TRacknGuide v1.0

⚙ Back Office

Organization-wide settings — changes apply to all patients

General

Antimicrobials

Kinetics / PK

HIV / ART

Anticoagulation

ESA / Anemia

TPN / Nutrition

Pain & Sed

Critical Drips

Insulin Drip

PCA Reference

Narrow Therapeutic

Steroid Taper

Diuretics

IV Concentrations

Lab Reference Ranges

Calculations

Providers

Drug Acq. Cost

Archives

Danger Zone

⚕ CLINICAL DISCLAIMER Reference information only — drawn from cited standard references^1–8 (numbered source legend on the Antimicrobials tab) but does not supersede clinical judgment, institutional protocols, or current prescribing information. Verify dosing against your formulary and current package inserts before clinical use.

FACILITY & DISPLAY

FACILITY NAME

DEPARTMENT / UNIT

DEFAULT PHYSICIAN LABEL

APP SUBTITLE

CLOUD SYNC & SUBSCRIPTION

Enter your TRacknGuide license key to enable automatic cloud backup, multi-device sync, and subscription management. All patient data is encrypted in transit and stored securely on AWS RDS.

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SSO / IDENTITY — AUTH0

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tenant: tracknguide.us.auth0.com

SYSTEM UPDATE LOG Recent feature additions and content updates

2026-05-03

Hover Reference Tooltips — Critical Drips, Steroid Taper, Diuretics

Added rich hover tooltips (ⓘ) to drug name cells in the Critical Drips, Steroid Taper, and Diuretics Back Office tables. Hovering over any highlighted drug name shows a structured popup with dose ranges, receptor mechanisms, clinical pearls, and equivalency conversions — consistent with the existing renal dose adjustment and AUC dosing tooltips in the NTI tracker and vancomycin kinetics modules.

2026-05-03

Calculations Module — Calcs 67 & 68 Added; Quick-Access Buttons

Added Calc 67 (Corticosteroid Equivalency Calculator) and Calc 68 (Loop Diuretic Dose Equivalency Calculator) to the Built-In Calculations reference table with complete formulas, potency factor tables, and source citations. Added quick-access jump buttons to the Interactive Calculators panel linking directly to these tools in their respective Back Office tabs.

2026-05-02

Anticoag Back Office — Thrombolytics Reference Card & Sources Block

Added a comprehensive Thrombolytics (Fibrinolytics) reference card to the Anticoagulation Back Office tab covering AIS (alteplase 0.9 mg/kg, tenecteplase 0.25 mg/kg), STEMI (alteplase, tenecteplase, reteplase), and massive PE (alteplase 100 mg) dosing. Includes absolute contraindications, AIS-specific exclusions, post-administration monitoring protocols, and reversal (cryoprecipitate, TXA, FFP). Added formal SOURCES block to anticoag tab covering CHA₂DS₂-VASc, HAS-BLED, 4T Score, and UFH nomogram references. All sources are linked.

2026-05-02

All Back Office Sources — Clickable Hyperlinks Added (56 Blocks)

Added DOI/URL hyperlinks to every citation in all 56 SOURCES blocks across the application — previously all citations were plain text. Coverage includes SSC/Evans, ATHOS-3/Khanna, PADIS/Devlin, ACURASYS/Papazian, EMPEROR-Reduced/Preserved, DAPA-HF, DOSE/Felker, RALES/Pitt, ADVOR/Verbrugge, TRANSFORM-HF, Rybak vancomycin consensus, ADA 2025, ASPEN 2022, CDC opioid guideline, all Lexicomp (→ online.lexi.com) and AHFS (→ ashp.org) references, and ~60 additional primary citations. All 300 hyperlinks open in new tab.

2026-05-02

Year Reference Updates — 2024 → 2025 Across All Modules

Updated all outdated 2024 year references in SOURCES blocks to 2025: Lexicomp Critical Care, Aminoglycosides, Vancomycin, TPN/Nutrition, Insulin, Digoxin, Anticonvulsants, Immunosuppressants, Psychiatric, Theophylline, Antineoplastic, Thyroid, Filgrastim monographs; AHFS Drug Information across all modules.

2026-04-28

Diuretics Back Office — Full Module Audit & New Calculators

Added SGLT2 Inhibitor section (empagliflozin EMPEROR-Reduced/Preserved, dapagliflozin DAPA-HF) with eGFR thresholds, euDKA perioperative hold requirements, and HF indications. Added Vasopressin Antagonist section (tolvaptan — ODS correction limits, BBW hepatotoxicity, aquaresis mechanism). Added Loop Diuretic Dose Equivalency Calculator (Furosemide IV as reference; torsemide 1:1, bumetanide 40:1). Updated torsemide citation with TRANSFORM-HF. Updated all sources to 2025.

2026-04-28

Steroid Taper Back Office — Corticosteroid Equivalency Calculator Added

Added interactive Corticosteroid Equivalency Calculator (HC=1×, Cortisone=0.8×, Prednisone/Pred=4×, Methylprednisolone=5×, Triamcinolone IM=5×, Dexamethasone=25×, Budesonide PO=9×). Displays simultaneous equivalents for all 7 agents. Updated monitoring and adrenal suppression source citations to 2025 with Poetker 2010 added.

2026-04-28

PCA Back Office — Multimodal Analgesia Card & ISMP Safety Alert

Added PCA Safety Alerts & Multimodal Analgesia card with ISMP High-Alert warning, basal rate contraindication in opioid-naive, hard-limit requirements, and non-opioid adjunct reference table (IV acetaminophen, ketorolac, sub-dissociative ketamine, dexmedetomidine). Added ASPMN 2016 and ISMP 2016 sources.

2026-04-25

NTI Back Office — Full Audit & SubQ Insulin Transition Calculator

Comprehensive audit of the Narrow Therapeutic Index (NTI) Back Office module. Verified therapeutic ranges, monitoring parameters, and toxicity thresholds for all 40+ NTI drug categories. Added interactive SubQ Insulin Transition Calculator (Calc 66) converting from insulin drip TDD to basal/bolus SubQ regimen using 80% conversion factor with customizable basal/correction split.

2026-04-25

Insulin Drip Back Office — Full Audit & Source Updates

Audited and updated the Insulin Drip Back Office reference: verified target glucose ranges, protocol indications, hypoglycemia protocol, monitoring frequency, transition criteria, and ICU glycemic control evidence base (van den Berghe 2001, NICE-SUGAR 2009, Jacobi/SCCM 2012, ADA 2025). Updated all sources to current year.

2026-04-24

PK/Kinetics — Hartford Nomogram & Urban-Craig Interactive Calculators

Added interactive Hartford Nomogram (plot-based ODA dosing) and Urban-Craig (pharmacokinetic-based individualized dosing with Ke estimation) calculators to the Vancomycin / Kinetics Back Office. Verified all AUC/MIC and trough-guided vancomycin calculations against 2020 ASHP/IDSA/SIDP consensus guidelines.

2026-04-20

Cloud Sync, Auth, Billing Infrastructure

Implemented cloud sync layer with AWS backend (facility_data table, /api/data endpoint), Auth0 SPA authentication, Stripe billing and license key system, and cloud sync activation UI in Back Office → General. Added data backup/restore and cross-version migration documentation.

GLOBAL LAB REFERENCE RANGES Changes apply instantly to all patient forms. Leave blank to suppress flagging for that lab.

QUICK RESOURCES 📋 IDSA Guideline Index A–Z ↗

AUTOMATIC SOFT-STOP Sets the default stop date for empiric antibiotics — can be overridden per drug at any time.

DEFAULT SOFT-STOP (DAYS FROM START)

When a start date is entered for a new antibiotic drug with no Duration of Therapy set, the Duration and Stop Date will automatically default to this many days. Both remain fully editable at any time.

ANTIMICROBIAL REFERENCE TABLE Grouped by type (Antibiotics → Antifungals → Antivirals), sorted alphabetically within each group · Dosing ranges are general guidelines — always verify per institutional protocol

⚠️

CLINICAL DISCLAIMER
The dosing information in this table is derived from standard pharmacological references^1–5 and is intended as a general reference only. It does not supersede clinical judgment, institutional protocols, or current manufacturer prescribing information.
Always verify dosing against your institution's formulary and current package inserts. Drug information is current as of the knowledge cutoff and may not reflect the most recent label changes or guideline updates. This tool is not a substitute for clinical pharmacist review.

SOURCES ¹ FDA Prescribing Information via DailyMed (dailymed.nlm.nih.gov) — PRIMARY dosing & renal adjustment source (public domain) · ² Lexicomp Online (Wolters Kluwer) — corroborating reference · ³ IDSA Practice Guidelines · ⁴ AHFS Drug Information · ⁵ Micromedex (Merative) · ⁶ DHHS HIV/ARV Guidelines 2024 (HIV/ART tab) · ⁷ CHEST 2022 / ASH 2018 (Anticoagulation tab) · ⁸ Surviving Sepsis Campaign / CMS SEP-1 (Sepsis cards)
Renal dosing tiers are cited to the FDA Prescribing Information (DailyMed)¹ as the primary source. Entries verified item-by-item against the current label by the clinical pharmacist are marked ✓ PI-verified with date.

Antimicrobial	Class	Route	Gram +	Gram −	Other Coverage	Renal Dose?	Formulary	Restricted Use	Standard Dose	Renal Dose Tiers (drug-specific thresholds)	Notes

ANTIBIOTIC MONITORING PARAMETERS Key lab & safety monitoring by drug class · Always verify per current PI and institutional protocol

DRUG	TDM / LEVELS	RENAL (SCr/CrCl)	HEPATIC (LFTs)	OTHER LABS	CLINICAL NOTES
BETA-LACTAMS
Amoxicillin / Amox-Clav	Not routinely monitored	Baseline; dose-adjust if CrCl <30	Monitor if prolonged; Augmentin — hepatotoxicity risk (monitor ALT/AST)	CBC if prolonged	Amox-Clav: cholestatic hepatitis risk, especially >14 days
Ampicillin / Amp-Sulbactam	Not routinely monitored	BMP baseline; adjust if CrCl <30	ALT/AST if prolonged use	CBC (neutropenia >10 days)	Monitor for rash (maculopapular in EBV/CLL)
Piperacillin-Tazobactam	Not routinely monitored	BMP q48–72h; CrCl-based dosing	LFTs if >7–10 days	CBC; electrolytes (Na/K)	High Na load; leukopenia >14 days; neurotoxicity (AMS) esp. with renal impairment + high doses
Cefepime	Not routinely monitored	SCr baseline; renal dose-adjust	Not routinely	CBC if prolonged	Neurotoxicity (non-convulsive status epilepticus) with renal impairment — EEG if AMS; reduce dose in AKI/CKD
Ceftriaxone	Not routinely monitored	No dose-adjust in renal failure	LFTs if >7 days	CBC; biliary sludge (esp. >10 days)	Avoid Ca-containing IV solutions (neonates); cholelithiasis/sludge with prolonged use
Meropenem / Imipenem	Not routinely monitored	BMP q48–72h; renal dose-adjust	LFTs if prolonged	CBC (cytopenias)	Imipenem: seizure risk (lower CNS threshold); reduces valproate levels — monitor VPA; neurotoxicity in renal impairment
Ertapenem	Not routinely monitored	Adjust if CrCl <30	Uncommon	CBC if prolonged	Reduces valproate levels; CNS side effects less than imipenem
Cefiderocol (Fetroja)	Not routinely monitored	BMP at baseline; q48–72h during therapy; significant dose adjustment at every CrCl tier — verify current dose against CrCl	Not primary concern	CBC if prolonged use; blood cultures to assess response	Siderophore cephalosporin — only β-lactam class agent with reliable MBL coverage (NDM, VIM, IMP); active vs. CRPA, CRAB; HAP/VAP and cUTI indications; clinical trials showed higher all-cause mortality vs. carbapenems in some settings (CREDIBLE-CR) — reserve for truly resistant organisms; significant renal dose adjustment required for all CrCl ranges
Recarbrio (Imipenem-Cilastatin-Relebactam)	Not routinely monitored	BMP q48–72h; significant renal dose adjustment required at every CrCl tier (proportional reduction from CrCl ≥90 down to HD)	LFTs if prolonged use	CBC (cytopenias); VPA level if on valproate; electrolytes	Relebactam restores imipenem activity vs. KPC-producing CRE and CRPA; does NOT cover MBL (NDM, VIM, IMP) — use cefiderocol or aztreonam-avibactam instead; seizure risk (imipenem component) — avoid/caution with CNS disease; reduces valproate levels (monitor VPA and adjust dose); significant renal dose adjustment required at each CrCl tier
GLYCOPEPTIDES
Vancomycin	AUC/MIC 400–600³ or trough 10–20 mg/L (non-AUC-guided)³	BMP q48–72h; SCr ↑ → suspect VIKI³	Not primary concern	CBC (leukopenia >14 days); audiology if prolonged	VIKI (vancomycin-induced kidney injury) esp. with Pip-Tazo combo³; Red Man Syndrome (infusion-rate reaction — not allergy)¹; ototoxicity with aminoglycosides
Daptomycin	Not routinely monitored	CrCl-based dosing; q48h if CrCl <30	Not primary	CK weekly (rhabdomyolysis); CBC	Hold statins during therapy; inactivated by lung surfactant (not for pneumonia); CK >1000 U/L → discontinue
AMINOGLYCOSIDES
Gentamicin / Tobramycin	Extended-interval: draw level 6–14h post-dose, use Hartford nomogram⁴ TID: peak 5–10 mg/L; trough <2 mg/L^1,2	BMP q48–72h; hold/adjust if SCr ↑ ≥0.5	Not primary	Audiology if >14 days or prior exposure^1,6	Nephrotoxicity synergistic with vancomycin³; ototoxicity (irreversible) — limit duration; avoid in pregnancy⁶
Amikacin	Peak 56–64 mg/L (extended-interval); trough <5 mg/L^1,2	BMP q48–72h; renal dosing	Not primary	Audiology if prolonged⁶	Similar nephro/ototoxicity profile to gentamicin; used for MDR gram-negatives and mycobacteria⁵
FLUOROQUINOLONES
Ciprofloxacin	Not routinely monitored	Dose-adjust if CrCl <30	Uncommon	⚡ QTc; glucose (dysglycemia)	QTc prolongation⁶; tendinopathy/rupture (esp. +steroids, age >60)⁶; CNS effects; reduces theophylline/caffeine clearance; hypoglycemia with sulfonylureas¹
Levofloxacin	Not routinely monitored	Adjust if CrCl <50	Uncommon	⚡ QTc; glucose	QTc prolongation (less than moxifloxacin)⁶; tendinopathy⁶; hypoglycemia; C. diff risk¹
Moxifloxacin	Not routinely monitored	No renal dose-adjust needed	Hepatic dose-adjust (Child-Pugh C)	⚡ QTc (high risk)	Highest QTc risk among fluoroquinolones⁶; avoid with other QT-prolonging agents; no renal dose-adjustment needed (hepatic metabolism)¹
Delafloxacin (Baxdela)	Not routinely monitored	IV form: avoid if CrCl <30 (SBECD vehicle accumulates); switch to PO 450 mg q12h; PO form: no renal dose adjustment	Not primary concern	⚡ QTc (lower risk vs. other FQs); glucose (dysglycemia — class effect)	Anionic FQ — uniquely active at acidic pH (abscesses, biofilm); MRSA coverage (differentiator from other FQs); IV form contains SBECD vehicle (avoid CrCl <30; switch to PO which has no renal restriction); QTc risk lower than ciprofloxacin/levofloxacin but monitor; tendinopathy risk (class effect); ABSSSI and CABP indications; avoid within 2h of divalent cations (oral form)
MACROLIDES
Azithromycin	Not routinely monitored	No dose-adjust	LFTs if >5 days IV	⚡ QTc	QTc prolongation; weak CYP3A4 inhibitor; GI motility effects (prokinetic); avoid in hepatic impairment (IV)
Clarithromycin	Not routinely monitored	Adjust if CrCl <30	LFTs; hepatotoxicity risk	⚡ QTc	Strong CYP3A4 inhibitor — major DDIs (statins → rhabdo, colchicine toxicity, etc.); QTc prolongation; GI upset
Erythromycin	Not routinely monitored	Minimal renal dose-adjust	LFTs; cholestatic hepatitis	⚡ QTc (highest risk in class)	Highest QTc risk in macrolides; strong CYP3A4 inhibitor; prokinetic at low doses; GI side effects common
TETRACYCLINES
Doxycycline	Not routinely monitored	No dose-adjust (safe in renal failure)	LFTs if hepatic impairment	BMP (photosensitivity, esophageal); CBC if prolonged	Photosensitivity; esophageal ulceration (take upright + water); avoid in pregnancy/children <8; antacids/Ca/Mg decrease absorption
Minocycline	Not routinely monitored	No dose-adjust needed	LFTs if prolonged	Vestibular (dizziness, vertigo)	Vestibular side effects dose-dependent; drug-induced lupus; hyperpigmentation (prolonged use); avoid dairy/antacids within 2h
Tigecycline	Not routinely monitored	No dose-adjust	Dose-reduce in severe hepatic impairment (Child-Pugh C)	PT/INR (anticoagulation effect); pancreatitis (lipase)	All-cause mortality signal in clinical trials⁶; nausea/vomiting common (premedicate); pancreatitis; monitor for hypofibrinogenemia¹
OXAZOLIDINONES
Linezolid	Not routinely monitored (AUC-guided in research)	No dose-adjust	No dose-adjust	CBC weekly (thrombocytopenia, anemia); lactate (lactic acidosis)	MAO inhibitor — serotonin syndrome risk (SSRIs, SNRIs, tramadol, meperidine)^1,6; myelosuppression >2 weeks⁶; peripheral/optic neuropathy; lactic acidosis¹
SULFONAMIDES
TMP-SMX	Not routinely monitored	BMP q3–7 days; SCr ↑ common (tubular secretion blockade — not true GFR drop); dose-adjust CrCl <30	LFTs if prolonged	CBC (cytopenias, esp. with folate deficiency); K⁺ (hyperkalemia — K-sparing effect of TMP)	TMP blocks tubular creatinine secretion → apparent SCr rise (not true AKI)^1,2; hyperkalemia esp. with ACEi/ARB/K-sparing diuretics¹; myelosuppression; Serious skin reactions (SJS/TEN) — discontinue at first rash⁶
NITROIMIDAZOLES
Metronidazole	Not routinely monitored	No dose-adjust (hepatic metabolism)	LFTs; dose-reduce in severe hepatic impairment	Neurological assessment if prolonged	Peripheral neuropathy, encephalopathy (especially CNS disease); disulfiram-like reaction with alcohol; INR potentiation (warfarin); metallic taste
POLYMYXINS
Colistin (Polymyxin E)	Css,avg target 2–4 mg/L⁵ AUC-guided when available	BMP q48–72h; high nephrotoxicity risk⁵	Not primary	Electrolytes (Ca, Mg, K, phosphate)	High nephrotoxicity (≥50% in some series)⁵; neurotoxicity (paresthesias, neuromuscular blockade); reserve for XDR/PDR gram-negatives⁵; dose in CBA units (loading dose critical)^1,6
Polymyxin B	AUC target 50–100 mg·h/L⁵ TDM emerging; less nephrotoxic than colistin	BMP q48–72h	Not primary	Electrolytes; CBC	Facial flushing/paresthesias with rapid infusion; no renal dose-adjustment (unlike colistin)^1,6; hyperpigmentation
RIFAMYCINS
Rifampin	Not routinely monitored	No dose-adjust in renal failure	LFTs at baseline, 2–4 weeks; hepatotoxic	CBC (thrombocytopenia, hemolytic anemia)	Potent CYP inducer — massive DDIs (warfarin, antiretrovirals, immunosuppressants, azoles)^1,7; orange body fluid discoloration; flu-like syndrome with intermittent dosing¹

SOURCES
¹ Lexicomp Online. Lexi-Drugs. Hudson, OH: Lexicomp, Inc. Accessed 2026. ² AHFS Drug Information 2026. American Society of Health-System Pharmacists. ³ Rybak MJ et al. ASHP/IDSA/SIDP Vancomycin Consensus Guidelines. Am J Health-Syst Pharm. 2020;77(11):835–864. PMID: 32202649. ⁴ Nicolau DP et al. Experience with a once-daily aminoglycoside program. Antimicrob Agents Chemother. 1995;39(3):650–655. PMID: 7793867. ⁵ Tamma PD et al. IDSA Guidance on AMR Gram-Negative Infections. Clin Infect Dis. 2022;74(12)075–2158. PMID: 35106677. ⁶ FDA Prescribing Information (drug-specific). U.S. Food & Drug Administration. ⁷ Sanford Guide to Antimicrobial Therapy 2025. Antimicrobial Therapy, Inc.

ANTIFUNGAL MONITORING PARAMETERS Drug-specific monitoring requirements — Echinocandins · Azoles · Polyenes

DRUG	CLASS	LEVELS / TDM	HEPATIC MONITORING	RENAL / OTHER	KEY INTERACTIONS & PEARLS
ECHINOCANDINS
Anidulafungin	Echinocandin	Not routinely needed. No TDM.	LFTs (AST/ALT/Alk Phos) at baseline; weekly if prolonged therapy or pre-existing liver disease.	No renal dose adjustment. Chemical degradation — not hepatically metabolized. Minimal drug interactions.	⬆ Infusion reaction with rapid infusion. Max infusion rate 1.1 mg/min. Most favorable drug-interaction profile of echinocandins. Active vs. Candida incl. fluconazole-resistant strains; Aspergillus.
Caspofungin	Echinocandin	Not routinely needed. No TDM.	LFTs at baseline; weekly if >2 weeks or Child-Pugh B/C (reduce maintenance to 35 mg/day for Child-Pugh B). Not recommended in severe hepatic impairment (Child-Pugh C).	No renal dose adjustment. Hepatically metabolized (not CYP3A4 substrate but induces).	Reduce dose to 70 mg loading → 35 mg/day maintenance if concurrent with rifampin, efavirenz, nevirapine, phenytoin, dexamethasone (enzyme inducers → reduce caspofungin exposure). Increase to 70 mg/day maintenance if receiving enzyme inducers.
Micafungin	Echinocandin	Not routinely needed. No TDM.	LFTs at baseline and weekly for prolonged courses. No adjustment for mild-moderate hepatic impairment; avoid in severe hepatic impairment.	No renal dose adjustment. Metabolized by arylsulfatase / catechol-O-methyltransferase — minimal CYP interactions.	Increases sirolimus and nifedipine levels (monitor)¹. Animal carcinogenicity data — avoid prolonged use unless benefits outweigh risk⁵. Active vs. Candida and Aspergillus; not vs. Cryptococcus^2,3.
AZOLES
Fluconazole ⚡ QTc	Triazole	TDM not routinely done. Predictable PK.	LFTs at baseline; weekly if prolonged use or hepatic disease. Hepatotoxicity uncommon but check if symptoms arise.	Renal dose adjustment required: CrCl <50 → reduce dose 50%. HD: give full dose post-dialysis.	Strong CYP2C9 + moderate CYP3A4 inhibitor. Major interactions: warfarin (INR can double — monitor closely), phenytoin, tacrolimus, cyclosporine, QT-prolonging agents. QTc monitoring if on concurrent QT-prolonging drugs.
Voriconazole ⚡ QTc	Triazole	✦ TDM RECOMMENDED^3,4 Trough: 1–5.5 mg/L⁴ Check after day 5–7 (steady state)	LFTs at baseline, weekly for first month; then monthly. Hepatotoxicity dose-dependent — hold/dose-reduce if transaminases >5× ULN⁵. Caution in cirrhosis (Child-Pugh A/B: standard dose; Child-Pugh C: avoid)⁵.	IV formulation contains sulfobutylether-β-cyclodextrin (SBECD) — accumulates in renal failure (CrCl <50). Use PO formulation in renal impairment if possible^1,5. No PO dose adjustment for renal impairment.	Strong CYP2C9/2C19/3A4 inhibitor. Major DDIs: tacrolimus (reduce 66%), cyclosporine (reduce 50%), sirolimus (CONTRAINDICATED), rifampin (contraindicated — reduces levels 96%), carbamazepine, phenobarbital^1,3. Monitor visual changes (photopsia), rash, neurologic AEs. Non-linear PK — small dose changes → large trough shifts⁴.
Isavuconazole ↓ QTc	Triazole	TDM optional. Trough: 1–4 mg/L (if used). More linear PK than voriconazole.	LFTs at baseline; periodic monitoring with prolonged use. Can be used in mild-moderate hepatic impairment (no dose adjustment); limited data in severe hepatic impairment.	No renal dose adjustment. IV formulation lacks SBECD — safe in renal failure.	Moderate CYP3A4 inhibitor. Major DDIs: tacrolimus (monitor levels), cyclosporine, sirolimus. Unlike voriconazole: shortens QTc (vs. prolonging) — do not use in familial short QT syndrome. Broad spectrum: Aspergillus, Mucorales, Candida. Active vs. mucormycosis — differentiator from voriconazole.
Posaconazole ⚡ QTc	Triazole	✦ TDM RECOMMENDED (prophylaxis & treatment)^3,4 Trough: ≥0.7 mg/L (prophylaxis); ≥1–1.5 mg/L (treatment)⁴ Check after day 5–7	LFTs at baseline and periodically. Caution in significant hepatic disease; no specific adjustment but monitor closely⁵.	No renal dose adjustment for tablet/DR formulation. Avoid PO suspension with CrCl <20 (PEG excipient). IV form contains SBECD — avoid if CrCl <50⁵.	Strong CYP3A4 inhibitor. Absorption highly food-dependent (suspension must be taken WITH high-fat meal or liquid nutritional supplement). DR tablets have more consistent absorption — preferred¹. QTc prolongation⁵. Major DDIs: tacrolimus (reduce dose 66%), cyclosporine, sirolimus, rifabutin (avoid), phenytoin^1,3.
Itraconazole ⚡ QTc	Triazole	TDM useful. Trough: 0.5–1.0 mg/L (prophylaxis/maintenance). Highly variable PK⁴.	LFTs at baseline; monitor regularly (hepatotoxicity risk, especially with pre-existing liver disease). Avoid in hepatic failure⁵.	IV form contains HPBCD — avoid if CrCl <30. No adjustment for oral form⁵.	Strong CYP3A4 inhibitor + P-gp inhibitor. Requires acidic environment for absorption — separate from PPIs/H2 blockers¹. Negative inotropic effect — avoid in HF (EF <35%)⁵. Major DDIs: statins (rhabdomyolysis risk), digoxin, quinidine, warfarin¹.
POLYENES
Amphotericin B Liposomal (AmBisome) Lipid Complex (ABLC)	Polyene	TDM not routinely done. No established target levels.	LFTs at baseline and weekly. Elevation common — monitor; adjust based on severity. Liposomal formulation significantly less hepatotoxic than conventional.	⚠ HIGH NEPHROTOXICITY RISK SCr + BUN + electrolytes daily. K+ and Mg²⁺ replacement often required. Hydration with NS pre-infusion recommended for conventional form.	Infusion-related reactions (fever, rigors, hypotension) — more common with conventional than lipid formulations. Premedicate with acetaminophen ± diphenhydramine ± meperidine (rigors)¹. Avoid concurrent nephrotoxins (aminoglycosides, vancomycin, NSAIDs, contrast). Hypokalemia and hypomagnesemia require aggressive replacement. Liposomal = less nephrotoxicity, same/better efficacy^2,3.
Nystatin	Polyene	No TDM. Not systemically absorbed.	No systemic monitoring required for topical/PO formulations.	No systemic absorption — no renal/hepatic monitoring needed.	Topical / PO use only — not absorbed systemically. Used for oral/esophageal/vaginal candidiasis and GI decontamination in transplant patients. Swish-and-swallow for oropharyngeal candidiasis. GI side effects (nausea, vomiting) at high doses.

