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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
ADENOSINE
Classification.
Antiarrhythmic
Indications..
Conversion of paroxysmal supraventricular tachycardia (psvt) to sinus rhythm
Reconstitution
Compatibility
• No reconstitution required.
• Available as a 3 mg/mL solution: 2 mL single-dose vial and PF syringe.
Vials should be stored at room temperature. Don’t refrigerate as
crystallization may occur. If crystallization has occurred, dissolve crystals
by warming to room temperature.
Physically compatible with NS, D5W and Lactated Ringer’s solutions.
Routes of Administration.
Intravenous
Administration Policy.
Continuous ECG monitoring during and for 3 - 5 minutes after
administration and then until stable
&
Stability.
Dosage.
Potential Hazards Of
Administration.
Important Implications
Initial Dose: 6 mg as a rapid intravenous push over 1 to 2 seconds
followed by a 0.9% sodium chloride flush.
Repeat Administration: 12 mg as a rapid intravenous push over 1 to 2
seconds followed by a 0.9% sodium chloride flush. A third dose of 12 mg
may be administered if the first doses are not effective in 1 to 2 minutes.
Light headness and dizziness as a result of decreased cerebral blood flowHeadache, Severe flushing, nausea, shortness of breath
- Side effects will usually last only 1 to 2 minutes due to the very short
half life of adenosine
- First, second or third degree heart block as well as "transient" asystole- Patients will experience transient asystole.
- May precipitate angina in patients with IHD as a result of coronary
steal.
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
AMINOPHYLLINE
Bronchodilator
• Symptomatic treatment of reversible bronchoconstriction.
• Apnea and bradycardia of prematurity.
• Relieve periodic apnea and increase arterial blood pH in patients with
Cheyne-Stokes respirations.
• Reverse adenosine-mediated effects of dipyridamole e.g. angina pectoris,
bronchospasm, severe hypotension, ventricular arrhythmias.
Reconstitution-&
• No reconstitution required. Available as aminophylline 25 mg/mL - 20
Satbility.
mL. Do not use if crystals are present.
Stable in dextrose, dextrose-saline combinations, saline and lactated
Ringer's solutions for 24 hours at room temperature.
Route of administration Direct Into IV Tubing, Intermittent Infusion, Continuous Infusion
Administration Policy. Direct into IV tubing and loading dose: Baseline BP, HR and RR, then
repeat q 5-15 minutes until stable.
Recommended - Serum theophylline levels.
Dosage.
Adult
- a) IV-Use 25 mg/mL undiluted.2 Max.@ 25mg/min.
Antidote for dipyridamole: over 30-60 seconds
b) Intermittent Infusion - Dilute in 50 - 100 mL @ infuse over 20 - 30 min.
c) Continuous Infusion- Add 500 mg to 500 mL
Paediatric Use 25 mg/mL undiluted.
Maximum rate 25 mg/minute
Continuous Infusion --As adults.
Important Implications Atrial and ventricular arrhythmias (associated with serum levels > 110
mcmol/L or pre-existing cardiacabnormalities).
• Hypotension and death (associated with too rapid IV injection).
• Palpitations, sinus tachycardia, peripheral constriction.
Focal or generalized seizures. (May occur without any other signs of
toxicity.)
• Headache, nervousness, insomnia, irritability.
-Anorexia, nausea, vomiting, abdominal discomfort.
Drug Interactions.
Is a substrate of cytochrome P450 CYP1A2 (major) and CYP3A4 (minor);
Increase in theophylline serum concentration with: alcohol, allopurinol,
beta-adrenergic blockers (e.g. propranolol),
clarithromycin, ciprofloxacin, verapamil.
• Serum concentrations of either one or both drugs may be reduced by
phenytoin, carbamazepine, ketoconazole, isoproterenol, rifampin.
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
AMIODARONE
Considered Class III Antiarrhythmic, but possesses characteristics of all
classes.
Indications.
Hemodynamically unstable ventricular tachycardia .
Initiation of amiodarone treatment in recurrent ventricular fibrillation
Supraventricular tachycardia, atrial fibrillation, Refractory Atrial
fibrillation, Arrest; Pulseless VT / VF; WPW Syndrome And PSVT.
Reconstitution-&
Stable in D5W in PVC infusion bags for 2 hours at room temperature at
Satbility.
concentrations between 1 – 6 mg/mL.
• Stable in D5W in non PVC containers, for at least 24 hours at room
temperature in concentrations between 1 – 6 mg/mL.
Compatibility
Compatible with NS.
Route of administration Intravenous Tubing / Infusions.
Administration Policy. Blood pressure, heart rate and QTc parameters should be clearly specified
in the orders.
Contraindicated in patients with sinus bradycardia, 1st, 2nd, 3rd heart
block, or cardiogenic shock.
Periodic laboratory indices such as LFT’s, TFT’s, PFT’s, RFT’s, and
serum electrolytes are recommended
Dosage.
Arrest/Pulseless-VT/VF -300mg IVP; repeat 150mg IVP in 3-5 min SOS
Loading Dose - Rapid: 150mg in 100ml D5W over 10 min (15mg/min)
followed by:--Slow: 360mg over the next 6 hours @ a rate of 1mg/min
Maintanence Dose: 540 mg over the remaining 18 hours at a rate of
0.5mg/min as titrated to patient response
Supplemental Dose: 150mg over 10 minutes for episodes of VF / VT
Unstable VT/VF doses up to 100mg/hr with aggresive monitoring.
Potential Hazards Of
Irritant: venous thrombosis, irritation and potential tissue necrosis with
Administration.
extravasation at IV site and surrounding nfiltrated area, especially with
conc. of 3 mg/mL or greater.
T/t-Apply cold intermittent compresses.
Important Implications Immediate Phlebitis, Hypotension, usually rate related PR and QT interval
prolongation, bradycardia, AV Block, GI Disturbances, constipation
Delayed Thyroid suppression, Corneal microdeposits, Interstitial
pneumonititis, pulmonary fibrosis
Drug Interactions.
• Quinidine, procainamide - may produce additive cardiac effects.
• Beta-blockers and calcium channel blockers (e.g. diltiazem and
verapamil) may produce synergistic/additive pharmacological effects.
• Oral anticoagulants: increased anticoagulant effect, monitor PT-INR
and adjust dose accordingly.
• Digoxin: possible increased plasma concentration of digoxin.
• Phenytoin: possible decrease in plasma amiodarone and increase in
plasma phenytoin concentrations.
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
ATROPINE
Classification.
Anticholinergic
Indications.
Bradyarrhythmias
Digoxin Overdose
Anticholinesterase overdose
Reconstitution
None required.
Compatibility-&
Available as 0.6 mg/mL – 1 mL ampoule and 0.1 mg/mL – 10 mL syringe.
Statbility.
• Neonatal dilution; dilute 1 mL atropine 0.6 mg/mL with 5 mL SWFI.
Compatible with D5W, NS, dextrose-saline combinations, Ringer’s and lactated
Ringer’s solutions.
Further dilution not recommended. If necessary dose may be diluted with NS or
D5W and used immediately.
Route of aministration.
DIRECT INTO IV TUBING
Administration Policy.
MONITORING REQUIRED - Baseline BP and heart rate, then q 3 min x 2, and
until stable – EXCEPTION: cardiac arrest
• Continuous ECG monitoring while giving dose and until stable.
RECOMMENDED- Bowel sounds and urine output if ordered for longer than 24
hours.
Dosage.
Dose: 0.5 to 1.0 mg IVP
Suggested Dosing Schedule:-0.5 mg every 5 minutes up to a total of 2 mg
In a 24 hour period: 4.0 mg < 50 years / 3.0 mg > 50 years.
Anticholinesterase overdose: 2-4mg every 5 to 10 minutes until muscarinic
symptoms disappear, up to 200mg total dose on 1st day.
Potential Hazards Of - Sustained hypertension
Administration.
Increased intracranial pressure , Tachycardia, angina,Urinary retention ,
Constipation .
Anticholinergic side effects:- flushed skin, dry mouth, mydriasis, blurred
vision, delirium
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications.
Reconstitution
Compatibility &
Satbility.
Route of
Administration
Administration
Policy.
Dosage.
Potential Hazards Of
Administration.
Side Effects
DIAZEPAM
( Benzodiazepine) Sedative/Hypnotic/Anxiolytic.
Restlessness, Anxiety, Agitation, Alcohol Withdrawal, Conscious Sedation,
Status- Epilepticus.
No reconstitution required.
• Diazemuls- diazepam 5 mg/mL in an oil-in-water emulsion, 2 mL
ampoules. Shake well before using.
• Also available as diazepam 5 mg/mL – 2 mL ampoules. Contains propylene
glycol and benzyl alcohol.
-Diazepam in propylene glycol:
Compatible with D5W, NS and lactated Ringer’s in a dilution of 0.25
mg/mL. Stable in a plastic syringe for 4 hours.3 If dilution is required, add
diluents solution to diazepam, not diazepam to diluents (i.e. draw up
diazepam first, then the diluents into the syringe).
• Important: - Do not further dilute with IV fluids; may destabilize emulsion.
Intravenous.
· Whenever possible administer doses orally
· For IV administration central line is preferred
· May be administered peripherally in a secure vein IVP should not exceed
5mg/minute.
Flush with 0.9% sodium chloride before and after administration.
Anxiety / Agitation: 2.5mg to 10 mg IVP not to exceed 5 mg / minute.
Status Epilepticus: 10mg to 30 mg IVP not to exceed 5 mg / minute.
Diazepam IV contains a vesicant; vesicants cause blisters, severe tissue
injury, or necrosis when they infiltrate (Refer to Nursing Policy for
management. Burning sensation may result at site of injection if administered
through peripheral access
Dosage adjustments may be required in :
Geriatric patients / Renal failure.
Hepatic failure.
- Cumulative effect may be observed, dosage adjustment may be required
-Hypotension, Bradycardia, Respiratory depression/arrest.
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name
Classification
Indications
Reconstitution
Compatibility&
Stability
Route of
Administration
Administration Policy
Dosage
Potential Hazards Of
Administration.
Side Effects
DIGOXIN
Positive Inotrope, Negative Chronotrope.
Atrial Fibrillation.
Paroxysmal SVT.
Heart Failure.
-None required. Available as digoxin 0.25 mg/mL – 2 mL ampoule and
digoxin 0.05 mg/mL – 1 mL ampoule.
• Neonatal dilution - if drug volume is less than 0.04 mL (i.e. too small to
accurately measure) pharmacy will dilute to 0.005 mg/mL. If pharmacy is
closed dilute 0.1 mL of 0.05 mg/mL digoxin with 0.9 mL NS for 0.005
mg/mL.
Compatible with D5W, NS, D5NS, and lactated Ringer’s. Compatibility
with 2/3 – 1/3 is assumed.
• When diluted, must be diluted at least 4 fold to prevent precipitation. Use
immediately after dilution.
Intravenous.
- Serum potassium concentration, urea and creatinine levels should be
known prior to administration of digoxin. Hypokalemia and hypercalcemia
may potentiate digoxin toxicity.
FOR DIGITALIZATION: 1 MG (Give 0.25 mg IV q.6 H times 4 doses).
One dose of 0.5 mg may be given as the first dose.
MAINTENANCE: 0.125 mg - 0.25 mg once or twice daily as titrated to
patient response and/or serum level
Pain at injection site, erythema and a burning sensation. Diazemuls has a
lower incidence of these reactions than diazepam in propylene glycol.
- ST depression or prolonged PR interval
- Heart Block, Ventricular Ectopy, - Regularization of atrial fibrillation,
accelerated junctional rhythm
- Visual Disturbances.
- Confusion.
- Gastrointestinal Disturbances.
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
Reconstitution
Compatibility -&
Satbility.
Route of Administration
Administration Policy.
Dosage.
Side Effects
Important Implications
DILTIAZEM
Calcum channel blocker,class iv antiarrhythmic.
Atrial-Fibrillation & Atrial Flutter
PSVT.
-None required. Available as diltiazem 5 mg/mL - 5 mL vial.
Compatible with and stable in dextrose, saline and dextrose-saline
combinations solutions for at least 24 hours at room temperature and in the
refrigerator.
• Vials should be refrigerated. Stable for up to 1 month at room
temperature.
Intravenous.
Prolonged infusions (>72hours) are not recommended and should be used
cautiously.
-Continuous monitoring of EKG and frequent measurement of blood
pressure
-Defibrillator and code cart readily available.
For continuous infusion: -Usual Dose and Route: Load: 0.25 mg/kg
(maximum dose 25mg) direct IV Bolus over 2 minutes.
For inadequate response :-an additional 0.35mg/kg IV over 2min (app. 25
to 30mg) may be given 15 minutes after initial dose.
Maintenance: Start immediately after loading dose.
Titrate by 2.5mg/hr every 0.5 to 2 hours to achieve desired heart rate;
recommended maximum 30mg/hr.
STANDARD CONCENTRATION--125mg (25ml) in 100ml IV fluid;
final concentration is 1:1; in D5W or NS.
MICROINFUSION: 100 mg/50 ml (2mg/ml)
Hypotension
Asystole,Bradycardia
AV-Block , exacerbation of heart failure
arrythmia (junctional rhythm or isorhytmic disassociation)
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
Reconstitution
Compatibility -&
Satbility.
PANCURONIUM
Nondepolarizing neuromuscular blocker.
• to facilitate endotracheal intubation and to provide skeletal muscle
relaxation during surgery or mechanical ventilation.
• Selected patients with increased ICP, decrease oxygen consumption,
facilitation of procedures or diagnostic studies.
• Supportive therapy for certain neuromuscular conditions (e.g. tetanus).
None required.
Stable in D5W, NS, D5NS and R.L. for at least 24 hours at room temp.
• Ampoules should be stored in the refrigerator.
Route of Administration
Intravenous.
Administration Policy.
Dosage.
BP and HR: baseline and every 1 hour.
2 to 4 mg IVP every 30 to 90 minutes patient should be assessed frequently
OR: 5-10mg loading dose given slowly over 2-3 minutes/hour titrated to
patient response and frequently evaluation of paralysis
STANDARD CONCENTRATIONS-Continuous infusions may be given
by using undiluted drug and a controlled microinfusion device
Pressure sores and decubitus ulcers due to immobilisation
• Transient skin rash.
• Salivation, paralysis causing secretion retention and atelectasis.
• Corneal drying/abrasions due to loss of blink reflex. Eye care required.
Prolonged paralysis and/or skeletal muscle weakness.
• Incomplete reversal of neuromuscular blockade when stopped.
• Achilles tendon contractures.
Moderate dose-dependent rise in heart rate, Increased mean arterial BP and
cardiac output. Bronchospasm, flushing, hypotension & tachycardia
Neonates: both hypo- or hypertension.
Potentiated by many drugs (e.g. aminoglycosides, clindamycin,
vancomycin), calcium channel blockers (e.g. verapamil), other
neuromuscular blockers, inhalation anaesthetics.
