Calculate the osmolarity of any IV admixture. Add the base solution and any drug additives to see the total osmolarity in mOsm/L — automatically classified as hypo-, iso-, or hyperosmolar. Guides peripheral vs central line selection.
Base IV Solution
mL
Drug Additives
Component Breakdown
Reference values: Serum osmolarity normal range 275–295 mOsm/L (measured) / 280–310 mOsm/L (physiological). Peripheral vein tolerance: ≤600–900 mOsm/L (INS 2021 standard: ≤900 mOsm/L; many institutions use ≤600 mOsm/L for routine peripheral). Central line required: >900 mOsm/L. Sources: INS Infusion Therapy Standards of Practice 2021 · ASHP Injectable Drug Information · Trissel's 2 · Gahart BL & Nazareno AR: Intravenous Medications 2024.
📊 Common IV Solution Osmolarity Quick Reference
Values in mOsm/L · Theoretical osmolarity = Σ(concentration × dissociation particles) · Measured osmolality may differ slightly · Source: Gahart 2024 · ASHP Injectable Drug Information
Compatibility Results
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💊 Carboplatin AUC
🧪 Serial Dilution
⚡ Infusion Rates
🩸 Iron Deficit
🧪 TPN Calculator
🔬 Beta-Lactam PD
💉 Aminoglycoside PD
🎩 Oncology Dosing
🧑 Peds / Neonatal
💉 Vancomycin AUC
Compatibility Check Results
💧 Pairwise Results
⚗️ Y-Site Matrix
📋 Clinical Notes
📊 Osmolarity
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PK / Dosing
Nutrition
Patient Metrics
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Dose (mg) = Target AUC × (GFR + 25) · Calvert AH et al. J Clin Oncol 1989 · GFR by Cockcroft-Gault or measured
⚠️ Clinical Reminders:
• The Calvert formula uses actual GFR, not BSA-normalized GFR. If an eGFR (normalized to 1.73m²) is used, de-normalize: GFR = eGFR × BSA / 1.73
• FDA 2010 label update: cap GFR at 125 mL/min to prevent overdosing (Vermorken cap)
• For elderly or cachectic patients: use actual weight; for obese patients: use IBW or adjusted BW for Cockcroft-Gault
• Round to nearest 50mg if dose >300mg, nearest 25mg if 100–300mg
• Carboplatin is a vesicant — confirm line patency before infusion
• Source: Calvert AH et al. J Clin Oncol 1989 · FDA 2010 · ASCO Guidelines
🧪 IV Compounding & Serial Dilution Calculator
Specify what you're trying to compound, then list the stock solutions you have available — the calculator solves for the volume of each needed to hit your target.
Step 1 — What are you trying to compound?
Step 2 — What stock solutions do you have available?
Quick presets:
⚠️ Compounding Reminders:
• Verify osmolarity of final solution before infusion (3% NaCl ≈ 1026 mOsm/L — central line required)
• 23.4% NaCl must be drawn up carefully — fatal if given undiluted; label bag prominently
• Hypertonic dextrose solutions (>12.5%) require central venous access
• All compounded solutions must be clearly labeled: drug, concentration, volume, date/time, expiry, pharmacist
• USP 797 guidelines apply to all sterile compounding
Calculate mL/hr from mcg/kg/min, units/kg/hr, or mg/kg/hr for any weight-based continuous infusion
Use actual body weight (ABW) unless specified
🎗️ Oncology Dose Calculator — BSA & Weight-Based
NCCN-referenced dosing · Mosteller BSA · Supports flat-dose, mg/kg, and mg/m² regimens · Always verify against current protocol and institutional SOPs
⚠️ Oncology Dosing Safety Reminders:
• All doses must be verified against the current NCCN guidelines, institutional protocol, and clinical trial data before administration
• Vincristine: CAP at 2mg absolute (regardless of BSA) — fatal overdose risk
• Bleomycin: cumulative lifetime cap 360 units — track all prior doses
• Doxorubicin: cumulative lifetime cap 450-550 mg/m² — verify prior anthracycline exposure
• High-dose methotrexate requires leucovorin rescue, aggressive hydration, urine alkalinization (pH >7.0), and serial MTX levels