SOURCES
¹ Lexicomp Online. Lexi-Drugs. Hudson, OH: Lexicomp, Inc. Accessed 2026. ² Pappas PG et al. (IDSA) Clinical Practice Guideline for Candidiasis. Clin Infect Dis. 20162(4):e1–50. PMID: 26679628. ³ Patterson TF et al. (IDSA) Guidelines for Aspergillosis. Clin Infect Dis./em> 2016;63(4):e1–60. PMID: 27365388. ⁴ Ashbee HR et al. TDM of Antifungal Agents (BSMM). J Antimicrob Chemother.014;69(5):1162–1176. PMID: 24379304. ⁵ FDA Prescribing Information (drug-specific). U.S. Food & Drug Administration. ⁶ Sanford Guide to Antimicrobial Therapy 2025. Antimicrobial Therapy, Inc.

ANTIVIRAL MONITORING PARAMETERS Herpesviruses (HSV/VZV/CMV) · Influenza · COVID-19 · Hepatitis (see Kinetics for HIV)

DRUG	TARGET VIRUS	LEVELS / TDM	RENAL MONITORING	HEMATOLOGIC / OTHER	KEY PEARLS & INTERACTIONS
HERPESVIRUSES (HSV / VZV)
Acyclovir	HSV, VZV, EBV	TDM not routinely used. Consider if neurotoxicity suspected.	⚠ NEPHROTOXICITY RISK (IV) SCr daily during IV therapy. Renal dose adjustment required for CrCl <50. Adequate hydration essential — crystalluria risk.	Neurotoxicity (confusion, tremors, hallucinations) — more common with renal impairment and high doses. Monitor mental status, especially in elderly.	IV: infuse over 1h, maintain urine output ≥150 mL/hr, hydrate with 500 mL NS before and during infusion^1,5. Dose-adjust for renal impairment. Drug interaction: probenecid (↑ acyclovir levels). HSV encephalitis: IV 10–15 mg/kg q8h × 14–21 days (weight-based, true body weight if not obese)⁶.
Valacyclovir	HSV, VZV, CMV (prophylaxis)	No TDM. Prodrug of acyclovir.	SCr at baseline; periodic in high-dose therapy. Renal dose adjustment required for CrCl <50. High-dose VCV (8–12 g/day for CMV ppx) — more nephrotoxic than standard doses.	TTP/HUS reported with high-dose in immunocompromised patients — monitor CBC, renal function, and platelets.	Substantially higher bioavailability than oral acyclovir (55% vs. 15–30%). For HSV suppression: 500 mg–1 g/day. For zoster: 1 g TID × 7 days (start within 72h of rash). CMV ppx in transplant: 900 mg BID (equivalent to valganciclovir).
CYTOMEGALOVIRUS (CMV)
Ganciclovir (IV)	CMV, HSV, VZV	TDM not routine. AUC-guided dosing in select transplant centers.	SCr daily. Dose adjustment required for CrCl <70 (significant). HD patients: 1.25 mg/kg 3× weekly post-dialysis.	⚠ MYELOSUPPRESSION^1,3 CBC 2–3× per week. ANC <500/μL or platelets <25,000 → hold or reduce. Use growth factors (filgrastim) if needed for ANC recovery.	Avoid or use with extreme caution with zidovudine (severe neutropenia), imipenem (seizure risk), mycophenolate (increased levels of both — monitor)¹. CMV treatment: 5 mg/kg IV q12h × 14–21 days → maintenance 5 mg/kg IV q24h³. Administer with food (reduces GI upset if PO ganciclovir used). IV ganciclovir preferred for serious CMV infection (PO = valganciclovir)³.
Valganciclovir (PO)	CMV, HSV, VZV	TDM not routine. Same ganciclovir target AUC as IV.	SCr at baseline and weekly. Dose adjustment required for CrCl <60. Avoid if CrCl <10 (use IV ganciclovir with HD dosing instead).	⚠ MYELOSUPPRESSION^1,3 CBC weekly. ANC and platelet monitoring same thresholds as IV ganciclovir.	Prodrug of ganciclovir; ~60% oral bioavailability. CMV treatment: 900 mg PO BID × 21 days → 900 mg q24h maintenance. CMV ppx after transplant: 900 mg PO q24h³. Take WITH food — bioavailability increases ~30% with high-fat meal⁵. Do NOT use valganciclovir tablets to prepare pediatric solution (different formulations)⁵.
Foscarnet	CMV, HSV (acyclovir-resistant), VZV	TDM not routinely used clinically. Research tool only.	⚠ SEVERE NEPHROTOXICITY SCr + electrolytes q48h (or daily in high-risk). Dose adjust for ALL CrCl thresholds. Aggressive NS hydration 750–1000 mL before each dose required.	Electrolyte chelation: Hypocalcemia, hypomagnesemia, hypo/hyperphosphatemia, hypokalemia. Check Ca²⁺, Mg²⁺, K+, PO₄ with each SCr check. Penile/genital ulcers (HSV reactivation vs. drug-related).	Reserve for ganciclovir-resistant CMV or acyclovir-resistant HSV/VZV^3,6. DO NOT give undiluted or as IV push — always infuse over ≥1h via infusion pump⁵. Use for CMV retinitis in HIV: 90 mg/kg IV q12h × 14–21 days induction. Seizure risk — avoid with drugs lowering seizure threshold. Hydration critical — hold nephrotoxins^1,5.
Letermovir	CMV prophylaxis (allo-HSCT)	No TDM. Predictable PK. Levels available in research settings.	SCr at baseline; no dose adjustment needed for renal impairment. IV formulation: avoid if CrCl <50 (excipient accumulation).	LFTs at baseline; hepatic impairment (Child-Pugh C): avoid IV; use PO with caution. Generally well-tolerated — minimal myelosuppression.	CMV-specific (DNA terminase complex inhibitor) — does NOT cover HSV/VZV. First-line CMV prophylaxis for CMV-seropositive allo-HSCT recipients³. Significant drug interactions: cyclosporine (↑ letermovir levels — reduce to 240 mg/day); voriconazole, posaconazole, statins (↑ risk). When combined with cyclosporine: dose 240 mg/day (not 480 mg). Duration: day 0 to day 100 post-transplant^3,5.
INFLUENZA
Oseltamivir	Influenza A & B	No TDM required. Predictable PK.	Dose adjust for CrCl <30. Treatment: 30 mg BID (CrCl 10–30). HD: 30 mg after each HD session.	GI side effects (nausea, vomiting) — reduced by taking with food. Neuropsychiatric events reported (rare) — monitor closely in pediatric patients.	Initiate within 48h of symptom onset for outpatients; hospitalized patients benefit even if >48h of symptoms⁴. ICU patients: 75 mg BID × 5 days (severe influenza may require 10-day course)⁴. Consider 150 mg BID in critically ill or immunocompromised (limited evidence)^4,6. Live attenuated influenza vaccine: avoid oseltamivir within 2 weeks of vaccine⁵. Baloxavir alternative for uncomplicated influenza⁴.
COVID-19 / BROAD-SPECTRUM
Remdesivir	SARS-CoV-2 (COVID-19), broad RNA viruses	No TDM. Triphosphate metabolite active intracellularly — plasma levels not clinically useful.	SCr at baseline; daily during treatment. IV formulation contains SBECD — avoid if GFR <30 (unless benefit outweighs risk; PO formulation in development). Check renal function before each dose if renal function declining.	LFTs at baseline and every 2–3 days during treatment. AST/ALT >5× ULN → consider discontinuation. Bradycardia (monitor HR). Transient PT/aPTT prolongation — not clinically significant at standard doses.	COVID-19 treatment: 200 mg IV loading dose day 1 → 100 mg IV q24h × 4 days (5-day course total)⁵. Administer over 30–120 min — hypersensitivity reactions with faster infusion⁵. Drug interaction: chloroquine/hydroxychloroquine reduces intracellular activation (avoid combination — antagonistic)¹. Monitor for infusion reactions (nausea, hypotension, sweating, bradycardia) during and 1h after infusion⁵.

SOURCES
¹ Lexicomp Online. Lexi-Drugs. Hudson, OH: Lexicomp, Inc. Accessed 2026. ² Ljungman P et al. Definitions of CMV Infection and Disease. Clin Infect Dis.> 2002;34(8):1094–7. PMID: 11914999. ³ Kotton CN et al. Third International Consensus Guidelines on CMV in SOT. Transplantation.Transplantation. 2018;102(6):900–931. PMID: 29596116. ⁴ Uyeki TM, et al. (IDSA) Clinical Practice Guidelines for Influenza. Clin Infect Dis. 2019;68(6):e1–e47. PMID: 30566567. ⁵ FDA Prescribing Information (drug-specific). U.S. Food & Drug Administration. ⁶ Sanford Guide to Antimicrobial Therapy 2025. Antimicrobial Therapy, Inc.

SITE-SPECIFIC SEPSIS PROTOCOL Upload your facility’s sepsis protocol or link to an online resource. Accessible from the Sepsis Screening panel in the ABX tracker.

PROTOCOL URL / LINK

Link to SharePoint, intranet, or any online protocol resource.

UPLOAD PROTOCOL FILE (PDF / DOC)

No file chosen

Stored locally in this browser. Max ~5 MB recommended.

REFERENCE
¹ Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026. Crit Care Med. 2026. ^↗

SEPSIS / SEP-1 BUNDLE GUIDELINES CMS SEP-1 early-management bundle & Surviving Sepsis Campaign. Linked from the Sepsis Screening panel in the ABX tracker.

TIME ZERO — the clock starts at the time of presentation (earliest chart documentation) of severe sepsis or septic shock, not the time of diagnosis. All bundle elements are measured from this point. SEP-1 is an all-or-none CMS measure — every required element must be met to pass.

3-HOUR BUNDLE — severe sepsis

① Measure lactate level.

② Obtain blood cultures before antibiotics.

③ Administer broad-spectrum antibiotics.

④ 30 mL/kg IV crystalloid for hypotension or lactate ≥ 4 mmol/L.

6-HOUR BUNDLE — septic shock

⑤ Repeat lactate if the initial lactate was elevated (> 2 mmol/L).

⑥ Vasopressors for fluid-refractory hypotension → target MAP ≥ 65 mmHg.

⑦ Reassess volume status & tissue perfusion (focused exam or 2 of: CVP, ScvO₂, bedside CV ultrasound, passive leg raise / fluid challenge) and document.

SURVIVING SEPSIS CAMPAIGN — HOUR-1 BUNDLE

SSC recommends initiating all of the following within the first hour of recognition: measure lactate (remeasure if > 2 mmol/L) · obtain blood cultures before antibiotics · give broad-spectrum antibiotics · begin rapid ≥ 30 mL/kg crystalloid (first 3 h) for hypotension or lactate ≥ 4 · start vasopressors if hypotensive during or after resuscitation to keep MAP ≥ 65. Antibiotics: give immediately (ideally ≤ 1 h) in septic shock and high-likelihood sepsis. In possible sepsis without shock (lower infection likelihood), SSC 2026 advises a rapid assessment within 3 h rather than immediate antibiotics — supporting antimicrobial stewardship.

⚠️

CLINICAL DISCLAIMER
Summary reference only — it does not supersede clinical judgment, your facility’s sepsis protocol, or current CMS specifications. CMS SEP-1 specifications and timing definitions are updated periodically; always verify against the current CMS measure specification manual and your institution’s approved protocol (see the Site-Specific Sepsis Protocol card above).

REFERENCES
¹ Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026. Crit Care Med. 2026. ^↗
² Centers for Medicare & Medicaid Services. Severe Sepsis and Septic Shock Early Management Bundle (SEP-1), National Hospital Inpatient Quality Measures — current specification manual.

PROCALCITONIN (PCT) — ANTIBIOTIC GUIDANCE Adult ED / ward thresholds for antibiotic initiation & cessation. Linked from the Infection Markers panel in the ABX tracker.

PCT rises within 2–6 h of bacterial infection, peaks ~12 h, half-life ~24 h. A rising or persistently elevated PCT supports bacterial infection and continued therapy; a falling PCT supports resolution and the opportunity to stop. PCT is an adjunct to clinical judgment, not a standalone test — always interpret alongside the full clinical picture and cultures.

ANTIBIOTIC INITIATION — suspected infection

PCT (ng/mL)	Interpretation	Antibiotics
< 0.1	Bacterial infection very unlikely	Strongly discouraged
0.1 – 0.25	Bacterial infection unlikely	Discouraged
0.26 – 0.5	Bacterial infection likely	Encouraged
> 0.5	Bacterial infection very likely	Strongly encouraged

ANTIBIOTIC CESSATION — patient on therapy

PCT (ng/mL)	Interpretation	Stop antibiotics?
< 0.1	Resolution likely	Strongly encouraged
0.1 – 0.25	Resolution likely	Encouraged
0.26 – 0.5	Ongoing infection	Discouraged
> 0.5	Ongoing infection	Strongly discouraged

KEY RULES

• ≥ 80% drop from peak (or fall to < 0.25 ng/mL) plus clinical improvement → discontinuation recommended.

• If PCT is low but clinical suspicion remains and no improvement → recheck in 6–24 h.

• If PCT is elevated (≥ 0.26) → remeasure every 2–3 days to find the opportunity to stop. Serial trend > single value.

• Failure to clear (PCT not falling by day 4) is associated with higher mortality — reassess source control and regimen.

MAY RAISE PCT WITHOUT BACTERIAL INFECTION

Major surgery / trauma / burns · cardiogenic or other shock · severe renal impairment / dialysis · first 48–72 h of life (neonates) · some medullary thyroid / neuroendocrine tumors · prolonged severe stress.

MAY BLUNT PCT DESPITE INFECTION

Localized / early infection · subacute or indolent infection (e.g., abscess, subacute endocarditis) · very early sampling (< 6 h). A normal PCT does not rule out localized infection.

CRP & ESR (adjuncts)
CRP — acute-phase reactant; rises in ~6–12 h, longer half-life than PCT, less specific for bacterial infection. Useful for trend but slower to fall. ESR (sed rate) — nonspecific, slow to change (days–weeks); best for chronic/indolent processes (e.g., osteomyelitis, endocarditis) rather than acute antibiotic decisions.

⚠️

CLINICAL DISCLAIMER
These thresholds are decision support only and do not supersede clinical judgment, institutional antimicrobial-stewardship protocols, or current prescribing information. Cutoffs and assay calibration vary by manufacturer; tailor to your institution’s algorithm, patient population, and acuity. PCT should be paired with active stewardship review, not used to start or stop antibiotics in isolation.

REFERENCES
¹ Chambliss AB, Patel K, Colón-Franco JM, et al. AACC Guidance Document on the Clinical Use of Procalcitonin. J Appl Lab Med. 2023;8(3):598–634. PMID: 37140163. ^↗
² Schuetz P, Wirz Y, Sager R, et al. Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections. Cochrane Database Syst Rev. 2017;10:CD007498. PMID: 29025194.

KINETICS / PK SETTINGS

DEFAULT VANCOMYCIN TARGET TROUGH (mg/L)

DEFAULT AUC TARGET (mg·h/L)

⚠️

CLINICAL DISCLAIMER
Aminoglycoside dosing information is for general reference only and does not supersede clinical judgment, institutional protocols, or current prescribing information. All nomogram recommendations require individualized patient assessment. Always verify against current FDA labeling, IDSA guidelines, and institutional pharmacy protocol. Nomogram breakpoints may vary by institution.

AMINOGLYCOSIDE DOSING WEIGHT & GENERAL PRINCIPLES

DOSING WEIGHT SELECTION

Patient BMI / Body Habitus	Dosing Weight
Non-obese (BMI < 30) / Normal	Actual Body Weight (ABW)
Obese (ABW > 120% IBW)	IBW + 0.4 × (ABW − IBW) — AdjBW
Underweight (ABW < IBW)	Actual Body Weight (ABW)
Pediatric	Per weight-based protocol; use ABW

Note: the > 120% IBW obesity threshold shown here is aminoglycoside-specific. All other drugs (including vancomycin) switch to AdjBW at > 130% IBW.

GENERAL CLINICAL NOTES

• Aminoglycosides exhibit concentration-dependent killing — higher peaks = greater efficacy

• Post-antibiotic effect (PAE) allows extended dosing intervals

• Nephrotoxicity and ototoxicity are concentration- and time-dependent

• Once-daily (extended-interval) dosing preferred when not excluded

• All levels should be drawn from the opposite arm from infusion

• Correct for renal function — monitor SCr every 48–72h during therapy

SOURCES
¹ Nicolau DP et al. Antimicrob Agents Chemother. 1995;39(3):650-5 ² Urban AW & Craig WA. Curr Clin Top Infect Dis. 1997;17:236-55 ³ Begg EJ & Barclay ML. Br J Clin Pharmacol. 1995;39(6):597-603 ⁴ Gilbert DN. J Infect Dis. 1991;163(4):923-5 ⁵ Sawchuk RJ et al. J Pharmacokinet Biopharm. 1976;4(2):183-95 ⁶ Bauer LA. Applied Clinical Pharmacokinetics, 3rd ed. McGraw-Hill; 2014 ⁷ Lexicomp Online. Gentamicin/Tobramycin/Amikacin monographs. Wolters Kluwer; 2025

TRADITIONAL (CONVENTIONAL) DOSING Multiple-daily dosing · Preferred: endocarditis, pregnancy, CrCl <20 mL/min, severe burns

INITIAL DOSING (Normal Renal Function)

Agent	Dose	Interval	Route
Gentamicin	1–2 mg/kg	q8h	IV over 30 min
Tobramycin	1–2 mg/kg	q8h	IV over 30 min
Amikacin	5–7.5 mg/kg	q8h	IV over 30–60 min
Synergy dosing (endocarditis): Gentamicin/Tobramycin 1 mg/kg q8h; target peak 3–5 mg/L

RENAL DOSE ADJUSTMENT — INTERVAL EXTENSION

CrCl (mL/min)	Gentamicin / Tobramycin	Amikacin
> 60	q8h	q8h
40–60	q12h	q12h
20–40	q24h	q24h
10–20	q48h	q48h
< 10 / HD	Levels-guided; q48–96h	Levels-guided
HD (supplement)	Redose after dialysis session	Redose after dialysis

TARGET SERUM LEVELS — TRADITIONAL DOSING

Agent	Goal Peak (mg/L)	Goal Peak — Synergy (mg/L)	Goal Trough (mg/L)	Level Draw — Peak	Level Draw — Trough
Gentamicin	5–10	3–5 (cardiac synergy)	< 2	30 min after end of 30-min infusion	Within 30 min before next dose
Tobramycin	5–10	3–5 (cardiac synergy)	< 2	30 min after end of 30-min infusion	Within 30 min before next dose
Amikacin	20–35	—	< 10	30–60 min after end of infusion	Within 30 min before next dose

⚑ Toxicity risk: troughs consistently > 2 mg/L (Gent/Tobra) or > 10 mg/L (Amikacin) — consider dose reduction or interval extension.
⚑ Gram-negative bacteremia / pneumonia: aim for peaks at the higher end of range (8–10 mg/L Gent/Tobra; 30–35 mg/L Amikacin).

SOURCES
¹ Bauer LA. Applied Clinical Pharmacokinetics, 3rd ed. McGraw-Hill; 2014 ² Streetman DS et al. Pharmacotherapy. 2001;21(9):1077-86 ³ Kashuba ADM et al. Antimicrob Agents Chemother. 1999;43(7):1549-55 ⁴ Lexicomp Online. Aminoglycoside monographs. Wolters Kluwer; 2025

HARTFORD NOMOGRAM — EXTENDED-INTERVAL / ONCE-DAILY DOSING Nicolau et al., 1995 · Gentamicin / Tobramycin

DOSING

Agent	Dose	Initial Interval	Route
Gentamicin	7 mg/kg	q24h (adjusted per nomogram)	IV over 30–60 min
Tobramycin	7 mg/kg	q24h (adjusted per nomogram)	IV over 30–60 min
Amikacin	15–20 mg/kg	q24h (adjusted per level)	IV over 60 min

Dose based on AdjBW for obese patients (ABW > 120% IBW). Use IBW or AdjBW — never ABW alone in obesity.

EXCLUSION CRITERIA — DO NOT USE EXTENDED-INTERVAL

❌ Pregnancy

❌ Burns > 20% BSA

❌ CrCl < 20–25 mL/min (pre-existing renal impairment)

❌ Hemodialysis or peritoneal dialysis

❌ Endocarditis (use synergy dosing)

❌ Significant ascites / third-spacing

❌ Pediatrics < 1 month old

LEVEL TIMING & NOMOGRAM INTERPRETATION (Gentamicin / Tobramycin 7 mg/kg)

Draw ONE random level 6–14 hours after the start of the first dose. Use the table below to determine dosing interval.

Hours After Dose Start	q24h Zone (mg/L)	q36h Zone (mg/L)	q48h Zone (mg/L)
6 h	< 6.8	6.8 – 11.8	> 11.8
7 h	< 5.0	5.0 – 9.0	> 9.0
8 h	< 4.0	4.0 – 6.8	> 6.8
9 h	< 3.0	3.0 – 5.5	> 5.5
10 h	< 2.6	2.6 – 4.2	> 4.2
11 h	< 2.0	2.0 – 3.4	> 3.4
12 h	< 1.7	1.7 – 2.9	> 2.9
13 h	< 1.4	1.4 – 2.4	> 2.4
14 h	< 1.2	1.2 – 2.0	> 2.0

If level falls in the q48h zone, consider switching to traditional dosing or consult pharmacy.
If patient has borderline renal function, prefer traditional dosing with therapeutic drug monitoring.

FOLLOW-UP MONITORING
• If CrCl changes significantly, repeat nomogram assessment
• Check SCr every 48–72h; recheck nomogram level if SCr rises ≥ 0.5 mg/dL from baseline
• No routine trough needed with once-daily dosing — single random level only
• Efficacy target (AUC/MIC): goal Cmax/MIC ≥ 8–10 for concentration-dependent killing

▸ HARTFORD NOMOGRAM CALCULATOR — Level Interpreter

Drug

Hours After Dose Start

Level (mg/L)

Dosing Wt (kg)

SOURCES
¹ Nicolau DP et al. Antimicrob Agents Chemother. 1995;39(3):650-5 ² Begg EJ & Barclay ML. Br J Clin Pharmacol. 1995;39(6):597-603 ³ Bauer LA. Applied Clinical Pharmacokinetics, 3rd ed. McGraw-Hill; 2014

URBAN & CRAIG NOMOGRAM — ONCE-DAILY DOSING Urban & Craig, 1997 · Gentamicin / Tobramycin · Single 8-hour post-dose level

DOSING & LEVEL TIMING

Parameter	Details
Dose (Gentamicin / Tobramycin)	7 mg/kg IV q24h
Dose (Amikacin)	15–20 mg/kg IV q24h
Dosing weight	IBW; AdjBW if obese (ABW > 120% IBW)
Level draw time	Exactly 8 h (± 1 h) after START of infusion
Level type	Single random level — no peak or trough required
Infusion time	30–60 min IV

EXCLUSION CRITERIA (same as Hartford)

❌ Pregnancy

❌ Burns > 20% BSA

❌ CrCl < 20 mL/min / dialysis

❌ Endocarditis (use synergy / traditional dosing)

❌ Significant volume of distribution changes (ascites, edema, cystic fibrosis)

8-HOUR LEVEL INTERPRETATION — Gentamicin / Tobramycin 7 mg/kg · Urban & Craig 1997

8-Hour Level (mcg/mL)	Interpretation	Action
< 1.0	Q24h — Adequate free interval	Continue every 24 hours dosing
1.0 – 2.0	Q36h — Borderline	Extend to every 36 hours; recheck level after next dose
> 2.0	Q48h — Extended interval needed	Extend to every 48 hours or switch to traditional (MDD) dosing

• Level must be drawn at exactly 8 hours after a once-daily dose — levels at other time points cannot be interpreted with this nomogram
• Recheck with any significant change in renal function (SCr rise ≥ 0.5 mg/dL)
• For synergy dosing (endocarditis, febrile neutropenia) use traditional multiple-daily dosing instead
• Ref: Urban AW, Craig WA. Curr Clin Top Infect Dis. 1997;17:236-55

▸ URBAN & CRAIG CALCULATOR — 8-Hour Level Interpreter

8-Hour Level (mg/L)

Dosing Wt (kg)

SOURCES
¹ Urban AW & Craig WA. Curr Clin Top Infect Dis. 1997;17:236-55 ² Freeman CD et al. Pharmacotherapy. 1997;17(4):797-807 ³ Bauer LA. Applied Clinical Pharmacokinetics, 3rd ed. McGraw-Hill; 2014 ⁴ Lexicomp Online. Aminoglycoside monographs. Wolters Kluwer; 2025

NOMOGRAM COMPARISON — QUICK REFERENCE

Feature	Traditional (MDD)	Hartford Nomogram	Urban & Craig
Dose (Gent/Tobra)	1–2 mg/kg	7 mg/kg	7 mg/kg
Frequency	q8h (renal-adjusted)	q24h / q36h / q48h (per nomogram)	q24h / q36h / q48h (per 8h level)
Level Draw	Peak + Trough each dose	Single random level 6–14h post-dose	Single random level at 8h post-dose
Peak Target (Gent)	5–10 mg/L (3–5 synergy)	Not routinely measured	Not routinely measured
Trough Target (Gent)	< 2 mg/L	Not used	Not used
Preferred Use	Endocarditis, pregnancy, burns, CrCl <20	Most gram-negative infections; inpatient	Gram-negative; single-level convenience
Exclusions	Fewer exclusions	See exclusion criteria above	Same as Hartford
Monitoring	Peak & trough every 3–7 days or with dose change	Repeat level if SCr changes; no routine trough	Repeat if SCr changes; repeat at 8h only
Amikacin Dose	5–7.5 mg/kg q8h	15–20 mg/kg q24h	15–20 mg/kg q24h
Evidence Base	Established; multiple guidelines	Nicolau et al., Am J Health-Syst Pharm 1995	Urban & Craig, J Antimicrob Chemother 1997

SOURCES
¹ Nicolau DP et al. Antimicrob Agents Chemother. 1995;39(3):650-5 (Hartford) ² Urban AW & Craig WA. Curr Clin Top Infect Dis. 1997;17:236-55 ³ Bauer LA. Applied Clinical Pharmacokinetics, 3rd ed. McGraw-Hill; 2014

VANCOMYCIN DOSING & NOMOGRAMS

⚠️

CLINICAL DISCLAIMER
This reference content is for educational purposes only. Vancomycin dosing requires individualized assessment by a qualified clinician or pharmacist. Current ASHP/IDSA/SIDP 2020 guidelines recommend AUC-guided monitoring as the preferred strategy. Conventional trough-based nomograms (URI, UCSF) remain in use at institutions without Bayesian software. Always verify dosing against institutional protocols, patient renal function, weight, infection site, and organism MIC. Consult pharmacy/ID for complex cases.

VANCOMYCIN KEY PARAMETERS & TARGETS

AUC-BASED (PREFERRED — 2020 GUIDELINES)

AUC₂₄ Target	400–600 mg·h/L
AUC/MIC Target	≥ 400 (MIC ≤ 1 mg/L)
Loading Dose	25–30 mg/kg × 1 (serious infxn)
Initial Maint. Dose	15–20 mg/kg q8–12h
Max Single Dose	3000 mg (cap; verify)
Infusion Rate	≤ 10 mg/min (slow infusion)
Level Timing	2-level method or Bayesian

CONVENTIONAL TROUGH-BASED (LEGACY)

General Trough	10–20 mg/L
Serious/MRSA	15–20 mg/L
HAPI / Bacteremia	15–20 mg/L
Mild / SSTI	10–15 mg/L
Nephrotoxicity risk ↑	Trough > 20 mg/L
Trough Draw Timing	30 min before next dose
Steady State (q12h)	After 3rd–4th dose

Dosing Weight: Use actual body weight (ABW) for initial dosing per 2020 guidelines. For obese patients (BMI > 30), some institutions use ABW; consult pharmacy. Adjust for renal function (CrCl by Cockcroft-Gault using ABW or adjusted if obese). HD patients: 15–20 mg/kg post-dialysis; monitor levels pre-dialysis for redosing.

