MOH/F/FAR/122.

24(GU)-e
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

FIRST EDITION (APRIL 2024)

Published by:
Pharmaceutical Services Programme
Ministry of Health (Malaysia)
Lot 36, Jalan Prof Diraja Ungku Aziz
46200 Petaling Jaya
Selangor, Malaysia.
Tel: 03-7841 3200
Website: pharmacy.gov.my

© All Rights Reserved

This document is copyrighted. The publication of the Dilution Guide for Fluid Restricted
Critically Ill Adults was coordinated by the Pharmaceutical Care Subdivision of the
Pharmacy Practice & Development Division, Ministry of Health Malaysia. The publisher
reserves copyright and renewal on all published materials and such material may not be
reproduced in any form without permission from the publisher.

Limitation of Liability:
While every effort was made to ensure the accuracy and relevance of the information
contained in this guideline, the committee assume no liability for inaccuracies or
misstatements in this document. Please use the guideline judiciously, and only apply the
minimum volumes where the clinical situation makes it necessary. It is important to note
that the information on suggested minimum dilution for each drug may differ from one
facility to another, depending on the brand of the drug used in a particular facility.

2
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

FOREWORD

Madam Wan Noraimi binti Wan Ibrahim

Director of Pharmacy Practice and Development
Division
Ministry of Health Malaysia

Critical care is a highly specialized and dynamic field that

requires close monitoring, timely interventions, and a
coordinated effort among healthcare providers to optimize
patient outcomes. The care of critically ill patients requires a
coordinated and multidisciplinary approach, involving intensivists, nurses, pharmacists,
and other healthcare professionals.
Critical care pharmacy services are essential to ensure the safe and effective use of
medications in critically ill patients. Critical care pharmacists contribute to various
aspects of patient care, from medication management to collaboration with the
multidisciplinary team and involvement in research and education.
Fluid restriction is one of the interventions implemented in critical care setting to manage
conditions that can be exacerbated by excessive fluid such as renal dysfunction and
electrolyte imbalances.
The recommended dilution for certain medications may not be applicable to patients with
fluid restriction. Thus, this guideline is developed to provide essential information to
Critical Care Pharmacists in ensuring critically ill patients receive safe and effective
medications.
We hope this guideline serves as a valuable reference for pharmacists managing critically
ill patients.

3
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

PREFACE
Critically ill patients are individuals with severe and often life-threatening
medical conditions that require round-the-clock monitoring and care by a
specialized team of healthcare professionals. The treatment of critically ill
patients involves a combination of advanced medical technology,
medications, and expert medical care aimed in stabilizing their condition and
facilitate the recovery process.

Pharmacotherapy in critically ill patients often requires many special

considerations. One of the most common and important consideration in
critically ill patients is fluid restriction. It is of utmost importance for
healthcare providers to carefully monitor fluid requirements and fluid intake
which should be tailored to each patient's unique needs to avoid any
unnecessary complications. Hence, it is often a challenge for Critical Care
Pharmacists to recommend the most judicious volume for drug dilution prior
to its administration.

The aim of this guideline is to provide practical guide for pharmacists in

managing patients with fluid restriction where normal recommendation for
certain drug dilution may not be feasible.

The working committee hopes that this document will be a useful guide for
Critical Care Pharmacists as well as other healthcare professionals involved
in the management of patients in this area.

4
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

ADVISORS

WAN NORAIMI BINTI WAN IBRAHIM

Director of Pharmacy Practice and Development Division
Pharmaceutical Services Programme
Ministry Of Health Malaysia

SYAHIDA BINTI CHE EMBI

Deputy Director of Pharmacy Practice and Development Division
Pharmaceutical Services Programme
Ministry Of Health Malaysia

5
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

EDITORS & CONTRIBUTORS

CLINICAL PHARMACY WORKING COMMITTEE
(CRITICAL CARE SUBSPECIALTY)

Alia Hayati binti Baharudin Nicole Foo Yen Fei

Hospital Tuanku Fauziah Hospital Umum Sarawak

Andrew Yem Weng Hoong Nurul Akma binti Hanan

Hospital Kuala Lumpur Hospital Tuanku Ja’afar

Charlene Tay Szu Lynn Nurul Hidayah binti Awang

Hospital Kuala Lumpur Pharmacy Practice & Development
Division
Chong Lai Peng
Hospital Melaka Dr. Rahela Ambaras Khan
Hospital Kuala Lumpur
Faridah Yusof
Hospital Sultanah Bahiyah Ros Sakinah binti Kamaludin
Hospital Raja Permaisuri Bainun
Ignatius Leon Guang Woei
Hospital Selayang Roslita binti Alivi
Hospital Sultanah Aminah
Jerry Liew Ee Siung
Hospital Queen Elizabeth Siti Amira Syarina binti Mohd Kasim
Hospital Putrajaya
Lee Yee Lin
Hospital Tengku Ampuan Afzan Siti Nur Aziela Binti Ab Manap
Hospital Raja Perempuan Zainab II
Lim Shiao Hui
Hospital Pulau Pinang Siti Nuraidah binti Mamat
Hospital Sultanah Nur Zahirah
Mardhiyah binti Kamal
Pharmacy Practice & Tan Guo Hong
Development Division Hospital Sultanah Bahiyah

EXTERNAL REVIEWERS

DR. MUHAMMAD ZIHNI BIN ABDULLAH DR. NORYANI BINTI MOHD SAMAT
Consultant Intensivist Consultant Intensivist
Hospital Tengku Ampuan Afzan Hospital Sultan Ismail Petra

MR. TAN CHEE CHIN

Pharmacist
Hospital Sultan Ismail

6
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

CONTENT
DRUG PAGE
NUMBER
Acetylcysteine 11
Acyclovir 12
Adenosine 13
Adrenaline 14
Alteplase 15
Amikacin 16
Aminophylline 17
Amiodarone 18
Amoxycillin/Clavulanate 19
Amphotericin B Sodium Deoxycholate 20
Amphotericin B Lipid complex 21
Ampicillin 22
Ampicillin/Sulbactam 23
Anidulafungin 24
Artesunate 25
Atracurium Besylate 26
Atropine 27
Azithromycin 28
Benzylpenicillin 29
Bromhexine 30
Calcitonin (Synthetic salmon calcitonin) 31
Calcium Gluconate 10% 32
Caspofungin 33
Cefazolin 34
Cefepime 35
Cefoperazone 36
Cefoperazone/Sulbactam 37
Cefotaxime 38
Ceftazidime 39
Ceftriaxone 40
Cefuroxime 41
Chlorpheniramine 42
Ciprofloxacin 43
Cisatracurium 44
Clindamycin 45
Cloxacillin 46
Colistimethate (Polymyxin E) 47
Co-trimoxazole 48
Cyanocobalamin 49
Dantrolene 50
Daptomycin 51
Desmopressin 52
Dexamethasone 53
Dexmedetomidine 54
Diazepam 55
Digoxin 56
Dobutamine 57
Dopamine 58
Ephedrine 59
Ertapenem 60

7
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

Erythromycin 61
Esmolol 62
Esomeprazole 63
Factor VIII (Human blood coagulation factor VIII) 64
Factor VIII/VWF (Human blood coagulation factor VIII and Von Willebrand 65
Factor Complex)
Factor IX (Human Coagulation Factor IX) 66
Factor VIIa (Eptacog alfa) 67
Fentanyl 68
Filgrastim (Recombinant Human Granulocyte Colony-stimulating Factor) 69
Fluconazole 70
Frusemide 71
Fusidic acid 72
Ganciclovir 73
Gentamicin 74
Glucagon 75
Glyceryl trinitrate 76
Glycopyrrolate 77
Granisetron 78
Haloperidol 79
Heparin 80
Human Albumin 20% 81
Human Albumin 25% 82
Hydralazine 83
Hydrocortisone 84
Iloprost 85
Imipenem/Cilastatin 86
Immunoglobulin G 87
Insulin Regular 88
Iron Dextran 89
Iron Sucrose 90
Isoprenaline 91
Isosorbide dinitrate 92
Ketamine 93
Labetalol 94
Leucovorin Calcium 95
Levetiracetam 96
Levofloxacin 97
Lignocaine 98
Linezolid 99
Magnesium Sulphate 100
Mannitol 101
Meropenem 102
Methylene Blue 103
Methylprednisolone 104
Metoclopramide 105
Metronidazole 106
Micafungin 107
Midazolam 108
Milrinone 109
Morphine 110
Moxifloxacin 111
Naloxone 112
Neostigmine 113

8
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

Nimodipine 114
Noradrenaline 115
Octreotide 116
Omeprazole 117
Ondansetron 118
Pamidronate 119
Pantoprazole 120
Paracetamol 121
Parecoxib 122
Parentrovite 123
Pentamidine 124
Phenobarbital Sodium 125
Phenylephrine 126
Phenytoin 127
Phytomenadione 128
Piperacillin/tazobactam 129
Piracetam 130
Polymyxin B 131
Potassium Chloride 132
Potassium Dihydrogen Phosphate 133
Pralidoxime 134
Procyclidine 135
Propofol 136
Protamine 137
Prothrombin Complex Concentrate (Factor II, IX & X) 138
Prothrombin Complex Concentrate (Factor II, VII, IX & X and Protein C & S) 139
Rasburicase 140
Remifentanil 141
Rocuronium 142
Salbutamol 143
Sodium Bicarbonate 144
Sodium Glycerophosphate 145
Sodium Nitroprusside 146
Sodium Valproate 147
Streptokinase 148
Streptomycin 149
Sugammadex 150
Suxamethonium 151
Tenecteplase 152
Terlipressin 153
Tetanus Immunoglobulin (Human) 154
Thiamine 155
Thiopental Sodium 156
Tigecycline 157
Tocilizumab 158
Tramadol 159
Tranexamic Acid 160
Triamcinolone Acetonide 161
Urokinase 162
Vancomycin 163
Vasopressin 164
Verapamil 165
Voriconazole 166
Zoledronic Acid 167

9
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

ABBREVIATIONS
bpm Beats per minute
D5 5% dextrose and water
g Gram
HCl Hydrochloride
IM Intramuscular
IT Intrathecal
IU International unit
IV Intravenous
kg Kilogram
mcg Microgram
mg Milligram
min Minute
ml Milliliter
mmol Millimol
MU Million units
NS Normal saline
RT Room temperature
SC Subcutaneous
VF Ventricular fibrillation
VT Ventricular tachycardia
w/v Weight over volume
WFI Water for injection

10
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

ACETYLCYSTEINE 5 G/25 ML
Brand name Hidonac

Reconstitution Not required

Suggested
Central: No further dilution required
minimum
Peripheral: 150 mg/kg in 200 ml
dilutions

Diluent D5, NS

I. IV infusion (Paracetamol poisoning – 3 bags regime, 21 hours):

150 mg/kg in 200 ml over 15 minutes, followed by
50 mg/kg in 500 ml over 4 hours, then
100 mg/kg in 1000 ml over 16 hours

II. IV infusion (Paracetamol poisoning – 2 bags regime, 20 hours):

200mg/kg in 250 ml over 4 hours
100mg/kg in 500 ml over 16 hours
Administration
III. IV infusion (Acute hepatic failure, non-paracetamol induced) [off-label dosage]:
150 mg/kg/hr for 1 hour, followed by
12.5 mg/kg/hr for 4 hours, then
6.25 mg/kg/hr for 67 hours

IV. IV infusion (Prophylaxis for radiographic contrast nephropathy) [off-label dosage]:

Dilute 600 – 1200 mg in 50 – 100 ml, infuse over 30 – 60 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 24 hours

Comments -
1. Alfasigma S.p.A. N-Acetylcysteine (Hidonac) Product Leaflet. Revised 18 Jan 2016.
2. Chiew AL et al. Summary statement: new guidelines for the management of
paracetamol poisoning in Australia and New Zealand. Med J Aust. 2015 Sep
7;203(5):215-8. doi: 10.5694/mja15.00614
3. Lee WM, Hynan LS, Rossaro L, et al. Intravenous N-acetylcysteine improves
transplant-free survival in early stage non-acetaminophen acute liver failure.
Gastroenterology. 2009;137:856–864.e1.
References 4. Sun Z, Fu Q, Cao L, Jin W, Cheng LL, Li Z. Intravenous N-acetylcysteine for
prevention of contrast-induced nephropathy: A meta-analysis of randomized,
controlled trials. PLoS ONE. 2013;8(1).
5. Truven Health Analytics. Micromedex.
6. United Kingdom Clinical Pharmacy Association. Minimum Infusion Volumes for
Critically Ill Patients. 4th ed. December 2012.
7. Wong A et al. Efficacy of two bag acetylcysteine regimen to treat paracetamol
overdose (2NAC study). Lancet. 2020; 20

11
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

ACYCLOVIR 250 MG
Brand name Vaxcel Acyclovir

Reconstitution Reconstitute 1 vial with 10 ml WFI or NS

Suggested
minimum Maximum concentration of 5 mg/ml (250 mg in 50 ml)
dilutions
Diluent HS, NS

Administration IV infusion: Infuse over at least 1 hour

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 48 hours

 Higher concentration (>10mg/ml) may produce phlebitis or inflammation

Comments
at the injection site.
1. Kotra Pharma. Vaxcel Acyclovir 250mg Product Leaflet. Revised 2 April
2019.
References 2. Truven Health Analytics. Micromedex.
3. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.

12
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

ADENOSINE 6 MG/2 ML
Brand name Adenorythm

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable

Administration IV bolus: Administer over 2 seconds

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

 Administer through a peripheral vein (using large bore cannula) only. Do

not administer through central line (may cause prolonged asystole).
Comments
 If given into an IV line, it should be injected as proximally as possible,
and followed by a rapid saline flush.
1. Truven Health Analytics. Micromedex.
References 2. Vanex S. A. Adenorythm Solution for Injection 3 mg/ml Product Leaflet.
Revised March 2016.

13
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

ADRENALINE 1 MG/1 ML
Brand name CCM Adrenaline

Reconstitution Not required

IM, SC, IV bolus

No further dilution required
Suggested
minimum
IV infusion
dilutions
Peripheral: Maximum concentration of 0.06 mg/ml (3 mg/50 ml)
Central: Maximum concentration of 0.12 mg/ml (6 mg/50 ml)

Diluent D5, NS
IM, SC
Administration IV bolus: Administer over at least 1 minute
IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 24 hours

 Administration via central line is recommended.

Comments  If administered peripherally (<24 hours), monitor IV site for blanching and
extravasation.
1. Duopharma (M) Sdn. Bhd. Adrenaline (CCM Adrenaline) Product Leaflet.
Revised 8 July 2011.
2. Lexi-Comp Inc. Lexi-Drug©. Version 6.4.0.
References 3. Truven Health Analytics. Micromedex.
4. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.

14
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

ALTEPLASE 50 MG
Brand name Actilyse

Reconstitution Reconstitute with 50 ml sterilized water (provided in package)

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable
I. Myocardial infarction:
Accelerated infusion (total 90 minutes) or 3 hours infusion regimen. Refer
to institution protocol

II. Acute ischemic stroke:

Administration 0.9 mg/kg (not to exceed 90 mg total dose) infused over 60 minutes with
10% of the total dose administered as an initial intravenous bolus over 1
minute

III. Pulmonary embolism:

IV infusion over 2 hours

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Reconstitution 24 hours 8 hours

 The reconstituted solution may be further diluted with NS up to a minimal

Comments
concentration of 0.2 mg/ml.
1. Boehringer Ingelheim Pharma GmbH & Co. Actilyse® Product Leaflet.
References
Revised 28 March 2020.

15
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

AMIKACIN 500 MG/2 ML

Brand name Apalin

Reconstitution Not required

Suggested
minimum Required dose to be diluted up to 50 ml
dilutions
Diluent D5, NS

Administration IV infusion: Infuse over 30 – 60 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution 60 days 24 hours

 Usual dilution 500 mg in 100 – 200 ml of diluent (Concentration of 2.5 –

Comments
5 mg/ml).
1. Duopharma (M) Sdn. Bhd. Apalin Product Leaflet. Revised 12 April 2019.
References 2. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.