• For obese patients (BMI >30): consider using actual body weight for most agents per ASCO 2012 guideline; discuss with oncologist
• Sources: NCCN Clinical Practice Guidelines · Lexicomp Oncology Drug Information · Micromedex · ASCO 2012 Chemotherapy Dosing
🧒 Neonatal & Pediatric Dose Calculator
Weight-based and BSA-based dosing · Neofax · Lexicomp Pediatrics · AAP Red Book · Always verify against current protocol and patient-specific factors
⚠️ Pediatric Dosing Safety Reminders:
• Always verify dose, frequency, and route against Neofax, Lexicomp Pediatrics, or AAP Red Book
• Neonatal PMA/PNA significantly affects drug clearance — adjust dose and frequency for prematurity
• Maximum single dose and maximum daily dose caps apply — check before rounding up
• Gentamicin neonatal dosing: once-daily extended interval per PMA — check institution NICU protocol
• Renal and hepatic function affect neonatal drug clearance significantly more than older children
• Weight must be current (within 24H for neonates) — growth changes rapidly in the first weeks
💉 Vancomycin AUC-Guided Dosing
ASHP/IDSA/SIDP 2020 Consensus — Population PK initial dosing + Patient-specific PK adjustment from trough levels. AUC₁₅/MIC target: 400–600 mg·h/L
⚠️ HIGH ALERT MEDICATION — Verify all doses independently. Obtain levels at steady state (≥3–4 doses). This tool supports but does not replace clinical judgment.
📚 Enter the current dose/interval and observed trough. The calculator uses your observed trough with population Ke to estimate AUC and recommend dose adjustments.
Standard: draw 30 min before next dose
Patient-Specific PK from Two Drug Levels
📈 Enter any two vancomycin levels drawn at known times during the elimination phase to calculate patient-specific Ke, t½, Vd, CL, and AUC. Peak levels are NOT routinely required — two trough-range samples at different times work well. Most accurate method per ASHP 2020.
Draw any time during elimination phase (not during/immediately after infusion)
Draw at any time after Level 1 — pre-dose trough is convenient (e.g. 11.5H for Q12H)
Standard: 25 mg/kg ABW × 1 (max 3,000 mg)
Seriously ill / ICU: 30–35 mg/kg (max 3,000 mg)
Infuse at ≤1,000 mg/hr to prevent Red Man Syndrome
Loading dose before first maintenance dose
Separate infusion; do NOT include in maintenance interval calculation
⚠ Nephrotoxicity & Monitoring
AUC >600 → nephrotoxicity risk increases
Trough >20 mg/L → HIGH nephrotoxicity risk
Draw trough at steady state (≥3–4 doses) Peak levels are NOT routinely recommended per ASHP 2020 — AUC-guided monitoring uses trough only or two elimination-phase levels
Recheck SCr every 48–72H during therapy
Avoid concurrent nephrotoxins (aminoglycosides, NSAIDs, contrast)
ASHP 2020: AUC monitoring reduces nephrotoxicity 35% vs trough-only
📋 Red Man Syndrome Prevention
Infuse at ≤500 mg/30 min (i.e. max 1,000 mg/hr) • Dilute to ≤5 mg/mL
Doses 1–1.5g: infuse over 60 min • Doses 1.5–2.5g: infuse over 90–120 min • Doses >2.5g: infuse over 150–180 min
If RMS occurs: stop infusion, give diphenhydramine 25–50 mg IV, resume at slower rate after resolution
Oral and IV iron dosing · Ganzoni formula · Ferinject / Venofer / Injectafer · BSH 2021 · KDIGO 2024
⚠️ Clinical Notes: IV iron dextran: test dose 25mg over 15 min, observe 60 min before full infusion. Ferric carboxymaltose: max 750mg/dose (1000mg if ≥50kg, EU label). Iron sucrose: max 200mg/infusion dialysis; 300-500mg slow infusion non-dialysis. CKD targets: non-dialysis ferritin >100, TSAT >20%; HD ferritin 200-500, TSAT 30-50%. Oral iron: every-other-day dosing improves absorption vs daily (hepcidin suppression — Moretti 2015). Sources: BSH IDA 2021 · KDIGO Anemia 2024 · Ganzoni AM Schweiz Med Wochenschr 1970.
