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Common Medications/Continuous Drips Used In the Critical Care Setting Drugs that cause vasoconstriction (improves BP) Medication Dose/Frequency Purpose Nsg. Considerations Dopamine (Intropin) .5-2 mcg/kg/min (not really a renal dose) -second drug choice for symptomatic bradycardias -use in shock states especially in distributive shock states. -correct patient’s hypovolemia first -give through central line; may cause tissue extravasation if IV infiltrates (Regitine 5-10 mg in 10-15 ml of saline) -increases HR; increases O2 demand on heart -causes vasoconstriction -no more renal dose; actually blocks effect of aldosterone; therefore, there’s a diuretic effect. -be careful of dose if patient in cardiogenic shock; use 5-10 mcg/kg/min -titrate drug; increase or decrease by 1-2 mcg/kg/min every 5-10 minutes. 2-5 mcg/kg/min (dopaminergic and beta) 5-10 mcg/kg/min (beta) 10-20 mcg/kg/min (pure alpha) Medication Dose/Frequency Levophed 2-4 mcg/min is average (Norepinephrine) maintenance dose; titrate every 5 minutes until desired effect -may go to 30 mcg/min via continuous infusion (this drug is not weight-based, unless used in Peds) Medication Neosynephrine Purpose -especially useful in distributive or vasodilatory shock states Dose/Frequency Purpose -40-60 mcg/min -vasodilatory by continuous hypotension/shock infusion and may titrate up every 5 minutes for optimal effect. -has been up to 200 mcg/min. Nsg. Considerations -mostly alpha effects with some Beta 1 effects (contractility) -coronary artery vasodilator (much more so than epinephrine) -can increase O2 demand on the heart -hyperglycemic action much less pronounced -as a continuous drip, should be given through a central line -can extravasate tissue if IV infiltrates; (Regitine 510 mg in 10-15 ml of saline). Nsg. Considerations -all alpha effects -increases SVR which may increase 02 demand on heart if already compromised. -as a continuous drip, should be given through a central line -can extravasate tissue if IV infiltrates; (Regitine 5-10 mg in 10-15 ml of saline). Medication Vasopressin (ADH) Dose/Frequency 40 units IVP as a 1-time dose only Purpose -Ventricular Fibrillation -Pulseless V-tach -PEA -Asystole .2-.9 units/min via continuous IV infusion Central Diabetes Insipidus .01-.04 units/min via continuous infusion Septic shock Nsg. Considerations -has a long half-life therefore titrate med every 30 minutes to desired effect (usually a U.O. < 300 cc/hr) -given as an alternative to the first or second dose of epinephrine but once only (during a code situation) -Watch for hyponatremia (may produce water intoxication) -blood pressure may rise -Severe vasoconstriction and local tissue necrosis if IV infiltrates Drugs that cause vasodilation; (decreases BP in hypertensive emergencies or reduces afterload in CHF) Medication Natrecor (Nesiritide) Dose/Frequency -bolus of 2 mcg/kg followed by a continuous infusion of 0.01mcg/kg/min Purpose acutely decompensated CHF Nsg. Considerations -Natriuretic peptide (BNP in a bag) -Dilation and natriuresis -Natrecor binds with heparin; it is suggested that it not be infused through a central heparin-coated catheter. - watch for further hypotension and hyponatremia -BNP levels will remain elevated while on drip. Nsg. Considerations Medication Dose/Frequency Purpose Nipride (Nitroprusside) .25 - .3 mcg/kg/min and titrate every 1-2 minutes to a maximum dose of 10 mcg/kg/min -hypertensive emergencies -acute left ventricular failure in combination with Dobutamine -hypotension can occur very quickly- if so, hold drip and place patient in trendelenberg -Potential of cyanide or thiocyanate toxicity -when weaning off, titrate drug down by 2-3 cc’s every 10-15 minutes (needs to be on oral antihypertensives first!) Nitroglycerine (Tridil) -5-10 mcg/min and titrate up every 5 minutes until desired effect. -maximum dosing (controversial) up to 200 mcg/min) -congestive heart failure - Control of chest pain, and hypertension -monitor for hypotension and for relief of chest pain -HA is common problem (use pain rx) -if becomes hypotensive, may give fluid and/or put in trendelenberg; may have to hold drip or titrate down by 5-10 mcg./min -when weaning off of drip, consider oral nitrates first and then