16
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

AMINOPHYLLINE 250 MG/10 ML

Brand name Aminophyllin IV Fresenius

Reconstitution Not required

Suggested
Peripheral: Maximum concentration of 1 – 2 mg/ml
minimum
Central: No further dilution required
dilutions
Diluent NS
IV infusion
Administration Loading dose: Infuse over 20 – 30 minutes
Maintenance dose: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 24 hours

Comments -
1. Fresenius Kabi. Aminophylline IV Fresenius Product Leaflet. Revised
February 2017.
2. McAuley D. [Internet]. Aminophylline Dilution. GlobalRPh; 2017.
Available from: https://globalrph.com/dilution/aminophylline/
3. Riaz M, Ami KH. Stability of aminophylline. Pakistan journal of
pharmaceutical sciences. 1993 Jan;6(1):35–44.
References
4. Schull PD. McGraw-Hill's I.V. Drug Handbook. New York: McGraw-Hill
Medical; 2009.
5. Truven Health Analytics. Micromedex.
6. Uptodate. Aminophylline Drug Information. Wolters Kluwer.
7. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.

17
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

AMIODARONE HYDROCHLORIDE 150 MG/3 ML

Brand name Amiodarone HCL

Reconstitution Not required

IV bolus
Peripheral: Dilute to a maximum concentration of 2 mg/ml (150 mg in 75
ml)
Suggested Central: Dilute to a maximum concentration of 6 mg/ml (150 mg in 25 ml)
minimum
dilutions IV infusion
Peripheral: Dilute to a maximum concentration of 2 mg/ml (900 mg in 500
ml)
Central: Dilute to a maximum concentration of 18 mg/ml (900 mg in 50 ml)
Diluent D5
Loading dose
IV bolus (pulseless VT/VF): Administer rapidly
IV infusion: Infuse 150 mg over 10 minutes
Administration
Maintenance dose
IV infusion: Infuse 360 mg over 6 hours (1 mg/min) followed by 540 mg over
18 hours (0.5 mg/min) (total 900 mg over 24 hours). Infusion rate of 0.5
mg/min can be given if maintenance dose exceeds 24 hours.

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments  Concentrations less than 0.6 mg/ml are unstable.

1. Bioindustria L.I.M. Amiodarone HCL 150mg/3ml Injection Product
Leaflet. Revised November 2016.
2. Gahart BL, Nazareno AR. 2011 intravenous medications: A handbook for
Nurses and Health Professionals. 27th ed. St. Louis, MO: Elsevier
References Mosby; 2010.
3. Trissel LA. Handbook on Injectable Drugs. 13th ed. Bethesda, MD:
American Society of Health-System Pharmacists; 2005.
4. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.

18
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

AMOXYCILLIN/CLAVULANATE 1.2 G (AMOXICILLIN 1000 MG &

POTASSIUM CLAVULANATE 200 MG)
Brand name Clavicin

Reconstitution Reconstitute 1.2 g in 20 ml WFI

Suggested
minimum Not further dilution required
dilutions
Diluent Not applicable

Administration IV bolus: Administer over 3 – 4 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Reconstitution - 4 hours

Comments -

References 1. Mylan. Clavicin Product Leaflet. Revised October 2016.

19
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

AMPHOTERICIN B SODIUM DEOXYCHOLATE 50 MG

Brand name Amphotret

Reconstitution Reconstitute with 10 ml WFI

Suggested
Peripheral: Maximum concentration of 0.2 mg/ml (50 mg in 250 ml)
minimum
Central: Maximum concentration of 0.5 mg/ml (50 mg in 100 ml)
dilutions
Diluent D5

Administration IV infusion: Infuse over 4 – 6 hours

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

 To minimize infusion related immediate reactions; premedicate with the

following 30 – 60 minutes prior to administration: paracetamol,
diphenhydramine and/or hydrocortisone.
 A test dose of 1 mg in 20 ml D5, infuse over 20 – 30 minutes may be
Comments considered.
 Rapid infusion may cause hypotension, hypokalemia, arrhythmia, and
shock. Infusion related reactions can occur with all amphotericin B
formulations.
 Protect from light during administration.
1. Bharat Serums and Vaccines Ltd. Amphotret® 50mg product leaflet.
2. Gahart BL, Nazareno AR. 2011 intravenous medications: A handbook for
Nurses and Health Professionals. 27th ed. St. Louis, MO: Elsevier
References
Mosby; 2010.
3. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.

20
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

AMPHOTERICIN B LIPID COMPLEX 50 MG/10 ML

Brand name Ampholip

Reconstitution Not required

Suggested
minimum Maximum concentration of 2 mg/ml
dilutions
Diluent D5

Administration IV infusion: Infuse at a rate of 2.5 mg/kg/hour

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution 48 hours 6 hours

 Flush existing intravenous line with D5 before and after infusion.

Comments  If the infusion time exceeds 2 hours, mix the contents by shaking the
infusion bag every 2 hours.
1. Bharat Serums and Vaccines Ltd. Ampholip Injection Product Leaflet.
Revised 22 July 2020.
References
2. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.

21
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

AMPICILLIN 500 MG
Brand name Kampibiotic

Reconstitution Reconstitute with 10 ml WFI

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable
IV bolus (<1 g): Administer over 3 – 4 minutes
Administration
IV infusion (≥1 g): Infuse over 10 – 15 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments  Rapid infusion may cause seizures.

1. Gahart BL, Nazareno AR. 2011 intravenous medications: A handbook for
Nurses and Health Professionals. 27th ed. St. Louis, MO: Elsevier
References Mosby; 2010.
2. Karnataka Antibiotics & Pharmaceuticals Ltd. Kampibiotic 500 Injection
Product Leaflet. Revised 25 July 2017.

22
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

AMPICILLIN/SULBACTAM 1.5 G INJECTION

(AMPICILLIN 1000 MG & SULBACTAM 500 MG)
Brand name Amsubac

Reconstitution Reconstitute with 3.2 ml WFI

Suggested
minimum Maximum concentration of 45 mg/ml (9 g in 200 ml)
dilutions
Diluent D5, NS
IV bolus: Administer over 3 minutes
Administration IV infusion: Infuse over 15 – 30 minutes or as extended over 4 hours
(Dose>3 g)

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution 48 hours 8 hours

Comments -
1. Karnataka Antibiotics & Pharmaceuticals Ltd. Amsubac 1.5g Injection
References
Product Leaflet. Revised 23 January 2018.

23
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

ANIDULAFUNGIN 100 MG
Brand name Eraxis

Reconstitution Reconstitute with 30 ml WFI

Suggested
minimum Maximum concentration of 0.77 mg/ml (100 mg in 130 ml)
dilutions
Diluent D5, NS

Administration IV infusion: Infuse 100 mg over 90 minutes or 200 mg over 180 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 48 hours

 Infusion rate > 1.1 mg/min may cause histamine mediated reactions (i.e.
Comments
dyspnea, flushing, hypotension, pruritus, rash, urticaria).
1. Gahart BL, Nazareno AR. 2011 intravenous medications: A handbook for
Nurses and Health Professionals. 27th ed. St. Louis, MO: Elsevier
Mosby; 2010.
References 2. Pharmacia and Upjohn Company LLC. Eraxis Product Leaflet (Revised
11 August 2020).
3. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.

24
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

ARTESUNATE 60 MG
Brand name Artesun

Reconstitution Reconstitute with 5% sodium bicarbonate solution (provided)

Suggested
minimum Maximum concentration of 10 mg/ml (60 mg in 6 ml)
dilutions
Diluent D5, NS

Administration IV bolus: Administer over 1 – 2 minutes (3 – 4 ml/min)

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 1 hour

Comments -
1. Guilin Pharmaceutical Co. Ltd. Artesunate Powder for Injection 60 mg
Product Leaflet.
References
2. Lexi-Comp Inc. Lexi-Drug©. Version 6.4.0.
3. Truven Health Analytics. Micromedex.

25
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

ATRACURIUM BESYLATE 25 MG/2.5 ML & 50 MG/5 ML

Brand name Atracurium Kalceks

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable
IV bolus: Administer undiluted
Administration
IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments  May be further diluted to concentration of 0.5 – 5 mg/ml with D5 or NS.

1. HBM Pharma S.R.O. Atracurium Kalceks 10 mg/ml Solution for
Injection/Infusion Product Leaflet. Revised May 2020.
References
2. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.

26
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

ATROPINE 1 MG/1 ML
Brand name Atropine Sulphate

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable
IM: Administer to the outer thigh
SC
Administration
IV bolus: Administer undiluted
IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments -
1. Hua-Huat S, Lee-Gong L, Peng-Hong C, Hu M. Sarawak Handbook of
Medical Emergencies. Sarawak: C.E. Publishing; 2011.
References
2. Pharmaniaga. Atropine Sulphate 1mg/ml Injection Product Leaflet.
Revised 27 December 2017.

27
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

AZITHROMYCIN 500 MG
Brand name Vaxcel Azithromycin

Reconstitution Reconstitute 500 mg vial with 4.8 ml WFI

Suggested
minimum Maximum concentration of 2 mg/ml
dilutions
Diluent D5, NS

Administration IV infusion: Infuse over 1 hour

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution 7 days 24 hours

Comments -
1. Kotra Pharma. Vaxcel Azithromycin 500 mg IV for Infusion Product
References
Leaflet. Revised 27 April 2017.

28
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

BENZYLPENICILLIN SODIUM 1 MU (600 MG) & 5 MU (3 G)

Brand name Bepen Injection
Reconstitute 1 MU with 2 ml WFI
Reconstitution
Reconstitute 5 MU with 10 ml WFI
Suggested
minimum Maximum concentration of 60mg/ml (1 MU in 10ml)
dilutions
Diluent D5, NS

Administration IV infusion: Infuse over 30 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - Use immediately

Comments -
1. Gahart BL, Nazareno AR. 2011 intravenous medications: A handbook for
Nurses and Health Professionals. 27th ed. St. Louis, MO: Elsevier
References Mosby; 2010.
2. Karnataka Antibiotics & Pharmaceuticals Ltd. Bepen Injection Product
Leaflet. Revised 14 February 2017.

29
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

BROMHEXINE HYDROCHLORIDE 4 MG/2 ML

Brand name Mucolex

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable

Administration IV bolus: Administer over 2 – 3 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments -
1. Duopharma (M) Sdn. Bhd. Mucolex Injection Product Leaflet. Revised 8
References
Dec 2020.

30
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

CALCITONIN (SYNTHETIC SALMON CALCITONIN) 50 IU/1 ML & 100

IU/1 ML
Brand name Miacalcic

Reconstitution Not required

Suggested
IM, SC: No further dilution required
minimum
IV infusion: 5 – 10 IU/kg in 500 ml
dilutions
Diluent NS
IM: If exceed 2 ml for IM injection, prefer administration at varying sites
Administration SC
IV Infusion: Infuse over at least 6 hours

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments -
1. SolupharmPharmazeutischeErzeugnisse GmbH. Miacalcic® Ampoules
References
Product Leaflet. Revised Nov 2017.

31
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

CALCIUM GLUCONATE 10% 10 ML

(CONTAINS 1 G CALCIUM, EQUIVALENT TO 2.25 MMOL CALCIUM)
Brand name Calcium Gluconate 10% B.Braun

Reconstitution Not required

Suggested
IV bolus/infusion/continuous infusion: Maximum concentration of 50 mg/ml
minimum
(1 g in 20 ml)
dilutions
Diluent D5, NS

IV bolus (cardiac arrest/hyperkalemia): Not exceeding 200 mg/min

IV infusion (hypocalcemia): Not exceeding 50 mg/min
Administration
Continuous infusion (beta-blocker and calcium channel blocker toxicity):
Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution 24 hours Use immediately

 For patients in cardiac arrest, administer as a rapid bolus via a central

Comments
line.
1. B. Braun. Calcium Gluconate 10% Product Leaflet.
References 2. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.

32
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

CASPOFUNGIN 50 MG & 70 MG
Brand name Cancidas

Reconstitution Reconstitute with 10.5 ml NS or WFI

Suggested
70 mg (loading dose): Further dilute in 200 ml
minimum
50 mg (maintenance dose): Further dilute in 100 ml
dilutions
Diluent NS

Administration IV infusion: Infuse over 1 hour

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution 48 hours 24 hours

Comments  Dilution of 70 mg in single 100 ml IV bag not recommended

1. Merck Sharp & Dohme (M). Cancidas Product Leaflet.
2. MIMS Online. Cancidas [Internet]. MIMS. [cited 2022]. Available from:
References https://www.mims.com/
3. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.

33
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

CEFAZOLIN 1 G
Brand name Cefazolin Sandoz

IM: Reconstitute with 4 ml 0.5% lidocaine

Reconstitution
IV bolus, IV infusion: Reconstitute with 4 ml NS or WFI
Suggested
IM: No further dilution required
minimum
IV bolus, IV infusion: Maximum concentration of 20 mg/ml
dilutions
Diluent D5, NS
IM: Inject deep IM into large muscle mass
Administration IV bolus: Administer over 3 – 5 minutes
IV infusion (for doses >1 g): Infuse over 30 – 60 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - Use immediately

Comments -

References 1. Sandoz GmbH. Cefazolin Sandoz Product Leaftlet.

34
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

CEFEPIME 1 G
Brand name Vaxcel Cefepime

IM: Reconstitute with 3 ml diluent

Reconstitution
IV bolus, IV infusion: Reconstitute with 10 ml diluent
Suggested
IM, IV bolus: No further dilution required
minimum
IV infusion: Maximum concentration of 40 mg/ml (1 g in 25 ml)
dilutions
Diluent D5, NS
IM: Inject deep IM into large muscle mass
Administration IV bolus: Administer over 3 - 5 minutes
IV infusion: Infuse over 30 minutes or as extended up to 4 hours

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution 7 days 24 hours

Comments -

References 1. Kotra Pharma. Vaxcel Cefepime Product Leaflet.

35
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

CEFOPERAZONE 1 G & 2 G
Brand name Bicafar

Reconstitution Reconstitute with 5 ml of D5 or NS

Suggested
minimum Maximum concentration of 100 mg/ml
dilutions
Diluent D5, NS

IV bolus: Administer over 3 – 5 minutes

Administration
IV infusion: Infuse over 15 – 60 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - Use immediately

 Cefoperazone is incompatible with aminoglycosides, perphenazine or

Comments
pethidine hydrochloride.
References 1. Duopharma (M) Sdn. Bhd. Bicafar Cefoperazone Product Leaflet.

36
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

CEFOPERAZONE/SULBACTAM 1 G
Brand name Vaxcel Cefobactam

Reconstitution Reconstitute with 3.4 ml diluent

Suggested
minimum Further dilute in 20 ml
dilutions
Diluent D5, NS

IV bolus: Administer over 3 – 5 minutes

Administration
IV infusion: Infuse over 15 – 60 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - Use immediately

 No maximum concentration data available.

Comments  Should not be directly mixed with aminoglycoside due to physical
incompatibility.
References 1. Kotra Pharma. Vaxcel Cefobactam Product Leaflet.

37
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

CEFOTAXIME 500 MG & 1 G

Brand name Rekaxime

Reconstitution IM, IV: Reconstitute each 1 g with 4 ml WFI

Suggested
IV bolus: Further dilute 1 – 2 g in 10 ml
minimum
IV infusion: Further dilute 1 – 2 g in 40 – 100 ml
dilutions
Diluent D5, NS

IV bolus: Administer over 3 – 5 minutes

Administration
IV infusion: Infuse over 20 minutes (short) or 60 minutes (continuous drip)

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - Use immediately

Comments  Sodium bicarbonate must not be mixed with cefotaxime.

References 1. Duopharma (M) Sdn. Bhd. Rekaxime Cefotaxime Product Leaflet.

38
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

CEFTAZIDIME 1 G & 2 G
Brand name Cefatum

Reconstitution Reconstitute with 10 ml WFI

Suggested
minimum Maximum concentration of 40 mg/ml (1 g in 25 ml)
dilutions
Diluent D5, NS

IV bolus: Administer over 3 – 5 minutes

Administration
IV infusion: Infuse over 30 minutes or as extended over 4 hours

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution 7 days 12 hours

Comments -
1. Duopharma (M) Sdn. Bhd. Cefatum Ceftazidime Product Leaflet.
References 2. Pharmaceutical Services Division. Antibiotic Dilution Protocol. Penang
State Health Department; 2016.

