20-40 mg IV or IM.

7,5 mg 1 hour prior.

5-10 mg IV; may repeat every 10-15 min; max 30 mg.

25-50 mcg IV, repeat every 15-20 min as needed; max 200 mcg

Status Asthmaticus and Anaphylactic Reaction

Adults
Solu-Cortef: Initial dose of 100–500 mg administered intramuscularly (i.m.) or intravenously (i.v.), occasionally higher doses may be necessary. Repeat every 2–6 hours as needed. For emergency initial treatment, IV injection is the preferred method; subsequently, consider using a longer-acting injectable or oral corticosteroid. Typically, high-dose therapy should be continued only until the patient’s condition stabilizes. If high-dose treatment is required for more than 48–72 hours, hydrocortisone should preferably be replaced with a glucocorticoid that causes less sodium retention, such as methylprednisolone.

In cases of liver disease, consider dose reduction.

1-2 g IV 30 min prior.

10 mg IV 30 min prior.

1-2 mg IV, titrated to effect; max 5 mg.

4-8 mg IV 30 min prior.

5-10 mg orally every 4-6 hours as needed for pain management; used post-procedure or if moderate to severe pain is anticipated.

1000 mg 1 hour before the procedure

Adrenaline injections are intended for intravenous (IV), intramuscular (IM), subcutaneous (SC), intraosseous, and intracardiac administration. Adrenaline 0.1 mg/ml is not suitable for IM or SC use. For adrenaline 1 mg/ml, it is advisable to dilute the solution before IV administration or to use the 0.1 mg/ml solution.

The auto-injectors of Emerade, Epipen, and Jext are exclusively designed for IM administration into the anterolateral part of the thigh, possibly through clothing.

Resuscitation

Adults
Adrenaline solution: 1 mg IV, intraosseous, or possibly intracardiac, as needed, repeated every 3–5 minutes until return of spontaneous circulation. After cardiac surgery cardiac arrest: 0.05–0.1 mg per dose, titrated to effect. Endotracheal administration: 2–2.5 mg per dose. However, endotracheal administration is not preferred according to the Resuscitation Council.

Anaphylaxis

Adults Adrenaline solution: 0.2–0.5 mg IM or SC; repeat as needed every 10–15 minutes; maximum of 1 mg per dose. With auto-injectors: 0.005–0.01 mg/kg body weight, occasionally more; the recommended dose is 0.3–0.5 mg IM per dose, with the possibility to repeat after 5–15 minutes.

Anaphylactic Shock

Adults
Adrenaline solution: 0.5 mg IM, followed by 0.025–0.05 mg IV, repeated as needed every 5–15 minutes; in critical situations: 0.1–0.25 mg IV, administered slowly at no more than 0.02 mg per minute (solution 0.1 mg/ml), repeated every 5–10 minutes as necessary. For IM use in this indication, the adrenaline solution should be 1 mg/ml.

Percutaneous Sclerotherapy with Aethoxysklerol in the Treatment of Simple Renal Cyst: A Five-Year Experience of a Single Institution All cysts were initially evaluated with US and if there was a suspicion of communication with the collecting system, contrast-enhanced CT or intravenous pyelography (IVP) was performed. Initial cyst puncture was done by an 18G needle under US guidance with the patient in the prone position under local anesthesia with lidocaine (Figure 1, 2). The first 10 ml of aspirate was taken for cytological and biochemical examination. In addition, a 2 ml sample of the fluid aspirated from the cyst was mixed with 2 ml of 95% ethanol. The sample was considered positive for protein if precipitation was immediately observed; otherwise, the sample was considered negative. Patients whose aspirate was negative for protein were not subjected to sclerotherapy as this might indicate that the cyst communicated with the collecting system. At the end of the aspiration, 2 ml of 1% aethoxysklerol was injected into the cystic cavity per 100 ml of cystic fluid aspirated. The patient was held in the supine, prone, and lateral decubitus positions for 5 minutes each to increase the contact between the surface of the cyst and the sclerosing agent. No attempt was made to aspirate or drain the sclerosing agent after instillation.

A 70% alcohol solution is ideal for stronger antimicrobial activity. Pure alcohol coagulates proteins on contact. When 70% alcohol is applied to a single-celled organism, the diluted alcohol coagulates the proteins more slowly, allowing it to penetrate the entire cell before coagulation occurs and blocks further activity.

(Sub)acute limb thrombosis

5 mg bolus, followed by 1.5 mg per hour infusion.

Anaesthesiology

Adults
Initial dose: 0.2 mg IV over 15 seconds; then, every 60 seconds, administer 0.1 mg additional until the desired level of consciousness is achieved. The usual dose ranges between 0.3–0.6 mg, with a maximum dose of 1 mg.

Intensive care

Adults
Initial dose of 0.3 mg IV. If the desired level of consciousness is not reached within 60 seconds, additional doses of 0.1 mg can be administered every 60 seconds until the goal is achieved; maximum of 2 mg. If drowsiness recurs, a second bolus injection may be given. Alternatively, treatment can be administered via infusion at a rate of 0.1–0.4 mg per hour (depending on the desired sedation level).

Sedation caused by benzodiazepines

Children > 1 year
Initial dose: 0.01 mg/kg body weight (up to 0.2 mg) IV over 15 seconds; if the desired level of consciousness is not achieved within 45 seconds, an additional dose of 0.01 mg/kg (up to 0.2 mg) can be given, then repeated every 60 seconds as needed (maximum 4 times, with a total dose of up to 0.05 mg/kg or 1 mg). There is no experience with repeated dosing in children if drowsiness reoccurs.

Sinus bradycardia and AV block

Adults
IV: 0.5 mg slowly, repeated as needed every 2–5 minutes; maximum total dose of 2 mg. Under ECG monitoring, 1–2 mg per dose, with a maximum total of 3 mg. In case of AV block, IV: 0.5 mg slowly, repeated every 3–5 minutes; maximum total dose of 3 mg.

Children 1 month – 18 years
According to the NKFK Pediatric Formulary: IV: 0.02 mg/kg body weight as a single dose; maximum 0.5 mg per dose, with a maximum of 1 mg per day.

Complicated urinary tract infections, including pyelonephritis

Adults and children ≥ 40 kg
IV or intramuscular: 1.5 g three times daily.

