STANDARDIZE 4 SAFETY INITIATIVE
Standardize 4 Safety is the first national, interprofessional eort to
standardize medication concentrations to reduce errors, especially
during transitions of care.
These national standards will cover:
• Concentrations and dosing units for intravenous continuous
medications for adult patients.
• Concentrations for compounded oral liquid medications.
• Concentrations and dosing units for intravenous continuous
medications for pediatric patients.
• Doses for oral liquid medications.
• Concentrations for intravenous intermittent medications.
• Concentrations for PCA and epidural medications.
1 ASHP Best Practices: Position and guidance documents of ASHP. 2014. ASHP, Bethesda, Maryland.
2 Larsen GY, Parker HB, Cash J. et.al. Standard Drug Concentrations and Smart-Pump Technology Reduce Continuous-Medication-Infusion Errors in Pediatric Patients. Pediatrics 2005;116:e21–e25.
3 Joint Commission. Preventing Pediatric Medication Errors. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/sea-39-ped-med-errors-rev-final-4-14-21.pdf. (accessed March 15, 2024)
4 Shekelle PG, Wachter RM, Pronovost PJ, et.al. An Updated Critical Analysis of the Evidence for Patient Safety Practices. Comparative Eectiveness Review No. 211. (Prepared by the Southern California-RAND Evidence-based Practice
Center under Contract No. 290-2007-10062-I.) AHRQ Publication No. 13-E001-EF. Rockville, MD: Agency for Healthcare Research and Quality. March 2013. www.ahrq.gov/research/findings/evidence-based-reports/ptsafetyuptp.html.
(accessed September 20, 2020)
The Standardize 4 Safety initiative began in 2008 when a multi-
stakeholder IV summit was held to address preventing patient harm
and death from intravenous (IV) medication errors. Among the
recommendations made by the participants was to establish national
standards for IV medications in hospitals including standardized
concentrations and dosing. In addition, it was recommended that
the national standards be created in collaboration with the Food
and Drug Administration (FDA), the pharmaceutical industry, and
other stakeholders. Since the summit, establishing standardized
concentrations has garnered strong support from ASHP members, the
Joint Commission, the Institute for Safe Medical Practices (ISMP), and
others.
1
2
3
4
In 2015 the FDA, through its Safe Use Initiative, awarded ASHP a grant
to develop and implement national standardized concentrations for IV
and oral liquid medications. The aims of the grant were to: (1) identify
a nationwide expert interprofessional panel consisting of physicians,
nurses, and pharmacists; (2) create standards for adult continuous IV
infusions, compounded oral liquid medications, pediatric continuous
IV infusions, doses for liquid medications, intravenous intermittent
infusions, and PCA and epidural medications; (3) disseminate the
standards and assess their adoption.
PEDIATRIC CONTINUOUS
INFUSION STANDARDS
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PEDIATRIC CONTINUOUS INFUSION STANDARDS
2
WHY STANDARDIZE
To Err is Human was published in 1999 and highlighted the harm to
patients from healthcare error. In that report, medication errors were
stated to be responsible for one of 131 outpatient and one of 854
inpatient deaths.
5
Healthcare continues to struggle to eliminate harm
to patients. A systematic review and meta-analysis in 2019 estimated
one in 20 patients are exposed to preventable medical harm with
the highest incidence of events due to medications. Compounded
medications,
6
especially those given intravenously, are known to be high
risk for error due to added complexity and multiple steps required for
determining dosing when ordering, concentrations for preparation, and
rates of infusion for administering.
7
8
Using standardization as a quality
improvement tool decreases variation, improves safety, and is the
foundation for using clinical pathways and evidence-based guidelines.
Standardization allows providers to manage excessive and unintended
variation as they customize care for patients.
9
5 Kohn LT, Corrigan J, Donaldson Molla S, eds; Institute of Medicine Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
6 Panagioti, M, Khan K, Keers RN, et.al. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ 2019;366:l4185 | doi: 10.1136/bmj.l4185.
7 Hedlund N, Beer I, Hoppe-Tichy T, Trbovich P. Systematic evidence review of rates and burden of harm of intravenous admixture drug preparation errors in healthcare settings. BMJ Open. 2017; 7(12): e015912.
8 Sutherland A, Canobbio M, Clarke J, et.al. Incidence and prevalence of intravenous medication errors in the UK: a systematic review. Eur J Hosp Pharm. 2020 Jan; 27(1): 3–8.
9 Lloyd R. Does Standardization Mean the End of Autonomy? Institute for Healthcare Improvement. https://www.ihi.org/insights/does-standardization-mean-end-autonomy. (accessed March 20, 2024)
PRINCIPLES FOR PEDIATRIC CONTINUOUS INFUSION
STANDARDS
Safety first — use
commercial when
possible
Try to limit to one
concentration when
possible
Consider
concentration
relative to fluid status.