39
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

CEFTRIAXONE 500 MG & 1 G

Brand name Unocef

IM: Reconstitute each 1 g with 3.6 ml D5 or NS

Reconstitution
IV infusion: Reconstitute each 1 g with 9.6 ml D5 or NS
Suggested
IM: No further dilution required
minimum
IV: Maximum concentration of 40 mg/ml (1 g in 25 ml)
dilutions

Diluent D5, NS
IM
Administration IV bolus: Administer over 3 – 5 minutes
IV infusion: Infuse over 30 minutes

Fridge (2 – 8°C) RT (< 25°C)

After
Stability Reconstitution 3 days 24 hours
(IM)
After Dilution (IV) 10 days 3 days

 Do not use diluents containing calcium, such as Ringer’s solution or

Comments
Hartmann’s solution, to reconstitute ceftriaxone.

References 1. Duopharma (M) Sdn. Bhd. Unocef Ceftriaxone Product Leaflet.

40
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

CEFUROXIME 750 MG & 1.5 G

Brand name Anikef
750 mg: Reconstitute with 6 ml WFI
Reconstitution
1.5 g: Reconstitute with 15 ml WFI
Suggested
IV bolus: No further dilution required
minimum
IV infusion: Further dilute in 50 ml
dilutions
Diluent D5, NS

IV bolus: Administer over 3 – 5 minutes

Administration
IV infusion: Infuse over 30 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution 7 days 24 hours

Comments  Incompatible with aminoglycosides.

References 1. Duopharma (M) Sdn. Bhd. Anikef Cefuroxime Product Leaflet.

41
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

CHLORPHENIRAMINE 10 MG/1 ML
Brand name Imach

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable

IM, SC
Administration
IV bolus: Administer over 1 minute

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments -
1. Gray AH. Injectable Drugs Guide. London: Pharmaceutical Press; 2011.
References 2. SM Pharmaceuticals Sdn. Bhd. Imach Chloramphenicol Maleate
Injection Product Leaflet.

42
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

CIPROFLOXACIN 200 MG/100 ML

Brand name Ciproxol

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable

Administration IV infusion: Infuse over 60 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

 Administer into a large vein to reduce risk of vein irritation. Slow infusion
Comments
can minimize risk of venous irritation.
1. Ain Medicare Sdn. Bhd. Ciproxol (Ciprofloxacin 0.2% w/v Intravenous
References
Infusion BP) Product Leaflet. Revised 25 September 2018.

43
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

CISATRACURIUM 2 MG/1 ML
Brand name Nimbex

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable
IV bolus: Administer over 5 – 10 seconds
Administration
IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

 Cisatracurium is stable only in acidic solution. It is not compatible with

Comments alkaline solutions with pH > 8.5.
 It is not compatible with ketorolac or propofol injectable emulsion.
1. Aspen SA Sterile Operations (Pty) Ltd. Nimbex (Intravenous Injection
Cisatracurium besylate) Product Leaflet. Revised 15 May 2022.
References 2. McAuley D. [Internet]. Nimbex-Cisatracurium. GlobalRPh;2017 [cited 1
Sept 2022]. Available from: https://globalrph.com/drugs/neuromuscular-
blocking-agents/#cisatracurium-nimbex.

44
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

CLINDAMYCIN 300 MG/2 ML

Brand name YSP Tidact

Reconstitution Not required

Suggested
minimum Maximum concentration of 18 mg/ml (900 mg in 50 ml)
dilutions
Diluent D5, NS

Administration IV infusion: Infuse over 10 – 60 minutes (not exceeding 30 mg/min)

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments -
1. Y.S.P. Industries (M). YSP Tidact 150 mg/ml Solution for Injection
References
Product Leaflet. Revised 27 April 2019.

45
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

CLOXACILLIN 500 MG
Brand name Cloxabiotic

Reconstitution IV: Reconstitute with 4.8 ml WFI

Suggested
IV bolus: No further dilution required
minimum
IV infusion: Further dilute to a maximum concentration of 50 mg/ml
dilutions
Diluent NS, D5

IV bolus: Administer over 10 minutes

Administration
IV infusion: Infuse over at least 30 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 24 hours

 Extending infusion over 60 minutes has been used for peripheral

Comments
administration to decrease risk of phlebitis.
1. Karnataka Antibiotics & Pharmaceuticals Ltd. Cloxabiotic Injection
Product Leaflet. Revised 12 February 2018.
2. Loeuille G, D'Huart E, Vigneron J et al. Stability Studies of 16 Antibiotics
for Continuous Infusion in Intensive Care Units and for Performing
References
Outpatient Parenteral Antimicrobial Therapy. Antibiotics (Basel).
2022;11(4):458.
3. MSF Medical Guidelines. [cited 31 Aug 2022]. Available from:
https://medicalguidelines.msf.org/en

46
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

COLISTIMETHATE (POLYMYXIN E) 1 MILLION UNITS (MU)

Brand name Xelcol

Reconstitution Reconstitute 1 MU with not more than 10 ml WFI or NS

Suggested
minimum Maximum concentration of 1 MU/5 ml (2 MU in 10 – 50ml)
dilutions
Diluent NS

Administration IV infusion: Infuse over 30 minutes – 1 hour

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments -
1. Lexi-Comp Inc. Lexi-Drug©. Version 6.4.0.
References 2. Xellia Pharmaceuticals ApS. Xelcol Product Leaflet. Revised 12 Oct
2020.

47
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

CO-TRIMOXAZOLE (SULFAMETHOXAZOLE 400 MG & TRIMETHOPRIM

80 MG)
Brand name Bactrim

Reconstitution Not Required

Suggested
minimum Maximum concentration of 1 ampoule (480 mg) in 75 ml
dilutions
Diluent D5

Administration IV infusion: Infuse over at least 90 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 2 hours

Comments -
1. Deva Holding A.S. Product Leaftlet Bactrim Inj 400 mg/80 mg.
References 2. NHS. Critical Care Intravenous Drug Administration Guide. 2008.
3. NHS. Pharmacy Drug Guideline Folder. 2017.

48
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

CYANOCOBALAMIN 1000 MCG/1 ML

Brand name Cyanocobalamin

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable

Administration IM, Deep SC

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

 Do not administer IV as it will result in most of the drug excreted rapidly

Comments
into the urine.
1. Mylan Pharmaceuticals ULC. Cyanocobalamin Injection USP 1000
mcg/ml Product Leaflet. Revised 23 May 2014.
References
2. Pharmaniaga. Cyanocobalamin 1000 mcg/ml Injection Product Leaflet.
Revised 6 Dec 2017.

49
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

DANTROLENE 20 MG
Brand name Dantrium

Reconstitution Reconstitute with 60 ml WFI

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable
IV bolus: Administer as rapid push
Administration
IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

 Stability of reconstituted solution: 6 hours at 15°C to 30°C.

Comments
 Protect from light.
1. Par Pharmaceutical, Inc. Dantrium Product Leaflet. Revised 23 Apr
References
2018.

50
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

DAPTOMYCIN 500 MG
Brand name Cubicin

Reconstitution Reconstitute with 10 ml NS

Suggested
minimum IV infusion: Further dilute required dose in 50 ml
dilutions
Diluent NS

Administration IV infusion: Infuse over 30 – 60 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

 To minimize foaming, avoid vigorous agitation or shaking of the vial

during or after reconstitution.
Comments
 Stability after reconstitution: 12 hours at room temperature, 48 hours at
2 – 8C.

References 1. Patheon Italia S.P.A. Cubicin Product Leaflet. Revised Feb 2021.

51
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

DESMOPRESSIN 4 MCG/1 ML
Brand name Minirin

Reconstitution Not required

SC
Undiluted
Suggested
minimum IV
dilutions Central diabetes insipidus: Undiluted
Haemophilia, von Willebrand’s Disease, & uremic bleeding: Further dilute
required dose in 50 ml
Diluent NS

SC
IV bolus (Central diabetes insipidus): Administer as IV push
Administration
IV infusion (Haemophilia, von Willebrand’s Disease, & uremic bleeding):
Infuse over 15 – 30 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments -
1. Ferring Pharmaceuticals. Minirin Product Leaftlet. Revised 1 May 2015.
2. McAuley D. [Internet]. Desmopressin (DDVAP) Dilution.
References GlobalRPh;2017. Available from:
https://globalrph.com/dilution/desmopressin-ddavp/
3. UpToDate. Desmopressin Drug Information. Wolters Kluwer.

52
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

DEXAMETHASONE 8 MG/2 ML
Brand name Penatone

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable
IM, SC
Administration
IV bolus/infusion: Administer over 5 – 15 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments  In shock and idiopathic thrombocytopenic purpura, use only the IV route.
1. Duopharma (M) Sdn. Bhd. Penatone Product Leaflet. Revised 11 Jul
References
2018.

53
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

DEXMEDETOMIDINE 200 MCG/2 ML

Brand name Precedex

Reconstitution Not required

Suggested
minimum Maximum concentration of 4 mcg/ml
dilutions
Diluent D5, NS

Administration IV infusion: Loading dose over 10 minutes followed by dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution 24 hours 24 hours

 Loading dose may be extended over 20 minutes to further reduce

Comments
vasoconstrictive effects.
1. Hospira Inc. Precedex Product Leaflet. Revised 4 Oct 2018.
2. McAuley D. [Internet]. Precedex-Dexmedetomidine Dilution. GlobalRPh;
References
2017. Available from: https://globalrph.com/dilution/precedex-
dexmedetomidine/

54
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

DIAZEPAM 10 MG/2 ML
Brand name Zopam

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable
IM
Administration
IV bolus: Administer not exceeding 5 mg/min

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments  Rapid injection may cause respiratory depression or hypotension.

1. SM Pharmaceuticals Sdn Bhd. Zopam Product Leaflet. Revised 23 Apr

References 2021.
2. UpToDate. Diazepam Drug Information. Wolters Kluwer.

55
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

DIGOXIN 0.5 MG/2 ML

Brand name Assos

Reconstitution Not required

Suggested
No further dilution required. However, minimum of 4-fold dilution with D5 or
minimum
NS is preferred (2 ml digoxin with 8 ml diluent)
dilutions
Diluent Not applicable
IV bolus: Administer over at least 5 minutes
Administration
IV infusion: Infuse over 15 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

 The use of less than a 4-fold volume of diluent could lead to precipitation
Comments
of digoxin.
1. McAuley D. [Internet]. Digoxin Dilution. GlobalRPh; 2017. Available from:
https://globalrph.com/dilution/digoxin-immune-fab/
References 2. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.
3. UpToDate. Digoxin Drug Information. Wolters Kluwer.

56
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

DOBUTAMINE 250 MG/20 ML

Brand name Mobitil

Reconstitution Not required

Suggested
Peripheral: Maximum concentration of 5 mg/ml (250 mg/50 ml)
minimum
Central: Maximum concentration of 10 mg/ml (500 mg/50 ml)
dilutions
Diluent D5, NS

Administration IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 24 hours

Comments  Administration via central line is recommended.

1. Duopharma (M) Sdn. Bhd. Mobitil Product Leaflet. Revised 9 Jul 2019.
2. McAuley D. [Internet]. Dobutamine Dilution. GlobalRPh; 2017. Available
from: https://globalrph.com/dilution/dobutamine-hydrochloride/
References
3. NHS. Critical Care Intravenous Drug Administration Guide. 2008.
4. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.

57
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

DOPAMINE 200 MG/5 ML

Brand name Loxin

Reconstitution Not required

Suggested
Peripheral: Maximum concentration of 0.8 mg/ml (200 mg/250 ml)
minimum
Central: Maximum concentration of 8 mg/ml (400 mg/50 ml)
dilutions
Diluent D5, NS

Administration IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 24 hours

Comments  Administration via central line is recommended.

1. Duopharma (M) Sdn. Bhd. Loxin Product Leaflet. Revised 14 Jun 2019.
2. McAuley D. [Internet]. Dopamine Dilution. GlobalRPh; 2017. Available
from: https://globalrph.com/dilution/dopamine-hydrochloride/
References
3. NHS. Critical Care Intravenous Drug Administration Guide. 2008.
4. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.

58
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

EPHEDRINE 30 MG/1 ML
Brand name Ephedrine

Reconstitution Not required

Suggested
minimum Maximum concentration of 10 mg/ml
dilutions
Diluent D5, NS

Administration IV bolus: Administer over 3 – 5 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments -

1. NHS. Critical Care Intravenous Drug Administration Guide. 2008.

References
2. Pharmaniaga. Ephedrine Product Leaflet. Revised 16 May 2017.

59
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

ERTAPENEM 1 G
Brand name Invanz
IM: Reconstitute with 3.2 ml 1 or 2% lidocaine (stable for 1 hour)
Reconstitution
IV: Reconstitute with 10 ml WFI or NS
Suggested
minimum Maximum concentration of 20 mg/ml
dilutions
Diluent NS
IM: Administer into large muscle mass
Administration
IV infusion: Infuse over 30 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution 24 hours 6 hours

Comments -

1. McAuley D. [Internet]. Ertapenem Dilution. GlobalRPh; 2017. Available

References from: https://globalrph.com/dilution/ertapenem-invanz/
2. Merck Sharp & Dohme (M).Invanz Product Leaflet. Revised 1 Feb 2021.

60
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

ERYTHROMYCIN 500 MG
Brand name Eritrotex

Reconstitution Reconstitute with 10 ml WFI

Suggested
Peripheral: Maximum concentration of 5 mg/ml
minimum
Central: Maximum concentration of 10 mg/ml
dilutions
Diluent D5, NS

Administration IV infusion: Infuse over 30 – 60 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 8 hours

 Thrombophlebitis and arrhythmia may occur when using concentrated

Comments
(>5 mg/ml) solution. Cardiac monitoring is recommended.
1. FisiopharmaS.r.L. Eritrotex Product Leaflet. Revised 22 Jan 2020.
2. McAuley D. [Internet]. Dopamine Dilution. GlobalRPh; 2017. Available
from: https://globalrph.com/dilution/erythromycin/
References
3. NHS. Critical Care Intravenous Drug Administration Guide. 2008.
4. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.

61
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

ESMOLOL 100 MG/10 ML

Brand name Esocard

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable
IV bolus: Administer over 30 – 60 seconds
Administration
IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

 Administration via central line is recommended.

Comments  Not to be used in in combination with sodium bicarbonate or other
medicinal product such as frusemide, diazepam, thiopental.
1. McAuley D. [Internet]. Esmolol Dilution. GlobalRPh; 2017. Available
from: https://globalrph.com/dilution/esmolol-brevibloc/
References
2. Samarth Life Sciences Pvt Ltd.Esocard Product Leaflet. Revised 1 Oct
2010. NHS. Critical Care Intravenous Drug Administration Guide. 2008.

62
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

ESOMEPRAZOLE 40 MG
Brand name Esomeprazole

Reconstitution Reconstitute with 5 ml NS

Suggested
IV bolus: No further dilution required
minimum
IV infusion: Maximum concentration of 0.8 mg/ml (40 mg in 50 ml)
dilutions
Diluent D5, NS
IV bolus: Administer over 3 minutes
Administration IV infusion: Infuse over 30 minutes
Continuous infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability 6 hours (D5),
After Dilution -
12 hours (NS)

Comments -

1. Kotra Pharma. Esomeprazole Product Leaflet (Vaxcel). Revised 26 Feb

2020.
References
2. McAuley D. [Internet]. Esmolol Dilution. GlobalRPh; 2017. Available
from: https://globalrph.com/dilution/esomeprazole-nexium/

63
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

FACTOR VIII (HUMAN BLOOD COAGULATION FACTOR VIII)

Fanhdi 250 IU powder and solvent for solution for injection
Fanhdi 500 IU powder and solvent for solution for injection
Fanhdi 1000 IU powder and solvent for solution for injection
MYVATE 250 IU powder and solvent for solution for injection
MYVATE 500 IU powder and solvent for solution for injection
Brand name
MYVATE 1000 IU powder and solvent for solution for injection
MYVATE 1500 IU powder and solvent for solution for injection
Beriate 250 IU Powder and solvent for solution for injection or infusion
Beriate 500 IU Powder and solvent for solution for injection or infusion
Beriate 1000 IU Powder and solvent for solution for injection or infusion

Reconstitution Reconstitute each vial with the provided prefilled syringe with diluent (WFI)
Suggested
minimum No further dilution required
dilutions
Diluent Not applicable

IV infusion: Administer slowly up to a maximum of 10 ml/min. Rapid

Administration
administration of Factor VIII concentrate may result in vasomotor reaction.

