Maximum Dose of Nicardipine Drip
The maximum dose of nicardipine IV infusion is 15 mg/hr, which is an absolute ceiling regardless of clinical scenario. 1, 2, 3
Standard Dosing Protocol
Start nicardipine at 5 mg/hr IV infusion and titrate by increasing 2.5 mg/hr every 5-15 minutes until desired blood pressure is achieved, with a maximum dose of 15 mg/hr. 1, 2, 3
The 15 mg/hr maximum is supported by all major guidelines including the American Heart Association and American College of Cardiology, and applies to all adult patients without significant renal impairment. 2, 3
Once goal blood pressure is achieved, reduce to 3 mg/hr as a maintenance dose. 2
Blood Pressure Targets by Clinical Context
The target blood pressure varies significantly by clinical scenario, but the maximum dose remains 15 mg/hr:
For acute ischemic stroke (pre-thrombolytic): Target BP <185/110 mmHg before rtPA administration. 1, 2, 3
For acute ischemic stroke (post-thrombolytic): Maintain BP <180-185 mmHg systolic and <105-110 mmHg diastolic. 1, 2, 3
For general hypertensive emergencies: Aim for 10-15% reduction in blood pressure within the first hour, not exceeding 25% reduction in the first 24 hours. 2, 3
Critical Monitoring Requirements
Monitor blood pressure every 15 minutes during active titration. 2, 3
For post-thrombolytic stroke patients: Check BP every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours. 1, 2, 3
The onset of action is 5-15 minutes, and offset occurs within 30-40 minutes after discontinuation. 2
When Maximum Dose Fails
If blood pressure remains uncontrolled at 15 mg/hr nicardipine:
Consider switching to sodium nitroprusside (0.5 mcg/kg/min IV infusion as initial dose, titrated to desired effect). 1, 3
Alternative option: Labetalol 10-20 mg IV bolus over 1-2 minutes, which may be repeated every 10-20 minutes up to 300 mg maximum. 1, 3
Do not administer rtPA if blood pressure cannot be maintained below 185/110 mmHg at maximum nicardipine dose (15 mg/hr). 1, 3
Common Pitfalls to Avoid
Never exceed 15 mg/hr - this is an absolute maximum with no exceptions in clinical practice. 2, 3
Avoid excessive blood pressure reduction - precipitous drops can cause stroke or organ hypoperfusion, especially in patients with chronic severe hypertension where autoregulation is disturbed. 2, 3
Infuse through a central line or large peripheral vein to minimize risk of phlebitis, which can occur after 14+ hours of infusion at a single site. 3, 4
Common side effects include flushing and headache, which are generally mild and related to vasodilation. 2, 5