq/hr

Rapid Na correction in chronic hyponatremia

D5W resuscitation

Forgetting compatibility on a single line

Heparin without baseline labs

Open-ended vasopressor orders

Septic shock resuscitation, written two ways