What is the proper protocol for administering nicardipine (Calcium Channel Blocker) intravenously (IV)?

How to Administer Nicardipine IV

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

Preparation and Administration Route

• Administer via central line or large peripheral vein using slow continuous infusion 2
• Change the infusion site every 12 hours if using peripheral vein to minimize risk of phlebitis and vascular impairment 2
• Avoid small veins such as those on the dorsum of the hand or wrist 2

Dilution Requirements

Single-dose vials (25 mg/10 mL):

• Must be diluted before infusion 2
• Dilute each 25 mg vial with 240 mL of compatible IV fluid to create 250 mL at 0.1 mg/mL concentration 2

Compatible IV fluids: 2

• Dextrose 5%
• Dextrose 5% with Sodium Chloride 0.45% or 0.9%
• Dextrose 5% with 40 mEq Potassium
• Sodium Chloride 0.45% or 0.9%

Incompatible fluids (do not use): 2

• Sodium Bicarbonate 5%
• Lactated Ringer's

Premixed flexible containers (0.1 mg/mL or 0.2 mg/mL):

• No dilution required 2
• Protect from light until ready to use 2

Initial Dosing Protocol

For Acute Ischemic Stroke (Pre-thrombolytic)

When BP >185/110 mm Hg and patient is otherwise eligible for rtPA: 1

• Start at 5 mg/hr IV infusion
• Titrate up by 2.5 mg/hr every 5-15 minutes
• Maximum dose: 15 mg/hr
• Goal: Reduce BP to ≤185/110 mm Hg before administering rtPA
• Once target BP achieved, reduce to 3 mg/hr maintenance 1

Post-thrombolytic BP management (maintain BP ≤180/105 mm Hg): 1

• Start at 5 mg/hr
• Titrate by 2.5 mg/hr every 5-15 minutes
• Maximum: 15 mg/hr

For General Hypertensive Emergencies

Gradual BP reduction: 2

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

Rapid BP reduction: 2

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

For Hypertensive Emergencies in Pregnancy/Pre-eclampsia

• Start at 5 mg/hr and titrate by 2.5 mg/hr every 5-15 minutes to maximum of 15 mg/hr 1

Pharmacokinetics

• Onset of action: 5-15 minutes 1, 3
• Time to 50% effect: Approximately 45 minutes with constant infusion 2
• Duration after discontinuation: 30-40 minutes 1, 3
• Blood pressure begins to fall within minutes of starting infusion 2

Monitoring Requirements

For Stroke Patients Receiving Thrombolytics

Intensive monitoring protocol: 1, 3

• Every 15 minutes for first 2 hours from start of rtPA
• Every 30 minutes for next 6 hours
• Every hour for subsequent 16 hours

For All Patients

• Monitor blood pressure and heart rate continuously during titration 2
• Watch for tachycardia (heart rate typically increases by ~10 beats/minute) 4
• Avoid too rapid or excessive reduction in systolic or diastolic BP 2

Managing Adverse Effects

If hypotension or tachycardia develops: 2

• Discontinue infusion immediately
• Wait for blood pressure and heart rate to stabilize
• Restart at low doses (3-5 mg/hr) and titrate carefully to maintain desired BP

Common side effects: 2, 4

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

Phlebitis prevention: 4

• Change infusion site every 12 hours when using peripheral veins (phlebitis typically occurs after ≥14 hours at single site)

Critical Safety Considerations

Contraindications

• Advanced aortic stenosis (absolute contraindication) 2

Special Populations Requiring Close Monitoring

• Patients with angina 2
• Congestive heart failure 2
• Impaired hepatic function 2
• Portal hypertension 2
• Renal impairment 2
• Pheochromocytoma 2

Stroke-Specific Cautions

• Exercise extreme caution to avoid systemic hypotension in acute stroke patients 3
• In ischemic stroke, excessive BP reduction within first 5-7 days is associated with adverse neurological outcomes 3
• Maintain BP at higher end of acceptable ranges in patients with cerebrovascular disease 3

Drug Interactions

• Cimetidine: Increases nicardipine plasma levels; use with caution 2
• Cyclosporine and tacrolimus: Nicardipine inhibits CYP3A4 and can significantly elevate immunosuppressant levels; monitor trough levels frequently 3, 2

Common Pitfalls to Avoid

• Do not use small peripheral veins (increases phlebitis risk) 2
• Do not mix with sodium bicarbonate or lactated Ringer's (incompatible) 2
• Do not add supplementary medications to premixed bags 2
• Do not use plastic containers in series connections (risk of air embolism) 2
• Do not assume nicardipine provides beta-blocker protection—withdraw beta-blockers gradually if discontinuing 2
• Do not target the same BP as acute phase when downtitrating—reassess target based on current clinical status 3