Children < 40 kg body weight
IV: 30–100 mg/kg body weight per day. For children older than 3 weeks, divided over 3–4 doses; for children up to 3 weeks old, divided over 2–3 doses.

Prophylaxis of postoperative infections

Adults
For gastrointestinal, gynecological, obstetric, and orthopedic surgeries: 1.5 g IV at anesthesia induction, followed if needed by 750 mg IM (or IV) after 8 and 16 hours.

For cardiovascular and esophageal surgeries: 1.5 g IV at induction, followed by 750 mg IM (or IV) after 8, 16, and 24 hours.

• Skin disinfection (alcoholic solution 0.5% FNA, sterile solution 1% FNA, impregnated cloth)
• Mucous membrane disinfection (irrigation 0.1% FNA, sterile solution 1% FNA)
• Wound disinfection (irrigation 0.1% FNA, sterile solution 1% FNA)
• Preoperative hand disinfection (Hibiscrub)
• Preoperative disinfection of the surgical site (Hibiscrub, impregnated cloth, Chloraprep solution)
• Bacterial skin infections (cream 1% FNA)
• Urethra disinfection during bladder catheterization or cystoscopy (Cathejell S catheter lubricant)

Adults
Oral: 500–750 mg twice daily, for at least 10 days. In certain specific cases (e.g., abscesses), the treatment duration may be longer than 21 days.

The NHG Guideline on Urinary Tract Infections (2013) recommends a treatment duration of 14 days for men.

For detailed dosing and treatment duration, refer to the SWAB advice on pyelonephritis.

This medication is also dosed based on blood levels; for more information, see the Amiodarone TDM monography at tdm-monografie.org.

The 200 mg tablets have a score line. Whether they can be split into equal doses or only to make swallowing easier depends on the specific preparation.

Before intravenous administration, dilute the contents of the ampoule; do not use a concentration lower than 300 mg/500 ml (due to solution stability) or higher than 1500 mg/500 ml (due to the risk of phlebitis).

When providing a repeated or continuous infusion, administration via a central line is recommended to minimize the risk of phlebitis.

Adults
According to the NHG Pharmacotherapeutic Guideline on Medications and Oxygen in Emergency Situations (2020):

Intramuscular or Intravenous: 4–8 mg per dose.

Adults
Oral: Typically 2–5 mg 2–3 times per day, with a maximum of 30 mg per day, divided over 2–4 doses. Do not use the maximum dose for longer than 4 weeks.

Intramuscular/Intravenous: In acute situations, 0.1–0.2 mg/kg every 8 hours, repeated until acute symptoms diminish.

Rectal: 5–10 mg 2–3 times per day; maximum of 60 mg per day.

Elderly and patients with liver impairment
Oral: Start with 2–2.5 mg once or twice daily.

Adults
It is advisable to keep the dose as low as possible in cases of shock due to heart failure. Four dosing levels with corresponding effects are distinguished:

• IV infusion: 1–2 microg/kg/min continuously up to approximately 20 microg/kg/min Effect: Improves renal blood flow and glomerular filtration.
• IV infusion: 2–10 microg/kg/min Effect: Increases cardiac output without significantly raising pulse rate or blood pressure.
• IV infusion: 10–20 microg/kg/min Effect: Raises blood pressure through vasoconstriction.
• IV infusion: > 20 microg/kg/min Effect: Causes generalized vasoconstriction, which may reduce renal blood flow again. The desired therapeutic effect usually occurs at infusion rates below 20 microg/kg/min. However, in some cases of severe circulatory failure, doses exceeding 50 microg/kg/min have been used.

Adults < 60 years and children > 12 years
IV: 2–2.5 mg slowly (1 mg over 30 seconds) 5–10 minutes before the procedure. If necessary, additional doses of 1 mg can be administered, up to a total dose of 3.5–7.5 mg.

Elderly, weakened, and chronically ill patients
Lower initial IV dose of 0.5–1 mg. If needed, follow-up doses of 0.5–1 mg should be given very slowly and carefully titrated. A total dose of approximately 3.5 mg is generally sufficient.

Children 6–12 years
IV: initial dose of 0.025–0.05 mg/kg (administered slowly over 2–3 minutes, then wait 2–5 minutes before starting the procedure or repeating the dose). A total dose up to 0.4 mg/kg may be required, with a maximum of 10 mg.

Rectally: 0.3–0.5 mg/kg.

Children ½–5 years
IV: initial dose of 0.05–0.1 mg/kg (administered slowly over 2–3 minutes, then wait 2–5 minutes before starting the procedure or repeating the dose). A total dose up to 0.6 mg/kg may be needed, with a maximum of 6 mg.

Rectally: 0.3–0.5 mg/kg.

Administer doses > 0.2 mg only under mechanical ventilation. Administer slowly over 1–2 minutes (to reduce the risk of muscle rigidity).

Note! In elderly patients (> 65 years), those with renal insufficiency, and weakened patients, use lower doses and monitor carefully for signs of toxicity. For patients with a BMI > 30 kg/m², dose based on estimated fat-free body weight to prevent (relative) overdose; titrate cautiously based on clinical effect.

Adults (< 65 years) and children > 12 years:
Initial dose generally 50–100 micrograms (0.7–1.4 microg/kg) administered slowly IV in combination with an antipsychotic such as droperidol. Repeat if necessary after 30–45 minutes.

For neuroleptanesthesia under mechanical ventilation, the initial dose is typically 200–600 micrograms (2.8–8.4 microg/kg) administered slowly IV with an antipsychotic like droperidol. Supplementary doses of 50–200 micrograms (0.7–2.8 microg/kg) can be given every 30–45 minutes as needed.

Kidney Dialysis

Adults
For continuous infusion: prior to dialysis, administer 4 nanograms/kg body weight per minute intravenously for 15 minutes; during dialysis, administer 4 nanograms/kg/min in the arterial blood flow directed toward the dialyzer. Stop administration at the end of dialysis.

Pulmonary Arterial Hypertension

Adults
Short-term titration to determine the infusion rate for continuous administration:

IV via a peripheral or central deep venous line: starting dose of 2 nanograms/kg/min; then, increase every 15 minutes or longer in steps of 2 nanograms/kg/min until the maximum hemodynamic effect is achieved or dose-limiting pharmacological effects occur. If the initial infusion rate of 2 nanograms/kg/min is not tolerated, use a lower dose.

