Download IV DRUGS in the EMERGENCY ROOM

Cardiovascular Effects of some
IV DRUGS
in the ER
S HA NE B A R CL AY
J U NE 3 0 , 20 1 5
Objectives
1. Review of the Cardiovascular Effects of some IV ER drugs
2. Review of Conscious Sedation drugs and protocols
3. Review of Ventilator Sedation management.
Cardiovascular effects
of some IV drugs
in the ER
Remember pharmacology from med school !
• Alpha 1 – Agonists cause peripheral vasoconstriction. Antagonists
cause vasodilation
• Alpha 2 – CNS mediated, agonists cause hypotension, sedation…
• Beta 1 – Heart effects: inotropic (strength of contraction),
chronotropic (heart rate), dromotropic (‘conduction’)
• Beta 2 – Lung effects: Agonists cause bronchodilation. Antagonists
cause bronchoconstriction
Drug
Phenylephrine
a1
+++
b1
b1
b1
Inotr Chron Dromo
b2
V/C
V/D
Phenylnephrine
• Uses: cardiogenic shock, decompensated atrial fib,
diastolic heart failure..
• Can be used as a bolus or infusion, although usually
it is used in small boluses.
Drug
Phenylephrine
Epinephrine
a1
b1
b1
b1
Inotr Chron Dromo
b2
+++
++
+++
++
++
++
V/C
V/D
Epinephrine
• Uses: ACLS – V. Fib/V-Tach, asystole (1:10,000
solution IV)
• Uses: Anaphylaxis – (1:1,000 solution S.C. )
• Pressor: post intubation
• As a pressor can be given as an IV bolus or infusion.
Mixing
Phenylephrine and Epinephrine
Phenylephrine:
With a 5 ml syringe, draw 1 ml of 50mg/ml (1 vial) Phenylnephrine.
Mix it in 100 cc minibag of normal saline
Draw out 3 – 5 cc of solution.
This is now Phenylephrine of 100 mcg/ml
Put labels on both the minibag and the syringe
Dose is 50 – 100 mcg/min ie give 0.5 – 1 ml q2-5 minutes.
Action is within 1 minutes and lasts for 10-20 min.
Mixing
Phenylephrine and Epinephrine
Epinephrine:
Take a 10 cc N/S syringe. Discard 1 cc.
Take a preloaded syringe of Epi 1:10,000 from the cardiac drawer.
Take the bottom stopper off the syringe.
With the 9 cc Saline syringe, draw out 1 cc Epi (1:10,000)
You now have 10 mls of Epinephrine 10 mcg/ml
Dose is 0.5 – 2 ml (5-20 mcg) q 2-5 min
Onset 1 minute, duration 2-5 minutes.
Drug
Phenylephrine
Epinephrine
Norepinephrine
a1
b1
b1
b1
Inotr Chron Dromo
b2
+++
++
+++
++
++
++
+++
++
++
++
+
V/C
V/D
Norepinephrine Dosage
“Up to Date” Dosages
Hypotension/Shock
Start 0.1 mcg/kg/min – (range 0.1-1.5 mcg/kg/min)
Sepsis
Start 0.01 mcg/kg/min (range 0.01 – 3 mcg/kg/min)
Norepinephrine Dosage
“One starting dose”
0.03 mcg/kg/min then titrate.
Drug
Phenylephrine
Epinephrine
Norepinephrine
Dobutamine
a1
b1
b1
b1
Inotr Chron Dromo
b2
+++
++
+++
++
++
++
+++
++
++
++
+
++
++
+
V/C
V/D
Dobutamine
The “cardiac squeeze” drug
Start 2 mcg/kg/min
Drug
a1
b1
b1
b1
Inotr Chron Dromo
b2
V/C
V/D
Dopamine
Dopaminergic:
0.5-2 mcg/kg/min
Renal
V/D
Beta 1 effects:
+
2-10 mcg/kg/min
Alpha effects:
> 10mcg/kg/min
+
+
Drug
Digoxin
Atropine
a1
b1
b1
b1
Inotr Chron Dromo
+
+
+SA/+AV
b2
V/C
V/D
Atropine and Scopolamine
Anticholinergic antimuscarinic
In addition to increasing heart rate can cause dry
mouth, urinary retention, blurred vision,
mydriasis, reduce bowel spasm, agitation,
confusion, drowsiness and amnesia.