• Antagonised by anticholinesterases, aminophylline, phenytoin, and
carbamazepine.
Potential Hazards Of
Administration.
Side Effects
Drug Interactions.
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
CALCIUM
Classification.
Electrolyte.
Indications..
Hypocalcemia
Adjunctive therapy-overdose of magnesium sulphate, in cardiac resuscitation when
hyperkalemia, hypocalcemia, or calcium-channel blocking agent toxicity is present.
Reconstitution-&
-None required.
Satbility.
-Stable in D5, NS, DNS and R. L. for at least 24 hours at room temperature.
Route of Administration
INTRAVENOUS(not to be administered IM, subcutaneously or intramyocardially)
Administration Policy.
- Serum electrolyte levels should be known prior to therapy and monitored
during calcium administration.
- May worsen AV block in patients receiving calcium channel blockers.
- infuse each dose of calcium gluconate over 1 to 2 hours
- check calcium level two hours post-infusion
- Calcium gluconate 1 g = 93 mg or 4.5 meq Ca++.
-Calcium-chloride 1g = 273mg or 13.5meqCa++
INITIAL DAILY DOSE: 1 - 2 gm / day.
TOTAL DAILY DOSE: 10 - 12 gm /day.
- Calcium Chloride (Centrally only)
- Calcium Gluconate (Centrally OR Peripherally).
Ca-Gluconate Peripheral -- 1G/50ml
Central --------1G/10ml
muscle flaccidity
Dosage.
Potential Hazards
Side Effects
Drug Interactions.
- AV block, ventricular arrhythmias
- hypotension, bradycardia.
- change in mental status.
- elevated bun.
Digoxin – may increase risk of arrhythmias; ECG monitoring is
recommended.
• Magnesium – administer through separate IV lines if required
simultaneously. Exception, TPN solutions.
9
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications.
Reconstitution-&
Satbility.
Route of Administration
Administration Policy.
Dosage.
Side Effects
Important Implications
Drug Interactions.
POTASSIUM
Electrolyte.
Hypokalemia, Alkalosis
Compatible with 5D, NS, DNS & RL.
• Stable in above solutions for at least 24 hours at room temperature
• In severe hypokalemia, solutions without dextrose are preferred.
• Compatible with potassium phosphate in the same solution for at least 24
hours at room temperature.
• Mix IV solution thoroughly after adding potassium chloride to prevent
bolus administration.
SLOW INTRAVENOUS.
- With syringe infusions, maximum 20 mEq should be hung at one time.
- ECG monitoring for concentrated mixes or rates greater than 10 mEq / hr
- Must be infused by infusion device.
- Monitor serum potassium levels
- Titrate cautiously in patients with renal failure
- Total additive potassium infusion must be considered when administering
potassium (e.g. potassium contained in TPNs).
5 - 20 mEq / hour IV based on patients' condition and Serum K+ level.
Central:--20mEq/100ml.
40mEq/100ml (Central Administration only).
Peripheral:80mEq/1000ml
40mEq/500ml
20mEq/250ml
Not to be administered IM or subcutaneously
Phlebitis.
Bolus may cause cardiac arrest , -EKG changes, widening of QRS,
peaked T waves.
Potassium-sparing diuretics (e.g. spironolactone or triamterene), ACEinhibitors (e.g. captopril, enalapril) – can produce hyperkalemia.
10
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
Reconstitution
Compatibility -&
Statbility.
Route of Administration
Administration Policy.
Dosage.
Side Effects
Side Effects
Drug Interactions.
STREPTOKINASE
Thrombolytic Agent
Acute Pulmonary Emboli
Acute Extensive DVT
Arterio-Venous Shunt Occlusion
Acute Coronary Thrombosis
Reconstitute with 5mL D5 or NS, add SLOWLY to side of vial rather
than into the powder.
• Roll and tilt vial GENTLY to mix. Do not shake. Check for
flocculation (thin translucent fibres). Discard if present.
Diluted solutions in NS stable for 24 hours at room temperature.
• Solutions of 500 IU/mL and ≥ 5000 IU/mL D5W stable for 12 and 24
hours respectively at room temperature.
• Reconstituted vials stable for 24 hours in refrigerator and at room
temperature.
Intravenous Intermittent/Continous Infusions.
- Check neuro vital signs every 2 hours
- Avoid intramuscular injections..
Coronary ThrombosisLoad: 250,000 IU over 30 minutes
Maintenance: 100,000 IU / hour
(Administer total dose over 60 minutes.)
STANDARD CONCENTRATIONS
750,000 IU / 250 ml / 750,000 IU / 90 ml
Nausea , Phlebitis at infusion site.
- Chest pain
- Hemorrhage,
-bleeding from iv sites
- Fever
- Hypotension
- Reperfusion arrhythmias
- Anaphylaxis
Drugs which affect platelet function such as dextran, ASA, NSAID's may
increase risk of bleeding.
• Vasodilators such as nitrates and morphine may exacerbate the
hypotensive effects of streptokinase.
11
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
MIDAZOLAM
Classification.
Benzodiazepine(Sedative/Hypnotic/Anxiolytic / Amnesic).
Indications..
Restlessness/Anxiety-short-term-sedation.
Status epileptics.
Reconstitution
None required.
Compatibility-&
-Compatible with dextrose, saline and lactated Ringer’s solution.
Statbility.
- Stable in D5W and NS for 24 hours at room temperature.
Route
of Direct Into IV Tubing, Continuous Infusion.
Administration
Administration Policy.
Direct: Baseline BP, HR and RR. Repeat q 5 minute x 3 and until stable, then q 15
minute
Continuous infusion: Continuous BP or non- - invasive BP monitoring q 5 minute.
HR, RR and O2 sats. q 15 minute until stable, then q 1 hour.
Conscious sedation: Baseline BP, HR, RR, O2 sats and sedation rating, then q 5 - 15
minute until procedure complete and q 15 minute until level 1 on the conscious
sedation rating scale.
Dosages
ANXIETY / AGITATION: 0.5 - 2.0 mg IVP
MAINTENANCE: 1 to 2.5 mg / hour
24 HOUR CUMULATIVE: 20 to 40 mg as titrated to patients' response
MICROINFUSION: 50mg/50ml
Side Effects
- Hypotension
- Bradycardia
- Respiratory depression
- Withdrawal symptoms after long term use
12
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications.
MANNITOL
Osmotic Diuretic
OsmoticDiuresis.
Contrast induced renal failure.
Increased Intracranial Pressure.
Reconstitution
None required.
Compatibility-&
Available as 20% (100 g/500 mL) and 25% (12.5 g/50 mL) solutions.
Statbility.
Compatible - D5W, DNS, NS and lactated Ringer’s solutions.
Routes-Of
Direct Into IV Tubing.
Administration.
Intermittent Infusion.
Continuous Infusion.
Administration Policy. Monitor serum & urine electrolytes, serum osmolality.
- IV infusions must have a 1 micron in-line filter
- Mannitol vials must be drawn up using a filter needle
- In the presence of end stage renal disease mannitol may be harmful by
causing an over expansion of intravascular fluid resulting in signs and
symptoms of pulmonary edema and CHF.
Dosage.
12.5 - 25 g IVP, may be repeated every 4 - 6 hours.
Potential Hazards Of
Thrombophlebitits, local pain at injection site
Administration.
• Red cell aggregation and crenation (deformation) if given IV direct too fast.
• Hypersensitivity e.g. chills, urticaria, fever, rhinitis
• Urinary retention.
Side Effects
-Angina, Tachycardia.
- Electrolyte Abnormalities..
- Hypo/Hypertension.
- Pulmonary Edema, CHF.
Drug Interactions
• Lithium: increased urinary excretion of lithium.
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
FENTANYL
Classification.
Opiate agonist - Narcotic Analgesic.
Indications.
Analgesia and Sedation.
Reconstitution-&
None required.
Stability.
Compatible and stable - in D5W or NS at room temperature for at least 24 hours.6
Routes-Of
Direct Into IV Tubing
Administration.
Intermittent Infusion
Continuous Infusion
Administration Policy.
RR, HR, BP, sedation scale before dose or start of infusion, at 5 and 15 minutes post
dose/post infusion.
Dosage.
Loading Dose:* 50- 100 mcg IVP given slowly over 1 - 2 minutes.
Maintenance Dose: 50 - 200 mcg/ hour titrated to patient's response
Microinfusion: 2500mcg/50ml (50mcg/ml)
Potential
Hazards
Administration.
Side Effects
Of 
Dose related:- Nausea, vomiting

Constipation

Allergy







Chest wall rigidity
Bronchospasm
Respiratory depression
Bradycardia / Tachycardia / Hypotension.
CNS Depression
Paralytic Ileus
Hallucinations
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications.
Reconstitution
Compatibility &
Statbility.
Routes of
Administration.
Administration Policy.
Dosage.
Potential Hazards Of
Administration.
Side Effects
PHENYTOIN
Anticonvulsant
- Tonic-clonic and psychomotor seizures; status epilepticus
- Prevention & treatment of seizures during neurosurgery
- Short-term substitute for oral phenytoin in NPO patients
- Cardiac glycoside induced dysrhythmias
None required.
Available as phenytoin 50 mg/mL - 2 and 5 mL vials.
Stable in NS, 0.45% saline and R.L, in conc. between 1-10 mg/mL for 4
hours.
• Prepare dilution just before use. Do not refrigerate diluted solution.
• Incompatible with dextrose solutions: precipitation occurs within
minutes.Use NS, 1/2 NS or lactated Ringers solutions instead.
• Check vial for haziness or precipitation.
A faint yellow colour does not affect potency.
Direct Into IV Tubing.
Intermittent Infusion.
Continuous ECG monitoring during infusion.
Serum phenytoin and albumin concentrations.
IV push/infuse at a rate no greater than 150 mg/ minute
Prophylaxis Loading Dose:15-18 mg /kg (1000mg).
Status Epilepticus Or Active Seizure
Loading dose: 15-25 mg /kg (maximum 30 mg/kg)
Maintenance Dose: 4-6 mg PE/kg I.V. or I.M. administered as a single daily
dose or divided two to three times daily
Dilute for intravenous administration with D5W or NS to 1.5-25 mg /ml
Administer intravenously at a rate of 100-150 mg PE/min
Intramuscular administration must be undiluted drug
Phlebitis and local pain. Administer through a large bore needle into a large
vein.
Slowing infusion rate or increasing volume of NS diluent (minimum
concentration 1 mg/mL) may also help.
Severe local reactions with or without extravasation: may lead to necrosis and
sloughing (rare).
Hypotension, bradycardia, borderline heart block, ECG changes
CNS depression (nystagmus, somnolence, ataxia)hypotension, may occur at
high doses or high rates of fosphenytoin.
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
FUROSEMIDE / Lasix
Classification.
Diuretic
Indications..
Edema/ Congestive Heart Failure/ Renal Failure.
Reconstitution
None required.
Compatibility-&
Available as furosemide 10 mg/mL – 2 and 4 mL ampoules and 25 mL vials
Stability.
Stable in D5W, NS and lactated Ringers solutions for 24 hours at room
temperature at concentrations of 0.2 - 5 mg/mL 10
• Compatible with dextrose, saline and dextrose-saline combination solutions
• Do not use if solution is yellow.
Route of Administration
Direct IV
Intermittent Infusion or Continuous Infusion.
Administration Policy.
• Fluid balance, daily weights; serum electrolytes and creatinine
• Monitor for decreased hearing in high-risk patients, including patients: receiving
large IV doses (greater than 120 mg);receiving other ototoxic drugs; with renal
disease; uremic patients
Dosage.
For the treatment of peripheral edema or edema associated with heart
failure or nephrotic syndrome:
Adults: Initially, 20—80 mg PO as a single dose; may repeat dose in 6—8
hours. Titrate upward in 20—40 mg increments. Max. dosage is 600
mg/day.
For the management of pulmonary edema or for the adjunctive
treatment of acute pulmonary edema:
Adults: Initially, 40 mg IV injected slowly; then 80 mg IV injected slowly
in 2 hours if needed.
For adjunctive treatment of hypertensive urgency† or hypertensive
emergency†:
Doses of 40—80 mg IV in patients with normal renal function.
Potential Hazards Of Anaphylaxis, i.e. urticaria, angioedema and hypotension (rare)
• Hyperglycaemia, glucosuria
Administration.
Important Implications
- Hypovolemia
- Hypokalemia
- Hyponatremia
-Hypomagnesemia
- Transient deafness
- Elevated uric acid
- Hyperglycemia
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
FLUCONAZOLE
Classification.
Anti-fungal
Indications..
Fungal infection; candidiosis, Cryptococcal meningitis, Coccidioidal meningitis .
Reconstitution
None required.
Compatibility-&
Available as fluconazole 2 mg/mL in normal saline - 100 mL glass bottle
Statbility.
Compatible with D5W, D10W, NS and RL.
• Do not use solution if cloudiness or precipitation is present
Route of Administration
Intermittent Infusion
Administration Policy.
monitor for signs of severe hepatic damage
Patients with risk factors for development of prolonged QTc interval (eg structural
heart disease, bradycardia, electrolyte abnormalities, hepatic impairment)
HIV infected patients; increased incidence of adverse effects
Dosage.
-Vulvogaginal candidiasis - single oral dose at 150mg.
-Oropharyngeal or esophageal candidiasis-load 400mg, maintenance 100-400mg
PO/IV once daily.
-Systemic infection-400-800mg PO/IV once daily.
Potential
Hazards
Administration.
Of - Nausea, vomiting, headacheHeadache
• QTc prolongation, torsades de pointes - rare. Reports included seriously ill
patients with multiple confounding risk factors
• Anaphylaxis - rare
Side Effects
- Hepatotoxoicity (rarely)
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
ENOXAPARIN
Classification.
Anticoagulant
Indications.
Prophylaxis of DVT
Treatment of DVT with or without pulmonary embolism
Unstable angina/ Non-ST elevation MI (UA/NSTEMI)
Acute ST segment elevation myocardial infarction (STEMI)
None required. Available in prefilled syringe
Do not expel the air bubble from the syringe before the injection Compatible with normal saline.
Direct Into S/C Tubing
Baseline CBC with platelets, then twice a week during therapy.
DVT prophylaxis: High risk: 30mg SC BID
DVT/PE treatment: 1mg/kg SC Q12H
Unstable angina/NSTEMI: Initial 30mg IV push (optional) followed by
1mg/kg SC Q12H
STEMI: (maximum of 8 days)
< 75 years: 30mg IV bolus followed by 1mg/kg SC Q12H (Maximum
100mg for first 2 SC doses)
> 75 years: 0.75mg/kg SC Q12H (Maximum 75mg/dose for first 2 SC
doses)
Enoxaparin dosing according to renal function:
Not recommended in acute renal failure, ESRD or dialysis
CrCl <30 mL/minute:
DVT prophylaxis: 30 mg once daily
DVT treatment: 1 mg/kg once daily
Hypersensitivity reactions.
