What is the protocol for administering a nicardipine (Calcium Channel Blocker) drip?

How to Administer Nicardipine Drip

Start nicardipine at 5 mg/hr IV infusion and titrate by increasing 2.5 mg/hr every 5-15 minutes to a maximum of 15 mg/hr until desired blood pressure is achieved. 1, 2, 3

Initial Setup and Preparation

Dilution Requirements

• Single-dose vials (25 mg/10 mL) must be diluted before use: Mix each 25 mg vial with 240 mL of compatible IV fluid to achieve a final concentration of 0.1 mg/mL (250 mL total volume). 3
• Flexible containers (0.1 mg/mL or 0.2 mg/mL) do not require dilution and can be used directly. 3

Compatible IV Fluids

• Dextrose 5% in water 3
• Normal saline (0.9% NaCl) 3
• Dextrose 5% with 0.45% or 0.9% NaCl 3
• Dextrose 5% with 40 mEq potassium 3

Incompatible Solutions (Do Not Use)

• Sodium bicarbonate 5% 3
• Lactated Ringer's solution 3

IV Access Considerations

• Administer via central line or large peripheral vein to minimize venous irritation. 3
• Avoid small veins (dorsum of hand or wrist) to reduce risk of thrombophlebitis. 3
• Change peripheral infusion site every 12 hours to prevent phlebitis, which can occur after 14+ hours at a single site. 3, 4

Dosing Protocols by Clinical Scenario

For Acute Ischemic Stroke (Pre-thrombolytic)

If systolic BP >185 mmHg or diastolic BP >110 mmHg before rtPA:

• Start at 5 mg/hr 1
• Titrate by 2.5 mg/hr at 5-15 minute intervals 1
• Maximum dose: 15 mg/hr 1
• Once target BP achieved (<185/110 mmHg), reduce to 3 mg/hr for maintenance 1
• If BP remains >185/110 mmHg despite maximum dose, do not administer rtPA 1

For Severe Hypertension (Non-stroke)

For gradual BP reduction:

• Start at 5 mg/hr 2, 3
• Increase by 2.5 mg/hr every 15 minutes 2, 3
• Maximum: 15 mg/hr 2, 3

For rapid BP reduction:

• Start at 5 mg/hr 2, 3
• Increase by 2.5 mg/hr every 5 minutes 2, 3
• Maximum: 15 mg/hr 2, 3

For Hypertensive Emergency in Pregnancy/Pre-eclampsia

• Start at 5 mg/hr 1, 5
• Titrate by 2.5 mg/hr every 5-15 minutes 1
• Maximum: 15 mg/hr 1
• Target BP: <160/105 mmHg 5

Conversion from Oral Nicardipine

Use equivalent IV infusion rates: 3

• Oral 20 mg TID → IV 0.5 mg/hr
• Oral 30 mg TID → IV 1.2 mg/hr
• Oral 40 mg TID → IV 2.2 mg/hr

Monitoring Requirements

During Titration

• Continuous blood pressure and heart rate monitoring during active titration 2, 3
• Monitor for hypotension (>10% decrease) or tachycardia (>20 bpm increase) 3, 6

Post-thrombolytic Patients (Stroke)

• BP every 15 minutes for first 2 hours 1, 2
• BP every 30 minutes for next 6 hours 1, 2
• BP every hour for subsequent 16 hours 1, 2

General Monitoring

• Inspect IV site frequently for signs of phlebitis or extravasation 3
• Monitor for headache, flushing, and reflex tachycardia 1, 3

Pharmacokinetics

• Onset of action: 5-15 minutes 2, 5
• Duration after discontinuation: 30-40 minutes (50% offset) 2, 5, 4
• Time to 50% of maximum effect: ~45 minutes with constant infusion 3

Management of Adverse Effects

If Hypotension or Excessive Tachycardia Occurs

• Immediately discontinue infusion 3
• After stabilization, may restart at lower dose (3-5 mg/hr) 3

Common Side Effects

• Headache (13% incidence) 3, 4
• Hypotension (5%) 3
• Tachycardia (4%) - typically increases heart rate by ~10 bpm 3, 4
• Nausea/vomiting (4%) 3
• Flushing 1, 4

Critical Contraindications and Precautions

• Absolute contraindication: Advanced aortic stenosis 3
• Not a beta-blocker substitute: Provides no protection against abrupt beta-blocker withdrawal 3
• Use caution in patients with heart failure, hepatic impairment, or renal dysfunction 3
• Avoid intraarterial administration or extravasation 3

Special Populations

Pregnancy

• Considered safe and effective for hypertensive emergencies in pregnancy 5
• Breastfeeding not recommended while on nicardipine 3

Pediatrics

• Safety and efficacy not established in patients <18 years 3