Use prior to intubation?
Drug
Digoxin
a1
b1
b1
b1
Inotr Chron Dromo
+
Atropine
Calcium
+
+
+SA/+AV
b2
V/C
V/D
Calcium - indications
1. Hypocalcemia
2. Calcium channel blocker overdose
3. Hemorrhagic shock
4. Hyperkalemia
5. Hypermagnesemia
Calcium – 2 Forms
Calcium Chloride
Is in the crash cart.
Quickly cleaved in the plasma to free Calcium and Chloride
Usual dose is 1-2 gm (but can be as much as 4-5 gm)
Is usually recommended to be given via a central line or
a Very good antecubital vein.
Injection into tissue/interstitial can cause necrosis and sloughing.
Calcium – 2 Forms
Calcium Gluconate
Now kept upstairs
Metabolized in the liver to free calcium
Usual dose is 3 times that of CaCl (ie 3 -6 gm)
Can be given through a peripheral IV line.
Calcium – Administration
Calcium Chrolide
Comes in 1 gm/10 ml vial
Give maximum 1 ml/minute – i.e. 10 minutes
Calcium Gluconate
Give 3 gm over 15-20 minutes.
Drug
DihydropyridoneNifedipine
Non-Dihydropyridone
(Phenylakytlamine)
Verapamil
Non-Dihydropyridone
(Benzothiazepine)
Diltiazem
Amiodarone
a1
b1
b1
b1
Inotr Chron Dromo
b2
V/C
V/D
-
-
-
Arterial V/D
No venous V/D
--
-
-
Min. Art V/D
-
-
-
Arterial V/D
+
-
Using Diltiazem versus Amiodarone
• Diltiazem has negative inotropic and chronotropic
effects, but does inhibit the SA and AV node to treat
arrhythmias.
• Amiodarone has positive inotropic effects along with
negative dromotropic effects on both the SA and AV
node.
Decompensated Atrial Fibrillation
• Patient presents with rapid Atrial Fibrillation.
• Heart rate is 185 bpm.
• BP 80/40 MAP 53
• Treatment options?
• Sure can try cardioversion, but it usually doesn’t
work.
Decompensated Atrial Fibrillation
• Get BP and MAP up first
• Phenylephrine 50 -100 mcg aliquots until systolic at least
up to 90 or ideally MAP up to 60-65.
• Then give Amiodarone 150 mg IV bolus then drip
or
• Diltiazem 2.5 mg/min until HR > 100 or maximum 50 mg.
Drug
a1
Beta Blockers
_
b1
b1
b1
Inotr Chron Dromo
_
__
-SA/AV
b2
-
V/C
V/D
Drug
b1
b1
b1
Inotr Chron Dromo
a1
Beta Blocker
-
Epinephrine
++
b2
-
--
-SA/AV
-
+++
++
+SA/AV
++
V/C
V/D
Clinical Scenario
58 year old presents with anaphylaxis after inadvertently eating
shellfish, to which he has a known severe allergy.
Past Hx: type 2 diabetes, AMI 1 yr ago.
Meds: Metformin, Atorvastatin, ASA, Ramipril, Metoprolol, Pantoloc.
105/68, HR 78, Sats 92%
Management:
You start IV, give 0.5 mg Epinephrine 1:1000 IM
No response to the Epi.
What do you do now?
Glucagon
Promotes gluconeogenesis
Promotes production of cAMP (including in the myocardium)
Therefore can ‘get around’ beta blockade.
Used for impacted food bolus in the esophagus, hypoglycemia,
blocker overdose or in patients on beta blockers having
anaphylactic reactions
Dose: 1 – 2 mg Glucagon IV
Drug
a1
Beta Blockers
_
Nitroglycerine
Low dose ven V/D
High dose art V/D
b1
b1
b1
Inotr Chron Dromo
_
__
+
-SA/AV
b2
V/C
V/D
+
+
Nitroglycerin
• Predominately a venodilator, but at high doses is also an arteriodilator.
• Reduce preload and afterload.
• Preload reduction (venous V/D) decreases myocardial O2 demand.