Use more concentrated
when possible
Consider operational
dispensing aspects and
steps including waste
Patient/
Clinical
Needs
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PEDIATRIC CONTINUOUS INFUSION STANDARDS
3
HOW THE NATIONAL MEDICATION
CONCENTRATION STANDARDS WERE
DEVELOPED
A comprehensive environmental scan was
conducted to identify the appropriate medications
to be addressed in the respective standard
concentrations. A multi-disciplinary expert panel
was convened for each standard concentration
category. Members were selected based on their
expertise in the subject matter and identified with
assistance from organizations such as The American
Society of Anesthesiologists, Society of Critical Care
Medicine, and American Association of Critical-
Care Nurses. Each expert panel was charged to
establish standard principles to guide their decisions
in creating the respective standard concentration
recommendations. Once a draft of standards was
established, it was released for public comment and
review by ASHP sta and ISMP. The expert panel
subsequently met to address all comments and
generate the National Medication Concentration
Standards.
PRINCIPLES FOR EXPERT PANEL DELIBERATIONS
Operational
considerations
(costs and waste)
Use more concentrated
when possible
Limit to one concentration when possible
FDA-approved commercial products
Patient clinical needs
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PEDIATRIC CONTINUOUS INFUSION STANDARDS
4
PHYSICIANS
Mitchell Goldstein
Loma Linda University Health
Randi Trope
Cohen Children’s Northwell Health
Vinay Vaidya
Phoenix Children’s Hospital
NURSES
Wendy Cross
American Association of Critical-Care Nurses
Rebecca Isbell
Rachel Joseph
Kimberly Whalen
Massachusetts General Hospital
Lori Williams
University of Wisconsin Health
PHARMACISTS
Jared Cash
Primary Children’s Hospital
Regine Cauthers White
Wolters Kluwer
Brandon Clubb
Riley Hospital for Children
Kim Jeong-eun
New York Presbyterian Hospital
Jake Luke
Primary Children’s Hospital
Rachel Meyers
Rutgers
Shelly Morvay
Nationwide Children’s Hospital
EXPERT PANEL
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PEDIATRIC CONTINUOUS INFUSION STANDARDS
5
DISCLAIMERS
• Suggested concentrations may dier from the package insert (PI) information
for a drug. This is due to clinical needs that may have transpired postmarket.
When this is the case, studies are available to support the use of a concentration
dierent than what the parent company originally pursued through the new
drug application (NDA) process.
• Please use the utmost caution when using a concentration dierent than the PI,
especially if rate information is used from the PI.
• Dosing units were derived from PI information, commonly used drug-reference
guides, and clinical practice guidelines.
• Of special note, the expert panel is recommending that weight-based dosing be
used for vasopressors (i.e., per kg, per minute), which may dier from institution
specific guidelines. We strongly encourage that drug libraries and electronic
health records (EHRs), including the electronic medication administration
record, make distinct dierences for weight-based vs. non-weight-based dosing
so nurses can easily distinguish what pump programming is needed.
• These concentrations are guidelines only and are not mandatory. It is our
hope that organizations will voluntarily adopt these concentrations and join
a national movement to use standardization across the care continuum as an
error-prevention strategy for patient safety.
• The information contained in this table is subject to the professional judgment
and interpretation of the practitioner. ASHP has made reasonable eorts
to ensure the accuracy and appropriateness of the information presented.
However, any reader of this information is advised that ASHP is not responsible
for the continued currency of the information, for any errors or omissions,
and/or for any consequences arising from the use of the information in the
self-assessment tool. Any user of the table is cautioned that ASHP makes no
representation, guarantee, or warranty, express or implied, as to the accuracy
and appropriateness of the information contained in it, and will bear no
responsibility or liability for the results or consequences of its use.
CONSIDERATIONS IN USING THE
PEDIATRIC CONTINUOUS INFUSION
STANDARDS
The 80/20 rule was applied by the expert panel to
determine recommended standard concentrations.
The concentrations listed reflect those applicable
to most patient care circumstances. The panel
recognizes situations occur where the most
appropriate concentration for a patient may not be the
recommended standard.
Whenever possible one standard infusion concentration
is the recommendation. When more than one
standard concentration was recommended it was to
accommodate patient care needs for extremely small
neonates, fluid restrictions, dierences required for
peripheral versus central lines, to simplify calculations
and accommodate limitations of pump infusion rates.
Medications with more than one recommended
concentration are listed from lowest to highest
concentration, with the numbering corresponding to
the respective stability reference(s).
The concept of bracketing was employed for references
for stability. For more information review: https://www.
fda.gov/regulatory-information/search-fda-guidance-
documents/q1d-bracketing-and-matrixing-designs-
stability-testing-new-drug-substances-and-products.
The Pediatric Continuous Infusion Standards are
intended for children less than 50 kg.