titrate down 5-10 mcg/min every 10-15 minutes Inodilators (Drugs that reduce afterload and improve contractility) Medication Dobutamine (Dobutrex) Dose/Frequency 5-20 mcg/kg/min via continuous infusion Primacor (Milrinone) -loading dose of 50 mcg/kg slowly over 10 minutes -0.25-0.75 mcg/kg/min (.375 mcg/kg/min is standard dosing) Purpose -decompensated congested heart failure -cardiogenic shock -other shock states in which there’s also reduced cardiac contractility -used in stress tests Nsg. Considerations -improves blood pressure by improving contractility and stroke volume -slight inodilator effect -can increase HR somewhat, which will increase O2 demand -should be given through central line -titrate drug; increase or decrease by 1-2 mcg/kg/min every 5-10 minutes. -decompensated -adjust dosage for patients CHF in renal failure -decreases SVR -long half-life and provides -proarrhythmic positive inotropic -thrombocytopenia support -can be used for up to 48 -decreases hours preload -NOT a Titratable med! -use in patients with low CO/CI, high PCWP, pulmonary hypertension Drugs that speed up the heart!!! Medication Dose/Frequency Purpose Nsg. Considerations Atropine -symptomatic bradycardias & blocks -PEA, Asystole -.5 mg IVP for the bradycardias and 1 mg for PEA or Asystole -+chronotropic med so increases O2 demand on heart. -Maximize dosing before moving to next medication or therapy -Blocks the vagus nerve .5-1 mg. IVP every 3-5 minutes up to total loading dose of .03-.04 mg/kg. Can be given down the ET tube if no IV access- double the dose, followed by 5 ml. saline chaser and ventilate with ambu bag (Hold compressions) Medication Dose/Frequency Epinephrine (adrenaline) -1 mg. (1:10,000) IVP every 3-5 minutes for as long as code continues Purpose -pulseless ventricular tachycardia -ventricular -can be used as fibrillation continuous drip in shock -PEA, asystole states (2-10 mcg/kg/min) -symptomatic bradycardia -can be given down the -shock states; ET tube if no IV access- especially the double the dose (using distributive 1:1000) followed by 5types 10 ml. of a saline chaser -anaphyllaxis and ventilate with ambu bag (hold compressions) Nsg. Considerations -has both alpha and beta 1 and 2 effects -increases O2 demand on the heart -significant hyperglycemic action -coronary artery dilator but to a lesser degree than norepinephrine -as a continuous drip, should be given through a central line -can extravasate tissue if IV infiltrates; (Regitine 5-10 mg in 10-15 ml of saline) -titrate drug; increase or decrease by 1-2 mcg/kg/min every 5 minutes Drugs that calm the heart down!!! Medication Dose/Frequency Adenosine Start with 6 mg IVP May repeat doses of 12 mg. twice PRN Purpose -SVT’s or Narrow QRS tachycardias if vagals were unsuccessful -can be used in accessory pathway rhythms Nsg. Considerations Chemical defibrillator in which there may be a brief period of asystole. -give the medication very quickly at the port closest to the insertion site (half-life is about 10 seconds) -300 mg. IVP Amiodarone followed by 150 mg (Cordarone) IVP in 3-5 minutes -pulseless ventricular tachycardia or ventricular fibrillation -can only be given with D5W, not NS -monitor patients for bradycardias and blocks -monitor for hypotension because it causes vasodilation and may have negative inotropic effects -may prolong QT interval -150 mg. IVP given over 10 minutes and may be repeated every 10 minutes until maximum dose (2.2 g IV/24 hours) Medication Dose/Frequency Cardizem .25-.35 mg/kg. (Diltiazem) followed by drip at 515 mg/hr. -Atrial and Ventricular tachyarrhythmias Purpose -tachyarrhythmias Nsg. Considerations -calcium channel blocker -negative inotrope (reduces contractility; therefore BP) -depresses AV node Medication Lidocaine Dose/Frequency .5-.75 mg/kg. loading dose IVP Follow-up with a drip at 1-4 mg/min Total loading dose of up to 3 mg/kg. If the patient in a code situation, may repeat the loading dose in 3-5 minutes. Medication Magnesium Dose/Frequency 1-2 gms. IV/IO diluted in 10 ml D5W given over 5-20 minutes Purpose Ventricular arrhythmias: -Multifocal PVC’s -R-on-T -PVC’s with chest pain -couplets, bigeminy Nsg. Considerations Lidocaine toxicity which is manifested through LOC changes and seizure activity. Consider toxicity for anybody