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LPN IV Series: IV Pharmacology

4 Contact Hours   -   1.00 CCU
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This peer reviewed course is applicable for the following professions:
Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN)
This course will be updated or discontinued on or before Friday, March 21, 2025

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.

This course is 1 of 8 courses on that totals to the 30 contact hours needed to meet the Florida LPN IV Certification requirement. Take a copy of all the certificates of completion to your employer. The employer determines how to teach and confirm your competency in actual practice in starting and administering IV therapy.

≥ 92% of participants will know how to administer IV medications and fluids safely and correctly.


After completing this continuing education course, the participant will be able to:

  1. Identify the types of IV medications that are commonly used.
  2. Summarize complications of IV medication administration.
  3. Evaluate essential principles of IV medication administration.
  4. Analyze adverse effects and warnings for medications covered in this course.
  5. Examine types of electrolytes that, when given IV, are high-alert medications.
  6. Outline the differences between crystalloid IV solutions.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Last Updated:
To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Authors:    Dana Bartlett (RN, BSN, MA, MA, CSPI) , Desiree Reinken (MSN, APRN, NP-C)


Administration of intravenous (IV) medications is a standard therapy. The following will be discussed in this course:

  1. The basic principles of IV medication administration.
  2. Administration of medications that are commonly given IV. The mechanism of action, administration, warnings, and adverse effects are outlined for each type and individual drug. Only drugs that are available as an IV preparation are included.
  3. Medication errors.

With some medication categories, there are so many drugs that a complete discussion of each one is impractical. In those instances, the discussion will be limited to issues common to all the drugs of that class.

Case Study

A 48-year-old female with a past medical history of breast cancer is treated with doxorubicin and cyclophosphamide. She has completed two days of treatment.

The nurse is administering a dose, and during the infusion, the patient says that the injection site “looks a little swollen.” The nurse notices what he considers mild swelling and some redness, but the patient is not having pain, and there is an immediate return of blood when he aspirates from the catheter.

The nurse knows that doxorubicin is a vesicant, and infiltration of this drug can cause extravasation and severe tissue damage. Per the healthcare facility’s protocol, he immediately stops the infusion, aspirates from the infusion catheter again, removes the catheter, and elevates the patient’s arm. The provider is contacted, and she recommends applying a cold compress for 20 minutes. A new IV catheter is inserted in the other arm, the doxorubicin and cyclophosphamide are infused, and the infusion is completed without a problem. The patient is instructed to apply a cold compress four times daily for one to two days. The provider decides that further treatment for this incident is not needed.

The next day’s infusion is completed without incident, and the infiltrated IV site looks fine.

However, when the patient comes the day after, the IV insertion site is now swollen, red, and painful. A small blister is immediately adjacent to the site, and some of the skin is blanched. After an examination, the provider makes the diagnosis of extravasation, and a plastic surgeon is consulted.

The primary issues of this case are:

  1. The nurse knew that infiltration of a chemotherapy drug could cause extravasation and severe tissue damage (Brock & Cruz-Carreras, 2020; Masood et al., 2022; Chinn & Colella, 2017).
  2. There is no universal and clinically validated treatment for extravasation (Cho et al., 2019). Still, every healthcare facility has (or should have) a protocol for immediate treatment of extravasation, and nurses should know it. In this case, the nurse knew the protocol, and he was able to provide immediate care.
  3. Extravasation may or may not cause pain, aspiration of blood from an IV catheter can occur even if there is an infiltration, and the effects of extravasation can be delayed (Pfizer, 2011; Ehmke, 2021).

Basics of IV Medication Administration

The Purpose of IV Administration

Accessing a patient’s vascular space with an IV catheter is done for two primary purposes:

  1. delivering fluids and
  2. administering medications

Accessing the vascular space with an IV catheter and IV drug/fluid administration are invasive procedures requiring sterile technique.

There are many specific reasons why IV fluid and/or drug administration is needed (Gomella & Haist, 2022; Tomlin, 2018).

  • The patient does not have a functioning gastrointestinal (GI tract), and maintenance fluid is needed.
  • A planned or recently performed procedure contradicts oral intake. Pre- and post-operative patients cannot have anything by mouth (NPO) and need maintenance fluids.
  • Fluid resuscitation: The patient has lost a significant amount of total body fluid from bleeding, diarrhea, vomiting, or poor intake. IV administration is also used when these conditions are likely to continue.
  • Providing energy to someone who cannot eat.
  • Correcting an acid-base or electrolyte disorder.
  • Oral intake is not possible or safe; the patient may be unconscious or at risk of aspiration.
  • The rapid absorption of a drug is needed, e.g., IV administration of 50% dextrose if a patient’s blood glucose is dangerously low.
  • IV medications are absorbed more quickly and rapidly; this is important in many situations (Lenz et al., 2017).
  • There is no oral preparation of a needed drug, or the required drug is not absorbed through the gut.

Peripheral and Central IV Lines

IV fluids and medications can be administered through a peripheral or central line catheter (Manrique-Rodríguez et al., 2022). A central line catheter is an IV catheter placed in a large, non-peripheral vein like the subclavian or through a peripheral IV, and the tip of a central line catheter is (usually) in the vena cava. Peripheral IV lines are associated with fewer complications than central IV lines and are easier to place. However, a central IV line is often necessary and sometimes essential for giving certain medications such as vasopressors, chemotherapy drugs, long-term parenteral nutrition, dialysis, or when rapid administration of large volumes of fluid is needed (Tian et al., 2020; Pérez Fidalgo et al., 2021; McConville & Patel, 2015).

Body Fluid, Electrolytes, and Fluid Balance

Understanding basic concepts of body fluids, electrolytes, and fluid balance is necessary to administer IV fluids and medications competently and safely.

Body fluid is divided into body water and blood (Gomella & Haist, 2022; Tomlin, 2018). Total body water (TBW) differs depending on age, gender, and body composition (Gomella & Haist, 2022).

Body water is divided into intracellular and extracellular. Extracellular fluid (ECF) is comprised of plasma (the fluid part of the blood), interstitial fluid (the fluid that is in the tissues, commonly called the third space), and lymph. Intracellular fluid (ICF) is the fluid contained in the cells. These two compartments are separate, but body water and electrolytes can and often move between the ECF and ICF (Tomlin, 2018).

Body water contains many electrolytes. An electrolyte is a compound dissolved in water and has a negative or positive charge. We get electrolytes from the foods and fluids we consume. Important physiologic functions like cardiac and muscle contraction and the formation and transmission of nerve impulses depend on electrolytes like calcium, magnesium, potassium, and sodium. Homeostatic mechanisms tightly control the levels of these electrolytes. The vital body processes that use electrolytes cannot function normally if the blood level of an electrolyte is too low or too high.

Fluid balance depends on fluid intake and fluid loss. Average fluid intake depends on many factors, and a normal fluid intake is 2500 mL/day from fluids and the water in food (Gomella & Haist, 2022).

Fluid loss comes from urine output, loss of fluid in feces, and insensible losses of water from the skin and breathing (Gomella & Haist, 2022). A high ambient temperature, physical activity, or fever can increase fluid loss. For example, every 1-degree increase in body temperature over 98.6°F increases insensible fluid loss by 2.5 mL/kg/day (Gomella & Haist, 2022).

A normal level of body fluid is essential. For example, a normal body fluid level is necessary to fill the vascular space, maintain blood pressure, and perfuse the brain, heart, and kidneys. Hypovolemia, a significant loss of blood volume, can occur when there is a loss of blood or body fluid and/or poor intake. A patient can become dehydrated when fluid loss exceeds fluid intake (Tomlin, 2018). Signs and symptoms of dehydration include decreased urine output, changes in the level of consciousness, dizziness, dry mucous membranes, hypotension, orthostatic hypotension, and tachycardia (Tomlin, 2018).

Electrolyte disorders can also be caused by poor intake and fluid loss. Persistent diarrhea and vomiting are common causes of electrolyte and fluid loss (Gomella & Haist, 2022).

IV fluids are given to correct fluid and/or electrolyte loss and to provide energy. Knowing the average fluid, electrolyte, and energy needs help to understand why specific IV solutions are prescribed. It is important to remember that the fluid requirement listed here is the maintenance IV fluid amount. Maintenance IV fluid is the amount that provides a patient with water, electrolytes, and energy when that patient cannot take oral fluids and food (Sterns, 2021). Maintenance fluid is different from replacement fluid; replacement fluid therapy corrects a problem, and maintenance fluid therapy prevents problems.

Maintenance fluid, electrolyte, and energy requirements include:

  • Fluid: Afebrile, 70 kg adult: 35 mL/kg/24 hours
  • Sodium: 80 to 120 mEq/day
  • Potassium: 50 to 100 mEq/day
  • Chloride: 80 to 120 mEq/day
  • Glucose: 100 to 200 g/day
  • Other electrolytes like calcium and magnesium are not given unless the patient has a deficit (Gomella & Haist, 2022)

IV Fluids

Standard IV fluids are colloids or crystalloids; colloids will be described but not discussed, as most IV fluid administration involves crystalloids.

Colloids are products like albumin that generate a high osmotic pressure that helps keep fluid in the intravascular space (Gomella & Haist, 2022).

Crystalloids are IV fluids like 5% dextrose in water and 0.9% normal saline that have a compound (dextrose, saline) dissolved in the fluid. The crystalloids are all used as a source of fluid and can also be a source of energy and electrolytes. Table 1 lists some of the commonly used crystalloids. The primary differences between crystalloid solutions are:

  1. the energy they provide and
  2. their electrolyte composition
Table 1: Crystalloids and their Contents
Crystalloid SolutionContents

5% dextrose in water

50 grams glucose/1000 mL, no electrolytes, 170 calories/liter

0.9% sodium chloride154 mEq/L of sodium, 154 mEq/L of chloride
5% dextrose and 0.45% NaCl, aka D5 ½ normal saline50 grams of glucose/L, 77 mEq/L of sodium and chloride, 170 calories/liter
Lactated Ringers130 mEq/L of sodium, 110 mEq/L of chloride, 4 mEq/L of potassium, 3 mEq/L magnesium, 27 mEq/L of HCO3
3% normal saline513 mEq/L sodium, 513 mEq/L of chloride

Crystalloid IV solutions have different compositions, which is important regarding the electrolytes and energy each provides. The composition of a crystalloid can also affect where the body fluid is and the electrolyte composition of a body fluid, which is due to a process called osmosis.

The ECF and the ICF each have specific concentrations of electrolytes. These concentrations are maintained by active processes and by the passive process of osmosis. Osmosis is the movement of molecules (in this case, electrolytes) from a less concentrated solution to a more concentrated one to maintain normal balance. For example, suppose the concentration of sodium in the ECF and/or the ICF is not at the correct level. In that case, sodium will passively move in one direction to regain and maintain the proper concentrations. The electrolytes and the glucose in a crystalloid each have a specific osmotic value. For example, 0.9% normal saline has an osmotic value of 308 mOsmol/liter, and 0.45% normal saline has an osmotic value of 154 mOsmol/liter. Depending on what is in the crystalloid, they are one of these three types:

  1. Isotonic: Isotonic crystalloids have the same electrolyte balance as plasma, so the administration of an isotonic crystalloid will increase plasma volume, but it will not cause electrolytes to move/shift. Lactated ringers and 0.9% normal saline are isotonic, which would be used to treat a patient who was hypotensive because of fluid loss.
  2. Hypotonic: Hypotonic crystalloids have a lower concentration of electrolytes than plasma. The administration of a hypotonic crystalloid will cause fluid to move out of the vascular space and into the ICF and the interstitial space. 0.45% normal saline is a hypotonic crystalloid, and it is used to help fluid move into the ICF.
  3. Hypertonic: Hypertonic crystalloids have a higher concentration of electrolytes than plasma. 3.3% normal saline is a hypertonic crystalloid often used to treat acute hyponatremia (Mount, 2022).