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PEDIATRIC CONTINUOUS INFUSION STANDARDS
6
Drug
Concentration
Standards
Dosing
units
Commercially
available
Concentration vs.
unit mismatch
References
Alprostadil 1. 5 mcg/mL
2. 10 mcg/mL
mcg/kg/min No Possibly
depending on
vial
1. Pharmacia & Upjohn Company. Prostin VR
Pediatric® (alprostadil sterile solution) injection
prescribing information. Kalamazoo, MI; 2013
April. AHFS
2. Pharmacia & Upjohn Company. Prostin VR
Pediatric® (alprostadil sterile solution) injection
prescribing information. Kalamazoo, MI; 2013
April. AHFS
Alteplase 1 mg/mL mg/kg/hour No No 1a. Frazen BS, Maximal Dilution of Activase. Am J
Hosp Pharm, 1990;47:2016.
1b. Product Information: Activase(R) intravenous
injection, alteplase intravenous injection.
Genentech, Inc.(per Manufacturer), South San
Francisco, CA, 2015- Micromedix
Amiodarone 1. 1.8 mg/mL
2. 3.6 mg/mL
mcg/kg/min* Yes - 1.8 mg/
mL
Yes 1a. Campbell S, Nolan PE, Bliss M et al. Stability of
amiodarone hydrochloride in admixtures with
other injectable drugs. Am J Hosp Pharm. 1986;
43:917–21.
1b. Product Information: amiodarone HCl
intravenous injection, amiodarone HCl
intravenous injection. Teva Canada Limited (per
Health Canada), Toronto, ON, Canada, 2016. -
Micromedix
2. Product Information: amiodarone HCl
intravenous injection, amiodarone HCl
intravenous injection. Teva Canada Limited (per
Health Canada), Toronto, ON, Canada, 2016. -
Micromedix
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PEDIATRIC CONTINUOUS INFUSION STANDARDS
7
Drug
Concentration
Standards
Dosing
units
Commercially
available
Concentration vs.
unit mismatch
References
Argatroban 1 mg/mL mcg/kg/min* Yes Yes 1a. Product Information: argatroban injection,
argatroban injection. GlaxoSmithKline, Research
Triangle Park, NC, 2009.
1b. Product Information: argatroban IV injection
aqueous solution, argatroban IV injection
aqueous solution. The Medicines Company (per
DailyMed), Parsippany, NJ, 2011.
Bumetanide 1. 0.04 mg/mL
2. 0.25 mg/mL
mcg/kg/hour* Yes - 0.25 mg/
mL undiluted
drug from the
vial
Yes 1. Cornish LA, Montgomery PA, Johnson CE.
Stability of Bemetanide in 5% dextrose injection.
AJHP 1997;54:422-3
2. Roche Laboratories. Bumex® (bumetanide)
tablets and injection prescribing information.
Nutley, NJ; 1999 Feb.
Cisatracurium 1. 1 mg/mL
2. 2 mg/mL
mg/kg/hour Yes, undiluted
from the 2
mg/mL vial
Yes 1. Pignard J. Physiochemical stability study of
injectable solutions of cisatracurium besilate
in clinical conditions. Ann Fr Anesth Reamnim.
2014; 33:304-9.
2. Abbvie. Nimbex® (cisatracurium besylate)
injection prescribing information. North Chicago,
IL; 2016 Dec.
Clevidipine 0.5 mg/mL mcg/kg/min*             Yes Yes 1. Product Information: Cleviprex (clevidipine)
injectable emulsion. Chiesi USA Inc. Cary, NC.
2021 April
DexmedeTOMIDine 4 mcg/mL mcg/kg/hour Yes 1. Hospira. Precedex® (dexmedetomidine) injection
prescribing information. Lake Forest, IL; 2016
Apr.
ashp.org/standardize4safety
PEDIATRIC CONTINUOUS INFUSION STANDARDS
8
Drug
Concentration
Standards
Dosing
units
Commercially
available
Concentration vs.
unit mismatch
References
DOBUTamine 1. 1000 mcg/mL
2. 2000 mcg/mL
3. 4000 mcg/mL
mcg/kg/min Yes Possibly,
depending on
pharmacy or
outsourcing
facility lab
1. Hospira. Dobutamine in 5% dextrose injection
prescribing information. Lake Forest, IL; 2006
June.
2. Hospira. Dobutamine in 5% dextrose injection
prescribing information. Lake Forest, IL; 2006
June.
3. Hospira. Dobutamine in 5% dextrose injection
prescribing information. Lake Forest, IL; 2006
June.
DOPamine 1. 800 mcg/mL
2. 1600 mcg/mL
3. 3200 mcg/mL
mcg/kg/min Yes Possibly,
depending on
pharmacy or
outsourcing
facility label
1. Hospira. Dopamine hydrochloride and 5%
dextrose injection prescribing information. Lake
Forest, IL; 2014 May.
2. Hospira. Dopamine hydrochloride and 5%
dextrose injection prescribing information. Lake
Forest, IL; 2014 May.
