Anesthetists frequently administer intravenous (IV) medications with narrow therapeutic windows and the potential for critical events. The drugs described in this section list agents that are not routinely administered by anesthetists but may be requested by others. It does not include agents that fall within the scope of the training and practice of anesthetists, for example, neuromuscular blockers.

1. Abciximab (ReoPro): Glycoprotein IIb/IIIa inhibitor preventing platelet adhesion and aggregation.
   1. Indications: Prevent thrombus formation peri–percutaneous transluminal coronary angioplasty (PTCA) and poststent placement.
   2. Administration guidelines
      1. Standard concentration: 9 mg/250 mL 0.9% sodium chloride.
      2. The IV tubing must have a filter on it (0.2- or 0.22-μm low–protein-binding filter) and no other medications should be piggybacked through this line.
      3. Loading dose (straight drug): 0.25 mg/kg administered 10 to 60 minutes prior to percutaneous coronary intervention (PCI). Withdraw through the 0.2- or 0.22-μm low–protein-binding filter the appropriate amount of abciximab for the patient’s weight. Hypotension may occur with bolus dose.
      4. Maintenance at a rate of 0.125 μg/kg/min to a maximum of 10 μg/min (17 mL/h) for 12 hours. To prepare, withdraw 4.5 mL (9 mg) of abciximab through 0.2- or 0.22-μm low–protein-binding filter and inject into a 250-mL bag of 0.9% sodium chloride.
2. Alprostadil (prostaglandin E1 [PGE₁]): Vasodilator; decreases peripheral resistance, which causes reflexive increase in cardiac output and heart rate.
   1. Indications:
      1. Primary nonfunctional liver transplant characterized by rising transaminases, minimal bile production, and coagulopathy within 4 to 34 hours after transplantation.
      2. Pulmonary hypertension.
      3. Distal ischemia (limb or digit) refractory to conventional revascularization or drug therapy.
      4. Vasospastic disorders (Raynaud disease), vasculitis, Buerger disease, atheroembolic diseases.
      5. Protection against tacrolimus nephrotoxicity.
   2. Administration guidelines:
      1. Standard concentration: 500 μg of alprostadil in 1,000 mL NS (1 μg = 1,000 ng).
      2. Infusion rates should be titrated to patient response.
         1. Remove rings/tight-fitting jewelry during the infusion since most experience extremity swelling. Patients often experience a “flushing” feeling during the initiation that is not necessarily an indication to stop the infusion, unless there is a drop in blood pressure (BP).
         2. Start the infusion at 1 ng/kg/min. If the patient becomes hypotensive, wean back to the previous dose. A starting dose of 0.4 ng/kg/min is recommended for patient with borderline low BP and/or poor left ventricular (LV) function.
         3. The infusion rate (dose) may be doubled every 30 minutes as tolerated to a peak dose of 16 ng/kg/min.
3. Alteplase (Activase): Tissue plasminogen activator (tPA)
   1. Indications:
      1. Acute myocardial infarction.
      2. Pulmonary embolism.
      3. Peripheral arterial or venous thrombosis.
      4. Catheter occlusion.
   2. Administration guidelines:
      1. Acute myocardial infarction
         1. Standard concentration: 100 mg/100 mL.
         2. Patient weight less than 67 kg: 15-mg bolus; then 0.75 mg/kg (maximum 50 mg) over 30 minutes. Initiate heparin therapy with a bolus; then 0.5 mg/kg (maximum 35 mg) over the next hour.
         3. Patient weight greater than 67 kg: 15-mg bolus; then 50 mg over the next 30 minutes. Institute heparin therapy with a bolus. Infuse remaining 35 mg of tPA over the next hour (total dose of tPA = 100 mg).
      2. Pulmonary embolus:
         1. Standard concentration: 100 mg/100 mL.
         2. Maintenance infusion: 100 mg continuous infusion over 2 hours.
      3. Peripheral arterial or venous thrombosis
         1. Standard concentration: 50 mg/500 mL, 25 mg/250 mL.
         2. Loading dose: none.
         3. Maintenance infusion: 0.5 to 4 mg/h for 24 hours (recommended maximum 50 mg/24 h). Heparin (no loading dose) should be started after alteplase infusion is completed to maintain activated partial thromboplastin time (aPTT) in a therapeutic range.
      4. Venous and arterial thrombosis catheter-directed thrombolysis
         1. Standard concentration: 50 mg/500 mL, 25 mg/250 mL.
         2. Loading dose: 4 to 10 mg.
         3. Maintenance infusion: 0.5 to 4 mg/h for 4 to 24 hours IV. Recommended cumulative maximum of 50 mg (load plus infusion). Heparin should be used at a low non–weight-adjusted dose (eg, 250 units/h) keeping aPTT less than 1.5 times baseline during alteplase infusion.
