💉 פרוטוקולי IV — שערי צדק

SZMC IV Drug Protocols • Geriatrics/Internal Medicine
🏠 דף הבית

💉 IV Insulin (Actrapid) ICU

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Target
Glucose 140-180 mg/dL
Contraindications
Glucose <70DKAHyperosmolar Coma
Preparation
ACTRAPID 50 units + NaCl 0.9% 50ml → 1 unit/ml
⚠️ בקרה כפולה — Double Check Required
Monitoring
  • During titration: BG every 2 hours
  • After rate change/bolus: 2 checks minimum, 2h apart
  • After stabilization: BG every 4 hours
Dosing Table
mg/dLNo DMDMHigh Req
<70STOP. D50% 50ml IV slow push. Check q15min.
70-99StopStop→ MD
100-140Stop0.5 cc/hr→ MD
141-180Stop1 cc/hr2 cc/hr
181-2001 cc/hr2cc bol + 1cc/hr2cc bol + 2cc/hr
201-2502cc bol + 2cc/hr2cc bol + 3cc/hr2cc bol + 5cc/hr
251-3002cc bol + 2cc/hr2cc bol + 4cc/hr2cc bol + 6cc/hr
301-3504cc bol + 4cc/hr4cc bol + 6cc/hr4cc bol + 8cc/hr
351-4004cc bol + 6cc/hr4cc bol + 6cc/hr6cc bol + 8cc/hr
>400If x2 consecutive → move to High Req column. Call MD.

🫧 IV Propofol 2% High Risk ICU Only

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Dosing
  • Start: 5 mcg/kg/min
  • Titrate: +5-10 mcg/kg/min every 10 min
  • Max: 50 mcg/kg/min
  • Target: Ramsay 3-5
Infusion Rate (ml/hr) by Weight
mcg/kg/min40kg50kg60kg70kg80kg90kg
50.60.80.91.11.21.4
101.21.51.82.12.42.7
151.82.32.73.23.64.1
202.43.03.64.24.85.4
253.03.84.55.36.06.8
303.64.55.46.37.28.1
404.86.07.28.49.610.8
506.07.59.010.512.013.5
⚠️ PRIS Warning: Risk ↑ if >50 mcg/kg/min or >48h. Monitor: CK, pH, TG, lactate q24h. Signs: unexplained acidosis, rhabdomyolysis, hyperK, cardiac failure. → STOP immediately.
Notes
  • Change syringe every 12 hours
  • Use Adjusted Body Weight if BMI >30
  • Y-set with Fentanyl or dedicated line
  • NOT for non-ventilated ward patients

💊 IV Fentanyl High Risk

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Loading Dose
12.5-25 mcg over 2 minutes
May repeat after 5 min peak if severe pain, no significant side effects.
Maintenance
20-50 mcg/hr. Titrate q30-60 min. Max increase: 10 mcg/hr per step.
Preparation (Syringe Pump)
1. 1 ampoule Fentanyl (0.5 mg / 10 ml)
2. + 40 ml NaCl 0.9%
50 ml total → 10 mcg / 1 ml
Rate Table
mcg/hrml/hr
101
202
303
505
⚠️ בקרה כפולה — Double Check Required

🧪 IV Dormicum (Midazolam) High Risk

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Preparation
1. NaCl 0.9% 100 ml — remove 20 ml
2. Add Dormicum 100 mg (= 20 ml concentrate)
100 mg / 100 ml → 1 mg / 1 ml
Rate per physician order. Titrate to target sedation.
⚠️ בקרה כפולה — Double Check Required

💊 IV Morphine High Risk

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Preparation
Ampoule: Morphine 100 mg / 5 cc
1. NaCl 0.9% 100 ml — remove 5 ml
2. Add 5 ml Morphine (100 mg)
100 mg / 100 ml → 1 mg / 1 ml
Rate per physician order (continuous or bolus as prescribed).
⚠️ בקרה כפולה — Double Check Required