Prescribing and Using IV Fluids

IV fluids are prescribed based on the patient's needs, the clinical condition that needs to be treated, and any pre-existing medical conditions like renal impairment that affect fluid balance. The most common uses of IV fluids are to provide fluids, energy, and electrolytes to patients who cannot take oral intake, administer IV medications, and correct volume depletion or acid-base disorders (Gomella & Haist, 2022).

After the IV fluid and rate of administration have been chosen, nurses are responsible for observing and monitoring the patient for adverse effects and the response to IV therapy.


Nurses must know and be able to identify the complications of IV medication administration.

Common complications of IV medication administration are infiltration, occlusion, phlebitis, infection, thrombus, and extravasation (Goel et al., 2020; Marsh et al., 2021).

Infiltration occurs when the IV catheter dislodges from the vein, and IV fluid infuses into the surrounding tissue. Signs and symptoms of infiltration include swelling in/around the area. Infiltration usually does not cause significant pain, but infiltration of certain medications, like chemotherapy drugs, can cause severe tissue damage (Brock & Cruz-Carreras, 2020; Masood et al., 2022).

Occlusion is simply a blockage somewhere in the IV system.

Phlebitis is an inflammation of the blood vessel. Common signs of phlebitis are pain, redness, and swelling at the catheter site.

Infection is also characterized by pain, redness, and swelling at the catheter site. Inserting a peripheral IV catheter is a simple procedure, but it is invasive, so there is a risk of infection.

A thrombus is a blood clot, and like infection and phlebitis, there can be pain, redness, and swelling at the catheter site.

Extravasation is the same as an infiltration; the IV catheter has dislodged from the vein, and IV fluid is moving into the tissue. The difference between them is the type of IV fluid and the consequences (Hadaway, 2007). Extravasation occurs when the IV medication is very irritating or it is a vesicant (Hadaway, 2007). A vesicant is a drug that can cause blistering, tissue damage, and/or necrosis. Chemotherapy drugs, IV contrast media, 50% dextrose, TPN, and vasopressors can be vesicants (Cho et al., 2019; Brock & Cruz- Carreras, 2020; Lawson et al., 2013; Masood et al., 2022; Shrestha et al., 2020).

Extravasation causes irritation, pain, and swelling. It can also cause compartment syndrome, severe tissue damage, and tissue necrosis (Chinn & Colella, 2017; Brock & Cruz-Carreras, 2020; Masood et al., 2022). Extravasation can cause delayed complications and may take 14 to 55 days to be resolved (Ehmke, 2021; Pluschnig et al., 2015).

Extravasation can happen with peripheral and central IV lines (Ehmke, 2021). Every healthcare facility should have a policy/procedure for managing extravasation. Specific treatments include fasciotomy for compartment syndrome, hyaluronidase, supportive treatments like the application of cold or heat, aspirating fluid from the IV line, splinting, and elevation of the affected limb (Mandlik et al., 2019; Thomas et al., 2022). However, currently, there is little evidence for the effectiveness of any extravasation treatment, and the appropriate protocol for preventing damage has not been identified (Cho et al., 2019).

Air embolism is a rare complication of IV medication administration. An air embolism happens when a large amount of air enters the IV system and moves through the circulation into the lungs (Abramson et al., 2020; Khaliq et al., 2018). Air embolisms usually happen if the patient has a central venous catheter, but they can happen with a peripheral IV line (Abramson et al., 2020). Signs and symptoms of an air embolism include (but are not limited to) chest pain, cough, and shortness of breath. An air embolism is a medical emergency, and fatalities do occur.

Principles of IV Medication Administration

Monitoring for complications: The IV catheter site should be inspected at least once a shift or at the frequency the healthcare facility/organization recommends (Webster et al., 2019). If the medication is not infusing correctly, or the patient has signs/symptoms of an air embolism or extravasation, a supervisor should be notified immediately.

Every healthcare facility/organization has policies and procedures for preventing and treating complications like changing the catheter at specific intervals or, if there are signs of complications like occlusion or extravasation, stopping the infusion and removing the IV catheter. Every situation is different, and nurses should know what to do if a complication occurs so that the right actions/treatments can be done without hesitation.

Monitoring: Observe for adverse effects, check the clinical response to the dose, adjust this if needed, and measure drug levels when necessary.

Intravenous medications are associated with the highest medication error frequencies and more serious consequences to the patient than any other administration route (Kuitunen et al., 2021). The error rate is not surprising; administering IV medications is a multi-step, complicated task. Some of the important issues of IV medication administration are:

  • Infusion speed: Unlike oral medications, IV medications must be given over a specific time, and administering an IV drug too fast or slow can be dangerous and change its effectiveness (ISMP, 2015; Khakurel & Rawal, 2021; UpToDate, 2022j). For example, a dose of the antibiotic vancomycin should be given over at least 60 minutes, with a recommended infusion period of ≥30 minutes for every 500 mg administered (UpToDate, 2022j). Exceeding this rate of administration can cause dizziness, hypotension, and even cardiac arrest (Khakurel & Rawal, 2021; UpToDate, 2022j).
  • Sterile technique: IV administration is an invasive technique, so sterile technique and safe injection practices must always be used (CDC, 2019; ISMP, 2015).
  • Drug-drug compatibility: The patient may have only one IV line, and some drugs are not compatible when infused through the same IV line. A drug-drug incompatibility can decrease the effectiveness of the medications, inactivate the drugs, and cause serious harm (Négrier et al., 2021; Sriram et al., 2020). Pharmacists check to see if medications can be infused through a single IV catheter, but it is sensible to confirm compatibility/incompatibility.
  • Timing: All medications should be given at the right time to maintain a therapeutic blood level. Also, for some drugs like IV vancomycin, dosing adjustments are made by measuring the drug's blood level at a specific time (Sault et al., 2022).
  • Air: Ensuring there is no air in an IV line is essential to prevent adverse effects.


Administering supplementary magnesium to correct hypomagnesemia and supplementary potassium to treat hypokalemia is a common procedure, and in some cases, they need to be given IV.

Potassium Chloride

Potassium is the primary intracellular electrolyte, essential for muscle contraction, the transmission of nerve impulses, and other physiologic functions. Hypokalemia is defined as serum potassium < 3.5 mEq/L. Hypokalemia is a common disorder caused by drugs, poor intake, or excessive potassium loss through the kidneys (Lewis III, 2022a). Signs and symptoms of hypokalemia include (but are not limited to) arrhythmias, ECG changes, hypotension, muscle weakness, and in some cases, paralysis (Lewis III, 2022a). Serious signs and symptoms of hypokalemia usually occur when the serum potassium is < 3.0 mEq/L (Lewis III, 2022a).

IV potassium is typically given if the patient cannot take oral potassium, if oral potassium supplementation has not been successful, or if the patient has symptomatic hypokalemia (Lewis III, 2022a). If the serum potassium is > 3.0 mEq/L oral supplementation is recommended (Lewis, 2022). The IV route is preferred at lower potassium concentrations or in urgent situations.

Potassium chloride is the form that is commonly used for IV administration; the information provided here applies to that form of potassium.

Administration: IV potassium must be administered cautiously; it is a high-alert medication, which is a drug that has a heightened risk of causing significant harm when they are used in error (ISMP, 2018). IV potassium administered incorrectly, especially when given too fast, can cause arrhythmias and cardiac arrest (Nakatani et al., 2019; Sur & Mohiuddin, 2022). Protocols for IV administration of potassium will differ between healthcare facilities, but authoritative sources agree on the following recommendations (Lewis III, 2022a; Lewis, 2022; Mount, 2018; Sur & Mohiuddin, 2022):

  • The patient should be on continuous cardiac monitoring.
  • IV potassium must be diluted. Undiluted potassium can cause dangerous adverse effects, and it is very irritating to the vein and is a vesicant, so extravasation can occur (Yan, 2021).
  • The serum potassium should be measured during the infusion.
  • The infusion rate depends on the patient’s serum potassium. If the serum potassium is 2.5 mEq/L to 3.0 mEq/L, the maximum rate should be 10 mEq/L/hour, the maximum concentration of the solution should be 40 mEq/L, and the 24-hour maximum dose should be 200 mEq. If the serum potassium is < 2.5 mEq/L, the maximum infusion rate is 40 mEq/hour, the maximum concentration of the solution is 80 mEq/L, and the 24-hour maximum dose is 400 mEq.

During the infusion, the patient should be monitored for signs and symptoms of hyperkalemia (serum potassium > 5.5 mEq/L), including arrhythmias, bradycardia, hypotension, ECG changes, and ascending paralysis (Mount, 2018; Sur & Mohiuddin, 2022).


Magnesium is an essential electrolyte involved in the functioning of cells, muscle contraction, nerve conduction, and other physiological processes. Hypomagnesemia, defined as serum magnesium < 1.8 mg/dL, is very common, especially in hospitalized patients (Cheungpasitporn et al., 2020; Lewis III, 2022b).

Signs and symptoms of hypomagnesemia include anorexia, arrhythmias, nausea, vomiting, tremors, weakness, hypocalcemia, and hypokalemia (Papadakis & McPhee, 2023b; Lewis III, 2022b).

Hypomagnesemia is caused by decreased absorption or intake, such as with alcohol use disorder, diarrhea, thyroid disease, or increased excretion by the kidneys because of a diuretic or other drugs (Papadakis & McPhee, 2023b).

IV magnesium is given to treat hypomagnesemia, treat arrhythmias caused by hypomagnesemia, and prevent seizures in patients with preeclampsia/eclampsia. IV magnesium sulfate is preferred to an oral preparation if the serum magnesium is < 1.25 mg/dL (Lewis III 2022b).

Administration: The dose and infusion rate depend on the serum magnesium level and the patient’s clinical condition (Coralic, 2022). There are differing dose and infusion time recommendations.

For an asymptomatic or mildly symptomatic patient, 1 to 2 grams mixed with 5% dextrose or 0.9% normal saline can be infused in over 5 to 60 minutes (Papadakis & McPhee, 2023b). If the patient is significantly symptomatic and/or has Torsades de Pointes (TDP), 1 to 2 grams diluted with 10 mL of 5% dextrose can be infused in over 15 minutes (Papadakis & McPhee, 2023b).

Adverse effects of IV magnesium include bradycardia, hypotension, hypothermia, flushing, flaccid paralysis, respiratory paralysis, and sweating (Coralic, 2022). Cardiac complications are rate-related, and rapid administration can cause circulatory collapse. IV magnesium has been identified as a high-alert medication (ISMP, 2018).


Antibiotics are a diverse group of medications used to fight bacterial infections.

The two basic classes of antibiotics are:

  1. bacteriostatic and
  2. bacteriocide (Levinson et al., 2022)

Bacteriostatics slow bacterial growth and bacteriocides kill bacteria (Levinson et al., 2022).

Antibiotics work in many ways, but their primary mechanism of action is to disrupt vital functions and processes like cell wall synthesis that bacteria need to multiply and survive (MacDougall, 2023). Depending on the drug, this can slow bacterial growth (bacteriostatic) or kill the bacteria (bacteriocide).

There are three primary ways that antibiotics are used (MacDougall, 2023):

  • Prophylactic: Antibiotics can be given to prevent infection, e.g., giving an antibiotic pre-operatively to prevent a surgical incision infection or before an invasive procedure (MacDougall, 2023).
  • Empiric: Empirical antibiotic therapy is used when a patient has an infection, is very ill, or may become very sick, but the causative bacteria has not yet been identified (MacDougall, 2023). Ideally, antibiotics are prescribed to treat a specific type of bacteria and/or for a bacterium susceptible to the antibiotic (MacDougall, 2023). However, identifying the bacteria and determining what it is susceptible to – the process called culture and sensitivity – takes 24 to 48 hours. The patient cannot wait, so a clinician will prescribe an antibiotic based on the type of infection, e.g., community-acquired pneumonia, and the type of antibiotics known to be effective against that infection (MacDougall, 2023). When the culture and sensitivity are complete, a different antibiotic can be prescribed if necessary.
  • Definitive: When the culture and sensitivity results are known, the empirical treatment can be changed, if needed, to a different antibiotic (MacDougall, 2023).