Continuous infusion Via a central venous catheter: start with a concentration 4 nanograms/kg/min lower than the maximum tolerated dose determined during titration. For a maximum tolerated dose of 5 nanograms/kg/min or less, begin the continuous infusion at 1 nanogram/kg/min. During chronic continuous infusion, increase the infusion rate in steps of 1–2 nanograms/kg/min with at least 15-minute intervals, guided by the effect, blood pressure, and heart rate. Dose reduction (in the case of dose-dependent pharmacological effects) should be gradual, with reductions of 2 nanograms/kg/min every 15 minutes or longer, except in life-threatening situations.

Forced Diuresis

Adults

IV: 20–40 mg per dose, administered in combination with fluid and electrolyte therapy.

For further details, consult the Pharmacotherapeutic Compass.

Adults

Volume: 500 ml to 3 liters per 24 hours.

Infusion rate:

The typical infusion rate is approximately 40 ml/kg/24 hours and should never exceed the patient's capacity to metabolize glucose, to prevent hyperglycemia. Therefore, the maximum infusion rate in acute cases is 5 mg/kg/min.

Pediatric Patients

The dosage depends on the child's weight:

• 0 to 10 kg: 100 ml/kg/24 hours
• 10 to 20 kg: 1000 ml + (50 ml/kg above 10 kg) / 24 hours
• 20 kg and more: 1500 ml + (20 ml/kg above 20 kg) / 24 hours
  
  Infusion rate:
  
  
• 0 to 10 kg: 6–8 ml/kg/hour
• 10 to 20 kg: 4–6 ml/kg/hour
• 20 kg and more: 2–4 ml/kg/hour
  
  To prevent hyperglycemia, the infusion rate should not exceed the patient’s capacity to metabolize glucose. In acute situations, the maximum infusion rate is 10–18 mg/kg/min, depending on the total body weight. For all patients, a gradual increase in the infusion rate should be implemented at the start of glucose therapy.

Treatment of Thromboembolic Disorders

Intravenous (IV)
Initial dose: 5,000 IU, followed by 20,000–40,000 IU per 24 hours, administered as an infusion in 5% glucose or 0.9% NaCl solution — approximately 15–25 IU/kg body weight per hour. Adjust doses based on coagulation testing or heparin monitoring.

Subcutaneous (SC)
2,500 IU per 10 kg body weight every 12 hours. An initial IV loading dose of 5,000 IU may be administered beforehand.

For more information read the manual

Status Asthmaticus and Anaphylactic Reaction

Adults
Solu-Cortef: Initial dose of 100–500 mg administered intramuscularly (i.m.) or intravenously (i.v.), occasionally higher doses may be necessary. Repeat every 2–6 hours as needed. For emergency initial treatment, IV injection is the preferred method; subsequently, consider using a longer-acting injectable or oral corticosteroid. Typically, high-dose therapy should be continued only until the patient’s condition stabilizes. If high-dose treatment is required for more than 48–72 hours, hydrocortisone should preferably be replaced with a glucocorticoid that causes less sodium retention, such as methylprednisolone.

In cases of liver disease, consider dose reduction.

Angina Pectoris

Adults
Oral: Immediate release tablets or tablets: starting dose of 80 mg 3 to 4 times daily. If needed, increase to a standard maintenance dose between 320 and 480 mg per day; maximum of 720 mg per day for several weeks. Controlled-release tablets: Starting dose of 240 mg once daily; if necessary, increase to a maintenance dose of 240 mg twice daily.

Hypertension

Adults
Oral: Immediate release tablets or tablets: starting dose of 80 mg 3 to 4 times daily. If needed, increase to a maintenance dose between 320 and 480 mg daily; maximum of 720 mg per day for several weeks. Controlled-release tablets: Starting dose of 120 mg once in the morning. If needed, increase to a maintenance dose of 240 mg once daily. If the blood pressure remains insufficiently controlled, add an evening dose of 120–240 mg.

Arrhythmias such as SVES and increased ventricular rate in atrial fibrillation and flutter

Adults
Oral: Immediate release tablets or tablets: starting dose of 80 mg 3 to 4 times daily. If needed, increase to a standard maintenance dose of 320–480 mg per day; maximum of 720 mg for several weeks. Intravenous injection: 5–10 mg administered slowly (max 5 mg/min) under observation and ECG monitoring; repeat if necessary after 30 minutes. IV infusion (under observation and ECG control): To achieve a plasma concentration of 150 ng/mL, administer: initial IV injection of 5–10 mg in 2 minutes, then a loading infusion of 0.187–0.375 mg/min for 30 minutes, followed by a maintenance infusion of 0.0625–0.125 mg/min. Max infusion rate: 5 mg/min. Dilute the injectable solution with glucose, fructose, or saline before use.

Children
Oral: Immediate release tablets or tablets: limited to paroxysmal supraventricular arrhythmias under careful monitoring: 4–8 mg/kg body weight per day, divided into 3 doses. IV: Only in severe resistant supraventricular tachycardia: under intensive monitoring, 0.1 mg/kg body weight.

Hypertrophic Obstructive Cardiomyopathy

Adults
Oral: Immediate release tablets or tablets: starting dose of 80 mg 3 to 4 times daily. If needed, increase to a maintenance dose between 320 and 480 mg per day; maximum of 720 mg for several weeks.

Prophylaxis of Myocardial Infarction

Adults
Oral: Immediate release tablets or tablets: 360 mg daily divided into multiple doses. Start treatment in the second week after a myocardial infarction. Controlled-release tablets: 360 mg per day, divided into 2 doses. Begin in the second week post-infarction.

Off-label Prophylaxis for Cluster Headaches

Adults
Oral: Immediate release tablets or tablets: under ECG monitoring and in consultation with a neurologist, start with 240 mg per day, increasing every 2 weeks by 80 mg to a typical maintenance dose of 480 mg/day; maximum 720 mg/day. Taper off verapamil when the cluster period is likely over. For the next cluster period, start at the minimum effective dose. ECG monitoring is always essential.