• Afterload reduction increases stroke volume and ejection fraction
• Active metabolite is Nitric Oxide (not nitrous oxide!)
Nitroglycerin – bioavailability
• Oral table Nitro - < 1% bioavailable due to liver metabolism.
• SL nitro – onset within 1-2 minutes and is about 30-40% bioavailable.
• So a 400 mcg spray dose has about 100 + mcg plasma level for 4-5
minutes
• Nitro patch – takes 15 minutes before any plasma level is detectable
and peaks by 3-4 hours. Is about 60-70% bioavailable.
• So a 400 mcg patch will have about 250 mcg plasma level but will take
up to 2 hours to attain that level.
Drug
a1
Beta Blockers
_
Nitroglycerine
ACE Inhibitors
b1
b1
b1
Inotr Chron Dromo
_
Low dose ven V/D
High dose art V/D
__
+
-
-SA/AV
b2
V/C
V/D
+
+
+
Drug
a1
Beta Blockers
_
Nitroglycerine
ACE Inhibitors
Mg Sulfate
b1
b1
b1
Inotr Chron Dromo
_
Low dose ven V/D
High dose art V/D
__
+
-SA/AV
b2
V/C
V/D
+
-
+
+
+
Drug
Phentolamine
a1
b1
b1
b1
Inotr Chron Dromo
b2
V/C
V/D
++
Phentolamine
Use in extravasation injuries from vasopressors
(ie norepi, vasopressin, epinephrine..)
Prevention:
1. Avoid hand and wrist IVs for pressors
2. Avoid lousy IV’s generally for pressors
3. Can add 10 mg Phentolamine to each liter of IV
solution containing norepinephrine.
4. Did I mention avoiding crappy peripheral IVs?
Treatment Steps:
Phentolamine
1. Stop the IV but don’t remove it.
2. Start the vasopressor in another line.
3. Suck out as much as you can from the blown IV.
4. Comes in 5 mg per 1 ml vial. Place in 9 ml of N/S
5. Administer up to 0.2 mg/kg into the catheter and S.C. around
the site
6. Watch for systemic hypotension (should be on a pressor)
7. Call plastics.
Drug
Ketamine
a1
b1
b1
b1
Inotr Chron Dromo
_
+
b2
+
V/C
V/D
Ketamine
- Interacts with at least 10 different receptors.
- One of these are the opioid receptors
- Negative inotrope but due to secondary CNS simulation causes
increase in pulmonary BP, heart rate, cardiac output and myocardial
O2 demand.
- Usually there will be no change in systemic vascular resistance.
- Possesses bronchodilator activity.
- Does not increase ICP. (NeuroCritCare Aug 2014)
Ketamine
Dosing
- Analgesic dosing (sub dissociative) – 0.1 - 0.2 mg/kg
- Procedural sedation – 0.25 – 0.5 mg/kg. Can be associated with
‘nightmare’ like haze.
- Dissociative dose – 1 – 2 mg/kg
- Withdrawal agitation associated more with younger age, comorbidity and dose. (~15-35%)
Drug
Ketamine
Fentanyl
a1
b1
b1
b1
Inotr Chron Dromo
_
+
_
b2
+
V/C
V/D
Fentanyl
Usually has minimal or no effect on BP, LV Pressure and cardiac
output.
Initial boluses can decrease MAP.
May have some negative Chronotropy (decrease HR) that can be
treated with atropine.
Addition of benzodiazepines can cause CV depression
Alfentanil
Opioid analgesic
1/4 - 1/10 as potent as Fentanyl.
Can be used in sublingual form for pain control
Single injection can last up to 30 minutes, S.L. 10-15 minutes.
Usual dose is 8- 40 mcg/kg IV, 0.56 mg SL
Onset of action IV is 4 times faster than Fentanyl
Very few CV effects other than bradycardia
Side effects can be respiratory depression, muscle rigidity
Remifentanil
Opioid analgesic
Approximately twice as potent as Fentanyl.
Usually used as an infusion.
Very short half life ~ 4 minutes (1 – 11 minutes)
Causes decrease HR, BP, RR, tidal volume.