Injection site pain and/or haematoma (mainly with subcutaneous injection)
• Transient rash, pruritus.
HIT.
-Increased risk of bleeding in patients on coumadin, aspirin, ticlopidine or
plavix.
-Epidural and Spinal anesthesia.
Platelet inhibitors (e.g. ASA, NSAID's, ticlopidine), dipyridamole, dextran:
may increase risk of bleeding.2
• Protamine sulphate neutralises enoxaparin activity.
Reconstitution
Compatibility-&
Statbility.
Route of Administration
Administration Policy.
Dosage.
Potential Hazards
Side Effects
Drug Interactions
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
GLUCAGON
Classification.
Hyperglycaemic agent.
Indications.
Hypoglycemia,
Beta blocker toxicity refractory to conventional treatment.
Reconstitution
Available as glucagon 1 mg (1 unit) vial and 1 mL glycerin as a diluting solution.
Compatibility & Statbility.
• Reconstitute each 1 mg vial with 1 mL of diluting solution provided - resulting
concentration glucagon 1 mg/mL.
• Vials can be reconstituted with D5W or D10W
Compatible with -- D5W or D10W.5
• Stability in D5W or D10W at concentrations of 1 mg/mL or less for 24 hours at
room temperature is assumed.
• Incompatible with solutions containing sodium chloride, potassium chloride,
or calcium chloride.
Routes Of Administration.
Direct into IV tubing,
Continuous infusion
Administration Policy.
Monitor serum & urine electrolytes and serum osmolality as indicated.
Use with caution in patients with ischemic heart disease.
Dosage.
5 mg bolus followed by an infusion of 1 - 5 mg/hr up to 10 mg/hr as titrated to
patient response
Potential Hazards
- Nausea, vomiting
Side Effects
Hyperglycemia / Hypokalemia.
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications.
Reconstitution
Compatibility-&
Statbility.
Routes Of
Administration.
Administration Policy.
Dosage.
Potential Hazards
Side Effects
Drug Interactions
HEPARIN
Anticoagulant
Unstable angina pectoris .
Adjuvant therapy to thrombolysis.
Status post ptca.
Arterial / venous pulmonary .thromboemboli
Disseminated intravascular coagulation.
Compatible with dextrose, saline, dextrose-saline combinations, Ringer's
and lactated Ringer's solutions.
• Stable in above solutions for at least 24 hours at room temperature
Direct IV
Intermittent Infusion Continuous Infusion
- Draw PTT prior to, 6 hours post initiation of therapy and 6 hours post any
dosage adjustment
-PTT should be drawn twice daily during maintenance therapy
- Should be used with caution with any clinical state in which there is an
increase risk of bleeding (e.g. gi bleed, post-op) .
Febrile illness, infections associated with thrombosing tendencies,
pulmonary embolism, myocardial infarction,extensive thrombotic disorders
especially those associated with neoplastic disease and following surgery:
possible increased resistance to heparin
• Avoid IM injections; avoid invasive procedures
Loading Dose: 80 units/kg
Maintenance Dose: 500 to 1500 units/hour to maintain PTT 1.5 - 2.5
times control
Wt. based dosing protocol: 80-100u/kg LD followed by 15-25 u/kg/hour to
maintain target PTT.
• Asymptomatic elevation of liver enzymes
• Alopecia, affecting the entire scalp or confined to the temple. Rare
• Itching or burning of the plantar surfaces of the feet
- Hemorrhage, bleeding from iv sites .
- Anaphylaxis.
- Type I and II thombocytopenia.
-Increased risk of bleeding in patients on coumadin, aspirin, ticlopidine or
plavix.
Protamine sulphate neutralises heparin activity. (See protamine sulphate IV
monograph)
20
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
INSULIN - HUMAN
Antidiabetic agent
Hyperglycemia
Diabetic-ketoacidosis
Hyperkalemia
Reconstitution
• None required. Available as 100 unit/mL – 10 mL multi dose vial.
Compatibility & Stability. • Do not use solution if cloudy, discoloured, or unusually viscous.
• Vial in use may be stored at room temperature for 1 month.
• Compatible with most commonly used IV solutions.
• Insulin is adsorbed to the surfaces of IV infusion solution containers,
glass and plastic.
Routes Of Administration. Direct Into Iv Tubing
Intermittent Infusion
Continuous Infusion
Administration Policy.
• Blood glucose – frequency depends on clinical condition of patient.
• Serum electrolytes.
Dosage.
Loading Dose: 5 to 20 Units IVP
Maintenance: 2 to 25 Units / hr IV titrated according to blood glucose
level once under control, patients may be changed to a sliding scale
coverage when appropriate.
Potential Hazards
• Local reactions: erythema and pruritus at injection site.
• Generalised hypersensitivity: urticaria, angioedema, anaphylactic
reactions.
Side Effects
• Hypoglycaemia characterised by hunger, cold sweats, rapid heart beat,
nervousness or shakiness, altered behaviour.
Symptoms can appear suddenly. If patient is conscious carbohydrates can
be given orally.
If patient is unconscious, IV glucagon or dextrose may be required.
• Too rapid decrease of serum glucose may lead to cerebral oedema.
Optimum rate of decrease of serum glucose 4.4 - 5.5 mmol/L/hour.
Drug interaction.
• Many drugs have an effect on blood glucose concentrations and may
alter insulin requirements.
• Non selective beta-adrenergic blocking agents, e.g. propranolol, may
mask certain symptoms of developing hypoglycaemia.
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
Reconstitution
Compatibility-&
Statbility.
Routes-Of
Administration.
Administration
Policy.
Dosage.
Potential Hazards
Side Effects
Drug Interactions
METHYLPREDNISOLONE.
Glucocorticoid - anti-inflammatory.
Adrenal insufficiency.
Chronic obstructive pulmonary disease.
Cerebral edema.
Inflammatory diseases.
Transplant rejection.
Reduction of neurologic damage secondary to spinal Cord injury.
Reduction of allergenic reactions to exogenous substances.
Asthma exacerbations.
Available as 40 mg, 125 mg, 500 mg and 1 g vials.
• Reconstitute vials with SW, NS or D5W.6 Reconstitution device can be used.
See vial for exact volume of diluent and resulting concentration.
Compatible with 5D, NS and DNS, for at least 24 hours at room temperature.
• Vials reconstituted with bacteriostatic water are stable at room temperature
for 48 hours.
Direct IV
Intermittent Infusion Continuous Infusion
- Monitor serum glucose, electrolytes, and osmolality.
- Prolonged administration may require tapering of dose to discontinue therapy.
- May require anti-hyperglycemic therapy in susceptible patients.
Maintenance:
40 - 60mg IVP every six hours (125 mg in Transplant Patients)
SPINAL CORD INJURY:
Loading Dose: 30mg/kg/50ml over 15 minutes
Maintenance: started 45 minutes after the loading dose is finished
5.4mg/kg/hr
Reduction Of Allergenic Drug Response:
32mg 12 hr and 2 hr before administration of offending drug
Bronchospasm, anaphylaxis
- Electrolyte imbalance
- CNS disturbances, hallucinations
- Gastrointestinal disturbances
- Adrenal suppression- Hyperglycemia
Rifampin, phenobarbital and phenytoin - increase methylprednisolone
metabolism. Antifungals, grapefruit and protease inhibitors – decrease
Methylprednisolone metabolism.
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
Reconstitution
Compatibility
Routes Of Administration.
Administration Policy.
Dosage.
Potential Hazards Of
Administration.
Important Implications
Drug Interactions
MORPHINE
Opiate Antagonist
Reversal of respiratory depression induced by opiates
0.4 - 2 mg IVP AT 2 to 3 minutes intervals as titrated to patient response
for known narcotic overdose up to a maximum of 10 mg.
Direct Into IV Tubing
Intermittent & Continuous Infusion
Baseline: RR, HR, BP, sedation scale before dose or start of infusion.
Monitor fluid intake and output; check for bladder distension.
• Check for abdominal distension, gas or constipation.
0.4 - 2 mg IVP AT 2 to 3 minutes intervals as titrated to patient response
Nausea, vomiting. Most common with the initial dose.
Slow and steady dose titration helps reduce nausea.
• Constipation; tolerance does not develop.
• True allergy (very rare).
Respiratory depression and apnoea
Sedation
Transient bradycardia (responds to atropine if treatment is required)
Transient hypotension, facial flushing.
Drug Interactions: CNS depressants – additive effects increase the risk of
respiratory depression.
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
Reconstitution
Compatibility-&
Statbility.
Routes of
Administration.
Administration Policy.
Dosage
Potential Hazards Of
Administration.
Important Implications
Drug Interactions
NALOXONE
Opioid antagonist
- Severe withdrawal symptoms
 Hypertension
 Tachycardia
 Nausea, vomiting
• None required.
Available as 0.4 mg/mL – 1 mL ampoule and 10 mL vial, and 1 mg/mL –
2 mL vial.
• Stable in D5W and NS for 24 hours at room temperature.
• Required concentration will vary widely based on dose requirement
Direct Into Iv Tubing.
Continuous Infusion.
• Monitor patient frequently until effects of opioid wear off when used for
reversal of CNS and/or respiratory depression.
Duration of action of some opioids exceeds that of naloxone and repeat
doses may be required.
• Assess level of pain following administration.
• Assess for signs and symptoms of too rapid reversal of opioid effect
(e.g., nausea, vomiting, sweating, tachycardia).
As advised
• Sweating, tremulousness
• Excitement and significant reversal of analgesia – associated with high
doses in postoperative patients.
• Irritability and increased crying in the newborn.
• Seizures in neonates of opioid-dependant mothers, responds to
morphine.
• Tachycardia, hypertension, cardiac arrest – associated with abrupt
reversal of opioid depression.
• Hypo-, hypertension, ventricular tachycardia and fibrillation – associated
with postoperative use in patients with preexisting cardiovascular disease.
-Nausea, vomiting.
Patients, including newborns of mothers, physically dependant to opioids,
as naloxone may precipitate severe withdrawal symptoms, including
seizures.
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications.
Reconstitution
Compatibility -&
Stability.
Routes Of Administration.
Administration Policy.
Dosage.
Potential Hazards Of
Administration.
Important Implications
Drug Interactions
NITROGLYCERIN
Vasodilating agent.
Unstable-angina
Preload-reduction
Afterload-reduction
Cereberal vasodilation
• None required.
Available as 1 and 5 mg/mL - 10 mL vials.
• Pre-mixed solutions of 25 mg/250 mL D5W (100 µg/mL), and 50
mg/250 mL D5W (200 µg/mL) in glass bottles.
• Compatible with D5W, saline, dextrose-saline combinations, Ringer's
and lactated Ringer's solutions.
• Commercially available pre-mixed solutions are stable until labelled
expiry date.
• Dobutamine, dopamine, lidocaine, nitroglycerin and sodium
nitroprusside prepared in D5W or NS, are compatible by Y-site in all
possible combinations.
Direct Into IV Tubing
Continuous Infusion
Continuous IBP or NIBP monitoring.
range -- 25 - 1000 mcg / min (varies from patient to patient)
• Immediate hypersensitivity reactions (rare)
• Hypoxemia
• Methaemoglobinaemia
• Tolerance to anti-anginal and haemodynamic effects, associated with
high doses and continuous infusions, may occur within 24 hours.
- Tachycardia, Hypotension.
- Methemoglobinemia.
Heparin - the anticoagulant effect may be decreased, monitor PTT.
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
Reconstitution
Compatibility-&
Stability.
Route of Administration
Administration Policy.
Dosage.
Potential Hazards
Important Implications
Drug Interactions
NITROPRUSSIDE SODIUM.
Antihypertensive
Hypertension
Afterload-Reduction
Aortic-Dissection
Congestive Heart Failure
- Reconstitute 50 mg vial with 50 mL D5W
Do not use normal saline.
• Compatible and stable in D5W, NS and lactated Ringer's solutions.
Solutions should be wrapped in opaque material as soon as practical
without delaying therapy.
• Any highly coloured solutions (blue, green or dark red) should be
discarded.
• Sodium nitroprusside, lidocaine, dobutamine, dopamine and nitroglycerin
prepared in D5W or NS, are compatible by Ysite in all possible
combinations.
Continuous Infusion.
• Haemodynamic monitoring and urine output when used for congestive
heart failure.
• Daily serum thiocyanate concentration in those receiving prolonged
infusions (greater than 2 to 3 days) of more than 3 µg/kg/min, or in renal
impairment.
range- 10 - 800 mcg / min.
Flushing, pain or redness at site of injection, skin rash.
Cyanide toxicity
- Decreased PA, PCW pressures
- Tachycardia
- Hypotension
Other antihypertensive agents: additive effects. Lower doses of
nitroprusside may be required.
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
Reconstitution
Route of
Administration.
Administration Policy
Dosage.
Potential Hazards
Important Implications
THEOPHYLLINE
Bronchodilator
Bronchospasm
Chronic Obstructive Pulmonary Disease
Asthma
Antidote for Dipyridamole, Adenosine Toxicity
None
Intravenous
- Theophylline 800 mg = aminophylline 1000 mg
- Dose must be expressed of either aminophylline or theophylline. they are
not interchangeable
- Theophylline therapeutics levels 5-15mcg/ml.
Loading Dose: 200 to 400 mg IV Bolus.
Rate should not exceed 20 mg/min.
Maintenance Dose: 8 to 64 mg / hour based on patient response.
Adenosine Toxicity: (acute broncospasm) administered by MD
dose=50mg of aminophylline.
Repeat in 5 minutes, if necessary then give 25mg after 5 minutes, may be
repeated after 5 minutes.
- Nausea & Vomiting
- CNS Stimulation
- Cardiac Arrhythmias
- Hypertension
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
UROKINASE
Thrombolytic Agent
Loculate pleural effusions/empyema
Indications..
Thrombotic occlusion of central venous access catheter
Route Of Administration Intravenous
Administration Policy
For: Loculated pleural effusion 80,000 units/50ml for instillation into chest
tube
- Avoid IM injections and vascular punctures
- Contraindications:- recent trauma, stroke, surgery, active gi bleed within 2
months, coagulopathy or known bleeding diathesis.
Thrombotic occlusion of central venous access catheter: 5000 I.U./ml.
· Remove protective cap and reconstitute according to directions in package
insert.
· Roll vial between palms to allow powder to go into solution. Do not
shake.
· After attempt has been made to aspirate the catheter, attach a syringe with
the urokinase to the obstructed catheter port.
· Slowly and gently inject 5000 units urokinase with the amount equal to
the internal volume of the catheter.
· Wait at least 10 - 15 minutes before attempting to aspirate. Repeat
aspiration attempts every 5 minutes.
· If the catheter is not open within 30 minutes, wait an additional 30 to 60
minutes before attempting again.
· If still unsuccessful, a second injection may be administered. When
patency is restored, aspirate 4 - 5 ml of blood to assure removal of all drug
and flush the catheter in the usual manner
Potential Hazards Of
Phlebitis at infusion site.
Administration.