Fridge (2 – 8°C) RT (< 25°C)

Stability After
24 hours 8 – 12 hours
Reconstitution

Comments -
1. Bioworld Technologies Sdn Bhd. Factor VIII (MYVATE) 250 IU, 500 IU,
1000 IU, 1500 IU Powder and Solvent for Solution for Injection Product
Leaflet. Revised 2 May 2018.
2. DKSH (M) Sdn Bhd. Factor VIII (Beriate) 250 IU, 500 IU, 1000 IU
References
Powder and Solvent for Solution for Injection or Infusion Product
Leaflet. Revised 23 Aug 2019.
3. Grifols Biologicals Inc. Factor VIII (Fandhi) 250 IU, 500 IU, 1000 IU
Product Leaflet. Revised 17 Dec 2007.

64
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

FACTOR VIII/VWF (HUMAN BLOOD COAGULATION FACTOR VIII AND

VON WILLEBRAND FACTOR COMPLEX)
AlphanateⓇ250 IU FVIII/5 mL single dose vial
AlphanateⓇ500 IU FVIII/5 mL single dose vial
AlphanateⓇ1000 IU FVIII/10 mL single dose vial
Alphanate1500 IU FVIII/10 mL single dose vial
Wilate 500, 500 IU VWF/500 IU FVIII, Powder and Solvent for Solution for Injection
Wilate 1000, 1000 IU VWF/1000 IU FVIII, powder and solvent for solution for
injection
Octanate 50 IU/ml, 250 IU powder and solvent for solution for injection
Brand name Octanate 50 IU/ml, 500 IU powder and solvent for solution for injection
Octanate 100 IU/ml, 1000 IU powder and solvent for solution for injection
Immunate 50 IU/ml, 250 IU FVIII / 190 IU VWF powder and solvent for solution for
injection
Immunate 100 IU/ml, 500 IU FVIII / 375 IU VWF powder and solvent for solution for
injection
Immunate 100 IU/ml, 1000 IU FVIII / 750 IU VWF powder and solvent for solution
for injection
Haemate P Powder and solvent for solution for injection or infusion
Reconstitution Reconstitute each vial with the provided prefilled syringe with diluent (sterile WFI)

Suggested
minimum No further dilution required
dilutions

Diluent Not applicable

IV infusion: Administer slowly at a rate not exceeding 10 ml/min. Rapid

Administration
administration of Factor VIII/VWF concentrate may result in vasomotor reaction.

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Reconstution - 8 hours

Comments -

1. DKSH (M) Sdn. Bhd. Haemate P 250IU FVIII/ 600IU VWF, 500 IU FVIII /1200
IU VWF, 1000 IU FVIII /2400 IU VWF Powder and Solvent for Solution for
Injection. Revised 30 Aug 2019.
2. Grifols Biologicals Inc. Factor VIII/VWF (AlphanateⓇ) 250 IU, 500 IU, 1000 IU,
1500 IU Product Leaflet. Revised Oct 2013.
References 3. Pharmaniaga. Factor VIII/VWF (OCTANATE) 50 IU/ml, 250 IU Powder and
Solvent for Solution for Injection. Revised May 2015.
4. Pharmaniaga. Factor VIII/VWF (Wilate) 500, 500 IU VWF/500 IU FVIII, Powder
and Solvent for Solution for Injection Product Leaflet. Revised 3 Aug 2020.
5. Takeda (M) Sdn Bhd. Factor VIII/VWF (IMMUNATE) 50 IU/ml, 100 IU/ml
Product Leaflet. Revised 16 Jun 2020.

65
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

FACTOR IX (HUMAN COAGULATION FACTOR IX)

AlphaNineSD500 IU FVIII powder and solvent for solution for injection
AlphaNineSD1000 IU FVIII powder and solvent for solution for injection
AlphaNineSD1500 IU FVIII powder and solvent for solution for injection
Brand name
OCTANINE F 500 IU powder and solvent for solution for injection
OCTANINE F 1000 IU powder and solvent for solution for injection
Immunine 600 IU powder and solvent for solution for injection

Reconstitution Reconstitute each vial with the provided prefilled syringe with diluent (WFI)
Suggested
minimum No further dilution required
dilutions
Diluent Not applicable
IV infusion: Administer slowly at a rate not exceeding 10 ml/min. Rapid
Administration
administration of Factor IX concentrate may result in vasomotor reaction.

Fridge (2 – 8°C) RT (< 25°C)

Stability After
- Use immediately
Reconstitution

 Use immediately and within three hours after reconstitution to avoid

Comments potential ill effect of any inadvertent bacterial contamination occurring
after reconstitution.
1. Grifols Biologicals Inc. Factor IX (AlphaNineⓇSD) 500 IU, 1000 IU, 1500
IU Product Leaflet. Revised Dec 2017.
2. Pharmaniaga. Factor XI (OCTANINE F) 500 IU, 1000 IU Product Leaflet.
References
Revised 15 May 2019.
3. Takeda (M) Sdn Bhd. Factor IX (Immunine) 600 IU Product Leaflet
(Revised Feb 2020).

66
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

FACTOR VIIA (EPTACOG ALFA)

NovoSeven 1 mg (50 KIU) powder and solvent for solution for injection
Brand name
NovoSeven 2 mg (100 KIU) powder and solvent for solution for injection
Reconstitute each vial with the provided prefilled syringe with diluent (sterile
Reconstitution
WFI)
Suggested
minimum No further dilution required
dilutions
Diluent Not applicable

Administration IV bolus: Administer slowly over 2 – 5 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability After
24 hours 6 hours
Reconstitution

Comments  Must not be mixed with infusion solutions or be given in a drip.

1. Novo Nordisk Pharma (M) Sdn Bhd. Factor VIIa (NovoSeven®) 1 mg (50
References KIU), 2mg (100 KIU) Powder and Solvent for Solution for Injection
Product Leaflet. Revised Apr 2021.

67
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

FENTANYL CITRATE 0.1 MG/2 ML

Talgesil
Brand name
Fentanyl-Piramal
Reconstitution Not required
Suggested
minimum Undiluted or maximum concentration of 10 mcg/ml (preferred)
dilutions
Diluent D5, NS

IV bolus: Administer rapidly

Administration
IV infusion, continuous infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 24 hours

 Product is preservative free, hence the injection should be freshly

Comments prepared and unused portions should be discarded.
 Incompatible with thiopental sodium.
1. DKSH (M) Sdn Bhd. Fentanyl-Piramal (Fentanyl) Injection 0.1 mg/2 ml
Product Leaflet. Revised Aug 2021.
2. Duopharma (M) Sdn. Bhd. Talgesil (Fentanyl) Injection 0.1 mg/2 ml
Product Leaflet. Revised 9 Jul 2019.
References 3. Fentanyl: Indication, Dosage, Side Effect, Precaution. MIMS Malaysia;
[cited 13 Jun 2022]. Available from:
https://www.mims.com/malaysia/drug/info/fentanyl?mtype=generic
4. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.

68
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

FILGRASTIM (RECOMBINANT HUMAN GRANULOCYTE COLONY-

STIMULATING FACTOR)
Neupogen 30 MU/1 ml (300 mcg/ml) vial
Brand name
Neupogen 30 MU/0.5 ml (300 mcg/0.5 ml) prefilled syringe

Reconstitution Not required

SC: No further dilution required

Suggested
IV infusion: Maximum concentration of 15 mcg/ml
minimum
*If Neupogen is diluted to less than 15 mcg/ml, 0.2 ml of 20% human albumin
dilutions
should be added.

Diluent D5

SC (preferred route of administration)

Administration
IV infusion: Infuse over 15 – 30 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution 24 hours 24 hours

 Dilution to a final concentration < 2 μg/mL is not recommended at any

Comments
time.

1. Amgen Biopharmaceuticals (M) Sdn Bhd. Filgrastim (Neupogen®) 30

MU/ml Vial Product Leaflet. Revised Aug 2018.
2. Cipla (M) Sdn Bhd. Filgrastim (Filpegla) 6 mg /0.6 ml Solution for
Injection in Pre-Filled Syringe Product Leaflet. Revised Sept 2020.
3. Hospira (M) Sdn Bhd. Filgrastim (Nivestim) 120 μg/0.2 ml, 300 μg/0.5
References
ml, 480 μg/0.5 ml Solution for Injection/Infusion Product Leaflet.
Revised 18 Feb 2020.
4. Mylan Healthcare Sdn Bhd. Filgrastim (Fulphila™) Pegylated
Granulocyte Colony Stimulating Factor Injection (PEG-GCSF Injection)
6 mg/0.6 ml Pre-filled Syringe Product Leaflet. Revised Nov 2020.

69
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

FLUCONAZOLE
Diflucan 100 mg/50 ml intravenous infusion
Diflucan 200 mg/100 ml intravenous infusion
Brand name Fluconol 100 mg/50 ml intravenous infusion
Fluconol 200 mg/100 ml intravenous infusion
Flucon 100 mg/50 ml intravenous infusion
Reconstitution Not required
Suggested
minimum No further dilution required
dilutions
Diluent Not applicable

Administration IV infusion: Infuse over 60 minutes, at rate <10 ml/min

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments -
1. Ain Medicare Sdn Bhd. Fluconazole (Fluconol®) 100 mg/50 ml, 200
mg/100 ml Intravenous Infusion Product Leaflet. Revised 1 Sept 2019.
2. Averroes Pharmaceuticals. Fluconazole (Flucon) 100 mg/50 ml
References
Intravenous Infusion Product Leaflet. Revised Jun 2007.
3. Pfizer (M) Sdn Bhd. Fluconazole (Diflucan) 100 mg/50 ml, 200 mg/100
ml Intravenous Infusion Product Leaflet. Revised 4 Aug 2021.

70
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

FRUSEMIDE 20 MG/2 ML
Brand name Fusix

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable
IV bolus: Administer undiluted
Administration
IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments -
1. SM Pharmaceuticals Sdn Bhd. Fusix (Frusemide) Injection 20 mg/2 ml
Ampoule Product Leaflet. Revised 07 Mar 2019.
References
2. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.

71
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

FUSIDIC ACID 500 MG

Brand name -

Reconstitution Reconstitute with 10 ml WFI

Suggested
minimum Maximum concentration of 2 mg/ml
dilutions
Diluent D5, NS

Administration IV infusion: Infuse over at least 2 hours

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 24 hours

Comments -
1. Fusidic acid: Indication, Dosage, Side Effect, Precaution. MIMS Malaysia; [cited
30 Jun 2022]. Available from:
References https://www.mims.com/malaysia/drug/info/fusidic%20acid?mtype=generiVivocin
2. Steril/Non-Steril Preparation Working Committee Members. Johore Antibiotics
Dilution Quick Reference

72
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

GANCICLOVIR 500 MG
Brand name Cymevene

Reconstitution Reconstitute with 10 ml WFI

Suggested
minimum Maximum concentration of 10 mg/ml
dilutions
Diluent D5, NS

Administration IV infusion: Infuse over 60 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution 24 hours 12 hours

Comments  Infusion concentrations greater than 10 mg/ml are not recommended.

1. DKSH (M) Sdn Bhd. Ganciclovir (Cymevene®) 500 mg/vial Powder for
Concentrate for Infusion. Revised Jan 2021.
References
2. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.

73
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

GENTAMICIN 80 MG/2 ML
Brand name Garasent

Reconstitution Not required

Suggested
minimum Dilute in at least 50 – 100 ml diluent and infuse over 30 – 60 minutes
dilutions
Diluent D5, NS
IV bolus: Administer over 2 – 3 minutes
Administration
IV infusion: Infuse over 30 minutes – 2 hours (preferred)

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution 48 hours 48 hours

Comments  High doses may require longer infusion time (up to 2 hours).
1. Duopharma (M) Sdn Bhd. Gentamicin (Garasent) 80 mg/2 ml Ampoule,
280 mg/2 ml Product Leaflet. Revised 28 May 2019.
2. McAuley D. [Internet]. Gentamicin Dilution. GlobalRPh;2017. Available
References
from: https://globalrph.com/dilution/gentamicin/
3. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. Dec 2012.

74
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

GLUCAGON 1 MG
Brand name GlucaGen

Reconstitution Reconstitute with provided diluent

IM, SC, IV bolus
No further dilution required
Suggested
minimum
IV infusion
dilutions
Peripheral: Maximum concentration of 0.1 mg/ml
Central: No further dilution required
Diluent D5
IM, SC
Administration IV bolus: Administer over 3 – 5 minutes
IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments  Use immediately after reconstitution

1. Lexi-Comp Inc. Lexi-Drug©. Version 6.4.0.
2. Novo Nordisk Pharma (M) Sdn. Bhd. GlucaGen® Product Leaflet.
Revised Jul 2020.
References
3. Pharmaceutical Services Programme. Antidote Quick Guide. 1st ed.
Ministry of Health; 2022.
4. UpToDate. Glucagon Drug Information. Wolters Kluwer.

75
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

GLYCERYL TRINITRATE 50 MG/10 ML

Brand name Gitrinil

Reconstitution Not required

Suggested
minimum Maximum concentration of 1 mg/ml
dilutions
Diluent D5, NS

Administration IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 24 hours

Comments  Glyceryl trinitrate should not be given by bolus injection.

1. Duopharma (M) Sdn Bhd. Gitrinil 50 mg/10 ml Injection Product Leaflet.
Revised 12 Jun 2019.
2. Hameln Pharma. Glyceryl Trinitrate-Hameln 1 mg/ml Injection Product
References
Leaflet. Revised Sept 2020.
3. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.

76
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

GLYCOPYRROLATE 200 MCG/1 ML

Brand name Pyronium

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable
IM
Administration
IV bolus: Administer over 1 – 2 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments -
1. Lexi-Comp Inc. Lexi-Drug©. Version 6.4.0.
2. SM Pharmaceuticals Sdn Bhd. Pyronium Product Leaflet. Revised Sept
References
2017.
3. UpToDate. Glycopyrrolate Drug Information. Wolters Kluwer.

77
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

GRANISETRON 1 MG/ML
Kytron 1 mg/1 ml & 3 mg/3 ml
Brand name Granisetron Kabi 1 mg/1 ml
Granil 3 mg/3 ml

Reconstitution Not required

Suggested
IV bolus: No further dilution required
minimum
IV infusion: Dilute required dose in 20 ml
dilutions
Diluent D5, NS
IV bolus: Administer over 30 seconds
Administration
IV infusion: Infuse over 5 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 24 hours

Comments -

1. Duopharma (M) Sdn Bhd. Kytron Product Leaflet. Revised 15 Oct 2019.
2. Lexi-Comp Inc. Lexi-Drug©. Version 6.4.0.
References 3. McAuley D. [Internet]. Kytril-Granisetron. GlobalRPh;2017. Available
from: https://globalrph.com/dilution/granisetron-kytril/
4. UpToDate. Granisetron Drug Information. Wolters Kluwer.

78
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

HALOPERIDOL 5 MG/1 ML
Brand name Manace

Reconstitution Not required

Suggested
minimum No further dilution needed
dilutions
Diluent Not applicable
IM
Administration
IV bolus: Administer not exceeding 5 mg/min

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments -
1. Duopharma (M) Sdn Bhd. Manace Product Leaflet. Revised 11 Sept
References
2019.

79
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

HEPARIN 5,000 IU/5 ML & HEPARIN 25,000 IU/5 ML

Brand name Heparinol

Reconstitution Not required

Suggested
SC: No further dilution required
minimum
IV infusion: Refer to institutional heparin protocol
dilutions
Diluent D5, NS
SC
Administration
IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 24 hours

Comments -
1. Ain Medicare Sdn Bhd. Heparinol Product Leaflet. Revised 1 Aug 2020.
References 2. Lexi-Comp Inc. Lexi-Drug©. Version 6.4.0.
3. UpToDate. Heparin Drug Information. Wolters Kluwer.

80
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

HUMAN ALBUMIN 20% (10 G/50ML & 20 G/100 ML)

Human Albumin Grifols 20%
Brand name
Albumex 20 Human Albumin 20%
Reconstitution Not required
Suggested
minimum No further dilution required
dilutions
Diluent Not applicable

Administration IV infusion: Infuse each vial over 30 minutes – 4 hours

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments -
1. CSL Behring Australia Pty Ltd. Albumex® 20 Human Albumin 20% (200
g/L) Product Leaflet. Revised 4 Mar 2015.
References 2. Grifols (M) Sdn Bhd. Human Albumin Grifols 20% Product Leaflet.
Revised Dec 2002.
3. Truven Health Analytics. Micromedex.