with hepatic insufficiency and the elderly population Therapeutic lidocaine level- 2-6 mcg/ml (send-out test) Ventricular tachycardia and Ventricular fibrillation Purpose Torsades de Pointes (V-tach associated with prolonged QT interval) Nsg. Considerations -occasional fall in blood pressure if given rapidly -give cautiously in patients with renal failure Drugs that anticoagulate/antiplatelet therapy (Acute Coronary Syndromes) Medication Dose/Frequency Angiomax Bolus dose of .75 mg/kg (slow IVP) just before PTCA; then begin 4-hour infusion at 1.75 mg/kg/hr (optional); after this, give up to 20-hour infusion at .2 mg/kg/hr PRN Nsg. Considerations - Give with aspirin 300-325 mg. -Bleeding is main potential problem-DC if bleeding Patients with HIT or occurs. at risk for HIT -May give with GP IIB/IIIA inhibitors -For patients with renal failure, give same bolus but decrease IV infusion by 20% (renal insufficiency) to 90% (dialysisdependent) Medication Dose/Frequency Purpose Nsg. Considerations Integrilin Bolus of 180 mcg/kg Patients with -Contraindications to GP IIb then continuous unstable angina or IIIa inhibitors are: infusion of 2 NSTEMI Active internal bleeding mcg/kg/min for 72-96 ► Recent GI or GU bleeding hours PCI ► History of CVA within the angioplasty/stent last 2 years or CVA with neurovascular deficit ► History of ICH, intracranial neoplasm, AVM, aneurysm Reopro .25 mg/kg bolus ► History of followed by continuous thrombocytopenia infusion of .125 ► Major surgical procedure or mcg/kg/min for 12-24 severe physical trauma within hours previous 6 weeks Aggrastat .4 mcg/kg/min for 30 minutes then .1 mcg/kg/min via continuous infusion for 48-96 hours. Purpose Unstable angina in patients undergoing PTCA -dose needs to be reduced if renal insufficiency/failure a problem -monitor for bleeding and thrombocytopenia Medication Aspirin Dose/Frequency 160-325 mg and non-enteric po (chewed is preferable) If unable to take by mouth, give 300 mg dose rectally Heparin (unfractionated) Lovenox (fractionated heparin) Purpose To reduce platelet aggregation (clumping) in patients with ACS’s. Also reduces coronary vasospasms by blocking thromboxane Loading dose of Blocks thrombin about 60 u/kg in the clotting IVP followed by cascade which a continuous drip doesn’t allow of about 12-15 fibrinogen to u/kg/hr. convert to fibrin. -used in patients with NSTEMI/USA 30 mg/kg bolus followed by 1 mg/kg subcutaneously BID NSTEMI/USA Nsg. Considerations -if patient already on daily aspirin and gets admitted for ACS, give another dose ASAP. -follow institution protocol regarding dosing/testing -usually maintain PTT at about 50-70 seconds -monitor for bleeding from all potential sources -monitor for HIT -Protamine sulfate (anecdote) -monitor for HIT -monitor for bleeding from all potential sources -Protamine sulfate (anecdote) Drugs Used To Keep Patients Sedated/Paralyzed (ie, maintenance on a mechanical ventilator) Medication Diprivan (Propofol) Medication Norcuron (Vecuronium) Dose/Frequency Purpose 5-50 mcg/kg/min -For RSI -maintenance on a mechanical ventilator -can be used for procedural sedation but only if anesthesiologist at the bedside to maintain airway Dose/Frequency Purpose .08-.1 mg/kg -RSI purposes IVP -maintenance of vented patient may be given by -patient with severe continuous intracranial infusion at .1 hypertension mg/kg/hr Nsg. Considerations -is only a sedative; has no pain control qualities (get an order for IV drip pain med) -check for egg allergies -is a negative inotropic med (may need inotropic support) -follow triglycerides -has caloric value -watch for propofol syndrome Nsg. Considerations -used as last resort -non-depolarizing NMBA -doesn’t address sedation or pain -requires pain/sedation meds via continuous infusion -monitor level of paralysis with TOF (goal is 2/4 twitches) -can cause long term neuropathy Good Brain Drug for Cerebral Edema Medication Mannitol (Osmitrol) Dose/Frequency Purpose Nsg. Considerations .5-1 gm/kg IVP -Cerebral edema Osmotic diuretic so avoid in hypovolemic or IVPB -Intracranial patients. Hypertension -Rhabdomyolysis Pulls water from normal brain tissue; not injured tissue Draw dose up using filtered needle. Maintain patient’s serum osmolality < 300-320. Monitor electrolytes and fluid status