🍶 Full TPN Builder — ASPEN Guidelines
Builds the complete TPN order: calories, protein, macronutrient split, electrolytes, infusion rate. Per ASPEN 2022 guidelines. Verify all orders with a clinical pharmacist or dietitian.
Step 1 — Patient Data
Needed for IBW, Penn State, REE
For Penn State equation
Minute ventilation (Penn State)
Step 2 — Current Chemistry
TPN maintains electrolytes — severe deficits must be corrected via separate IV repletion first.
Step 3 — Macronutrient Options
⚠ ASPEN Safety Reminders:
Max dextrose oxidation rate 4–5 mg/kg/min · Max lipid 2.5 g/kg/day · Refeeding syndrome: start at 50% goal kcal in severely malnourished patients, monitor K/Mg/Phos q6H ·
Ca × Phosphate precipitation check required · All TPN orders must be verified by a clinical pharmacist before compounding
Risk Tiers: ANC ≥1500 normal · 1000–1499 mild neutropenia · 500–999 moderate · 100–499 severe (neutropenic precautions) · <100 profound (reverse isolation, prophylactic antimicrobials per protocol)
🧮 Child-Pugh Score — Hepatic Impairment
Classifies cirrhosis severity (Class A/B/C) — used to guide dose adjustment for hepatically cleared drugs
📐 Body Surface Area (BSA) Calculator
Mosteller, Du Bois, and Haycock formulas — used for BSA-based dosing (chemotherapy, pediatrics)
🧂 Sodium Correction Calculator
Adrogué-Madias equation for hyponatremia/hypernatremia correction · Predicts ΔNa from 1L of chosen IV fluid
⚠️ Max correction rate: 8–10 mEq/L per 24H (chronic) to avoid osmotic demyelination syndrome (ODS). Severe acute symptomatic hyponatremia may warrant faster initial correction per institutional protocol.
Therapeutic aPTT range:60–100 seconds(customizable in Protocol Settings)
aPTT Nomogram (current institutional settings)
Therapeutic Anti-Xa range:0.3–0.7 units/mL(customizable in Protocol Settings)
ℹ️ Anti-Xa levels should be drawn 4–6 hours after any rate change and after rate is stable for at least 2 hours. Draw peak level 4H after dose initiation or rate change.
Anti-Xa Nomogram (current institutional settings)
⚙️ Institutional Protocol Customization
Adjust ranges and actions to match your institution's heparin protocol. Changes apply immediately to the aPTT and Anti-Xa titration nomograms above.
aPTT Ranges & Actions
Nomogram actions and bolus/rate changes are auto-calculated from these therapeutic limits.
Loading dose 5 mg CBA/kg · Maintenance per Garonzik PK model (2.5–3 × MIC target AUC) · Maintenance starts 24H after loading dose
⚠ Critical Safety Notes: All colistin doses expressed as Colistin Base Activity (CBA), not as colistimethate (CMS) units.
1 million IU CMS ≈ 30 mg CBA (approx). Confirm unit convention with your pharmacy before ordering.
Renal function is the primary driver of maintenance dosing — dose every 12H for most patients.
Nephrotoxicity risk is significant; monitor SCr daily and hold if SCr rises >50% from baseline.
📚 References:
• Garonzik SM et al. Clin Infect Dis 2011 — Population PK model for CMS/colistin
• IDSA 2022 Guidance on Polymyxins — loading dose and AUC-based maintenance
• Maintenance formula: CrCl-adjusted daily dose targeting Css,avg 2.5–3× MIC
• Inhaled colistin may be considered adjunctively for VAP/HAP (not calculated here)
⚠️ IV Antibiotic Desensitization Protocols
Graded-dose IV desensitization protocols for documented beta-lactam allergy
Ampicillin IV Intravenous Desensitization Protocol
🚨 CRITICAL — READ BEFORE STARTING
⚠️ Have a hypersensitivity emergency kit at chair/bedside BEFORE starting desensitization
⚠️ Monitor continuously for signs and symptoms of allergic reaction throughout all doses
⚠️ Space each dose 1 hour apart
🛑 STOP desensitization immediately and alert prescriber if ANY allergic reaction occurs
📦 Hypersensitivity Emergency Kit — Verify at Bedside
Ampicillin IV — 6-Step Graded Dose Protocol
All doses IV Push · Wait 1 hour between doses · Monitor 30 min after final dose
Done
Dose
Ampicillin
Volume
Rate
Time Given
Reaction?