Side effects can be muscle rigidity (dose and speed related), pruritus
Drug
Ketamine
a1
b1
b1
b1
Inotr Chron Dromo
_
Fentanyl
Morphine
+
b2
V/C
V/D
+
_
_
++
Morphine
Lowers BP via decreasing alpha adrenergic tone
mediated through the CNS.
Drug
Ketamine
a1
b1
b1
b1
Inotr Chron Dromo
_
Fentanyl
Morphine
Propofol
+
b2
V/C
V/D
+
_
_
++
++
Propofol
• Can cause large reduction in MAP via venous and
arterial vasodilation.
• It also blocks normal baroreceptor mediated
tachycardia which would normally counteract these
changes.
Drug
Ketamine
a1
b1
b1
b1
Inotr Chron Dromo
_
Fentanyl
Morphine
Propofol
Midazolam
+
b2
V/C
V/D
+
_
_
++
++
Midazolam
Has minimal CV effects.
In the pipeline
Etomidate
- Hypnotic amnestic drug with no analgesic properties
- Onset of action within 1 minute, lasts 3-5 minutes
- Minimal CV or pulmonary effects except in the elderly.
Dexmedetomidine
Alpha 2 receptor agonist
Used in ICU by continuous infusion on ventilated patients
Questions?
Procedural Sedation
The biggest obstacles for emergency physicians
to effectively and safely treat patients with
analgesia and sedation are:
Hospital Bureaucracy and Anesthesiologists
Procedural Sedation
ACEP October 2013 – “Procedural Sedation and Analgesia in the Emergency
Department”
1. Does preprocedural fasting reduce risk of emesis or aspiration?
n0 – preprocedural fasting has not shown to reduce the risk of
emesis or aspiration. (level B)
2. Does capnography reduce the incidence of adverse respiratory events?
- capnography may detect hypoventilation and apnea earlier
than oximetry and/or clinical assessment. (level B)
Procedural Sedation
ACEP October 2013 – “Procedural Sedation and Analgesia in the
Emergency Department”
3. What is the minimum number of personnel necessary to manage
sedation complications?
Besides the attending physician, one other nurse or qualified
individual should be present for sedation. (level C)
4. Can Propofol and Ketamine be safely administered in the ER for
sedation?
Ketamine can be safely administered to children. Propofol can
safely be administered to children and adults. (level A)
Procedural Sedation
Pre-oxygenate with non re-breather for 5 minutes.
Will delay/blunt the O2 saturation measurements.
Use EtCO2 – more sensitive for apnea/hypoxia
Procedural Sedation
First – consider the degree of sedation you want and
the implications.
Can be from simple IM/PO analgesia, which is
sedating, to full general anesthesia.
Procedural Sedation
Minimal sedation
Analgesia
Responsiveness
Airway
Spontaneous
ventilation
Moderate sedation
“conscious sedation”
Deep sedation
General Anesthesia
Procedural Sedation
Moderate sedation
“conscious sedation”
Deep sedation
Responsiveness
Purposeful response to Purposeful response
verbal or tactile
following repeated
stimulation
or painful stimuli
Airway
No intervention
required
Intervention may be
required
Spontaneous
ventilation
Adequate
May be inadequate
Procedural Sedation
• In recent years, the most common PSA medications have
been Midazolam and Fentanyl. These were used for ‘deep
sedation’ procedures ie fracture reduction etc.
• However, as per the previous slide, responsiveness is often
only to painful or repeated stimuli.
• Once the procedure is complete, you can still have 30 +/minutes of deep sedation on board.
• This is traditionally when interventions for airway and
ventilation could/did occur.
Drug
Ketamine
a1
b1
b1
b1
Inotr Chron Dromo
_
Fentanyl
Morphine
Propofol
Midazolam
+
b2
V/C
V/D
+
_
_
++
++
Midazolam and Fentanyl
ER literature is suggesting using this combination in
lower doses for ‘moderate sedation’ that traditionally
only local anesthesia or nothing was given.
i.e. I&D of abscess, LP, complex lacerations, road rash
debridement, burn dressings …
Propofol
Dr. James Miner
Chief of Emergency Medicine Hennepin County Medical Center,
Hennepin, Minnesota.
Dr. James Miner
• Miner, James R, Mark Danahy, Abby Moch, and Michelle Biros. 2006. Randomized clinical trial of etomidate versus propofol
for procedural sedation in the emergency department. Annals of emergency medicine, no. 1 (September 25).
http://www.ncbi.nlm.nih.gov/pubmed/16997421.
