What is the proper procedure for administering an intravenous (IV) bolus with dilution?

IV Bolus Administration with Dilution: Standardized Protocol

Most IV bolus medications should be administered slowly over 1-2 minutes after appropriate dilution to minimize adverse effects, with specific timing varying by medication class and patient factors. 1

General Preparation Standards

Pre-Administration Requirements

• Verify the correct concentration and total dose in both mg and mL to prevent fatal dosing errors, as confusion between concentrations is a leading cause of accidental overdose 2
• Ensure resuscitative equipment and reversal agents (e.g., naloxone for opioids) are immediately available before initiating therapy 2
• Confirm IV line patency and appropriate vascular access before drug preparation 3
• Use aseptic technique throughout preparation, including swabbing vial taps before each entry 4

Dilution Principles

• Dilute concentrated medications to reduce venous irritation and allow controlled administration - for example, D50W should be diluted to D25W when possible 5
• Calculate dilution volumes based on patient weight and desired final concentration 5
• Label all syringes with drug name, concentration, total dose, and preparation time 3, 6

Medication-Specific Administration Protocols

Ultra-Rapid Bolus (1-3 seconds)

• Adenosine: 6 mg rapid IV push over 1-3 seconds, followed immediately by saline flush; second dose of 12 mg after 1-2 minutes if needed 1
• Have defibrillator immediately available due to risk of precipitating atrial fibrillation 1

Standard Slow Bolus (1-2 minutes)

• Most medications default to this timing unless otherwise specified 1
• Morphine: 0.1-0.2 mg/kg administered slowly to prevent chest wall rigidity from rapid injection 2
• Diltiazem: 15-20 mg (0.25 mg/kg) over 2 minutes, with potential repeat dose of 20-25 mg after 15 minutes 1
• Esmolol: 500 mcg/kg loading dose over 1 minute 1

Extended Bolus (>2 minutes)

• Enalaprilat: 1.25 mg over 5 minutes to prevent overshoot hypotension 1
• Hydralazine: 10 mg via slow IV infusion (maximum initial dose 20 mg) 1

Pediatric Dosing Adjustments

• Glucose for hypoglycemia: 200 mg/kg as D10W only (2 mL/kg), with D50W diluted to D25W to reduce venous irritation 5
• Haloperidol for agitation: 0.05-0.15 mg/kg (maximum 5 mg single dose), may repeat hourly 7
• Insulin for hyperkalemia: 0.1 unit/kg with 400 mg/kg glucose (ratio 1:4) 5

Critical Safety Monitoring During Administration

Hemodynamic Monitoring

• Assess blood pressure approximately 2 hours before each dose - if below target, administer 250-500 mL NS or LR bolus over 30-60 minutes 5
• Monitor for hypotension, particularly with beta-blockers, calcium channel blockers, and rapid opioid administration 1, 2
• Consider intra-arterial monitoring for vasodilators like sodium nitroprusside 1

Respiratory Monitoring

• Maintain oxygen saturation >92% - permanently discontinue medications if supplemental oxygen required at time of next dose 5
• Monitor for chest wall rigidity with rapid opioid administration 2
• Assess for pulmonary edema or pleural effusions with serial physical exams 5

Cardiac Monitoring

• Monitor for QT prolongation and arrhythmias, especially with repeated haloperidol doses >7.5 mg/day 7
• Assess for bradycardia with beta-blockers and calcium channel blockers 1
• Check telemetry for sustained tachycardia >130 bpm for >1 hour 5

Common Pitfalls and Prevention Strategies

Dosing Errors

• The most common error is administering bolus doses faster than recommended, occurring more frequently during morning medication rounds at 8:00 AM 4
• Wrong drug selection has been documented - implement double-check procedures before administration 4
• Calculation errors are frequent - verify all weight-based dosing independently 3

Dose Adjustments for Special Populations

• Reduce doses by 50% in elderly patients and those with renal impairment (CrCl <50 mL/min for most medications) 5, 1
• Start with lower doses in hepatic impairment and titrate slowly while monitoring for adverse effects 2
• Avoid bolus administration in post-cardiac transplant patients without dose reduction 1

Infusion Rate Escalation

• If a patient requires 2 bolus doses within 1 hour, double the continuous infusion rate for opioids and sedatives 1
• This prevents repeated bolusing and provides more stable drug levels 1

Contraindications to Bolus Administration

Absolute Contraindications

• Never administer boluses in patients with drug-specific contraindications: beta-blockers in acute asthma, calcium channel blockers in decompensated heart failure, opioids in respiratory depression without resuscitative equipment 1, 2
• Avoid rapid bolus in patients with cardiovascular instability unless specifically indicated 2

Relative Contraindications Requiring Caution

• Chronic obstructive pulmonary disease or cor pulmonale for opioids 2
• Complete heart block for calcium channel blockers 1
• Increased intracranial pressure for ketamine 5