Perioperatieve profylaxe

Volwassenen
Pre-operatief: 30 minuten tot 1 uur vóór de start van de operatie i.v. 1000 mg. Bij langdurige operaties (2 uur of langer) tevens: i.v. 500–1000 mg toedienen gedurende de operatie. Postoperatief: i.v. 500–1000 mg elke 6–8 uur gedurende 24 uur; bij operaties waarbij het ontstaan van infecties een groot risico vormt (zoals open-hartoperatie of prothetische artroplastiek) gedurende 3–5 dagen na het einde van de operatie.

Chronic Heart Failure or Supraventricular Arrhythmias

Adults and children aged 10 years and older
Rapid digitalization: Oral: 0.75–1.5 mg in a single dose. If less urgent or in patients with higher risk of toxicity (elderly, renal impairment), the total loading dose should be reduced by up to 50% and divided into multiple doses (e.g., 50%–25%–25%) with intervals of 6 hours. After 24 hours, initiate an individual maintenance dose. Before administering each part of the loading dose, assess the clinical response to the previous dose.

According to the NHG Standard for Atrial Fibrillation: In adults with atrial fibrillation, administer 0.75 mg once. In patients with higher risk of toxicity, including those over 70 years, with impaired kidney function (eGFR < 50 mL/min), or body weight under 55 kg, give 0.125 mg three times daily, followed by a maintenance dose.

Intravenous infusion
0.5–1 mg divided into doses (50%–25%–25%) over 4–8 hours, then continue with the maintenance dose. If in the previous two weeks cardiac glycosides have been used, start with a lower initial dose. Before administering each part of the loading dose, assess the clinical response to the previous dose.

Slow digitalization
Oral: 0.25–0.75 mg daily for one week, then switch to maintenance dosing.

Maintenance dose
Oral (and IV): generally 0.125–0.25 mg daily (see below for calculations). Sometimes a lower dose per day (0.0625 mg or less) may be appropriate. According to the NHG Standard for Atrial Fibrillation: In adults with atrial fibrillation, 0.25 mg once daily orally; In patients at higher risk of toxicity, including those over 70 years, with renal impairment (creatinine clearance <50 mL/min), or body weight under 55 kg: 0.125 mg once daily; For patients over 85 years or with multiple risk factors, 0.0625 mg daily. Dose titration should be guided by ventricular rate control.

According to the ESC guidelines for Atrial Fibrillation: In adults, 0.125–0.5 mg once daily.

Anesthesia

Adults

• Injectable solution: epidural 5–7.5 mg/mL. A bolus of 10–20 mL administered over 5 minutes. For cesarean section, epidural 5 mg/mL: 15–30 mL over 15–20 minutes, maximum total dose 150 mg.
• Intrathecal 5 mg/mL: 3 mL.
• Perineural (peripheral nerve): 2.5–5 mg/mL: 1–40 mL, maximum 150 mg.
• Peribulbar block: 7.5 mg/mL: 5–15 mL.
• Local infiltration: 2.5 mg/mL: 1–60 mL, maximum 150 mg.

Pain management

Adults

Injectable solution: epidural 2.5 mg/mL.

• During labor: 6–10 mL per dose, with intervals of more than 15 minutes between injections.
• Epidural infusion 1.25 mg/mL: 4–10 mL per hour, up to 12.5 mg/hour.
• Postoperative: 10–15 mL per hour, maximum 18.75 mg/hour.

Epidural infusion solution (1.25 mg/mL)

• For continuous postoperative epidural infusion (10–15 mL/hour): 12.5 to a maximum of 18.75 mg/hour.
• For lumbar epidural analgesia during labor (4–10 mL/hour): 5 to maximum 12.5 mg/hour.

Localized Anesthetic

Adults and children > 12 years:

• General guidelines: The dosages below are based on a typical adult weighing approximately 70 kg. Adjust the dose according to the patient's age, weight, and condition. The numbers given reflect the expected dosing margin needed. Use the minimum effective dose and do not exceed the maximum.
• Maximum dose for an adult (70 kg): 200 mg lidocaine without adrenaline per administration; with adrenaline, up to 500 mg lidocaine per administration.
• Preference: Use lidocaine without preservative; do not use vials containing preservatives for intrathecal, intracisternal, intraorbital, or retrobulbar injections.
  
  

Anesthesia during surgery

• Lumbar epidural block: (20 mg/mL) 300–500 mg; onset in 15–20 minutes; duration 2–3 hours (with adrenaline).
• Thoracic epidural block: (20 mg/mL) 200–300 mg; onset in 10–20 minutes; duration 1.5–2 hours (without adrenaline); 2–3 hours (with adrenaline).
• Caudal epidural block: (10 mg/mL) 200–300 mg; onset in 15–30 minutes; duration 1–2 hours (with adrenaline); or (20 mg/mL) 300–500 mg; onset in 15–30 minutes; duration 2–3 hours (with adrenaline).
• Intravenous block (Bier’s block): (5 mg/mL) 200–300 mg; onset in 10–15 minutes; duration >20 minutes (without adrenaline).
• Intra-articular block: (10 mg/mL) maximum 400 mg; onset in 5–10 minutes; duration 30–60 minutes after 'wash out'.
• Infiltration anesthesia: (10 mg/mL) maximum 400 mg; onset in 1–2 minutes; duration 2–3 hours (without adrenaline); 3–4 hours (with adrenaline).
• Finger block: (10 mg/mL) 10–50 mg; onset 2–5 minutes; duration 1.5–2 hours (without adrenaline).
• Intercostal nerve block: (10 mg/mL) 20–50 mg per nerve, up to 8 nerves; onset 3–5 minutes; duration 1–2 hours (without adrenaline); 3–4 hours (with adrenaline).
• Retrobulbar block: (20 mg/mL) 80 mg; onset 3–5 minutes; duration 1.5–2 hours (without adrenaline).
• Peribulbar block: (10 mg/mL) 100–150 mg; onset 3–5 minutes; duration 1.5–2 hours (without adrenaline).
• Pudendal block: (10 mg/mL) 100 mg; onset 5–10 minutes; duration 1.5–2 hours (without adrenaline); 2–3 hours (with adrenaline).
• Otolaryngology (excluding tonsillectomy): (20 mg/mL) 10–200 mg.
• Tonsillectomy (bilateral): (10 mg/mL) 100–150 mg.
  