Important Implications
-Hemorrhage, bleeding from IV sites/ Fever /Hypotension
- Anaphylaxis
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
VALPROATE SODIUM
Anticonvulsant
Treatment of Grand Mal, Petit Mal, Myoclonic, and Temporal Lobe
Seizures & manic episodes associated with bipolar disorder and
prophylaxis of migraine headache
Reconstitution
• None required.
Compatibility -&
Available as valproate sodium equivalent to valproic acid 100 mg/mL – 5
Stability.
mL vial.
• Compatible with D5W, NS or lactated Ringer’s.
• Diluted solutions are stable for 24 hours at room temperature.
Routes Of Administration. Direct Into IV Tubing
Intermittent Infusion
Continuous Infusion
Administration Policy.
• Liver function tests should be monitored prior to the initiation of therapy
and then at frequent intervals. Liver toxicity has occurred mainly during
the first 6 months of therapy.
• CBC with platelet counts and coagulation tests should be undertaken
before and during therapy at periodic intervals, and prior to planned
surgeries.
• Monitor valproic acid concentrations; increase frequency of monitoring
when other antiepileptic drugs are introduced or withdrawn.
Dosage.
Usual-Adult-Dosage-Range/Route: 10-15mg/kg/day in divided doses
Intravenous-Administration:
125mg to 1000mg-IV every 6 hours.
Infuse each dose over 30 - 60 minutes
Standard Concentration: 500mg - 1g/100ml D5W or 0.9% NaCl
Suggested Adult Maximum Dose: 4g/24h in divided doses (60mg/kg/day)
Potential Hazards Of
• Hypotension with large doses.
Administration.
• Reversible thrombocytopenia; may be dose related.
• Hepatic failure has occurred mostly in children 2 years of age or
younger
• Life-threatening pancreatitis has been reported in both children and
adults shortly after initial use and after several years of use.
• Injection site reactions including inflammation and pain.
• Skin rash, photosensitivity, generalized pruritus, erythema multiforme,
and Stevens-Johnson syndrome.
Important Implications
Excessive sedation
• Tremor, ataxia, fatigue, dizziness, confusion, headache.
• Diarrhoea, nausea and vomiting.
• Abdominal cramps
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
Reconstitution
Compatibility -&
Stability.
Routes Of
Administration.
Administration Policy.
Dosage.
Potential Hazards Of
Administration.
Important Implications
Drug Interactions
VERAPAMIL
Calcium channel blocker
Supraventricular tachycardia.
Control of ventricular rate during atrial flutter or fibrillation.
Angina unresponsive to other medications.
Hypertension.
None required. Available as verapamil 2.5 mg/mL - 2 mL vial.
• Compatible with D5W, normal saline, dextrose-saline combinations,
lactated Ringer's and Ringer's solutions.
• Diluted solutions are stable for at least 24 hours at room temperature.
• Incompatible with sodium bicarbonate.
Direct Into IV Tubing
Intermittent Infusion
Continuous Infusion
• Observe for signs of heart failure.
• In patients with compromised ventricular function - measure PCWP
• Observe for signs of adverse effects if continued longer than 12 hrs.
Loading dose: 2.5 mg to 10 mg ivp no greater than 5 mg / 5 min
Maintenance: 5 - 20 mg / hr as titrated to patient response. After a stable
dose has been determined.
• Itch, urticaria, broncholaryngeal spasm (rare)
• Apnoea may occur in children less than one year of age.
• Hypotension, can be reversed by intravenous calcium chloride.
• Bradycardia, AV block, asystole, responds to intravenous atropine.2
• Severe tachycardia
• Dizziness, headache.
IV beta blockers: additive decrease in cardiac contractility. Do not give
concurrently.
• Disopyramide: additive decrease in cardiac contractility. Do not give 48
hrs before or 24 hrs after verapamil.
• Digoxin: additive bradycardia and AV conduction disturbances; digoxin
levels may increase.
• Carbamazepine: increased plasma carbamazepine concentrations; dose
reduction may be required.
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
Reconstitution
Compatibility-&
Statbility.
VECURONIUM
Neuromuscular blocking agent
Production of skeletal muscle paralysis during mechanical ventilation
• Available as vecuronium 10 mg vial.
• Vials may be reconstituted with SW, NS, D5W, D5S or lactated Ringer's.
• Stable in D5W, NS, D5S and lactated Ringer's solutions for 24 hours.
• Unstable in alkaline solutions, e.g. sodium bicarbonate.
Routes-of
Direct Into IV Tubing
Administration.
Continuous Infusion
Administration Policy. • Peripheral nerve stimulation is recommended to guide sustained
neuromuscular blockade.
• Blood gases and serum electrolytes.
Dosage.
Loading Dose 5 - 10 mg IV bolus over 1 -3 minutes
Maintainance Dose 1 - 10 mg /hour as titrated to patient response and
frequently evaluate adequate level of paralysis and train of four monitoring.
Potential Hazards Of
• Bronchospasm, flushing, hypotension and tachycardia. (Rare)
Administration.
• Keratitis and corneal abrasion due to immobility: prophylactic eye care
required.
Important
- Hypotension. / Tachycardia./Paralytic Ileus / Bronchospasm.
Implications
Drug Interactions
• Potentiated by many drugs including; some antibiotics (e.g.
aminoglycosides, clindamycin, vancomycin), calcium-channel blockers
(e.g. verapamil), antiarrhythmics (e.g. procainamide), and β-adrenergic
blockers.
• Antagonised by anticholinesterases, aminophylline, phenytoin, ranitidine
and carbamazepine.
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications
Reconstitution
Compatibility &
Stability.
Routes Of
Administration.
Administration Policy.
Dosage.
Potential Hazards Of
Administration.
Important Implications
Drug Interactions
PROPOFOL
Anaesthetic – general
For short term sedation during mechanical ventilation
• None required.
Available in 10 mg/mL – 10 mL ampoule and 50 mL infusion bottle.
• Shake well before using.
• Compatible with D5W, D5-1/2S, D5LR and lactated Ringer’s solutions.
• Ampoule and bottle should not be refrigerated.
• When a bottle is used for continuous infusion, it must be used within 12
hours of hanging or the remainder discarded.
• Stable for 12 hours in a syringe. Solutions do not need to be protected
from light during infusion.
Direct Into IV Tubing
Continuous Infusion
• Assess level of consciousness as required.
• Monitor triglycerides should infusion continue for longer than 3 days.
Starting Dose: 25 - 75 mg/hr
Maintenance Dose: Titrate by 25 mg increments every 15 minutes until
desired response is achieved; usual max dose is 300 mg.
Bolus Dose: 10-50mg
• Respiratory acidosis during weaning.
• Anaphylaxis/anaphylactoid reactions.
• Pain at injection site: can be minimised by using large veins, or a central
line.
• Transient green discolouration of the urine.
• Hypotension, may be severe, generally dose and infusion rate dependent.
Responds to IV fluids, and/or vasopressor therapy if required.
• Bradycardia.
• Asystole, heart block, and other arrhythmias
• Convulsions, opisthotonus, myoclonus and choreoathetoid movements
have occurred during emergence from anaesthesia.
• CNS depressants, e.g. inhalation anaesthetics, narcotics,
benzodiazepines: effects will be potentiated.
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ICU Nurses Drug Index-2011
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Drug Name.
Classification.
Indications
Reconstitution ,
Compatibility-&
Stability.
Route of
Administration
Administration Policy.
Dosage.
Potential Hazards Of
Administration.
Important Implications
Drug Interactions
QUINIDINE GLUCONATE
Antimalarial; anti-protozoal agent; antipyretic
• Treatment of severe and complicated malaria and infections due to
chloroquine-resistant or multi-drug resistant strains of malaria.
• None required.
• Available as quinine dihydrochloride salt 300 mg/ mL – 2 mL ampoule.
Equivalent to 250 mg quinine base /mL.
• Compatible with D5W and NS. Prepare immediately before use.
Intermittent Infusion
• Baseline BP and HR then q 15 minutes x 4, then hourly during infusion.
• Blood glucose.
• ECG monitoring for those with a history of underlying cardiac disease.
• IM administration should only be used as a last resort, since it is
highly irritating and may cause focal necrosis and abscess formation.
Loading Dose: 500 to 1000 mg / 100 ml D5W (OVER 30 to 60 minutes)
blood pressures should be checked every 5-10 minutes
Maintenance: Sustained released tablets 324 mg po t.i.d.
• Haemoglobinuria, hypoglycaemia (quinine-induced hyperinsulinaemia),
hypoprothrombinaemia.
• Injection site (abscess, focal necrosis, pain), particularly with IM
injection.
• Dysrhythmia, asystole, hypotension, angina. Associated with rapid direct
IV injection, give maintenance doses over 4 hours.
• Cinchonism; including tinnitus, impaired hearing, headache, nausea,
blurred vision, vomiting, abdominal pain, diarrhoea, vertigo.
• Confusion, oculo-toxicity (sudden blindness)
• Hypersensitivity reactions including angioedema, blood disorders
(thrombocytopenia and intravascular coagulation) and acute renal failure.
• Fever, rashes, dyspnoea.
• Amiodarone; increased risk of ventricular arrhythmias.
• Digoxin; serum concentration of digoxin increased. Monitor for signs and
symptoms of digoxin toxicity.
33
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name
Classification.
Indications
Reconstitution
Compatibility-&
Statbility.
Route of Administration
Dosage.
Potential Hazards Of
Administration.
Important Implications
Drug Interactions
IMEPENEM
Antibiotic - carbapenem beta lactam
• Treatment of various infections due to susceptible organisms
Gram Positive: active against most gram positive organisms except S.
faecium and methicillin-resistant Staphylococcus.
Gram Negative: active against most gram negative aerobic organisms
including Pseudomonas aeruginosa.
Anaerobes: active against most anaerobes except Clostridium difficile.
Poor activity against Burkholderia cepacia or Stenotrophomonas
maltophilia.
• Available as 250 and 500 mg vials.
• Vials may be reconstituted with sterile water, D5W or normal saline.
• Compatible with dextrose, saline and dextrose-saline combination
solutions.
• Stable in normal saline at 5 mg/mL for 11 hours at room temperature and
at least 24 hours in the refrigerator. Stability is concentration dependent.
• Stable in dextrose and dextrose-saline combination solutions for 4 hours
at room temperature and at least 24 hours when refrigerated.
Intermittent Infusion
ADULTS
 Dilute 250 mg in 50 - 100 mL.
 Dilute 500 mg in 100 mL
Infuse over 20 - 30 minutes.
 Dilute 1 g in 200 - 250 mL and infuse over 40 - 60 minutes.
Fluid restricted pt: max concentration 7 mg/mL
NEONATE
Withdraw required dose from minibag and infuse over 20 - 30 minutes.
• Anaphylaxis, including bronchospasm and hypotension
• Seizures, associated with high doses in patients with renal impairment.
LOCAL REACTIONS
• Pain on injection, thrombophlebitis.
GASTROINTESTINAL
• Nausea and vomiting, decreasing infusion rate may alleviate symptoms.
• Diarrhoea
 Do not administer with probenecid (increases imipenem/cilastatin
levels) or ganciclovir (increases risk of seizures)
 Phenytoin may precipitate seizures
34
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
ACYCLOVIR
Antiviral
Antiviral for herpes simplex virus types-1 and 2,
Varicella-zoster-virus,
Epstein-barr-virus
CMV prophylaxis
Reconstitution
None required. Available as acyclovir 50 mg/mL - 10 mL vial.
Compatibility-&
Compatible with D5W, NS, dextrose 5% - saline combinations, and lactated
Statbility.
Ringer's solutions.
Stable in above solutions for 24 hours at room temperature. Do not refrigerate.
Routes of
Intermittent Infusion –
Administration.
It is also available in oral form
ADMINISTRATION Assess IV site for signs of phlebitis.
POLICY.
Serum creatinine should be moitored closely.
Patient should be well hydrated
Should be infused via controlled infusion device over 1 hour to prevent
crystallization in the kidneys
DOSAGE.
5 - 10 mg/kg every eights hours for 5 - 7 days
If creatinine is greater than 2.5 mg/dL, dosing is every 12 hours.
Potential Hazards Of LOCAL REACTIONS
Administration.
• Phlebitis or inflammation at the injection site (pain, swelling or redness).
Anorexia, nausea or vomiting.
Light-headedness.
Important
RENAL
Implications
• Acute renal failure, due to precipitation of acyclovir in renal tubules. Risk is
decreased by ensuring adequate hydration during and for at least 2 hours
following administration.
CNS
• Confusion, hallucinations, seizures, tremors, coma: associated with high
plasma concentrations. (Rare).
Drug Interactions
Other nephrotoxic medications, e.g. amphotericin B, increased potential for
nephrotoxicity.
35
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
Reconstitution
Compatibility & Stability.
Routes Of Administration.
Administration Policy.
Dosage.
Potential Hazards Of
Administration.
Important Implications
DESMOPRESSIN
Synthetic antidiuretic hormone
Haemostatic agent
Diabetes Insipidus
Hemorrhaging associated with nephrotic syndrome
Management of perioperative bleeding in patients with a known
bleeding diathesis
None required.
Solutions in NS should be mixed just prior to infusion.
Compatible with D5W, NS and Ringers lactate solutions.
Compatible by Y site with potassium chloride and calcium gluconate.
Ampoules must be refrigerated and protected from light.
Direct Into IV Tubing ; Intermittent Infusion
Serum and urinary electrolyte levels should be known prior to therapy
and monitored during desmopressin administration.
Heart rate and BP every 10 minutes during infusion, then as required.
Administer as infusion only to avoid hypotension
Diabetes insipidus:
• 1 - 4 mcg daily as a single dose or in 2 divided doses.1, 3, 6
Haemostatic agent
• 0.2 – 0.4 mcg/kg (maximum dose 20 mcg).
If used preop, give 30 minutes prior to scheduled procedure.
• Tachyphylaxis will develop with repeat administration: two
infusions of 0.3 mcg/kg in one day appear to induce a near
maximum response;
LOCAL REACTION
• Burning, local erythema and swelling at injection site.
MISCELLANEOUS
• Transient headache, vulval pain; respond to a decrease in dose.
• Facial flushing
• Allergic reactions including anaphylaxis (rare)
GASTROINTESTINAL
• Abdominal cramps, nausea; respond to a decrease in dose
CARDIOVASCULAR
• Blood pressure: either a slight elevation or a transient fall with a
compensatory increase in heart rate.
36
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
Reconstitution
Compatibility-&
Stability.
Routes Of
Administration.
Administration Policy.
Dosage.
Potential Hazards Of
Administration.
Important Implications
Drug Interactions
DEXAMETHASONE
Corticosteriod
Adrenal Insufficiency
Chronic Obstructive Pulmonary Disease
Cerebral Edema
Inflammatory Diseases
Dexamethasone Suppression Test (Diagnosistic test for Cushing's disease
None required.
Compatible with dextrose, saline, dextrose-saline combinations and
lactated Ringer's solutions.