SOURCES
¹ Rybak MJ et al. Pharmacotherapy. 2020;40(4):363-405 (2020 Vancomycin Consensus) ² Matzke GR et al. Am J Health-Syst Pharm. 1984;41(9):1789-95 (URI Nomogram) ³ Bauer LA et al. Am J Health-Syst Pharm. 1999;56(2):176-80 (Bayesian PK) ⁴ Murry KR et al. UCSF Vancomycin Dosing Nomogram. UCSF Medical Center; 2021 ⁵ Liu C et al. Clin Infect Dis. 2011;52(3):e18-e55 (IDSA MRSA Guidelines) ⁶ ASHP/IDSA/SIDP Vancomycin Monitoring Guidelines. 2020 ⁷ Bauer LA. Applied Clinical Pharmacokinetics, 3rd ed. McGraw-Hill; 2014 ⁸ Lexicomp Online. Vancomycin monograph. Wolters Kluwer; 2025

VANCOMYCIN PK DOSE ADJUSTMENT — METHODOLOGY Formulas used in Kinetics Tracker auto-calc

AUC-GUIDED · TWO-LEVEL STEADY-STATE (ASHP/IDSA/SIDP 2020)

PK Parameter Derivation

K_e = ln(C₁/C₂) ÷ (t₂ − t₁)

t½ = 0.693 / K_e

Cmax_EOI = C₁ × e^{K_e × t₁}

Vd = D × (1 − e^−K_e·Tinf) ÷ (K_e · Tinf · Cmax_EOI · (1 − e^−K_e·τ))

CL = K_e × Vd

AUC₂₄ = (D × 24/τ) ÷ CL

Cmin (pred.) = Cmax_EOI × e^{−K_e·(τ−Tinf)}

Dose Recommendation & Options Table

D_rec = TargetAUC_mid × CL × τ ÷ 24

Rounded to nearest 250 mg

Proj. AUC₂₄ (per step) = (D_step × 24/τ) ÷ CL

Options table: all 250 mg steps within 10–30 mg/kg across standard intervals (q6h, q8h, q12h, q24h, q36h, q48h, q72h). ★ = step with AUC₂₄ closest to TargetAUC_mid. mg/kg color: green = 15–20 mg/kg (ASHP preferred range); amber = outside 15–20. Intervals with no dose step in 10–30 mg/kg window are excluded.

C₁ = earlier level (higher, closer to EOI); C₂ = later level (lower); both timed as hours after EOI. C₁ must be > C₂. Levels drawn at steady state (≥3–5 half-lives). Tinf = infusion duration (hr); τ = dosing interval (hr).

TROUGH-GUIDED · PROPORTIONAL STEADY-STATE ADJUSTMENT (LEGACY / CONVENTIONAL)

Single-Level Dose Scaling

D_new = D_current × TargetTrough_mid ÷ C_trough

Rounded to nearest 250 mg

C_trough,new = C_trough × D_new ÷ D_current

(Projected trough for each 250 mg step in options table)

Dose Options Table

Enumerates all 250 mg steps within 10–30 mg/kg (or 500–3000 mg if weight unknown).

For each step: Proj. Trough = C_trough × D_step ÷ D_current

★ = dose closest to TargetTrough_mid. mg/kg color: green = 15–20 mg/kg; amber = outside 15–20.

Assumes trough drawn at true steady state (≥3rd–4th dose for q12h; ≥4th–5th dose for q24h). Assumes linear (first-order) PK — proportional scaling is unreliable if PK is non-linear or if trough is not at steady state. For patients with rapidly changing renal function, interval changes, or complex PK, AUC-guided two-level monitoring is strongly preferred.

AUC-GUIDED DOSING ASHP / IDSA / SIDP 2020 Consensus Guidelines · Preferred Method

STEP 1 — INITIAL DOSING BY RENAL FUNCTION

CrCl (mL/min)	Dose	Interval	Daily Dose Approx	Notes
> 90	15–20 mg/kg	q8–12h	30–45 mg/kg/day	Standard; use q8h for critical infections
50–89	15–20 mg/kg	q12h	30–40 mg/kg/day	Most common interval for stable CKD Ⅱ–Ⅲ
30–49	15–20 mg/kg	q24h	15–20 mg/kg/day	Monitor closely; AUC check after 2nd dose
15–29	15–20 mg/kg	q48h	~7–10 mg/kg/day	Pharmacy consult recommended
< 15 / ESRD	Individualize per levels			Pharmacy/ID consult required
HD (intermittent)	15–20 mg/kg post-HD; redose when level < 15–20 mg/L pre-HD			Check level before each HD session

STEP 2 — TWO-LEVEL AUC ESTIMATION (When Bayesian Software Not Available)

Level	Draw Timing	Steady State (q12h)	Steady State (q8h)	Notes
Level 1 (C_max surrogate)	1–2h after end of infusion	After 3rd–4th dose	After 4th–5th dose	Record exact clock time
Level 2 (C_trough surrogate)	Within 30 min before next dose	Same dose as Level 1	Same dose as Level 1	Do not draw early

AUC Calculation (analytical / clearance-based — ASHP-IDSA 2020):
K_e = ln(C₁/C₂) / (t₂ − t₁) · V_d = Dose·(1−e^−K_eT_inf) / [K_e·T_inf·C_max·(1−e^−K_eτ)] · CL = K_e × V_d
AUC₂₄ = Dose × (24 / τ) / CL
At steady state, AUC over a dosing interval equals Dose/CL (exact for a one-compartment model; agrees with linear-log trapezoidal to <0.2%). C₁/C₂ are measured from end of infusion (t₁ < t₂); τ = dosing interval (h).
Bayesian Software (Preferred): Uses population PK model + patient-specific levels to estimate AUC more accurately; reduces the number of levels needed. Examples: DoseMeRx, InsightRx, Vizient/RxKinetics.

STEP 3 — DOSE ADJUSTMENT

AUC₂₄ Result	Interpretation	Recommended Action
< 400 mg·h/L	Sub-therapeutic — risk of treatment failure	Increase total daily dose 10–20%; re-check AUC in 24–48h
400–600 mg·h/L	Therapeutic — target achieved	Continue current dose; recheck q48–72h or if SCr changes ≥ 0.5
600–800 mg·h/L	Supra-therapeutic — nephrotoxicity risk ↑	Reduce dose 10–15%; recheck in 24h
> 800 mg·h/L	Toxic — significant nephrotoxicity risk	Hold 1 dose; reduce 20–25%; pharmacy consult; recheck STAT

URI VANCOMYCIN NOMOGRAM Conventional Trough-Based · Weight + CrCl Dosing Table

Conventional trough-targeted nomogram. Initial dose (mg) selected by actual body weight; interval selected by CrCl (Cockcroft-Gault). Target trough: 10–20 mg/L (15–20 for serious MRSA infections). Draw trough within 30 min before next dose at steady state (after 3rd–4th dose for q12h).

INITIAL DOSE SELECTION BY WEIGHT

Actual Body Weight	Initial Dose (per dose)	Approx mg/kg	Notes
< 50 kg	750 mg	15–20	Round to nearest 250 mg
50–69 kg	1000 mg	15–20	Most common outpatient dose
70–89 kg	1250 mg	14–18	Round to 1250 mg common
90–109 kg	1500 mg	14–17	Max single dose per many protocols
110–129 kg	1750 mg	14–16	Consider q8h for critical infections
≥ 130 kg	2000–2500 mg	15–19	Pharmacy consult; use ABW unless morbidly obese

DOSING INTERVAL BY RENAL FUNCTION (CrCl)

CrCl (mL/min)	Interval	Trough Check	Trough Target
≥ 70	q12h	Before 4th dose	10–20 mg/L
40–69	q18–24h	Before 3rd dose	10–20 mg/L
20–39	q24–36h	Before 2nd dose	10–20 mg/L
10–19	q48–72h	Before 2nd dose	10–20 mg/L; pharmacy consult
< 10	q72–96h	Per levels	Individualize; pharmacy required
HD	Post-HD dosing	Pre-HD level	Redose when pre-HD level < 15–20 mg/L

TROUGH-BASED DOSE ADJUSTMENT

Trough Level	Interpretation	Action
< 5 mg/L	Critically low	Increase dose 25–50%; consider more frequent interval
5–9 mg/L	Sub-therapeutic	Increase dose 20–25% or shorten interval
10–20 mg/L	Therapeutic	Continue; recheck q48–72h or with SCr change
20–25 mg/L	Supra-therapeutic	Hold 1 dose; reduce 10–15%; repeat trough in 24h
> 25 mg/L	Toxic — hold and reassess	Hold 1–2 doses; reduce 20–25%; check SCr; pharmacy consult

UCSF VANCOMYCIN DOSING NOMOGRAM Murry et al. · Conventional Trough-Based · Weight × CrCl Matrix

Weight-stratified dosing by CrCl (Cockcroft-Gault). Initial empirical dosing for adults; adjust based on trough levels at steady state. Loading dose of 25 mg/kg × 1 may be given for serious infections regardless of renal function. Trough target: 10–20 mg/L (15–20 mg/L for serious MRSA / deep-seated infections).

INITIAL DOSE (mg) AND INTERVAL — BY WEIGHT & CrCl

Weight	CrCl ≥ 80	CrCl 50–79	CrCl 30–49	CrCl 15–29	CrCl < 15
< 60 kg	1000 mg q12h	750 mg q12h	750 mg q24h	500 mg q24h	500 mg q48h†
60–79 kg	1250 mg q12h	1000 mg q12h	1000 mg q24h	750 mg q24h	750 mg q48h†
80–99 kg	1500 mg q12h	1250 mg q12h	1250 mg q24h	1000 mg q24h	1000 mg q48h†
100–119 kg	1750 mg q12h	1500 mg q12h	1500 mg q24h	1000 mg q24h	1000 mg q48h†
≥ 120 kg	2000 mg q12h	1750 mg q12h	1750 mg q24h	1250 mg q24h	1250 mg q48h†

† CrCl < 15: Pharmacy consult strongly recommended; check trough before 2nd dose. Round doses to nearest 250 mg. Infuse over 60 min per 500 mg (minimum); for doses ≥ 1500 mg, infuse over ≥ 90–120 min to reduce infusion-related reactions.

TROUGH-GUIDED MONITORING SCHEDULE

Dosing Interval	1st Level Draw	Repeat Frequency	When to Repeat Early
q8h	Before 5th dose	q48–72h (stable)	SCr change ≥ 0.5, dose change, worsening infection
q12h	Before 4th dose	q48–72h (stable)	SCr change ≥ 0.5, dose change
q24h	Before 3rd dose	Every 48h	Any SCr change; AKI
≥ q48h	Before 2nd dose	Before each dose	Pharmacy consult for all intervals

VANCOMYCIN MONITORING STRATEGY COMPARISON — QUICK REFERENCE

Parameter	AUC-Guided (2020 ASHP/IDSA)	URI Nomogram (Trough)	UCSF Nomogram (Trough)
Current Standard?	Yes — Preferred	Legacy / Institutional	Legacy / Institutional
PK Target	AUC₂₄ 400–600 mg·h/L	Trough 10–20 mg/L	Trough 10–20 mg/L
Efficacy Surrogate	AUC/MIC ≥ 400	Trough/MIC ≥ 10	Trough/MIC ≥ 10
Nephrotoxicity Risk	Reduced vs. trough-only	Higher if trough > 20	Higher if trough > 20
Levels Required	2 levels (or Bayesian 1–2)	1 trough	1 trough
Software Required	Preferred (Bayesian); manual OK	No	No
Dosing Weight	ABW (or adjusted for obesity)	ABW	ABW (per protocol)
Loading Dose	25–30 mg/kg (serious infxn)	25 mg/kg (optional)	25 mg/kg (serious infxn)
Guideline Support	ASHP/IDSA/SIDP 2020	Institutional protocol	Institutional protocol
Best Used For	All inpatient vancomycin	Institutions w/o Bayesian software	Outpatient / limited monitoring

Key References: Rybak MJ et al. — Therapeutic monitoring of vancomycin for serious methicillin-resistant Staphylococcus aureus infections: a revised consensus guideline and review by ASHP, IDSA, and SIDP. Am J Health-Syst Pharm 2020;77(11):835–864. · Murry KR et al. — UCSF vancomycin dosing nomogram. · Liu C et al. — IDSA MRSA guidelines, Clin Infect Dis 2011;52(3):e18–e55.

SITE-SPECIFIC POLICIES & PROTOCOLS Add your institution's kinetics / PK protocols, dosing policies, and clinical notes

e.g. Vancomycin AUC Protocol, Aminoglycoside Dosing Policy, PK Consult Criteria, Bayesian Software Instructions

HIV / ANTIRETROVIRAL THERAPY

Drug reference · Preferred regimens · Monitoring · OI Prophylaxis — sourced from DHHS 2024 guidelines

📋 Guidelines

💊 Drug Reference

⭐ Preferred Regimens

🔬 Monitoring

🛡 OI Prophylaxis

DHHS Adult/Adolescent ARV Guidelines

U.S. Dept. of Health & Human Services — updated continuously

clinicalinfo.hiv.gov ↗

DHHS Perinatal HIV Guidelines

Prevention of perinatal transmission; ART in pregnancy

clinicalinfo.hiv.gov ↗

DHHS OI Prevention & Treatment

Opportunistic infections in HIV-infected adults and adolescents

clinicalinfo.hiv.gov ↗

IAS-USA Drug Resistance Mutations

Resistance mutation figures updated annually

iasusa.org ↗

Stanford HIV Drug Resistance Database

Genotype interpretation; resistance scoring

hivdb.stanford.edu ↗

Liverpool HIV Drug Interactions

Comprehensive ARV DDI checker — check before prescribing

hiv-druginteractions.org ↗

⚠ DDI Warning: Antiretroviral drugs have extensive drug-drug interactions — particularly PIs (ritonavir, cobicistat boosted) and NNRTIs. Always check the Liverpool HIV Drug Interactions checker before adding or modifying ANY concomitant medication in an HIV patient on ART.

Parameter	Goal / Reference	Frequency	Notes
CD4 Count	>500 cells/mm³ (normal); >200 to discontinue OI ppx	q3–6 months (stable); q3 months (new ART/clinical change)	May measure less frequently once VL suppressed and CD4 consistently >300 for >2 years
HIV Viral Load	Undetectable (<20–50 copies/mL per assay)	2–4 weeks after ART start/change; q3 months until suppressed; then q6 months (stable)	Blips (<200) may occur; confirmed viremia >200 warrants resistance testing and regimen review
HLA-B*5701	Negative required before abacavir	Once (at baseline)	Positive = abacavir/ABC-containing regimens CONTRAINDICATED (Triumeq, Epzicom, Ziagen)
Tropism Assay	CCR5-tropic required for maraviroc	Before maraviroc initiation	Tropism can shift — retest if viremia after initial CCR5-tropic result
Resistance Genotype	Guide regimen selection	At entry; on virologic failure (VL >500–1000)	Stanford HIVDB for interpretation; archived mutations may not be detected
HBsAg / HBV status	Rule out HBV co-infection before selecting NRTI backbone	At entry; repeat if negative and high-risk	HBV-active: include TAF or TDF (± FTC/3TC). Never use 3TC or FTC alone for HBV (resistance). HBV flare on NRTI discontinuation
Hepatitis C (HCV Ab)	Screen all HIV+ patients	At entry; annually if high-risk	HCV/HIV co-infection increases liver disease progression; treat HCV — major DDIs with some DAAs and ARVs
BMP / Renal	SCr, BUN, electrolytes	Baseline; q3–6 months (TDF/COBI); q6–12 months (others)	TDF nephrotoxic. DTG/COBI raise SCr (tubular secretion block — not true GFR decline). Fanconi syndrome with TDF: glucosuria, phosphaturia, proteinuria
LFTs	Baseline; as indicated per drug	Baseline; q2–4 wk for NVP (first 12 wk); per drug profile	NVP, TPV, ATV, EFV: hepatotoxicity monitoring. ATV: benign unconjugated hyperbilirubinemia (cosmetic — not hepatotoxic)
Lipid Panel	Fasting lipid profile	Baseline; after 4–6 weeks of ART; annually	PIs (especially LPV/r) cause dyslipidemia. TAF increases LDL more than TDF. Statins: multiple DDIs with PIs (avoid simvastatin/lovastatin)
Glucose / HbA1c	Screen for diabetes	Baseline; annually	PIs and some NRTIs increase insulin resistance. Weight gain (especially INSTIs) increases DM risk
Bone Density (DEXA)	T-score > −1.0 (normal)	Baseline in high-risk; per standard osteoporosis screening	TDF decreases BMD. TAF preferred when bone concerns. Supplemental Ca + Vit D for all patients on TDF
CBC	WBC, Hgb, platelets	Baseline; q4 weeks with ZDV; per regimen	ZDV: macrocytic anemia and neutropenia. Linezolid (used in TB/HIV): thrombocytopenia

Pathogen	CD4 Threshold	Preferred Prophylaxis	Alternative	Discontinue When
PCP (P. jirovecii)	<200 cells/mm³ or <14% or prior PCP	TMP-SMX 1 DS tablet daily	TMP-SMX 1 SS daily; dapsone 100 mg daily; atovaquone 1500 mg daily; aerosolized pentamidine 300 mg q4wk	CD4 >200 × ≥3 months on ART
Toxoplasma gondii	<100 cells/mm³ + IgG positive	TMP-SMX 1 DS daily (covers PCP + Toxo)	TMP-SMX 1 DS TIW; dapsone 50 mg + pyrimethamine 50 mg + leucovorin 25 mg weekly	CD4 >200 × ≥3 months on ART
MAC (M. avium)	<50 cells/mm³	Azithromycin 1200 mg weekly	Clarithromycin 500 mg BID; rifabutin 300 mg daily	CD4 >100 × ≥3 months on ART
CMV Retinitis	<50 cells/mm³ (high risk)	Not routinely recommended; ophthalmology referral	Valganciclovir 900 mg daily (if active CMV retinitis is present)	CD4 >100–150 × ≥3–6 months (if on secondary ppx)
Cryptococcus	<100 cells/mm³ (select high-prevalence settings)	Fluconazole 200 mg daily (in high-prevalence settings or prior crypto)	Itraconazole 200 mg daily	CD4 >100–200 × ≥3–6 months on ART
Histoplasma	<150 cells/mm³ (endemic areas only)	Itraconazole 200 mg daily	—	CD4 >150 × ≥6 months on ART
TB (LTBI)	TST ≥5 mm or IGRA positive; all HIV+ regardless of CD4	Isoniazid 300 mg + pyridoxine 25–50 mg daily × 9 months	INH/rifapentine 3HP (12 doses weekly); rifampin × 4 months	After completing full LTBI treatment course

⚠️

CLINICAL DISCLAIMER
Dosing information is for general reference only and does not supersede clinical judgment, institutional protocols, or current prescribing information. ESA and iron dosing require individualized assessment. Always verify against current FDA labeling, KDIGO/NCCN/ASCO guidelines, and institutional formulary.

KDIGO GUIDELINES — ANEMIA IN CHRONIC KIDNEY DISEASE KDIGO 2026 Clinical Practice Guideline · For reference only — verify per current full guideline text

SOURCES
¹ Kidney Disease: Improving Global Outcomes (KDIGO) Anemia Work Group. KDIGO 2026 Clinical Practice Guideline for the Management of Anemia in Chronic Kidney Disease. Kidney Int. 2026;109(1 Suppl):S1–S76. PMID: 41485812.
² Executive Summary of the KDIGO 2026 Clinical Practice Guideline for the Management of Anemia in Chronic Kidney Disease (CKD). Kidney Int. 2026;109(1). PMID: 41485807.
³ KDIGO Anemia Work Group. KDIGO 2012 Clinical Practice Guideline for Anemia in Chronic Kidney Disease. Kidney Int Suppl. 2012;2(4):279–335. [superseded — retained for historical reference]

Anemia Definition & Screening Frequency

Parameter	Criterion	Source
Anemia — Males	Hgb <13 g/dL (<130 g/L)	WHO / KDIGO 2026 Ch. 1 (Figure 6)
Anemia — Females	Hgb <12 g/dL (<120 g/L)	WHO / KDIGO 2026 Ch. 1 (Figure 6)
Initial workup	CBC, reticulocytes (RPI), ferritin, TSAT	PP 1.2.1
Screening — CKD G3	At minimum annually	PP 1.2.1 (Figure 5)
Screening — CKD G4	At minimum twice per year	PP 1.2.1 (Figure 5)
Screening — CKD G5 / G5D	At minimum every 3 months	PP 1.2.1 (Figure 5)
Hgb monitoring — ESA initiation / dose change	Every 2–4 weeks; reduce dose rather than hold if Hgb rising rapidly (avoid >1 g/dL rise per 2–4 wk interval)	PP 3.4.3.2
Hgb monitoring — ESA maintenance	At least every 3 months	PP 3.4.3.3
Iron studies — ND-CKD / PD on iron Rx	Every 3 months (Hgb, ferritin, TSAT)	PP 2.5
Iron studies — CKD G5HD on iron Rx	Every 1–3 months	PP 2.5

Target Hemoglobin (Hgb)

KDIGO 2026 Rec 3.2.1 (Grade 1D): Do not intentionally maintain Hgb ≥11.5 g/dL in adults with CKD on ESA therapy. Targets are now individualized based on symptoms, QoL, and risk — a single fixed target range is no longer recommended.^1,2

Population	Initiate ESA When (Rec 3.1)	Individualized Target	Do Not Exceed (Rec 3.2.1 · Grade 1D)	Key Note
ND-CKD	No fixed threshold (Rec 3.2.2, Grade 2D) — individualize based on symptoms attributable to anemia, QoL, potential benefits of higher Hgb, and transfusion risk¹	Symptom-guided; <11.5 g/dL	11.5 g/dL	Weigh QoL vs. CV risk; avoid ESA with active malignancy, recent stroke, or uncontrolled HTN¹
CKD-HD	Hgb ≤9.0–10.0 g/dL; optimize iron stores first¹	Symptom-guided; <11.5 g/dL	11.5 g/dL	↑ stroke, thrombosis, mortality above 11.5 g/dL (TREAT, CHOIR, CREATE); use lowest effective dose¹
CKD-PD	Hgb ≤9.0–10.0 g/dL; optimize iron first¹	Symptom-guided; <11.5 g/dL	11.5 g/dL	Same CV considerations as HD; use lowest effective ESA dose¹
Transplant	No fixed threshold (Rec 3.2.2, Grade 2D) — treat underlying cause first; individualize decision; insufficient data to assess risk with HIF-PHIs post-transplant¹	Symptom-guided; <11.5 g/dL	11.5 g/dL	R/O rejection, CNI toxicity, ACEi/ARB effect, parvovirus B19; ESA use less common post-Tx¹

Iron Supplementation — %TSAT & Ferritin Thresholds

2026 TERMINOLOGY UPDATE^1,2
Systemic iron deficiency (formerly "absolute iron deficiency"): criteria differ by dialysis status — see table below.
Iron-restricted erythropoiesis (formerly "functional iron deficiency") = elevated or normal ferritin but low TSAT (≤30%) → impaired iron availability for erythropoiesis; trial of IV iron may still improve ESA response.
⚠ Initiation thresholds are NOT the same across populations — HD uses TSAT ≤30% & ferritin ≤500; ND-CKD/PD uses two-condition criteria (see table). Withhold routine iron if ferritin >700 ng/mL or TSAT ≥40% (PP 2.2).

Population	Initiate Iron If (systemic iron deficiency)	Hold / Reassess If	Route	Target TSAT	Target Ferritin
ND-CKD	Ferritin <100 ng/mL AND TSAT <40% — OR — Ferritin 100–299 ng/mL AND TSAT <25%¹ (Rec 2.3)	Ferritin >700 ng/mL or TSAT ≥40% (PP 2.2)	Oral 1st; IV if intolerant or no response after 1–3 mo	>20%	>100 ng/mL
CKD-HD (G5D)	TSAT ≤30% AND Ferritin ≤500 ng/mL¹ (Rec 2.1)	Ferritin >700 ng/mL or TSAT ≥40% (PP 2.2)	IV preferred (poor oral absorption in HD)	>20%	>200 ng/mL
CKD-PD	Ferritin <100 ng/mL AND TSAT <40% — OR — Ferritin 100–299 ng/mL AND TSAT <25%¹ (Rec 2.3)	Ferritin >700 ng/mL or TSAT ≥40% (PP 2.2)	IV preferred; oral if IV access limited	>20%	>100 ng/mL
Transplant / Other	Ferritin <100 ng/mL AND TSAT <40% — OR — Ferritin 100–299 ng/mL AND TSAT <25%¹ (Rec 2.3)	Ferritin >700 ng/mL or TSAT ≥40% (PP 2.2)	Oral 1st; IV if poor response or intolerance	>20%	>100 ng/mL

HIF Prolyl Hydroxylase Inhibitors (HIF-PHIs) — 2026 Guideline Addition

KEY POSITION^1,2
ESAs remain the preferred first-line therapy for CKD-related anemia due to persisting cardiovascular safety concerns with HIF-PHIs and methodological limitations in available HIF-PHI trials. Insufficient data exist to recommend different Hgb initiation thresholds or targets for HIF-PHIs compared to ESAs. HIF-PHIs may be considered when ESAs are not appropriate or not tolerated. Use lowest effective dose; apply same Hgb ceiling (<11.5 g/dL).

ESA Hyporesponsiveness

Definition (KDIGO 2026¹)	Common Causes	Action
Initial: No increase in Hgb from baseline after the first month of ESA at appropriate weight-based dose → avoid escalation beyond 2× initial weight-based dose. Acquired/Subsequent: Requires 2 consecutive dose increases of up to 50% beyond the previously stable dose in an effort to maintain Hgb → avoid escalation beyond 2× stable dose.¹ (KDIGO 2026 Table 10)	Systemic iron deficiency · Iron-restricted erythropoiesis · Infection/inflammation (↑ hepcidin) · Occult blood loss · Hyperparathyroidism · Hemoglobinopathy · Pure red cell aplasia (rare — anti-ESA Ab)	Do NOT escalate ESA beyond 2× starting dose without investigating cause. Identify and treat underlying etiology. Abrupt Hgb drop with ESA on board → workup for PRCA (anti-ESA antibodies).¹

Abbrev: ND-CKD = non-dialysis CKD · G5D = CKD stage 5 on dialysis · HD = hemodialysis · PD = peritoneal dialysis · TSAT = transferrin saturation · ESA = erythropoiesis-stimulating agent · HIF-PHI = hypoxia-inducible factor prolyl hydroxylase inhibitor · CNI = calcineurin inhibitor · PRCA = pure red cell aplasia · QoL = quality of life. Quick-reference only — verify against full KDIGO 2026 guideline text and institutional protocols.

ANEMIA CLINICAL CALCULATORS Ganzoni Iron Replacement · Reticulocyte Production Index (RPI) · KDIGO 2026

SOURCES
¹ Ganzoni AM. Intravenous iron-dextran: therapeutic and experimental possibilities. Schweiz Med Wochenschr. 1970;100(7):301-303.
² Kidney Disease: Improving Global Outcomes (KDIGO) Anemia Work Group. KDIGO 2026 Clinical Practice Guideline for the Management of Anemia in Chronic Kidney Disease. Kidney Int. 2026;109(1 Suppl):S1–S76. PMID: 41485812. (PP 1.2.1, PP 2.2)
³ Hillman RS, Finch CA. Red Cell Manual. 5th ed. Philadelphia: FA Davis; 1985. (Maturation correction factor for RPI)

GANZONI IRON REPLACEMENT DOSE

Total Iron (mg) = Wt (kg) × [Target Hgb − Actual Hgb] (g/dL) × 2.4 + Iron Stores
Iron Stores: 500 mg if Wt > 35 kg; 15 × Wt (mg) if Wt ≤ 35 kg
Ref: Ganzoni 1970¹ · KDIGO 2026 PP 2.2²

Weight (kg)

Actual Hgb (g/dL)

Target Hgb (g/dL)

Iron Product (mg/mL)

Enter weight, Hgb values, and product to calculate.

⚠ KDIGO 2026 (Rec 3.3.1): Do not intentionally maintain Hgb ≥11.5 g/dL. Use 11.0 g/dL as target in CKD unless clinical context warrants otherwise. Max single-dose and total-dose caps vary by product — verify per PI.