81
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

HUMAN ALBUMIN 25% (12.5 G/50 ML & 25 G/100 ML)

Brand name Plasbumin® -25

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable

Administration IV infusion: Infuse each vial over 30 minutes – 4 hours

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments -

1. Grifols (M) Sdn Bhd. Product Insert for Human Albumin 25% by
Plasbumin®-25. Revised Oct 2016.
References 2. Grifols (M) Sdn Bhd. Human Albumin Grifols 25% (12.5 g/50 ml, 25 g/100
ml) Product Leaflet. Revised Dec 2017.
3. Truven Health Analytics. Micromedex.

82
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

HYDRALAZINE 20 MG/1 ML
Brand name Hydralazine hydrochloride

Reconstitution Not required

Suggested
minimum No further dilution needed
dilutions
Diluent Not applicable
IM
Administration
IV bolus: Administer over 3 – 5 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments -
1. Ciron Drugs & Pharmaceuticals Pvt. Ltd. Hydralazine Hydrochloride 20
References mg/ml Product Leaflet. Revised 5 Apr 2022)
2. UpToDate. Hydralazine Drug Information. Wolters Kluwer.

83
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

HYDROCORTISONE 100 MG
Brand name Zycort

Reconstitution Reconstitute with not more than 2 ml WFI

Suggested
minimum No further dilution is required
dilutions
Diluent -

Administration IV infusion: Infuse over 5 – 30 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability After
- 72 hours
Reconstitution

 If further dilution is needed, 100 mg doses may be added to 50 ml NS or

Comments
D5 (stable for 4 hours).

1. SM Pharmaceuticals Sdn. Bhd. Product Insert for Zycort. Revised 24 Oct

2018.
References
2. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.

84
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

ILOPROST 0.5 ML
(CONTAINS 67 MCG ILOPROST TROMETAMOL EQUIVALENT TO 50 MCG
ILOPROST)
Brand name Ilomedin

Reconstitution Not required

Suggested
For infusion pump use: Maximum concentration of 0.2 mcg/ml
minimum
For syringe pump use: Maximum concentration of 2 mcg/ml
dilutions
Diluent D5, NS

Administration IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

 Solution must not be administered undiluted.

Comments  The infusion solution should be made up freshly each day to ensure
sterility.
References 1. Bayer. Iloprost (Ilomedin) Product Leaflet. Revised 14 Oct 2013.

85
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

IMIPENEM/CILASTATIN 500 MG
Brand name Imipenem/Cilastatin Kabi

Reconstitution Reconstitute with 10 ml NS

Suggested
minimum Maximum concentration of 5 mg/ml
dilutions
Diluent D5, NS (preferred)

Administration IV infusion: Infuse over 30 minutes – 3 hours

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution 24 hours 4 hours

Comments -
1. Fresenius Kabi Malaysia Sdn. Bhd. Imipenem/cilastatin Kabi Product
Leaflet. Revised Jan 2020.
References
2. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.

86
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

IMMUNOGLOBULIN G (IVIG)
Flebogamma 5% DIF (2.5 g/50 ml)
Brand name
Intragam P (3 g/50 ml)
Reconstitution Not required
Suggested
minimum No further dilution required
dilutions
Diluent Not applicable
IV infusion: Infuse at an initial rate of 0.01 – 0.02 ml/kg/min for the first 30
Administration minutes. If well tolerated, the rate may gradually be increased to a maximum
of 0.1 ml/kg/min

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

 Should be administered by separate IV line.

Comments
 Administration rate may differ between brands.
1. CSL Behring (Australia) Pty Ltd. Product Insert for Intragam P. Revised
Nov 2020.
References
2. Grifols (M) Sdn Bhd. Product Insert for Flebogamma 5% DIF. Revised
Aug 2011.

87
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

INSULIN REGULAR
Brand name Actrapid

Reconstitution Not required

Suggested
SC, IV bolus: No further dilution required
minimum
IV infusion: Maximum concentration of 0.5 – 1 IU/ml
dilutions
Diluent D5, D10, NS
SC, IV bolus
Administration
IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 24 hours

Comments -

References 1. Novo Nordisk. Actrapid® Product Leaflet. Revised 2019.

88
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

IRON DEXTRAN 100 MG/2 ML

Brand name CosmoFer

Reconstitution Not required

Suggested
minimum Refer to Administration
dilutions
Diluent NS (recommended), D5

IV Injection
Total dose
Slow IV IV infusion
infusion
Administer 25 mg
Administer 25 mg Administer 25 mg
Test dose over 1 – 2
over 15 minutes over 15 minutes
minutes
Observation Observe for hypersensitivity reaction for at least 15
period minutes after test dose

Administration Max per dose: 20

Dose 100 – 200 mg 100 – 200 mg
mg/kg
Volume of
10 – 20 ml 100 ml 500 ml
diluent
Administer over Infuse over at Infuse over 4 – 6
Rate
10 – 20 minutes least 30 minutes hours

Deep IM
Administer undiluted in doses of up to 100 mg in the upper outer quadrant of
the buttocks, alternate buttocks with subsequent injections.

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - Use immediately

 Discontinue oral iron preparations before starting IV therapy as

Comments concomitant use can cause the absorption of oral iron to be reduced. Oral
iron should not be given within 5 days of last injection.
1. Lexi-Comp Inc. Lexi-Drug©. Version 6.4.0.
References 2. Pharmacosmos. Iron Dextran 50 mg/ml Product Leaflet. Revised Mar
2019.

89
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

IRON SUCROSE 100 MG/5 ML

Brand name Ranofer

Reconstitution Not required

Suggested
IV bolus: No further dilution required
minimum
IV infusion: Maximum concentration of 1 mg/ml
dilutions
Diluent NS

I. Test dose (20 mg iron, 1 ml)

IV bolus: Administer over 1 – 2 minutes
IV infusion: Infuse over 15 minutes
If no adverse reactions occur, the remaining dose can be administered.
Administration
II. Total dose
IV bolus: Administer no faster than 20 mg per minute
IV infusion: Infuse no faster than 6 mg per minute (100 mg over at least
15 minutes)

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - Use immediately

 Monitor signs and symptoms of hypersensitivity reaction and hypotension

Comments
during and after administration.
1. Duopharma (M) Sdn Bhd. Ranofer Product Leaflet. Revised Apr 2019.
References 2. Lexi-Comp Inc. Lexi-Drug©. Version 6.4.0.
3. Truven Health Analytics. Micromedex.

90
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

ISOPRENALINE 0.2 MG/1 ML & 1 MG/5 ML

Brand name Isolin

Reconstitution Not required

Suggested
minimum Maximum concentration of 20 mcg/ml
dilutions
Diluent D5, NS

Administration IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

 In dire emergencies, the drug may be administered by intracardiac

injection. If time is not of the utmost importance, initial therapy by IM or
Comments SC injection is preferred.
 If HR > 110 bpm, it is advisable to decrease the infusion rate or
temporarily discontinue.

1. Lexi-Comp Inc. Lexi-Drug©. Version 6.4.0.

2. Samarth Life Sciences. Isolin Product Leaflet.
References
3. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.

91
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

ISOSORBIDE DINITRATE 10 MG/10 ML (0.1%)

Brand name Isoket

Reconstitution Not required

Suggested
minimum Maximum concentration of 0.5 mg/ml
dilutions
Diluent D5, NS

Administration IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

 Avoid use of PVC infusion containers, administration sets and in-line

filters if possible.
 Rigid plastics, i.e. polyethylene, polytetrafluoroethylene or polypropylene
Comments
administration sets and syringes, should be used if available.
 Due to oversaturation of active ingredient, crystallization may occur in
undiluted form.

1. Isosorbide Dinitrate 0.05% w/v Solution for Injection or Infusion. Torbay

&amp; South Devon NHS Foundation Trust; 2019. Available from:
References https://www.medicines.org.uk/emc/product/1994/smpc#gref
2. Gray AH. Injectable Drugs Guide. London: Pharmaceutical Press; 2011.
3. GSK. Isosorbide Dinitrate (Isoket®) Product Leaflet. Revised 2014.

92
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

KETAMINE 200 MG/20 ML

Brand name Aneket

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable
IV bolus: Administer at 0.5 mg/kg/min
Administration
IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

 Rapid administration of IV bolus may result in respiratory depression and

enhance pressor response (suggest to administer over 2 – 3 minutes).
Comments
 Do not mix with barbiturates or diazepam in the same syringe (precipitate
formation is possible).

1. Neon Laboratories. Aneket Ketamine HCl Injection USP Product Leaflet.

2. United Kingdom Clinical Pharmacy Association. Minimum Infusion
References
Volumes for Critically Ill Patients. 4th ed. December 2012.
3. Uptodate. Ketamine Drug Information. Wolters Kluwer.

93
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

LABETALOL 25 MG/5 ML
Brand name Labetalol Hydrochloride

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable
IV bolus: Administer over 1 – 2 minutes
Administration
IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

 Patients should remain supine during and for up to 3 hours following

Comments
injection (postural hypotension may occur).
1. Lexi-Comp Inc. Lexi-Drug©. Version 6.4.0.
2. Pharmaniaga. Labetalol HCl Injection Product Leaflet. Revised 19 Apr
2017.
3. Phelps SJ, Hageman TM, Thompson AJ, Lee KR. Pediatric injectable
References drugs ; the teddy bear book /by Stephanie J.Phelps, Emily B. Hak and
Catherine M. Crill. 10th ed. Bethesda: American Society of Health-
System Pharmacists; 2013.
4. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.

94
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

LEUCOVORIN CALCIUM 50 MG/5 ML

Brand name Leucovorin Calcium

Reconstitution Not required

Suggested
minimum No further dilution is required
dilutions
Diluent D5, NS

IM
Administration IV bolus: Administer over 3 minutes
IV infusion: Infuse over 15 minutes – 2 hours (rate not to exceed 160 mg/min)

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution 24 hours 24 hours

 Leucovorin should not be mixed in the same infusion as 5-fluorouracil

Comments since this may lead to formation of precipitate.
 Protect from light.

1. Fresenius Kabi. Leucovorin Calcium Inj. USP Product Leaflet. Revised

Jan 2018.
References 2. Lexi-Comp Inc. Lexi-Drug©. Version 6.4.0.
3. McAuley D. [Internet]. Leucovorin Calcium. GlobalRPh;2017. Available
from: https://globalrph.com/oncology/leucovorin-calcium/

95
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

LEVETIRACETAM 500 MG/5 ML

Epitech
Brand name
Keppra
Reconstitution Not required
Suggested
minimum Maximum concentration of 15 mg/ml (1500 mg in 100 ml)
dilutions
Diluent D5, NS

Administration IV infusion: Infuse over 15 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 24 hours

Comments -

1. Averroes Pharmaceuticals. Epitech Product Leaflet. Revised 5 Nov

2020.
References 2. Lexi-Comp Inc. Lexi-Drug©. Version 6.4.0.
3. Patheon Italia S.p.A. Keppra Product Leaflet. Revised 13 Mar 2020.
4. Truven Health Analytics. Micromedex. Version 3.2.0.

96
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

LEVOFLOXACIN 500 MG/100 ML

Brand name Levofloxol

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable
Dose < 500 mg: Infuse over 60 minutes
Administration
Dose ≥ 750 mg: Infuse over 90 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments -

1. Ain Medicare Sdn Bhd. Package Insert Levofloxol Injection

References
500mg/100ml. Revised 9 Feb 2009.

97
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

LIGNOCAINE HCL 20 MG/ML

(PRESERVATIVE FREE)
Brand name INJECSOL LIG2 2% w/v

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent D5

IV bolus: Administer at rate of 25 – 50 mg/min

Administration
Continuous infusion: Infusion rate of 1 – 4 mg/min

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

 In cardiac arrest (e.g.: ventricular fibrillation or pulseless ventricular

Comments tachycardia), lignocaine may be administered rapidly into peripheral vein.
 Infusion should be given under ECG monitoring to avoid toxicity.

1. Ain Medicare Sdn. Bhd. Package Insert INJECSOL LIG2 2% w/v.

Revised 26 Aug 2019.
References
2. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.

98
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

LINEZOLID 600 MG/300 ML

Brand name Zyvox

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable

Administration IV infusion: Infuse over 30 – 120 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

 Keep infusion bags in foil overwrap until ready to use.

Comments  Linezolid solution is chemically incompatible when combined with
ceftriaxone sodium.

References 1. Pfizer (M) Sdn Bhd. Package Insert Zyvox 2mg/ml. Revised 11 Aug 2017.

99
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

MAGNESIUM SULPHATE 50% W/V 5 ML

(CONTAINS 2.465 G MAGNESIUM EQUIVALENT TO 10 MMOL MAGNESIUM)
Brand name INJECSOL MgSO4

Reconstitution Not required

Suggested
Peripheral: Maximum concentration of 10% (1 ampoule in 50 ml)
minimum
Central: No further dilution required
dilutions
Diluent D5, NS

IM: Undiluted
IV infusion (Hypomagnesemia): Infuse over 60 minutes
Administration
IV infusion (Asthma/Pre-Eclampsia/Eclampsia): Titrate as per dose
prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

 Incompatible with calcium salts, as calcium sulphate may precipitate

Comments
when mixed together in the same intravenous solution.
1. Ain Medicare Sdn. Bhd. Package Insert INJECSOL MgSO4. Revised 8
Oct 2020.
2. McAuley D. [Internet]. Magnesium Sulfate Dilution. GlobalRPh;2017.
References
Available from: https://globalrph.com/dilution/magnesium-sulfate/.
3. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.

100
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

MANNITOL 10% & 20%

Brand name Infusol M10 / M20

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable

Administration IV infusion: Infuse over 30 – 60 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

 Use filter to avoid administration of crystallize solution.

Comments  If crystallization occurs, warm up the solution to 70°C (using water bath)
until crystals dissolve.
1. Ain Medicare Sdn. Bhd. Package Insert Infusol® M10 / M20. Revised 1
References
Apr 2020.

101
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

MEROPENEM 500 MG & 1 G

Brand name Meropenem Kabi

Reconstitution Reconstitute every 500 mg with 5 ml WFI

Suggested
minimum IV infusion: Maximum concentration of 20 mg/ml
dilutions
Diluent NS

IV bolus: Infuse over at least 5 minutes

Administration
IV infusion: Infuse over 30 minutes or as extended over 4 hours

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 8 hours

Comments  Alternatively can be diluted with D5 (stability 1 hour)

1. Fresenius Kabi. Product Leaflet Meropenem Kabi 500 mg/1g. Revised
Apr 2018.
2. Loeuille G, D'Huart E, Vigneron J et al. Stability Studies of 16 Antibiotics
for Continuous Infusion in Intensive Care Units and for Performing
References
Outpatient Parenteral Antimicrobial Therapy. Antibiotics (Basel).
2022;11(4):458.
3. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.

102
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

METHYLENE BLUE (METHYLTHIONINIUM CHLORIDE)

Brand name Blue Beam

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent -

Administration IV infusion: Infuse over 5 – 30 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

 Product is hypotonic. Thus, it may be diluted in 50 ml D5 to avoid local

pain.
Comments
 Do not mix with NS as it has been demonstrated that chloride reduces
the solubility of methylene blue.
1. Provepharm Life Solutions. Package Insert PROVAYBLUE™. Revised
Apr 2016.
References
2. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.

103
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

METHYLPREDNISOLONE 500 MG & 1000 MG

Brand name Solu-Medrol

Reconstitution Reconstitute with diluent provided

Suggested
Peripheral: Maximum concentration of 5 mg/ml
minimum
Central: No further dilution required
dilutions
Diluent D5, NS
IV bolus (Dose < 250 mg): Administer over 5 minutes
Administration
IV infusion (Dose ≥ 250 mg): Infuse over at least 30 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 48 hours

Comments -

1. McAuley D. [Internet]. Solu Medrol-Methylprednisolone Dilution.

GlobalRPh;2017. Available from:
https://globalrph.com/dilution/methylprednisolone-solu-medrol/
References 2. Pfizer (M) Sdn. Bhd. Package Insert Solu-Medrol 500mg, 1000mg.
Revised 2 Jul 2021.
3. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.