Stable in above solutions for at least 24 hours at room temperature
Direct Into IV Tubing
Intermittent Infusion
- Repeat as required during therapy.
- Monitor serum glucose, serum electrolytes, serum osmolality
- Prolonged administration will require tapering of dose to discontinue
therapy
- May require hyperglycemic therapy in susceptible patients
- Dosage range may vary greatly depending on disease state
Initial Dose: 1 - 10 Mg IVP Every Six Hours
Suppression Test Dose: 1mg IV
24 HOUR CUMULATIVE DOSE: 100 Mg
Bronchospasm, anaphylaxis (rare).
Gastrointestinal perforation and GI haemorrhage in neonates. Occurs
more frequently when therapy starts on Day 1
Nausea.
Depression, euphoria.
Occur with use of high doses for prolonged periods and are less likely to
occur with short term use.
CARDIOVASCULAR
Transient hypotension, cardiopulmonary arrest (rare).
Oedema, hypertension, congestive heart failure.
ENDOCRINE
Growth suppression in children, hyperglycaemia, adrenal suppression.
DERMATOLOGICAL
Impaired wound healing, petechiae, ecchymoses.
Rifampin, phenobarbital and phenytoin - induce hepatic enzymes and
increase dexamethasone metabolism.
Indomethacin – avoid concurrent use in neonates, increased incidence of
gastrointestinal perforation and GI haemorrhage.
37
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
CLASSIFICATION
Indications
Reconstitution And
Stability
Compatibility
Routes Of
Administration
Administration Policy
Dosage
Potential Hazards
Important
Implications
DOBUTAMINE
Sympathomimetic
Treatment of cardiac decompensation due to depressed contractility resulting
from organic heart disease or following cardiac surgical procedures in which
parenteral therapy is necessary for inotropic support.
Stable at room temperature
Stable x 24 hours at room temp. when diluted in commonly used iv solutions
Slight pink colour does not indicate a significant loss in potency
Compatible with commonly used IV solutions
Incompatible with aminophylline, calcium, diazepam, digoxin, furosemide,
heparin, insulin, phenytoin, potassium phosphate and alkaline solutions (e.g.
Sodium bicarbonate)
IV infusion only (with an automated infusion control device)
Dilute 250 mg, 500 mg or 1,000 mg in 250 ml of infusion solution to provide
a concentration of 1 mg/ml (1,000 mcg/ml), 2 mg/ml (2,000 mcg/ml) (doublestrength) and 4 mg/ml (4,000 mcg/ml) (quadruple strength) respectively
For myocardial perfusion imaging: dilute 100 mg in 250 ml NS
Restricted to Critical Care Areas. Continuous blood pressure monitoring via
intra-arterial catheter and ECG monitoring required. Use of syringe/infusion
pump recommended.
Individualized according to patient response
Adults: 2.5-10 mcg/kg/minute; up to 40 mcg/kg/min may be required
Subcutaneous infiltration may cause local pain without local ischemia
Adverse effects include: tachycardia, increase in premature ventricular beats,
transient bigeminy, angina, elevation in blood pressure
Continuous monitoring of heart rate, blood pressure and ecg is required
(preferably via an arterial line)
Patients with pre-existing hypertension have increased risk of exaggerated
pressor response
Patients with atrial fibrillation are at risk of developing rapid ventricular
response
In patients who have atrial fibrillation with rapid ventricular response, a
digitalis preparation should be used prior to dobutamine
Do not use in the presence of tachycardia or ventricular fibrillation
Use with caution in patients with hyperthyroidism, and in patients receiving
anesthetic agents, or in patients on other sympathomimetic amines
Due to very short half-life of the drug most adverse effects usually disappear
quickly if the infusion is slowed or interrupted
Formulation contains sodium bisulfite
38
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Classification
Indications
Reconstitution And
Stability
Compatibility
Routes Of
Administration
Administration
Policy
Dosage
Potential Hazards Of
Administration
Important
Implications
DOPAMINE
Sympathomimetic
To increase cardiac output and improve renal blood flow (doubtful) in shock
due to myocardial infarction, sepsis, trauma, acute renal failure, open heart
surgery and chronic congestive heart failure
Control of cerebral perfusion pressure
Stable at room temperature, protect from light
Yellow, brown, or pink to purple discoloration indicates decomposition of
dopamine; discolored solutions should not be used
Compatible with D5W, NS, D5S, LR, Mannitol.
Compatible with all inotrops
Incompatible with alkaline solutions (e.g. Sodium bicarbonate), insulin
IV Infusion ONLY (must be administered via central line only)
Use premixed solution of 400 mg in 250 ml D5W (1600 mcg/ml) ) or 800 mg
in 250 ml D5W (3200 mcg/ml - double-strength)
Restricted to Critical Care Areas.
Continuous blood pressure monitoring via intra-arterial catheter and ECG
monitoring required.
Use of syringe/infusion pump recommended.
Individualized according to patient response
Usual: 1-5 mcg/kg/minute initially with gradual increases of 1-4
mcg/kg/minute at 10-30 minute intervals up to 20-50 mcg/kg/minute
Most patients can be maintained on 20 mcg/kg/minute or less
Cerebral perfusion pressure control: 10-40 mcg/kg/minute
Extravasation may cause necrosis and sloughing of surrounding tissue
High doses over prolonged periods and low doses in patients with occlusive
vascular disease have led to gangrene of the extremities due to
vasoconstriction.
Adverse effects include; nausea, vomiting, ectopic beats, tachycardia, anginal
pain, dyspnea, vasoconstriction, hypertension, hypotension, headache
Due to a very short half-life of the drug most adverse effects disappear quickly
if the infusion is slowed or interrupted.
If extravasation occurs, 10-15 ml of ns containing 5-10 mg of phentolamine
may be infiltrated liberally within 12 hours throughout the area which is
identified by coldness, hardness and pallid appearance.
Avoid flushing the tubing as a bolus of the drug could be fatal
Correct hypovolemia as indicated.
Use with caution in patients with tachyarrhythmia or ventricular fibrillation
and ischemic heart disease
Use with caution in patients with pre-existing vascular disease since these
patients are more prone to severe peripheral vascular constriction
Closely monitor blood pressure, urine flow and cardiac output whenever
possible
ECG monitoring is recommended whenever possible.
39
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
Reconstitution
Compatibility &
Stability
Routes Of
Administration.
Administration
Policy.
Dosage.
Potential Hazards Of
Administration.
Important
Implications
Drug Interactions
ENALAPRILAT
Angiotensin converting enzyme inhibitor
Hypertension
None required. Available as 1.25 mg/mL – 2 mL vial; contains benzyl alcohol.
Stable in D5W, NS, D5NS and D5W in lactated Ringer’s solutions for 24
hours at room temperature.
Neonatal dilution with NS required. 1.25 mg (1 mL) diluted with 49 mL NS to
give 25 mcg/mL.3
Do not use if initial solution is discoloured.
Direct Into Iv Tubing
Intermittent Infusion
- Use caution when concomitent administration of potassium supplements or
potassium sparing diuretics
- Hyponatremia can occur in patients on diuretics and low salt diets
- Cumulative effects may be observed in renal insufficiency. Dosage
adjustment may be required
- Hypotensive effects may be potentiated when administered to patients
receiving duiretics
Initial or loading dose must be administered in the presence of a physician
Loading dose: 0.625 - 1.25mg IV push over 5 minutes
Maintanence dose: 0.625, 1.25, 2.5, to 5.0 mg repeated every 6 hours as
titrated to patient response.After a stable dose has been determined rn may
administer intermitent IVP maintenance doses
Fatigue, sweating, muscle cramps, dyspnea, Hyperkalemia, Liver enzymes
and/or serum bilirubin elevations – usually reversible
CARDIOVASCULAR (Hypotension: Flattening the bed is generally
adequate, with IV normal saline being reserved for excessive hypotension)
GASTROINTESTINAL ( Nausea, vomiting, diarrhoea, abdominal pain)
RENAL ( Renal failure)
CNS (Headache, dizziness, insomnia, nervousness)
HYPERSENSITIVITY
• Cough, rash, pruritus
• Angioedema of tongue, glottis or larynx should be treated with 0.5 mL
subcutaneous epinephrine 1:1000.
• Angioedema limited to face, lips and mouth may respond to antihistamines.
HEMATOLOGIC (Neutropenia, agranulocytosis (rare))
Diuretics – may potentiate hypotension
Potassium sparing diuretics, potassium supplements – hyperkalemia.
Lithium salts – reduced lithium clearance
40
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications
Reconstitution
Compatibility & Stability
Routes Of Administration.
Administration Policy.
Dosage
Potential Hazards
Important Implications
Drug Interactions
EPINEPHRINE ( ADRENALIN)
Sympathomimetic
Ventricular fibrillation, Asystole, Bronchospasm/Upper-airway-edema,
Anaphylaxis, Hypotension, Low cardiac output
None required.
Available as epinephrine 0.1 mg/mL (1:10,000) - 10 mL pre-filled
syringe and epinephrine 1 mg/mL (1:1000) - 1 mL ampoule and 30 mL
vial.
Compatible and stable in D5W, NS, DNS combinations and RL
Solutions containing a precipitate or discolored should not be used.
Incompatible with sodium bicarbonate solution.
Direct Into IV Tubing, Continuous Infusion
IBP monitoring should be considered when centrally administered
- Should be used with caution in patients with ischemic heart disease
-Do not use in patients with droperidol induced hypotension: may result
in a paradoxical lowering of BP
Anaphylaxis: 0.5 - 1.0 mg SQ (1:1000 Ampule 1 ml)
Asystole, V-FIB: 0.5 - 1.0 mg IVP (1:10,000 Syringe 10 ml)
Cardiac Arrest for 5 - 10 mg
Maintenance: 1 - 12 mcg / minute IV infusion as titrated
Bronchospasm: IV infusion 0.25-1 mcg/minute as titrated
Pulmonary oedema , Lactic acidosis, hyperglycaemia
Cardiovascular (Excessive rise in BP, Arrhythmias, Palpitations, anginal
pain.)
CNS (Anxiety, dizziness, headache, ICH: due to hypertension)
Extravasation
Results in sloughing and necrosis. Central line required for continuous
infusion.
Inhalation hydrocarbon anaesthetics: may increase risk of ventricular
arrhythmias.
MAO inhibitors and some antihistamines (e.g. diphenhydramine): may
potentiate pressor response.
Digoxin or tricyclic antidepressants: may increase risk of cardiac
arrhythmias.
Beta-adrenergic blocking agents: may result in mutual inhibition of
therapeutic effects.
41
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications
Reconstitution
Compatibility -&
Stability.
Routes Of Administration.
Administration Policy.
Dosage.
Potential Hazards
Important Implications
Drug Interactions
ESMOLOL
Beta Adrenergic Antagonist
Supraventricular Tachycardia
Unstable Angina
To determine effects of beta blocker therapy in unstable patients
Available as Esmolol 250 mg/mL - 2.5 g/10 mL ampoule. This is a
concentrated solution, which must be diluted prior to infusion.
Also available as esmolol 10 mg/mL (100 mg/10 mL vial). Use undiluted
for bolus injections.
Compatible with D5W, Ringer’s, dextrose-saline combinations, saline
and 40mEq KCl/L in D5W
Incompatible with 5% sodium bicarbonate.1
Direct Into IV Tubing, Continuous Infusion
PA-line monitoring of cardiac output, cardiac index, PCWP, CVP, SVR,
is encouraged during maintenance infusions
- Doses exceeding 300 mcg/kg/min (ie. 21 mg/min for a 70 kg person) are
discouraged due to lack of data of any increased efficacy and loss of
unique pharmacokinetic properties.
Initial or loading dose must be administered In the presence of a
physician
LOADING DOSE: 20 - 30mg iv over 1 min. using the 10 mg/ml
MAINTENANCE DOSE: 2 To 12 Mg / Min as titrated to patient
response. maintenance infusions may be increased by 2 to 3 mg/min at 10
minute intervals until desired response is achieved.
Phlebitis at IV infusion site if given peripherally.
CARDIOVASCULAR
• Hypotension; should reverse within 30 minutes of decreasing rate or
discontinuing drug.
CNS
• Dizziness, somnolence, confusion, headache and agitation
GASTROINTESTINAL
• Nausea, vomiting
Digoxin – increased digoxin levels, synergistic with digoxin, both drugs
slow AV conduction
IV morphine - increases esmolol steady-state levels by 50%
Concurrent use of epinephrine is contraindicated
Concurrent use of IV verapamil may cause severe depression of
ventricular function.
42
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
Reconstitution
Compatibility -&
Statbility.
Routes Of Administration.
Administration Policy.
Dosage.
Potential Hazards
Important Implications
Drug Interactions
HALOPERIDOL
Antipsychotic
Psychotic Behavior / Nausea and Vomiting.
None required. Available as 5 mg/mL haloperidol - 1 mL ampoule.
Stable in NS for 24 hours at room temperature
• Stable in D5W for 24 hours at room temperature; maximum
concentration 3 mg/mL, i.e. 75 mg in at least 25 mL D5W.
• Incompatible with heparin
Direct Into IV Tubing, Intermittent Infusion, Continuous Infusion
Required
• Baseline BP and then at 15 minutes.
• Continuous infusion; continuous ECG monitoring.
Recommended
• With cumulative doses greater than 35 mg/24 hours: daily ECG and
QTc monitoring is recommended. Notify physician if QTc interval is
greater than 450 ms or an increase of greater than 25% in QTc occurs.
• Serum magnesium and potassium levels: hypomagnesium and
hypokalemia increase risk for QT prolongation.
• Assess for signs of extrapyramidal side effects, e.g. rigidity, fine
tremor of limbs, upward rotation of eyes.
Initial Dose: 2 to 10 mg IVP doses may be repeated every 20 minutes
24 Hour Cumulative: 240 mg higher doses may require psychiatric
consultation
Nausea and Vomiting: 0.25mg IV, may repeat in 30 minutes
Insomnia, agitation, depression, confusion, drowsiness, lethargy
CARDIOVASCULAR
• Prolonged QTc interval, torsades de pointes; predominately in
critically ill patients receiving high doses.
• HTN, usually caused by hypovolemia, tachycardia, hypertension.
CNS
• Extrapyramidal symptoms: dystonic reactions, akathisia. Symptoms
respond to treatment with anticholinergic agents (i.e. IV
diphenhydramine or benztropine).
• Neuroleptic malignant syndrome characterized by muscular rigidity,
hyperpyrexia, autonomic instability and marked changes in mental
status. (Rare)
CNS depressants ( narcotics, barbiturates, benzodiazepines): additive or
potentiating effects. Dose reductions of 66 - 75% required.
• Drugs that may prolong the QT interval: possible additive effect.1
• Epinephrine: for treatment of hypotension due to haloperidol, a
pressor other than epinephrine, such as norepinephrine
should be used to avoid unopposed β-adrenergic activity.