RETICULOCYTE PRODUCTION INDEX (RPI)

RPI = (Retic % × Patient HCT / Normal HCT) ÷ Maturation Factor
Normal HCT: 45% male / 40% female. Maturation factor by HCT: ≥40→1.0; 30–39→1.5; 20–29→2.0; <20→2.5
RPI <2 = hypoproliferative · RPI ≥2 = hyperproliferative (loss/hemolysis)
Ref: Hillman 1985³ · KDIGO 2026 PP 1.2.1²

Reticulocyte Count (%)

Patient HCT (%)

Sex

Enter reticulocyte % and HCT to calculate.

Interpretation: RPI <2 → bone marrow hypoproliferative response (iron deficiency, EPO deficiency, anemia of inflammation, myelosuppression). RPI ≥2 → adequate marrow response despite anemia (blood loss, hemolysis). Per KDIGO 2026 PP 1.2.1 — reticulocyte assessment is part of the initial CKD anemia workup.

ERYTHROPOIESIS-STIMULATING AGENTS (ESAs) Alphabetical · dosing varies by indication

Agent	Class	Route	Indication	Starting Dose	Frequency	Dose Adjustment	Target HGB	Renal Dose?	Monitoring	Notes

INJECTABLE IRON SUPPLEMENTATION IV and IM formulations

Agent	Route	Indication	Standard Dose	Max Single Dose	Infusion Time	Test Dose?	Renal Dose?	Notes

ORAL / ENTERAL IRON SUPPLEMENTATION Elemental iron content varies by formulation

Agent	Route	Elemental Fe / Unit	Standard Dose	Frequency	Take With / Avoid	GI Tolerability	Notes

ESA DOSE CONVERSION CHARTS Reference tables for switching between erythropoiesis-stimulating agents · per prescribing information

CONVERSION NOTES
• When switching agents, administer the new ESA at the next scheduled dose interval of the previous agent.
• Starting doses are estimates — individual response may vary. Monitor Hgb every 2–4 weeks after conversion and titrate per guidelines.
• Iron stores must be replete before/during ESA therapy (TSAT ≥20%, Ferritin ≥100 ng/mL for CKD dialysis).
• FDA Black Box Warning applies to all ESAs: target the lowest dose to avoid RBC transfusions; do not use to target Hgb >11 g/dL in CKD; do not use to treat CIA with curative intent.
• KDIGO 2026 ceiling (Rec 3.3.1, Grade 1D): Do not intentionally maintain Hgb ≥11.5 g/dL — note this is slightly higher than the FDA Black Box threshold; both ceilings apply.

MANUAL ENTRIES & CUSTOM CONVERSIONS Add facility-specific conversion notes, dose adjustments, or non-standard regimens

e.g. formulary-specific dose thresholds, biosimilar conversion notes, patient-specific adjustments

FACILITY-SPECIFIC ESA PROTOCOLS Add and edit your institution's ESA management protocols

e.g. CKD ESA Initiation, CIA Dosing Protocol, HD ESA Management, Anemia of Inflammation

⚠️

CLINICAL DISCLAIMER
Anticoagulant dosing information is for general reference only and does not supersede clinical judgment, institutional protocols, or current prescribing information. Always verify against your institution's formulary and current guidelines. Doses may require adjustment for renal/hepatic impairment, weight, and indication.

ORAL ANTICOAGULANTS Sorted alphabetically

Agent	Class	Indication	Mechanism	Renal Dose?	Standard Dose	Renal Dose Tiers (drug-specific thresholds)	Reversal Agent	Monitoring	Periop Hold (CHEST 2022)	Notes

INJECTABLE ANTICOAGULANTS IV and subcutaneous agents

Agent	Class	Route	Indication	Mechanism	Renal Dose?	Standard Dose	Renal Dose Tiers (drug-specific thresholds)	Reversal Agent	Monitoring	Notes

WARFARIN DOSING NOMOGRAM Customise dose-adjustment rules per target INR range — applied in daily entry dosing panel

Target INR range:

UFH IV HEPARIN DRIP CALCULATOR Weight-based dosing (Raschke nomogram) — CHEST-endorsed

PATIENT WEIGHT

Weight (kg)

PTT-BASED ADJUSTMENT (optional — enter current PTT to get adjustment)

Current PTT (sec)

Current Rate (units/hr)

RASCHKE PTT NOMOGRAM

PTT (sec)	Action
<35	Bolus 80 units/kg · ↑ rate 4 units/kg/hr
35–45	Bolus 40 units/kg · ↑ rate 2 units/kg/hr
46–70	No change — therapeutic
71–90	↓ rate 2 units/kg/hr · no hold
>90	Hold 1 hr · ↓ rate 3 units/kg/hr

Enter weight to calculate initial dosing.

Raschke RA et al. Ann Intern Med 1993;119:874–881 · Stevens SM et al. Chest 2021;160(2S):e545–e608 · Round bolus to nearest 100 units; rate to nearest 50 units/hr · Check PTT q6h until therapeutic × 2, then daily · Goal PTT 46–70 sec (1.5–2.3× control ~30 sec)

HEPARIN DRIP PROTOCOL — SITE-SPECIFIC NOMOGRAM Customizable weight-based nomogram · Loaded in the Anticoag Tracker when Heparin Drip is selected

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⚠️ THROMBOLYTICS (FIBRINOLYTICS) — REFERENCE ONLY CVA • STEMI • Massive PE — Not for routine order entry — confirm with attending/neurology/cardiology

HIGH-ALERT MEDICATION. Thrombolytics carry significant risk of serious bleeding including intracranial hemorrhage. Administration requires physician order, institutional protocol, and careful eligibility screening. BP must be ≤185/110 mmHg before and during AIS tPA. Do not use this panel as a standalone prescribing reference — always verify against current institutional protocol and guidelines.

DOSING BY INDICATION

Agent	Indication	Dose & Administration	Window	Notes
Alteplase (tPA, Activase)	Acute Ischemic Stroke (AIS)	0.9 mg/kg IV (max 90 mg total) 10% as IV bolus over 1 min 90% infused over 60 min	≤3 h (label); 3–4.5 h (extended eligibility per AHA/ASA)¹	BP ≤185/110 required pre-dose and during infusion; hold anticoag ×24 h post; repeat neuro checks q15 min ×2 h, q30 min ×6 h, q1 h ×16 h
Tenecteplase (TNK-tPA, TNKase)	Acute Ischemic Stroke (AIS)	0.25 mg/kg IV bolus (max 25 mg) Single bolus over 5 seconds	≤4.5 h²	Non-inferior to alteplase in AIS (EXTEND-IA TNK, NOR-TEST 2); single-bolus simplifies logistics; preferred in some systems; AHA/ASA 2024 update supports use²
Alteplase (Activase)	STEMI (if PCI unavailable >120 min)	15 mg IV bolus, then 0.75 mg/kg over 30 min (max 50 mg) then 0.5 mg/kg over 60 min (max 35 mg) Max total 100 mg	≤12 h from symptom onset³	Administer UFH concurrently (60 U/kg bolus, then 12 U/kg/h). Transfer for rescue PCI if no reperfusion at 3–24 h
Tenecteplase (TNKase)	STEMI	Weight-based single IV bolus: <60 kg: 30 mg \| 60–70 kg: 35 mg 70–80 kg: 40 mg \| 80–90 kg: 45 mg ≥90 kg: 50 mg (max)	≤12 h from symptom onset³	Equivalent efficacy to alteplase in STEMI (ASSENT-2); simpler single bolus; concurrent UFH required
Reteplase (Retavase)	STEMI	10 units IV bolus over 2 min Repeat 10 units IV bolus at 30 min	≤12 h from symptom onset³	Double-bolus regimen; do not use same IV line as heparin. Concurrent anticoag required
Alteplase (Activase)	Massive PE (hemodynamic instability)	100 mg IV over 2 h Cardiac arrest: 0.6 mg/kg over 15 min (max 50 mg)	ASAP when massive PE confirmed⁴	Hold anticoag during infusion; restart UFH (no bolus) when aPTT <80 s. Monitor BP, SpO₂, hemodynamics q15–30 min

CONTRAINDICATIONS

ABSOLUTE CONTRAINDICATIONS (all indications)

Active internal bleeding (excluding menses)
Prior intracranial hemorrhage (any time)
Intracranial/intraspinal surgery or trauma ≤3 months
Intracranial neoplasm, AVM, or aneurysm
Suspected aortic dissection
Significant head/facial trauma ≤3 months
Ischemic stroke ≤3 months (except acute AIS being treated)

AIS-SPECIFIC EXCLUSIONS¹

BP >185/110 mmHg refractory to treatment
Platelets <100,000/mm³
INR >1.7 or aPTT >40 s (on anticoag)
Direct oral anticoagulant within 48 h (or detectable level)
Blood glucose <50 or >400 mg/dL
CT evidence of multilobar infarction (>1/3 hemisphere)
Recent LP or arterial puncture at non-compressible site ≤7 days

MONITORING & REVERSAL

Post-Thrombolytic Monitoring

AIS: Neuro exam q15 min ×2 h, q30 min ×6 h, q1 h ×16 h
AIS: BP monitoring q15 min ×2 h, then per protocol
AIS: NIHSS at 24 h; CT head at 24 h before starting anticoag/antiplatelet
PE/STEMI: Hemodynamics, SpO₂, HR, ECG q15–30 min
All: Monitor for bleeding (urinary, GI, oral, neuro change)
Hold anticoag per indication-specific timing

Thrombolytic Reversal (Bleeding)

Stop infusion immediately
Cryoprecipitate 10 units IV (replaces fibrinogen; repeat if fibrinogen <150 mg/dL)
Tranexamic acid (TXA) 1 g IV over 10 min (antifibrinolytic)
FFP 2–4 units if coagulopathy persists
Neurosurgery / IR consult for intracranial or accessible bleeding
Platelets if <100,000/mm³

SOURCES
¹ Powers WJ et al. AHA/ASA 2019 Guidelines for Early Management of AIS. Stroke. 2019;50(12):e344-e418 ² Turc G et al. AHA/ASA 2024 Focused Update: Tenecteplase for AIS. Stroke. 2024;55(2):e46-e63 ³ O'Gara PT et al. ACC/AHA 2013 STEMI Guideline. J Am Coll Cardiol. 2013;61(4):e78-e140 ⁴ Konstantinides SV et al. ESC 2019 Guidelines on Pulmonary Embolism. Eur Heart J. 2020;41(4):543-603 ⁵ Lexicomp Online. Alteplase / Tenecteplase / Reteplase monographs. Wolters Kluwer; 2025 ⁶ AHFS Drug Information 2025. American Society of Health-System Pharmacists.

SOURCES
¹ January CT et al. 2019 AHA/ACC/HRS Focused Update of 2014 AF Guideline. Circulation. 2019;140(2):e125-e151 ² January CT et al. 2014 AHA/ACC/HRS Guideline for Management of AF. J Am Coll Cardiol. 2014;64(21):e1-e76 ³ Lo GK et al. Pretest Probability of HIT: 4Ts Score. J Thromb Haemost. 2006;4(4):759-765 ⁴ Cuker A et al. Predictive Value of 4Ts Score for HIT. Chest. 2012;142(3):718-729 ⁵ Raschke RA et al. Weight-based Heparin Nomogram. Ann Intern Med. 1993;119(9):874-881 ⁶ Lexicomp Online. Anticoagulant drug monographs. Wolters Kluwer; 2025 ⁷ AHFS Drug Information 2025. American Society of Health-System Pharmacists. ⁸ Douketis JD et al. Perioperative Management of Antithrombotic Therapy: CHEST 2022 CPG. Chest. 2022;162(5):e207–e243 ⁹ Douketis JD et al. Perioperative Bridging Anticoagulation in AF (BRIDGE Trial). N Engl J Med. 2015;373(9):823-833 ¹⁰ Douketis JD et al. Perioperative Management of DOAC Therapy (PAUSE Study). N Engl J Med. 2019;380(24):2290-2302 ¹¹ Cuker A et al. ASH Clinical Practice Guidelines on HIT. Blood Adv. 2018;2(22):3360–3392

⚠ HIT — HEPARIN-INDUCED THROMBOCYTOPENIA MONITORING 4Ts Score · ASH 2018 · JC NPSG 03.05.01 · document PLT trends and 4Ts in the Anticoag daily log

Sources: Cuker A et al. ASH 2018 HIT Guidelines. Blood Adv. 2018;2(22):3360–3392 · Lo GK et al. 4Ts Score. J Thromb Haemost. 2006;4(4):759-765 · Cuker A et al. 4Ts Validation. Chest. 2012;142(3):718-729

PLATELET MONITORING THRESHOLDS (JC NPSG 03.05.01)

FLAG	THRESHOLD	ACTION
CRITICAL DROP	≥50% fall from baseline while on heparin	Complete 4Ts assessment immediately; consider stopping heparin and sending HIT antibody
SEVERE THROMBOCYTOPENIA	PLT <100 × 10⁹/L	Evaluate HIT; assess bleed risk; consider hematology consult
MODERATE DROP	30–50% fall OR PLT <150 × 10⁹/L on heparin	Monitor daily; document 4Ts; assess for other causes
NORMAL RANGE	PLT 150–400 × 10⁹/L; fall <30% from baseline	Routine monitoring q2–3 days per protocol for therapeutic heparin

4Ts SCORING CRITERIA (Lo GK 2006)

CRITERION	2 PTS	1 PT	0 PTS
T1 — Thrombocytopenia Magnitude of platelet fall	Fall >50% AND nadir ≥20 × 10⁹/L	Fall 30–50% OR nadir 10–19 × 10⁹/L	Fall <30% OR nadir <10 × 10⁹/L
T2 — Timing Onset of platelet fall	Clear day 5–10; or ≤1 day with prior heparin exposure within 30 days	Day 5–10 (unclear); after day 10; or ≤1 day with heparin 30–100 days ago	Fall <4 days without recent heparin
T3 — Thrombosis Thrombosis or other sequelae	New confirmed thrombosis (VTE/ATE); skin necrosis; anaphylactoid reaction to IV UFH bolus	Progressive/recurrent thrombosis; erythematous skin lesions; suspected thrombosis (not yet confirmed)	None
T4 — oTher causes Alternative explanation	No other cause evident	Possible other cause	Definite other cause present (sepsis, post-cardiac surgery, DIC, drug, etc.)

SCORE INTERPRETATION & MANAGEMENT

SCORE	PROBABILITY	PRE-TEST PROB	RECOMMENDED ACTION (ASH 2018)
0–3	Low	~1%	HIT unlikely; heparin may be continued if clinically indicated. No need for HIT antibody testing if score ≤3.
4–5	Intermediate	~14%	Send HIT antibody panel (SRA preferred; or ELISA with OD >1.0). Consider switching to non-heparin anticoagulant while awaiting results.
6–8	High	~64%	Discontinue ALL heparin products immediately (including heparin flushes, LMWH, heparin-coated catheters). Start non-heparin anticoagulant. Send HIT antibody panel (SRA). Do NOT give warfarin until platelet recovery to >150 × 10⁹/L.

NON-HEPARIN ANTICOAGULANTS FOR HIT (ASH 2018)

AGENT	DOSE	MONITORING	NOTES
Argatroban	2 mcg/kg/min IV; reduce to 0.5–1.2 mcg/kg/min in hepatic impairment	aPTT 1.5–3× baseline q2h until stable	Hepatic metabolism — no renal adjustment. FDA-approved for HIT. Elevates INR — complex warfarin transition.
Bivalirudin	0.15–0.2 mg/kg/h IV (adjust for renal); 0.75 mg/kg bolus + 1.75 mg/kg/h during PCI	aPTT 1.5–2.5× baseline	Renal clearance — reduce in CrCl <30. Short half-life (~25 min). Preferred for HIT patients undergoing PCI.
Fondaparinux	5–10 mg SubQ daily (weight-based)	Anti-Xa monitoring if CrCl <50	Does not bind PF4 — HIT does not occur. Renal clearance — avoid CrCl <30. Not FDA-approved for HIT but widely used.
Danaparoid	750 anti-Xa units q8–12h SubQ (non-surgical); IV bolus + infusion for urgent anticoag	Anti-Xa level	Not available in US. Widely used in Canada/Europe. Cross-reactivity with HIT antibody in ~10% — test first.

WARFARIN IN HIT — CRITICAL TIMING RULES (ASH 2018)

⚠ Do NOT initiate warfarin until platelet count has recovered to >150 × 10⁹/L.
Premature warfarin in acute HIT can precipitate venous limb gangrene or warfarin-induced skin necrosis due to transient depletion of Protein C before thrombin generation is controlled.

Transition protocol: Overlap therapeutic non-heparin anticoagulant + warfarin for ≥5 days AND until INR in therapeutic range on 2 consecutive days before stopping the parenteral agent. Resume warfarin at patient's previously known maintenance dose — avoid loading doses.

PLATELET RECOVERY TIMELINE

After discontinuing heparin: PLT typically begin to recover within 2–5 days and normalize (≥150 × 10⁹/L) within 4–14 days in most patients. Slower recovery may occur with concurrent thrombosis or HIT-associated consumptive coagulopathy. HIT antibodies typically become undetectable within 50–85 days — re-exposure to heparin after antibody clearance can be considered in select cases (e.g., cardiac surgery), but requires hematology input.

HIT LABORATORY TESTING

TEST	SENSITIVITY	SPECIFICITY	NOTES
SRA (Serotonin Release Assay)	>95%	>97%	Gold standard. Functional assay. Available at reference labs — turnaround 3–7 days.
PF4/Heparin ELISA	>95%	~74–86%	Higher sensitivity, lower specificity. OD >2.0 highly specific. Available at most centers — rapid turnaround.
Lateral Flow Immunoassay (HemosIL)	~97%	~82%	Rapid POC-type test. Intermediate specificity. Useful for rapid triage.

References: Cuker A et al. ASH 2018 HIT Guidelines. Blood Adv. 2018;2(22):3360–3392 · Lo GK et al. J Thromb Haemost. 2006;4(4):759-765 · Cuker A et al. Chest. 2012;142(3):718-729 · Joint Commission NPSG 03.05.01 — Anticoagulation Safety

🔪 PERIOPERATIVE ANTITHROMBOTIC MANAGEMENT CHEST 2022 CPG · Douketis et al. · document periop holds in the Anticoag daily log

Source: Douketis JD et al. CHEST. 2022;162(5):e207–e243 · doi: 10.1016/j.chest.2022.07.025 · Defer to most current published guidelines when managing individual patients.

STEP 1 — PATIENT THROMBOEMBOLIC RISK (CHEST 2022 Table 1)

RISK LEVEL	MECHANICAL HEART VALVE (MHV)	ATRIAL FIBRILLATION (AFib)	VTE
HIGH Annual TE risk >10%	Any mitral valve prosthesis; caged-ball or tilting-disc aortic prosthesis; stroke/TIA within 6 months	CHA₂DS₂-VASc ≥7; stroke/TIA within 3 months; rheumatic mitral valve disease	VTE within 3 months; severe thrombophilia (e.g., protein C/S deficiency, antiphospholipid Ab syndrome)
MODERATE Annual TE risk 4–10%	Bileaflet aortic prosthesis + ≥1 risk factor (AFib, prior stroke/TIA, HTN, DM, HF, age >75)	CHA₂DS₂-VASc 5–6	VTE within 3–12 months; non-severe thrombophilia; recurrent VTE; active cancer
LOW Annual TE risk <4%	Bileaflet aortic prosthesis with no AFib and no other risk factors	CHA₂DS₂-VASc ≤4 (no prior stroke/TIA)	Single VTE >12 months ago with no other risk factors

STEP 2 — PROCEDURAL BLEEDING RISK (CHEST 2022 Table 2)

RISK LEVEL	ESTIMATED BLEED RISK	EXAMPLE PROCEDURES
HIGH (>2%)	Major cardiac, thoracic, abdominal, orthopedic; intracranial/spinal surgery; kidney biopsy; TURP; bowel resection; cancer surgery	CABG, valve replacement, total hip/knee, lobectomy, nephrectomy, prostatectomy, craniotomy
LOW-TO-MODERATE (0–2%)	Abdominal hernia repair, cholecystectomy, endoscopy with biopsy, pacemaker/ICD implantation, peripheral vascular surgery, soft-tissue procedures	Laparoscopic cholecystectomy, colonoscopy with polypectomy, pacemaker insertion, cataract surgery (no hold needed)
MINIMAL (~0%)	Minor dental extractions, skin biopsies, cataract surgery — anticoag typically can be continued	Dental cleaning/filling, suture removal, superficial skin procedures

VKA (WARFARIN) PERIOPERATIVE MANAGEMENT

STEP	RECOMMENDATION
Pre-op hold	Stop warfarin ≥5 days before surgery. Check INR day before — if still >1.5 consider low-dose Vit K.
Resume	Restart at usual dose within 24 hr post-op once hemostasis achieved. Bridge if needed (see below).
Bridging — AFib	Strongly against bridging (BRIDGE trial: no net benefit; increased major bleeding).
Bridging — VTE	Against bridging for most VTE patients. Consider if VTE <3 months or severe thrombophilia.
Bridging — MHV	Against bridging for bileaflet aortic prosthesis (low risk). Suggest LMWH bridge for high-risk MHV (mitral, caged-ball/tilting-disc, or prior stroke/TIA).
Bridge agent	Therapeutic-dose LMWH (enoxaparin 1 mg/kg q12h or dalteparin 100 units/kg q12h). Last prophylactic/therapeutic LMWH dose ≥24 hr before surgery. Resume ≥24 hr post-op.

DOAC PERIOPERATIVE HOLD TIMES (CHEST 2022 / PAUSE Study)

DOAC	LOW-BLEED-RISK PROCEDURES	HIGH-BLEED-RISK PROCEDURES	RENAL NOTE	RESUME	BRIDGING
Apixaban Eliquis	1 day	2 days	No adjustment needed	>24 hr post-op	Not recommended
Dabigatran Pradaxa	1 day (CrCl ≥50) 2 days (CrCl <50)	2 days (CrCl ≥50) 3–4 days (CrCl <50)	⚠ 75–80% renal clearance — extend hold if CrCl <50 mL/min	>24 hr post-op	Not recommended
Edoxaban Savaysa	1 day	2 days	No adjustment needed	>24 hr post-op	Not recommended
Rivaroxaban Xarelto	1 day	2 days	No adjustment needed	>24 hr post-op	Not recommended

* All DOAC periop hold times assume once- or twice-daily dosing and last dose taken at scheduled time. Resume when adequate hemostasis confirmed. No DOAC-to-LMWH bridging recommended.

ANTIPLATELET THERAPY

AGENT	MANAGEMENT
Aspirin (ASA)	Continue perioperatively in most cases (especially coronary artery disease). No interruption recommended unless high bleed-risk surgery where surgeon requests hold. If held: stop 7–10 days prior.
P2Y12 Inhibitors (clopidogrel, prasugrel, ticagrelor)	Interrupt before surgery: clopidogrel/ticagrelor 5 days; prasugrel 7 days. Balance thrombosis risk (especially recent stent <6 months) vs. bleeding. Continue ASA if possible. Resume 24 hr post-op when hemostasis achieved.
Coronary Stents	⚠ Elective surgery should be deferred if <1 month post-BMS or <6 months post-DES. For urgent surgery: continue DAPT and coordinate with cardiology. No bridging with GP IIb/IIIa inhibitors recommended.

KEY RECOMMENDATIONS SUMMARY

1. Classify patient TE risk (Table 1) and procedure bleed risk (Table 2) before every periop anticoag decision.
2. DOACs: Hold 1–2 days (low-bleed) or 2–4 days (high-bleed, adjust for dabigatran/renal). No bridging.
3. Warfarin: Hold ≥5 days; resume within 24 hr. Bridge only for high-risk MHV — strongly against for AFib (BRIDGE trial).
4. ASA: Continue for most patients. Interrupt P2Y12 5–7 days before surgery; resume 24 hr post-op.
5. Document hold start date, planned resume date, and bridging decision in the Anticoag daily log periop section.

References: Douketis JD et al. CHEST 2022 · BRIDGE Trial (Douketis, NEJM 2015) · PAUSE Study (Douketis, NEJM 2019) · Defer to most current guidelines for individual patient management.

🔄 ANTICOAGULANT REVERSAL AGENTS Quick-reference dosing · ISTH 2024 / AHA 2023 · document reversal events in the Anticoag daily log

📄 ISTH 2024 — DOAC Reversal Guidance (Levy et al., J Thromb Haemost) 📄 AHA/ASA 2022 — Anticoagulation Reversal in ICH 📄 ASH 2023 — Bleeding in Patients on Anticoagulants

HEPARIN & LMWH REVERSAL — PROTAMINE SULFATE

Anticoagulant	Time Since Last Dose	Protamine Dose	Max / Notes
UFH (IV Drip)	< 30 min	1 mg per 100 units heparin infused in last hour	Max 50 mg IV slow push over 10 min. Repeat aPTT 15 min post-dose. Monitor for hypotension / bradycardia.
	30–60 min	0.5–0.75 mg per 100 units heparin
	> 60 min (or SQ)	0.25–0.375 mg per 100 units heparin
Enoxaparin (LMWH)	< 8 hr since dose	1 mg protamine per 1 mg enoxaparin given	Protamine partially reverses LMWH (~60–80% anti-Xa activity). If bleeding persists, repeat 0.5 mg per 1 mg enoxaparin. Max 50 mg. Consider Andexanet alfa (off-label LMWH data).
Enoxaparin (LMWH)	8–12 hr since dose	0.5 mg protamine per 1 mg enoxaparin given
Dalteparin / Tinzaparin	Any	1 mg protamine per 100 anti-Xa units dalteparin (within 3–4 hr); 0.5 mg if >3–4 hr	Partial reversal. Max 50 mg. Monitor anti-Xa level if available.
UFH SQ prophylaxis	Any	1 mg per 100 units SQ heparin given (conservative)	Rarely required; use only for active major bleeding. Protamine itself may cause hypotension.

WARFARIN REVERSAL — VITAMIN K & REVERSAL AGENTS

Scenario / INR	Preferred Agent	Dose / Route	Onset / Notes
Supratherapeutic INR 4.5–10, no bleeding	Vitamin K (PO)	1–2.5 mg PO once	INR correction within 24–48 hr. Restart warfarin when INR therapeutic.
INR > 10, no bleeding	Vitamin K (PO)	2.5–5 mg PO; repeat INR in 24 hr	Hold warfarin. May give up to 10 mg PO if INR very high. IV if PO not tolerated.
Serious / major bleeding (non-ICH)	4F-PCC (Kcentra) + Vitamin K IV	4F-PCC: 25–50 units/kg IV (INR-guided, max 5000 units) + Vitamin K 5–10 mg IV slow infusion	Rapid INR reversal within 15–30 min. FFP 15–30 mL/kg if PCC unavailable. Re-check INR 30–60 min post.
Life-threatening / ICH	4F-PCC (Kcentra) + Vitamin K IV	4F-PCC: 50 units/kg IV (max 5000 units) + Vitamin K 10 mg IV slow infusion; rFVIIa 15–90 mcg/kg off-label if refractory	Immediate neurosurgical consult. INR target <1.4. 4F-PCC preferred over FFP (faster, less volume).
4F-PCC Kcentra dose guide (INR-based): INR 2–<4: 25 units/kg · INR 4–6: 35 units/kg · INR >6: 50 units/kg · Max 5,000 units per dose · Give Vitamin K concurrently to sustain reversal (PCC half-life <24 hr).