Antibiotic Categories

Antibiotics are categorized by chemical and pharmacologic properties. Antibiotics in the same category are likely effective against the same types of bacteria (Falagas & Bliziotis, 2017). 

Categories of antibiotics, with examples of specific drugs, are listed in Table 2 (Calhoun et al., 2022; Falagas & Bliziotis, 2017).

Table 2: IV Antibiotics
  • gentamicin
  • tobramycin
  • carbapenems
  • cephalosporins
  • penicillin
  • ciprofloxacin
  • levofloxacin
  • vancomycin
  • tigecycline
  • clindamycin
  • lincomycin
  • daptomycin
  • azithromycin
  • erythromycin
  • metronidazole
  • linezolid
  • tedizolid
Sulfonamide derivatives
  • sulfamethoxazole/trimethoprim
  • doxycycline
  • minocycline

Safety, Adverse Reactions, and Allergic Reactions

IV antibiotics should be administered using sterile technique, safe injection practices, and the basic principles of safe medication administration: The right drug, right dose, right route, right time, and to the right patient. An IV antibiotic must be infused at the correct speed.

Common adverse reactions for each of the antibiotic classes are listed below.

  • Aminoglycosides: Hearing loss can happen in > 60% of patients taking an aminoglycoside; it usually happens with high doses and chronic use (Steyger, 2021).
  • Beta-lactams: Beta-lactams like penicillin are safe (Roger & Louart, 2021). However, they can cause neurological adverse effects like confusion, hallucinations, and seizures (Roger & Louart, 2021).
  • Fluoroquinolones: Neurologic pathologies like peripheral neuropathy are common adverse effects of fluoroquinolones (Huruba et al., 2022; Etminan et al., 2014). Fluoroquinolone can also cause arrhythmias and tendon ruptures; these are less common.
  • Glycopeptides: Infusing vancomycin too quickly can cause dizziness, hypotension, and even cardiac arrest (Khakurel, S. & Rawal, 2021; UpToDate, 2022j). Vancomycin can also cause acute kidney damage (Kan et al., 2022).
  • Glycylcyclines: Diarrhea, nausea, and vomiting are common adverse effects of tigecycline (UpToDate, 2022i).
  • Lincosamides: GI adverse effects are common with clindamycin. IV clindamycin can cause Clostridium difficile (C. difficile) infection, a potentially dangerous and easily transmissible GI tract infection that causes abdominal pain, fever, and watery diarrhea (Duffy et al., 2020).
  • Lipopeptides: The most common adverse effect of daptomycin is diarrhea (Merck & Dohme Corporation, 2021). Daptomycin can also cause muscle pain and rhabdomyolysis, especially if the patient takes a statin (Chuma et al., 2022).
  • Macrolides: GI distress, such as diarrhea, is a common adverse effect of the macrolides. Macrolide antibiotics can also cause arrhythmias and hearing loss (Rybak et al., 2019; Teng et al., 2019).
  • Nitroimidazoles: Common adverse effects of metronidazole are diarrhea and headache. Metronidazole can cause serious neurological complications like encephalopathy and seizures, but these are rare (Rybak et al., 2022).
  • Oxazolidinones: Linezolid and tedizolid can cause adverse GI effects, anemia, a low white blood cell count, and peripheral neuropathy (Kato et al., 2021; Poon et al., 2021).
  • Sulfonamide derivatives: Sulfamethoxazole and trimethoprim are usually used together; trimethoprim is used alone as an IV solution. IV trimethoprim can cause rash and liver damage, but these appear uncommon (Cao et al., 2021).
  • Tetracyclines: Like all antibiotics, tetracyclines can cause GI distress (Shutter & Akhondi, 2022). They can also cause a photosensitivity skin reaction that resembles sunburn with erythema, redness, and pain (Odorici et al., 2021).


Given the wide range of antibiotics and the clinical conditions they treat, no single monitoring parameter could/would be used for all. Specific drugs require specific monitoring, and several examples are provided.

For aminoglycosides, measuring blood levels to determine an appropriate dose and prevent complications is frequently recommended, and patients should be monitored for hearing impairments.

Macrolide antibiotics put patients at risk for QT prolongation and TDP, so an assessment of a patient’s cardiac status should be performed. Drug-drug interactions that may cause QT prolongation and/or TDP should be evaluated, and a 12-lead ECG should be done before starting and during treatment with a macrolide (Al-Jazairi & Alotaibi, 2020).

For lincosamides, observe the patient for persistent and/or severe GI distress, as this may be a sign of C. difficile infection.

Recognizing the signs and symptoms of an allergic reaction and knowing what to do if an allergic reaction occurs is essential.

Penicillin allergy is one of the most common drug allergies, but most allergic reactions to penicillin are mild (Castells et al., 2019). Serious allergic reactions that can be fatal - an anaphylactic reaction - occur, but fortunately, these are rare (Castells et al., 2019; Har & Solensky, 2017). Also, cross-reactivity can occur. For example, approximately 2% of patients allergic to penicillin are also allergic to cephalosporins (Shenoy et al., 2019).

The signs and symptoms of an allergic reaction include flushing, pruritus (itching), rash, and urticaria (hives); an anaphylactic reaction has these same signs and symptoms but also difficulty breathing, hypotension, and wheezing (Castells et al., 2019; Hong and Boyce, 2022).

Allergic reactions can occur within minutes of administering a drug (Hong & Boyce, 2022). If the patient is or may be having an allergic reaction, stop the infusion immediately and notify a supervisor or a physician.


Anticoagulants treat or prevent thrombi and pulmonary embolisms (PE). The goal of anticoagulation therapy is to promote anticoagulation while minimizing hemorrhagic issues.

The most used anticoagulants are:

  1. direct-acting oral anticoagulants, including apixaban, dabigatran, edoxaban, and rivaroxaban,
  2. heparin,
  3. Low-molecular-weight dalteparin, enoxaparin and heparins, and
  4. warfarin (commonly called coumadin).

These drugs prevent clots and emboli by affecting the clotting process, each in different ways. Heparin is given IV and subcutaneously (SC); the others are given orally or SC. The low-molecular-weight heparins can be given IV, but only for a patient that is having an acute myocardial infarction.


Heparin prevents and treats venous thromboembolism (VTE) and PE by interrupting the clotting process, specifically by irreversibly inactivating thrombin, factor Xa, and other clotting factors (Katzung et al., Chapter 34, 2021g). The onset of anticoagulation caused by heparin is immediate (Katzung et al., Chapter 34, 2021g). In most cases, an oral anticoagulant will be given until the therapeutic effect of the drug is established, e.g., two days for warfarin. Then the IV heparin infusion will be stopped.

  • Indications for IV heparin: The primary indication for IV heparin is preventing and treating VTE and PE.
  • Dose: Heparin is dosed in units, not milligrams or grams. The dose is weight-based and depends on why the drug is being used. For example, for treating VTE or PE, a bolus dose is given, and then 18 units/kilogram/hour is infused (UpToDate, 2022e).
  • Adjusting the dose: The heparin dose is adjusted by measuring and monitoring coagulation tests like the activated partial thromboplastin time (aPTT). Other tests that can be used are the anti-factor Xa and activated clotting time (UpToDate, 2022e).
  • Monitoring: Heparin makes the blood less likely to clot, so the patient should be closely monitored for signs and symptoms of bleeding. A complete blood count (CBC), platelet count, and prothrombin time (PT) should be measured periodically (UpToDate, 2022e).

The most significant adverse effect of IV heparin is bleeding. Drug information sources mention other adverse effects like liver damage, hyperkalemia, or heparin-induced thrombocytopenia (HIT), but these adverse effects are very uncommon (Hogan & Berger, 2020; Livertox, 2017; UpToDate, 2022e).

The Institute for Safe Medication Practices (ISMP) considers anticoagulants to be high-alert medications that can cause significant harm if given incorrectly. The Joint Commission requires healthcare facilities to have approved protocols and evidence-based guidelines for using anticoagulants (ISMP, 2018; UpToDate, 2022e). Anticoagulants, including heparin, can cause serious harm if given incorrectly, and medication errors involving heparin, such as incorrect doses, are common (El-Bosily et al., 2022).

Administering IV heparin safely requires nurses to:

  1. Carefully check the dose (there are several IV heparin solution concentrations, e.g., 25,000 units/500 mL) and the infusion rate.
  2. Closely monitor the patient for signs and symptoms of bleeding.
  3. Make sure that laboratory tests that adjust the heparin dose and monitor for the presence of bleeding are done. Check the results of these tests before starting an IV heparin infusion and changing the infusion rate.
  4. Intramuscular (IM) injections are not recommended. Follow the healthcare facility’s protocols for giving SQ injections.


Anticonvulsants are used to control seizure activity and prevent seizures. Anticonvulsants are given IV to control acute seizures, and they are given orally to prevent seizures. The mechanism of action of each anticonvulsant is specific to the drug. Still, anticonvulsants work primarily by preventing the epileptic cells in the brain from depolarizing and initiating a seizure (Katzung et al., Chapter 24, 2021d).

Anticonvulsants available as an IV preparation are listed in Table 3.

Table 3: Anticonvulsants
Generic NameBrand Name
PhenobarbitalGeneric only
Valproic acidDepakote®

There are a few adverse effects that are common to all IV anticonvulsants, such as central nervous system (CNS) depression. Administration issues and adverse effects of individual anticonvulsants are described next; administration issues and adverse effects common to all the anticonvulsants will be discussed later.

Lacosamide: Lacosamide should be infused over 30 to 60 minutes, but if needed, a 15-minute infusion duration is acceptable (UCB Pharmaceuticals, 2022b). A diluted preparation of lacosamide should not be stored at room temperature for > 4 hours. Common adverse effects are dizziness, headache, nausea, and somnolence (UCB Pharmaceuticals, 2022b). IV lacosamide can cause bradycardia, ECG changes, and arrhythmias. If the patient has a cardiac condition, an ECG should be done before starting therapy and when the maintenance dose has been established (UCB Pharmaceuticals, 2022b).

Levetiracetam: Levetiracetam should be infused in over 15 minutes (UCB Pharmaceuticals, 2022a). A diluted solution of levetiracetam should be stored at room temperature and be used within 4 hours (UCB Pharmaceuticals, 2022a). Common adverse effects of levetiracetam include asthenia (lack of energy, weakness), hypertension, behavioral abnormalities such as aggression, psychotic signs/symptoms, and abnormal blood counts (UCB Pharmaceuticals, 2022a).

Phenobarbital: IV phenobarbital can cause hypotension and respiratory depression (Doshi et al., 2019; Pugin et al., 2014; Hocker et al., 2018).

Phenytoin: Hypotension, arrhythmias, and other adverse cardiac effects can happen if IV phenytoin is given faster than the recommended infusion rate (Guldiken et al., 2014; Smollin, 2018; UpToDate, 2022h). Use a slower infusion rate that is less than the maximum 50 mg/minute for elderly patients or those who have a cardiac condition, and closely monitor their blood pressure and heart rate (Guldiken et al., 2014; UpToDate, 2022h). Neurological adverse effects of phenytoin include mild CNS depression, fatigue, and nystagmus (Farrokh et al., 2018). If the serum level is abnormally high, ataxia, incoordination, slurred speech, and seizures can occur (Farrokh et al., 2018; Smollin, 2018). A diluted solution should be used within 4 hours.