#1
0.002 mg
8 mL NS
IV Push 3–5 min
#2
0.02 mg
8 mL NS
IV Push 3–5 min
#3
0.2 mg
8 mL NS
IV Push 3–5 min
#4
2 mg
8 mL NS
IV Push 3–5 min
#5
20 mg
8 mL NS
IV Push 3–5 min
#6
200 mg
8 mL NS
IV Push 3–5 min
✅ If patient tolerates Ampicillin through Dose #6: Therapeutic ampicillin regimen may begin 1 hour after Dose #6. Notify prescriber to place therapeutic order.
Protocol Progress0 of 6 doses completed
Check each dose box after administration to track progress.
🧪 Compounding Instructions
You Will Need:
• 500 mg Ampicillin (1 vial)
• 2 × 100 mL 0.9% Normal Saline IV bags (for Dilutions A and B)
• 6 × 10 mL syringes (one per dose)
• 1 × 1 mL syringe (for small-volume draws)
STEP 1 — Prepare and Label the Following Dilutions
Solution
Concentration
Instructions
Stock Solution
200 mg/mL
Dissolve 500 mg Ampicillin in 2.3 mL NS
Dilution A
2 mg/mL
Take 1 mL of Stock [200 mg/mL] and dilute in 100 mL NS
Dilution B
0.02 mg/mL
Take 1 mL of Dilution A [2 mg/mL] and dilute in 100 mL NS
STEP 2 — Prepare and Label Each Dose (all in 10 mL syringe, qs to 8 mL with NS)
Dose
Final Dose
Draw From
Volume
Then Add NS to
#1
0.002 mg
Dilution B (0.02 mg/mL)
0.1 mL
8 mL total
#2
0.02 mg
Dilution B (0.02 mg/mL)
1 mL
8 mL total
#3
0.2 mg
Dilution A (2 mg/mL)
0.1 mL
8 mL total
#4
2 mg
Dilution A (2 mg/mL)
1 mL
8 mL total
#5
20 mg
Stock (200 mg/mL)
0.1 mL
8 mL total
#6
200 mg
Stock (200 mg/mL)
1 mL
8 mL total
📋 Label each syringe with: Drug name, Dose #, Concentration, Volume, Date/Time prepared, Pharmacist initials · Prepare doses in a laminar flow hood per USP <797> sterile compounding standards
Ceftriaxone IV Intravenous Desensitization Protocol
🚨 CRITICAL — READ BEFORE STARTING
⚠️ Have a hypersensitivity emergency kit at chair/bedside BEFORE starting desensitization
⚠️ Monitor continuously for signs and symptoms of allergic reaction throughout all doses
⚠️ Space each dose 30 minutes apart
🛑 STOP desensitization immediately and alert prescriber if ANY allergic reaction occurs
📦 Hypersensitivity Emergency Kit — Verify at Bedside
Ceftriaxone IV — 6-Step Graded Dose Protocol
Wait 30 minutes between doses · Begin therapeutic dose 2 hours after Dose #6
Done
Dose
Ceftriaxone
Volume
Rate
Time Given
Reaction?
#1
0.001 mg
8 mL NS
IV Push 2–3 min
#2
0.01 mg
8 mL NS
IV Push 2–3 min
#3
0.1 mg
8 mL NS
IV Push 2–3 min
#4
1 mg
8 mL NS
IV Push 2–3 min
#5
10 mg
10 mL NS
IV Push 3–5 min
#6
100 mg
8 mL NS
IV Push 3–5 min
✅ If patient tolerates Ceftriaxone through Dose #6: The first therapeutic dose may begin 2 hours following completion of desensitization (i.e., 2 hours after Dose #6). Notify prescriber to place therapeutic order.
Protocol Progress0 of 6 doses completed
Check each dose box after administration to track progress.