Large nerve blocks

• Paracervical block (bilateral): (10 mg/mL) 100 mg; onset 3–5 minutes; duration 1–1.5 hours (without adrenaline); 2–2.5 hours (with adrenaline).
• Peripheral nerve block: (10 mg/mL) 30–200 mg; or (20 mg/mL) 60–400 mg.
• Brachial plexus block: (10 mg/mL) 400–500 mg; onset 15–30 minutes; duration 3–4 hours (with adrenaline).
• Subclavian block: (10 mg/mL) 300–400 mg; onset 15–30 minutes; duration 3–4 hours (with adrenaline).
• Sciatic nerve block: (20 mg/mL) 300–400 mg; onset 15–30 minutes; duration 3–4 hours (with adrenaline).
• 3-in-1 block (femoral, obturator, lateral cutaneous): (10 mg/mL) 300–400 mg; onset 15–30 minutes; duration 2–4 hours (with adrenaline).

Sympathetic nerve blocks

• Stellate ganglion block: (10 mg/mL) 75–100 mg.
• Lumbar sympathetic block: (10 mg/mL) 75–100 mg.
• Children 1–12 Years
• (10 mg/mL): Maximum 5 mg/kg (without adrenaline) or 7 mg/kg (with adrenaline).
• In obese children, base the dosage on ideal body weight.

Ventricular Arrhythmias

Adults
Administer intravenously under ECG monitoring; for prolonged treatment (via infusion), base dosing on clinical response, plasma concentration (1.5–6 micrograms/mL), and QRS duration on ECG.

• Initial dose: 50–100 mg IV (or approximately 1 mg/kg as a guideline) given as a bolus over 1–2 minutes (effects typically within 1–2 minutes, duration 15–20 minutes).
• Repetition: If necessary, repeat once or twice after 5–10 minutes with 25–100 mg injections.
• Maintenance infusion: 2–4 mg/min (1–2 mg/mL); maximum 200–300 mg/hour.
• During infusion: If ventricular tachycardia recurs, a small bolus of 0.5 mg/kg can be administered prior to increasing the infusion rate.
• Special considerations: Reduce dose in elderly, patients with impaired renal function, or liver failure. Start with a lower dose in patients with decreased cardiac function.

It is recommended to continue infusion for at least 24 hours after the last episode of ventricular tachycardia. Use preservative-free solutions for IV injections.

Patients with Impaired Renal Function
Adjust dose or prolong dosing intervals to minimize dose-dependent side effects. Guidelines for dosing intervals based on creatinine clearance:

• 50 mL/min: 4-hour intervals
• 10–50 mL/min: 6–12-hour intervals
• <10 mL/min: 8–24-hour intervals
  
  

Children

• According to the manufacturer: IV dose of 0.5–1 mg/kg body weight over 1 minute; repeat as needed up to a total of 3–5 mg/kg, possibly followed by continuous infusion of 10–50 micrograms/kg/min.
• According to the NKFK Pediatric Formulary: starting dose of 1 mg/kg/dose over 2–3 minutes, repeat after 5–10 minutes if necessary, and possibly repeat once more.
• Maximum total dose: 3 mg/kg/day.

Deep Vein Thrombosis

Adults
Administer as an IV infusion: 4,400 IU per kg of body weight over 10–20 minutes, followed by 100,000 IU per hour for 2–3 days. In patients at higher risk, give 15,000 IU over 10–20 minutes, followed by 40,000–60,000 IU per hour for 2–3 days. If the desired effect is not achieved after 72 hours, the dose may be increased. It is crucial that the infusion rate remains constant during administration.

Pulmonary Embolism

Adults
Administer IV infusion: 4,400 IU per kg of body weight over 10–20 minutes, followed by 4,400 IU per kg per hour for 12 hours. If the desired effect is not observed after 24 hours, the dose can be increased. Again, maintaining a constant infusion rate is essential.

Peripheral Arterial Occlusion

Adults
Administer 4,000 IU per minute via intra-arterial catheter during the first 2–4 hours or until antegrade flow is restored, then reduce to 1,000–2,000 IU per minute. Discontinue administration when lysis is complete, angiography shows no further progression, or after 48 hours.

Thrombosed Shunts

Adults
Inject 5,000–25,000 IU/mL dissolved in 0.9% NaCl or sterile water for injections into both branches of the arteriovenous shunt, then occlude the shunt. If necessary, repeat after 30–45 minutes.

Adults
Immediate-release tablet: As monotherapy or in combination with other oral blood glucose-lowering agents, start with 500 mg or 850 mg two to three times daily, taken during or after meals. After 10–15 days, adjust the dose based on blood glucose levels, up to a maximum of 3000 mg/day, divided into three doses. For high daily doses of metformin (2000–3000 mg/day), two 500 mg tablets can be replaced with one 1000 mg tablet.

Modified-release (Glucient) tablet
As monotherapy or combined with other oral agents, start with 500 mg once daily during the evening meal. After 10–15 days, titrate the dose in steps of 500 mg based on blood glucose, up to a maximum of 2000 mg once daily with the evening meal. If glycemic control remains inadequate at 2000 mg once daily, consider increasing to 1000 mg twice daily (morning and evening meals). If insufficient effect persists, switch to immediate-release tablets, with a maximum dose of 3000 mg/day.

Transitioning from immediate-release to modified-release tablets
The daily dose should be equal to the current total daily dose of immediate-release metformin. Administer this once daily during the evening meal, up to a maximum of 2000 mg/day.

Switching from another oral glucose-lowering agent to metformin
Discontinue the other medication and start with the initial dose of metformin as described above.

Combination of metformin and insulin
Begin metformin at the usual starting dose while adjusting insulin dosage based on blood glucose levels.

Renal impairment
Assess risk factors for lactic acidosis before and during treatment (see also Warnings and Precautions). For immediate-release tablets, in patients with creatinine clearance between 60 and 89 mL/min, the maximum is 3000 mg/day divided into 2–3 doses; consider dose reduction with declining renal function. In patients with creatinine clearance between 45 and 59 mL/min, the maximum is 2000 mg/day in 2–3 doses, with a starting dose no more than 1000 mg/day. For creatinine clearance between 30 and 44 mL/min, the maximum is 1000 mg/day in 2–3 doses, starting doses no more than 500 mg/day.

Adolescents and children ≥ 10 years
Immediate-release tablets: Start with 500 mg or 850 mg once daily. After 10–15 days, adjust the dose based on blood glucose levels, with a maximum of 2000 mg/day divided into two or three doses.