🔴 IV Noradrenaline High Risk Shock

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⚡ Shock states ONLY. After/concurrent with fluid resuscitation. Central line preferred.
Key Rules
  • Dilute in D5% ONLY (NOT NaCl)
  • Run on dedicated separate line
  • Very short T½ — replace bag immediately when finishing
  • Large peripheral IV acceptable temporarily; ensure patent
Preparation
1. D5% 100 ml — remove 4 ml
2. Add 1 ampoule Noradrenaline (4 mg / 4 ml)
4 mg / 100 ml → 40 mcg / ml
Start: ~0.05-0.1 mcg/kg/min. Titrate to MAP ≥65. Continuous BP monitoring.
⚠️ בקרה כפולה — Extravasation → tissue necrosis!

🔴 IV Dopamine High Risk

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Indications
VF (post-resuscitation)Hemodynamic instabilitySymptomatic bradyarrhythmia
Preparation
Ampoule: Dopamine 200 mg / 5 ml
D5% or NaCl base + 5 ampoules (1000 mg total)
~5 mg/ml final concentration
Rate per physician order. IV pump required.
⚠️ בקרה כפולה — Double Check Required

⚡ IV Procor (Amiodarone) High Risk

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Loading
300 mg in D5% 100 ml → over 30 minutes
Maintenance Options
DoseDiluent12hr rate24hr rate
900 mgD5% 500ml75 mg/hr = 43 ml/hr38 mg/hr = 22 ml/hr
1200 mgD5% 500ml101 mg/hr = 43 ml/hr50 mg/hr = 22 ml/hr
Contraindications
Amiodarone allergyBradycardia <50AV block (no pacer)
⚡ Phlebitis risk with peripheral IV. Use 500ml dilution standard. Volume-restricted → 50ml with MD written order.
⚠️ בקרה כפולה — Double Check Required

🩸 IV Heparin (UFH) High Risk

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Preparation
Ampoule: 10,000 units per vial
Target: 100 units / 1 ml
Add heparin to NaCl 0.9% bags per total units ordered.
Contraindications
HIT (type II)DIC (relative)Active major bleeding
Monitoring
  • aPTT q6h initially (target 1.5-2.5x control)
  • CBC + platelets daily (watch for HIT: >50% drop)
  • Signs of bleeding: hematomas, retroperitoneal, GI, CNS
Reversal: Protamine 1 mg per 100 units heparin (last 2-3h)
⚠️ בקרה כפולה — Double Check Required

⚡ IV Lidocaine Arrhythmia

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Preparation
2000 mg in NaCl 0.9% 500 ml → 4 mg/ml
Dosing
  • Loading: 1-1.5 mg/kg IV over 5 min. May repeat x1.
  • Maintenance: 1-4 mg/min (~15-60 ml/hr by weight)
Toxicity Signs
Perioral numbnessTinnitusConfusionSeizuresCV collapse

🧂 IV Magnesium Sulfate

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Preparation
MgSO4 50% ampoules added to NaCl 0.9% 100 ml
Infuse over ~2 hours
Monitoring
  • Check Mg level before repeat dosing
  • Watch: loss of DTR (early toxicity), respiratory depression, hypotension
  • Antidote: Calcium Gluconate 10% 10 ml IV over 10 min

🧪 IV Potassium Phosphate High Risk

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Peripheral IV
15 mmol in 500 ml (D5% / NaCl 0.45% / NaCl 0.9%) → over 6 hours
Diluent choice depends on patient's serum sodium.
Central Line
15 mmol in 250 ml → over 4 hours
⚠️ בקרה כפולה — Double Check Required

🦠 SBE (Bacterial Endocarditis) Antibiotics

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Treatment by Pathogen
PathogenFirst LineDuration
Strep (native)Ampicillin + Gentamicin4-6w + 2w
Staph MSSA (native)Cloxacillin6w
Staph (prosthetic)Vanc + Rifampin + Gent≥6w
EnterococcusAmpicillin + Gent4-6w
Always: 3 blood cultures before ABx. TTE → TEE. ID consult.
SZMC Geriatrics/Internal Medicine • Dr. D.S. Shapira (32398) • May 2024
For clinical use only. Verify all doses before administration.