43
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
Reconstitution
Compatibility & Statbility
Routes Of Administration.
Administration Policy.
Dosage.
Potential Hazards Of
Administration.
Important Implications
Drug Interactions
HYDRALAZINE
Antihypertensive
Hypertension, Afterload Reduction
Available as hydralazine 20 mg ampoule.
• Reconstitute each 20 mg ampoule with 1 mL sterile water without
preservative to provide hydralazine 19.7 mg/mL
• Should be freshly prepared and unused portion discarded.
Compatible with normal saline, and Ringer’s solution for 24 hours at
room temperature.
• Due to slow reaction between dextrose-containing solutions and
hydralazine, a yellowish colour ensues which does not alter hypotensive
effects. However, manufacturer does not recommend a dextrosecontaining solution as a diluent.
Direct Into IV Tubing, Intermittent Infusion, Continuous Infusion
REQUIRED
Direct: BP q 5 minutes until stable.
ECG monitoring for 30 minutes and continue until stable.
Intermittent infusion: BP and HR every 5 minutes until stable, then q15
minute x 2
Continuous infusion: At start of infusion and with any rate increase, BP
every 5 minutes until stable, then every 1 hour
Continuous ECG monitoring
RECOMMENDED
• Monitor ECG in patients with a high risk of cardiac arrhythmias.
Loading Dose: 5 - 20 mg IVP every 30 minutes up to 400 mg as
titrated to patient response.
Maintenance Dose: 5 - 20 mg IVP as titrated to patient response
repeated every 4 - 6 hours
- After a stable dose has been determined intermittent IVP maintenance
doses may be administered
Flushing, sweating.
• Dry mouth, unpleasant taste.
Cardiovascular
• Severe hypotension, Tachycardia, palpitation, Angina and/or CHF
CNS
• Headache, dizziness, anxiety.1,2
Gastrointestinal
• Diarrhoea, nausea, vomiting.
Epinephrine: avoid concomitant use as epinephrine enhances the
cardiac-accelerating effects of hydralazine.
44
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications
Reconstitution
Compatibility-&
Statbility.
Route of Administration
Administration Policy.
Dosage.
Potential Hazards Of
Administration.
Important Implications
Drug Interactions
HYDROCORTISONE
Glucocorticoid
Adrenal-Insufficiency, COPD, Cerebral-Edema, Inflammatory Diseases
Available as 100, 250, 500 mg and 1 g vials.
• Vials requiring reconstitution can be reconstituted with sterile water or
normal saline.
• Compatible in dextrose, saline, dextrose-saline combinations, Ringer's
and lactated Ringer's solutions.
• Reconstituted vials are stable at room temperature or in refrigerator for 3
days.
Direct Into I V Tubing, Intermittent Infusion, Continuous Infusion
RECOMMENDED
• Neonates: Measure BP and blood glucose frequently during acute illness.
• Baseline Serum Potassium and Blood Glucose for short term high dose
therapy. Repeat as required during therapy.
Single Dose: 50 to 100 mg IVP every 8 hours
24 Hour Cumulative Dose: 2 Gms
Bronchospasm, anaphylaxis (rare).
• Depression, euphoria, mood swings.
Impaired wound healing, petechiae,ecchymoses.
Occur with use of high doses for prolonged periods and are less likely to
occur with short term use.
Fluid And Electrolyte
• Sodium and fluid retention, hypokalemia, hypocalcemia.
Cardiovascular
• Transient hypotension, cardiopulmonary arrest (rare)5
• Edema, hypertension, congestive heart failure.
Endocrine
• Growth suppression in children, hyperglycaemia, adrenal suppression.
Gastrointestinal
• Nausea, peptic ulcer.
- Is metabolised by cytochrome P450 3A4. Rifampin, phenobarbital and
phenytoin
- increase hydrocortisone metabolism. Antifungals, grapefruit and protease
inhibitors
- decrease hydrocortisone metabolism.
45
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name
Classification.
Indications..
Reconstitution
Compatibility
Statbility.
-&
Routes Of Administration.
Administration Policy.
Dosage.
Potential Hazards
Important Implications
Drug Interactions
KETAMINE
Beta Adrenergic Agonist
AV-Block,
sick-sinus-syndrome
Stokes-Adams-Syndrome
PulmonaryHypertension
Bradycardia
Status-asthmaticus
Extrinsic sympathetic stimulation post cardiac transplantation
None required. Available as isoproterenol HCl 0.2 mg/mL (1:5,000) 1 mL ampoule and 5 mL vial. Contains sodium metabisulfite.
Compatible with dextrose, saline, dextrose-saline combinations,
Ringer's and lactated Ringer's solutions.
• Stable in D5W, D10W, NS, dextrose-saline combinations, and
lactated Ringer's solutions for at least 24 hours at room temperature.
• Discoloured solutions (pink/brown) or solutions containing a
precipitate should not be used.
• Incompatible with sodium bicarbonate solution.
Continuous Infusion, Direct Into IV Tubing
 Use cautiously in patients with tachycardia, arrhythmias, angina,
coronary artery disease, digoxin toxicity
 PA - line monitoring of cardiac output, cardiac index, pcwp, cvp,
svr, is encouraged during maintenance infusions
 IBP monitoring should be considered when frequent changes in
infusion rate are required.
0.1 to 20 mcg / min IV as titrated to patient response
Sweating, nausea, vomiting
CARDIOVASCULAR
• Tachycardia, arrhythmias including PVC's, ventricular tachycardia,
ectopic ventricular beats or fibrillation.
• Palpitations, flushing.
• Anginal pain, slight increase in BP followed by severe hypotension:
associated with excessive doses.
CNS
• Headache, nervousness, dizziness or light-headedness, tremor.
Inhalation hydrocarbon anaesthetics: may increase risk of ventricular
arrhythmias.
• Epinephrine; possible additive effects and increased cardiotoxicity;
simultaneous use is not recommended.
• Beta-adrenergic blocking agents: may result in mutual inhibition of
therapeutic effect
MAO inhibitors: may potentiate pressor response.
46
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
Reconstitution
Compatibility
& Statbility.
Routes Of Administration.
Administration Policy.
Dosage.
Potential Hazards Of
Administration.
Important Implications
Drug Interactions
LABETALOL
Adrenergic AntagonistAntihypertensive: Non selective β1, β2
and selective α1 adrenergic blocker
Hypertension, Dissecting Aortic Aneurysm
None required. Available as labetalol 5 mg/mL – 20 mL vial.
Also contains parabens as preservatives.
Stable in D5W, NS, dextrose-saline combinations, lactated
Ringer’s and Ringer’s solutions for 24 hours at room temp.
• Incompatible with sodium bicarbonate
Direct Into IV Tubing, Continuous Infusion
PA - line monitoring of cardiac output, cardiac index, PCPW,
CVP, SVR, is encouraged during maintenance infusions intubated patients should have PIP evaluated periodically
LOADING DOSE: 2.5 - 10 mg over 2 minutes repeated at 5
minute intervals or for aggressive control may double dose at 5
minute intervals until desired response is achieved
MAINTENANCE: 10 to 20 mg / hour initially, then slowly
titrated up to 40 to 180 mg / hour as per patient response or 2.5 to
10 mg ivp every 15 minutes to 1 hour as needed
Tingling of scalp or skin.
• Flushing, sweating
• Hypersensitivity reactions, skin rash
• Nausea and vomiting
CARDIOVASCULAR
• Orthostatic hypotension/dizziness. May require NS boluses,
elevating patient’s legs, or vasopressors.
• Ventricular arrhythmias; intensification of AV block.
• Bradycardia, may respond to atropine. Possible reduced risk of
occurrence compared to other beta-blockers.
• Congestive heart failure; responds to digitalis and diuretics.
RESPIRATORY
• Dyspnea, wheezing, bronchospasm. Possible reduced risk of
occurrence compared to other beta-blockers.
HEPATIC
• Hepatic injury, usually reversible.
Calcium channel blockers (e.g. verapamil); additive negative
effects on myocardial contractility, heart rate and AV conduction.
• Halothane, enflurane, isoflurane: increased risk of myocardial
depression and hypotension.
• Diuretics, or other hypotensive agents: may increase
hypotensive effect.
47
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
Reconstitution
Compatibility
Statbility.
Routes Of Administration.
Administration Policy.
Dosage.
Potential Hazards Of
Administration.
Important Implications
Drug Interactions
LIDOCAINE
Type IB antiarrhythmic
Ventricular Arrhythmias
None required.
Stable in dextrose, saline, dextrose-saline combinations, and
lactated Ringer's solutions
• Lidocaine, dobutamine, dopamine, nitroglycerin and sodium
nitroprusside prepared in D5W or NS, are compatible by Y-site in
all possible combinations.
Direct Into IV Tubing, Intermittent Infusion, Continuous Infusion
Serum electrolytes and serum lidocaine concentrations during
continuous infusions continued beyond 12 - 24 hours.
• When used for pain control, if patient is male over 65 years or
female over 55 years and/or known or suspected of
having cardiac problems, ECG within 14 days prior to 1st
infusion.
- Dosage adjustments may be required in:
* Geriatric patients, Renal Failure, Severe Congestive Heart
Failure
- Use with caution in patients with history of seizure activity
- Dosage adjustments may be required after 24 hours of therapy
due to decreased metabolism
Loading Dose: 1 mg / kg (50 - 100 mg) IVP over 1 minute.
Additional Loading Doses: 0.5 mg / kg at 10 minute intervals up
to 3 mg / kg
MAINTENANCE: 1 to 4 mg / min
HYPERSENSITIVITY
• Rare: dermatological reactions, urticaria, oedema, anaphylactoid
reactions.
• CNS depressant effects may be preceded by excitatory CNS
effects, restlessness, tremors and shivering. Drowsiness and/or
slurred speech may be an early sign of a toxic level. Unrest,
tremor and facial twitching are warning signs of impending
generalised seizures.
• Perspiration, dyspnea and short intervals of apnea are warning
signs of impending respiratory arrest.
• Nervousness, dizziness, blurred vision, tinnitus, vomiting,
miosis, chills.
CARDIOVASCULAR Rare at therapeutic doses.
• Hypotension, myocardial depression (prolongation of PR
interval and QRS complex), bradycardia.
• Heart block, ventricular arrhythmias, cardiac arrest.
Is metabolised by cytochrome P450 3A4.1
48
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications.
Reconstitution
Compatibility -&
Statbility.
Routes Of Administration.
Administration Policy.
Dosage.
Potential Hazards Of
Administration.
Important Implications
Drug Interactions
LORAZEPAM
Sedative/Hypnotic, Anxiolytic
Restlessness/Anxiety
Conscious-Sedation
Status-epilepticus
Alcohol Withdrawal
None required. Available as lorazepam 4 mg/mL, 1 mL vial.
Do not use if discoloured or contains a precipitate 1
• Compatible with sterile water, NS, D5W, and lactated Ringer’s
solutions
• Stable in D5W and NS in concentrations of 0.04 – 0.2 mg/mL
For fluid restricted patients: dilutions of 2 mg/mL in D5W or NS are
reported stable for 24 hours at room temperature.
Concentrations of 0.5 – 1 mg/mL are not recommended too be stored.
Direct IV, Continuous Infusion
Monitoring Required
• Direct IV: Baseline RR, BP and HR, then at 5 and 15 minutes post
dose
• Continuous infusion: Baseline RR, BP and HR, with start of infusion
and with any rate increase; then q 15 minutes until stable, then q 1 hour
RECOMMENDED
• Assess level of consciousness as required
• Serum osmolarity, electrolytes and osmolal gap daily, with high dose
continuous infusions (greater than 0.1 mg/kg/hour) for longer than 48
hrs.
Anxiety / agitation: 1 to 4 mg IV
Status epilepticus: 2 to 8 mg IV
30 to 40 mg in 24 hours as titrated to patients' response
Pain at injection site, erythema and a burning sensation
• Propylene glycol toxicity marked by acute renal failure, metabolic
acidosis; with continuous infusions of 7 days or longer
CENTRAL NERVOUS SYSTEM
• Drowsiness and excessive sedation, especially in patients over 50
years. Can be rapidly reversed by flumazenil IV if treatment required
• Vertigo, weakness and unsteadiness
• Restlessness, confusion, depression, delirium, hallucinations, diplopia,
amnesia
CARDIOVASCULAR
• Hypertension or hypotension
RESPIRATORY
• Respiratory depression and partial airway obstruction
Additive CNS effects with phenothiazines, narcotic analgesics,
barbiturates, alcohol, antidepressants, scopolamine, and MAO inhibitors
49
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications
Reconstitution
Compatibility
& Statbility.
Routes Of Administration.
Administration Policy.
Dosage.
Important Implications
Drug Interactions
MAGNESIUM SULFATE
Electrolyte-Replacement, Antiarrhythmic
Hypomagnesemia
Acute Phase of MI (initate during first 24 hours)
Eclampsia and Pre-eclampisa
None required. Available as magnesium sulphate 50% solution - 10 mL
vial. 5 g (20 mmol) per 10 mL vial.
Stable in dextrose, saline, dextrose-saline combinations and lactated
Ringer solutions for 24 hours, at room temperature.
Direct Into IV Tubing, Intermittent Infusion, Continuous Infusion
Infuse each dose of magnesium sulfate over 1 to 2 hours recheck level
two hours post-infusion
Magnesium Replacement: 0.5 - 5 G IV not to exceed 20 G IN A 24
hour period, rate should not exceed 150 mg / min
Eclampsia and Pre-eclampsia 4-6gm bolus over 30 min, then 2-4gm Q
one hour
Serum Level
Adverse Effect 8-13 mmol/L
1 - 2.5 Reduced ability to pass urine and stool, hypotension, flushing of
skin, sweating, chest pain
3 - 6 Loss of deep tendon reflexes, CNS depression, nausea, vomiting,
ECG changes – increased P-R interval, duration of QRS, height of T
waves
> 5 - 7.5 Respiratory depression and/or respiratory arrest, cardiac
conduction altered
> 12.5 Cardiac arrest
• Respiratory support, followed by intravenous calcium, is given in
magnesium overdose.
Non-depolarising muscle relaxants - potentiation of relaxant effect.1
• Calcium channel blockers (e.g. nifedipine) - hypotension.4
• Gentamicin - respiratory arrest in unventilated newborn exposed to
MgSO4 immediately before birth.
50
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
MEROPENEM
Antibiotic - carbapenem, beta-lactam
Treatment of various infections due to susceptible organisms, including the
following: lower respiratory tract, skin and soft tissue, intra-abdominal,
gynaecological, meningitis and bacteraemia
SPECTRUM OF ACTIVITY
gram positive: most gram positive organisms except E. faecium and methicillinresistant Staphylococcus
gram negative: most gram negative aerobic organisms including Pseudomonas
and Burkholderia cepacia. Poor activity vs. Stenotrophomonas maltophilia
anaerobes: most anaerobes including Bacteroides and Clostridium
Reconstitution
Available as meropenem 500 mg and 1 g vials
Compatibility &
• Vials may be reconstituted with sterile water, NS or D5W
Stability.