104
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

METOCLOPRAMIDE 10 MG/2ML
Brand name Malon

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable
IM
Administration
IV bolus: Administer over at least 3 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments  Dose > 10 mg requires dilution in at least 50 ml NS.

1. Duopharma (M) Sdn. Bhd. Package Insert Malon Injection 10 mg/2 ml.
References
Revised 6 Apr 2020.

105
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

METRONIDAZOLE 500 MG/100ML

Brand name Metronol

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable

Administration Infuse over 30 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments -
1. Ain Medicare Sdn. Bhd. Package Insert Metronol® 0.5% w/v Injection.
References
Revised 1 Jul 2019.

106
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

MICAFUNGIN 50 MG
Brand name Mycamine

Reconstitution Reconstitute each vial with 5 ml NS or D5

Suggested
minimum Maximum concentration of 1 mg/ml
dilutions
Diluent D5, NS

Administration IV infusion: Infuse over 1 hour

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 6 hours

Comments -
1. Astellas Pharma Tech Co. Ltd. Package Insert Mycamine 50 mg.
Revised 22 Aug 2017.
References
2. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.

107
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

MIDAZOLAM 5 MG/ML & 15 MG/3 ML

Brand name Domi

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable

IV bolus (procedural sedation): Administer over at least 2 minutes

Administration
IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

 Generally diluted in D5 or NS to a concentration of 1 mg/ml (stable for 24

Comments
hours).
1. Duopharma (M) Sdn. Bhd. Package Insert Domi Injection 5mg/ml.
Revised 14 Jan 2021.
References
2. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.

108
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

MILRINONE 10 MG/10 ML
Brand name Primacor

Reconstitution Not required

Suggested
minimum Maximum concentration of 0.2 mg/ml
dilutions
Diluent D5, NS

IV bolus: Administer over 10 minutes

Administration
IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments -

1. United Kingdom Clinical Pharmacy Association. Minimum Infusion

References
Volumes for Critically Ill Patients. 4th ed. December 2012.

109
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

MORPHINE 10 MG/1 ML
Brand name Morpheas

Reconstitution Not required

Suggested
minimum Maximum concentration of 2 mg/ml
dilutions
Diluent D5, NS
SC
Administration IV bolus: Administer over 4 – 5 minutes
IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 24 hours

Comments  Generally diluted in D5 or NS to a concentration of 1 mg/ml.

1. Duopharma (M). Sdn. Bhd. Package Insert Morpheas Injection
10mg/ml. Revised 13 Feb 2020.
References
2. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.

110
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

MOXIFLOXACIN 400 MG/250 ML

Brand name Avelox

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable

Administration IV infusion: Infuse over 1 hour

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments -
1. Bayer. Package Insert Avelox. Revised 27 Nov 2020.
References 2. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.

111
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

NALOXONE 0.4 MG/1 ML

Brand name Mapin

Reconstitution Not required

Suggested
minimum No further dilution is required
dilutions
Diluent Not applicable

Administration IV bolus: Administer over 3 - 5 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

 May further dilute in 10 ml D5 or NS (concentration 0.04 mg/ml),

Comments
administer over 3 - 5 minutes.
1. Duopharma (M) Sdn. Bhd. Package Insert MAPIN 0.4 mg/ml Injection.
Revised 13 Mar 2019.
References
2. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.

112
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

NEOSTIGMINE METHYLSULPHATE 2.5 MG/1 ML

Brand name Setisin

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent -
IM, SC
Administration
IV bolus: Administer over at least 1 minute

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments  Dose equivalent 0.5 mg IV = 1.0 – 1.5 mg IM/SC.

1. Duopharma (M) Sdn. Bhd. Package Insert Neostigmine Methylsulphate

References
BP; Setisin Injection. Revised 22 Nov 2019.

113
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

NIMODIPINE 10 MG/50 ML
Brand name Nimotop

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable

IV infusion (central line only):

BW < 70 kg: Infuse 0.5 mg/hour or less
BW ≥ 70 kg: Infuse 1 mg/hour for 2 hours, then 2 mg/hour
Administration
Nimodipine solution should be co-infused with 1:4 ratio of NS or D5 via a
three-way stopcock (e.g.: Nimodipine 50 ml : co-infusion 200 ml)

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - Use immediately

Comments -

References 1. Bayer. Package Insert Nimotop ® 10mg/50ml. Revised 20 Aug 2019.

114
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

NORADRENALINE 4 MG/4 ML
Brand name Cardiamed

Reconstitution Not required

Suggested
Peripheral: Maximum concentration of 0.08 mg/ml (4 mg in 50 ml)
minimum
Central: Maximum concentration of 0.64 mg/ml (32 mg in 50 ml)
dilutions
Diluent D5

Administration IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 24 hours

 Preferred dilution ranges from 4 – 8 mg in 50 ml (0.08 – 0.16 mg/ml).

 Administration via central line is recommended.
Comments
 Highly concentrated preparation may cause peripheral ischemia, use
with caution.
1. Duopharma (M) Sdn. Bhd. Package Insert Cardiamed Injection 1mg/ml.
Revised 31 Oct 2019.
References
2. United Kingdom Clinical Pharmacy Association. Minimum Infusion
Volumes for Critically Ill Patients. 4th ed. December 2012.

115
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

OCTREOTIDE 0.05 MG/1 ML & 0.1 MG/1 ML

Brand name Sandostatin

Reconstitution Not required

Suggested
SC, IV bolus: No further dilution required
minimum
IV infusion: Maximum concentration of 10 mcg/ml
dilutions
Diluent D5, NS
SC
Administration IV bolus: Administer over 3 minutes
IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 24 hours

Comments  NS is the preferred diluent as octreotide can affect glucose homeostasis.

1. Graham-Clarke E. Minimum Infusion Volumes [Internet]. 4.4 ed. Vol. 4.

United Kingdom Clinical Pharmacy Association; 2012. Available from:
https://www.scottishintensivecare.org.uk/uploads/2014-07-24-19-56-30-
References
MinimuminfusionvolumesinI-40262.pdf.
2. Package Insert Sandostatin® 0.05mg/ml or 0.1mg/ml or 0.5mg/ml.
Novartis (M) Sdn. Bhd. Revised Sept 2021.

116
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

OMEPRAZOLE 40 MG
Brand name Vaxcel Omeprazole

Reconstitution Reconstitute with 10 ml solvent provided

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable

Administration IV bolus: Administer over at least 3 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability After
- 4 hours
Reconstitution
 Protect from light. Vials that have been taken out of their original box can
Comments
be kept in normal indoor light up to 24 hours.
1. Graham-Clarke E. Minimum Infusion Volumes [Internet]. 4.4 ed. Vol. 4.
United Kingdom Clinical Pharmacy Association; 2012. Available from:
https://www.scottishintensivecare.org.uk/uploads/2014-07-24-19-56-30-
References
MinimuminfusionvolumesinI-40262.pdf.
2. Package Insert Vaxcel Omeprazole 40mg Injection. Kotra Pharma.
Revised 27 Nov 2020.

117
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

ONDANSETRON 8 MG/4 ML
Brand name Ondatron

Reconstitution Not required

Suggested
Dose 4 – 8 mg: No further dilution required
minimum
Dose > 8 mg: Maximum concentration of 0.32 mg/ml (16 mg in 50 ml)
dilutions
Diluent D5, NS
IV bolus (Dose 4 – 8 mg): Administer over 2 – 5 minutes
Administration
IV infusion (Dose > 8 mg): Infuse over at least 15 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 24 hours

 Alternatively, 4 mg dose may be administered intramuscularly (undiluted)

Comments
as a single injection for adults.
1. Ain Medicare Sdn. Bhd. Package Insert Ondatron 2 mg/ml. Revised 1
Jun 2020.
References 2. McAuley D. Zofran ® – Ondansetron [Internet]. GlobalRPH. 2017 [cited
2023 Apr 18]. Available from: https://globalrph.com/dilution/zofran-
ondansetron/

118
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

PAMIDRONATE 30 MG/10 ML
Brand name Pamisol

Reconstitution Reconstitute with 10 ml WFI

Suggested
minimum Maximum concentration of 0.36 mg/ml (90 mg in 250ml)
dilutions
Diluent D5, NS

Administration IV infusion: Infuse over 2 – 24 hours

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution 24 hours 24 hours

 Administer through a separate infusion line. Do not allow pamidronate

disodium infusion to come in contact with any calcium or divalent cation-
Comments
containing solutions.
 Longer infusion time > 2 hours may reduce risk for renal toxicity.
1. Lexi-Comp Inc. Version 6.4.0. Lexi-Drug©. [cited 2023 Apr 18].
References
2. Pamisol Product Leaflet. Pfizer. Revised Sept 2020.

119
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

PANTOPRAZOLE 40 MG
Brand name Vaxcel

Reconstitution Reconstitute with 10 ml NS

Suggested
IV bolus: Maximum concentration of 4 mg/ml (40 mg in 10 ml)
minimum
IV infusion: Maximum concentration of 2 mg/ml (40 mg in 20 ml)
dilutions
Diluent D5, NS
IV bolus: Administer over 2 – 15 minutes
Administration
IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 24 hours

Comments  Do not administer other IV solution simultaneously through the same line.

1. Graham-Clarke E. Minimum Infusion Volumes [Internet]. 4.4 ed. Vol. 4.

United Kingdom Clinical Pharmacy Association; 2012. Available from:
https://www.scottishintensivecare.org.uk/uploads/2014-07-24-19-56-30-
MinimuminfusionvolumesinI-40262.pdf
References 2. Kotra Pharma. Vaxcel Product Leaflet. Revised 22 Feb 2019.
3. Lexi-Comp Inc. Version 6.4.0. Lexi-Drug©. [cited 2023 Apr 18].
4. McAuley D. Zofran ® – Pantoprazole-Protonix [Internet]. GlobalRPH.
2017 [cited 2023 Apr 18]. Available from:
https://globalrph.com/dilution/pantoprazole/

120
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

PARACETAMOL 1 G/100 ML
Paracetamol Kabi
Brand name
Ifimol IV

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable

Administration IV infusion: Infuse over 15 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

 May be further diluted to 1/10 of current dilution (1 part paracetamol to 9

Comments
parts D5 or NS).
1. Fresenius Kabi. Paracetamol Kabi Product Leaflet. Revised Jun 2014.
References
2. Lexi-Comp Inc. Version 6.4.0. Lexi-Drug©. [cited 2023 Apr 18].

121
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

PARECOXIB 40 MG
Brand name Dynastat

Reconstitution Reconstitute with 2 ml D5 or NS

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable
IM
Administration
IV bolus: Administer rapidly

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 24 hours

 Use of WFI for reconstitution is not recommended (solution is not

Comments
isotonic).

References 1. Pfizer. Dynastat Product Leaflet. Revised 10 Sept 2018.

122
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

PARENTROVITE (AMPOULE NO. 1, 5 ML & AMPOULE NO. 2, 5 ML)

(CONTAINS ASCORBIC ACID, NICOTINAMIDE, PANTOTHENIC ACID, PYRIDOXINE,
RIBOFLAVIN AND THIAMINE)
Brand name Trovite

Reconstitution Not required

Suggested
IV bolus: No further dilution required
minimum
IV infusion: Maximum concentration of 1 pair in 50 ml
dilutions
Diluent D5, NS
IV bolus: Administer over 10 minutes
Administration
IV infusion: Infuse over 30 minutes

Fridge (2 – 8°C) RT (< 25°C)

Mixed Ampoules
Stability - 4 hours
(Before Dilution)
After Dilution - 4 hours

Comments  IV infusion is the preferred method of administration.

References 1. Duopharm (M) Sdn. Bhd. Trovite Product Leaflet. Revised 5 Sept 19.

123
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

PENTAMIDINE 300 MG
Brand name DBL Pentamidine Isethionate

Reconstitution Reconstitute with 3 to 5 ml WFI

Suggested
IM: No further dilution required
minimum
IV infusion: Maximum concentration of 6 mg/ml (300 mg in 50 ml)
dilutions
Diluent D5, NS
IM: Deep IM
Administration
IV infusion: Infuse over 60 – 120 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 24 hours

Comments -
1. Lexi-Comp Inc. Version 6.4.0. Lexi-Drug©. [cited 2023 Apr 18].
References 2. Pfizer. DBL Pentamidine Isethionate Product Leaflet. Revised 8 Feb
2018.

124
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

PHENOBARBITAL SODIUM 200 MG/1 ML

Brand name Phenobarbital Sodium

Reconstitution Not required

IM
No further dilution required
Suggested
minimum
IV infusion
dilutions
Dose < 100 mg: Dilute with 50 ml
Dose > 100 mg: Dilute with 100 ml

Diluent D5, NS
IM: Deep IM. Not to exceed a volume of 5 ml per injection site (risk of tissue
Administration irritation)
IV infusion: Not to exceed rate of 60 mg/min

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments -
1. Micromedex Drug Reference. Version 4.0.0 (881) Merative US L.P. [cited
References 2023 Apr 18].
2. Product Leaflet Phenobarbital Sodium Injection. Revised Jan 2018.

125
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

PHENYLEPHRINE 10 MG/1ML
Brand name Zyphrin

Reconstitution Not required

Suggested
minimum Maximum concentration of 1 mg/ml
dilutions
Diluent D5, NS (preferred)
IV bolus: Administer over 20 – 30 seconds
Administration
IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution 24 hours 4 hours

 Central line is preferred if administered via continuous infusion

Comments
(extravasation may cause severe ischemic necrosis).

1. Graham-Clarke E. Minimum Infusion Volumes [Internet]. 4.4 ed. Vol. 4.

United Kingdom Clinical Pharmacy Association; 2012. Available from:
References https://www.scottishintensivecare.org.uk/uploads/2014-07-24-19-56-30-
MinimuminfusionvolumesinI-40262.pdf.
2. Lexi-Comp Inc. Version 6.4.0. Lexi-Drug©. [cited 2023 Apr 18].

126
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

PHENYTOIN 250 MG/5 ML

Brand name Pharmaniaga phenytoin sodium

Reconstitution Not required

Suggested
minimum Maximum concentration of 10 mg/ml
dilutions
Diluent NS

Administration IV infusion: Rate not exceeding 50 mg/min. Complete within 1 hour

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - Use immediately

 Intravenous solutions should be preceded by a saline flush and followed

by an injection of sterile saline through the same needle or catheter to
Comments avoid local venous irritation due to the alkalinity of the solution:
o Fluid restricted patients: 10 ml NS
o Non-fluid restricted patients: 50 ml NS
1. Graham-Clarke E. Minimum Infusion Volumes [Internet]. 4.4 ed. Vol. 4.
United Kingdom Clinical Pharmacy Association; 2012. Available from:
https://www.scottishintensivecare.org.uk/uploads/2014-07-24-19-56-30-
References MinimuminfusionvolumesinI-40262.pdf
2. Lexi-Comp Inc. Version 6.4.0. Lexi-Drug©. [cited 2023 Apr 18].
3. Pharmaniaga. Phenytoin Sodium 250 mg/5 ml Injection Leaflet. Revised
30 May 2017.

127
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

PHYTOMENADIONE 10 MG/1ML
Brand name Kisan

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable

Administration IV infusion: Should not exceed 1 mg/min

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

 IM administration are not advisable due to difficulties with the re-

Comments
institution of anticoagulation therapy and risk of haematoma formation.
1. Duopharma (M) Sdn. Bhd. Product Leaflet Kisan Injection 10 mg/ml.
References
Revised 23 May 2019.

128
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

PIPERACILLIN/TAZOBACTAM 4.5 G
(PIPERACILLIN 4 G & TAZOBACTAM 0.5 G)
Brand name Aurotaz-P

Reconstitution Reconstitute with 20 ml NS or WFI

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable

IV bolus: Administer over 3 – 5 minutes

Administration
IV infusion: Infuse over 20 – 30 minutes or as extended over 4 hours

Fridge (2 – 8°C) RT (< 25°C)

Stability After
48 hours 24 hours
Reconstitution

 Further dilution with 50 ml D5 or NS is recommended for extended

Comments
infusion administration.
1. Aurobindo Pharma Ltd. Aurotaz-P Product Leaflet. Revised Aug 2019.
2. Graham-Clarke E. Minimum Infusion Volumes [Internet]. 4.4 ed. Vol. 4.
United Kingdom Clinical Pharmacy Association; 2012. Available from:
References https://www.scottishintensivecare.org.uk/uploads/2014-07-24-19-56-30-
MinimuminfusionvolumesinI-40262.pdf
3. Lexi-Comp Inc. Version 6.4.0. Lexi-Drug©. [cited 2023 Apr 18].
4. Medscape. Version 1124.0. WebMD, LLC. [cited 2023 Apr 18].