3. Hospira. Dopamine hydrochloride and 5%
dextrose injection prescribing information. Lake
Forest, IL; 2014 May.
ashp.org/standardize4safety
PEDIATRIC CONTINUOUS INFUSION STANDARDS
9
Drug
Concentration
Standards
Dosing
units
Commercially
available
Concentration vs.
unit mismatch
References
EPINEPHrine
1
1. 10 mcg/mL
2
2. 20 mcg/mL
3. 40 mcg/mL
mcg/kg/min No Possibly,
depending on
pharmacy or
outsourcing
facility label
1. Hook R, Neault A, Scharrer, et.al. Chemical
stability of epinephrine 10 mcg/mL diluted
in 0.9% sodium chloride and stored in
polypropylene syringes at 4 degrees and 25
degrees C. Int J Pharm Compd. 2023;27:347-351.
2a. Allwood MD. The stability of four
catecholamines in 5% glucose infusions. J Clin
Pharm Ther. 1991:16:337-40.
2b. VanMatre ET, Ho KC, Lyda C, et.al. Extended
Stability of Epinephrine Hydrochloride Injection
in Polyvinyl Chloride Bags Stared in Amber
Ultraviolet Light-Blocking Bags. Hospital
Pharmacy. 2017;52:570-573.
3a. Carr RR, Decarie D, EnsomMHH. Stability of
Epinephrine at Standard Concentrations. Can J
Hosp Pharm. 2014;67:197-202.
3b. Peddicord TE, Olsen KM, ZumBrunnen TL,
et.al. Stability of high-concentration dopamine
hydrochloride, norepinephrine bitartrate,
epinephrine hydrochloride and nitroglycerin
5% dextrose injetion. Am J Health-Syst Pharm.
1997;54:1417-19.
ashp.org/standardize4safety
PEDIATRIC CONTINUOUS INFUSION STANDARDS
10
Drug
Concentration
Standards
Dosing
units
Commercially
available
Concentration vs.
unit mismatch
References
Esmolol 1. 10 mg/mL
2. 20 mg/mL
mcg/kg/min* Yes Yes 1. Baxter. Brevibloc® injection (esmolol
hydrochloride) prescribing information. (dated
1998 Jun). In: Physicians’ desk reference. 54th
ed. Montvale NJ: Medical Economics Company
Inc; 2000:655-7.
2. Baxter. Brevibloc® injection (esmolol
hydrochloride) prescribing information. (dated
1998 Jun). In: Physicians’ desk reference. 54th
ed. Montvale NJ: Medical Economics Company
Inc; 2000:655-7.
FentaNYL 1. 10 mcg/mL
2
2. 50 mcg/mL
mcg/kg/hour Yes, as
undiluted
from 50 mcg/
mL vial
Possibly
depending on
pharmacy or
oursourcing
facility label
1. Extedned Stability for Parenteral Drugs 6th
Edition, 2017. Ed. Bing, CD et. al. ASHP, 4500
East-West Highway, Suite 900, Bethesda, MD
20814
2. Hospira, INC. Fentanyl Citrate injection, solution.
prescribing information. Lake Forest, IL; 2019,
December.
Furosemide 1. 2 mg/mL
2. 10 mg/mL
mg/kg/hour Yes, as
undiluted
from 10 mg/
mL vial
No 1. Negro S, Rendon AL, Azuara M, et.al.
Compatibility and Stability of Furosemide and
Dexamethasone Comined in Infusion Solutions.
Arzneimittelforschung. 2006;56:714-20.
2. American Pharmaceutical Partners, Inc.
Furosemide Injection, USP prescribing
information. Schaumburg, IL; 2002 Apr.
Heparin
(anticoagulation
therapy)
1. 50 units/mL
2. 100 units/mL
units/kg/hour Yes No 1. B.Braun Medical Inc. Heparin Sodium in Dextrose
Injection prescribing information. Bethlehm, PA.
2018. April
2. B.Braun Medical Inc. Heparin Sodium in Dextrose
Injection prescribing information. Bethlehm, PA.
2018. April
Heparin (arterial
line maintenance) 
2 Units/mL Yes No 1. Butt W, et.al. Eect of heparin concentration
and infusion rate on the patency of arterial
catheters. Crit Care Med. 1987,15:230-2.
ashp.org/standardize4safety
PEDIATRIC CONTINUOUS INFUSION STANDARDS
11
Drug
Concentration
Standards
Dosing
units
Commercially
available
Concentration vs.
unit mismatch
References
HYDROmorphone
3
1. 0.2 mg/mL
2. 1 mg/mL
3. 5 mg/mL
mg/kg/hr No, but many
pharmacies
purchase from
outsourcing
facilities
Possibly
depending on
pharmacy label
or oursourcing
facility label
1. Ensom MHH, DeCarie D, Leung K, et al. Stability
of hydromorphone-ketamine solutions in
glass bottles, plastic syringes, and IV bags
for pediatric use. Can J Hosp Pharm. 2009;
62(2):112b.
