What is the appropriate protocol for administering Nicardipine 2mg IV?

Nicardipine 2mg IV Push is NOT the Correct Administration Method

Nicardipine should NEVER be administered as a 2mg IV push or bolus in routine clinical practice—it must be given as a continuous IV infusion starting at 5 mg/hr and titrated by 2.5 mg/hr increments every 5-15 minutes to a maximum of 15 mg/hr. 1, 2, 3

Correct Administration Protocol

Initial Setup and Dilution

• Single-dose vials (25 mg/10 mL) must be diluted before infusion to 240 mL of compatible IV fluid, resulting in a final concentration of 0.1 mg/mL 3
• Flexible containers (0.1 mg/mL or 0.2 mg/mL) do not require dilution 3
• Administer via central line or large peripheral vein, changing the infusion site every 12 hours if using peripheral access to prevent phlebitis 3

Dosing Algorithm for Acute Hypertension

For patients requiring blood pressure reduction before thrombolytic therapy (BP >185/110 mmHg):

• Start at 5 mg/hr IV infusion 1, 2, 3
• Titrate by increasing 2.5 mg/hr every 5-15 minutes 1, 2
• Maximum dose: 15 mg/hr 1, 2, 3
• Target: BP ≤185/110 mmHg before rtPA administration 1, 2

For severe hypertension without thrombolytic indication:

• Start at 5 mg/hr IV infusion 2, 4, 3
• For gradual BP reduction: increase by 2.5 mg/hr every 15 minutes 5, 4
• For rapid BP reduction: increase by 2.5 mg/hr every 5 minutes 5, 4
• Maximum dose: 15 mg/hr 2, 4, 3
• Target: 10-15% reduction in blood pressure 5, 4

Pharmacokinetics

• Onset of action: 5-15 minutes 2, 4
• Duration after discontinuation: 30-40 minutes 2, 4
• Blood pressure begins to fall within minutes and reaches approximately 50% of ultimate decrease in about 45 minutes 3

Monitoring Requirements

Intensive Monitoring Protocol

• Continuous blood pressure and heart rate monitoring during titration 2, 5
• For post-thrombolytic stroke patients: 1, 5
  • Every 15 minutes for first 2 hours
  • Every 30 minutes for next 6 hours
  • Every hour for subsequent 16 hours

Expected Hemodynamic Changes

• Heart rate typically increases by approximately 10 beats/minute 2, 6
• Cardiac output increases while systemic vascular resistance decreases 6, 7
• Left ventricular end-diastolic pressure remains relatively constant 7

Critical Safety Considerations

Common Adverse Effects

• Headache (13% incidence) 2, 3
• Hypotension (5%) 2, 3
• Tachycardia (4%) 2, 3
• Nausea/vomiting (4%) 2, 3
• Flushing 1, 2
• Local phlebitis (especially after >14 hours at single site) 6

Management of Hypotension or Tachycardia

• If hypotension or excessive tachycardia occurs, immediately discontinue the infusion 3
• After stabilization, restart at lower doses (3-5 mg/hr) 3

Special Population Warnings

Acute Stroke Patients:

• Exercise extreme caution to avoid systemic hypotension 5
• Excessive BP reduction within first 5-7 days of ischemic stroke is associated with adverse neurological outcomes 2
• Maintain BP <180/105 mmHg after thrombolytic administration 1

Contraindications:

• Do not use in patients with advanced aortic stenosis 3

Drug Interactions

• Cimetidine increases nicardipine plasma levels—use with caution 1, 3
• Nicardipine increases cyclosporine and tacrolimus levels—monitor immunosuppressant trough levels closely 3

Common Pitfalls to Avoid

1. Never administer as IV push/bolus in routine practice—this is not the FDA-approved route and could cause precipitous hypotension 3
2. Do not use small veins (dorsum of hand/wrist) to reduce risk of thrombophlebitis 3
3. Avoid intraarterial administration or extravasation 3
4. Do not mix with sodium bicarbonate or lactated Ringer's solution—incompatible 3
5. Change peripheral IV site every 12 hours to prevent phlebitis 3
6. Nicardipine is not a beta-blocker—provides no protection against abrupt beta-blocker withdrawal 3