4. Argatroban: Direct thrombin inhibitor
   1. Indications:
      1. Anticoagulation in patients with suspected or confirmed heparin-induced thrombocytopenia (HIT type II).
      2. Anticoagulation during and immediately following PCIs.
   2. Administration guidelines
      1. Standard concentration (1 mg/mL): 50 mg/50 mL premixed vial in NaCl for large volume infusion pump.
      2. Low concentration (0.05 mg/mL): 2.5 mg/50 mL bag.
      3. Microinfusion: 2.5 mg/50 mL syringe.
      4. Bolus: None.
      5. Maintenance:
         1. Start 0.5 to 2 μg/kg/min as a continuous infusion.
         2. Reduce initial dose to 0.5 μg/kg/min for hepatic and/or renal dysfunction, and critically ill.
         3. Check the partial thromboplastin time (PTT) 2 hours after the start of the infusion and after any rate change until stable (ie, two consecutive values within the goal range). Goal: aPTT 1.5 to 3× baseline not to exceed a PTT of 100 seconds.
         4. When activated clotting time (ACT) is greater than 450 seconds, reduce maintenance to 15 μg/kg/min and recheck in 5 to 10 minutes.
5. Bivalirudin (Angiomax): Direct thrombin inhibitor
   1. Indication: Anticoagulation in patients with strongly suspected or confirmed HIT (type II).
   2. Administration guidelines
      1. Standard concentration (5 mg/mL): 250 mg/50 mL bag.
      2. Low concentration (1 mg/mL): 100 mg/100 mL bag (low concentration).
      3. Microinfusion: 250 mg/50 mL syringe.
      4. Bolus: None.
      5. Maintenance
         1. Starting dose: 0.15 mg/kg/h (CrCl > 60 mL/min).
         2. If CrCl 30 to 60 mL/min: 0.05 mg/kg/h.
         3. If CrCl less than 30 mL/min or renal replacement therapy: 0.025 mg/kg/h.
         4. Goal aPTT: 1.5 to 2.5 times baseline. Check the PTT 2 hours after the start of the infusion and after any rate change until two consecutive PTT values are within the goal range.
6. Cangrelor: Antiplatelet agent. It is a direct P2Y₁₂ platelet-receptor inhibitor that blocks adenosine diphosphate (ADP)–induced platelet activation and aggregation.
   1. Indication: Use in PCI to reduce risk of myocardial infarction (MI), repeat coronary revascularization, and stent thrombosis for patients not previously treated with P2Y₁₂ inhibitor or glycoprotein IIb/IIIa inhibitor.
   2. Administration guidelines
      1. Bolus: 30 μg/kg. Administer over 1 min (<100 kg); 2 min (100-200 kg); or 3 min (>300 kg)
      2. Starting rate: 4 μg/kg/min
7. Epoprostenol sodium (Flolan): Potent vasodilator that also inhibits platelet aggregation.
   1. Indication: Pulmonary hypertension.
   2. Administration guidelines
      1. Do not give with other parenteral medications or carriers.
      2. A dedicated central venous catheter is required for administration with an air-eliminating filter.
      3. Do not flush catheter with epoprostenol in-line.
      4. Bolus: None.
      5. Maintenance infusion:
         1. Initial dose: 1 to 2 ng/kg/min IV.
         2. Titrate in 1 to 2 ng/kg/min increments every 15 to 30 minutes.
      6. If catheter needs to be flushed, withdraw 3 mL of fluid/blood from the catheter into a syringe and discard. The line should be primed with epoprostenol-specific diluent only.
      7. Avoid abrupt withdrawal that may cause rebound pulmonary artery hypertension.
      8. Syringe is only stable for 8 hours at room temperature.
8. Eptifibatide (Integrilin)
   1. Indication: Prevention of thrombus formation after PCI.
   2. Dosage: Bolus (180 μg/kg); then 2 μg/kg/min continuous infusion.
   3. Effect: Inhibits glycoprotein IIb/IIIa; prevents platelet adhesion and aggregation.
   4. Comments: Bleeding complications and thrombocytopenia are common side effects.
9. Insulin, regular (human): Humulin R, Novolin R
   1. Indications: Hyperglycemia, hyperkalemia, diabetic ketoacidosis.
   2. Administration guidelines:
      1. Regular insulin is the only insulin that can be administered intravenously.
      2. Insert infusion into y-site below any inline filters.
      3. Standard concentration for microinfusion: 50 units/50 mL normal saline.
      4. Loading dose: 5 to 20 units intravenous push (IVP) or bolus (usually given prior to starting maintenance).
      5. Maintenance infusion: 2 to 25 units/h IV titrated according to blood glucose level.
      6. Once under control, blood glucose should be monitored at a minimum of every 2 hours and more often as needed.
10. Potassium chloride (KCl)
    1. Indication: Correction of hypokalemia.
       1. Caution: Hypokalemia is not usually treated in the operating room (OR).
       2. The decision to administer KCl requires anesthesia attending approval in advance of administration.
    2. Administration guidelines:
       1. Bolus dose: None. May cause cardiac arrest.
       2. Peripheral concentration: 80 mEq/1,000 mL.
       3. Central concentration: 20 mEq/100 mL; 40 mEq/100 mL.
       4. Rate: Not to exceed 20 mEq/h.