2. Extended Stability for Parenteral Drugs 6th
Edition, 2017. Ed. Bing, CD et. al. ASHP, 4500
East-West Highway, Suite 900, Bethesda, MD
20814
3. Extended Stability for Parenteral Drugs 6th
Edition, 2017. Ed. Bing, CD et. al. ASHP, 4500
East-West Highway, Suite 900, Bethesda, MD
20814
Insulin (regular) 1. 0.2 units/mL
2. 1 unit/mL
units/kg/hour Yes Possibly
depending on
pharmacy label
or oursourcing
facility label
1. Product Information: HUMULIN(R) R
subcutaneous injection, intravenous injection,
insulin human subcutaneous injection,
intravenous injection. Lilly USA LLC (per FDA),
Indianapolis, IN, 2018. Micromedex
2a. Nolan PE, Hoyer GL, LeDoux JH et al. Stability
of ranitidine hydrochloride and human insulin
in 0.9% sodium chloride injection. Am J Health-
Syst Pharm. 1997.
2b. Product Information: HUMULIN(R) R
subcutaneous injection, intravenous injection,
insulin human subcutaneous injection,
intravenous injection. Lilly USA LLC (per FDA),
Indianapolis, IN, 2018. Micromedex
ashp.org/standardize4safety
PEDIATRIC CONTINUOUS INFUSION STANDARDS
12
Drug
Concentration
Standards
Dosing
units
Commercially
available
Concentration vs.
unit mismatch
References
Isoproterenol 1. 20 mcg/mL
2. 64 mcg/mL
mcg/kg/min No Possibly
depending on
pharmacy label
or oursourcing
facility label
1. Isuprel (isoproterenol hydrochloride injection,
USP) [prescribing information]. Lake Forest,
IL: Hospira Inc; March 2013. Pediatric Injectable
drugs 11th edition
2a. Sinclair-Pingel J, Grisso AG, Hargrove FR,
Wright L. Implementation of standardized
concentrations for continuous infusions using
a computerized provider Order Entry System
[published correction appears in Hosp Pharm.
2007; 42:84-85]. Hosp Pharm. 2006;41:1102-
1106.
2b. Sturgill MG, Kelly M, Notterman DA.
Pharmacology of the cardiovascular system.
In: Fuhrman BP, Zimmerman JJ, eds. Pediatric
Critical Care. 4th ed. Philadelphia, PA: Elsevier
Saunders; 2011. Pediatric Injectable Drugs 11th
edition
Ketamine 1. 2 mg/mL
2. 10 mg/mL
mg/kg/hour Yes, undiluted
drug from the
vial of 10 mg/
mL
Possibly
depending on
pharmacy label
or oursourcing
facility label
1. Product Information: KETALAR intravenous
injection, intramuscular injection, ketamine HCl
intravenous injection, intramuscular injection.
Par Pharmaceutical (per FDA), Chestnut Ridge,
NY, 2017.
2. Product Information: KETALAR intravenous
injection, intramuscular injection, ketamine HCl
intravenous injection, intramuscular injection.
Par Pharmaceutical (per FDA), Chestnut Ridge,
NY, 2017.
ashp.org/standardize4safety
PEDIATRIC CONTINUOUS INFUSION STANDARDS
13
Drug
Concentration
Standards
Dosing
units
Commercially
available
Concentration vs.
unit mismatch
References
Labetalol 1. 1 mg/mL
2. 5 mg/mL
mg/kg/hour Yes, undiluted
drug from the
vial of 5 mg/
mL
Possibly
depending on
pharmacy label
or oursourcing
facility label
1. Product Information: labetalol HCl intravenous
injection, labetalol HCl intravenous injection.
Hospira, Inc. (per DailyMed), Lake Forest, IL,
2015.
2. Product Information: labetalol HCl intravenous
injection, labetalol HCl intravenous injection.
Hospira, Inc. (per DailyMed), Lake Forest, IL,
2015.
Lidocaine
4
1. 4 mg/mL
2. 8 mg/mL
mcg/kg/min* Yes, with
commercially
available
product
1a. Smith FM, Nuessle NO. Stability of lidocaine
hydrochloride in 5% dextrose injection in plastic
bags. Am J Hosp Pharm. 1981; 38:1745–7.
1b. Product Information: Lidocaine HCl dextrose
5% intravenous injection, lidocaine HCl dextrose
5% intravenous injection. Baxter Healthcare
Corporation (per FDA), Deerfield, IL, 2017.
2a. Stewart JT, Warren FW. Stability of ranitidine
hydrochloride and seven medications. Am J
Hosp Pharm. 1994; 51:1802–7.
2b. Product Information: Lidocaine HCl dextrose
5% intravenous injection, lidocaine HCl dextrose
5% intravenous injection. Baxter Healthcare
Corporation (per FDA), Deerfield, IL, 2017.
ashp.org/standardize4safety
PEDIATRIC CONTINUOUS INFUSION STANDARDS
14
Drug
Concentration
Standards
Dosing
units
Commercially
available
Concentration vs.
unit mismatch
References
Midazolam 1. 0.3 mg/mL
(easier pump
programming
than 0.35
mg/mL less
decimal)
2. 1 mg/mL
3. 5 mg/mL
mg/kg/hour Yes, undiluted
drug from the
vial of 1 mg/
mL vial and 5
mg/mL vial
Possibly,
depending on
pharmacy or
outsourcing
facility label
1. Good PD, Schneider JJ, Ravenscroft PJ. The
compatibility and stability of midazolam and
dexamethasone in infusion solutions. J Pain
Sympt Manag. 2004;27: 471-5.
