Bolus Administration Protocol
Boluses should be administered as slow intravenous injections over 1-2 minutes for most medications, with specific timing adjusted based on the drug class and clinical indication. 1
General Principles of Bolus Administration
Standard Administration Technique
- Most IV bolus medications should be given slowly over 1-2 minutes to minimize adverse effects and allow for assessment of patient response 1, 2
- The intravenous route provides immediate drug delivery and should be used when rapid onset is required or oral administration is not feasible 2
- Always inspect medications visually for particulate matter and discoloration before administration 2
Medication-Specific Timing
Cardiovascular Medications:
- Adenosine: 6 mg rapid IV push over 1-3 seconds, followed immediately by saline flush; if ineffective, give 12 mg after 1-2 minutes 1
- Diltiazem: 15-20 mg (0.25 mg/kg) IV over 2 minutes; may repeat with 20-25 mg (0.35 mg/kg) after 15 minutes 1
- Verapamil: 2.5-5 mg IV over 2 minutes; may repeat as 5-10 mg every 15-30 minutes 1
- Metoprolol: 5 mg over 1-2 minutes, repeated every 5 minutes as needed 1
- Propranolol: 0.5-1 mg over 1 minute, repeated up to total 0.1 mg/kg 1
- Esmolol: Loading dose 500 mcg/kg over 1 minute 1
- Labetalol: 0.3-1.0 mg/kg (maximum 20 mg) slow IV injection every 10 minutes 1
- Phentolamine: 5 mg IV bolus, additional doses every 10 minutes as needed 1
Antihypertensive Agents:
- Hydralazine: 10 mg via slow IV infusion (maximum initial dose 20 mg), repeat every 4-6 hours 1
- Enalaprilat: 1.25 mg over 5 minutes, may increase up to 5 mg every 6 hours 1
Diuretics:
- Furosemide: 20-40 mg given slowly over 1-2 minutes for edema; 40 mg over 1-2 minutes for acute pulmonary edema, may increase to 80 mg if no response within 1 hour 2
Opioids for Pain Management:
- Morphine/Hydromorphone boluses: Should be ordered every 15 minutes as required for adequate pain control 1, 3
- Fentanyl boluses: Should be ordered every 5 minutes as required 1
- For patients on continuous infusions experiencing breakthrough pain, give a bolus dose equal to or double the hourly infusion rate 1, 3
Sedatives:
- Midazolam boluses: Should be ordered every 5 minutes as required for breakthrough agitation 1
- For patients on continuous midazolam infusions, give bolus dose of 1-2× the hourly infusion rate for breakthrough symptoms 1
Critical Safety Considerations
Monitoring During Administration
- Intra-arterial blood pressure monitoring is recommended when administering sodium nitroprusside to prevent "overshoot" hypotension 1
- Monitor for bradycardia when administering beta-blockers or calcium channel blockers 1
- A defibrillator should be readily available when administering adenosine due to risk of precipitating atrial fibrillation 1
Dose Adjustment Principles
- If a patient requires 2 bolus doses within 1 hour, it is reasonable to double the continuous infusion rate for opioids and sedatives 1, 3
- Reduce doses in elderly patients, those with renal or hepatic impairment, and post-cardiac transplant patients 1, 3
Common Pitfalls to Avoid
- Never administer boluses too rapidly as this increases risk of hypotension, bradycardia, and other adverse effects 1
- Do not mix acidic medications with furosemide in the same IV line as precipitation may occur 2
- Avoid bolus administration in patients with contraindications specific to each drug class (e.g., beta-blockers in asthma, calcium channel blockers in heart failure) 1
- For pediatric septic shock, administer fluid boluses over 15-20 minutes rather than 5-10 minutes to reduce risk of mechanical ventilation and fluid overload 4