Extravasation of IV phenytoin can cause purple glove syndrome (Perez Del Nogal et al., 2022; Garbovsky et al., 2015). Purple glove syndrome is characterized by edema, pain, discolored skin, and in severe cases, compartment syndrome, tissue ischemia, and necrosis (Perez Del Nogal et al., 2022; Garbovsky et al., 2015). Purple glove syndrome can happen with the first infusion of phenytoin and can occur without extravasation (Garbovsky et al., 2015; Perez Del Nogal et al., 2022). If extravasation with phenytoin happens, the IV infusion should be stopped immediately (Garbovsky et al., 2015; UpToDate, 2022h).

Valproic acid: IV valproic should be infused over 60 minutes. The prescribing information for valproic acid has a black box warning: “Hepatic failure resulting in fatalities has occurred in patients receiving valproate. These incidents usually occur during the first six months of treatment. Serious or fatal hepatotoxicity may be preceded by nonspecific symptoms such as malaise, weakness, lethargy, facial edema, anorexia, and vomiting.” (UpToDate, 2022g). A black box warning means that a drug can cause a severe adverse effect, and nurses should be aware of this adverse effect (Livertox, 2020b). A high serum ammonia level is one of the causes of liver damage from valproic acid, and ammonia levels should be periodically measured (Livertox, 2020b). Drowsiness and thrombocytopenia are common adverse effects of valproic acid (Buoli et al., 2018; Duman et al., 2019).

Administration issues and adverse effects of anticonvulsants include:

  • Blood levels: Blood levels of phenobarbital, phenytoin, and valproic acid are periodically measured, and the dose will be adjusted depending on the level (Kanner & Bicchi, 2022). For these drugs, nurses should know subtherapeutic and toxicity levels. Blood levels of levetiracetam can be done, and they may be useful, depending on the patient and the situation (Sourbron et al. 2018). Blood levels of all the anticonvulsants can be measured to determine the correct dose or if a low or a high blood level is causing an adverse effect, to see how a dose change affects the level, and to make sure that the dose is appropriate for a specific age group of patients, such as children and the elderly, or for people who have medical conditions like hepatic and/or renal impairment (Patsalos et al., 2018; Sourbron et al., 2018).
  • Suicide: Anticonvulsant use has been associated with an increased risk for suicide, which is mentioned in the prescribing information for these drugs (Mula, 2022).
  • Rate of infusion: Adverse effects can occur if an IV anticonvulsant is administered too quickly.
  • Withdrawal seizures: Anticonvulsants must be slowly tapered to prevent withdrawal seizures (Gloss et al., 2021; Loro et al., 2022).


Hypertension is a common disease that can cause serious complications like kidney damage, myocardial infarction, and stroke (Hall et al., 2022).

Antihypertensive medications treat elevations of systolic blood pressure, diastolic blood pressure, or both. Categories of the antihypertensives and available IV preparations are listed in Table 4. The only IV centrally acting alpha2 antagonist, dexmedetomidine, is not used to treat hypertension. IV nitroglycerin can be used to treat hypertension; it is discussed in the section on antianginals.

Table 4: IV Antihypertensives
Angiotensin-converting enzyme (ACE) inhibitors
  • Enalapril (Enalaprilat®)
  • esmolol
  • labetalol
  • propranolol
Calcium channel blockers
  • diltiazem
  • nicardipine
  • nifedipine
Centrally acting alpha1 antagonists
  • phentolamine
Dopamine agonist
  • fenoldopam (Corlopam®)
  • hydralazine
  • nitroprusside

ACE Inhibitors

The ACE inhibitors lower blood pressure by decreasing vasoconstriction.

IV enalapril is used when the patient cannot take oral enalapril and can be used to treat hypertensive emergencies (Pfizer Pharmaceuticals, 2021; Whelton et al., 2018). Hypertensive emergencies will be explained in the section on beta-blockers.

IV enalapril can be delivered undiluted as an IV push dose, infused over at least 5 minutes, or mixed with up to 50 mL of an appropriate diluent and infused over 5 minutes (Pfizer Pharmaceuticals, 2021).

Adverse effects: Adverse effects of IV enalapril are uncommon but include headache, hypotension, and nausea (Pfizer Pharmaceuticals, 2021). Cough is not mentioned in the prescribing information as an adverse effect of IV enalapril, but a cough is a very common adverse effect of ACE inhibitors (Pfizer Pharmaceuticals, 2021); Wilkerson & Winters, 2022).

Angioedema: Angioedema is a rare but potentially fatal adverse effect of ACE inhibitors (Pfizer Pharmaceuticals, 2021). ACE-associated angioedema is characterized by edema and swelling, usually on the face, lips, mouth, and tongue (Wilkerson & Winters, 2022). Swelling of the larynx and throat can cause life-threatening airway obstruction (Wilkerson & Winters, 2022). ACE-associated angioedema can happen soon after starting therapy with the drug but can also begin years later (Wilkerson & Winter, 2022).


The beta-blockers lower blood pressure by decreasing the force of myocardial contraction and/or by vasodilation.

The available IV preparations of the beta-blockers are esmolol, labetalol, metoprolol, propranolol, and sotalol. Oral beta-blockers are used to treat chronic hypertension. IV beta-blockers, specifically esmolol and labetalol, are used to treat a hypertensive emergency or severe asymptomatic hypertension, aka hypertensive urgency (Stanistreet et al., 2018). A hypertensive emergency is elevated blood pressure (> 220 mmHg systolic, 120 mm Hg diastolic), and a serious complication like an MI or pulmonary edema is possible (Sutters, 2023). A patient who is having a hypertensive emergency should be admitted to intensive care (Peixoto, 2019).

Esmolol: Using IV esmolol to treat hypertensive urgency or emergency is an off-label use of the drug, but it is commonly used for these conditions (Sutters, 2023; Whelton et al., 2018).

  1. Administration: During hypertensive urgency or emergency, blood pressure should be lowered slowly, so esmolol should be titrated to reduce the mean arterial blood pressure (MAP) by no more than 20% to 25% in the first 2 hours (Stanistreet et al., 2018; Sutters, 2023). Lowering very elevated blood pressure too fast can decrease blood flow to the brain and/or heart and cause serious harm and death (Peixoto, 2019; Stanistreet et al., 2018). IV esmolol has a very rapid onset of action, so close blood pressure monitoring is crucial. After the first 2 hours, titrate the drug over the next 2 to 6 hours to reach the goal of a systolic blood pressure of 160 mmHg and a diastolic blood pressure of 100 to 110 mmHg (Miller et al., 2020).
  2. Adverse effects: Common adverse effects of IV esmolol are bradycardia, hypotension, and irritation at the injection site. Esmolol is a vesicant, it can cause tissue damage if extravasation happens, and it should not be given through a butterfly needle or a small vein (Baxter HealthCare Corporation, 2000).

Labetalol: Labetalol is approved for treating hypertensive emergencies and is commonly used for this (Peixoto, 2019).

  1. Administration: When using labetalol, blood pressure should be lowered slowly, and the infusion should be titrated to decrease the MAP by no more than 20% to 25% in the first hour (Peixoto, 2019). After the first hour, titrate the drug over the next 2 to 6 hours to reach the goal of a systolic blood pressure of 160 mmHg and a diastolic blood pressure of 100 to 110 mmHg (Miller et al., 2020).
  2. Adverse effects: IV labetalol can cause bradycardia, hypotension, and orthostatic hypotension.

Calcium Channel Blockers

The calcium channel blockers lower blood pressure by decreasing the force of myocardial contraction and by vasodilation. The IV calcium channel blockers are clevidipine, diltiazem, nicardipine, and verapamil; clevidipine and nicardipine are the only two used to treat hypertension or hypertensive emergencies (Whelton et al., 2018; Peixoto, 2019).

Clevidipine: Clevidipine is a first-line drug for treating hypertensive emergencies (Watson et al., 2018). Clevidipine lowers blood pressure by causing peripheral vasodilation.

  1. Administration: Clevidipine has a very rapid onset of action, 2 to 4 minutes, and its hypotensive effects last only 5 to 15 minutes after the infusion is stopped (Chiesi USA INC., n.d.). The infusion rate should be titrated to attain the desired blood pressure level; start with 1 to 2 mg/h and double the infusion rate every 90 seconds until the target blood pressure level is reached (Whelton et al., 2018). Clevidipine can cause hypotension and reflex tachycardia, so blood pressure should be closely monitored.
  2. Adverse effects: Common adverse effects of clevidipine are atrial fibrillation, headache, hypotension, nausea, and reflex tachycardia (Chiesi USA INC., n.d.).

Nicardipine: Nicardipine is one of the preferred drugs for treating hypertensive emergencies (Peixoto, 2019; Whelton et al., 2018). Nicardipine lowers blood pressure by causing peripheral vasodilation and reducing systemic vascular resistance (Baxter Healthcare Corporation, 2004).

  1. Administration: Nicardipine should be given through a central or large peripheral IV line (Baxter Healthcare Corporation, 2004). IV nicardipine has a very rapid onset of action; a decrease in blood pressure will occur within minutes of starting the infusion (Baxter Healthcare Corporation, 2004). The infusion rate should be titrated to attain the desired blood pressure level; start with 5mg/hour and increase every 5 minutes by 2.5 mg/h, maximum dose of 15mg/hour (Whelton et al., 2018).
  2. Adverse effects: Common adverse effects of IV nicardipine are headache, hypotension, nausea, tachycardia, and vomiting (Baxter Healthcare Corporation, 2004).

Centrally Acting Alpha-1 Antagonists

Centrally acting alpha-1 antagonists like phentolamine prevent the catecholamines (epinephrine and norepinephrine) from binding to adrenergic receptors. Typically, when the catecholamine binds to these receptors, the blood vessels constrict, but phentolamine prevents this and lowers blood pressure.

Phentolamine: Phentolamine is the only drug of this category that has an IV preparation, and phentolamine can be used to treat hypertensive crises and hypertension caused by specific situations, including certain drug overdoses, drug-drug interactions, and the diagnosis of pheochromocytoma (Brathwaite & Rief, 2019; Whelton et al., 2018). Pheochromocytoma is a rare tumor of the adrenal glands that produce excess amounts of catecholamines like norepinephrine. Phentolamine lowers blood pressure by causing vasodilation. Phentolamine is available as a generic drug and the brand name preparation OraVerse®.

  1. Administration: IV phentolamine is given by IV bolus, with additional bolus doses as needed (Whelton et al., 2018). The dose depends on the clinical situation. The onset of effects is almost immediate, and the duration of action is 15 to 30 minutes (Braithwaite & Reif, 2019; Rossi et al., 2022).
  2. Adverse effects: Adverse effects include pain at the injection site (very common), bradycardia, and tachycardia (common with higher doses). Serious cardiac adverse effects like MI and shock can occur (Septodont, 2016).

Dopamine Agonist

Fenoldopam: Fenoldopam (brand name Corlopam®) is the only IV dopamine agonist used to treat hypertension. Fenoldopam lowers blood pressure by vasodilation and has a labeled, approved use for treating severe hypertension and hypertensive emergencies (Hospira Inc., 2015).

  1. Administration: Start the infusion at 0.01 to 0.3 mcg/kg/minute and increase the dose in increments of 0.05 to 0.1 mcg/kg/minute every 15 minutes or longer until the desired blood pressure level is attained. Fenoldopam is diluted before administration, and a diluted preparation is stable for 4 hours at room temperature; after that point, it should be discarded (Hospira Inc., 2015).
  2. Adverse effects: Adverse effects of fenoldopam include headache, nausea, pain at the injection site, dose-related tachycardia (high doses), and vomiting (Hospira Inc., 2015).


Hydralazine: Hydralazine lowers blood pressure by dilating the arteries and decreasing systemic vascular resistance. Hydralazine has often been used to treat hypertension and hypertensive emergencies. However, the response to the drug is considered unreliable, and it has a long duration of action of 1 to 4 hours (Peixoto, 2019; Braithwaite & Reif, 2019; Whelton et al., 2018). Hydralazine is not the first choice for severe hypertension or hypertensive emergencies (Peixoto, 2019).

