Bolus Administration Protocol

General Principles of Bolus Administration

Most IV bolus medications should be given slowly over 1-2 minutes to minimize adverse effects and allow for assessment of patient response, as recommended by the American Heart Association 1, 2

Adenosine should be administered as a 6 mg rapid IV push over 1-3 seconds, followed immediately by saline flush, with a potential second dose of 12 mg after 1-2 minutes if ineffective, according to the American College of Cardiology 1
Diltiazem should be administered as a 15-20 mg (0.25 mg/kg) IV over 2 minutes, with a potential repeat dose of 20-25 mg (0.35 mg/kg) after 15 minutes, as recommended by the American Heart Association 1
Esmolol should be administered as a loading dose of 500 mcg/kg over 1 minute, as recommended by the American College of Cardiology 1, 2
Labetalol should be administered as a 0.3-1.0 mg/kg (maximum 20 mg) slow IV injection every 10 minutes, according to the American Heart Association 2
Phentolamine should be administered as a 5 mg IV bolus, with additional doses every 10 minutes as needed, as recommended by the American College of Cardiology 2
Hydralazine should be administered as a 10 mg via slow IV infusion (maximum initial dose 20 mg), with repeat doses every 4-6 hours, according to the American Heart Association 2
Enalaprilat should be administered as a 1.25 mg over 5 minutes, with a potential increase up to 5 mg every 6 hours, as recommended by the American College of Cardiology 2

Intra-arterial blood pressure monitoring is recommended when administering sodium nitroprusside to prevent "overshoot" hypotension, as recommended by the American Heart Association 2
Monitor for bradycardia when administering beta-blockers or calcium channel blockers, according to the American College of Cardiology 1
A defibrillator should be readily available when administering adenosine due to risk of precipitating atrial fibrillation, as recommended by the American Heart Association 1
If a patient requires 2 bolus doses within 1 hour, it is reasonable to double the continuous infusion rate for opioids and sedatives, according to the Society of Critical Care Medicine 3, 4
Reduce doses in elderly patients, those with renal or hepatic impairment, and post-cardiac transplant patients, as recommended by the American College of Cardiology 1
Never administer boluses too rapidly, as this increases risk of hypotension, bradycardia, and other adverse effects, according to the American Heart Association 1, 2
Avoid bolus administration in patients with contraindications specific to each drug class, such as beta-blockers in asthma or calcium channel blockers in heart failure, as recommended by the American College of Cardiology 1