DOAC REVERSAL — SPECIFIC & NON-SPECIFIC AGENTS

Anticoagulant	Preferred Reversal Agent	Dose / Protocol	Fallback / Notes
Dabigatran (Pradaxa) Direct Thrombin Inhibitor	Idarucizumab (Praxbind)	5 g IV as two separate 2.5 g doses ≤15 min apart (or continuous infusion over 5–10 min each). FDA approved.	4F-PCC 50 units/kg if idarucizumab unavailable. Activated charcoal if <2–3 hr since ingestion. Hemodialysis can remove dabigatran (60–70% clearance).
Rivaroxaban ≥ 10 mg or Apixaban ≥ 5 mg within 8 hr of last dose	Andexanet Alfa (Andexxa) HIGH-DOSE	800 mg IV bolus over 15–30 min, then 960 mg IV infusion over 2 hr. FDA approved.	4F-PCC 50 units/kg off-label if Andexanet unavailable. Monitor anti-Xa levels (not reliable in first 2 hr after andexanet). Thrombotic risk post-reversal — restart anticoag as soon as hemostasis achieved (ISTH 2024 recommends ≥24–48 hr).
Rivaroxaban < 10 mg or Apixaban < 5 mg or Edoxaban (any dose) or > 8 hr since last dose	Andexanet Alfa (Andexxa) LOW-DOSE	400 mg IV bolus over 15–30 min, then 480 mg IV infusion over 2 hr. FDA approved.
Argatroban / Bivalirudin IV Direct Thrombin Inhibitors	No approved specific antidote	Stop infusion (half-life ~45 min argatroban, ~25 min bivalirudin). Supportive care.	Bivalirudin: partially removed by HD. Argatroban: hepatic elimination — prolonged in liver failure. rFVIIa off-label for refractory life-threatening bleeding only.
Fondaparinux Indirect FXa inhibitor	No approved specific antidote	No specific reversal agent. rFVIIa 90 mcg/kg off-label may partially reverse.	Half-life 17–21 hr (extended in renal impairment). Supportive care. Avoid in CrCl <30 mL/min. Not removed by HD.
After reversal: Re-evaluate thrombotic risk vs. bleeding risk. Restart anticoagulation at earliest safe opportunity — ISTH 2024 recommends restarting within 1–2 weeks for most indications after major bleeding event. Discuss with prescribing team and document in chart.

Sources: Levy JH et al. Reversal of direct oral anticoagulants: guidance from the SSC of the ISTH. J Thromb Haemost. 2024;22:2889–2899. doi:10.1016/j.jtha.2024.07.009 · Greenberg SM et al. 2022 Guideline for the Management of Patients With Spontaneous ICH. Stroke. 2022;53(7):e282–e361. doi:10.1161/STR.0000000000000407 · Tomaselli GF et al. 2020 ACC Expert Consensus on Novel Anticoagulants. J Am Coll Cardiol. 2020;75(13):1651–1664 · Lexicomp Online. Protamine Sulfate, Vitamin K1, Kcentra, Praxbind, Andexanet alfa monographs. 2025.

FACILITY-SPECIFIC PROTOCOLS Add and edit your institution's anticoagulation protocols below

e.g. Heparin Drip Protocol, Warfarin Initiation, DVT Bridge

⚠️

CLINICAL DISCLAIMER
TPN dosing requires individualized assessment by a qualified clinician, dietitian, and/or pharmacist. Goals vary significantly by disease state, metabolic stress level, organ function, and clinical trajectory. These tables reflect ASPEN/SCCM guideline ranges for reference only. Always verify against institutional protocols, current labs, and patient-specific factors.

TPN DOSING WEIGHT CALCULATION Used for kcal/kg and protein g/kg goals · ASPEN Guidelines

WEIGHT SELECTION ALGORITHM

Body Habitus / BMI	TPN Dosing Weight
Underweight (ABW < IBW)^1,2	Actual Body Weight (ABW)
Normal weight (IBW ≤ ABW ≤ 130% IBW)^1,2	Actual Body Weight (ABW)
Obese (ABW > 130% IBW, BMI ≤ 50)^1,2	Adjusted BW = IBW + 0.25 × (ABW − IBW)
Super-obese (BMI > 50)^1,2	IBW

Note: The 0.25 AdjBW correction factor for TPN (ASPEN) differs from the 0.40 factor used in the Cockcroft-Gault equation for drug dosing. Use ABW for all non-obese patients — do not substitute IBW when ABW > IBW in normal-weight patients.

FORMULAS

IBW (M): 50 kg + 2.3 × (Ht[in] − 60)

IBW (F): 45.5 kg + 2.3 × (Ht[in] − 60)

AdjBW (obese): IBW + 0.25 × (ABW − IBW)

%IBW: (ABW ÷ IBW) × 100

BMI: ABW (kg) ÷ [Ht (m)]²

Tracker auto-calculation: The TPN tracker's Dosing Weight field is auto-computed using this algorithm from height, sex, and actual weight. The label (ABW / AdjBW / IBW) indicates which type was applied.

SOURCES
¹ ASPEN Board of Directors. Clinical Guidelines for PN and EN. JPEN. 2022;46(S1):S1-S59 ² Mirtallo J et al. Safe Practices for Parenteral Nutrition. JPEN. 2004;28(6):S39-S70 ³ McClave SA et al. ASPEN/SCCM Guidelines for Adult ICU Patients. JPEN. 2016;40(2):159-211 ⁴ Btaiche IF et al. Critical Illness and Drug Therapy. Pharmacotherapy. 2010;30(12):1195-1211 ⁵ Mehanna HM et al. Refeeding syndrome. BMJ. 2008;336(7659):1495-1498 ⁶ ASPEN Parenteral Nutrition Safety Consensus Recommendations. JPEN. 2014;38(3):296-333 ⁷ Lexicomp Online. Parenteral Nutrition Monograph. Wolters Kluwer; 2025 ⁸ AHFS Drug Information 2025. American Society of Health-System Pharmacists

CALORIC GOALS BY PATIENT POPULATION ASPEN / SCCM Guidelines · kcal/kg/day unless noted

Population	Caloric Goal	Dosing Weight	Notes
General / Non-critical	25–35 kcal/kg/day	ABW (or AdjBW if obese)	Standard range for stable, non-stressed adults¹
Critically Ill (ICU)	25–30 kcal/kg/day	ABW (or IBW if obese)	Initiate at 80–100% of goal; full calories by day 3–5^1,3
Critically Ill — Early Phase (d1–2)	≤ 20 kcal/kg/day	ABW	Permissive underfeeding during acute stress phase; advance over 3–5 days³
Obesity — BMI 30–50	11–14 kcal/kg ABW or 22–25 kcal/kg IBW	ABW or IBW	Hypocaloric, high-protein strategy; use lower of ABW or IBW-based calc^1,3
Obesity — BMI > 50	22–25 kcal/kg IBW	IBW	Use IBW exclusively; avoid ABW-based calculations in super-obesity^1,3
Renal Failure (Non-dialysis)	25–35 kcal/kg/day	ABW (or IBW if obese)	Restrict phos, K, Mg additives; monitor electrolytes daily¹
CRRT / Dialysis	25–35 kcal/kg/day	ABW	Account for dextrose load from CRRT fluid (typically 300–700 kcal/day)^1,3
Hepatic Failure / Cirrhosis	25–35 kcal/kg/day	Dry weight	Use dry weight (subtract estimated ascites/edema); restrict Na and fluid¹
Burns (> 20% TBSA)	Individualize via Curreri / Harris-Benedict	Pre-burn ABW	Curreri: (25 × kg) + (40 × %TBSA); reassess weekly; avoid overfeeding^1,3
Pulmonary Failure / Vent-Dependent	25–30 kcal/kg/day	IBW or AdjBW	Avoid excess dextrose (↑CO₂ production); limit CHO to < 50% of total kcal^1,3
Cardiac Failure	20–30 kcal/kg/day	Dry weight	Fluid restriction; concentrate formula; restrict Na; goal 1–1.5 L/day volume¹
Pancreatitis (Severe)	25–30 kcal/kg/day	IBW or AdjBW	Prefer EN if tolerated; use TPN only if EN route not feasible; limit lipids initially^1,3

PROTEIN (AMINO ACID) GOALS BY DISEASE STATE g/kg/day · 4 kcal/g

Disease State / Condition	Protein Goal (g/kg/day)	Dosing Weight	Notes / Rationale
General / Non-stressed	0.8–1.5	ABW	RDA minimum 0.8; most hospitalized patients need 1.2–1.5¹
Critical Illness (general)	1.2–2.0	ABW	SCCM/ASPEN 2016; higher end for most ICU patients^1,3
Burns / Major Trauma / Wounds	1.5–2.5	Pre-illness ABW	High catabolism; reassess weekly via nitrogen balance or urinary urea nitrogen^1,3
Obesity (BMI 30–50)	2.0–2.5 g/kg IBW	IBW	High-protein hypocaloric strategy; preserves lean mass during weight loss^1,3
Obesity (BMI > 50)	2.5 g/kg IBW	IBW	Super-obesity; protein needs disproportionately higher relative to lean mass^1,3
AKI — Non-dialysis	0.8–1.2	ABW	Caution: protein restriction does not protect kidneys; avoid severe restriction¹
AKI — CRRT	1.5–2.5	ABW	Large AA losses in effluent; increase protein to compensate; verify with nephro^1,3
CKD — Hemodialysis	1.2–1.4	ABW	Intradialytic amino acid losses; ensure adequate provision¹
CKD — Peritoneal Dialysis	1.2–1.5	ABW	Account for dialysate amino acid losses; Subtract dextrose load from PD fluid calories¹
Hepatic Failure / Cirrhosis	1.2–1.5	Dry weight	Protein restriction NOT routinely recommended; branched-chain AA (BCAA) if HE¹
Hepatic Encephalopathy (HE)	0.5–1.0 initially → titrate up	Dry weight	BCAA-enriched formulas; titrate protein up as HE resolves; monitor ammonia¹
Ventilator-Dependent / ARDS	1.5–2.0	ABW or IBW	Prevent respiratory muscle catabolism; reassess with vent weaning progress^1,3

DEXTROSE & LIPID DOSING GUIDELINES

DEXTROSE (CHO) — 3.4 kcal/g

Parameter	Value
Typical daily range^1,2	100–350 g/day
Max oxidation rate^1,2	4–5 mg/kg/min
% of total kcal	50–70% (general)
Vent / Pulmonary^1,3	< 50% of kcal
ICU glucose target	140–180 mg/dL
General glucose target	140–180 mg/dL
Peripheral max conc.	10% dextrose
Central max conc.	Up to 70%

IV LIPID EMULSION (ILE) — 10 kcal/g

Parameter	Value
% of total kcal	20–30%
Dose range	1.0–1.5 g/kg/day
Max dose	2.5 g/kg/day
Infusion duration	≥ 12–24h (TNA)
TG — reduce dose^1,6	TG > 250 mg/dL
TG — hold lipids^1,6	TG > 400 mg/dL
Essential FA min^1,2	2–4% of total kcal
Soy lipid HOLD if^1,6	Hypertriglyceridemia, pancreatitis

Lipid Product Notes: Soybean oil-based ILE (Intralipid 20%): 2 kcal/mL; 10%: 1.1 kcal/mL. SMOF Lipid (fish oil/olive oil/MCT/soybean blend) preferred in critically ill — reduced pro-inflammatory ω-6 load. SMOFlipid 20%: 2 kcal/mL. Pancreatitis: withhold lipids until TG < 400 or for first 48–72h in severe acute pancreatitis. Provide minimum 2–4% of calories as linoleic acid to prevent essential fatty acid deficiency during lipid-free TPN.

PERIPHERAL vs CENTRAL TPN — ACCESS & CONCENTRATION LIMITS

Parameter	Peripheral (PPN)	Central (CPN / TPN)
Osmolarity Limit	≤ 900 mOsm/L^1,2,6	No practical limit
Dextrose Max Conc.	10%	Up to 70%
Amino Acid Max Conc.	≤ 3–4%	Up to 15%
Caloric Density	0.5–0.7 kcal/mL (typically)	Up to 2 kcal/mL
Volume Required	High (~2–3 L/day for full needs)	Low (1–2 L/day)
Phlebitis Risk	High — requires line rotation q48–72h	Low (flows into high-volume vessel)^1,2,6
Line Placement Needed	PIV, Midline (not PICC)	CVC, PICC, Port, Tunneled CVC
Duration Suitability	Short-term bridging (< 7–14 days)	Short- or long-term^1,2
When to Use PPN	Central access unavailable, anticipated short TPN course, supplemental PN when partial EN tolerated^1,2

STANDARD ELECTROLYTE ADDITIVES — DAILY REQUIREMENTS

Electrolyte	Standard Adult Range / Day	Renal Failure Adjustment	Notes
Sodium (Na⁺)	60–150 mEq/day	Restrict to 40–60 mEq/day	As Cl⁻ or acetate depending on acid-base status; restrict in cardiac/hepatic failure^1,2
Potassium (K⁺)	60–100 mEq/day	Restrict or omit; add PRN per levels	Monitor daily; critical in refeeding syndrome; as Cl⁻, Phos, or acetate salt^1,2,5
Magnesium (Mg²⁺)	8–24 mEq/day	Restrict; use low dose 4–8 mEq/day	Watch for accumulation in renal failure; GI losses increase needs substantially^1,2
Phosphorus (Phos)	20–40 mmol/day	Restrict or omit if phos > 4.5	Critical in refeeding syndrome — low phos is hallmark; replete aggressively if < 2.5^1,2,5
Calcium (Ca²⁺)	10–15 mEq/day	Reduce; monitor iCa	As gluconate only (not chloride) in TPN; watch CaPhos compatibility precipitate risk^1,2,6
Chloride (Cl⁻)	Adjust per acid-base	Adjust per acid-base	Metabolic alkalosis → increase Cl⁻ (less acetate); metabolic acidosis → increase acetate^1,2
Acetate	Adjust per acid-base	Often increase acetate (buffer load)	Renal failure typically requires more acetate; converts to bicarbonate in liver^1,2
MVI (Multivitamin)	1 vial daily	Same	Standard MVI-12 (e.g., Infuvite); add to TPN bag; light-sensitive — protect from UV^1,6
Trace Elements	1 vial daily (standard multi-TE)	Hold Cr, Se, Mo if anuric	Contains Zn, Cu, Mn, Cr, Se. Restrict Mn in liver failure (neurotoxicity). Extra Zn for GI losses^1,6
Zinc (Zn)	2.5–5 mg/day (standard)	Standard dose	Increase to 12–17 mg/day for major GI losses (ostomy, fistula); critical for wound healing^1,2

REFEEDING SYNDROME — RISK IDENTIFICATION & PREVENTION

HIGH-RISK CRITERIA (NICE / ASPEN)

ONE of the following:

• BMI < 16 kg/m²

• Unintentional weight loss > 15% in past 3–6 months

• Little or no nutritional intake for > 10 days

• Low pre-feeding levels of K, Phos, or Mg

TWO or more of the following:

• BMI < 18.5 kg/m²

• Weight loss > 10% in 3–6 months

• No intake for > 5 days

• Alcohol excess or drug history (diuretics, antacids, insulin, chemotherapy)

PREVENTION PROTOCOL

Start calories	10–15 kcal/kg/day × 2–3 days
Advance rate	Increase 200–300 kcal/day as tolerated^1,5
Thiamine (B₁)	100–300 mg IV BEFORE starting TPN^1,5
Phosphorus target	Maintain ≥ 2.5 mg/dL; replete aggressively^1,5
Potassium target	Maintain ≥ 3.5 mEq/L^1,5
Magnesium target	Maintain ≥ 1.8 mg/dL^1,5
Glucose monitoring	q4–6h for first 48h; target 140–180^1,5

Key Labs to Monitor: Phosphorus, Potassium, Magnesium, Glucose — check before starting and q6–12h for first 48–72h in high-risk patients. Hypophosphatemia is the hallmark — watch for weakness, respiratory failure, cardiac arrhythmia, hemolysis, and neurologic symptoms.

TPN MONITORING — LAB SCHEDULE & CLINICAL PARAMETERS

Parameter	Initiation / Day 1–3	Stable (Day 4+)	Target / Action Value
Glucose	q4–6h (or per insulin protocol)	q6–8h or daily	140–180 mg/dL; avoid < 110 or > 180^1,3
Electrolytes (Na, K, Cl, CO₂)	Daily or BID	Daily	Adjust TPN additives per results same day¹
Phosphorus	BID or q6h (refeeding risk)	Daily	≥ 2.5 mg/dL; replete aggressively if low^1,5
Magnesium	Daily	Daily	1.8–2.4 mg/dL; replete for < 1.8¹
Calcium	Daily	Daily → q3 days (stable)	Adjust Ca and Phos content; watch CaPhos precipitate risk^1,6
BUN / Creatinine	Daily	Daily	BUN rise may indicate excess protein or dehydration — evaluate both¹
Triglycerides	Baseline; recheck 24h after lipid start	Weekly (or with dose change)	Hold lipids if TG > 400; reduce dose if > 250; draw 4–6h after infusion end^1,6
Liver Function (AST/ALT/ALP/TBili)	Baseline	Weekly	TPN-associated cholestasis risk with prolonged use (> 2 weeks); evaluate lipid cycling¹
Prealbumin / Albumin	Baseline	Weekly	Poor short-term markers — affected by inflammation; use trends, not absolute values¹
Weight / Fluid Balance	Daily weight; strict I&O	Daily weight	Rapid weight gain usually fluid; adjust TPN volume; goal ≤ 0.5 lb/day lean gain¹
Nitrogen Balance (optional)	Weekly (if protein goals uncertain)	Weekly	N balance = (AA intake g/6.25) − (UUN + 4); positive balance goal + 2–4 g/day¹

Key References: McClave SA et al. — ASPEN/SCCM Clinical Nutrition Guidelines for the Adult Critically Ill Patient, JPEN 2016;40(2):159–211. · Boullata JI et al. — ASPEN Safe Practices for Parenteral Nutrition, JPEN 2014;38(2 Suppl):S77–S208. · NICE CG32 — Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition, 2006 (updated 2017).

SLIDING SCALE INSULIN (SSI) PROTOCOLS Patient SSI level is set in TPN Edit Record → Endocrine. BG entered in the daily log auto-fills SSI units using these ranges. All values are editable — changes save instantly.

Each row defines a BG range (inclusive). Leave BG ≤ blank for an open upper bound (e.g. BG > 400). A BG value below the first defined threshold will not auto-fill. SSI units field remains manually adjustable in the daily log at all times.

SITE-SPECIFIC POLICIES & PROTOCOLS Add your institution's TPN protocols, nutrition policies, and ordering guidelines

e.g. TPN Initiation Criteria, Electrolyte Replacement Protocol, Refeeding Policy, Line Placement Requirements, Cyclic TPN Guidelines

TPN COMPOUNDING — STOCK CONCENTRATIONS, MIN VOLUME & KCAL FORMULAS Auto-calculated in the TPN daily log — cannot be manually overridden

Set your institution's stock solution concentrations below. The daily log will use these to compute Min Volume (mL) and Total Kcal automatically from entered macros and additives. These fields cannot be manually overridden.

MINIMUM VOLUME FORMULA

MinVol = AA(g) ÷ AA% + Dextrose(g) ÷ Dex% + Lipid(g) ÷ Lipid% + Σ Electrolytes & Additives

Electrolyte volumes = amount ÷ stock conc. | MVI & Trace elements added directly (already in mL)

TOTAL KCAL FORMULA

Total Kcal = AA(g) × 4 kcal/g + Dextrose(g) × 3.4 kcal/g + Lipid(g) × 10 kcal/g

Standard caloric densities: Protein 4 kcal/g | Dextrose monohydrate 3.4 kcal/g | Lipid emulsion (20%) ≈ 10 kcal/g fat | Auto-calculated — cannot be manually overridden

TPN OSMOLARITY FORMULA (mOsm/L)

mOsm/L = [Dextrose(g) × 5 + AA(g) × 8 + NaCl(mEq) × 2 + KCl(mEq) × 2 + Na-Phos(mmol) × 3 + K-Phos(mmol) × 3 + Na-Acetate(mEq) × 2 + K-Acetate(mEq) × 2 + Ca-Gluc(mEq) × 1.4 + MgSO4(mEq) × 2] ÷ Volume (L)

INFUSION RATE

Rate (mL/hr) = Ordered Volume (mL) ÷ Infusion Time (hr)

Auto-calculated from the ordered volume and infusion duration entered in the daily log | Ordered volume defaults to Min Volume if not manually set | Rate displayed in mL/hr, rounded to nearest whole number

CORRECTED CALCIUM

Corrected Ca (mg/dL) = Serum Ca (mg/dL) + 0.8 × (4.0 − Albumin (g/dL))

Payne formula — adjusts serum calcium for hypoalbuminemia | Normal albumin assumed 4.0 g/dL | Auto-calculated when serum Ca and albumin labs are entered in the daily log | Note: corrected calcium is an approximation; ionized calcium is preferred for clinical decisions

CALCIUM × PHOSPHORUS PRECIPITATION RISK

Ca × P product = Ca-Gluconate (mEq) ÷ Vol (L) × Total Phos (mmol) ÷ Vol (L)

Total Phos (mmol) = Na-Phos (mmol) + K-Phos (mmol) | Vol (L) = Min Volume ÷ 1000
In-bag admixture flag — Ca (mEq/L) × P (mmol/L): <200 compatible · 200–250 verify · >250 precipitation likely. Confirm against the specific amino-acid product’s calcium-phosphate solubility curve (product package insert / ASPEN); add phosphate before calcium when compounding.
Note: this in-bag admixture product (mEq/L × mmol/L) is distinct from the serum Ca×PO₄ check — the >72 threshold belongs only to the serum product (mg²/dL², KDOQI) and must not be applied to the admixture.
Auto-calculated in the TPN daily log from entered electrolytes and computed min volume

PREMIX MODE — MIN VOLUME (Clinimix / Clinimix E)

Premix Vol (mL) = Selected Container Vol (mL) × (Adjusted AA (g) ÷ Full Bag AA (g))

Min Vol = Premix Vol + Lipid Vol + Electrolyte & Additive Vols

Lipid Vol = Lipid (g) ÷ Lipid stock (%) | Electrolyte vols computed from supplemental amounts only (not from the Clinimix E bag) when Clinimix E is selected
Ratio = Adjusted AA ÷ Full Bag AA | Full Bag AA = Bag AA%/L × Container volume (L)
Dextrose and electrolytes (for Clinimix E) scale proportionally with the AA ratio — see bag info panel in the daily log
Osmolarity in premix mode uses the manufacturer-stated value from the formulation label, not the derived formula above

MACRONUTRIENT STOCK SOLUTIONS

AMINO ACIDS STOCK (%)
e.g. 10% = Travasol 10%, Clinimix

DEXTROSE STOCK (%)
e.g. 70% = D70W stock vial

LIPID EMULSION STOCK (%)
e.g. 20% = Intralipid 20%

ELECTROLYTE STOCK CONCENTRATIONS

NaCl (mEq/mL)
Default: 4 mEq/mL

Na-Phosphate (mmol Phos/mL)
Default: 3 mmol/mL

Na-Acetate (mEq/mL)
Default: 2 mEq/mL

KCl (mEq/mL)
Default: 2 mEq/mL

K-Phosphate (mmol Phos/mL)
Default: 3 mmol/mL

K-Acetate (mEq/mL)
Default: 2 mEq/mL

Ca-Gluconate (mEq/mL)
Default: 0.465 mEq/mL (10%)

MgSO4 (mEq/mL)
Default: 4.06 mEq/mL (50%)

ADDITIVE STOCK CONCENTRATIONS (MVI & Trace elements are entered directly in mL)

Famotidine (mg/mL)
Default: 10 mg/mL

Zinc (mg/mL)
Default: 1 mg/mL

Vit C — Ascorbic Acid (mg/mL)
Default: 500 mg/mL

Folic Acid (mg/mL)
Default: 5 mg/mL

Thiamine B1 (mg/mL)
Default: 100 mg/mL

Pyridoxine B6 (mg/mL)
Default: 100 mg/mL

Selenium (mcg/mL)
Default: 40 mcg/mL

Chromium (mcg/mL)
Default: 4 mcg/mL

Vit B12 (mcg/mL)
Default: 1000 mcg/mL

Insulin Regular (units/mL)
Default: 100 units/mL

CLINIMIX & CLINIMIX E — PREMIX FORMULATION REFERENCE Baxter · All volumes & values per container

Clinimix E — Amino Acids with Electrolytes in Dextrose

Electrolyte package constant per liter: Na 35 mEq (NaCl 19 + Na-Acetate 16) · K 30 mEq (as K₂HPO₄) · Phos 15 mmol · Ca 4.5 mEq (CaCl₂) · Mg 5 mEq (MgCl₂) · Cl 39 mEq | Acetate totals below include amino-acid-bound acetate

Strength	Vol	AA (g)	Dex (g)	Na (mEq)	K (mEq)	Ca (mEq)	Phos (mmol)	Mg (mEq)	Acetate (mEq)	Cl (mEq)	Osmol (mOsm/L)	kcal
2.75% AA / 5% Dex	1L	27.5	50	35	30	4.5	15	5	51	39	665	280
	2L	55	100	70	60	9	30	10	102	78	665	560
2.75% AA / 10% Dex	1L	27.5	100	35	30	4.5	15	5	51	39	920	450
	2L	55	200	70	60	9	30	10	102	78	920	900
4.25% AA / 5% Dex	1L	42.5	50	35	30	4.5	15	5	70	39	815	340
	2L	85	100	70	60	9	30	10	140	78	815	680
4.25% AA / 10% Dex	1L	42.5	100	35	30	4.5	15	5	70	39	1070	510
	2L	85	200	70	60	9	30	10	140	78	1070	1020
4.25% AA / 25% Dex	1L	42.5	250	35	30	4.5	15	5	70	39	1825	1020
	2L	85	500	70	60	9	30	10	140	78	1825	2040
5% AA / 15% Dex	1L	50	150	35	30	4.5	15	5	80	39	1395	710
	2L	100	300	70	60	9	30	10	160	78	1395	1420
5% AA / 20% Dex	1L	50	200	35	30	4.5	15	5	80	39	1650	880
	2L	100	400	70	60	9	30	10	160	78	1650	1760
5% AA / 25% Dex	1L	50	250	35	30	4.5	15	5	80	39	1900	1050
	2L	100	500	70	60	9	30	10	160	78	1900	2100

Clinimix — Amino Acids in Dextrose (no electrolytes added)

No electrolyte additives — acetate and chloride values below are from amino-acid salts only. Clinimix 2.75/5 available in 1L only. All other strengths available in 1L and 2L.

Strength	Vol	AA (g)	Dex (g)	Acetate (mEq)	Cl (mEq)	Osmol (mOsm/L)	kcal
2.75% AA / 5% Dex	1L only	27.5	50	24	11	525	280
4.25% AA / 5% Dex	1L	42.5	50	37	17	675	340
	2L	85	100	74	34	675	680
4.25% AA / 10% Dex	1L	42.5	100	37	17	930	510
	2L	85	200	74	34	930	1020
4.25% AA / 20% Dex	1L	42.5	200	37	17	1435	850
	2L	85	400	74	34	1435	1700
4.25% AA / 25% Dex	1L	42.5	250	37	17	1685	1020
	2L	85	500	74	34	1685	2040
5% AA / 15% Dex	1L	50	150	42	20	1255	710
	2L	100	300	84	40	1255	1420
5% AA / 20% Dex	1L	50	200	42	20	1505	880
	2L	100	400	84	40	1505	1760
5% AA / 25% Dex	1L	50	250	42	20	1760	1050
	2L	100	500	84	40	1760	2100

Source: Baxter Clinimix Nutrient Profile Guide (USMP/78/14-0004) | Lipids: Not included — must be added separately (IVLE bag) | Use "Premix (Clinimix)" mode in the +Add Day formula section to auto-populate from this reference.

