How many boluses of medication, such as metoprolol (beta blocker), are administered before starting a maintenance drip?

Metoprolol IV Bolus Dosing Before Starting a Drip

For metoprolol specifically, administer up to 3 boluses of 5 mg IV (given over 2 minutes each, at 2-minute intervals) for a maximum total of 15 mg before considering transition to oral therapy—IV metoprolol drips are not standard practice. 1, 2

Standard IV Bolus Protocol

The established approach for IV metoprolol administration follows a specific three-bolus maximum protocol:

• Give 5 mg IV bolus over 2 minutes 1, 2
• Repeat every 2-5 minutes as needed 1, 2
• Maximum total dose: 15 mg (three 5 mg boluses) 1, 2
• Monitor blood pressure, heart rate, and ECG continuously during administration 2

Critical Distinction: No Metoprolol Drip Exists

Metoprolol is NOT administered as a continuous IV infusion/drip in standard practice. 1 This distinguishes it from other rate-control agents:

• Esmolol uses bolus followed by continuous infusion (50-300 mcg/kg/min) 1
• Diltiazem uses 0.25 mg/kg bolus followed by 5-15 mg/h infusion 1
• Amiodarone uses 150-300 mg over 1 hour, then 10-50 mg/h infusion 1

Transition to Oral Therapy

After IV bolus administration, transition to oral metoprolol rather than a drip:

• Begin oral metoprolol 15 minutes after the last IV dose 3, 2
• Initial oral dose: 25-50 mg every 6 hours for 48 hours (for acute MI) 2
• For atrial fibrillation: 25-100 mg twice daily (metoprolol tartrate) 1, 3
• Patients who don't tolerate full 15 mg IV dose should start at 25 mg orally every 6 hours 2

Absolute Contraindications to IV Boluses

Do not administer any IV metoprolol boluses if the patient has: 3, 2

• Decompensated heart failure or cardiogenic shock
• Second or third-degree AV block without pacemaker
• PR interval >0.24 seconds
• Severe bradycardia (HR <60 bpm)
• Systolic BP <120 mmHg
• Active asthma or severe reactive airways disease

Common Pitfall

The most critical error is attempting to use metoprolol as a continuous infusion. 1 If sustained beta-blockade via infusion is needed (e.g., critically ill patients, ongoing rate control), switch to esmolol, which has a 9-minute half-life and is designed for continuous infusion with rapid titration. 1