💊 Ampicillin IV — Compounding Directions
You will need:
• 500 mg Ampicillin vial
• 2 × 100 mL 0.9% Normal Saline IV bags
• 6 × 10 mL syringes
• 1 × 1 mL syringe
STEP 1 — Make the following dilutions and label each:
Label
Concentration
Preparation
Stock
200 mg/mL
Dissolve 500 mg ampicillin in 2.3 mL NS
Dilution A
2 mg/mL
Take 1 mL of Stock [200 mg/mL] and dilute in 100 mL NS bag
Dilution B
0.02 mg/mL
Take 1 mL of Dilution A [2 mg/mL] and dilute in 100 mL NS bag
STEP 2 — Prepare the following doses and label each:
Dose
Ampicillin
From
Instructions
Container
#1
0.002 mg
Dilution B
Take 0.1 mL of Dilution B → qs to 8 mL with NS
10 mL syringe
#2
0.02 mg
Dilution B
Take 1 mL of Dilution B → qs to 8 mL with NS
10 mL syringe
#3
0.2 mg
Dilution A
Take 0.1 mL of Dilution A → qs to 8 mL with NS
10 mL syringe
#4
2 mg
Dilution A
Take 1 mL of Dilution A → qs to 8 mL with NS
10 mL syringe
#5
20 mg
Stock
Take 0.1 mL of Stock → qs to 8 mL with NS
10 mL syringe
#6
200 mg
Stock
Take 1 mL of Stock → qs to 8 mL with NS
10 mL syringe
⚠️ Label each syringe clearly with: Drug name, concentration, dose number, date/time prepared, pharmacist initials. Prepare all doses immediately before administration. Discard unused syringes after protocol completion.
👁 Signs & Symptoms Monitoring
🔴 Urticaria / hives / angioedema
🔴 Anaphylaxis / hypotension
🔴 Bronchospasm / wheezing
🔴 Pruritus / flushing / rash
🟡 Nausea / vomiting / GI sx
🟡 Changes in vital signs
🛑 If ANY red symptom occurs: STOP immediately, call prescriber, administer epinephrine if anaphylaxis, initiate emergency response.
This protocol is intended for use under direct supervision of a licensed pharmacist and prescriber. Patient must have established IV access and continuous monitoring capability. Not appropriate for SJS, TEN, or prior ICU-level anaphylaxis. Consult Allergy/Immunology for complex cases.
Vancomycin IV Intravenous Desensitization Protocol
🚨 CRITICAL — READ BEFORE STARTING
⚠️ Have a hypersensitivity emergency kit at chair/bedside BEFORE starting desensitization
⚠️ Monitor continuously for signs and symptoms of allergic reaction throughout all doses
⚠️ Space each dose 30 minutes apart
🛑 STOP desensitization immediately and alert prescriber if ANY allergic reaction occurs
📦 Hypersensitivity Emergency Kit — Verify at Bedside
Vancomycin IV — 7-Step Graded Dose Protocol
Wait 30 minutes between doses · Begin usual doses 8 hours after completion
Done
Dose
Vancomycin
Volume / Form
Route / Rate
Time Given
Reaction?
#1
0.001 mg
10 mL syringe
IV Push 2–3 min
#2
0.01 mg
10 mL syringe
IV Push 2–3 min
#3
0.1 mg
10 mL syringe
IV Push 2–3 min
#4
1 mg
10 mL syringe
IV Push 2–3 min
#5
10 mg
10 mL syringe
IV Push 3–5 min
#6
100 mg
50 mL IVPB
IV Infusion 30 min
#7
500 mg
100 mL IVPB
IV Infusion 60 min
✅ If patient tolerates desensitization through Dose #7: Begin usual vancomycin doses and intervals 8 hours following completion of desensitization. Notify prescriber to place therapeutic order.
Protocol Progress0 of 7 doses completed
Check each dose box after administration to track progress.