💊 Drug Acquisition Cost — Cost per unit for restricted-use antimicrobials (used by HCA report)

VASOPRESSORS

DRUG	USUAL DOSE RANGE	NOTES / PEARLS
Norepinephrine (Levophed) ⓘ	0.01–3 mcg/kg/min IV	First-line vasopressor for septic shock (SSC 2021). α₁ > β₁ effects. Central line preferred; peripheral IV acceptable short-term if central access delayed (SSC 2021 Rec 5.1).^1,2
Vasopressin ⓘ	0.03–0.04 units/min IV	Second-line agent; fixed dose. Non-catecholamine. No titration typically. Can spare NE dose.¹
Epinephrine ⓘ	0.01–1 mcg/kg/min IV	α + β agonist. Use in anaphylaxis, cardiac arrest, refractory shock. Causes lactic acidosis.^1,7
Phenylephrine (Neo-Synephrine) ⓘ	0.5–6 mcg/kg/min IV	Pure α₁ agonist. Increases SVR; can reduce CO. Preferred in tachyarrhythmias.^1,7
Dopamine ⓘ	2–20 mcg/kg/min IV	Low dose: DA₁ (renal); Mid: β₁ (inotropy); High: α₁ (vasoconstriction). Higher arrhythmia risk.^1,2
Angiotensin II (Giapreza) ⓘ	20–80 ng/kg/min IV	Adjunct in refractory vasodilatory shock. Raises DVT risk; VTE prophylaxis required.^3,7
Methylene Blue	1.5–2 mg/kg IV over 15–60 min; may repeat q4–6h (max 7 mg/kg/day)	Inhibits nitric oxide synthase and guanylyl cyclase — reverses pathological nitric oxide–mediated vasodilation (vasoplegic shock). Used in post-cardiac surgery vasoplegia, anaphylactic shock refractory to epinephrine, and septic shock refractory to catecholamines. Contraindicated in G6PD deficiency (hemolytic anemia risk) and severe renal failure. Turns urine/secretions blue — benign. Avoid concurrent serotonergic agents (serotonin syndrome risk).^7,8

SOURCES
¹ Evans L et al (SSC). Crit Care Med. 2021;49(11):e1063-e1143 ² De Backer D et al. N Engl J Med. 2010;362(9):779-89 ³ Khanna A et al (ATHOS-3). N Engl J Med. 2017;377(5):419-430 ⁴ Devlin JW et al (PADIS). Crit Care Med. 2018;46(9):e825-e873 ⁵ Papazian L et al (ACURASYS). N Engl J Med. 2010;363(12):1107-16 ⁶ January CT et al. J Am Coll Cardiol. 2014;64(21):e1-e76 ⁷ Lexicomp Online. Critical care drug monographs. Wolters Kluwer; 2025 ⁸ AHFS Drug Information 2025. American Society of Health-System Pharmacists

INOTROPES

DRUG	USUAL DOSE RANGE	NOTES / PEARLS
Dobutamine	2.5–20 mcg/kg/min IV	β₁ > β₂ agonist. Increases CO/CI. May cause hypotension and tachycardia. No renal dose adj.^7,8
Milrinone	0.375–0.75 mcg/kg/min IV	PDE-3 inhibitor. Inodilator. Long half-life (~2h). Optional load: 50 mcg/kg IV over 10 min (often omitted to reduce hypotension risk). Renal dose reduction required (CrCl <50: reduce 50%). Avoid in cardiogenic shock without adequate filling pressures. Note: DOREMI trial (2019) showed no significant difference in outcomes vs. dobutamine in cardiogenic shock — use per clinical context.^7,8
Isoproterenol (Isuprel)	2–20 mcg/min IV	Non-selective β₁/β₂ agonist. Chronotropic and inotropic; lowers SVR (vasodilation). Used for symptomatic bradycardia/AV block (bridge to pacing), drug-induced bradycardia (β-blocker/CCB OD), Brugada syndrome, electrical storm. Potent arrhythmogen — monitor continuously. Use lowest effective dose.^7,8

ANTIARRHYTHMIC DRIPS

DRUG	LOADING / MAINTENANCE	NOTES / PEARLS
Amiodarone	Load: 150 mg over 10 min; Maint: 1 mg/min × 6h, then 0.5 mg/min × 18h	Wide-complex & narrow-complex tachyarrhythmias. Monitor LFTs, TFTs, PFTs long-term.^6,7
Lidocaine	Load: 1–1.5 mg/kg; Maint: 1–4 mg/min IV	Ventricular arrhythmias. Hepatically metabolized — reduce dose in liver failure or low CO.^7,8
Procainamide	Load: 20–50 mg/min (max 17 mg/kg); Maint: 1–4 mg/min	WPW, AF, stable VT. Monitor BP during load. Renal adjustment required. Monitor QTc.^6,7
Diltiazem	Load: 0.25 mg/kg IV; Maint: 5–15 mg/hr	Rate control in AF/AFl. Avoid in HFrEF < 40%, WPW. Non-dihydropyridine CCB.^6,7
Esmolol	Load: 500 mcg/kg over 1 min; Maint: 50–300 mcg/kg/min	Ultra-short-acting β₁ blocker. Rapid on/off. SVT, AF rate control, perioperative HTN.^7,8
Ibutilide (Corvert)	1 mg IV over 10 min; may repeat ×1 if no conversion after 10 min (max 2 mg)	Class III antiarrhythmic. Acute termination of recent-onset AF/AFl (≤90 days). Monitor QTc continuously for ≥4 h post-dose — TdP risk (3–8%). Contraindicated if QTc > 440 ms, hypokalemia, hypomagnesemia. Correct electrolytes prior. Resuscitation equipment must be available.^6,7

ANTIHYPERTENSIVE DRIPS

DRUG	DOSE RANGE	NOTES / PEARLS
Nicardipine (Cardene)	Start 5 mg/hr; titrate 2.5 mg/hr q5–15 min; max 15 mg/hr	Dihydropyridine CCB. Preferred IV antihypertensive for most hypertensive emergencies (ischemic stroke, hypertensive encephalopathy, perioperative). Predictable, titratable. Reflex tachycardia possible. No cyanide toxicity. Phlebitis risk at peripheral IV — central line preferred for prolonged use.^7,8,13
Clevidipine (Cleviprex)	Start 1–2 mg/hr; double q90 sec until target; typical maint 4–6 mg/hr; max 16–21 mg/hr (formulary-dependent)	Ultra-short-acting dihydropyridine CCB. Rapid onset/offset. Metabolized by plasma esterases — organ-independent; no dose adj for renal/hepatic failure. Contains lipid emulsion (1.5 kcal/mL) — monitor triglycerides if >24h. Maximum IV fat limit: 3.2 mL/kg/day of 20% lipid from all sources.^7,8,13
Nitroglycerin (NTG)	5–200 mcg/min IV; start 5 mcg/min, titrate q3–5 min	Primary vasodilator (venous > arterial). Preferred in hypertensive emergency with acute coronary syndrome, acute pulmonary edema, or HF. Reflex tachycardia; tolerance develops with >24h continuous use (mitigate with nitrate-free interval). Adsorbs to PVC tubing — use non-PVC/non-DEHP tubing. Severe headache common. Contraindicated with PDE-5 inhibitors (sildenafil, tadalafil — fatal hypotension).^7,8
Labetalol	Bolus: 20 mg IV over 2 min, then 40–80 mg q10 min (max 300 mg); Infusion: 0.5–2 mg/min IV	Combined α₁ + β₁/β₂ blocker (α:β ratio ≈ 1:7 IV). Preferred in aortic dissection (with esmolol), hypertensive emergency in cocaine OD, pregnancy (eclampsia). Avoid in decompensated HFrEF, bradycardia, reactive airway disease. Onset 5 min; duration 3–6h.^7,8,13
Esmolol	Load: 500 mcg/kg over 1 min; Maint: 50–300 mcg/kg/min	Ultra-short-acting cardioselective β₁ blocker. Preferred for aortic dissection (first drug given to reduce dP/dt before vasodilator), perioperative HTN, AF rate control. Half-life ~9 min. Safe to use and stop rapidly if BP drops too far.^7,8
Sodium Nitroprusside (SNP)	0.3–0.5 mcg/kg/min (start); max 10 mcg/kg/min; limit high-dose use to <10 min	Potent arterial and venous vasodilator. Metabolized to cyanide → thiocyanate. Cyanide toxicity risk with high doses (>4 mcg/kg/min), prolonged use (>24–48h), or hepatic failure. Signs: metabolic acidosis, elevated lactate, hemodynamic instability. Tx: hydroxocobalamin or sodium thiosulfate. Protect from light (wrap bag). Coronary steal possible — caution in CAD. Increased ICP — avoid in neuro emergencies. Use nicardipine or clevidipine preferentially.^7,8,13
Hydralazine	10–20 mg IV q4–6h PRN (intermittent bolus; not typically a continuous infusion)	Direct arteriolar vasodilator. Unpredictable and prolonged effect (variable half-life 3–7h); BP response difficult to titrate. Reflex tachycardia and fluid retention. Used primarily in pregnancy (eclampsia). Not preferred for continuous infusion in most ICU contexts — use nicardipine or clevidipine instead.^7,8
Phentolamine	Bolus: 1–5 mg IV; Infusion: 0.2–0.5 mg/min	Non-selective α-blocker. Used for pheochromocytoma crisis and cocaine-induced hypertension/coronary vasospasm. Reflex tachycardia (may require β-blockade). Short duration 15–30 min. Note: in cocaine toxicity, β-blockers alone are contraindicated (unopposed α-stimulation worsen hypertension).^7,8

SOURCES
⁷ Lexicomp Online. Critical care drug monographs. Wolters Kluwer; 2025 ⁸ AHFS Drug Information 2025. American Society of Health-System Pharmacists ¹³ Whelton PK et al (ACC/AHA HTN Guidelines). J Am Coll Cardiol. 2018;71(19):e127-e248 ¹⁴ Marik PE, Varon J. Hypertensive crises. Chest. 2007;131(6):1949-62

SEDATION & ANALGESIA DRIPS (ICU)

DRUG	USUAL DOSE RANGE	NOTES / PEARLS
Propofol ⓘ	5–80 mcg/kg/min IV	Sedative/hypnotic. Rapid onset/offset. Monitor triglycerides >48h. PRIS risk at high doses/prolonged use. 1.1 kcal/mL from lipid.^4,7
Dexmedetomidine (Precedex) ⓘ	0.2–1.5 mcg/kg/hr IV	α₂ agonist. Cooperative sedation; no resp. depression. Bradycardia/hypotension risk. Duration: 24h limitation removed from FDA label (2021); use beyond 24h in ICU acceptable per current labeling. Consider rebound hypertension/tachycardia on discontinuation after prolonged use.^4,7
Midazolam ⓘ	0.02–0.1 mg/kg/hr IV	Benzodiazepine sedation. Accumulates with prolonged use (active metabolite). Higher delirium risk. Renal adj.^4,7
Ketamine ⓘ	0.1–0.5 mg/kg/hr IV (analgesia); 1–4 mg/kg/hr (sedation)	Dissociative anesthetic. Bronchodilator. Preserves airway reflexes. Opioid-sparing. Raises BP/HR.^4,7
Fentanyl ⓘ	25–200 mcg/hr IV	First-line analgesia. Lipophilic — accumulates with renal failure. No histamine release.^4,7
Morphine ⓘ	2–10 mg/hr IV	Active metabolite (M6G) accumulates in renal failure. Histamine release — avoid in hemodynamic instability.^4,7
Hydromorphone (Dilaudid) ⓘ	0.2–1 mg/hr IV (titrate to effect)	Semisynthetic opioid; 5× more potent than morphine IV. No active metabolites of concern. Preferred over morphine in renal impairment. Less histamine release than morphine. Monitor for respiratory depression.^4,7
Remifentanil	0.025–0.2 mcg/kg/min IV (analgesia/sedation)	Ultra-short-acting synthetic opioid. Context-insensitive: rapidly metabolized by plasma esterases — offset <10 min regardless of infusion duration. Ideal where frequent neurologic assessments needed. High risk of acute opioid tolerance with prolonged infusion; abrupt discontinuation causes acute pain — transition plan required. No dose adjustment for renal/hepatic failure.^4,7
Lorazepam (Ativan) ⓘ	0.01–0.1 mg/kg/hr IV	Benzodiazepine. Propylene glycol vehicle in high doses — monitor osmol gap. Prolonged half-life in renal failure.^4,7

PARALYTICS / NMBA

DRUG	DOSE RANGE	NOTES / PEARLS
Cisatracurium ⓘ	0.5–10 mcg/kg/min IV; titrate to TOF	Preferred NMBA drip in ICU. Hofmann elimination — organ-independent. ACURASYS (2010) suggested benefit in P/F <150 ARDS; however ROSE trial (2019) showed no mortality benefit of early routine NMBA vs. light sedation in moderate-to-severe ARDS. Current SSC does not recommend routine NMBA for ARDS — use selectively (ventilator dyssynchrony, refractory hypoxemia, prone positioning). Monitor TOF: target 1–2 twitches of 4.^5,7,12
Vecuronium	0.8–1.2 mcg/kg/min IV; titrate to TOF	Intermediate-duration NMBA. Active metabolite accumulates in renal failure. Titrate to TOF 1–2/4.^7,8
Rocuronium ⓘ	10–12 mcg/kg/min IV; titrate to TOF	Reversible with sugammadex. Hepatically eliminated. Suitable for RSI (1.2 mg/kg bolus).^7,8
Pancuronium	0.8–1.7 mcg/kg/min IV; titrate to TOF	Long-acting NMBA. Active metabolite (3-OH pancuronium) accumulates in renal failure — avoid in renal impairment; use cisatracurium instead. Tachycardia and hypertension common (vagolytic, sympathomimetic effects). Low cost. Not recommended for routine ICU paralysis; reserved for specific situations.^7,8

PULMONARY & CARDIAC VASODILATORS

DRUG	DOSE RANGE	NOTES / PEARLS
Epoprostenol (Flolan / Veletri)	Initial: 2 ng/kg/min IV; titrate ↑ by 1–2 ng/kg/min q15 min; maintenance typically 20–40+ ng/kg/min	Prostacyclin (PGI₂) analog. Continuous IV infusion for WHO Group I PAH. Vasodilates pulmonary & systemic vasculature; inhibits platelet aggregation. Half-life ~3–5 min — NEVER abruptly discontinue (rebound PAH crisis). Requires dedicated IV line. Veletri is room-temperature stable; Flolan requires ice packs. Monitor for systemic hypotension, flushing, jaw pain, diarrhea.^9,10
Nesiritide (Natrecor)	Bolus: 2 mcg/kg IV; Infusion: 0.01 mcg/kg/min (range 0.005–0.03 mcg/kg/min)	Recombinant B-type natriuretic peptide (BNP). Used for acute decompensated HF (ADHF) to reduce PCWP and dyspnea. Arterial and venous vasodilation; promotes natriuresis. Hypotension is primary risk — avoid if SBP < 90 mmHg. No mortality benefit demonstrated (ASCEND-HF). Bolus may be omitted to reduce hypotension risk. Adjust or hold for SBP drops > 20 mmHg.^7,11

SOURCES
⁷ Lexicomp Online. Critical care drug monographs. Wolters Kluwer; 2025 ⁸ AHFS Drug Information 2025. American Society of Health-System Pharmacists ⁹ Humbert M et al (ESC/ERS PAH Guidelines 2022). Eur Heart J. 2022;43(38):3618-3731 ¹⁰ Sitbon O et al. N Engl J Med. 2015;373(26):2522-33 ¹¹ O'Connor CM et al (ASCEND-HF). N Engl J Med. 2011;365(1):32-43

RESPIRATORY STIMULANTS

DRUG	DOSE RANGE	NOTES / PEARLS
Doxapram (Dopram)	COPD/resp. failure: 1–2 mg/min IV infusion (max 3 mg/min; 3 g/day); Post-anesthetic: 0.5–1 mg/kg IV bolus or 5 mg/min infusion × 5 min	CNS and peripheral carotid chemoreceptor respiratory stimulant. Used as adjunct in COPD exacerbation with hypercapnic respiratory failure (when NIV unavailable/failed) and post-anesthetic respiratory depression. Stimulates tidal volume and respiratory rate. Contains benzyl alcohol — avoid in neonates. Contraindications: seizure disorders, severe hypertension, coronary artery disease, hyperthyroidism, mechanical airway obstruction. Monitor ABG, BP, HR. Limited evidence base in modern ICU practice.^7,8

SOURCES
⁷ Lexicomp Online. Critical care drug monographs. Wolters Kluwer; 2025 ⁸ AHFS Drug Information 2025. American Society of Health-System Pharmacists

DRIP DOSE RATE CALCULATOR mcg/kg/min ↔ mL/hr · mcg/min ↔ mL/hr · units/hr ↔ mL/hr

Converts between ordered weight-based or fixed dose rates and pump delivery rates given drug concentration. Verify all calculations with pharmacy and institutional protocols.

INPUTS

Dose Mode

Ordered Dose (mcg/kg/min)

Patient Weight (kg)

Drug Amount in Bag

Drug Amount Unit

Bag Volume (mL)

RESULT

⚠ Always verify pump rates with pharmacy and against your institution's concentration standards. Double-check weight-based calculations with a second clinician for high-alert medications (vasopressors, insulin, heparin, concentrated electrolytes).

COMMON STANDARD CONCENTRATIONS (verify with your formulary)

Drug	Typical Concentration	Example Bag
Norepinephrine	32–64 mcg/mL	8 mg / 250 mL = 32 mcg/mL
Vasopressin	0.4 units/mL	100 units / 250 mL NS
Epinephrine	16–32 mcg/mL	4 mg / 250 mL = 16 mcg/mL
Phenylephrine	200–400 mcg/mL	100 mg / 250 mL = 400 mcg/mL
Dopamine	1,600–3,200 mcg/mL	800 mg / 500 mL = 1,600 mcg/mL
Dobutamine	1,000–4,000 mcg/mL	1,000 mg / 250 mL = 4,000 mcg/mL
Milrinone	200 mcg/mL	200 mg / 1,000 mL (premix)
Nicardipine	0.1–0.2 mg/mL	25 mg / 250 mL = 0.1 mg/mL
Nitroglycerin	200–400 mcg/mL	50 mg / 250 mL = 200 mcg/mL
Sodium Nitroprusside	200–400 mcg/mL	50 mg / 250 mL = 200 mcg/mL
Propofol	10 mg/mL (1%)	200 mL vial, ready-to-use
Dexmedetomidine	4 mcg/mL	200 mcg / 50 mL = 4 mcg/mL
Cisatracurium	0.1–0.4 mg/mL	200 mg / 500 mL = 0.4 mg/mL

PHENYTOIN LEVEL CORRECTION CALCULATOR Winter‑Tozer formula · hypoalbuminemia & dialysis correction

INPUTS

Measured Phenytoin Level (mcg/mL)

Serum Albumin (g/dL)

Renal Status

Standard formula: Corrected = Measured ÷ (0.2 × Alb + 0.1)
Dialysis (HD): Corrected = Measured ÷ (0.1 × Alb + 0.1)
Target total range: 10–20 mcg/mL • Free: 1–2 mcg/mL

CORRECTED PHENYTOIN LEVEL

Enter level and albumin on the left.

SOURCES
¹ Winter ME. Basic Clinical Pharmacokinetics, 5th ed. Lippincott Williams & Wilkins; 2010 ² Winter MG et al. Neurology. 1988;38(Suppl 1):209 (albumin correction) ³ Patsalos PN et al. Epilepsia. 2018;59(8):1489-1521 (ILAE TDM consensus)

SITE-SPECIFIC POLICIES & PROTOCOLS Add your institution's drip protocols, titration guides, and clinical policies

e.g. Vasopressor Titration Protocol, Sedation Algorithm, Spontaneous Awakening Trial, MAP Goals

INSULIN DRIP PROTOCOLS — REFERENCE ICU Glycemic Control · DKA · HHS · TPN Glycemic Management

PROTOCOL / USE	DOSING / APPROACH	CLINICAL PEARLS & MONITORING
Regular Insulin ICU Glycemic Control	Std Conc: 1 unit/mL (100 units in 100 mL NS) Starting rate: glucose-based algorithm (institution-specific) Common starting range: 0.02–0.1 units/kg/hr Target glucose: 140–180 mg/dL (ICU per AACE/ADA); 110–140 mg/dL (surgical/cardiac — protocol-dependent)	Glucose monitoring: q1h until stable ×4h, then q2h. Tubing adsorption: Insulin binds to IV tubing/bag — prime line with 20–50 mL of insulin solution before connecting to patient. Hypoglycemia protocol: BG <70 mg/dL → D50W 25 mL IV; recheck in 15 min. Hold infusion; restart when BG >100 mg/dL or per protocol. Concurrent nutrition: Ensure continuous EN/PN or dextrose-containing IV while on drip — define a hold plan if feeds pause. Transition to SubQ: Overlap long-acting basal insulin 2h before stopping drip. TDD = last 6–8h rate ×24 ×0.7–0.8; split ~50% basal / 50% prandial.^1,5
Regular Insulin DKA Protocol	No-bolus (ADA preferred): 0.14 units/kg/hr Bolus method: 0.1 units/kg bolus → 0.1 units/kg/hr Add D5 to IVF when glucose <200–250 mg/dL — continue insulin until anion gap closes, not just glucose normalization Reduce rate ~50% if glucose drops >50–100 mg/dL/hr without gap closing	⚠ Check K+ BEFORE starting insulin — hold if K+ <3.5 mEq/L; replace IV first. Insulin drives K+ intracellularly — fatal arrhythmia risk if severely hypokalemic. Primary endpoint = anion gap closure (AG ≤12), not glucose. Monitor AG, bicarb, β-hydroxybutyrate q2–4h. Do NOT stop insulin if glucose dropping — add D5 to fluids instead. SubQ transition: Once AG closed + tolerating PO: give long-acting insulin (glargine/detemir), stop drip 1–2h later. Calculate new TDD from drip ×24 ×0.8 or confirm home regimen.^1,5
Regular Insulin HHS Protocol	Rate: 0.05 units/kg/hr (lower than DKA — fluid repletion is primary) Add D5 to IVF when glucose <250–300 mg/dL — continue until serum osmolality <310–315 mOsm/kg and mental status improves IVF: 1–1.5 L NS first hour → 0.45% NS at 200–500 mL/hr	Fluid is the primary treatment — glucose drops substantially with IVF alone before insulin is needed. Glucose correction rate: Target ~50–75 mg/dL/hr; faster drops risk cerebral edema. Calculated osmolality: 2×Na + BUN/2.8 + glucose/18; normalize gradually over 24–36h. K+ replacement: Same caution as DKA — total-body K+ depletion may be profound despite a normal serum level. SubQ transition: Same approach as DKA; most HHS patients will require initiation of a new insulin regimen at discharge.^1,2
Regular Insulin TPN Glycemic Management	Starting coverage: Add regular insulin to TPN bag (start ~0.1 units per gram dextrose in bag) Sliding scale supplement: Separate SubQ correction scale q6h Separate insulin drip: Preferred if BG persistently >180 mg/dL despite bag insulin; run separate 1 unit/mL drip while TPN infusing	Monitor BG q6h while on TPN; q1–2h if on concurrent insulin drip. Do not change insulin in TPN bag retroactively — only adjust the next compounded bag. Use separate drip for acute correction. If TPN is interrupted: Hang D10W at the same rate to prevent hypoglycemia if patient still on insulin. Target BG: 140–180 mg/dL in most TPN patients. Tighter control (110–140) in post-cardiac surgery or high-risk patients — use dedicated drip, not bag insulin.^3,4,5
Regular Insulin Acute Hyperkalemia	Insulin 10 units IV push + D50W 50 mL (25 g) IV over 5 min If BG > 250 mg/dL: omit dextrose (insulin only; BG will fall adequately) Onset: ~15–30 min; Duration: 4–6h K⁺ lowering: Expected 0.5–1.5 mEq/L reduction; repeat q4h PRN	Redistribution only — does NOT remove K⁺ from body. Always pair with definitive removal: loop diuretics (if urine output preserved), kayexalate/patiromer, or dialysis. Calcium gluconate first if ECG changes (peaked T, widened QRS, sine wave) — cardiac membrane stabilization before redistribution. Rebound hyperkalemia: Expected 4–6h after insulin wanes — re-check K⁺ + BG at 1h and 3–4h post-dose. Give extra D50W 25 mL if BG <70 mg/dL. Concurrent options: Sodium bicarbonate (if pH <7.2), albuterol 10–20 mg nebulized (additive K⁺ lowering via β₂ stimulation).^1,8
Regular Insulin Labor & Delivery / GDM	Target BG: 70–100 mg/dL (active labor); 80–110 mg/dL (antepartum) Starting rate: 0.5–1 unit/hr IV; titrate q1h BG Concurrent dextrose: D5LR or D5½NS at 100–125 mL/hr (prevents ketosis) Type 1 DM: Higher rates expected; D/C at delivery or immediately postpartum	Intrapartum glycemic control reduces neonatal hypoglycemia — fetal BG mirrors maternal; target maternal BG 70–100 mg/dL during active labor. Type 2 / GDM on oral agents: Hold metformin and glyburide during labor; switch to insulin drip per protocol. Postpartum GDM: Most patients do NOT require insulin after delivery — reassess fasting BG; perform 75 g OGTT at 6–12 weeks postpartum. Neonatal monitoring: Check neonatal BG at 1–2h of life per NBS protocol.^1,9
Regular Insulin Peri-operative Glycemic Control	Target BG: 140–180 mg/dL intra/post-op (cardiac surgery: 110–140 mg/dL per many protocols) Starting rate: Per institutional algorithm (e.g., Portland Protocol, Yale Protocol) Usual range: 0.5–5 units/hr; adjust per q1h BG	Peri-op hyperglycemia is associated with increased SSI risk, delayed wound healing, and longer LOS. Treat BG >180 mg/dL in all surgical patients regardless of diabetes history. NPO status: Do not hold insulin drip when patient is NPO — reduce rate if BG falling, do not stop. Start D5W or D10W if needed. Post-op transition: Restart home oral DM agents when eating; add basal insulin if not on pre-op regimen and BG persistently elevated.^1,5

SOURCES
¹ American Diabetes Association PPC. Diabetes Care. 2025;48(Suppl 1) [Section 16: Diabetes Care in the Hospital] ² Kitabchi AE et al. Diabetes Care. 2009;32(7):1335-43 ³ van den Berghe G et al. N Engl J Med. 2001;345(19):1359-67 ⁴ NICE-SUGAR Study Investigators. N Engl J Med. 2009;360(13):1283-97 ⁵ Jacobi J et al. Crit Care Med. 2012;40(12):3251-76 ⁶ Lexicomp Online. Insulin regular monograph. Wolters Kluwer; 2025 ⁷ AHFS Drug Information 2025. American Society of Health-System Pharmacists ⁸ Kovesdy CP. Epidemiology of hyperkalemia. Kidney Int Suppl. 2016;6(1):3-6; ACEP Clinical Policy: Hyperkalemia. Ann Emerg Med. 2020 ⁹ ACOG Practice Bulletin #190. Gestational Diabetes Mellitus. Obstet Gynecol. 2018;131(2):e49-e64

MONITORING PARAMETERS — INSULIN DRIP

PARAMETER	FREQUENCY / TARGET	CLINICAL NOTES
Blood Glucose	q1h until stable ×4h → q2h Target: 140–180 mg/dL (ICU)	Use consistent site (fingerstick vs. ABG glucose — document method). Discrepancy >50 mg/dL between POC and lab — use lab value. Critical Care: ABG glucose preferred in hypoperfused states (peripheral POC unreliable).^1,5
Potassium (K+)	q2–4h in DKA/HHS q4–6h in stable ICU Target: 3.5–5.0 mEq/L	Insulin drives K+ intracellularly — K+ will fall. Replace IV if <3.5 mEq/L and hold insulin drip if K+ <3.3 mEq/L (DKA). Check before initiating and every few hours while on drip.^1,2
Sodium (Na+)	q4–6h in DKA/HHS Daily in stable glycemic control	Corrected Na+ in hyperglycemia: add 1.6–2.4 mEq/L per 100 mg/dL glucose above 100 (classic Katz formula: 1.6; updated Hillier et al. JAMA 1999: 2.4 mEq/L preferred in DKA/HHS for accuracy). In HHS, monitor for rapid sodium normalization — goal gradual correction over 24–36h.^1,2
Anion Gap / Bicarb / β-OHB	q2–4h until closed (DKA) Not needed in ICU glycemic control	DKA endpoint is AG closure (≤12), not glucose normalization. β-hydroxybutyrate <0.6 mmol/L = resolution. Do not stop insulin early based on glucose alone — transition to SubQ requires AG closure + tolerating PO.^1,2
Serum Osmolality	q2–4h in HHS until <315 mOsm/kg	HHS: Calculated osmolality = 2×Na + BUN/2.8 + glucose/18 (normal: 285–295). Mental status improvement correlates with osmolality normalization, not glucose alone. Correct gradually over 24–36h.^1,2
Phosphate (PO₄)	q4–6h in DKA; daily in ICU	Insulin drives phosphate intracellularly — phosphate depletion is common in DKA. Replace if symptomatic or <1.0 mg/dL. Severe hypophosphatemia can cause respiratory muscle weakness.^1,2
BUN / Creatinine	Daily	Renal function affects fluid resuscitation strategy and SubQ insulin dosing at transition. Elevated BUN in HHS (pre-renal) improves with fluid repletion.^1,2
Feeding Status / Rate	Each shift / infusion rate change	Insulin requirements change with feeding status. If EN/PN held: reduce drip rate 50% (or per protocol); consider D10W to avoid hypoglycemia. Restart drip titration when feeds resume.^1,5

SOURCES
¹ American Diabetes Association PPC. Diabetes Care. 2025;48(Suppl 1) [Section 16: Diabetes Care in the Hospital] ² Kitabchi AE et al. Diabetes Care. 2009;32(7):1335-43 ³ van den Berghe G et al. N Engl J Med. 2001;345(19):1359-67 ⁴ NICE-SUGAR Study Investigators. N Engl J Med. 2009;360(13):1283-97 ⁵ Jacobi J et al. Crit Care Med. 2012;40(12):3251-76 ⁶ Lexicomp Online. Insulin regular monograph. Wolters Kluwer; 2025 ⁷ AHFS Drug Information 2025. American Society of Health-System Pharmacists ⁸ Evans L et al. Surviving Sepsis Campaign 2021. Crit Care Med. 2021;49(11):e1063-e1143 (glycemic target: 144–180 mg/dL)

SubQ INSULIN TRANSITION — REFERENCE CALCULATIONS

TRANSITION TYPE	CALCULATION METHOD	NOTES / TIMING
ICU Glycemic Control	TDD = (avg rate last 6–8h) × 24 × 0.7–0.8 Basal: ~50% TDD (glargine or detemir once or twice daily) Prandial: ~50% TDD ÷ 3 meals (lispro/aspart/glulisine)	Give long-acting insulin 2h before stopping drip. Multiply by 0.7 in renally impaired or older patients. Use 0.8 in well-controlled, lower-risk patients.^1,5
DKA	TDD = drip rate at time of transition × 24 × 0.8 New to insulin: start glargine 0.2–0.3 units/kg/day + correction scale Established regimen: restart home regimen	Criteria before transitioning: AG closed (≤12), bicarb ≥18, patient tolerating PO. Overlap long-acting 1–2h before stopping drip.^1,2
HHS	Same as ICU glycemic control calculation Most type 2 DM: likely new insulin initiation at discharge	HHS resolution: Osm <315 mOsm/kg, glucose <300, mental status normal. Many HHS patients had subtherapeutic home DM regimen — reassess outpatient management at discharge.^1,2

SubQ INSULIN TRANSITION CALCULATOR Drip‑to‑SubQ conversion · TDD estimation · Basal/Prandial split

DRIP INPUTS

Rate Entry Method

Average Drip Rate (units/hr)

Reduction Factor

Meals per Day

SubQ TRANSITION RESULTS

Enter drip rate on the left to calculate.