Clonidine can enhance the effects of opioid preparations and sedatives in ICU patients, potentially allowing for dose reduction.

Acute and Chronic Severe Pain

Adults

• Oral: 10–20 mg per dose, as needed every 4 hours. Transition from parenteral to oral: Typically, higher doses (50–100% more) are required to achieve adequate analgesia.
• Subcutaneous or intramuscular: 5–20 mg (usually 10 mg) per dose, as needed every 4 hours.
• Intravenous: 2.5–15 mg in 4–5 mL over 4–5 minutes.
• Epidural (Sendolor): Starting dose 5 mg; if pain relief is insufficient, repeat after 1 hour with 1–2 mg, as needed. Max 10 mg per day.
• Epidural infusion (Maracex): Starting dose 2–4 mg; if necessary, repeat after 6–24 hours with 1–2 mg. The manufacturer of Sendolor recommends: opioid-naïve patients: initial dose 3.5–7.5 mg per 24 hours, increasing by 1–2 mg daily if needed. Patients with some opioid tolerance: 4.5–10 mg per 24 hours. During treatment, the dose may significantly increase, sometimes requiring 20–30 mg/24 hours, or even 100 mg in late stages of disease or in long-term treatment.
• Intrathecal: 0.2–1 mg once, preferably not repeated. Dose reduction possible when combined with bupivacaine.
• Implanted micro-infusion system: Dose may gradually increase up to 25 mg per day after 40 weeks of continuous therapy.
• Rectal: 10–20 mg per dose, as needed every 4 hours.
  
  

Elderly Patients
Usually 5–10 mg per dose. When administered IV, IM, or subcutaneously, starting at 2.5 mg may be appropriate. Begin with a lower dose and titrate according to response. Clearance is slower; dose reduction or extended dosing intervals may be necessary, especially with ongoing morphine therapy.

Kidney Impairment

Due to decreased renal clearance, serious side effects may occur because an active metabolite is excreted via the kidneys. Titrate cautiously; in moderate impairment (creatinine clearance 30–60 mL/min), maintain 75% of the normal dose. In severe impairment (<30 mL/min), maintain 50% of the usual dose interval.

Liver Impairment

Elimination half-life increases. Consider halving the dose frequency in severe liver dysfunction (doubling the interval between doses).

Guideline for Sedation and/or Analgesia (PSA) Outside the Operating Room

General:
Morphine acts on opioid receptors, altering pain perception and emotional response.

Well-absorbed after subcutaneous and intramuscular administration. Maximal analgesia occurs within 50–90 minutes after subcutaneous injection, 30–60 minutes after IM, and 20 minutes IV. Effects can last up to 7 hours. Approximately 70% of morphine is metabolized in the liver into inactive metabolites, and about 3% into the active 6-glucuronide metabolite, which crosses the blood-brain barrier and has a stronger analgesic effect. 90% of morphine and its metabolites are excreted via urine; the remaining 10% via feces, largely through biliary excretion.

Side Effects

• Central nervous system: Respiratory depression, cough suppression, mood changes, miosis, hypothermia.
• Nausea and vomiting due to direct stimulation of the chemoreceptor trigger zone.
• Rarely, seizures reported.
• Gastrointestinal and biliary system: Reduced gastric motility and emptying, decreased secretion from liver, intestines, and pancreas, increased colonic tone leading to spasms, constipation, biliary colic, and urinary retention.
• Can prolong labor by decreasing uterine motility.
• Histamine release: Urticaria and pruritus.
• Cardiovascular: generally minor in a supine patient at low doses: peripheral vasodilation, reduced peripheral resistance, baroreceptor reflex.
• Orthostatic hypotension and syncope may occur upon standing.
• High doses can cause hypotension and bradycardia even when lying down.

Precautions / Contraindications

Morphine should not be used in cases of acute respiratory depression, obstructive pulmonary disease, cyanosis, brain trauma, increased intracranial pressure, coma, diarrhea caused by pseudomembranous colitis due to antibiotics, diarrhea from poisoning, ileus, or hypersensitivity.

Caution is advised in elderly patients, children, and patients with hypothyroidism, myxedema, cardiovascular disease, gallbladder disease or gallstones, recent urinary or gastrointestinal surgery, chronic respiratory conditions, epilepsy, concomitant treatment with MAO inhibitors, liver impairment, severe renal impairment, or prostate hypertrophy. Children are particularly sensitive, especially to respiratory depression.

Pregnancy
As far as is known, morphine is not harmful to the fetus if administered well before labor. However, when given shortly before (2–3 hours) or during delivery, it can cause respiratory depression and irreversible damage to the neonate, with increased risk in preterm infants.

Notes: In cases of poor circulation, morphine should be administered slowly via IV, as subcutaneous absorption will be minimal.

CNS Respiratory Depression Due to Opioids

Adults (including the elderly)
Initial dose: 0.1–0.2 mg (¼–½ of a 1 mL ampoule) administered intravenously (IV). If the desired level of antagonism and respiratory function improvement is not immediately achieved, repeat 0.1 mg (¼ mL IV) every 2–3 minutes as needed. After 1–2 hours, additional injections may be necessary depending on the response, dosage, and duration of the administered opioid.

Children
According to the manufacturer: starting dose of 0.01–0.02 mg/kg body weight, with intervals of 2–3 minutes until the desired level of consciousness and respiration is achieved. After 1–2 hours, additional doses may be required depending on the response, dosage, and duration of action of the opioid given.

According to the NKFK Pediatric Formulary, in children aged 1 month to 18 years with suspected or known opioid overdose: IV or IM bolus of 0.01 mg/kg body weight per dose, maximum 0.4 mg per dose. Repeat if no effect after 3 minutes. In cases of opioid overdose during anesthesia or post-operative pain management: 0.001–0.01 mg/kg per dose, maximum 0.1 mg per dose. Titrate doses based on respiratory rate and the desired level of analgesia and consciousness. After high doses, morphine-mimetics are inactive for several hours.

Neonates Whose Mothers Used Opioids
According to the manufacturer: the typical dose is 0.01 mg/kg IV. If respiratory function is not adequately improved, repeat every 2–3 minutes as needed. If IV administration is not possible, IM injection can be used, starting with 0.01 mg/kg.

According to the NKFK Pediatric Formulary, in term neonates: Maximum dose per administration is 0.1 mg/kg (either IV or IM).