  1. Administration: Hydralazine is given as a slow IV infusion over 10 minutes; the dose can be repeated every 4 to 6 hours if needed (Whelton et al., 2018).
  2. Adverse effects of hydralazine include headache, flushing, palpitations, postural hypotension, and tachycardia (SteriMax, 2008).

Nitroprusside: Nitroprusside (brand name Nipride® RTU) lowers blood pressure by dilating peripheral arteries and veins (Excela Pharma Sciences, 2017b). Nitroprusside is used to immediately decrease blood pressure, control hypotension during surgery, and treat acute heart failure (Excela Pharma Sciences, 2017b).

  1. Administration: The initial dose is 0.3 mcg/kg/minute (Excela Pharma Sciences, 2017b). Wait at least 5 minutes before decreasing or increasing the dose; the maximum dose is 10 mcg/kg/minute (Excela Pharma Sciences, 2017b). Patients must be on continuous blood pressure monitoring. A decrease in blood pressure happens almost immediately after an infusion begins, and this effect stops almost immediately after an infusion is stopped (Rossi et al., 2022). Nipride must be administered through an infusion pump (Excela Pharma Sciences, 2017b).
  2. Warnings: Nitroprusside can cause significant hypotension and increase intracranial pressure (Excela Pharma Sciences, 2017b). Conversion to cyanide is likely with high doses, so limit the maximum dose to the shortest possible duration (Excela Pharma Sciences, 2017b). (Note: Cyanide decreases oxygen delivery to the body, causing signs and symptoms of hypoxia).
  3. Adverse effects: Hypotension and reflex tachycardia are known adverse effects (Excela Pharma Sciences, 2017b; Rossi et al., 2022).


Diuretics increase fluid excretion through the kidneys, reducing the circulating blood volume and blood pressure. Classes of diuretics include loop diuretics, thiazide diuretics, and potassium-sparing diuretics. Each type works at a different site within the kidney.

Loop Diuretics

The loop diuretics include bumetanide, ethacrynic acid, furosemide, and torsemide. These are all available as IV preparations. Ethacrynic acid is more likely to cause ototoxicity and is only used if a patient cannot take one of the other loop diuretics (Jackson, 2023).

Loop diuretics are not the first choice for treating hypertension, but IV loop diuretics can be used to treat acute, severe hypertension, hypertensive emergencies, acute heart failure, and pulmonary edema (Felker et al., 2020; Kiefer et al., 2023; Whelton et al., 2018; Papadakis & McPhee, 2023a). In these situations, IV boluses or a continuous infusion can be used (Felker et al., 2020).

Adverse effects of loop diuretics are electrolyte disorders, especially hyponatremia and hypokalemia (this increases the risk of cardiac arrhythmias), hypotension because of excess diuresis, and ototoxicity (Jackson, 2023; Papadakis & McPhee, 2023a). Ototoxicity, deafness, hearing impairment, and tinnitus can occur when the IV infusion rate of a loop diuretic is too fast (Jackson, 2023).

The loop diuretics and the sulfonamide antibiotics are structurally similar. There is a very small risk of an allergic reaction to a loop diuretic if one of these drugs is given to a patient allergic to sulfonamide antibiotics (Chow & Khan, 2022).

Thiazide Diuretics

The thiazide and thiazide-like diuretics include chlorthalidone, chlorothiazide, hydrochlorothiazide, indapamide, methyclothiazide, and metolazone. Thiazide and thiazide-like diuretics are a first-line treatment for hypertension, but only chlorothiazide is available as an IV preparation, and it is not used to treat hypertension or hypertensive urgency/emergencies (Papadakis & McPhee, 2023a).

Potassium-Sparing Diuretics

The potassium-sparing diuretics include amiloride, eplerenone, spironolactone, and triamterene. These drugs treat chronic hypertension and are available only as oral preparations.

Nonsteroidal Anti-inflammatories (NSAIDs) and Acetaminophen

NSAIDs are used as analgesics, antipyretics, and anti-inflammatories, and they are available as over-the-counter drugs like aspirin and naproxen and as prescription drugs (Shagroni et al., 2021). Ibuprofen and meloxicam are the only NSAIDs available as IV preparations.

The primary way that NSAIDs reduce inflammation is by inhibiting cyclooxygenase (COX-1 and COX-2) enzymes (Shagroni et al., 2021). The COX-1 and COX-2 enzymes help synthesize prostaglandin production, and prostaglandin is a lipid compound that controls the inflammatory process.

Older NSAIDs like ibuprofen inhibit COX-1 and COX-2 (Shagroni et al., 2021). The inhibition can affect platelet function and cause GI bleeding. Some of the newer NSAIDs, like celecoxib, are selective COX inhibitors. They only inhibit COX-2 and do not affect platelet function, so the risk of GI bleeding is reduced (Shagroni et al., 2021).

Ibuprofen and meloxicam are available as IV preparations. There are two IV ibuprofen preparations, Caldolor® and Neoprofen®. Neoprofen is used to treat clinically significant patent ductus arteriosus (PDA) in premature infants who are no more than 32 weeks gestational age when usual medical management (fluid restriction, diuretics, respiratory support, etc.) is ineffective (Recordati Rare Diseases Inc., n.d.).

Ibuprofen: Caldolor

Caldolor is a COX-1 and COX-2 inhibitor, and it is used to treat mild to moderate pain; it is used with opioids to treat moderate to severe pain; and to reduce fever (Cumberland Pharmaceuticals Inc., n.d.).

  1. Administration:  The dose is determined by age and the reason for use (Cumberland Pharmaceuticals Inc., n.d.).
    • Adults, pain – 400 mg to 800 mg, infused over 30 minutes, every 6 hours as needed.
    • Adults, fever – 400 mg, infused in over 30 minutes, then 400 mg every 4 to 6 hours as needed or 100 to 200 mg every 4 hours as needed.
    • Ages 12 to 17, pain and fever – 400 mg infused in over 10 minutes every 4 to 6 hours as needed.
    • Ages 6 months to 12 years, pain and fever – 10 mg/kg, infused in over 10 minutes, every 4 to 6 hours as needed. The maximum dose is 400 mg.
  2. All the NSAIDs have this warning:
    • NSAIDs can cause an increased risk of serious cardiovascular thrombotic events, including myocardial infarction and stroke, which can be fatal. NSAIDs can cause an increased risk of serious GI adverse events, including bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal. These events can occur at any time during use and without warning symptoms. Elderly patients and patients with a prior history of peptic ulcer disease and/or GI bleeding are at greater risk for serious GI events.
    • Cardiovascular adverse effects of NSAIDs can happen even after one week of use (Badimon & Santos-Gallegos, 2018).
    • NSAIDs can cause bleeding and damage throughout the GI tract, bleeding can happen at any time, and the patient may be asymptomatic. In clinical trials of Caldolor, 10% of the patients had a hemorrhage (Bjarnason et al., 2018; Cumberland Pharmaceuticals Inc., n.d.).
  3. Adverse effects: Common adverse effects of Caldolor include dizziness, flatulence, headache, hemorrhage, nausea, and vomiting (Cumberland Pharmaceuticals Inc., n.d.).

Meloxicam: Anjeso

Anjeso is a COX-1 and COX-2 inhibitor, and it is used alone or with non-NSAID analgesics to treat moderate to severe pain (Baudax Bio., 2021).

Anjeso has a delayed onset of 2 to 3 hours in most patients; using Anjeso is not recommended if the patient needs rapid relief (Baudax Bio, 2021).

  1. Administration: 30 mg once daily, given as an IV bolus, infused over 15 seconds (Baudax Bio, 2021). Because of its delayed onset of effects, some patients may need a supplemental analgesic. Also, for some patients, the duration of action may be < 24 hours, and they may need a supplemental analgesic. All NSAIDs can cause kidney damage, so the patient should be well-hydrated (Baudax Bio, 2021).
  2. Adverse effects: Common adverse effects are anemia, constipation, and elevation of the liver enzyme GGT. Anemia is likely caused by GI bleeding, and serious liver damage caused by meloxicam is rare (Baudax Bio, 2021; Livertox, 2020a).


Acetaminophen (brand name Tylenol®) is a non-opioid analgesic. The mechanism of action of acetaminophen is not well understood. Acetaminophen is used to treat mild pain and reduce fever.

IV acetaminophen (brand name Ofirmev®) treats mild to moderate pain in children two years and older. For adults, it is used to treat moderate to severe pain in combination with an opioid analgesic. It is used for treating fever in patients over two years of age (Mallinckrodt Hospital Products, 2018).

  1. Administration: It is infused over 15 minutes. The dose is based on age and weight, and the frequency of the dosing can be every 4 or 6 hours. The 24-hour maximum dose depends on the patient’s age and weight.
  2. Warnings: Acetaminophen in more than the recommended amount can cause liver damage, liver failure, and death (Olson, 2018). Medication errors and acetaminophen overdoses in the United States are the leading cause of liver failure (Sudanagunta et al., 2023). Patients who are chronically malnourished and patients who have liver disease, a history of alcohol abuse, or who have kidney disease may have a higher risk for liver damage from excess acetaminophen (Olson, 2018; Mallinckrodt Hospital Products, 2018).
  3. Adverse effects: For adults, the adverse effects of IV acetaminophen include dizziness, drowsiness, headache, insomnia, nausea, and vomiting; for pediatric patients, constipation, nausea, pruritus, and vomiting (Kolli et al., 2022; Mallinckrodt Hospital Products, 2018).

Antineoplastics: Chemotherapy

Antineoplastics are used to treat cancer, and there are > 200 drugs that are/can be categorized as antineoplastics (Kim-Katz, 2022). Discussing all of them would be very lengthy; this module will cover the primary categories of antineoplastics (Katzung et al., Chapter 54, 2021i). Other sources categorize antineoplastics differently.

Antineoplastics include alkylating agents, antibiotics, antimetabolites, natural products, and miscellaneous agents.

  1. Administration: Chemotherapy drugs are typically vesicants, and extravasation can cause serious tissue injuries (Karius & Colvin, 2021). Patients may complain of pain when extravasation occurs. Still, tissue injury can be delayed. Karius & Colvin (2021) wrote: “Lack of immediate signs of injury can lead to a false sense of security by nurses, providers, and patients. Consequently, tissue damage can be significant when the patient returns for their regular follow-up appointment, which could be 1 to 3 weeks after the event.” The exact incidence of extravasation of chemotherapy drugs is not known. Reported incidences have ranged from 0.01% to 6.5%, and the risk is higher for a peripheral IV line (Jackson-Rose et al., 2017). It is recommended that chemotherapy drugs be administered through a central line (Jackson-Rose et al., 2017).
  2. Adverse effects: Chemotherapy drugs typically cause alopecia, diarrhea, fatigue, nausea, vomiting, and bone marrow suppression (Amjad et al., 2022; Katzung et al., Chapter 54, 2021i).
    • Alkylating agents: Common adverse effects of alkylating agents include alopecia, anemia, amenorrhea, intestinal mucosal damage, pancytopenia, impaired spermatogenesis, and an increased risk of malignancy (Livertox, 2019).
    • Antibiotics: Anthracycline antibiotics such as doxorubicin, daunorubicin, idarubicin, epirubicin, and mitoxantrone can cause ECG abnormalities and, possibly, arrhythmias, and long-term use can cause cardiomyopathy and heart failure (Katzung et al., Chapter 54, 2021i). Bleomycin can cause hypersensitivity reactions (common), skin blisters, pulmonary fibrosis, and pneumonitis. Mitomycin can cause serious bone marrow suppression and heart, kidney, liver, and lung damage (Katzung et al., Chapter 54, 2021i).
    • Antimetabolites: Common adverse effects include alopecia, bone marrow suppression, mucositis, inflammation and ulceration of the GI tract, neutropenia, and hepatic damage (Katzung et al., Chapter 54, 2021i).
    • Natural products: Natural products cause alopecia, bone marrow depression, and GI distress, and some natural products like vincristine, docetaxel, and paclitaxel can cause neurotoxicity. Other adverse effects are paralytic ileus and hypersensitivity reactions (Katzung et al., Chapter 54, 2021i).
    • Miscellaneous agents: Tyrosine kinase inhibitors like imatinib can cause fluid retention, heart failure, and myalgia (Katzung et al., Chapter 54, 2021i).
    • Monoclonal antibodies like trastuzumab can cause heart failure. Other monoclonal antibodies can cause arterial thrombosis, bleeding complications, hypertension, hypersensitivity reactions, impaired healing, and infusion reactions (Katzung et al., Chapter 54, 2021i).