💊 Preparation Instructions
Stock: Vancomycin 500 mg in 10 mL SWFI → 50 mg/mL Dilution 1: 0.1 mL of 50 mg/mL + 9.9 mL NS → 0.5 mg/mL Dilution 2: 0.1 mL of 0.5 mg/mL + 9.9 mL NS → 0.005 mg/mL Dilution 3: 0.1 mL of 0.005 mg/mL + 9.9 mL NS → 0.00005 mg/mL
Dose
From
Draw + Diluent
Final
Container
#1
0.00005 mg/mL
20 mL (neat)
0.001 mg
10 mL syringe
#2
0.005 mg/mL
2 mL + 8 mL NS
0.01 mg
10 mL syringe
#3
0.5 mg/mL
0.2 mL + 9.8 mL NS
0.1 mg
10 mL syringe
#4
0.5 mg/mL
2 mL + 8 mL NS
1 mg
10 mL syringe
#5
50 mg/mL
0.2 mL + 9.8 mL NS
10 mg
10 mL syringe
#6
50 mg/mL
2 mL + 48 mL NS
100 mg
50 mL IVPB
#7
50 mg/mL
10 mL + 90 mL NS
500 mg
100 mL IVPB
⚠️ Red Man Syndrome (flushing, pruritus, erythema of face/neck/upper torso) is rate-related — NOT a true allergic reaction. If it occurs during desensitization, slow the infusion rate. Do not stop unless clinical deterioration. Premedicate with diphenhydramine 25–50 mg IV 30 min before if history of Red Man Syndrome.
👁 Signs & Symptoms Monitoring
🔴 Urticaria / hives / angioedema
🔴 Anaphylaxis / hypotension
🔴 Bronchospasm / wheezing
🔴 True allergic rash / pruritus
🟡 Flushing / Red Man Syndrome (rate-related — slow infusion)
🟡 Changes in vital signs
🛑 TRUE allergic reaction: STOP, call prescriber, give epinephrine if anaphylaxis.
🟡 Red Man Syndrome only: Slow infusion rate — do NOT stop unless clinical deterioration occurs.
For true IgE-mediated vancomycin hypersensitivity only — not for Red Man Syndrome. Patient must have established IV access and continuous monitoring capability. Consult Allergy/Immunology for complex cases.
TMP/SMX Oral Desensitization Protocol
🚨 CRITICAL — READ BEFORE STARTING
⚠️ Have a hypersensitivity emergency kit at chair/bedside BEFORE starting desensitization
⚠️ Monitor continuously for signs and symptoms of allergic reaction throughout all doses
⚠️ Space each dose 1 hour apart
🛑 STOP desensitization immediately and alert prescriber if ANY allergic reaction occurs
📦 Hypersensitivity Emergency Kit — Verify at Bedside
TMP/SMX Oral — 6-Step Graded Dose Protocol
Wait 1 hour between doses · Doses #1–5 given as oral suspension · Dose #6 given as DS tablet · Begin therapeutic dose 12 hours after Dose #6
Done
Dose
TMP / SMX
Volume / Form
Route
Time Given
Reaction?
#1
0.004 / 0.02 mg
10 mL oral suspension
Oral
#2
0.04 / 0.2 mg
10 mL oral suspension
Oral
#3
0.4 / 2 mg
10 mL oral suspension
Oral
#4
4 / 20 mg
10 mL oral suspension
Oral
#5
40 / 200 mg
10 mL oral suspension
Oral
#6
160 / 800 mg
1 DS Tablet
Oral (tablet)
✅ If patient tolerates TMP/SMX through Dose #6: The typical therapeutic regimen may begin 12 hours after Dose #6. Notify prescriber to place therapeutic order.
Protocol Progress0 of 6 doses completed
Check each dose box after administration to track progress.
💊 Preparation Instructions
Stock suspension: TMP/SMX oral suspension = 8/40 mg/mL (8 mg TMP / 40 mg SMX per mL) Dilution 1: 1 mL suspension + 99 mL water → 0.08/0.4 mg/mL Dilution 2: 1 mL of Dilution 1 + 99 mL water → 0.0008/0.004 mg/mL
Dose
From
Draw
Final TMP / SMX
Form
#1
Dilution 2 (0.0008/0.004 mg/mL)
5 mL + 5 mL water
0.004 / 0.02 mg
10 mL oral suspension
#2
Dilution 1 (0.08/0.4 mg/mL)
0.5 mL + 9.5 mL water
0.04 / 0.2 mg
10 mL oral suspension
#3
Dilution 1 (0.08/0.4 mg/mL)
5 mL + 5 mL water
0.4 / 2 mg
10 mL oral suspension
#4
Stock (8/40 mg/mL)
0.5 mL + 9.5 mL water
4 / 20 mg
10 mL oral suspension
#5
Stock (8/40 mg/mL)
5 mL + 5 mL water
40 / 200 mg
10 mL oral suspension
#6
—
—
160 / 800 mg
1 TMP/SMX DS tablet (standard)
📋 Reference: Sanford Guide to Antimicrobial Therapy, 42nd Ed. 2012. Table 7 — Methods for Drug Desensitization. p.80
👁 Signs & Symptoms Monitoring
🔴 Urticaria / hives / angioedema
🔴 Anaphylaxis / hypotension
🔴 Bronchospasm / wheezing
🔴 Rash / maculopapular eruption
🟡 Nausea / vomiting / GI sx
🟡 Fever / changes in vital signs
🛑 If ANY allergic reaction occurs: STOP desensitization immediately, call prescriber, administer epinephrine if anaphylaxis, initiate emergency response per facility protocol.