SOURCES
¹ American Diabetes Association PPC. Diabetes Care. 2025;48(Suppl 1) [Section 16: Diabetes Care in the Hospital] ² Jacobi J et al. Crit Care Med. 2012;40(12):3251-76 (SCCM insulin infusion guideline for glycemic management in critically ill patients) ³ Dungan K et al. Endocr Pract. 2012;18(Suppl 2):1-82 (AACE/ADA inpatient glycemic control consensus)

SITE-SPECIFIC INSULIN DRIP PROTOCOLS & POLICIES Add your institution's insulin drip protocols, glycemic targets, and titration algorithms

e.g. ICU Insulin Protocol, DKA Titration Algorithm, Peri-op Glucose Targets, SubQ Transition Criteria

CARDIAC GLYCOSIDES & ANTIARRHYTHMIC MONITORINGDigoxin · Oral Amiodarone chronic monitoring

DRUG	THERAPEUTIC RANGE	TOXIC LEVEL	DRAW TIMING	NOTES / PEARLS
Digoxin	0.5–0.9 ng/mL (HF) 0.5–2.0 ng/mL (AF)	> 2.0 ng/mL	≥ 6h post-dose (trough preferred)	Renally cleared; narrow TI. Hypokalemia/hypomagnesemia potentiate toxicity. Signs: nausea, visual changes, bradycardia.^1,2,3,4
Amiodarone (oral, chronic)	1.0–2.5 mcg/mL (amiodarone) DEA metabolite: 0.5–1.5 mcg/mL Levels rarely guide dosing; organ monitoring is primary	> 2.5 mcg/mL (clinical toxicity correlation poor)	Trough (any consistent time — SS takes 3–6+ months; t½†40–55 days)	Organ function monitoring is the clinical standard — serum levels have poor correlation with toxicity or efficacy: TFTs (TSH + free T4) q6 months — both hypo- and hyperthyroidism occur; amiodarone contains ~37% iodine by weight. LFTs q6 months — hepatotoxicity (transaminase elevation, cirrhosis with chronic use). PFTs + CXR at baseline then annually (or with new respiratory sx) — pulmonary toxicity risk ~2–17% with long-term use. Corneal microdeposits — virtually universal; vision loss only with very high doses. QTc at baseline, 1–4 weeks after loading, then periodically — correct K⁺ + Mg²⁺. Major DDIs: Warfarin (CYP2C9/3A4 inhibition — INR doubles; reduce warfarin dose ~30–50%); Digoxin (↑ levels ~70%); Statins (myopathy risk).^1,3,4,5,6

SOURCES
¹ Rathore SS et al. Ann Intern Med. 2003;138(8):620-8 (optimal digoxin range) ² The Digitalis Investigation Group. N Engl J Med. 1997;336(8):525-33 (DIG trial) ³ Lexicomp Online. Digoxin monograph. Wolters Kluwer; 2025 ⁴ AHFS Drug Information 2025. American Society of Health-System Pharmacists ⁵ Zimetbaum P. Amiodarone for Atrial Fibrillation. N Engl J Med. 2007;356(9):935-941 ⁶ January CT et al. 2019 AHA/ACC/HRS Focused Update. Circulation. 2019;140(2):e125-e151

ANTICONVULSANTS

DRUG	THERAPEUTIC RANGE	TOXIC LEVEL	DRAW TIMING	NOTES / PEARLS
Phenytoin	10–20 mcg/mL (total) 1–2 mcg/mL (free)	> 20 mcg/mL (total)	Trough (before next dose)	Highly protein-bound; correct for albumin/renal disease. Corrected phenytoin = measured / (0.2 × albumin + 0.1). Non-linear (Michaelis-Menten) kinetics — small dose increases can cause disproportionate level rises.^1,2,3,4
Fosphenytoin	10–20 mcg/mL (phenytoin equiv, total)	> 20 mcg/mL	Draw ≥ 2h after IV or ≥ 4h after IM (complete conversion to phenytoin)	Pro-drug of phenytoin — interpret levels as phenytoin equivalents. Same albumin correction applies. Monitor for infusion-site burning, cardiovascular effects (rate-dependent). Can give IM (unlike phenytoin).^1,2,3,4
Carbamazepine	4–12 mcg/mL	> 12 mcg/mL	Trough (before next dose)	CYP3A4/1A2 inducer — many DDIs. Autoinduction: levels drop ~30–50% after 3–4 weeks. Hyponatremia (SIADH — monitor Na). Monitor CBC (aplastic anemia, agranulocytosis — rare but serious); HLA-B*1502 screening before use (SJS risk in Asian populations).^1,2,3,4
Valproic Acid	50–100 mcg/mL	> 150 mcg/mL	Trough	Inhibits CYP2C9/glucuronidation — increases lamotrigine/phenobarbital levels. Monitor LFTs (hepatotoxicity, fatal in children <2 on polytherapy), ammonia (encephalopathy), CBC (thrombocytopenia). Teratogenic (neural tube — contraindicated in pregnancy where alternatives exist). Highly protein-bound.^1,2,3,4
Lamotrigine	3–15 mcg/mL	> 15 mcg/mL (↑ SJS risk)	Trough	Slow titration essential — SJS/TEN risk with rapid escalation. Valproate doubles levels (inhibits glucuronidation); enzyme inducers halve levels. Half-life varies 13–70h depending on DDI. Monitor for rash and fever during titration.^1,2,3,4
Phenobarbital	15–40 mcg/mL	> 40 mcg/mL	Trough	CYP inducer (broad). Long half-life ~100h. Sedation, tolerance, dependence — taper slowly to avoid withdrawal seizures. Respiratory depression in overdose.^1,2,3,4
Levetiracetam	20–40 mcg/mL	> 40 mcg/mL (limited data)	Trough	Renally cleared — dose-adjust when CrCl <80 mL/min. Few DDIs (minimal CYP involvement). Behavioral/psychiatric side effects common (irritability, depression). Routine TDM less established than older agents — monitor in renal impairment, adherence concern, or toxicity.^1,2,3,4
Oxcarbazepine	12–35 mcg/mL (MHD active metabolite)	> 35 mcg/mL	Trough (measure MHD/monohydroxyderivative)	Hyponatremia more common than with carbamazepine (monitor Na regularly — risk increases with age, diuretics, SIADH). Weaker CYP inducer than CBZ. Cross-reactivity with CBZ allergy ~25%. Dose-adjust in renal impairment (CrCl <30).^1,2,3,4

SOURCES
¹ Patsalos PN et al. Epilepsia. 2018;59(8):1489-1521 (TDM consensus guideline) ² Glauser T et al. Epilepsia. 2013;54(3):551-563 (AAN/AES treatment guideline) ³ Lexicomp Online. Anticonvulsant monographs. Wolters Kluwer; 2025 ⁴ AHFS Drug Information 2025. American Society of Health-System Pharmacists

TRANSPLANT IMMUNOSUPPRESSANTS

DRUG	THERAPEUTIC RANGE (trough)	TOXIC LEVEL	DRAW TIMING	NOTES / PEARLS
Tacrolimus (FK506)	5–15 ng/mL (varies by organ/time post-Tx; kidney 8–12 early, 5–8 maintenance)	Protocol-dependent; >20 ng/mL — high toxicity risk	Trough (30 min before AM dose)	Nephrotoxic, neurotoxic. CYP3A4 substrate — azoles/macrolides ↑ levels (major DDIs). Monitor SCr, K⁺, Mg²⁺, glucose (new-onset DM post-transplant), BP. Whole-blood LCMS preferred. Narrow TI; intra-patient variability important.^1,3,4
Cyclosporine	100–300 ng/mL trough (C0); or C2 1000–1400 ng/mL (varies by indication)	Protocol-dependent; >350 trough — nephrotoxicity risk	Trough (C0) or 2h post-dose (C2); consistent timing critical	Nephrotoxic, hypertensive. CYP3A4 substrate — grapefruit interaction. Monitor SCr, BP, LFTs, K⁺, Mg²⁺, uric acid. Differentiate nephrotoxicity from rejection (may need biopsy). Inhibits CYP3A4/P-gp — affects many co-medications.^2,3,4
Sirolimus	5–15 ng/mL (renal Tx); 12–20 ng/mL with cyclosporine minimization	> 15–20 ng/mL (protocol-dependent)	Trough (24–48h post-dose for loading; steady-state ~5–7 days)	mTOR inhibitor — not nephrotoxic alone but impairs wound healing (hold peri-operatively). Hyperlipidemia (monitor lipids), thrombocytopenia, anemia. Interstitial pneumonitis (rare but serious). CYP3A4 substrate. Oral ulcers common.^3,4
Everolimus	3–8 ng/mL (with CNI minimization); 6–10 ng/mL (with low-exposure CsA)	> 12 ng/mL (↑ toxicity risk)	Trough (before next dose; steady-state ~4–5 days)	mTOR inhibitor — similar profile to sirolimus. Used for renal/liver Tx and oncology (breast, RCC, PNET). Monitor CBC (thrombocytopenia), lipids, glucose, SCr, LFTs. Non-infectious pneumonitis risk. CYP3A4 substrate — azoles markedly increase levels.^3,4
Mycophenolate Mofetil	1–3.5 mg·h/L (AUC₀₋₁₂h); trough 1–3.5 mg/L (less validated)	AUC > 60 mg·h/L — GI/hematologic toxicity	AUC by limited sampling (0, 0.5, 2h post-dose per protocol) — routine TDM not universal	Monitor CBC (leukopenia, anemia, thrombocytopenia — hold if WBC <2.5). GI toxicity (N/V/D) common; enteric-coated formulation better tolerated. Teratogenic — strict contraception required. Proton pump inhibitors may ↓ absorption. Level monitoring most useful in rejection/toxicity workup.^3,4

SOURCES
¹ Staatz CE & Tett SE. Clin Pharmacokinet. 2010;49(2):95-122 (Tacrolimus TDM) ² Le Meur Y et al. Clin Biochem. 2007;40(5-6):328-36 (Cyclosporine C2 monitoring) ³ Lexicomp Online. Immunosuppressant monographs. Wolters Kluwer; 2025 ⁴ AHFS Drug Information 2025. American Society of Health-System Pharmacists ⁵ KDIGO 2022 CPG for CKD in Kidney Transplant Recipients. Kidney Int.ant Recipients. Kidney Int. 2022;101(4S):S1-S272

PSYCHIATRIC AGENTS

DRUG	THERAPEUTIC RANGE	TOXIC LEVEL	DRAW TIMING	NOTES / PEARLS
Lithium	0.6–1.2 mEq/L (acute) 0.4–0.8 mEq/L (maintenance)	> 1.5 mEq/L (early tox) > 2.0 (severe)	Trough (12h post-dose)	Renally excreted — Na⁺-depleting diuretics and NSAIDs raise levels; thiazides increase 30–50%. Monitor SCr, TSH (hypothyroidism common with long-term use). Dehydration/sodium depletion are major risk factors for toxicity. Toxicity signs: tremor, ataxia, confusion, AMS.^1,2,3,4
Clozapine	350–600 ng/mL	> 600 ng/mL (seizure risk)	Trough (before AM dose)	Agranulocytosis — ANC monitoring mandatory (REMS program; weekly × 6 months, then bi-weekly). CYP1A2 substrate — smoking cessation sharply raises levels. Metabolic syndrome, orthostatic hypotension, myocarditis (rare but fatal — monitor CRP/troponin in first month). QTc prolongation risk.^1,2,3,4
Nortriptyline	50–150 ng/mL	> 200 ng/mL	Trough (≥ 12h post-dose; steady-state 5–7 days)	TCA — active metabolite of amitriptyline. Monitor QTc (⚡ risk). Anticholinergic: dry mouth, constipation, urinary retention. Sedation, orthostatic hypotension. CYP2D6 substrate — poor/ultrarapid metabolizers have markedly different levels. Lethal in overdose.^1,2,3,4
Desipramine	100–300 ng/mL	> 400 ng/mL	Trough (≥ 12h post-dose)	TCA — active metabolite of imipramine; least sedating TCA. QTc prolongation risk (⚡). CYP2D6 substrate. Cardiac conduction effects (widen QRS at toxic levels). Monitor ECG. Lethal in overdose — narrow therapeutic window.^1,2,3,4
Haloperidol	5–17 ng/mL	> 20 ng/mL (↑ EPS/TD risk)	Trough (12h post-dose)	Typical antipsychotic — high D2 blockade. EPS (acute dystonia, akathisia, parkinsonism), tardive dyskinesia with long-term use. QTc prolongation (especially IV route and high doses). Monitor ECG. CYP3A4/CYP2D6 substrate.^1,2,3,4

SOURCES
¹ Hiemke C et al. Pharmacopsychiatry. 2018;51(1-2):9-62 (AGNP TDM consensus) ² Stahl SM. Stahl's Essential Psychopharmacology. 5th ed. Cambridge Univ Press; 2021 ³ Lexicomp Online. Psychiatric drug monographs. Wolters Kluwer; 2025 ⁴ AHFS Drug Information 2025. American Society of Health-System Pharmacists

BRONCHODILATORS

DRUG	THERAPEUTIC RANGE	TOXIC LEVEL	DRAW TIMING	NOTES / PEARLS
Theophylline	5–15 mcg/mL (asthma/COPD) 5–10 mcg/mL (neonatal apnea)	> 20 mcg/mL	Trough (before next dose)	CYP1A2 substrate — smoking cessation ↑ levels significantly; fluoroquinolones/macrolides also ↑ levels. Toxicity: seizures, arrhythmias, nausea. Non-linear kinetics in hepatic disease. Adjust for heart failure, cirrhosis, age, fever.^1,2,3,4
Aminophylline	5–15 mcg/mL (as theophylline)	> 20 mcg/mL	Trough; interpret as theophylline equivalent (aminophylline = 79% theophylline)	IV salt of theophylline; same monitoring, same toxicity profile. Monitor levels and report as theophylline. Rate of IV infusion critical — rapid bolus causes arrhythmias. Rarely used in adults; still occasionally used in neonatal apnea/COPD.^2,3,4

SOURCES
¹ Barnes PJ. Pharmacol Ther. 2013;137(1):142-152 (Theophylline pharmacology) ² Bauer LA. Applied Clinical Pharmacokinetics, 3rd ed. McGraw-Hill; 2014 ³ Lexicomp Online. Theophylline/Aminophylline monographs. Wolters Kluwer; 2025 ⁴ AHFS Drug Information 2025. American Society of Health-System Pharmacists

ANTINEOPLASTICS

DRUG	TARGET / MONITORING LEVEL	CONCERN LEVEL	DRAW TIMING	NOTES / PEARLS
Methotrexate (HD)	< 1 µmol/L at 24h; < 0.1 µmol/L at 48h	> 1 µmol/L at 48h	24h, 48h, 72h post-infusion	Requires leucovorin rescue. Adequate hydration and urine alkalinization essential. Renally excreted — hold NSAIDs, penicillins. Monitor CBC, SrCr, LFTs.^1,3,4
Busulfan	AUC target per protocol (900–1350 µmol·min/L)	Protocol-dependent	PK sampling per institution protocol	Used in HSCT conditioning. Highly variable PK — therapeutic drug monitoring (TDM) recommended. VOD/SOS risk.^3,4
Fluorouracil (5-FU)	AUC-based dosing: target AUC 20–25 mg·h/L (continuous infusion)	Myelosuppression; mucositis	CBC w/diff; optional PK-guided dosing (MyDose/Saladax)	DPD deficiency → severe toxicity (screen with DPYD genotype or UGT1A1). Standard BSA dosing is variable — PK-guided AUC dosing reduces toxicity. Monitor mucositis, hand-foot syndrome, cardiotoxicity (rare vasospasm).^3,4
Cyclophosphamide	No standard TDM; dose by BSA or AUC per protocol	Hemorrhagic cystitis; myelosuppression	CBC; UA; BMP; LFTs; urine specific gravity	Mesna uroprotection required at high doses (≥ 1 g/m²). Vigorous IV hydration essential. Monitor for SIADH/hyponatremia. CYP2B6 substrate — drug interactions possible. Cardiotoxicity at very high doses (HSCT conditioning).^3,4
Carboplatin	AUC-based dosing (Calvert formula): AUC 4–7 mg·mL⁻¹·min depending on regimen	Thrombocytopenia; nephrotoxicity	CrCl (Cockcroft-Gault or measured); CBC; BMP; Mg²⁺	Calvert formula: Dose (mg) = AUC × (GFR + 25). Use actual CrCl; avoid GFR capping in obese patients (overdosing risk). Monitor Mg²⁺ — hypomagnesemia common. Thrombocytopenia is dose-limiting toxicity. Cross-sensitivity with cisplatin possible.^2,3,4

SOURCES
¹ Joerger M. Onco Targets Ther. 2012;5:21-30 (High-dose MTX TDM) ² Calvert AH et al. J Clin Oncol. 1989;7(11):1748-56 (Carboplatin Calvert formula) ³ Lexicomp Online. Antineoplastic drug monographs. Wolters Kluwer; 2025 ⁴ AHFS Drug Information 2025. American Society of Health-System Pharmacists

THYROID AGENTS Levothyroxine and antithyroid monitoring parameters

Drug	Target / Therapeutic Range	Toxicity Threshold	Monitoring Frequency	Clinical Notes
Levothyroxine (T4)	TSH 0.4–4.0 mIU/L (standard); 0.1–2.5 mIU/L (pregnancy); Free T4 0.8–1.8 ng/dL	TSH < 0.1 (suppressed) → AF, osteoporosis risk; TSH > 10 → hypothyroid	TSH + Free T4 q6–8 weeks after dose change; annually once stable	Take on empty stomach, 30–60 min before breakfast. Separate from Ca²⁺, Fe, antacids by ≥ 4 h. Many DDIs (cholestyramine, PPIs, warfarin). In cardiac patients: start low (12.5–25 mcg), titrate slowly. Target TSH per indication (e.g., thyroid CA suppression: TSH < 0.1).^1,3,4
Methimazole	TSH within normal range; Free T4 normal; euthyroid state	Agranulocytosis (ANC < 500); hepatotoxicity	TFTs q4–8 weeks until stable; CBC at baseline and if fever/sore throat	First-line antithyroid drug (preferred over PTU except in 1st trimester/thyroid storm). Instruct patient to report fever/sore throat immediately — agranulocytosis can occur. Monitor LFTs. Teratogenic — avoid in 1st trimester; use PTU instead.^1,2,3,4
Propylthiouracil (PTU)	TSH within normal range; euthyroid state; Free T4 normal	Hepatotoxicity (rare fulminant); agranulocytosis; ANCA vasculitis	TFTs q4–8 weeks; LFTs baseline + if symptoms; CBC if fever	Reserved for 1st trimester pregnancy, thyroid storm, methimazole allergy. Black Box Warning: severe liver injury. Inhibits peripheral T4→T3 conversion (advantageous in thyroid storm). Shorter half-life — TID dosing required. Monitor for ANCA-associated vasculitis in long-term use.^2,3,4

SOURCES
¹ Garber JR et al. Thyroid. 2012;22(12):1200-1235 (ATA/AACE hypothyroid guideline) ² Ross DS et al. Thyroid. 2016;26(10):1343-1421 (ATA hyperthyroid guideline) ³ Lexicomp Online. Thyroid agent monographs. Wolters Kluwer; 2025 ⁴ AHFS Drug Information 2025. American Society of Health-System Pharmacists

COLONY-STIMULATING FACTORS (CSF) G-CSF & GM-CSF · hematologic response monitoring · no serum drug level — monitor WBC and ANC

MONITORING FRAMEWORK
CSF agents do not have a measurable serum drug level. Therapeutic response is assessed by hematologic recovery: ANC target > 1,500 cells/µL (G-CSF) or WBC < 20,000 cells/µL during active therapy (GM-CSF). Hold if WBC > 100 k/µL (G-CSF) to prevent leukostasis. Monitor CBC with differential daily during active therapy; bone pain is the most common side effect (managed with NSAIDs/acetaminophen). Splenomegaly and ARDS are rare but serious — report LUQ pain or respiratory deterioration promptly.

G-CSF — SHORT-ACTING (DAILY DOSING)

DRUG / BRAND	TYPE	STANDARD DOSE & ROUTE	RESPONSE TARGET / HOLD	MONITORING	NOTES / PEARLS
Filgrastim Neupogen · Reference	G-CSF Recombinant human	5 mcg/kg/day SubQ or IV 10 mcg/kg/day for PBSC mobilization	ANC target > 1,500/µL ⛔ Hold: WBC > 100 k/µL D/C when ANC ≥ 10,000/µL post-nadir (or per protocol)	CBC w/diff daily Platelets, LFTs, uric acid (mobilization)	Start 24–72h after chemo (not same day). Bone pain most common SE — NSAIDs/acetaminophen. Splenomegaly (rare — assess by palpation). ARDS reported rarely. Avoid if AML/CML (may accelerate blasts). Sickle cell: risk of splenic sequestration crisis.^1,2,3,4
Tbo-filgrastim Granix · Biosimilar-like	G-CSF Biosimilar	5 mcg/kg/day SubQ	ANC target > 1,500/µL ⛔ Hold: WBC > 100 k/µL	CBC w/diff daily	Biosimilar to filgrastim — comparable efficacy and safety. Approved for myelosuppressive chemo-induced neutropenia prophylaxis. SubQ only (no IV formulation approved). Same monitoring parameters and hold criteria as filgrastim.^1,3,4
Filgrastim-aafi Nivestym · Biosimilar	G-CSF FDA Biosimilar	5 mcg/kg/day SubQ or IV 10 mcg/kg/day (PBSC mobilization)	ANC target > 1,500/µL ⛔ Hold: WBC > 100 k/µL	CBC w/diff daily	FDA-approved biosimilar to Neupogen (filgrastim). All approved indications of reference product. Interchangeable per FDA designation — verify institutional formulary status. Same dosing and monitoring as reference filgrastim.^1,3,4
Filgrastim-ayow Nyvepria · Biosimilar	G-CSF Long-acting PEGylated biosimilar	6 mg SubQ Once per chemo cycle	ANC target > 1,500/µL ⛔ Hold: WBC > 100 k/µL Do not give within 14 days before next chemo	CBC w/diff per cycle	PEGylated biosimilar to pegfilgrastim (Neulasta). FDA-approved; single dose per cycle. Administer 24h after chemotherapy. Do not administer between 14 days before and 24h after cytotoxic chemo.^1,3,4

G-CSF — LONG-ACTING · PEGYLATED (ONCE PER CYCLE)

DRUG / BRAND	TYPE	STANDARD DOSE & ROUTE	RESPONSE TARGET / HOLD	MONITORING	NOTES / PEARLS
Pegfilgrastim Neulasta · Reference	PEGylated G-CSF Long-acting	6 mg SubQ Once per chemo cycle (day after chemo)	ANC target > 1,500/µL ⛔ Hold: WBC > 100 k/µL Do not give ≤ 14 days before next chemo or same day as chemo	CBC w/diff per cycle LFTs, uric acid if mobilization	Reference long-acting G-CSF. PEG extends half-life — sustained neutrophil recovery over full chemotherapy cycle. On-body injector (Onpro) delivers ~27h after activation. Bone pain and splenomegaly risk same as filgrastim. ARDS rare but serious — monitor respiratory status. Pediatric dosing by weight (<10 kg: 0.1 mg/kg; 10–20 kg: 1.5 mg; 21–30 kg: 2.5 mg; 31–44 kg: 4 mg; ≥45 kg: 6 mg).^1,2,3,4
Pegfilgrastim-bmez Ziextenzo · Biosimilar	PEGylated G-CSF FDA Biosimilar	6 mg SubQ once per cycle	ANC target > 1,500/µL ⛔ Hold: WBC > 100 k/µL Not within 14 days before next chemo	CBC w/diff per cycle	FDA-approved biosimilar to Neulasta. All approved indications of reference product. Administer ≥ 24h after chemo. Same dosing, monitoring, and hold criteria as reference pegfilgrastim. Verify formulary interchangeability status at your institution.^1,3,4
Pegfilgrastim-cbqv Udenyca · Biosimilar	PEGylated G-CSF FDA Biosimilar	6 mg SubQ once per cycle	ANC target > 1,500/µL ⛔ Hold: WBC > 100 k/µL Not within 14 days before next chemo	CBC w/diff per cycle	FDA-approved biosimilar to Neulasta. On-body injector also available (Udenyca Onbody). Same clinical parameters as reference product. Administer ≥ 24h after cytotoxic chemotherapy — do not administer on the same day as chemotherapy.^1,3,4
Pegfilgrastim-jmdb Fulphila · Biosimilar	PEGylated G-CSF First FDA Biosimilar	6 mg SubQ once per cycle	ANC target > 1,500/µL ⛔ Hold: WBC > 100 k/µL Not within 14 days before next chemo	CBC w/diff per cycle	First FDA-approved biosimilar to Neulasta (2018). All reference product indications. Administer ≥ 24h after chemo. Same dosing and monitoring as reference pegfilgrastim. Single-dose prefilled syringe.^1,3,4
Lipegfilgrastim Lonquex · EMA Approved	GlycoPEGylated G-CSF Long-acting	6 mg SubQ Once per cycle (day 2 of cycle, 24h post-chemo)	ANC target > 1,500/µL ⛔ Hold: WBC > 100 k/µL	CBC w/diff per cycle	Not FDA-approved — EMA-approved for use in Europe. GlycoPEGylated (different modification from Neulasta). Clinical profile similar to pegfilgrastim. Monitor per same criteria if used off-label in US or in international practice. Verify regulatory status before clinical use.^2,3,4

GM-CSF — GRANULOCYTE-MACROPHAGE COLONY-STIMULATING FACTOR

DRUG / BRAND	TYPE	STANDARD DOSE & ROUTE	RESPONSE TARGET / HOLD	MONITORING	NOTES / PEARLS
Sargramostim Leukine · Reference	GM-CSF Recombinant human yeast-derived	250 mcg/m²/day IV over 2–4h or SubQ for some indications Post-HSCT: start day 0 or day +1 per protocol	ANC target > 1,500/µL × 3 consecutive days ⚠ WBC > 20,000 or ANC > 20,000 → reduce dose 50% or interrupt ⛔ Hold: WBC > 50,000 cells/µL	CBC w/diff twice weekly CMP (renal, hepatic) Fluid balance Vitals during IV infusion	Different from G-CSF: stimulates granulocytes, monocytes, macrophages, and eosinophils — broader cell stimulation. Higher incidence of side effects vs. filgrastim: fever, rigors, myalgias, edema, capillary leak syndrome, pleural/pericardial effusion. First-dose effect with IV: flushing, hypotension, tachycardia, hypoxia — monitor vitals for first 30–60 min. Monitor for fluid retention. Avoid within 24h of chemo or radiation. Contains benzyl alcohol — avoid in neonates.^1,2,3,4

KEY ADVERSE EFFECTS — CLASS SUMMARY

⚠ Bone Pain — most common G-CSF SE. Often managed with NSAIDs or acetaminophen; severe pain → dose reduction or loratadine pre-treatment (evidence-based).