Antivirals are used to treat and manage viral infections, including coronavirus disease (COVID-19), cytomegalovirus, herpes simplex, herpes zoster, human immunodeficiency virus (HIV), and influenza. There are several classes of antivirals, and each antiviral disrupts a different stage of the viral life cycle. The exact mechanism of action is different for each drug.

IV antivirals include:

  1. remdesivir for COVID-19
  2. acyclovir for herpes simplex and herpes zoster
  3. peramivir for influenza, and
  4. oscarnet and ganciclovir for cytomegalovirus retinitis

COVID-19 - Remdesivir

Remdesivir (Veklury®) is an antiviral that is used to treat adults and children 28 days of age and older who have a positive COVID-19 test and who are hospitalized, or people who are not hospitalized, have mild to moderate COVID-19 and who have a high risk for severe COVID-19, hospitalization, or death (Gilead Sciences, Inc., 2022). Remdesivir has been shown to improve the outcomes for hospitalized and non-hospitalized patients and reduce the risk of hospitalization or death (Gottlieb et al., 2022).

  1. Administration: There are two types: 100 mg in a single-dose vial that must be reconstituted and 100/mg/20 mL that must be diluted, and there are differences in how each one is prepared. Pediatric patients must be given 100 mg preparations. Dosing and treatment duration depends on age, weight, and if the patient is hospitalized or at home (Gilead Sciences, Inc., 2022). Usually, a loading dose is given on the first day, followed by daily maintenance doses. Infusion times vary from 30 to 120 minutes, depending on the patient’s age and volume. For hospitalized patients, remdesivir should be started as soon as possible. For non-hospitalized people, remdesivir should be started as soon as possible and within seven days of when symptoms began (Gilead Sciences, Inc., 2022).
  2. Adverse effects: Common adverse effects of remdesivir are mild and non-specific, including (but not limited to) cough, diarrhea, headache, and nausea, and serious adverse effects appear to be rare (Gilead Sciences, Inc., 2022). The prescribing information for Veklury® has a warning that states that Veklury® has been associated with elevated liver enzymes. The enzyme elevations were not extremely high, and no liver damage occurred, but it is recommended that before and during treatment, liver function tests should be done (Gilead Sciences, Inc., 2022).

Influenza- Peramivir

Peramivir, trade name Rapivab™, is an antiviral used to treat patients 18 years of age and older who have had uncomplicated influenza for ≤ 2 days (Biocryst Pharmaceuticals, Inc., 2021). Peramivir has been shown to decrease the time to alleviate flu symptoms (Liu et al., 2021); it has the advantage of being a one-time dose and can be used for people who cannot take oral medication (Świerczyńska et al., 2022).

  1. Administration: 600 mg, administered over 15 to 30 minutes (Biocryst Pharmaceuticals, Inc., 2021).
  2. Adverse effects: Peramivir is generally well tolerated (Świerczyńska et al., 2022). During clinical trials, serious adverse effects associated with/caused by Rapivab™ were not reported. Adverse effects of peramivir include diarrhea and neutropenia (Biocryst Pharmaceuticals, Inc., 2021; Świerczyńska et al., 2022). Hyperglycemia, elevated creatinine phosphokinase (CK), and alanine aminotransferase (ALT) have occurred during clinical trials (Biocryst Pharmaceuticals, Inc., 2021).

Herpes Simplex, Herpes Zoster - Acyclovir

Acyclovir is an antiviral that inhibits DNA synthesis and replication. IV acyclovir has labeled uses and is a first-line treatment for the following conditions (Kubota et al., 2019; Patil et al., 2022; Stahl & Mailles, 2019):

  • Central nervous system infection (encephalitis or meningitis) with herpes simplex virus.
  • Herpes zoster (shingles) infection.
  • Varicella (chickenpox) infection in immunocompromised patients with a complicated or severe infection.
  1. Administration: Acyclovir should be infused over at least 1 hour; rapid infusion can cause kidney damage (UpToDate, 2022a). Acyclovir is an irritant, so the IV site should be checked for phlebitis and/or extravasation (UpToDate, 2022a). Kidney damage caused by acyclovir is common, so the patient should be well-hydrated (Al-Alawi et al., 2022; UpToDate, 2022a). The dose depends on the patient's age and why acyclovir is being used.
  2. Adverse effects: Kidney damage has been reported in up to 48% of patients receiving IV acyclovir (Al-Alawi et al., 2022). Neurological effects like agitation, confusion, lethargy, and tremors can be caused by acyclovir (Patel et al., 2019); dehydration, high doses of the medication, and kidney damage increase the risk for neurologic adverse effects (Patel et al., 2019; UpToDate, 2022a).

Herpes simplex – Foscarnet

Foscarnet (Foscavir®) treats herpes simplex infection that has not responded to acyclovir (Clinigen Healthcare Ltd., 2020; Patil et al., 2022).

  1. Administration: The dose is 40 mg/kg every 8 or 12 hours for 2 to 3 weeks or until the patient is healed (UpToDate, 2022c). Correct administration of foscarnet is imperative: the recommendations listed here must be followed. An infusion of foscarnet that is too fast can cause a high blood level and increase the risk of adverse effects such as electrolyte disorders and renal damage. Dehydration also increases the risk of adverse effects (Clinigen Healthcare Ltd., 2020).
    • Foscarnet should be administered no faster than 1 mg/kg/minute (Clinigen Healthcare Ltd., 2020; UptoDate, 2022c).
    • Foscarnet must be administered through an infusion pump (Clinigen Healthcare Ltd., 2020; UptoDate, 2022c).
    • Foscarnet should never be given as an IV bolus.
    • Dehydrated patients should be given fluids until this condition is corrected; this should be done before giving foscarnet.
    • All patients should be given 750 to 1000 mL of 5% dextrose or normal saline before the first doses of foscarnet. With subsequent doses, give 500 to 1000 mL of fluid concurrently with each dose (Foscavir®2020). The amount of fluid depends on the dose of the drug: the lower the dose, the lower the fluid amount (Clinigen Healthcare Ltd., 2020).
  2. Warnings: The prescribing information for foscarnet has warnings that state: Renal impairment results from major toxicity of Foscavir®. Kidney function must be frequently monitored, and adequate hydration is crucial. Foscavir® can cause electrolyte abnormalities, and these can cause seizures. Electrolyte and mineral supplementation may be needed. Foscarnet is a vascular irritant.
  3. Adverse effects: Common systemic, non-specific adverse effects of foscarnet include asthenia, fatigue, fever, malaise, and pain. Anemia, leukopenia, and thrombocytopenia are common adverse effects (Clinigen Healthcare Ltd., 2020; Metafuni et al., 2018). Foscarnet can cause abnormal calcium, magnesium, phosphorus, and potassium blood levels. These are common adverse effects of the drug, which can be severe and cause seizures (Clinigen Healthcare Ltd., 2020; UpToDate, 2022c; Huycke et al., 2000). Kidney injury has been reported in up to 60% of patients receiving foscarnet (Pierce et al., 2018).
  4. Monitoring: Patients should be monitored for these four complications.
    • IV site irritation and/or extravasation.
    • Nephrotoxicity: Renal function studies, such as serum creatinine, should be checked before starting and during treatment (Clinigen Healthcare Ltd., 2020; UpToDate, 2022c).
    • Electrolyte abnormalities: Serum calcium, magnesium, phosphorus, and potassium (especially calcium) should be measured before beginning treatment with foscarnet, and they should be closely monitored during treatment.

Cytomegalovirus, retinitis – Foscarnet

Cytomegalovirus (CMV) is a common virus that can cause retinitis. Retinitis is an infection of the retina. CMV retinitis can cause retinal detachment and vision loss, and it is a well-known complication of HIV infections (Ude et al., 2022).

Foscarnet is a second-line treatment for CMV retinitis; it’s used when the patient does not respond to ganciclovir or valganciclovir or if the patient cannot take ganciclovir (Ude et al., 2022; UpToDate, 2022c). The patient is given induction treatment for 14 to 21 days and maintenance therapy for ≥ 3 to 6 months until specific clinical endpoints are reached (UpToDate, 2022c). Aside from that, the administration recommendations, warnings, adverse effects, and monitoring are the same as for treating herpes simplex.

Cytomegalovirus retinitis - Ganciclovir

Ganciclovir inhibits DNA synthesis. It is the first-line treatment for CMV retinitis and has a labeled use as a prophylactic for transplant patients at risk for CMV disease (Ude et al., 2022). Ganciclovir is a generic drug; there is no brand name preparation.

The dose and the duration of therapy of prophylactic ganciclovir are different than for CMV retinitis. Aside from that, the administration recommendations, warnings, adverse effects, and monitoring are the same as for treating CMV retinitis.

  1. Administration: An induction dose is given at a constant rate over 1 hour every 12 to 14 hours for 21 days (Excela Pharma Sciences, 2017a). The induction dose is followed by maintenance therapy, a once-daily dose infused over 1 hour, 5 mg/kg, once a day for 7 seven days a week or 6 mg/kg, once a day, five days a week. The dose will be determined and adjusted as needed by kidney function (Excela Pharma Sciences, 2017a). The recommended infusion rate should not be exceeded, and ganciclovir should not be given as an IV bolus; this can cause high blood levels and may cause adverse effects.  Ganciclovir should be given through a vein with good blood flow. Ensure the patient is well-hydrated before starting ganciclovir. Renal function should be measured before treatment (Excela Pharma Sciences, 2017a).
  2. Warnings: Ganciclovir has a warning. Ganciclovir can cause significant hematologic abnormalities: anemia, granulocytopenia (low level of granulocytes), pancytopenia, and thrombocytopenia. Ganciclovir can suppress fertility in females and impair spermatogenesis. Ganciclovir may cause birth defects, and it may be carcinogenic.
  3. Adverse effects: Common adverse effects (> 20%) include anemia, urinary catheter infections/sepsis, diarrhea, elevated creatinine, fever, and leukopenia (Excela Pharma Sciences, 2017a).
  4. Monitoring: Serum creatinine and a CBC with a platelet count should be measured periodically during treatment.


Antipsychotics treat schizophrenia, bipolar disorder, and other psychiatric illnesses. Some older antipsychotics have anti-emetic effects (Katzung et al., Chapter 29, 2021e). Antipsychotics are also commonly administered for off-label uses.

Antipsychotics are divided into two classes: The original, first-generation antipsychotics, also known as typical antipsychotics, and second-generation, also known as atypical antipsychotics. The terms typical and atypical refer to the adverse effect profile. The first-generation antipsychotics caused movement disorders that were common or “typical” for these drugs. The second-generation antipsychotics, initially, were thought to be far less likely to cause movement disorders, so they were called atypical. Also, a distinction was made between them because they had slightly different mechanisms of action.

The primary mechanism of action of antipsychotics is changing the balance of dopamine transmission in the CNS. Atypical antipsychotics also do this to a lesser degree and are more active at other neuroreceptor sites (Katzung et al., Chapter 29, 2021e).