2a. Karlage K, Earhart Z, Green-Boesen K, Myrdal
PB. Stability of midazolam hydrochloride
injection 1-mg/mL solutions in polyvinyl chloride
and polyolefin bags.Am J Health Syst Pharm.
2011;68(16):1537-1540.[PubMed 21817086].
2b. McMullin ST, Schai RA, and Dietzen DJ,
“Stability of Midazolam Hydrochloride in
Polyvinyl Chloride Bags Under Fluorescent
Light,” Am J Hosp Pharm, 1995, 52(18), 2018-20.
3a. Pramar YV, Loucas VA, & El-Rachidi A: Stability
of midazolam hydrochloride in syringes and IV
fluids. Am J Health-Syst Pharm 1997; 54:913-915.
3b. Product Information: MIDAZOLAM HCl
intravenous intramuscular injection, midazolam
HCl intravenous intramuscular injection. Heritage
Pharmaceuticals (per DailyMed), Eatontown, NJ,
2017.
ashp.org/standardize4safety
PEDIATRIC CONTINUOUS INFUSION STANDARDS
15
Drug
Concentration
Standards
Dosing
units
Commercially
available
Concentration vs.
unit mismatch
References
Milrinone 1. 100 mcg/mL
2. 200 mcg/mL
mcg/kg/min Yes - 200
mcg/mL
No 1. Wilson TD, Forde MD. Stability of milrinone
and epinephrine, atropine sulfate, lidocaine
hydrochloride, or morphine sulfate injection. Am
J Hosp Pharm. 1990;47(11):2504-7.
2a. Wilson TD, Forde MD, Crain AVR, Dombrowski
LJ, Joyce MA. Stability of milrinone in 0.45%
sodium chloride, 0.9% sodium chloride, or
5% dextrose injections.Am J Hosp Pharm.
1986;43(9):2218-2220.
2b. Wong F, Gill MA. Stability of milrinone lactate
200 mcg/mL in 5% dextrose injection and
0.9% sodium chloride injection. Int J Pharm
Compound. 1998; 2(2):168b
Morphine 1. 0.2 mg/mL
2. 0.5 mg/mL
3. 1 mg/mL
mg/kg/hour Yes, undiluted
drug from
the vial of 1
mg/mL vial
or ready-to-
use products
or premix
products
available
Possibly
depending on
pharmacy label
or oursourcing
facility label
1. Veechio M, Walker SE, Iazzetta J et al. The
stability of morphine intravenous infusion
solutions. Can J Hosp Pharm. 1988; 41:5–9.
2a. McMullin ST, Schai RA, and Dietzen DJ,
“Stability of Midazolam Hydrochloride in
Polyvinyl Chloride Bags Under Fluorescent
Light,” Am J Hosp Pharm, 1995, 52(18), 2018-20.
2b. Altman L, Hopkins RJ, Ahmed S, et al: Stability
of morphine sulfate in Cormed III (Kalex)
intravenous bags. Am J Hosp Pharm 1990;
47:2040-2042
3. Stiles ML, Tu YH, & Allen LV Jr: Stability of
morphine sulfate in portable pump reservoirs
during storage and simulated administration.
Am J Hosp Pharm 1989; 46:1404-1407.
ashp.org/standardize4safety
PEDIATRIC CONTINUOUS INFUSION STANDARDS
16
Drug
Concentration
Standards
Dosing
units
Commercially
available
Concentration vs.
unit mismatch
References
Naloxone
5
1. 16 mcg/mL
2. 40 mcg/mL
3. 400 mcg/mL
mcg/kg/hour Yes, 0.4 mg/
mL vials,
however will
most likely
compound
from 1 mg/mL
vials
Yes 1a. Product Information Naloxone Hydrochloride
Injection, solution. Hospira Inc. Lake Forest, IL.
9/2019. 4 mcg/ml.
1b. Lewis JM, Klein-Schwartz W, Benson BE,
et al. Continuous naloxone infusion in
pediatric narcotic overdose. Am J Dis Child.
1984;138(10):944–946. 8 mcg/ml
2. American Pain Society.Principles of Analgesic
Use in the Treatment of Acute Pain and Cancer
Pain. 6th ed. Glenview, IL: American Pain
Society; 2008.
3. Product Information Naloxone Hydrochloride
Injection, solution. Hospira Inc. Lake Forest, IL.
9/2019.
NiCARdipine 1. 0.1 mg/mL
2. 0.2 mg/mL
3. 0.5 mg/mL
mcg/kg/min* Yes - 0.1 mg/
mL
Yes 1. Product Information: CARDENE(R) IV solution
for IV infusion, nicardipine HCL solution for IV
infusion. EKR Therapeutics, Inc, Bedminster, NJ,
2014.