⚠ Splenomegaly / Rupture — rare but serious. Assess for LUQ pain or fullness; splenic rupture reported. Discontinue if suspected.

⚠ ARDS — rare, potentially fatal. Monitor for dyspnea, hypoxia, fever, infiltrates. Discontinue CSF and provide supportive care.

⚠ Capillary Leak Syndrome — more common with sargramostim. Monitor BP, urine output, weight, peripheral edema.

⛔ Leukostasis Risk — WBC > 100 k/µL can cause pulmonary or CNS leukostasis. Hold G-CSF if WBC reaches this threshold.

Sickle Cell Disease — risk of severe sickle cell crisis; use with extreme caution only if clearly indicated.

SOURCES
¹ Lyman GH et al. J Clin Oncol. 2015;33(31):3570-3608 (ASCO G-CSF guideline) ² Klastersky J et al. J Clin Oncol. 2016;34(11):1187-1212 (ESMO/ASCO myeloid growth factors) ³ Lexicomp Online. Filgrastim/Pegfilgrastim monographs. Wolters Kluwer; 2025 ⁴ AHFS Drug Information 2025. American Society of Health-System Pharmacists

SITE-SPECIFIC POLICIES & PROTOCOLS Add your institution's NTI monitoring protocols, dosing policies, and clinical notes

e.g. Tacrolimus Monitoring Protocol, Digoxin Toxicity Management, Phenytoin Correction Formula

CORTICOSTEROID TAPER MONITORING PARAMETERS Drug-specific thresholds, monitoring frequency, and clinical pearls

Drug	Relative Potency (vs Hydrocortisone)	Key Monitoring	Toxicity / Safety Thresholds	Clinical Notes
Prednisone ⓘ	4× (anti-inflammatory); 0.8× mineralocorticoid	Glucose (esp. postprandial); BP; weight; K⁺; Na⁺; SCr; mood/psych sx; GI symptoms; AM cortisol if tapering long-term	Glucose > 180 mg/dL postprandial; BP > 140/90; K⁺ < 3.5; weight gain > 2 kg/week; GI bleeding sx	Most common oral steroid. Prodrug → active prednisolone. PUD prophylaxis (PPI or H2RA) for doses > 20 mg × > 4 weeks. Calcium + Vit D if prolonged use. Monitor for adrenal insufficiency when tapering (especially > 3 weeks duration). Insulin adjustments likely needed in diabetic patients.^1,3,4,5,6
Prednisolone ⓘ	4× (anti-inflammatory); 0.8× mineralocorticoid	Same as prednisone: glucose, BP, weight, K⁺, Na⁺, SCr, mood/psych sx, GI symptoms, AM cortisol	Same as prednisone	Active form — preferred in hepatic impairment (bypasses hepatic conversion). Liquid formulation available for dysphagia.^3,5,6
Methylprednisolone ⓘ	5× (anti-inflammatory); minimal mineralocorticoid	Glucose (more pronounced hyperglycemia); BP; weight; K⁺; Na⁺; SCr; mood/psych sx; GI symptoms; AM cortisol	Glucose > 200 mg/dL; significant fluid retention; dysphoria/psychosis; GI bleeding	High-dose pulse: 1 g IV × 3 days (MS, transplant rejection, severe COPD). Less mineralocorticoid activity → less sodium/water retention vs prednisone. IV to PO conversion: methylprednisolone 4 mg = prednisone 5 mg.^3,4,5,6
Dexamethasone ⓘ	25–30× (anti-inflammatory); negligible mineralocorticoid	Glucose (markedly elevated, esp. AM); BP; weight; K⁺; SCr; mood/psych sx (insomnia, psychosis); GI symptoms; AM cortisol	Glucose > 250 mg/dL (common); severe psychiatric sx; muscle weakness	Long half-life (36–54 h) — once or twice daily dosing. Used in oncology (premedication, brain mets), COVID-19, COPD, allergy. Very high potency → significant HPA axis suppression even at short courses. Negligible sodium retention. No AM cortisol check valid while on dexamethasone — wait 2 weeks post-taper.^1,3,5,6
Hydrocortisone ⓘ	1× (reference); 1× mineralocorticoid	Glucose; BP; Na⁺; K⁺; SCr; weight; edema; mood/psych sx; GI symptoms; AM cortisol (for stress dose tapering)	Na⁺ > 145 mEq/L; K⁺ < 3.5; SCr rising (fluid depletion); significant fluid retention	Used for adrenal insufficiency replacement (15–25 mg/day divided TID) and stress dosing (50–100 mg q8h). Highest mineralocorticoid activity → most fluid/sodium retention. Stress dose regimens should taper over 3–5 days unless primary AI.^1,2,3,5,6
Budesonide (systemic) ⓘ	~9× (but high first-pass → lower systemic effect)	Glucose (less pronounced); BP; K⁺; SCr; GI symptoms; AM cortisol if prolonged; LFTs (hepatic metabolism)	Same as prednisone but less frequent; still causes HPA suppression	Used in IBD (Crohn's, microscopic colitis, eosinophilic esophagitis). 90% first-pass metabolism → fewer systemic effects vs prednisone. NOT equivalent to oral prednisone for systemic conditions. Monitor LFTs — CYP3A4 substrate; azole antifungals dramatically increase levels.^3,5,6

SOURCES
¹ Liu D et al. Eur J Intern Med. 2013;24(3):186-196 (HPA suppression) ² Dinsen S et al. Eur J Intern Med. 2013;24(6):501-503 (Adrenal insufficiency) ³ Nieman LK. UpToDate: Glucocorticoid withdrawal. Accessed 2025 ⁴ Buttgereit F et al. Ann Rheum Dis. 2002;61(8):718-722 (Monitoring parameters) ⁵ Lexicomp Online. Corticosteroid monographs. Wolters Kluwer; 2025 ⁶ AHFS Drug Information 2025. American Society of Health-System Pharmacists ⁷ Poetker DM & Reh DD. Otolaryngol Clin North Am. 2010;43(4):753-768 (Corticosteroid adverse effects review)

ADRENAL SUPPRESSION & TAPER GUIDANCE HPA axis risk stratification and recommended taper approach

Scenario	Suppression Risk	Recommended Approach
Prednisone < 20 mg × < 3 weeks	Low — can abruptly stop	Abrupt discontinuation acceptable; no AM cortisol needed^1,3
Prednisone 20–40 mg × 3–4 weeks	Moderate	Taper by 25–50% per week; check AM cortisol at physiologic dose (prednisone 5 mg equivalent)^1,2,3
Any dose × > 1 month or Cushingoid features	High — assume suppression	Slow taper; check AM cortisol (target > 18 µg/dL before discontinuation); may need endocrine consult^1,2,3
Dexamethasone any dose × > 1 week	High	Convert to equivalent prednisone, then taper. Do NOT check AM cortisol while on dexamethasone (suppresses assay).^1,3,5
Stress dose — surgery / illness	Variable	Hydrocortisone 50–100 mg IV q8h × 1–3 days, then taper to maintenance or previous dose within 5 days^2,3,5

CORTICOSTEROID EQUIVALENCY CALCULATOR Convert between corticosteroids — anti-inflammatory equivalents only

DRUG

DOSE (mg)

SOURCES
¹ Liu D et al. Eur J Intern Med. 2013;24(3):186-196 (HPA suppression & equivalencies) ³ Nieman LK. UpToDate: Glucocorticoid withdrawal. Accessed 2025 ⁷ Poetker DM & Reh DD. Otolaryngol Clin North Am. 2010;43(4):753-768 (Corticosteroid adverse effects)

DOSE PACK TEMPLATES Configurable dosing templates that auto-populate the Steroid Taper enrollment form — includes standard Medrol Dose Pack

Select a template in the Steroid Taper enrollment form to auto-fill starting dose, taper schedule, route, and duration

SITE-SPECIFIC STEROID TAPER PROTOCOLS Add institution-specific steroid taper policies, diabetes management protocols, and osteoporosis prevention guidelines

e.g. Steroid-Induced Diabetes Protocol, HPA Axis Testing Policy, Osteoporosis Prevention Guideline

DIURETIC MONITORING PARAMETERS Drug-specific monitoring, electrolyte thresholds, and clinical pearls

Drug / Class	Mechanism	Key Monitoring	Toxicity Thresholds	Clinical Notes
LOOP DIURETICS
Furosemide (Lasix) ⓘ	Loop of Henle — Na⁺/K⁺/2Cl⁻ cotransporter inhibitor	K⁺, Na⁺, Mg²⁺, BUN, SCr, weight daily (inpatient); UO; BP; edema; hearing (high doses)	K⁺ < 3.0 (hold/replace); SCr ↑ > 0.5 mg/dL from baseline; UO < 0.5 mL/kg/h; hearing loss (ototoxicity)	PO:IV conversion = 2:1 (40 mg PO ≈ 20 mg IV). Ototoxicity with high IV doses (≥ 240 mg/dose) — infuse slowly (< 4 mg/min). Sulfonamide structure — caution in sulfur allergy. Thiazide combination (metolazone 30–60 min before) for diuretic resistance. Monitor for metabolic alkalosis.^1,4,5,6,7
Torsemide ⓘ	Same as furosemide	Same as furosemide	Same as furosemide; longer duration → more sustained diuresis	Higher PO bioavailability than furosemide (80–90% vs 50%). Better suited for CHF outpatients (more predictable absorption). No IV:PO conversion needed. PO torsemide 20 mg ≈ PO furosemide 40 mg ≈ bumetanide 1 mg. TRANSFORM-HF trial: no mortality difference vs furosemide.^1,5,6,7,8
Bumetanide (Bumex) ⓘ	Same as furosemide	Same as furosemide; check glucose (may affect)	Same electrolyte concerns; high potency (40:1 vs furosemide)	40× potency of furosemide on a mg basis. PO bioavailability ~80%. Bumetanide 1 mg = furosemide 40 mg = torsemide 20 mg. Less ototoxic than furosemide at equimolar doses. Sulfonamide allergy — same cross-reactivity considerations as furosemide.^6,7
THIAZIDE & THIAZIDE-LIKE
Hydrochlorothiazide (HCTZ)	DCT — Na⁺/Cl⁻ cotransporter inhibitor	K⁺, Na⁺, Mg²⁺, BUN, SCr, glucose, uric acid, lipids; BP	K⁺ < 3.5; hyponatremia (Na⁺ < 130); hyperglycemia; gout flare	First-line for hypertension. Ineffective if CrCl < 30 mL/min — use loop diuretic. Increases uric acid → gout risk. Hyponatremia risk in elderly (SIADH-like). Calcium-sparing (unlike loops). Lose Mg²⁺ → supplement if needed. Drug interactions: NSAIDs reduce efficacy; Li⁺ toxicity risk.^6,7
Chlorthalidone	DCT — same as HCTZ but longer half-life (40–60 h)	Same as HCTZ; electrolytes q3–6 months outpatient	K⁺ < 3.5; hyponatremia; glucose elevation	Preferred over HCTZ in major outcome trials (ALLHAT). Longer duration → more sustained BP control. Higher risk of electrolyte disturbances due to prolonged action. Do not double dose if missed — risk of significant hypokalemia.^6,7
Metolazone	DCT + proximal tubule — thiazide-like	K⁺, Na⁺, SCr q24–48h (inpatient); daily weight; UO	Profound hypokalemia and hyponatremia common when combined with loops; SCr ↑ expected	Used for diuretic resistance: give 30–60 min BEFORE loop diuretic (synergistic). Even 1–2.5 mg effective in combination. Effective in renal impairment (unlike other thiazides). Monitor electrolytes very closely — can cause profound depletion. Typically used short-term.^4,6,7
POTASSIUM-SPARING
Spironolactone ⓘ	Aldosterone antagonist (MR antagonist)	K⁺ (hyperkalemia risk!); Na⁺; SCr; BUN; BP; gynecomastia/breast tenderness	K⁺ > 5.5 — hold; K⁺ > 6.0 — discontinue; SCr > 2.5 mg/dL or > 30% increase	Mortality benefit in NYHA III–IV HF (RALES trial) and post-MI (EPHESUS). AVOID with K⁺ > 5.0, CrCl < 30, or concurrent ACEi+ARB combo. Slow onset (2–3 days). Anti-androgenic effects → gynecomastia in men (~10%). Monitor K⁺ 1–2 weeks after initiation, dose change, and renal function changes.^2,5,6,7
Eplerenone ⓘ	Selective aldosterone antagonist (MR); no anti-androgenic activity	K⁺; SCr; BUN; BP	Same as spironolactone (K⁺ > 5.5 — hold)	Selective for mineralocorticoid receptor — no gynecomastia. Shorter half-life than spironolactone. CYP3A4 substrate — azole antifungals, clarithromycin, etc. greatly increase levels. Approved post-MI HF and hypertension. Monitor K⁺ similarly to spironolactone.^6,7
CARBONIC ANHYDRASE INHIBITOR
Acetazolamide	Proximal tubule carbonic anhydrase inhibitor → NaHCO₃ loss	ABG/venous pH; HCO₃⁻; K⁺; SCr; BUN; urine output	Metabolic acidosis (pH < 7.35, HCO₃⁻ < 18); K⁺ < 3.5; SCr ↑	Used for metabolic alkalosis (diuretic-induced HCO₃⁻ excess), glaucoma, altitude sickness, intracranial hypertension. Dose: 250–500 mg IV/PO q6–24h. Sulfonamide allergy cross-reactivity (rare). Self-limiting — acidosis limits efficacy. Avoid in severe hepatic impairment (↑ NH₃).^6,7
SGLT2 INHIBITORS (HF & CKD ADJUNCT)
Empagliflozin Jardiance	SGLT2 blockade → proximal tubular Na⁺/glucose co-transport inhibition → osmotic diuresis + natriuresis; nephroprotective via reduced intraglomerular pressure	eGFR/SCr (q3–6 months); K⁺; BP (orthostatic); weight; UTI/genital mycotic infection sx; signs of euDKA (AG, ketones) if fasting or acutely ill; HbA1c if diabetic	eGFR < 20 — not indicated; eGFR 20–44 — CKD indication only (HF OK per AHA 2022); BP < 90/60 — hold; K⁺ < 3.5 — hold; euDKA (ketones, AG > 12 with normal glucose)	Approved HFrEF (EMPEROR-Reduced) and HFpEF/HFmrEF (EMPEROR-Preserved). Cardioprotective independent of glycemic effect — T2DM not required for HF indication. Mechanism unlike loops: preserves K⁺ and Mg²⁺, mild natriuresis. Reduces loop diuretic requirements. Also CKD (EMPA-KIDNEY). Hold ≥ 3 days before elective surgery or prolonged NPO (euDKA risk). Does not replace loop diuretics.^6,7,9,10
Dapagliflozin Farxiga	Same as empagliflozin	Same as empagliflozin	eGFR < 25 — avoid for T2DM; eGFR 25–44 — CKD/HF use with caution; same BP/K⁺ thresholds; euDKA	Approved HFrEF (DAPA-HF) and HFmrEF/HFpEF (DELIVER). Also CKD (DAPA-CKD). CV death + worsening HF reduced in both HFrEF and HFpEF trials vs placebo. Clinical profile and monitoring identical to empagliflozin. T2DM not required for HF indication. Hold perioperatively (euDKA risk).^6,7,9,11
VASOPRESSIN ANTAGONIST (VAPTAN)
Tolvaptan Samsca / Jynarque	V2 receptor antagonist → aquaresis (electrolyte-free water excretion without Na⁺ loss) — distinct from osmotic diuresis	Na⁺ q4–6h during first 24h then q6–8h; fluid intake (must NOT restrict water); BUN/SCr; LFTs (hepatotoxicity); daily weight; thirst level; BP; volume status	Na⁺ correction > 10–12 mEq/L per 24h → osmotic demyelination syndrome (ODS) risk — HOLD if this threshold approached; Na⁺ > 145 — hold (hypernatremia); LFTs > 3× ULN — discontinue immediately	Indicated for clinically significant euvolemic or hypervolemic hyponatremia (SIADH, HF). Initiate in hospital only — requires close Na⁺ monitoring for first 24–48h. CRITICAL: Patient must have FREE access to water — fluid restriction is contraindicated (risk of hypernatremia). Max correction target: 10 mEq/L/24h (some guidelines 12). FDA Black Box Warning: hepatotoxicity — do not use > 30 days; contraindicated in liver disease. NOT for hypovolemic hyponatremia. Start 15 mg PO daily; may titrate to 30–60 mg after 24h. Jynarque (higher doses) for autosomal dominant polycystic kidney disease (ADPKD) only.^6,7

SOURCES
¹ Felker GM et al (DOSE). N Engl J Med. 2011;364(9):797-805 ² Pitt B et al (RALES). N Engl J Med. 1999;341(10):709-717 ³ Verbrugge FH et al (ADVOR). N Engl J Med. 2022;387(13):1185-1195 ⁴ Mullens W et al. Eur Heart J. 2019;40(12):973-985 (Diuretic resistance) ⁵ Ellison DH & Felker GM. N Engl J Med. 2017;377(20):1964-1975 ⁶ Lexicomp Online. Diuretic monographs. Wolters Kluwer; 2025 ⁷ AHFS Drug Information 2025. American Society of Health-System Pharmacists ⁸ Mentz RJ et al (TRANSFORM-HF). JAMA. 2023;329(3):214-223 ⁹ Packer M et al (EMPEROR-Reduced). N Engl J Med. 2020;383(15):1413-1424 ¹⁰ Anker SD et al (EMPEROR-Preserved). N Engl J Med. 2021;385(16):1451-1461 ¹¹ McMurray JJV et al (DAPA-HF). N Engl J Med. 2019;381(21):1995-2008

DIURETIC RESISTANCE MANAGEMENT Approach when inadequate diuresis despite escalating loop diuretic doses

Strategy	Mechanism / Rationale	Practical Approach
IV over PO	Bypasses erratic GI absorption in CHF (gut edema)	Switch to IV furosemide; use 2× oral dose as starting IV dose^1,4,5
Continuous Infusion	Maintains constant tubular concentration vs. bolus	Bolus 40–80 mg IV, then infusion 5–20 mg/hr; titrate to UO goal. DOSE trial: no superiority over bolus but less variability.^1,4,5
Metolazone combination	Blocks DCT reabsorption (sequential nephron blockade)	Metolazone 2.5–5 mg PO 30–60 min before IV furosemide; monitor K⁺/Na⁺ closely^4,5
Acetazolamide (if alkalotic)	Corrects metabolic alkalosis, restoring loop sensitivity	250–500 mg IV/PO × 3 days if HCO₃⁻ > 30 mEq/L (ADVOR trial: improved decongestion)^3,4
Address underlying causes	NSAID use, hypoalbuminemia, hypovolemia, reduced renal perfusion	D/C NSAIDs; albumin infusion if severe hypoalbuminemia (< 2 g/dL); optimize hemodynamics^4,5

LOOP DIURETIC DOSE EQUIVALENCY CALCULATOR Convert between furosemide, torsemide, and bumetanide — PO and IV routes

DRUG

DOSE (mg)

ROUTE

SOURCES
¹ Felker GM et al (DOSE). N Engl J Med. 2011;364(9):797-805 ⁵ Ellison DH & Felker GM. N Engl J Med. 2017;377(20):1964-1975 ⁸ Mentz RJ et al (TRANSFORM-HF). JAMA. 2023;329(3):214-223

SITE-SPECIFIC DIURETIC PROTOCOLS Add institution-specific diuretic titration guidelines, electrolyte replacement protocols, and decongestion goals

e.g. CHF Decongestion Protocol, Electrolyte Replacement Guideline, Diuretic Resistance Algorithm

MONTHLY ARCHIVE Move DC'd records and patients to a dated snapshot — keeps active trackers lean while preserving continuity of care

Collects all DC'd records across every tracker and all patients with no remaining active therapies,
moves them into a labeled monthly snapshot. Records remain fully viewable and restorable at any time.

DATA BACKUP & RESTORE Export all data to a .json file, or import a backup to restore it — including data from previous versions

Downloads a .json backup of all patients, tracker records, and settings.

⬆ Import Data

Load a .json backup from this or any previous version.

MIGRATING FROM A PREVIOUS VERSION?

Each version of this app stores data separately in your browser. To move data from an older version:
1. Open the old version (e.g. v40) in Chrome and press F12 → Console tab
2. Paste and run: copy(localStorage.getItem('clinicalDB'))
3. Click ⬆ Import Data above, or open v41 console and run:
localStorage.setItem('clinicalDB', '<PASTE>'); location.reload()

DANGER ZONE

Permanently deletes all patients, tracker records, and data. Settings are preserved.

Field	Description
Patient Name	Full name as it appears on the medical record.
MRN	Medical Record Number for identification.
Room #	Current room or bed assignment.
Primary DR	Attending or primary physician (select from provider list).
Date of Birth	Auto-calculates patient age when entered.
Sex	M or F — used for IBW, CrCl, and eGFR calculations.
Height (cm)	Auto-converts to inches; used for IBW and BSA calculations.
Current Weight (kg)	Used for dosing weight, AdjBW, CrCl, and TPN calculations.
Serum Creatinine	mg/dL; drives CrCl (Cockcroft-Gault) and eGFR (CKD-EPI 2021) calculations.
eGFR	Auto-calculated; displayed to one decimal place in mL/min/1.73m².
Dialysis / HD	Flag for renal replacement therapy — affects dosing guidance.
Lab Values	Na⁺, K⁺, Cl⁻, CO₂, BUN, Creatinine, Glucose, WBC, Hgb, Platelets, Albumin, Bili, ALT, AST, Phos, Ca, Mg. Flagged high/low against reference ranges.
Allergies	Free-text field for documented allergies.
Admit / Discharge Date	Discharge date moves patient to the Discharged Patients list.

Field	Description
Drug Name	Select from list or free-text entry.
Bug / Organism	Targeted organism (e.g., MRSA, ESBL Klebsiella).
Indication	Clinical indication (e.g., HAP, bacteremia, UTI).
Route / Dose / Frequency	IV, PO, IM, inhaled; dose with units; dosing interval.
Start / Stop Date	Therapy dates; Duration auto-calculated (Days of Therapy).
Status	Active or DC'd (discontinued).

Field	Description
IBW / AdjBW	Auto-calculated from height and sex; AdjBW when ABW > 130% IBW (aminoglycosides: > 120% IBW). ABW used when ABW < IBW.
CrCl	Cockcroft-Gault using age, sex, weight, and SCr.
Ke	Elimination rate constant (hr⁻¹).
t½	Half-life (hours).
Vd	Volume of distribution (L).
CL	Drug clearance (L/hr).
Cmax (EOI)	Predicted peak at end of infusion (mg/L).
Cmin (pred)	Predicted trough concentration (mg/L).
AUC₂₄	24-hour area under the curve (mg·h/L) — target 400–600 for vancomycin.

Field	Description
Dosing Weight	Automatically selects ABW, AdjBW, or IBW based on weight criteria.
Total Daily KCAL	Dosing weight × KCAL/kg goal.
Protein (g/day)	Dosing weight × protein goal (g/kg).
Dextrose (g)	Auto-calculated: total KCAL − protein KCAL − lipid KCAL (or enter manually).
TPN Osmolarity	Calculated from amino acid, dextrose, and electrolyte concentrations.
%IBW	Displayed to one decimal place; drives dosing weight selection.

Report	Description
Monthly Tracker	Antibiotic counts, Days of Therapy (DOT), cost per 1,000 patient-days.
Yearly Summary	Annual roll-up of AMS metrics with month-by-month trend data.
Quarterly Roll-up	Quarter-level aggregation for committee reporting.
ABX Cost & DOT	Drug-level cost and DOT analysis for Medication Use Evaluation (MUE).
High-Cost ABX / MUE	Identifies high-spend antibiotics for formulary and stewardship review.
Daily Antibiotic List	Printable daily census of all patients on active antibiotics.

Reference	Application
ASHP / IDSA / SIDP 2020	Vancomycin AUC Monitoring Consensus Guidelines
Joint Commission MM.09.01.01	Antimicrobial Stewardship EPs 3–16
ASPEN	Parenteral Nutrition Handbook, 3rd Edition
SCCM / ASPEN	Critical Illness Nutrition Guidelines
CDC NHSN 2023	Antimicrobial Use Option Protocol
CDC 2022	Clinical Practice Guideline for Opioid Prescribing (MEDD/MME)
KDIGO 2026	Clinical Practice Guideline for the Management of Anemia in Chronic Kidney Disease. Kidney Int. 2026;109(1 Suppl):S1–S76. PMID: 41485812. (Supersedes KDIGO 2012)
CKD-EPI 2021	Race-Free eGFR Equation
Cockcroft & Gault 1976	Creatinine Clearance Estimation Equation
ISMP	High-Alert Medications and safety guidelines
Winter-Tozer	Phenytoin correction formula for hypoalbuminemia
Sawchuk-Zaske	Two-compartment vancomycin pharmacokinetic model
Lexicomp / Micromedex / AHFS	Drug dosing, renal adjustment, and interaction reference

Abbreviation	Definition
ABW	Actual Body Weight
AdjBW	Adjusted Body Weight
AMS	Antimicrobial Stewardship
AUC	Area Under the Curve (pharmacokinetic parameter)
BSA	Body Surface Area
CrCl	Creatinine Clearance (Cockcroft-Gault)
DC'd	Discontinued
DKA	Diabetic Ketoacidosis
DOAC	Direct Oral Anticoagulant
DOT	Days of Therapy
eGFR	Estimated Glomerular Filtration Rate (CKD-EPI 2021)
EMR	Electronic Medical Record
ESA	Erythropoiesis-Stimulating Agent
HD	Hemodialysis
HHS	Hyperosmolar Hyperglycemic State
IBW	Ideal Body Weight (Devine formula)
KPI	Key Performance Indicator
MEC	Medical Executive Committee
MEDD	Morphine Equivalent Daily Dose
MME	Morphine Milligram Equivalent
MRN	Medical Record Number
NTI	Narrow Therapeutic Index
PCA	Patient-Controlled Analgesia
P&T	Pharmacy & Therapeutics Committee
SCr	Serum Creatinine
TDM	Therapeutic Drug Monitoring
TPN	Total Parenteral Nutrition
TSAT	Transferrin Saturation
WBC	White Blood Cell count
%IBW	Percent of Ideal Body Weight