Compatible with dextrose, saline, dextrose-saline combinations, Ringer's and
lactated Ringer's solution
• Vials reconstituted with sterile water or NS are stable for 2 hours at room
temperature and at least 12 hours in the refrigerator
Stability is concentration and temperature dependent
Route of Administration. Direct IV, Intermittent Infusion, Continuous Infusion
Dosage.
ADULT
• 500 mg - 1 g every 8 hours, depending on severity of infection
• 2 g every 8 hour for meningitis
• Has been given by continuous infusion in critically ill patients and in cystic
fibrosis. Stability in solution is concentration and temperature dependent
Renal Impairment adjustments as per Creatinine clearance
Hepatic Impairment Adjustment
• None required as long as renal function is normal
Hemo/Peritoneal Dialysis
• Meropenem is removed by haemodialysis, give dose after dialysis
• CAPD: 50% recommended dose every 24 hours7
• CRRT: 100% recommended dose every 12 hours8
Potential Hazards Of
Local Reactions
Administration.
• Inflammation at injection site, thrombophlebitis
Miscellaneous
Headache, rash
• Seizures
Important Implications
Hypersensitivity
• Anaphylaxis, including bronchospasm and hypotension (rare)
• Urticaria, pruritus
Gastrointestinal
• Nausea and vomiting, diarrhoea
• Pseudomembranous colitis (rare)
51
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications
Reconstitution
Compatibility
& Stability.
Routes Of Administration.
Administration Policy.
Dosage.
Potential Hazards Of
Administration.
Important Implications
Drug Interactions
METOCLOPRAMIDE
Upper GIT motility modifier, antiemetic
Diabetic-gastrostasis, Post-surgical-gastrostasis, GERD,
Chemotherapy induced nausea and vomiting
None required. Available as 5 mg/mL; 2 and 10 mL.
Compatibility in dextrose 5%, normal saline and dextrose-saline
combinations for at least 24 hours at room temperature.
Direct Into IV Tubing, Intermittent Infusion, Continuous Infusion
Dosage adjustments may be required in:
- geriatric patients, renal failure, hepatic failure
- Cumulative effect may be observed, dosage adjustment may be
required
- Moderate to high doses of metoclopramide may be combined with
diphenhydramine to avoid dystonic and extrapyramidal side effects
Primary gut dysfunction: 10 mg IV every 6 to 8 hours
Chemotherapy induced n/v: 2 mg/kg 30 minutes prior to
chemotherapy and 1 mg/kg at 2 - 3 hour intervals post chemotherapy
Nausea, diarrhoea.
• Hypersensitivity reactions.
Central Nervous System
• Restlessness, drowsiness, fatigue and lassitude.
• Anxiety and agitation, especially following rapid IV injection.
• Extrapyramidal reactions, particularly in children and young adults
following high doses. Generally, occurs within 24-48 hours and
subsides 24 hours after discontinuation. If intervention required,
responds to treatment with diphenhydramine or benztropine.
• Dystonic reactions, particularly in young adults (18 to 30 years)
receiving high doses (i.e. 2 mg/kg per dose).
• Insomnia, headache, dizziness and neuroleptic malignant syndrome.
May decrease absorption of drugs from stomach (e.g. digoxin) and
increase absorption from small bowel (e.g. acetaminophen, levodopa).
52
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indication
Reconstitution
Compatibility
& Stability.
Routes Of Administration.
Administration Policy.
Dosage.
Potential Hazards Of
Administration.
Important Implications
Drug Interactions
METOPROLOL
β-adrenoceptor blocking agent
Hypertension
SVT
Angina-pectoris
Post myocardial infarction therapy in selected patients
None required.
Available as metoprolol 1 mg/mL - 5 mL vial.
Stable in D5W and NS for at least 24 hours at room temperature.
Direct Into IV Tubing
- PA- line monitoring of cardiac output, cardiac index, PCWP, CVP,
SVR, is encouraged during initiation of therapy in unstable patients
- Should be used with caution in patients with known history of
bronchospasm OR chronic obstructive pulmonary disease
Load: 5.0 mg IV every 2 minutes up TO 15 mg
Maintenance: Oral therapy should be initiated as soon as possible as
25-50 mg orally every six to 12 hours titrated to patient tolerance
 Rash
 Diarrhoea, nausea
Cardiovascular
• Hypotension. May require normal saline boluses, elevating patient's
legs, epinephrine or dopamine.
• Bradycardia: May respond to atropine.
• Congestive heart failure: Responds to digitalis and diuretics.
• Intensification of AV block, cardiac arrest.
CNS
• Fatigue, dizziness
Respiratory
• Wheezing, dyspnea, bronchospasm
IV calcium channel blockers, e.g. verapamil, diltiazem: may
potentiate both drugs and result in severe depression of
myocardium and AV conduction.
53
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
Reconstitution
Compatibility
& Stability.
Routes Of
Administration.
Administration Policy.
Dosage.
Potential Hazards
Important Implications
Drug Interactions
METRONIDAZOLE
Antibacterial – antiprotozoal
Treatment of serious infections due to susceptible anaerobic bacteria,
including C. difficile.
• Perioperative prophylaxis in potentially contaminated surgery
None required.
Compatibility with normal saline, D5W and Lactated Ringer’s solutions.
• Incompatible with dextrose 10% solutions.
Intermittent Infusion
CNS disease; possibility of seizures and peripheral neuropathy.
• Patients with evidence or a history of blood dyscrasia.
• Severe hepatic and renal disease.
• Patients receiving corticosteroids or those predisposed to oedema, as
each 500 mg provides 14 mmol
ADULT
• Treatment of serious anaerobic infection: 500 mg every 8-12 hours.
HEPATIC IMPAIRMENT ADJUSTMENTS
• Decrease dose and/or frequency empirically.
• Haemodialysis: dose after dialysis
• CAPD: 250 mg every 8-12 hours.
Deep red-brown urine, thrombophlebitis.
Gastrointestinal: - GI discomfort, nausea, furred tongue, dry mouth and
unpleasant metallic taste, Diarrhoea and vomiting.
CNS:- Peripheral neuropathy manifested as tingling of extremities,
Headache, transient ataxia, dizziness, drowsiness, confusion and
insomnia.
Dermatological :- Rash and pruritus
Haematological:- Transient eosinophilia or leucopenia .
• Warfarin – potentiates effect of warfarin, monitor PT-INR.
• Phenytoin and phenobarbital therapy - increase the elimination of
metronidazole, resulting in reduced plasma levels.
54
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
Reconstitution
Compatibility
Stability.
Routes Of
Administration.
Administration Policy.
Dosage.
Potential Hazards
Important Implications
NEOSTIGMINE METHYLSULPHATE
Parasympathomimetic
Reversal of muscle paralysis
• Treatment of urinary retention or postoperative intestinal atony,
• Treatment of myasthenia gravis, usually given IM.
Treatment of acute colonic pseudo-obstruction.
None required.
Compatible with D5, NS, DNS, RL.
• Compatible in a syringe with glycopyrrolate.
Direct Into IV Tubing, Intermittent Infusion
Observe for signs of cholinergic crisis (increased muscle weakness)
• Continuous ECG monitoring during administration and until stable.
Monitor for a minimum of 5 minutes.
• Baseline heart rate.
ADULT
For reversal of nondepolarizing neuromuscular blockade:
• 0.5 - 2 mg to be given with atropine or glycopyrrolate.
• 5 mg is normal maximum total dose.
Treatment of myasthenia gravis: usually given IM.
• 0.5 – 2.5 mg. Repeat every 1 to 3 hours as required.
Treatment of acute colonic pseudo-obstruction - 2 – 2.5 mg
• Skin rash.
Cardiovascular Bradycardia, cardiac arrhythmias and arrest.
Respiratory Shortness of breath, difficulty breathing, wheezing or
tightness in chest.
• Excessive increases in bronchial secretions.
Gastrointestinal
• Abdominal cramps, diarrhoea, nausea, vomiting.
CNS
• Anxiety, slurred speech, unusual irritability, seizures.
Skeletomuscular
• Increasing muscle weakness or paralysis, especially in the arms, neck,
shoulders and tongue; muscle cramps or twitching.
55
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug name.
Classification.
Indications..
Reconstitution
Compatibility -&
Statbility.
Routes Of
Administration.
Administration Policy.
Dosage.
Important Implications
Drug Interactions
NOREPINEPHRINE
Sympathomimetic
Temporary restoration and maintenance of blood pressure in acute
hypotension or shock states, such as surgery, trauma, sepsis.
None required.
Available as norepinephrine base 1 mg/mL – 4 mL ampoule.
Stable in dextrose, normal saline and dextrose-saline combination
solutions
• Compatible with D5, NS, DNS, RL.
• Do not use if solution is discoloured or contains a precipitate.
Continuous Infusion
• Continuous ECG, BP monitoring.
• Hemodynamic monitoring, Fluid balance.
• Assess extremities for changes in colour or temperature.
• If given peripherally, assess IV site for signs of extravasation; area will
appear cold, hard and pale.
Do not stop infusion abruptly; rate should be gradually tapered.
• Initial rate varies considerably: 8 – 12 mcg/minute1 or 0.01 – 0.5
mcg/kg/min, titrated to establish and maintain blood pressure.
Patients with liver disease may have an increased response
Cardiovascular
• Severe peripheral and visceral vasoconstriction.
• Plasma volume depletion
• Decreased cardiac output due to increased peripheral vascular resistance.
• Hypertension (responds to IV phentolamine), reflex bradycardia.
• Arrhythmias, more likely to occur with large doses
CNS
• Anxiety or restlessness, dizziness, headache, trembling.
Extravasation
• Results in sloughing and necrosis. Central line required.
• Treatment: Stop infusion. Restart norepinephrine at new IV site.
Physician to infiltrate area of extravasation with phentolamine: 5 – 10 mg
diluted in 10 mL NS1. Max total dose 10 mg
Cyclopropane or halothane anaesthesia: may increase risk of ventricular
arrhythmias.
• MAO inhibitors, tricyclic antidepressants, ergotamine, oxytocin,
doxapram: may potentate pressor response.
• Methyldopa: may enhance the pressor response to norepinephrine, while
norepinephrine may decrease hypotensive effect of methyldopa.
• Digoxin: may increase risk of cardiac arrhythmias.
• Beta-adrenergic blocking agents: may result in mutual inhibition of
therapeutic effects.
56
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
ONDANSETRON
Antiemetic
Prevention of nausea and vomiting associated with emetogenic
chemotherapy and radiotherapy, post-operative nausea and vomiting.
Reconstitution
None required.
Compatibility -&
Available as ondansetron 2 mg/mL - 2 and 4 mL vials.
Stability.
Stable in D5W, NS, Ringer's, Ringer's lactate, dextrose-saline
combination
• Incompatible with drugs having alkaline pH, e.g. sodium bicarbonate.
Routes Of Administration. Direct Into IV Tubing, Intermittent Infusion, Continuous Infusion
Dosage.
ADULT
In association with chemotherapy:
• 8 mg 30 minutes pre-chemo. 8 mg every 8 - 12 hours post
chemotherapy. Doses post chemotherapy are commonly given PO.
• 8 mg loading dose followed by a continuous infusion of 1 mg/h for 24
hours.
• A single 32 mg dose pre-chemo, with no post-chemotherapy doses.
Postoperative nausea:
• 4 mg before anaesthesia induction or immediately after surgery.
• Repeat doses are commonly given at 3- to 4-hour intervals.5
Hepatic Impairment Adjustments
• Maximum 8 mg/day recommended for severe hepatic insufficiency.
Potential Hazards Of
Miscellaneous
Administration.
• Hypersensitivity reactions: rash, bronchospasm, urticaria, angioedema
• Dry mouth, unusual tiredness or weakness.
• Blurred vision: associated with infusions of 30 mg in less than 15
minutes.
• Fever, chills.
Important Implications
Gastrointestinal
• Constipation.
• Abdominal pain, stomach cramps.
CNS
• Headache, usually mild but may be severe. Responds to acetaminophen.
• Dizziness or light-headedness.
• Drowsiness.
Hepatic
• Transient increases of AST and ALT (not related to dose or duration of
therapy)
57
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
Reconstitution
Compatibility
& Stability.
Routes Of
Administration.
Dosage.
Potential Hazards
Drug Interactions
PANTOPRAZOLE
H+, K+-ATPase inhibitor
To rapidly reduce gastric acid secretion
Available as pantoprazole 40 mg vials
• Reconstitute with 10 mL preservative free NS.
Stable in NS and D5W for 24 hours at room temperature from the time of
initial reconstitution of the vial
• Compatible with NS, D5W, 2/3-1/3 and Ringer’s lactate
• Incompatibility with calcium chloride, ciprofloxacin, clindamycin,
dobutamine, esmolol, hydromorphone, labetalol, magnesium sulphate,
midazolam, moxifloxacin, norepinephrine, octreotide, potassium
phosphate4 or zinc2
Direct IV, Intermittent Infusion, Continuous Infusion
Adult
• When oral ingestion is not practical; 40 mg once daily.1 Switch to oral
therapy as soon as possible
• Pathological hypersecretion associated with Zollinger-Ellison syndrome:
80 mg every 12 hours. Doses up to 240 mg/day have been used.
• For upper GI bleeding to maintain gastric pH greater than 6; 80 mg
initial bolus, followed by 8 mg/hour.
Max duration of infusion: 72 hours
Pediatric
• Doses have been extrapolated from adult data
• When oral ingestion is not practical, 1- 1.5 mg/kg/day once daily. Max
dose 40 mg/dose
• For upper GI bleeding to maintain gastric pH greater than 6;
Weight Dose
5-15 kg 2 mg/kg/dose x 1 then 0.2 mg/kg/hour
Greater than 15 kg – 40 kg 1.8 mg/kg/dose x 1 then 0.18 mg/kg/hour
Greater than 40 kg 80 mg x 1 then 8 mg/hour
Max duration of infusion: 72 hours
Neonate
• No information available at this time. Use ranitidine IV
Headache, Abdominal pain, cramps, bloating, diarrhoea,
vomiting/retching
DRUG INTERACTIONS:
• Medications whose absorption is pH-dependent, e.g. ketoconazole
58
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
Reconstitution
Compatibility -& Stability.
Routes Of Administration.
Administration Policy.
Dosage.
Potential Hazards
Important Implications
Drug Interactions
PARALDEHYDE
Anticonvulsant
Status epilepticus refractory to traditional anticonvulsant therapy.
None required.
Available as 100% paraldehyde - 5 mL ampoule. Each mL solution
contains 1 g paraldehyde.
Compatible with D5W and NS.
• Stable in NS for at least 6 hours at room temperature in PVC infusion
bags and glass syringes. IV tubing should be changed with each new
bag of solution.
• Plastic syringes may be used to prepare solutions for infusions, but
should not be used to infuse paraldehyde solutions via syringe
pumps. Only glass syringes should be used in syringe pumps.