Typical antipsychotics like haloperidol are commonly referred to by their discontinued brand name form (haloperidol = Haldol), but these drugs are now all generic.

Three antipsychotics are available as IV preparations: chlorpromazine, droperidol, and haloperidol. The atypical antipsychotic olanzapine is often given IV to treat agitated patients, but this is an off-label use (Wang et al., 2022a).

IV chlorpromazine is approved for treating prolonged, intractable hiccups, and IV droperidol is approved for use as an antiemetic. Other uses of IV chlorpromazine, droperidol, and haloperidol, while not uncommon, are unlabeled uses.

Typical antipsychotics include chlorpromazine (Thorazine®), droperidol (Inapsine®), fluphenazine (Modecate®), haloperidol (Haldol®), perphenazine, and thioridazine (Mellaril®).

Atypical antipsychotics include aripiprazole (Abilify®), lurasidone (Latuda®), olanzapine (Zyprexa®), quetiapine (Seroquel®), and risperidone (Risperdal®).

  1. Administration: There is little information on the rate of administration of IV antipsychotics, but available information states that slow administration is preferred. For example, an IV dose of chlorpromazine, 25 to 50 mg, should be given no faster than 1 mg/minute (UpToDate, 2022b).
  2. Warnings: All antipsychotics have warnings stating that elderly patients who have psychosis caused by dementia and who are being treated with an antipsychotic are at an increased risk of death. Warnings are based on studies of patients receiving oral antipsychotics on a chronic basis (Maust et al., 2015).
  3. Adverse effects: These adverse effects can occur with IV antipsychotics.
    • Anticholinergic signs/symptoms: Blurred vision, drowsiness, dry mouth, urinary retention, and tachycardia (Katzung et al., Chapter 29, 2021e).
    • Hypotension and orthostatic hypotension (UpToDate, 2022b; Katzung et al., Chapter 29, 2021e).
    • Extrapyramidal symptoms: Reversible neurologic movement disorders, including akathisia (excessive restlessness and repetitive movements), dystonic reactions, and Parkinsonism (Katzung et al., Chapter 29, 2021e). Akathisia and Parkinsonism happen with chronic use; dystonic reactions can occur after IV administration (Caroff & Campbell, 2016). A dystonic reaction is an involuntary, intermittent, spasmodic movement in the face, neck, extremities, or trunk. For example, facial/lingual dystonia is characterized by the tongue moving in and out and facial movements. Except for laryngeal dystonia, which can cause dangerous airway obstruction, acute drug-induced dystonias are uncomfortable and frightening for the patient, but they are not dangerous (Alkharboush & Alsalamah, 2020).
    • Arrhythmias: Antipsychotics can cause QT prolongation and ventricular arrhythmia, which can cause sudden death (Katzung et al., Chapter 29, 2021e; Ruiz-Diaz et al., 2020; Wang et al., 2022b). There is little information on IV antipsychotics, TDP, and sudden death (Wang et al., 2022a). IV haloperidol has been associated with QT prolongation and TDP (Hunt & Stern, 1995; Metzger & Friedman, 1993). A 12-lead ECG and cardiac monitoring are recommended (UpToDate, 2022d).


Antiarrhythmic medications treat heart rate and/or rhythm disturbances, also known as arrhythmias. Arrhythmias are caused by abnormal cardiac impulse conductions, such as a heart block, or an abnormal cardiac impulse formation, such as atrial or ventricular fibrillation (Katzung et al., Chapter 14, 2021c).

Cardiac contraction and recovery and the electrical activity of the heart are controlled by two processes:1) calcium, potassium, and sodium moving into and out of myocardial cells and 2) autonomic nervous system activity. The therapeutic effect of antiarrhythmics is mediated by their activity on one or both of those processes; that is also how they are categorized (Katzung et al., Chapter 14, 2021c; Lei et al., 2018).

Table 5 lists a basic classification system for antiarrhythmics. There are more drugs in each class; the ones listed in Table 5 are the available IV preparations. The beta-blockers, calcium channel blockers, and digoxin are discussed in other sections of this course.

Table 5: IV Antiarrhythmics
Class 1: Sodium channel blockers
  • 1a: Procainamide
  • 1b: Lidocaine
  • 1c: Flecainide and propafenone (no IV preparations)
Class 2: Beta-blockers

Esmolol, metoprolol, and propranolol

Class 3: Potassium channel blockersAmiodarone, bretylium, ibutilide, sotalol
Class 4: Calcium channel blockersDiltiazem and verapamil
Class 5: Miscellaneous antiarrhythmicsAdenosine and digoxin

Adverse effects include hypotension, seizures, and TDP (Katzung et al., Chapter 14, 2021c).

Adenosine treats paroxysmal supraventricular tachycardia (PSVT); PSVT is characterized by a heartbeat > 100, sudden onset and a short duration (30 seconds), and signs and symptoms like dizziness, palpitations, and shortness of breath. Adenosine is the first-line choice for treating PSVT (Katzung et al., Chapter 14, 2021c; Hospira Inc., 2020).

Cardiac Glycosides and the Antidote


Cardiac glycosides are drugs used to treat atrial fibrillation, heart failure, and supraventricular arrhythmias. Digoxin is the only cardiac glucoside used in the United States, and the only approved use for IV digoxin is to control heart rate in patients with atrial flutter.

The primary therapeutic mechanisms of action of digoxin are decreasing heart rate and increasing the force of myocardial contraction (Alobaida & Alrumayh, 2021; Katzung et al., Chapter 13, 2021b).

Atrial fibrillation is the most common arrhythmia in adults (Alobaida & Alrumayh, 2021). Atrial fibrillation is characterized by a rapid heart rate (> 100 beats/minute and often higher), an irregularly irregular heart rate, and decreased cardiac output (Mitchell, 2022). Atrial fibrillation is a significant cause of stroke and heart failure, and controlling heart rate is a primary treatment for atrial fibrillation (Alobaida & Alrumayh, 2021). Pharmacologic rate control is done with a beta-blocker, a calcium channel blocker, or digoxin; digoxin is the last choice (Alobaida M & Alrumayh, 2021).

  1. Administration: 0.25 mg to 0.5 mg IV, infused ≥ 5 minutes (Mitchell, 2022). The loading dose is followed by 0.25 mg every 6 hours to a maximum dose of 1.25 mg over 24 hours (Mitchell, 2022). After loading and maintenance doses, the patient should be started on oral digoxin (Mitchell, 2022).
  2. Adverse reactions: Digoxin toxicity is a significant adverse drug reaction (Mitchell, 2022). The signs and symptoms of digoxin toxicity include arrhythmias, hyperkalemia, nausea, visual disturbances, and vomiting (Benowitz, 2022; Katzung et al., Chapter 13, 2021b; Mitchell, 2022). Digoxin toxicity is often caused by renal impairment, decreased drug excretion, drug interactions, diuretics, electrolyte abnormalities (hypercalcemia, hypomagnesemia, and hypokalemia), and unintentional overdose (Digiovanni-Kinsley et al., 2021; Katzung et al., Chapter 13, 2021b). Digoxin toxicity is more likely in elderly patients (Nix et al., 2022).
  3. Monitoring: Digoxin is a vesicant, so the injection site should be closely monitored (Mitchell, 2022). Before giving digoxin, check the patient’s pulse, serum potassium, and last digoxin level. Normal serum digoxin level is 0.5 to 1.0 ng/mL.

Cardiac Glycoside Antidote: Digoxin-Specific Antibodies

Digoxin-specific antibodies, or Fab fragments, are the antidote for digoxin toxicity. Digoxin-specific antibodies bind digoxin, and the Fab fragment-digoxin complex is excreted by the kidneys (Ma, 2022). Digoxin-specific antibodies are given if the patient has an elevated digoxin level, a serious arrhythmia, is hemodynamically unstable, and/or has a serum potassium > 5 mEq/mL (Ma, 2022).

The dose is measured in vials based on the steady-state serum digoxin level or the amount of digoxin ingested (Ma, 2022); the formula is provided here with an example. Example: The steady-state digoxin level (12-16 hours after the last dose) is 2.8 ng/mL, and the patient weighs 80 kg. 2.8 x 80 = 224, 224 ÷ 100 = 2.24 vials. After dilution, the vials of digoxin-specific antibodies should be infused over 30 minutes (Ma, 2022).

Adverse effects include exacerbation of heart failure, increased heart rate after the effect of digoxin has been neutralized, and hypokalemia (Ma, 2022).



Oral and IV beta-blockers, calcium channel blockers, and nitrates can be used to treat angina. The beta-blockers and calcium channel blockers were previously discussed; this section will discuss IV nitroglycerin.

Angina is caused by myocardial ischemia, and IV nitroglycerin has a labeled use as a treatment for acute angina. Nitroglycerin relieves angina by decreasing myocardial oxygen demand and increasing oxygen supply to the heart, primarily by causing vasodilation (Katzung et al., Chapter 12, 2021a).

  1. Administration: IV nitroglycerin should be given cautiously because it can cause bradycardia and hypotension and increase intracranial pressure (UpToDate, 2022f). Begin with a dose of 5 to 10 mcg/minute, and increase as needed (O’Gara et al., 2013; UpToDate 2022f). Continuous cardiac monitoring should be used during IV nitroglycerin infusion. IV nitroglycerin should be given in containers that do not contain polyvinyl chloride (PVC), as the drug will adhere to a PVC IV bag (UpToDate, 2022f). A special infusion set should be supplied with the drug. IV nitroglycerin should be infused with an infusion pump (UpToDate, 2022f).
  2. Warning: IV nitroglycerin should not be used if the systolic blood pressure is <90 mm Hg or > 30 mm Hg above baseline (O ’Gara et al., 2013). IV nitroglycerin can cause bradycardia, hypotension, and orthostatic hypotension (UpToDate, 2022f). IV nitroglycerin can increase intracranial pressure (Update, 2022f). Do not use IV nitroglycerin if the patient has taken a phosphodiesterase type 5 inhibitor like sildenafil (generic Viagra®) in the past 24 to 48 hours (O’ Gara et al., 2013). Combining these two can cause hypotension.
  3. Adverse effects: Headache, hypotension (UpToDate, 2022f).


Corticosteroids are naturally occurring hormones. Pharmaceutical corticosteroids are synthetic corticosteroids divided into two categories: glucocorticoids and mineralocorticoids (Katzung et al., Chapter 39, 2021h).


The glucocorticoids affect the metabolism of carbohydrates, fats, and proteins and help control and mediate the immune response and inflammation (Katzung et al., Chapter 39, 2021h).

IV glucocorticoids are used, on-label and off-label, for a wide variety of conditions, including (but not limited to) acute respiratory distress syndrome (ARDS), adrenal crisis, COVID-19, allergic reactions, exacerbations of asthma, chronic obstructive pulmonary disease (COPD), multiple sclerosis, sepsis, systemic lupus erythematosus, and rheumatic arthritis (Shah et al., 2022). These are immune-driven pathologies and/or characterized by inflammation, so glucocorticoids can be a helpful treatment. There are many glucocorticoids, and they are used to treat many conditions; a full discussion would be very lengthy. Administration issues, warnings, and adverse effects common to all IV glucocorticoids will be covered.

  1. Administration: Glucocorticoids should be tapered, not abruptly discontinued. Abrupt discontinuation, even after short-term (< 4 weeks) treatment with a low dose, can cause signs and symptoms of adrenal insufficiency like abdominal pain, fatigue, headache, and loss of appetite or cause adrenal insufficiency (Pelewicz & Miśkiewicz, 2021).
  2. Adverse effects: The adverse effects of glucocorticoids usually happen with chronic treatment, but hyperglycemia and psychiatric effects can occur with short-term use (Katzung et al., Chapter 39, 2021h).
    • Hyperglycemia: Temporary hyperglycemia can occur after a single use of a glucocorticoid, but 1 to 7 days of glucocorticoid therapy can cause insulin resistance and affect glucose control (Shah et al., 2022; Li & Cummins, 2022).
    • Psychiatric effects: Psychiatric disorders like depression, mania, and psychosis are common adverse effects of glucocorticoids, and these can occur after just a few days of Treatment (Ciriaco et al., 2013; Corbett et al., 2016).