129
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

PIRACETAM 1 G/5 ML
Brand name YSP Knowful

Reconstitution Not required

Suggested
minimum Dilute with diluent for IV infusion
dilutions
Diluent D5, NS

Administration IV bolus: Administer over several minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments -
1. MIMS Online. Knowful-Piracetam [Internet]. MIMS. [cited 2023 Apr 18].
Available from: https://www.mims.com/malaysia/drug/info/knowful
References 2. Medscape. Version 1124.0. WebMD, LLC. [cited 2023 Apr 18].
3. Y.S.P. Industries (M). Product leaflet YSP Knowful Injection 200 mg/ml.
Revised 25 Aug 2015.

130
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

POLYMYXIN B SULPHATE 500,000 UNITS (50 MG)

Brand name Poly-MxB

Reconstitution Reconstitute with 10 ml NS

Suggested
IT: No further dilution required
minimum
IV infusion: Maximum concentration of 20,000 units/ml (2 mg/ml)
dilutions
Diluent D5, NS
IT: Use a preservative-free preparation for IT administration
Administration
IV infusion: Infuse over 60 – 90 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution 24 hours 24 hours

Comments -

1. Bharat Serums and Vaccines Ltd. Poly-MxB Product Leaflet. Revised

31 Oct 18.
2. Lexi-Comp Inc. Version 6.4.0. Lexi-Drug©. [cited 2023 Apr 18].
References 3. Lim TP, Hee DK, Lee W, Teo JQ, Cai Y, Chia SY, Leaw JY, Lee SJ, Lee
LS, Kwa AL. Physicochemical Stability Study of Polymyxin B in Various
Infusion Solutions for Administration to Critically Ill Patients. Annals of
Pharmacotherapy. 2016 Sep;50(9):790-2.

131
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

POTASSIUM CHLORIDE 10% W/V 10 ML

(CONTAINS 1 G POTASSIUM CHLORIDE EQUIVALENT TO 13.4 MMOL
POTASSIUM, 13.4 MMOL CHLORIDE)
Brand name Injecsol K10

Reconstitution Not required

Peripheral: Maximum concentration of 1 g potassium chloride (13.4 mmol
Suggested
potassium) in at least 140 ml
minimum
Central: Maximum concentration of 1 g potassium chloride (13.4 mmol
dilutions
potassium) in at least 34 ml
Diluent NS
Peripheral: Infuse 1 g potassium chloride (13.4 mmol potassium) over at least
60 minutes
Administration
Central: Infuse 1 g potassium chloride (13.4 mmol potassium) over at least
30 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

 Do not administer undiluted or by IV push; may cause fatal cardiac arrest.

Comments  Dilution in glucose solution may decrease serum potassium
concentration, producing intracellular shift.

1. Ain Medicare Sdn. Bhd. Product Leaflet Potassium Chloride 10% w/v
Injection BP. Revised 1 Jun 2020.
2. Gray A. Injectable drugs guide. Pharmaceutical Press; 2011.
3. McAuley D. Potassium Chloride – KCl. [Internet]. GlobalRPH. 2017 [cited
References 2023 Apr 18]. Available from: https://globalrph.com/dilution/potassium-
chloride-kcl/
4. UpToDate [Internet]. www.uptodate.com. Wolters Kluwer; [cited 2023 Apr
18]. Available from: https://www.uptodate.com/contents/potassium-
chloride-drug-information.

132
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

POTASSIUM DIHYDROGEN PHOSPHATE 10 ML

(CONTAINS 10 MMOL POTASSIUM & 10 MMOL PHOSPHATE)
Brand name DBL Potassium Dihydrogen Phosphate

Reconstitution Not required

Suggested
Peripheral: Maximum concentration of 10 mmol phosphate in 250 ml
minimum
Central: Maximum concentration of 10 mmol phosphate in 50 ml
dilutions
Diluent D5, NS
IV infusion: Infuse no faster than 7.5mmol phosphate per hour
Administration
(recommended 4 – 6 hours)

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 24 hours

 Phosphates are incompatible with calcium and/or magnesium containing

Comments
solutions.
1. Graham-Clarke E. Minimum Infusion Volumes [Internet]. 4.4 ed. Vol. 4.
United Kingdom Clinical Pharmacy Association; 2012. Available from:
https://www.scottishintensivecare.org.uk/uploads/2014-07-24-19-56-30-
References MinimuminfusionvolumesinI-40262.pdf
2. Lexi-Comp Inc. Version 6.4.0. Lexi-Drug©. [cited 2023 Apr 18].
3. Pfizer. Product leaflet DBL Potassium Dihydrogen Phosphate
Concentrated Injection. Revised 25 Jun 2019.

133
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

PRALIDOXIME 500 MG/20 ML INJECTION

Brand name Pampara

Reconstitution Not required

Loading dose
No further dilution required
Suggested
minimum
Maintenance dose
dilutions
I. Fluid restricted patients: No further dilution required
II. Non-fluid restricted patients: Maximum concentration of 20 mg/ml

Diluent NS

IV bolus, IV infusion
I. Loading dose: Administer over at least 5 minutes
Administration
II. Maintenance dose: Infuse over 15 – 30 minutes (not to exceed 200
mg/min)

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments -
1. Averroes Pharmaceuticals. Product Leaflet Pampara Injection 500 mg/20
References
ml. Revised 22 Nov 2017.

134
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

PROCYCLIDINE 10 MG/2 ML
Cyclid
Brand name
Kemadrin
Reconstitution Not required
Suggested
minimum No further dilution required
dilutions
Diluent Not applicable
IM
Administration
IV bolus: Administer rapidly

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments -
1. Incepta Pharmaceuticals Ltd. Product Leaflet Cyclid 10 mg/2 ml
References
Injection.

135
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

PROPOFOL 1% & 2%
Brand name Propofol Injectable Emulsion USP Hypro-Melt 1%

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable

Administration IV bolus, IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

 Avoid rapid bolus administration to minimize hypotension.

 Emulsion transferred to a syringe should be done immediately after
Comments
opening the vial and must be used within 12 hours from transfer.
 If two layers can be seen after shaking, the emulsion should not be used.
1. Celon Laboratories Ltd. Product Leaflet Propofol Injectable Emulsion
USP Hypro-Melt 1%.
References
2. Micromedex Drug Reference. Version 4.0.0 (881) Merative US L.P. [cited
2023 Apr 18].

136
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

PROTAMINE 50 MG/5 ML
Brand name Protamine Sulphate

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable

Administration IV infusion: Infuse over 10 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

 No more than 50 mg of protamine sulphate should be given in any one

dose.
Comments
 Too rapid administration of protamine sulphate may cause severe
hypotension and anaphylactic reactions.
1. Antah Pharma Sdn. Bhd. Product Leaflet Protamine Sulphate 10 mg/ml
References
Solution for Injection. Revised 25 Oct 2013.

137
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

3 FACTORS PROTHROMBIN COMPLEX CONCENTRATE 500 IU

(FACTOR II, IX & X)
Brand name Prothrombinex

Reconstitution Reconstitute with 20 ml solvent given

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable

Administration IV infusion: Infuse at rate of 3 ml/min

Fridge (2 – 8°C) RT (< 25°C)

Stability After
- Use immediately
Reconstitution

 Allow the vials of Prothrombinex and solvent to reach temperature 20-

Comments
30°C before reconstituting.
1. CSL Behring Australia Pty Ltd. Product Leaflet Prothrombinex. Revised
References
5 Mar 2015.

138
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

4 FACTORS PROTHROMBIN COMPLEX CONCENTRATE

(FACTOR II, VII, IX & X AND PROTEIN C & S)
Brand name Octaplex

Reconstitution Reconstitute with 20 ml solvent provided

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable

Administration IV infusion: Initially 1ml/min, then not faster than 2 – 3ml per minute

Fridge (2 – 8°C) RT (< 25°C)

Stability After
8 hours 8 hours
Reconstitution

 If the powder fails to dissolve completely or an aggregate is formed, do

Comments
not use the preparation.
1. OctapharmaPharmazeutika. Product Leaflet Octaplex. Revised 22 May
References
2018.

139
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

RASBURICASE 1.5 MG
Rasburnat
Brand name
Elitek
Reconstitute 1.5 mg with 1 ml solvent provided.
Reconstitution
Mix gently. Do not shake or vortex.
Suggested
minimum Maximum concentration of 0.2 mg/kg in 50 ml
dilutions
Diluent NS

Administration IV infusion: Infuse over 30 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution 24 hours Use within 3 hours

 Infuse through a separate line or flush IV line with at least 15 ml saline

prior to and following rasburicase infusion.
Comments  Discard reconstituted solution if particulate matter is visible or product is
discolored.
 Do not use filters during reconstitution or infusion.
1. Lexi-Comp Inc. Version 6.4.0. Lexi-Drug©. [cited 2023 Apr 18].
References
2. Sanofi-Aventis. Rasburicase Product Leaflet. Revised Oct 2009.

140
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

REMIFENTANIL 5 MG/10 ML
Brand name Ultiva

Reconstitution Not required

Suggested
minimum Maximum concentration of 0.4 mg/ml (10 mg in 25 ml)
dilutions
Diluent D5, NS
IV bolus: Administer over at least 30 seconds
Administration
IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 24 hours

Comments -
1. GlaxoSmithKline. Remifentanil (ULTIVA®) Product Leaflet. Revised 15
Mar 2021.
2. Graham-Clarke E. Minimum Infusion Volumes [Internet]. 4.4 ed. Vol. 4.
United Kingdom Clinical Pharmacy Association; 2012. Available from:
References
https://www.scottishintensivecare.org.uk/uploads/2014-07-24-19-56-30-
MinimuminfusionvolumesinI-40262.pdf
3. Micromedex Drug Reference. Version 4.0.0 (881) Merative US L.P. [cited
2023 Apr 18].

141
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

ROCURONIUM 25 MG/2.5 ML & 50 MG/5 ML

Brand name Rocuronium Kabi

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable
IV bolus: Administer rapidly
Administration
IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

 IV infusion can be further diluted to concentration of 0.1 to 5 mg/ml with

Comments
D5 or NS if required.
1. Fresenius Kabi. Rocuronium Kabi Product Leaflet. Revised Jun 2021.
2. Lexi-Comp Inc. Version 6.4.0. Lexi-Drug©. [cited 2023 Apr 18].
References 3. Medscape. Version 1124.0. WebMD, LLC. [cited 2023 Apr 18].
4. Micromedex Drug Reference. Version 4.0.0 (881) Merative US L.P. [cited
2023 Apr 18].

142
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

SALBUTAMOL 0.5 MG/1 ML

Brand name YSP Salbutamol

Reconstitution Not required

Suggested
IV bolus: Maximum concentration of 0.05 mg/ml
minimum
IV infusion: Maximum concentration of 0.2 mg/ml
dilutions
Diluent D5, NS
IV bolus: Administer slowly
Administration
IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 24 hours

Comments -
1. Graham-Clarke E. Minimum Infusion Volumes [Internet]. 4.4 ed. Vol. 4.
United Kingdom Clinical Pharmacy Association; 2012. Available from:
References https://www.scottishintensivecare.org.uk/uploads/2014-07-24-19-56-30-
MinimuminfusionvolumesinI-40262.pdf
2. Y.S.P Industries (M). Salbutamol Product Leaflet. Revised 16 Jun 2017.

143
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

SODIUM BICARBONATE 8.4% W/V 10 ML

(CONTAINS 10 MMOL BICARBONATE & 10 MMOL SODIUM)
Brand name DB Sodium Bicarbonate

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent D5, NS
IV bolus: Administer slowly
Administration
IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

 Administration with catecholamines in the same IV catheter will result in

Comments
inactivation of catecholamines.
1. Duopharma (M) Sdn. Bhd. DB Sodium Bicarbonate 8.4% w/v Injection
Product Leaflet. Revised 26 Aug 2019.
2. McAuley D. Sodium Bicarbonate [Internet]. GlobalRPH. 2017 [cited 2023
Apr 18]. Available from: https://globalrph.com/dilution/zofran-
References
ondansetron/
3. Medscape. Version 1124.0. WebMD, LLC. [cited 2023 Apr 18].
4. Micromedex Drug Reference. Version 4.0.0 (881) Merative US L.P. [cited
2023 Apr 18].

144
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

SODIUM GLYCEROPHOSPHATE 20 ML
(CONTAINS 20 MMOL PHOSPHATE & 40 MMOL SODIUM)
Brand name Glycophos

Reconstitution Not required

Suggested
Peripheral: Maximum concentration of 20 mmol phosphate in 100 ml
minimum
Central: Maximum concentration of 20 mmol phosphate in 50 ml
dilutions
Diluent D5, NS
IV infusion: Infuse no faster than 7.5 mmol phosphate per hour
Administration
(recommended 4 – 6 hours)

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 24 hours

Comments -

1. Fresenius Kabi. Glycophos Product Leaflet. Revised 3 Dec 2019.

2. Graham-Clarke E. Minimum Infusion Volumes [Internet]. 4.4 ed. Vol. 4.
United Kingdom Clinical Pharmacy Association; 2012. Available from:
References
https://www.scottishintensivecare.org.uk/uploads/2014-07-24-19-56-30-
MinimuminfusionvolumesinI-40262.pdf
3. Lexi-Comp Inc. Version 6.4.0. Lexi-Drug©. [cited 2023 Apr 18].

145
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

SODIUM NITROPRUSSIDE 50 MG/2 ML

Brand name Nipride

Reconstitution Not required

Suggested
minimum Maximum concentration 1 mg/ml
dilutions
Diluent D5

Administration IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 24 hours

 Product should always be protected from light, even during

Comments
administration.
1. Graham-Clarke E. Minimum Infusion Volumes [Internet]. 4.4 ed. Vol. 4.
United Kingdom Clinical Pharmacy Association; 2012. Available from:
https://www.scottishintensivecare.org.uk/uploads/2014-07-24-19-56-30-
MinimuminfusionvolumesinI-40262.pdf
2. Lexi-Comp Inc. Version 6.4.0. Lexi-Drug©. [cited 2023 Apr 18].
References (Retrieved from missing)
3. Medscape. Version 1124.0. WebMD, LLC. [cited 2023 Apr 18].
4. Pfizer. Sodium Nitroprusside Product Leaflet. Revised 27 Jul 2017.
5. UpToDate [Internet]. www.uptodate.com. Wolters Kluwer; [cited 2023 Apr
18]. Available from: https://www.uptodate.com/contents/nitroprusside-
drug-information

146
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

SODIUM VALPROATE 400 MG

Brand name Epilim

Reconstitution Reconstitute with solvent (4 ml) provided

Suggested
IV bolus: No further dilution required
minimum
IV infusion: Dilute prescribed dose with 50 ml
dilutions
Diluent D5, NS
IV bolus: Administer over 3 – 5 minutes
Administration
IV infusion: Infuse over 1 hour (maximum rate of 20 mg/min)

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution 24 hours 24 hours

 Rapid infusion is associated with increased risk of adverse events, but

Comments
reported to be well-tolerated in limited studies.
1. Lexi-Comp Inc. Version 6.4.0. Lexi-Drug©. [cited 2023 Apr 18].
2. Medscape. Version 1124.0. WebMD, LLC. [cited 2023 Apr 18].
3. Micromedex Drug Reference. Version 4.0.0 (881) Merative US L.P. [cited
2023 Apr 18].
References 4. Sanofi-Aventis. Sodium Valproate (Epilim) Product Leaflet. Revised May
2020.
5. UpToDate [Internet]. www.uptodate.com. Wolters Kluwer; [cited 2023 Apr
18]. Available from: https://www.uptodate.com/contents/valproate-
chloride-drug-information.