2. Product Information: CARDENE(R) IV solution
for IV infusion, nicardipine HCL solution for IV
infusion. EKR Therapeutics, Inc, Bedminster, NJ,
2014.
3. Baaske DM, DeMay JF, Latona CA, et al.
Stability of Nicardipine Hydrochloride in
Intravenous Solutions.Am J Health Syst
Pharm.1996;53(14):1701-1705
Nitroglycerin 1. 200 mcg/mL
2. 400 mcg/mL
mcg/kg/min Yes No, product
does have
concentration in
mcg/mL
1. Product Information: Nitroglycerin Injection.
Abbott Laboratories, North Chicago, IL,October
2014
2. Product Information: Nitroglycerin Injection.
Abbott Laboratories, North Chicago, IL,October
2014
ashp.org/standardize4safety
PEDIATRIC CONTINUOUS INFUSION STANDARDS
17
Drug
Concentration
Standards
Dosing
units
Commercially
available
Concentration vs.
unit mismatch
References
Nitroprusside 1. 200 mcg/mL
2. 500 mcg/mL
mcg/kg/min Yes Possibly
depending on
pharmacy label
or oursourcing
facility label
1. Product Information: NIPRIDE RTU intravenous
injection, sodium nitroprusside intravenous
injection. Exela Pharma Sciences, LLC (per FDA),
Lenoir, NC, 2017.
2. Product Information: NIPRIDE RTU intravenous
injection, sodium nitroprusside intravenous
injection. Exela Pharma Sciences, LLC (per FDA),
Lenoir, NC, 2017.
Norepinephrine 1. 16 mcg/mL
2
2. 32 mcg/mL
3. 64 mcg/mL
mcg/kg/min Yes Possibly
depending on
pharmacy label
or oursourcing
facility label
1. Tremblay M, Lessard MR, Trepanier CA, et al:
Stability of norepinephrine infusions prepared
in dextrose and normal saline solutions. Can J
Anaesth 2008; 55(3):163-167.
2. Hasegawa GR, Eder JR. Visual compatibility of
dobutamine hydrochloride with other injectable
drugs. Am J Hosp Pharm 1984;41:949-51.
3. Walker SE, Law S, Garland J, et al: Stability of
norepinephrine solutions in normal saline and
5% dextrose in water. Can J Hosp Pharm 2010;
63(2):113-118.
Octreotide 1. 2.5 mcg/mL
2. 10 mcg/mL
3. 50 mcg/mL
mcg/kg/hour No, however
the 50
mcg/ml
concentration
may be used
undiluted
from the
available vial/
ampule.
Possibly
depending on
pharmacy label
or oursourcing
facility label
1. Novartis Pharmaceuticals. Sandostatin®
(octreotide acetate) injection prescribing
information. East Hanover, NJ; 2012 March.
2. Novartis Pharmaceuticals. Sandostatin®
(octreotide acetate) injection prescribing
information. East Hanover, NJ; 2012 March.
3. Novartis Pharmaceuticals. Sandostatin®
(octreotide acetate) injection prescribing
information. East Hanover, NJ; 2012 March.
ashp.org/standardize4safety
PEDIATRIC CONTINUOUS INFUSION STANDARDS
18
Drug
Concentration
Standards
Dosing
units
Commercially
available
Concentration vs.
unit mismatch
References
Pantoprazole 0.8 mg/mL mg/kg/hour No No 1a. Donnelly RF. Stability of pantoprazole sodium
in glass vials, polyvinyl chloride minibags, and
polypropylene syringes. Can J Hosp Pharm. 2011;
64:192-8.
1b. Wyeth. Protonix® (pantoprazole sodium) I.V. for
injection prescribing information. Philadelphia,
PA; 2012 May.
PENTobarbital 1. 8 mg/mL
2. 50 mg/mL
mg/kg/hour Yes, undiluted
drug from the
50 mg/mL vial
no 1. Walker SE, Iazzetta J. Compatibility and stability
of pentobarbital infusions. Anesthesiology. 1981;
55:487–9.
2a. Gupta VD. Stability of pentobarbital sodium
after reconstitu tion in 0.9% sodium chloride
injection and repackaging in glass and
polypropylene syringes.International Journal of
Pharmaceutical Compounding.2001, 5(6): 482-
484.
2b. Nembutal(R) Sodium intravenous injection,
intramuscular injection, pentobarbital sodium
intravenous injection, intramuscular injection.
Akorn, Inc. (per DailyMed), Lake Forest, IL, 2012.
Phenylephrine 1. 80 mcg/mL
2. 400 mcg/mL
mcg/kg/min No Possibly
depending on
pharmacy label
or oursourcing
facility label
1a. West-Ward Pharmaceuticals. Phenylephrine
hydrochloride injection prescribing information.
Eatontown, NJ; 2012 Dec.
1b. Éclat Pharmaceuticals. Vazculep® (phenylephrine
hydrochloride) injection prescribing information.