• Miner, James R, Richard O Gray, Jennifer Bahr, Roma Patel, and John W McGill. 2010. Randomized clinical trial of propofol
versus ketamine for procedural sedation in the emergency department. Academic emergency medicine : official journal of the
Society for Academic Emergency Medicine, no. 6. doi:10.1111/j.1553-2712.2010.00776.x.
http://www.ncbi.nlm.nih.gov/pubmed/20624140.
• Miner, James R, Richard O Gray, Dana Stephens, and Michelle H Biros. 2009. Randomized clinical trial of propofol with and
without alfentanil for deep procedural sedation in the emergency department. Academic emergency medicine : official
journal of the Society for Academic Emergency Medicine, no. 9. doi:10.1111/j.1553-2712.2009.00487.x.
http://www.ncbi.nlm.nih.gov/pubmed/19845550.
• Miner, James R, Marc L Martel, Madeline Meyer, Robert Reardon, and Michelle H Biros. 2005. Procedural sedation of
critically ill patients in the emergency department. Academic emergency medicine : official journal of the Society for Academic
Emergency Medicine, no. 2. http://www.ncbi.nlm.nih.gov/pubmed/15692132.
• Miner, James R, Johanna C Moore, Erin J Austad, David Plummer, Laura Hubbard, and Richard O Gray. 2014. Randomized,
double-blinded, clinical trial of propofol, 1:1 propofol/ketamine, and 4:1 propofol/ketamine for deep procedural sedation in
the emergency department. Annals of emergency medicine, no. 5 (October 16). doi:10.1016/j.annemergmed.2014.08.046.
http://www.ncbi.nlm.nih.gov/pubmed/25441247.
• Miner, James R, Johanna C Moore, David Plummer, Richard O Gray, Sagar Patel, and Jeffrey D Ho. 2013. Randomized clinical
trial of the effect of supplemental opioids in procedural sedation with propofol on serum catecholamines. Academic
emergency medicine : official journal of the Society for Academic Emergency Medicine, no. 4. doi:10.1111/acem.12110.
http://www.ncbi.nlm.nih.gov/pubmed/23701339.
Propofol – key points
1. Propofol for short procedures (2-3 minutes) in a stable patient is safer
than any other sedation medication.
2. Use Pre- procedural analgesia rather than peri-procedural.
3. Use 1 – 2 mg/kg Propofol.
4. Use less in the elderly, especially if they have opioids on board.
5. Use more in thin and obese patients.
6. Use less in volume depleted patients.
7. Need to wait 60 seconds (by the clock!) before giving a second dose
Propofol
8. Patient will have 30 – 60 seconds retrograde amnesia.
9. Amnesia is while Propofol is starting to work, NOT when it is
wearing off.
10. After the first dose of 1.5 mg/kg the patient may still be talking etc,
but as long you have the given the patient adequate pre-analgesia, they
will have amnesia for the event.
Ketamine
• Can be used to start and maintaining anesthesia, sedation,
analgesia, amnesia and treatment of bronchospasm.
• Acts on many receptors, one of which are the opioid
receptors. Can be used is sub dissociative doses for pain.
• Downside is the psychological reactions as it wears off –
agitation, confusion, psychosis.
• ‘Recovery agitation’ is associated with dosage, younger age
and co-morbid conditions, thus ranging from 15-35%.
Ketamine
• Historically recommended for intubation of asthmatics and
head injury patients as it causes bronchodilation and does
not increase ICP.
• Now is recommended for procedural sedation in children
and adults.
• Can be used for the above as well as RSI in hypotensive
trauma patients.
• In combination?
A Procedural Sedation Protocol?
1. Have a PSA check list
2. Pre-oxygenate with non rebreather for 5 minutes
3. Use SpO2 and EtCO2 monitor
4. Have at least one other person – nurse
5. Plan your procedure before you give the drugs
6. Use pre- procedure analgesia – fentanyl, morphine, hydromorph …
7. Bolus Propofol 1 -1.5 mg/kg.
8. Do the procedure
PSA Checklist
One example in your handouts.
Questions ?