147
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

STREPTOKINASE 1,500,000 IU
Streptokinase Karma 1,500,000
Brand name Streptase
Streptokinase Biofactor
Reconstitution Reconstitute with 5 ml NS or WFI
Suggested
minimum Maximum concentration of 30,000 IU/ml (1,500,000 IU in 50 ml)
dilutions
Diluent D5, NS
Myocardial infarction: 1.5 MU over 1 hour
Administration Pulmonary embolism, deep vein thrombosis: 250,000 IU over 30 minutes,
then 100,000 IU/hour for 24 hours (72 hours for DVT)

Fridge (2 – 8°C) RT (< 25°C)

Stability 12 hours (Biofactor)

After Dilution 24 hours (Streptokinase -
Karma & Streptase)

 Solution should be swirled gently to facilitate quick reconstitution, avoid

Comments shaking to avoid foaming.
 Stability of diluted solution is brand specific.
1. Biofactor GmbH. Streptokinase Product Leaflet. Revised Jul 2009.
2. CSL Behring Canada Inc. Streptase® Product Leaflet. Revised 23 Feb
References 2007.
3. Karma Pharmatech GmbH. Streptokinase Karma Product Leaflet.
Revised Dec 2020.

148
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

STREPTOMYCIN 1 G
Brand name Streptin
Reconstitute with NS or WFI;
Reconstitution 3.5 ml (250 mg/ml)
4.5 ml (200 mg/ml)
Suggested
IM: No further dilution required
minimum
IV infusion: Dilute prescribed dose in 100 ml
dilutions
Diluent D5, NS
IM
Administration
IV infusion: Infuse over 30 – 60 minutes (off label route)

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 24 hours

Comments -
1. Micromedex Drug Reference. Version 4.0.0 (881) Merative US L.P.
References
[cited 2023 Apr 18].

149
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

SUGAMMADEX 200 MG/2 ML

Brand name Bridion

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable

Administration IV bolus: Administer over 10 seconds

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

 Flush the infusion line with NS between administration of sugammadex

and other medicinal agents.
Comments
 Some experts suggest administering slow IV push to reduce incidence of
serious adverse events.
1. Merck Sharp & Dohme (M) Sdn Bhd. Sugammadex Sodium (Bridion)
Injection Product Leaflet. Revised May 2020.
References
2. Micromedex Drug Reference. Version 4.0.0 (881) Merative US L.P. [cited
2023 Apr 18].

150
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

SUXAMETHONIUM CHLORIDE 100 MG/2 ML

Brand name Scolax

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable

Administration IV bolus: Administer over 10 – 30 seconds

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments  Incompatible with alkaline solutions.

1. Chandra Bhagat Pharma Ltd. Product Leaflet Scolax® Injection 50
mg/ml.
2. Medscape. Version 1124.0. WebMD, LLC. [cited 2023 Apr 18].
References 3. Micromedex Drug Reference. Version 4.0.0 (881) Merative US L.P.
[cited 2023 Apr 18].
4. Patricia Dwyer Schull. Mcgraw-Hill’s I.V. drug handbook. New York
Mcgraw Hill Professional; 2009.

151
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

TENECTEPLASE 50 MG (10,000 UNITS)

Brand name Metalyse

Reconstitution Reconstitute with provided solvent 10 ml WFI

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable

Administration IV bolus: Administer over 5 – 10 seconds

Fridge (2 – 8°C) RT (< 25°C)

Stability After
24 hours 8 hours
Reconstitution

Comments  Incompatible with dextrose.

1. Boehringer Ingelheim Pharma GmbH & Co. KG. Product Leaftlet
References Metalyse® Powder and Solvent for Solution for Injection. Revised 7 Feb
2014.

152
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

TERLIPRESSIN 1 MG/8.5 ML
Brand name Glypressin

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable

Administration IV bolus: Administer over 3 – 5 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

 Injection must be given intravenously to avoid local necrosis at the

Comments
injection site.
1. Nottingham University Hospital. Critical Care Pharmacy Drug Guidelines
Folder. Jan 2019.
References
2. Zentiva. Product Leaflet Glypressin® 1 mg/8.5 ml Solution for Injection.
Revised Jan 2019.

153
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

TETANUS IMMUNOGLOBULIN (HUMAN) 250 IU/1 ML

Brand name Sero-Tet

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable

Administration IM

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments  Should not be administered intravenously.

References 1. Green Cross Corp. Product Insert Sero-Tet Injection.

154
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

THIAMINE HYDROCHLORIDE 100 MG/1 ML & 200 MG/2 ML

Benerva
Brand name
Thiamin
Reconstitution Not required
Suggested
IM, IV bolus: No further dilution required
minimum
IV infusion: Prescribed dose in 50 ml
dilutions
Diluent D5, NS
IM
Administration IV bolus: Administer over 5 – 10 minutes
IV infusion: Infuse over 15 – 30 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution 24 hours 24 hours

 Protect from light.

Comments  An extended infusion time over 15 – 30 minutes is suggested for doses
≥ 100 mg.
1. Exeltis Rethinking Healthcare. Thiamin ® Product Leaftlet.
2. Joint Formulary Committee. BNF 83 (British National Formulary) March
2022. S.L.: Pharmaceutical Press; 2022.
3. Lexi-Comp Inc. Version 6.4.0. Lexi-Drug©. [cited 2023 Apr 18].
4. McAuley D. Thiamine [Internet]. GlobalRPH. 2017 [cited 2023 Apr 18].
References
Available from: https://globalrph.com/dilution/thiamine/
5. Patricia Dwyer Schull. Mcgraw-Hill’s I.V. drug handbook. New York
Mcgraw Hill Professional; 2009.
6. Young P, Psirides A. Intensive Care Drug Manual. 2nd ed. Wellington
Regional Hospital; 2013.

155
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

THIOPENTAL SODIUM 500 MG

Brand name Pentotex

Reconstitution Reconstitute with diluent

Suggested
IV bolus: Maximum concentration of 50 mg/ml
minimum
IV infusion: Maximum concentration of 4 mg/ml
dilutions
Diluent D5, NS
IV bolus: Administer over at least 30 seconds
Administration
IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution 24 hours -

 Administer centrally, as high pH of thiopental sodium can cause

Comments
peripheral vein irritancy.
1. Graham-Clarke E. Minimum Infusion Volumes [Internet]. 4.4 ed. Vol. 4.
United Kingdom Clinical Pharmacy Association; 2012. Available from:
https://www.scottishintensivecare.org.uk/uploads/2014-07-24-19-56-30-
MinimuminfusionvolumesinI-40262.pdf
2. McAuley D. Thiopental – Pentothal ® [Internet]. GlobalRPH. 2017 [cited
2023 Apr 18]. Available from: https://globalrph.com/dilution/thiopental/
References
3. Nottingham University Hospital. Critical Care Pharmacy Drug Guidelines
Folder. Jan 2019.
4. Pharmaforte Malaysia. Product Leaflet Pentotex Injection 0.5g. Revised
Oct 2018.
5. Young P, Psirides A. Intensive Care Drug Manual. 2nd ed. Wellington
Regional Hospital; 2013.

156
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

TIGECYCLINE 50 MG
Brand name Tygacil

Reconstitution Reconstitute with 5.3 ml NS (10 mg/ml)

Suggested
minimum Maximum concentration of 1 mg/ml
dilutions
Diluent D5, NS

Administration IV infusion: Infuse over 30 – 60 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability 48 hours (if kept in IV
After Dilution -
bag)
Comments  Flush IV line before and after tigecycline administration.
1. McAuley D. Tigecycline – Tygacil ® [Internet]. GlobalRPH. 2017 [cited
2023 Apr 18]. Available from: https://globalrph.com/dilution/tigecycline-
tygacil/
References
2. Micromedex Drug Reference. Version 4.0.0 (881) Merative US L.P. [cited
2023 Apr 18].
3. Pfizer. Product Leaflet Tygacil 50mg. Revised Sept 2013.

157
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

TOCILIZUMAB 80 MG/4 ML & 400 MG/20 ML

Brand name Actemra

Reconstitution Not required

Suggested
< 30 kg: Dilute to 50 ml
minimum
≥ 30 kg: Dilute to 100 ml
dilutions
Diluent NS

Administration IV infusion: Infuse over 1 hour

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution 24 hours 24 hours

Comments -
1. Chungai Pharma Manufacturing Co. Ltd.
2. Joint Formulary Committee. BNF 83 (British National Formulary) March
2022. S.L.: Pharmaceutical Press; 2022.
References
3. Micromedex Drug Reference. Version 4.0.0 (881) Merative US L.P.
[cited 2023 Apr 18].
4. Product Leaftlet Actemra® Concentrate Solution for Infusion.

158
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

TRAMADOL HYDROCHLORIDE 50 MG/1 ML

Brand name Acugesic

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable
IM
Administration
IV bolus: Administer over at least 2 – 3 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments -
1. Duopharma (M) Sdn. Bhd. Product Leaftlet Tramadol Hydrochloride.
Revised 18 Apr 2019.
References 2. Gray AH. Injectable Drugs Guide. London: Pharmaceutical Press; 2011.
3. Young P, Psirides A. Intensive Care Drug Manual. 2nd ed. Wellington
Regional Hospital; 2013.

159
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

TRANEXAMIC ACID 500 MG/5 ML

Brand name Tranexamic Acid

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable

Administration IV infusion: Infuse at rate not more than 100 mg/min (1 ml/min)

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

 Administration faster than 1 ml/min may cause hypotension.

Comments  May be further diluted in D5 or NS to a maximum concentration of 20
mg/ml (stable for 24 hours refrigerated or room temperature).
1. McAuley D. Tranexamic Acid [Internet]. GlobalRPH. 2017 [cited 2023 Apr
18]. Available from: https://globalrph.com/dilution/tranexamic-acid/
2. Micromedex Drug Reference. Version 4.0.0 (881) Merative US L.P. [cited
References 2023 Apr 18].
3. UpToDate [Internet]. www.uptodate.com. Wolters Kluwer; [cited 2023 Apr
18]. Available from: https://www.uptodate.com/contents/tranexamic-acid-
drug-information.

160
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

TRIAMCINOLONE ACETONIDE 40 MG/ 1ML

Brand name Sivkort

Reconstitution Not required

Suggested
minimum No further dilution required
dilutions
Diluent Not applicable
Deep IM
Administration
Intra-articular

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments -

1. Siu Guan Hem. Ind. Co. Ltd. Triamcinolone Acetonide 40 mg/Ml Sterile
References
Suspension For Injection Product Leaftlet. Revised 2017.

161
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

UROKINASE 5,000 IU & 500,000 IU

Brand name U-frag

Reconstitution Reconstitute with 2 ml WFI

Suggested
minimum Further dilute reconstituted solution with 200 ml of compatible diluents
dilutions
Diluent D5, NS

Administration IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution 24 hours 24 hours

 After administration, the infusion tubing should be flushed with NS or D5.

Comments
This volume of fluid should be flushed through the entire tubing length.

1. Micromedex Drug Reference. Version 4.0.0 (881) Merative US L.P. [cited

References
2023 Apr 18].

162
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

VANCOMYCIN 500 MG
Brand name Vivocin

Reconstitution Reconstitute with 10 ml WFI

Suggested
Peripheral: Maximum concentration of 5 mg/ml
minimum
Central: Maximum concentration of 10 mg/ml
dilutions
Diluent D5, NS

Administration IV infusion: Infuse over at least 60 minutes (not exceeding 10 mg/min)

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution 96 hours 24 hours

 Infusion-related events are related to both concentration and rate of

Comments administration of vancomycin. If infusion-related events occur, slow the
infusion rate to over 1.5 – 2 hours and increase the dilution volume.
1. Gland Pharma Ltd. Vivocin Product Leaflet. Revised 5 Sept 2019.
2. Graham-Clarke E. Minimum Infusion Volumes [Internet]. 4.4 ed. Vol. 4.
United Kingdom Clinical Pharmacy Association; 2012. Available from:
https://www.scottishintensivecare.org.uk/uploads/2014-07-24-19-56-30-
MinimuminfusionvolumesinI-40262.pdf
3. McAuley D. Vancomycin [Internet]. GlobalRPH. 2017 [cited 2023 Apr 18].
References
Available from: https://globalrph.com/dilution/vancomycin/
4. Micromedex Drug Reference. Version 4.0.0 (881) Merative US L.P. [cited
2023 Apr 18].
5. UpToDate [Internet]. www.uptodate.com. Wolters Kluwer; [cited 2023 Apr
18]. Available from: https://www.uptodate.com/contents/vancomycin-
drug-information.

163
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

VASOPRESSIN 20 IU/1 ML
Brand name Vasopressin

Reconstitution Not required

Suggested
minimum Maximum concentration of 1 units/ml
dilutions
Diluent D5, NS

Administration IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - -

Comments  Infusion through central line is recommended.

1. McAuley D. Vasopressin – Pitressin ® [Internet]. GlobalRPH. 2017 [cited
2023 Apr 18]. Available from: https://globalrph.com/dilution/vasopressin-
pitressin/
2. Micromedex Drug Reference. Version 4.0.0 (881) Merative US L.P. [cited
References
2023 Apr 18].
3. UpToDate [Internet]. www.uptodate.com. Wolters Kluwer; [cited 2023 Apr
18]. Available from: https://www.uptodate.com/contents/vasopressin-
drug-information.

164
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

VERAPAMIL 5 MG/2 ML
Brand name Zypamil

Reconstitution Not required

Suggested
IV bolus: No further dilution required
minimum
IV infusion: Maximum concentration of 0.5 mg/ml
dilutions
Diluent D5, NS
IV bolus: Administer over at least 2 minutes
Administration
IV infusion: Titrate as per dose prescribed

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution - 24 hours

Comments -
1. McAuley D. Verapamil [Internet]. GlobalRPH. 2017 [cited 2023 Apr 18].
Available from: https://globalrph.com/dilution/verapamil/
2. Micromedex Drug Reference. Version 4.0.0 (881) Merative US L.P. [cited
References 2023 Apr 18].
3. UpToDate [Internet]. www.uptodate.com. Wolters Kluwer; [cited 2023 Apr
18]. Available from: https://www.uptodate.com/contents/verapamil-drug-
information.

165
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

VORICONAZOLE 200 MG
Brand name Vfend

Reconstitution Reconstitute with 19 ml WFI

Suggested
minimum Maximum concentration of 5 mg/ml
dilutions
Diluent D5, NS

Administration IV infusion: Infuse over 1 – 2 hours (maximum rate of 3 mg/kg/hr)

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution 24 hours 24 hours

 Do not infuse concomitantly into the same line or cannula with other drug
infusions.
Comments
 Do not infuse concomitantly even in separate lines or cannulas with
concentrated electrolyte solutions or blood products.
1. Pfizer (M) Sdn. Bhd. Product Leaflet Voriconazole 200 mg. Revised 15
Nov 2017.
References 2. UpToDate [Internet]. www.uptodate.com. Wolters Kluwer; [cited 2023 Apr
18]. Available from: https://www.uptodate.com/contents/voriconazole-
drug-information.

166
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

ZOLEDRONIC ACID 4 MG/5 ML

Brand name Oledron

Reconstitution Not required

Suggested
minimum Dilute prescribed dose with 100 ml
dilutions
Diluent D5, NS

Administration IV infusion: Infuse over at least 15 minutes

Fridge (2 – 8°C) RT (< 25°C)

Stability
After Dilution 24 hours 24 hours

 If refrigerated, allow solution to reach room temperature before

administration.
Comments
 Flush IV line with 10 ml NS flush following infusion.
 Patients must be appropriately hydrated prior to treatment.
1. McAuley D. Zoledronic Acid [Internet]. GlobalRPH. 2017 [cited 2023 Apr
18]. Available from: https://globalrph.com/dilution/zoledronic-acid/
2. Micromedex Drug Reference. Version 4.0.0 (881) Merative US L.P. [cited
References 2023 Apr 18].
3. UpToDate [Internet]. www.uptodate.com. Wolters Kluwer; [cited 2023 Apr
18]. Available from: https://www.uptodate.com/contents/zoledronic-acid-
drug-information.

167
 DILUTION GUIDE FOR FLUID RESTRICTED CRITICALLY ILL ADULTS

FIRST EDITION (APRIL 2024)

Pharmaceutical Services Programme

Ministry of Health (Malaysia)
Lot 36, Jalan Prof Diraja Ungku Aziz
46200 Petaling Jaya
Selangor, Malaysia.
Tel: 03-7841 3200
Website: pharmacy.gov.my

© All Rights Reserved

168