Diagnosis and Treatment of Suspected Opioid Overdose

Adults
Initial dose usually 0.4–2 mg IV. If respiratory function does not improve immediately, repeat every 2–3 minutes as needed. If IV access is not feasible, administer 0.4–2 mg IM. If 10 mg does not produce significant improvement, consider alternative causes for respiratory depression besides opioids.

Children
Initial dose typically 0.01 mg/kg IV. If the desired clinical response is not achieved, increase the dose to up to 0.1 mg/kg at the next dose. Depending on the individual response, a continuous IV infusion may be necessary. If IV administration is not possible, IM naloxone can be given, starting at 0.01 mg/kg.

Acute Angina Pectoris Attack

Adults (including the elderly)
Administer 1–2 sprays under the tongue at the onset of an attack. If needed, repeat after 5 minutes. If there is no sufficient effect after a total of 3 doses, contact a healthcare professional immediately.

Prophylaxis of Expected Angina Pectoris Attacks

Adults (including the elderly)
Before situations of emotional stress or physical exertion, spray 1–2 times under the tongue.

Off-label Use: Acute Heart Failure

Adults
According to the 2010 Multidisciplinary Heart Failure Guidelines: for pulmonary congestion/oedema with systolic blood pressure > 90 mmHg, administer 0.8–1.6 mg via spray per dose every 3 minutes until symptoms improve sufficiently or systolic BP drops below 90 mmHg.

Unstable Angina Pectoris, Including Prinzmetal Angina

Adults
Start with 10 micrograms per minute; this can be increased every approximately 30 minutes in steps of 10 micrograms per minute until the desired effect is achieved. The dosing typically ranges from 5 to 200 micrograms per minute.

During Heart Surgery to Prevent Hypertensive Periods and/or Myocardial Ischemia

Adults
For blood pressure control: Start with 25 micrograms per minute, then gradually increase in steps of 25 micrograms per minute every 5 minutes, with careful blood pressure monitoring. For prevention of myocardial ischemia: Start with 15–20 micrograms per minute, then increase in steps of 10–15 micrograms per minute until the desired effect is achieved.

Individual dosing can vary widely, often requiring doses from 10 to 200 micrograms per minute, and in some surgical procedures, up to 400 micrograms per minute may be necessary.

Left-sided Heart Failure, Especially During the Acute Phase of Infarction

Adults
According to the manufacturer of Nitro Pohl: Start with 5 micrograms per minute, then increase gradually every 5 minutes under clinical supervision and precise blood pressure measurement. Individual doses can vary significantly, sometimes by a factor of 10; typical doses range from 5 to 200 micrograms per minute.

Acute Heart Failure

Adults
According to the generic manufacturer, the recommended starting dose is 20–25 micrograms per minute, which can be reduced to 10 micrograms per minute or increased every 15–30 minutes in steps of 20–25 micrograms until the desired effect is achieved. According to the 2010 Multidisciplinary Heart Failure Guidelines: For pulmonary congestion/oedema with systolic blood pressure > 90 mmHg, administer intravenously, starting with 10–20 micrograms per minute, up to a maximum of 200 micrograms per minute.

One or more drops may be used per application into the conjunctival sac as needed.

Gently pressing on the tear duct or keeping the eyes closed for 3 minutes can reduce the risk of systemic reactions and enhance local effectiveness.

Adults
Oral: 500–1000 mg per dose, as needed, every 4 or 6 hours.

Patients ≥ 16 years
0.3–4.0 mg/kg/hour administered via continuous infusion. The maximum rate is 4 mg/kg/hour.

GUIDELINE FOR SEDATION AND/OR ANALGESIA (PSA) OUTSIDE THE OPERATING ROOM GENERAL INFORMATION
Propofol is a short-acting sedative/hypnotic agent with a narrow therapeutic window. Loss of consciousness occurs within 1 minute after injection. It is a lipophilic compound processed in an emulsion containing egg lecithin and fractionated soybean oil. Propofol is metabolized in the liver into inactive metabolites, which are approximately 90% excreted in the urine. The elimination occurs in two phases with half-lives of approximately 40 minutes and 3 hours or more. For short procedures (less than 1 hour), distribution and initial elimination determine the clearance. Propofol is preferably administered via continuous infusion. Its controllability can be further improved using Target-Controlled Infusion (Diprifusor®), enabling rapid and easy achievement of a preset plasma concentration of propofol.

ADVERSE EFFECTS
Approximately 30% of patients experience pain at the injection site, which can be prevented by administering 20 mg of lidocaine intravenously just before the infusion. Other possible side effects include transient excitation, brief apnea, hypotension, bradycardia, and thrombophlebitis. Short-term agitation and euphoria with uninhibited fantasies may occur after stopping propofol administration.

CAUTIONS / CONTRAINDICATIONS
Starting doses do not need adjustment in patients with liver or kidney impairment. Propofol should not be used in children under 3 years, as safety and efficacy have not been established in this age group. Children generally require higher doses than adults. Side effects are less frequently observed in children compared to adults. Regarding use during pregnancy, human data are limited; no evidence of harm has been found in animal studies.

SPECIAL CONSIDERATIONS
Because propofol is formulated in an emulsion (Diprivan®), it must not be administered through a membrane filter. Dilution should not exceed 1:5; exclusively use 5% glucose for dilution. The concentration must not be less than 2 mg/mL. The effect of propofol is non-antagonizable. Propofol is not approved for indications other than general anesthesia in children under 16 years.

IMPORTANT WARNING
In recent years, several case reports have described the "Propofol Infusion Syndrome," a rare but often fatal condition characterized by lactic acidosis, hyperlipidemia, and cardiac failure (Cremer 2001; Fudickar 2006). This syndrome can occur after prolonged infusion of high doses of propofol. Therefore, current recommendations advise limiting propofol infusion to no more than 72 hours at a maximum dose of 5 mg/kg/hour.

Inactivering van Heparine

Volwassenen
Op geleide van bloedstollingstesten.

Matig tot ernstige bloedingen na iv Heparine

Volwassenen
Flacon van 1000 IE/ml zeer langzaam i.v. injecteren; zo nodig met intervallen van 15 minuten één of meerdere keren herhalen.