This protocol is for sulfonamide desensitization under direct supervision of a licensed pharmacist and prescriber. Not appropriate for patients with SJS, TEN, or severe hypersensitivity reactions requiring ICU management. Consult Allergy/Immunology for complex or high-risk cases.
Penicillin G IV Intravenous Desensitization Protocol
🚨 CRITICAL — READ BEFORE STARTING
⚠️ Have a hypersensitivity emergency kit at chair/bedside BEFORE starting desensitization
⚠️ Monitor continuously for signs and symptoms of allergic reaction throughout all doses
⚠️ Space each dose 30 minutes apart
🛑 STOP desensitization immediately and alert prescriber if ANY allergic reaction occurs
📦 Hypersensitivity Emergency Kit — Verify at Bedside
Penicillin G IV — 6-Step Graded Dose Protocol
Wait 30 minutes between doses · Begin therapeutic dose 1 hour after Dose #6
Done
Dose
Penicillin G
Volume
Rate
Time Given
Reaction?
#1
100 units
1 mL
IV Push 3–5 min
#2
200 units
1 mL
IV Push 3–5 min
#3
400 units
1 mL
IV Push 3–5 min
#4
800 units
1 mL
IV Push 3–5 min
#5
2,400 units
1 mL
IV Push 3–5 min
#6
8,000 units
1 mL
IV Push 3–5 min
#7
25,000 units
1 mL
IV Push 3–5 min
#8
50,000 units
1 mL
IV Push 3–5 min
#9
500,000 units
10 mL
IV Push / slow 5 min
✅ If patient tolerates Penicillin G through Dose #9: Therapeutic Penicillin G may begin 1 hour after Dose #9. Notify prescriber to place therapeutic order.
Protocol Progress0 of 9 doses completed
Check each dose box after administration to track progress.
💊 Compounding Directions
You will need:
• 1 vial Penicillin G Potassium (5,000,000 units / 10 mL) → 500,000 units/mL
• 4 × sterile NS or SWFI for dilutions
• 9 × syringes (1 mL for doses #1–8; 10 mL for dose #9)
STEP 1 — Prepare Serial Dilutions and Label:
Label
Concentration
Preparation
Stock
500,000 units/mL
Reconstituted Penicillin G 5,000,000 unit vial (neat)
Dilution A
10,000 units/mL
1 mL Stock + 49 mL NS
Dilution B
1,000 units/mL
1 mL Dilution A + 9 mL NS
Dilution C
100 units/mL
1 mL Dilution B + 9 mL NS
STEP 2 — Prepare Each Dose and Label:
Dose
Units
From
Draw + Diluent
Container
#1
100 units
Dilution C
1 mL neat
1 mL syringe
#2
200 units
Dilution B
0.2 mL + 0.8 mL NS
1 mL syringe
#3
400 units
Dilution B
0.4 mL + 0.6 mL NS
1 mL syringe
#4
800 units
Dilution B
0.8 mL + 0.2 mL NS
1 mL syringe
#5
2,400 units
Dilution A
0.24 mL + 0.76 mL NS
1 mL syringe
#6
8,000 units
Dilution A
0.8 mL + 0.2 mL NS
1 mL syringe
#7
25,000 units
Stock
0.05 mL + 0.95 mL NS
1 mL syringe
#8
50,000 units
Stock
0.1 mL + 0.9 mL NS
1 mL syringe
#9
500,000 units
Stock
1 mL + 9 mL NS
10 mL syringe
⚠️ Label each syringe with: Drug name, units/mL, dose number, date/time prepared, pharmacist initials. Prepare all doses immediately before administration. Discard unused syringes after protocol.