Chesterfield, MO; 2014
2. Jansen JJ, Oldland AR, Kiser TH. Evaluation of
phenylephrine stability in polyvinyl chloride
bags. Hosp Pharm. 2014; 49:455-7.
Propofol 10 mg/mL mcg/kg/min* Yes Yes 1. Fresenius Kabi USA, LLC. Diprivan® (propofol)
injectable emulsion prescribing information.
Lake Zurich, IL; 2017 Nov.
ashp.org/standardize4safety
PEDIATRIC CONTINUOUS INFUSION STANDARDS
19
Drug
Concentration
Standards
Dosing
units
Commercially
available
Concentration vs.
unit mismatch
References
Remifentanil 1. 50 mcg/mL
(non-recon vial
straight drug)
2. 250 mcg/mL
mcg/kg/min No Possibly
depending on
pharmacy label
or oursourcing
facility label
1. Mylan Institutional LLC. Ultiva® (remifentanil
hydrochloride) prescribing information.
Rockford, IL; 2017 Dec.
2. Mylan Institutional LLC. Ultiva® (remifentanil
hydrochloride) prescribing information.
Rockford, IL; 2017 Dec.
Rocuronium 10 mg/mL mg/kg/hr Yes, undiluted
drug from the
vial of 10 mg/
mL
Possibly
depending on
pharmacy label
or oursourcing
facility label
1. Hospira. Rocuronium bromide injection
prescribing information. Lake Forest, IL: 2014
Feb.
Sodium
Bicarbonate
1. 0.5 mEq/mL
2. 1 mEq/mL
mEq/kg/hour Yes, undiluted
if using the
prefilled 0.5
mEq/mL
syringes and
as undiluted
drug from the
1 mEq/mL vial
No 1. Hospira. Sodium Bicarbonate Injection, USP
Vial dosage and administration. Lake Forest, IL.
1/2018.
2. Hospira. Sodium Bicarbonate Injection, USP
Vial dosage and administration. Lake Forest, IL.
5/2018.
Sodium Chloride 0.5 mEq/mL (3%) mL/kg/hour
vs. mEq/kg/
hour, depending
on institution
protocols
Yes, as 500
mL bags
Yes, based on
dosing units
used
1. Product information: sodium chloride 3%
5% intravenous injection, Baxter Healthcare
Corporation (per DailyMed) Deerfield, IL, 20014.
Tacrolimus 0.02 mg/mL mg/kg/day No Possibly
depending on
pharmacy label
or oursourcing
facility label
1. Astellas Pharma US, Inc. Prograf® (tacrolimus)
capsules and injection prescribing information.
Northbrook, IL; 2015 May.
ashp.org/standardize4safety
PEDIATRIC CONTINUOUS INFUSION STANDARDS
20
Drug
Concentration
Standards
Dosing
units
Commercially
available
Concentration vs.
unit mismatch
References
Terbutaline 1 mg/mL mcg/kg/min* Yes, undiluted
from the 1
mg/mL vial
Possibly
depending on
pharmacy label
or oursourcing
facility label
1. Glascock JC, DiPiro JT, Cadwallader DE et al.
Stability of terbutaline sulfate repackaged in
disposable plastic syringes. Am J Hosp Pharm.
1987; 44:2291–3.
Tranexamic Acid 100 mg/mL
(straight drug)
mg/kg/hour Yes, undiluted
from the 100
mg/mL vial
No 1. Pfizer Injectables. Cyklokapron® (tranexamic
acid) injection prescribing information. New
York, NY; 2013 May.
Vasopressin 1. 0.04 units/mL
2. 0.2 units/mL
3. 1 units/mL
VASOCONSTRICTION/
GI BLEED:
milliunits/kg/
min*
     
DIABETES INSIPIDUS:
milliunits/kg/hr*
No Yes 1. Wise-Faberowski L, Soriano SG, Ferrari L, et
al. Perioperative management of diabetes
insipidus in children. J Neurosurg Anesthesiol.
2004;16(3):220-225.
2. ASHP Interactive Handbook on Injectable Drugs
Accessed July 13, 2020
3. Par Pharmaceutical Companies, Inc. Vasostrict®
(vasopressin) injection prescribing information.
Spring Valley, NY; 2015 Mar.
Vecuronium 1 mg/mL
2
mg/kg/hr No, but when
the vial is
diluted then
no further
dilution is
needed
Yes 1. Product InformationL Vecuronium bromide
ntravenous injection lyophilized powder
for solution. Fresenius Kabi USA, LLC (per
DailyMed) Lake Zurich, IL. 2016
*BOLD - dosing units dier from concentration units
Updated: June 2024
NOTES
1 The expert panel and ISMP recommend dierent concentrations of epinephrine vs. norepinephrine given dierent indications despite same dosing units.
2 Babies under 500 gms may require a lower concentration.
3 The hydromorphone standard concentrations are intended for continuous infusion devices and NOT via PCA.
4 The recommended concentrations are intended for cardiac indications only.
5 The panel recognizes these two concentrations are 10x dierences, however these are the only two concentrations studied for stability.