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

Nicardipine Drip Administration Protocol

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

Preparation and Setup

Dilution Requirements:

• Single-dose vials (25 mg/10 mL) must be diluted with 240 mL of compatible IV fluid to achieve a final concentration of 0.1 mg/mL (250 mL total volume) 3
• Pre-mixed flexible containers (0.1 mg/mL or 0.2 mg/mL) do not require dilution 3

Compatible IV Fluids: 3

• D5W
• D5W with 0.45% or 0.9% NaCl
• D5W with 40 mEq potassium
• 0.45% or 0.9% NaCl alone
• NOT compatible with sodium bicarbonate 5% or lactated Ringer's 3

Administration Route: 3

• Administer via central line or large peripheral vein
• Change peripheral IV site every 12 hours to prevent phlebitis (which can occur after 14+ hours at a single site) 3, 4
• Avoid small veins (dorsum of hand/wrist), intraarterial administration, or extravasation 3

Initial Dosing and Titration

Starting Dose: 1, 2, 3

• Begin at 5 mg/hr for all patients (drug-free or converting from oral therapy)

Titration Schedule: 1, 2, 3

• For gradual BP reduction: Increase by 2.5 mg/hr every 15 minutes
• For rapid BP reduction: Increase by 2.5 mg/hr every 5 minutes
• Maximum dose: 15 mg/hr
• Target: 10-15% reduction in blood pressure 1, 2

Specific Clinical Scenarios: 1, 2

• Acute ischemic stroke (pre-rtPA): Start at 5 mg/hr if BP >185/110 mmHg, titrate every 5-15 minutes to max 15 mg/hr
• Hypertensive emergency in pregnancy/pre-eclampsia: Same protocol, target BP <160/105 mmHg
• Severe hypertension (DBP >120 mmHg): Standard protocol applies

Monitoring Requirements

During Titration: 1, 2

• Continuous blood pressure and heart rate monitoring
• Adjust dose every 5-15 minutes based on urgency until target achieved

Post-Thrombolytic Patients (Stroke): 1

• Every 15 minutes for first 2 hours
• Every 30 minutes for next 6 hours
• Every hour for subsequent 16 hours

All Other Patients: 3

• Monitor BP and heart rate continuously during titration
• Continue frequent monitoring to avoid excessive/rapid BP reduction or tachycardia

Pharmacokinetics

Onset and Duration: 1, 2

• Onset of action: 5-15 minutes
• Duration after discontinuation: 30-40 minutes (50% offset)
• Blood pressure reaches approximately 50% of ultimate decrease in 45 minutes with constant infusion 3

Conversion from Oral Nicardipine

Equivalent IV Infusion Rates: 1

• Oral 30 mg TID = IV 1.2 mg/hr
• Oral 40 mg TID = IV 2.2 mg/hr

Management of Adverse Effects

If Hypotension or Tachycardia Occurs: 3

• Discontinue infusion immediately
• After stabilization, restart at lower dose (3-5 mg/hr)

Common Side Effects: 1, 3

• Headache (13% incidence)
• Flushing
• Hypotension (5%)
• Tachycardia (4%)
• Nausea/vomiting (4%)

Expected Heart Rate Increase: 4

• Approximately 10 beats/minute increase is normal and does not require intervention unless excessive

Critical Pitfalls to Avoid

• Do not use in advanced aortic stenosis (absolute contraindication) 3
• Never abruptly discontinue beta-blockers when starting nicardipine—it provides no protection against beta-blocker withdrawal 3
• Change peripheral IV sites every 12 hours to prevent phlebitis 3
• Do not combine with other products in the same IV line or premixed container 3
• Monitor closely in patients with: congestive heart failure, hepatic impairment, portal hypertension, renal impairment, pheochromocytoma, or angina 3