What is the proper preparation and infusion rate for nicardipine IV infusion?

Nicardipine IV Preparation and Infusion Rate

Preparation

Single-dose vials (25 mg/10 mL) must be diluted before infusion by adding each vial to 240 mL of compatible IV fluid to achieve a final concentration of 0.1 mg/mL in a total volume of 250 mL. 1

Compatible IV Fluids

• Dextrose 5% Injection 1
• Dextrose 5% and Sodium Chloride 0.45% Injection 1
• Dextrose 5% and Sodium Chloride 0.9% Injection 1
• Dextrose 5% with 40 mEq Potassium 1
• Sodium Chloride 0.45% Injection 1
• Sodium Chloride 0.9% Injection 1

Incompatible Solutions (Do Not Use)

• Sodium Bicarbonate 5% Injection 1
• Lactated Ringer's Injection 1

Premixed Flexible Containers

Premixed nicardipine in 0.9% Sodium Chloride (20 mg/200 mL or 40 mg/200 mL) requires no dilution and can be used directly. 1

Infusion Rate

Initial Dosing for Drug-Free Patients

Start 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. 2, 3, 4, 1

• For gradual blood pressure reduction: Increase by 2.5 mg/hr every 15 minutes 1
• For rapid blood pressure reduction: Increase by 2.5 mg/hr every 5 minutes 3, 4, 1

Onset and Duration

• Onset of action: 5-15 minutes 3, 4
• Time to 50% of maximum effect: Approximately 45 minutes 1
• Duration after discontinuation: 30-40 minutes, though plasma levels persist for hours 3, 1

Conversion from Oral Nicardipine

When substituting for oral therapy, use equivalent IV infusion rates 1:

• Oral 20 mg TID = IV 0.5 mg/hr 1
• Oral 30 mg TID = IV 1.2 mg/hr 3, 1
• Oral 40 mg TID = IV 2.2 mg/hr 3, 1

Administration Guidelines

Route and Site

Administer by slow continuous infusion through a central line or large peripheral vein. 1

Change the infusion site every 12 hours if administered via peripheral vein to minimize risk of phlebitis. 1, 5

Monitoring Requirements

• Monitor blood pressure and heart rate continuously during titration 4, 1
• Check BP every 15 minutes for the first 2 hours 3
• Then every 30 minutes for the next 6 hours 3
• Then hourly for the subsequent 16 hours 3

Critical Safety Considerations

Hypotension or Tachycardia Management

If hypotension or tachycardia occurs, discontinue the infusion immediately. 1 Once blood pressure and heart rate stabilize, restart at low doses of 3-5 mg/hr and titrate carefully to maintain desired blood pressure 1

Target Blood Pressure Reduction

• Reduce systolic BP by no more than 25% within the first hour for most hypertensive emergencies 4
• Aim for BP of 160/100 mmHg within the next 2-6 hours 4
• For aortic dissection or severe preeclampsia/eclampsia, reduce systolic BP to <140 mmHg during the first hour 4

Common Pitfalls to Avoid

• Do not use small veins such as those on the dorsum of the hand or wrist 1
• Avoid intraarterial administration or extravasation 1
• Do not combine with other products in the same IV line when using premixed containers 1
• Inspect solution before use; discard if particulate matter, precipitate, or crystallization is present 1

Special Populations Requiring Close Monitoring

• Patients with congestive heart failure 1
• Impaired hepatic function 1
• Renal impairment 1
• Acute stroke patients (exercise extreme caution to avoid systemic hypotension) 3

Common Adverse Effects

• Headache (13% incidence) 1
• Hypotension (5% incidence) 1
• Tachycardia (4% incidence, typically increases heart rate by ~10 beats/minute) 1, 6
• Flushing 2, 4, 6
• Phlebitis at infusion site (especially after 14+ hours at single site) 6, 5