Diabetic Medications (Insulin)

Diabetic patients are treated with insulin, oral medications, or both. Insulin is primarily given SC, but it can be given as an IV bolus or infusion, and it is the only diabetic medication that can be given IV. IV insulin is used to treat diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS), and it is used to treat patients who have taken an overdose of a calcium channel blocker (Masharani, 2022; Benowitz & Wagner, 2022). Although these are off-label uses, IV insulin is standard care for these conditions.

Insulin lowers blood sugar by activating transport molecules that move glucose into the cells. Insulin also increases the glycogen stored in the liver (Katzung et al., Chapter 54, 2021i).

The most common adverse effect of insulin is hypoglycemia.

Insulin: DKA

DKA is a complication of type 1 diabetes and occasionally type 2; it is a medical emergency (Masharani, 2022). Diabetic ketoacidosis is characterized by a blood glucose level > 250 mg/dL and metabolic acidosis, CNS depression, dehydration, electrolyte abnormalities, hypotension, nausea, and vomiting. Without proper treatment, the patient can die (Masharani, 2022).

The primary treatments for DKA are lowering blood glucose with insulin, IV fluid resuscitation, correcting acidosis, and correcting electrolyte abnormalities (Masharani, 2022). Treating DKA is very complicated, and there are different protocols:

  • Insulin: The insulin dose depends on a patient’s condition, and there are several ways to administer insulin to a patient who has DKA; a commonly used approach is to give an IV bolus of regular insulin and then start a continuous infusion of regular insulin at a low dose, such as 0.01 unit/kg/hour (Calimag et al., 2022; Masharani, 2022). During the insulin infusion, blood glucose must be monitored very closely (blood glucose may be measured every 15 minutes in the first several hours of insulin therapy). Potassium, arterial or venous pH, and ketones should also be closely monitored. SC insulin can be given concurrently with the IV infusion; this may decrease the time the IV infusion is needed and help with the eventual transition to SC insulin (Calimag et al., 2022; Masharani, 2022).
  • The duration of the infusion will depend on a patient’s clinical condition and laboratory tests. The patient’s normal SC insulin regimen should be started before the insulin infusion is discontinued (Calimag et al., 2022; Masharani, 2022). If the IV insulin is discontinued without starting SC insulin, blood insulin levels can be too low, and DKA can reoccur (Masharani, 2022).

Insulin: Hyperosmolar Hyperglycemic State (HHS)

HHS is an uncommon diabetic complication with a mortality rate of> 10 times that of DKA (Masharani, 2022). It can cause severe complications like MI and stroke (Masharani, 2022).

HHS is characterized by a blood glucose level > 600 mg/dL (and sometimes much higher), very high serum osmolality, a normal pH, lethargy, dehydration, polyuria, and polydipsia (Masharani, 2022). The hyperosmolar hyperglycemic state tends to occur in older adults (Masharani, 2022).

Treatment of HHS is essentially the same as that of DKA.

Insulin: Calcium Channel Blocker Overdose

Calcium channel blocker overdose is characterized by bradycardia, hypotension, and hyperglycemia and is a life-threatening emergency (Benowitz & Wagner, 2022).

An IV infusion of regular insulin and an IV infusion of 10% dextrose in water is an effective treatment for calcium channel blocker overdose (Benowitz & Wagner, 2022). A calcium channel blocker overdose inhibits insulin release, so glucose cannot move into the myocardium, and the heart is deprived of an energy source (Benowitz & Wagner, 2022). The 10% dextrose provides energy, and the insulin provides a way to deliver the dextrose to the myocardium (Stassinos, 2022). Myocardial contractility is improved, and hypotension can be reversed. There are no standard dosing protocols for this as it is an off-label use. However, insulin-dextrose is commonly used to treat calcium channel blocker overdose, and a typical regimen is described below (Stassinos, 2022).

  • Give a bolus dose of regular insulin, 1 unit/kg. If the blood glucose is < 200 mg/dL, give a bolus dose of 50% glucose.
  • After the insulin bolus dose, start an infusion of regular insulin at 1 unit/kg/hour and titrate the dose as needed, up to 10 units/kg/hour (Stassinos, 2022).
  • Make sure the patient is euglycemic. Use an infusion of 10% dextrose, and give boluses of 50% dextrose, as needed.
  • Measure blood glucose closely, such as every 15 minutes when the insulin dose changes, and closely monitor serum potassium.

Opioids and Opiates

Opioids and opiates are natural, synthetic, and semi-synthetic compounds used as analgesics,  antitussives (cough relief), antidiarrheals, as an adjunct to anesthesia, and to treat opioid use disorder or addiction (Katzung et al., Chapter 31, 2021f). The analgesic effect of opioids makes them suitable for a wide range of uses, such as postoperative pain, pain caused by a non-ST segment elevation myocardial infarction, sickle cell disease, and breakthrough pain in patients with chronic pain. 

Opioids and opiates bind to opioid receptors in the brain and the CNS, and the therapeutic and adverse effects are caused by drug-receptor binding (Katzung et al., Chapter 31, 2021f). Opioids that can be given IV include buprenorphine, butorphanol, codeine, fentanyl, hydromorphone, meperidine, morphine, and nalbuphine. Discussing the clinical indications for use, the administration and monitoring issues, and the adverse effects of each drug would be very lengthy. Also, the adverse effects of all opioids and warnings are essentially the same.

  1. Adverse effects: Common acute adverse effects of opioids are sedation, miosis, nausea and vomiting, and respiratory depression (Katzung et al., Chapter 31, 2021f). Sedation, miosis, and respiratory depression are such common adverse effects of opioids that, together, are often called opioid toxidrome (Brocato & Paley, 2021). Chronic use can cause constipation, dependence, tolerance, and hyperalgesia (Katzung et al., Chapter 31, 2021f). Hyperalgesia is defined as an increased sensitivity to pain. Opioids can also cause bradycardia and vasodilation, which can cause hypotension (Chen & Ashburn, 2015).
    • Respiratory depression is a common adverse effect of opioids. It is caused by an opioid binding to an opioid receptor in the respiratory center of the brain and, subsequently, decreased sensitivity to blood carbon dioxide levels, one of the primary drivers of ventilation (Katzung et al., Chapter 31, 2021f). People can develop a tolerance to this effect, but even experienced opioid users can develop respiratory depression (Algera et al., 2022).
  2. Warning: All opioids have a warning, and it states:
    • The use of opioids can result in abuse, addiction, and misuse, which can result in overdose and death.
    • Opioids can cause life-threatening respiratory depression.
    • Healthcare providers are strongly encouraged to complete a Risk Evaluation Management Strategy (REMS) program. A REMS program provides education on the dangers of opioids and strategies for safely managing the use of opioids and counsels patients and caregivers on the dangers of disposal, safe use, and risk of opioids.
    • Opioid use during pregnancy can cause neonatal opioid withdrawal syndrome.
    • Accidental ingestion of an opioid can cause serious harm and death, especially in children.
    • Dosing errors with oral solutions can cause serious harm. Medication errors with opioids are common, and serious harm from an opioid medication error is not uncommon (Heneka et al., 2018; Linden-Lahti et al., 2021).
  3. Monitoring: Check the patient’s blood pressure, pulse, respiratory rate, and oxygen saturation before giving an IV opioid. Use the healthcare facility’s protocols to avoid medication errors.

Narcotic Antagonists: Naloxone and Nalmefene

The narcotic antagonist's naloxone and nalmefene are used to reverse sedation and respiratory depression caused by opioids and opiates. Nalmefene was only recently (2022) available again in the United States. Naloxone (Narcan®) is widely used, and nalmefene will not be discussed.

Naloxone is a competitive antagonist that blocks opioids from binding to all three types of opioid receptors; naloxone is a pure opioid antagonist and does not cause any opioid-like effects (Go, 2022). Naloxone is used to 1) reverse sedation and respiratory depression caused by opioids/opiates and 2) as a diagnostic aid for patients with CNS depression and/or respiratory depression from an unknown cause (Go, 2022). Naloxone has been used to reverse the signs and symptoms of clonidine overdose (Smollin, 2022). However, this is an unlabeled use, and the effectiveness and safety of naloxone for treating clonidine overdose have not been proven (Bader et al., 2021).

  1. Administration:
    • IV push: Naloxone can be given IV, IM, SC, intranasally (IN), and as a nebulized solution (Go, 2022). The IV route is preferred, but IN naloxone is often used by emergency medical services (EMS) personnel (Go, 2022). The initial dose is 0.2 to 0.4 mg, given IV push (Albertson, 2022; Go, 2022). The dose can be repeated every 2 to 3 minutes until the patient responds (Go, 2022). The lowest effective dose is recommended (Nelson & Olsen, 2019). Doses of 10 to 20 mg may be needed to fully arouse patients (Albertson, 2022; Go, 2022).
    • IV infusion: The effects of naloxone only last 1 to 2 hours, much shorter than the effects of some opioids. The duration of effects of some of the opioids, like methadone and sustained-release preparations, is quite a bit longer (Albertson, 2022; Go, 2022). Repeat IV bolus doses can be given, but an IV infusion is more convenient. The dose is 0.4 to 0.8 mg/hour, and the infusion can be titrated as needed (Go, 2022). Another method can be used to give two-thirds of the initial successful dose each hour (Go, 2022).
  2. Adverse effects: Adverse effects of naloxone are very rare. They are caused by acute opioid withdrawal in opioid-dependent patients or the unmasking of the effects of another drug that the patient had taken (Go, 2022; Nelson & Howland, 2022). Signs and symptoms of acute opioid withdrawal include (but are not limited to) agitation, confusion, diarrhea, hypertension, nausea, seizure, tachycardia, and vomiting (Go, 2022).

Medication Errors

Medication errors account for over 98,000 deaths annually, a large part of healthcare costs (Pham et al., 2012). The Institute of Medicine revealed the seriousness of these errors and found that most were preventable (Kohn et al., 1999; Radley et al., 2013).

IV medications “are associated with the highest medication error frequencies and more serious consequences to the patient than any other administration route” (Kuitunen et al., 2021). Administering IV medications is an ongoing, multi-step, complicated task. IV medications are a common source of medication errors, and many of the classes of medications discussed in this module have been identified by the ISMP (2018) as high-alert medications.

Example: The ISMP considers anticoagulants to be high-alert medications, drugs that can cause significant harm if they are given incorrectly (ISMP, 2018), and the Joint Commission requires healthcare facilities to have approved protocols and evidence-based guidelines for the use of anticoagulants (UpToDate, 2022h).

The ISMP has published a list of high-alert medications in acute care settings. Examples of these drugs discussed in this course are listed in Table 6.

Table 6: High-Alert Medications in Acute Care Settings
Adrenergic agonists (Epinephrine, phenylephrine, norepinephrine)
Adrenergic antagonists (propranolol, metoprolol, labetalol)
Antiarrhythmics (lidocaine, amiodarone)
Anticoagulants (heparin)
Chemotherapeutic agents
Dextrose, hypertonic, 20% or greater
Moderate sedation agents, IV (lorazepam, midazolam)


IV medication therapy is a common form of therapy. It is often used for NPO patients who cannot tolerate other forms of administration and electrolyte imbalances. There are many complications of IV therapy, including infiltration and extravasation, that can severely affect the patient. Many medications can be administered via IV, but some are considered high-risk and require extra monitoring and laboratory testing. As medication errors are common, monitoring works to reduce these occurrences.

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Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.


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