👁 Signs & Symptoms Monitoring
🔴 Urticaria / hives / angioedema
🔴 Anaphylaxis / hypotension
🔴 Bronchospasm / wheezing
🔴 Pruritus / flushing / rash
🟡 Nausea / vomiting / GI sx
🟡 Changes in vital signs
🛑 If ANY allergic reaction occurs: STOP, call prescriber, administer epinephrine if anaphylaxis, initiate emergency response.
Protocol for true IgE-mediated penicillin allergy under direct pharmacist and prescriber supervision. Doses based on standard published penicillin desensitization protocols (Wendel et al.). Consult Allergy/Immunology for complex cases.
SMX-TMP IV Intravenous Desensitization Protocol
🚨 CRITICAL — READ BEFORE STARTING
⚠️ Have a hypersensitivity emergency kit at chair/bedside BEFORE starting desensitization
⚠️ Monitor continuously for signs and symptoms of allergic reaction throughout all doses
⚠️ Space each dose 1 hour apart
🛑 STOP desensitization immediately and alert prescriber if ANY allergic reaction occurs
📦 Hypersensitivity Emergency Kit — Verify at Bedside
SMX-TMP IV — 5-Step Graded Dose Protocol
Wait 1 hour between doses · Therapeutic dose begins immediately after Dose #5 if tolerated
Done
Dose
SMX / TMP
Volume / Diluent
Rate
Time Given
Reaction?
#1
0.8 / 0.16 mg
1 mL in 50 mL D5W
IV over 60 min
#2
8 / 1.6 mg
1 mL in 50 mL D5W
IV over 60 min
#3
40 / 8 mg
5 mL in 50 mL D5W
IV over 60 min
#4
200 / 40 mg
25 mL in 100 mL D5W
IV over 60 min
#5
800 / 160 mg
Full dose in 250 mL D5W
IV over 60–90 min
✅ If patient tolerates SMX-TMP through Dose #5 (full therapeutic dose): Desensitization is complete. Continue therapeutic dosing at usual intervals.
Protocol Progress0 of 5 doses completed
Check each dose box after administration to track progress.
💊 Compounding Directions
Stock solution: IV TMP-SMX = 80 mg SMX / 16 mg TMP per mL (standard 5 mL vial = 400 mg SMX / 80 mg TMP) Dilution A: 1 mL stock + 9 mL D5W → 8 mg SMX / 1.6 mg TMP per mL
All doses diluted in D5W per package insert (do not use NS for admixture)
Dose
SMX / TMP
From
Preparation
Final Volume
#1
0.8 / 0.16 mg
Dilution A
0.1 mL Dil A + 49.9 mL D5W
50 mL IVPB
#2
8 / 1.6 mg
Dilution A
1 mL Dil A + 49 mL D5W
50 mL IVPB
#3
40 / 8 mg
Stock
0.5 mL stock + 49.5 mL D5W
50 mL IVPB
#4
200 / 40 mg
Stock
2.5 mL stock + 97.5 mL D5W
100 mL IVPB
#5
800 / 160 mg
Stock
10 mL stock + 240 mL D5W
250 mL IVPB
📋 Standard IV TMP-SMX: 5 mL ampule = 80 mg TMP / 400 mg SMX (16 mg TMP/mL, 80 mg SMX/mL). SMX:TMP ratio always 5:1. All doses expressed as SMX / TMP. Dilute in D5W only per manufacturer labeling.
👁 Signs & Symptoms Monitoring
🔴 Urticaria / hives / angioedema
🔴 Anaphylaxis / hypotension
🔴 Bronchospasm / wheezing
🔴 Maculopapular rash / SJS signs
🟡 Fever / chills
🟡 Changes in vital signs / GI sx
🛑 If ANY reaction occurs: STOP, call prescriber. Note: TMP-SMX desensitization is NOT appropriate for patients with prior SJS, TEN, or severe mucocutaneous reactions — these are absolute contraindications.
SMX-TMP IV desensitization for true sulfonamide allergy under direct pharmacist and prescriber supervision. Absolute contraindications: prior SJS, TEN, DRESS, or severe mucocutaneous reactions. Consult Allergy/Immunology for complex cases.
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