Adults (< 65 years) and children aged 12 years and older

Induction of anesthesia (in combination with a hypnotic such as propofol or thiopental)
The recommended IV bolus is 10–40 micrograms per kilogram of body weight in healthy adults.

Maintenance of anesthesia
For procedures lasting less than 10 minutes: generally, a bolus of 7–30 micrograms/kg (1.0–4.2 ml for a 70 kg individual) is sufficient. If the procedure exceeds 10 minutes, supplement this dose with additional doses of 7–15 micrograms/kg (1.0–2.1 ml for 70 kg) every 10–15 minutes or as needed.

For procedures lasting 10–30 minutes
An initial IV bolus of 10–30 micrograms/kg (1.4–4.2 ml for 70 kg); For procedures lasting 30–60 minutes: A bolus of 30–50 micrograms/kg (4.2–7.0 ml for 70 kg).

If the procedure continues or becomes more painful
Administer an additional dose of 10–15 micrograms/kg (1.4–2.1 ml for 70 kg) every 10–15 minutes (but avoid during the last 10 minutes of the procedure to prevent postoperative respiratory depression), or as a continuous infusion at a rate of 1 microgram/kg/minute (0.14 ml per 70 kg per minute).

For longer procedures
Adjust the IV bolus dose individually and tailor the infusion rate based on the severity of surgical stimuli and patient responses.

Before the end of the procedure
Discontinue administration 10 minutes before the end of injections, or 5–10 minutes before the end of infusion.

In patients with chronic opioid use or a history of opioid addiction, a higher dose may be necessary.

Elderly (> 65 years), and patients with liver or kidney impairment
Reduce the dosage in older and weakened patients. For liver or renal insufficiency, lower doses may be appropriate.

Note
Alfentanil clearance remains unchanged in renal failure; however, the free fraction is increased, which may necessitate a lower dose.

General information
Alfentanil is a synthetic opioid with potent analgesic properties. Its pain-relieving effect is almost immediate, reaching maximum within a few minutes and lasting 10–20 minutes. It is metabolized in the liver into inactive metabolites. The half-life is approximately 80 minutes.

Depending on the medication to be dissolved.

Anaphylaxis and Angioedema

Adults 2 mg IV, with the option to repeat after 15 minutes if necessary.

Children > 1 year According to the manufacturer: 0.025 mg/kg per day, administered in 2 doses.

Children > 1 month
According to the NKFK Pediatric Formulary: 0.025–0.050 mg/kg per dose, maximum of 2 doses per day, administered IM, IV, or orally.

Prophylaxis

Adults 2 mg IV administered immediately before a potential anaphylactic or histamine-triggered reaction.

Use only the thrombin component (Component 2). The amount administered depends on the size of the aneurysm.

General Infections

Adults and children ≥ 12 years
Standard dosage: 960 mg twice daily. For severe infections, dose is increased to 1.5 times the standard dose. Treatment duration: For acute infections, prescribe cotrimoxazole until 2 days after symptoms resolve, with a minimum of 5 days. If no clear clinical improvement is observed after 7 days, reconsider the treatment. For prolonged therapy, the dose is usually halved after 14 days.

Children aged 1 month to < 18 years According to the NKFK Pediatric Formulary: 18 mg/kg body weight twice daily, maximum of 1920 mg/day. According to the manufacturer: children from 6 weeks to < 18 years should receive 18 mg/kg twice daily. This translates into the following standard oral doses per age group when using tablets or suspension:

• 6 weeks to 6 months: 120 mg twice daily
• 6 months to 6 years: 240 mg twice daily
• 6 years to 12 years: 480 mg twice daily
• For severe infections, use 1.5 times this dosage.
  
  

Treatment duration
For acute infections, cotrimoxazole is given until 2 days after symptoms disappear, with at least 5 days of therapy. If no significant clinical improvement occurs after 7 days, reconsider the treatment. For long-term therapy, the dose is typically halved after 14 days.

Off-label Treatment of Complicated Infections

Adults and children ≥ 12 years
According to the NHG standard for urinary tract infections (2013): for tissue-invasive urinary tract infections in non-pregnant women, administer 960 mg twice daily. Treatment duration: 10 days. In men, the dosing and duration are the same, but treatment extends to 14 days.

Note: Reassess the indication for use in patients with a urinary catheter; if the catheter remains indicated, replace it before the end of the course if it persists.

Children < 12 years
According to the NHG standard for urinary tract infections (2013): 18 mg/kg twice daily, maximum of 1920 mg per day. Treatment duration: 10 days.

Sclerotherapy with Use of Doxycycline after Percutaneous Drainage of Postoperative Lymphoceles Mark V. Caliendo, MD et al

PURPOSE To assess the use of doxycycline as a sclerosing agent after percutaneous drainage of postoperative lymphoceles.

MATERIALS AND METHODS Symptomatic postoperative lymphoceles ( n = 21) in 18 patients were treated by percutaneous tube drainage for an average of 10.8 days. Sclerosis was performed when the patient became asymptomatic, drainage had slowed to less than 30 mL/d and follow-up imaging (CT or US) showed either near complete or total resolution of the lymphocele. Doxycycline (500 mg) combined with 1% lidocaine (5 mL) was instilled into the cavity with use of a syringe after any remaining lymphocele fluid was removed through the tube. When possible, patients were instructed to perform a series of maneuvers for the next hour to distribute the sclerosing agent evenly throughout the cavity. After 1 hour, the sclerosing agent was aspirated from the cavity and the drainage tube was removed. Three patients with four lymphoceles underwent sclerotherapy immediately after percutaneous insertion of a drainage tube and aspiration of the lymphocele. No patients underwent previous sclerosis with any agent.

RESULTS Successful treatment of postoperative lymphoceles was achieved in 17 of 18 patients. Primary success was achieved in 17 of 21 lymphoceles treated. There were four lymphocele recurrences in three patients. Three of the four recurrences were successfully treated by means of repeated drainage and sclerotherapy. One recurrent lymphocele persisted after re-treatment with1gof doxycycline. This patient underwent successful surgical repair. There were no complications related to doxycycline sclerosis. The mean duration of drainage for initial and recurrent lymphoceles was 10.8 days (range, 0–30 days).

CONCLUSION Sclerotherapy with use of doxycycline after percutaneous drainage is an easy, safe, inexpensive, and effective means of treating postoperative lymphoceles.