Intermittent Infusion, Continuous Infusion
Monitoring Required
• Continuous HR, RR and BP monitoring or q3 - 5 minutes as an interim
measure, until continuous monitoring is available.
Recomended
• Serum electrolytes, urea and creatinine, and acid-base status daily.
• Check IV site frequently.
• 0.1 - 0.15 mL/kg (100 - 150 mg/kg).
Hepatic Impairment Adjustments
• Loading dose does not change. Infusion rate should be decrease to 5
mg/kg/hr.
Unpleasant breath odour.
Acute Toxicity
• Respiratory depression, cyanosis, pulmonary oedema, acidosis, coma,
hypotension, cardiac failure.
Cardiovascular
• Pulmonary oedema, cough, pulmonary haemorrhage and respiratory
distress.
• Dilation of the right side of the heart, circulatory collapse.
Dermatological
• Thrombophlebitis: redness, swelling or pain at injection site. Central
line recommended for prolonged infusions.
• Erythematous skin rash.
Alcohol or other CNS depressants: effects are enhanced. Dosage of one
or both agents may need to be reduced.
59
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
Reconstitution
Compatibility
Stability.
Routes Of Administration.
Administration Policy.
Dosage.
Potential Hazards Of
Administration.
Important Implications
Drug Interactions
PHENOBARBITAL SODIUM
Barbiturate
Anticonvulsant: Treatment of status epilepticus and other types of
persistent convulsions.
Not required. Available as 30 mg/mL and 120 mg/mL – 1 mL ampoules
Compatible in D5W, D10W, NS, 0.45% saline, dextrose-saline
combinations and lactated Ringer’s solutions.
Direct Into IV Tubing, Intermittent Infusion, Continuous Infusion
• Baseline BP, HR and RR, then q 15 min x 4 and until stable.
• Assess IV site for signs of extravasation.
• Status epilepticus: Loading dose: 10-20 mg/kg, in single or divided
doses. May give an additional 5 mg/kg every 15- 30 minutes up to a
maximum dose of 30 mg/kg. Maintenance dose: 1-3 mg/kg once daily
or 0.5-1.5 mg/kg every 12 hours.
• Antenatally to prevent IVH:2 10 mg/kg
Renal Impairment Adjustments
• Dosing interval may need to be prolonged, monitor serum
concentration.
Hepatic Impairment Adjustments
• Dose reduction may be required, monitor serum concentrations.
Local Reactions
• Phlebitis, tissue irritation at injection site, necrosis if extravasated.
Dermatologic
• Skin rash, exfoliative dermatitis, erythema multiforme, StevensJohnson syndrome.
Withdrawal symptoms include seizures, diaphoresis, irritability, tremor,
sleep disturbances, weight loss and anorexia.
CNS
• Sedation, drowsiness, confusion, Paradoxical excitement or
hyperactivity, Respiratory depression if administered too rapidly.
Cardiovascular
• Hypotension if administered too rapidly.
Haematopoietic
• Megaloblastic anaemia, agranulocytosis and thrombocytopenia.
Hepatic
• Toxic hepatitis
Drug Interactions:
• Administration with CNS depressants may result in increased effects.
• Oral anticoagulants – decreased anticoagulant effect.
• Phenytoin – decreased or increased serum concentrations of phenytoin.
• Valproate – increased serum concentrations of phenobarbital.
• Oral contraceptives – reduced effect of oral contraceptives.
60
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
PIPERACILLIN SODIUM with TAZOBACTAM SODIUM
Antibiotic – extended-spectrum
penicillin and beta-lactamase inhibitor
Indications..
Treatment of various infections due susceptible organisms, typically
piperacillin resistant beta-lactamase producing organisms.
• Gram positive: piperacillin resistant beta-lactamase producing S.
aureus
• Gram negative: piperacillin resistant beta-lactamase producing E. coli
and H. influenzae.
• Anaerobes: piperacillin resistant beta-lactamase producing B. fragilis.
Reconstitution
Available as 2 g/0.25 g, 3 g/0.375 g and 4 g/0.5 g vials.
Compatibility -& Stability. Vials may be reconstituted with sterile water, normal saline, D5W.
• Incompatible with Lactated Ringers solution
Routes Of Administration.
Intermittent Infusion, Continuous Infusion
Dosage.
ADULT
• Usual total daily dose 12 g piperacillin /1.5 g tazobactam
• Cystic fibrosis: 350 – 600 mg/kg/24 hours divided every 4-6 hours.
• Max recommended dose: 24 g/24 hours.
RENAL IMPAIRMENT ADJUSTMENTS
• Creatinine clearance (mL/s) Creatinine clearance (mL/min)
Recommended dose
> 0.67 >40 3 g/0.375 g every 6 hours
0.33 – 0.67 20-40 2 g/0.25 g every 6 hours
< 0.33 <20 2 g/0.25 g every 8 hours
HEMO/PERITONEAL DIALYSIS
• Haemodialysis: 2 g/0.25 g every 8 hours
• CAPD: 2 g/0.25 g every 8 hours.
• CAVH: 2 g/0.25 g every 6 hours.
Potential Hazards
Thrombophlebitis, pain at injection site.
Important Implications
Hypersensitivity
• Urticaria, wheezing, anaphylaxis, Rash and drug fever.
Gastrointestinal
• Diarrhoea, loose stools, Nausea, vomiting, Pseudomembranous colitis
Central Nervous System
• Myoclonia, convulsive seizures and/or depressed consciousness, occur
with high CNS concentrations, Headache, dizziness, fatigue.
Drug Interactions
Aminoglycoside (e.g. gentamicin, tobramycin): piperacillin may
chemically inactivate the aminoglycoside and reduce
serum levels in patients with severe renal failure.
• Probenecid: concomitant administration will prolong the half lives of
both piperacillin and tazobactam.
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
Reconstitution
Compatibility -& Stability.
Routes Of Administration.
Administration Policy.
Dosage.
Potential Hazards
Important Implications
Drug Interactions
PROMETHAZINE
Antihistamine, phenothiazine - irritant
Control of nausea and vomiting of different etiologies
• Treatment of allergic reactions, Procedural sedation
None required.
Available as 25 mg/mL promethazine - 1 mL ampoule
• Compatible with 5D, NS, DNS and lactated Ringer’s solutions
Direct Into IV Tubing, Intermittent Infusion
MONITORING REQUIRED
• Direct into IV tubing:BP and HR, then q 5 minutes x 2 and until stable
• Intermittent infusion: monitor peripheral IV site for signs of local
reaction (i.e. burning/stinging/pain)
ADULT
• Antiemetic: 6.25 – 25 mg every 4 – 6 hours as needed
• Sedative – hypnotic and premedication: 25 – 50 mg/dose as needed
• Treatment of allergic reactions: 25 mg, may be repeated within 2 hours
if necessary
• Maximum daily dose: 100 mg
ELDERLY - Reduced starting dose (ie 6.25 mg) may be indicated
• Dry mouth
Cardiovascular
• Hyper- or hypotension, tachycardia, bradycardia, Faintness, dizziness
Extravasation
• Irritant: may cause severe tissue damage and necrosis at IV site and
surrounding infiltrated area. Avoid hand/wrist veins whenever possible,
administer through a large-bore vein. Because promethazine discolors
blood on contact; aspiration of dark blood at the site of injection does
not rule out the possibility of intra-arterial placement of the needle
• Treatment: Discontinue drug immediately and notify physician. Apply
cold intermittent compresses.
CNS
• Sedation, paradoxical excitation in children and the elderly
• Extrapyramidal side effects (associated with high doses)
HYPERSENSITIVITY
• Urticaria, dermatitis, asthma
May potentiate CNS depressant effects of opiates, barbiturates or other
sedatives, and tranquillizers – reduce dose of promethazine
• Epinephrine – concurrent use not recommended, may cause
precipitous hypotension
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications
Reconstitution
Compatibility -&
stability
Route Of
Administration
Administration Policy
Dosage
Potential Hazards
Important Implications
Drug Interactions
PROPRANOLOL HYDROCHLORIDE
Beta-adrenergic receptor blocking agent
Life-threatening arrhythmias, recurrent MI, and VF in hemodynamically
stable individuals
None required. Available as propranolol 1 mg/mL - 1 mL vial.
Stable in D5W, NS, DNS, and RL for at least 24 hours at room temperature.
• Neonates: further dilution with NS recommended, 1 mg (1 mL) diluted
with 9 mL NS to give 0.1 mg/mL.
Direct Into IV Tubing, Intermittent Infusion, Continuous Infusion
MONITORING REQUIRED
• Continuous ECG monitoring.
• Bolus or infusion: Baseline BP and HR, then q 3 - 5 minutes until stable.
RECOMMENDED
•Regular respirations for signs of breathing difficulty and/or wheezing.
• Pulmonary wedge pressure or central venous pressure monitoring.
• Neonates: blood glucose during initiation and/or change in dosage.
• Arrhythmias: 1 to 3 mg given 1 mg at a time. After 3 mg has been given,
may repeat cycle in 2 minutes
• Continuous infusion: 2-3 mg/hour. Titrate to HR and BP.
PAEDIATRIC
• Arrhythmias: 0.01 - 0.1 mg/kg/dose. Repeat dose every 2 minutes up to 1
mg/dose for infants; 3 mg/dose for children. May repeat every 6-8 hours
SOS
• Tetralogy spells: 0.15 - 0.25 mg/kg/dose. May repeat once in 15 minutes.
NEONATE
• 0.01 mg/kg/dose every 6 hours. Increase as needed to maximum of 0.15
mg/kg/dose every 6 hours.
Cold extremities, Dizziness, fatigue, sleep disturbances. Hypersensitivity
reactions, skin rash, Hypoglycaemia
Cardiovascular
• Hypotension, may be severe and protracted.
• Bradycardia, asystole: may respond to atropine. If atropine is not
effective, glucagon may be administered.
• Congestive heart failure due to decreased contractility: responds to
digitalis and diuretics.
• Intensification of AV block, cardiac arrest.
Respiratory
• Bronchospasm: responds to salbutamol and epinephrine.
• Laryngospasm, respiratory distress.
IV calcium channel blockers, e.g. verapamil: additive effects, i.e. decrease
in cardiac contractility and increased AV block.
Do not give concurrently.
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
Reconstitution
Compatibility -& Stability.
Routes Of Administration.
Administration Policy.
Dosage.
Potential Hazards Of
Administration.
Important Implications
Drug Interactions
ROCURONIUM BROMIDE
Nondepolarizing neuromuscular blocker
Intubation, Skeletal muscle relaxation
None required. Available as rocuronium 10 mg/mL – 5 mL vial.
• Store vials in the refrigerator.
Stable in D5W, NS, D5S and RL for at least 24 hours.
• Unstable in alkaline solutions, e.g. SBC, phenytoin, barbiturates.
Direct Into IV Tubing, Continuous Infusion
RECOMMENDED
• Peripheral nerve stimulation is recommended to guide sustained
neuromuscular blockade.
• Blood gases and serum electrolytes.
ADULT
• Intubation. Bolus dose: 600 mcg/kg;
• Infusion: 0.01 to 0.012 mg/kg/min. Must be individualized.
• Rapid sequence induction:4,5 Bolus dose: 0.9-1.2 mg/kg.
• Obesity: use actual body weight for dosage calculations.
PAEDIATRIC
• Bolus dose: 0.6-1.2 mg/kg/dose, repeat doses 0.1 - 0.2 mg/kg every
20-30 minute. Infusion: Start at 10-12 mcg/kg/min and titrate to effect.
RENAL IMPAIRMENT ADJUSTMENTS
• Close monitoring of neuromuscular blockade.
HEPATIC IMPAIRMENT ADJUSTMENTS
• Inter-individual variation of rocuronium response may be increased.
Close monitoring of neuromuscular blockade is strongly
recommended.
Severe burning injection site pain, Hypersensitivity: bronchospasm,
flushing, hypotension and tachycardia.
NEUROMUSCULAR
• Prolonged paralysis and/or skeletal muscle weakness.
• Incomplete reversal of neuromuscular blockade when stopped.
Manage with manual or mechanical ventilation until complete
recovery of normal respiration is assured.
Potentiated by many drugs including some antibiotics (e.g.
aminoglycosides, clindamycin, vancomycin), calciumchannel
blockers (e.g. verapamil), other neuromuscular blockers, inhalation
anaesthetics (e.g. enflurane, isoflurane and halothane).
• Antagonised by anticholinesterases, furosemide, phenytoin,
theophylline, and carbamazepine
64
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
Reconstitution
Compatibility-&
Stability.
Route of
Administration.
Administration Policy.
Dosage.
Important Implications
Drug Interactions
SALBUTAMOL SULPHATE
Bronchodilator - Beta2-adrenergic stimulant
Severe bronchospasm associated with acute exacerbations of chronic
bronchitis and bronchial asthma, and for the treatment of status asthmaticus.
Hyperkalemia
None required. Available as 1 mg/mL - 5 mL vial
Stable in 5D, NS and DNS combinations. Maximum recommended
concentration 0.5 mg/mL (500 mcg/mL - range 10 - 500 mcg/mL).
Direct Into IV Tubing, Intermittent Infusion, Continuous Infusion
Serum potassium and glucose monitoring
ADULT
• Administration by continuous infusion is preferred.
• Direct IV: 250 mcg (4 mcg/kg). Repeat after 15 minutes if necessary to a
maximum of 1000 mcg (1 mg) daily.
• Continuous infusion: 5 mcg/minute increased to 10 mcg/minute and then
20 mcg/minute at 15 - 30 minute intervals as needed.
PAEDIATRIC
Hyperkalemia: 4 mcg/kg.2
Acute severe asthma:
• Intermittent single dose: 15 mcg/kg.
• Continuous infusion: 1 mcg/kg/min; increase by 1 mcg/kg/min every 15
minutes PRN up to a maximum of 10 mcg/kg/min.
CARDIOVASCULAR
• Palpitations, tachycardia
• Arrhythmias (atrial fibrillation, supraventricular tachycardia and
extrasystoles).
• Angina, peripheral vasodilatation, hypo- or hypertension.
CENTRAL NERVOUS SYSTEM
• Nervousness, muscle tremor, headache - common. A reduction in dosage
might lessen symptoms.
• Agitation.
HYPERSENSITIVITY
• Urticaria, oedema, rash, bronchospasm, anaphylaxis.
Hyperglycaemia, usually slight and transient.
• Hypokalemia.
MAO inhibitors or tricyclic antidepressants: effect on the vascular system
may be potentiated.
65
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
Reconstitution
Compatibility-&
Statbility.
Route of
Administration
Administration Policy.
Dosage.
Important Implications
SODIUM BICARBONATE
Alkalinising agent – irritant
Metabolic acidosis, uncontrolled diabetes, extracorporeal circulation of the
blood, cardiac arrest.
• Urinary Alkalisation in certain drug intoxications, and haemolytic
reactions.
• In severe diarrhoea when loss of bicarbonate has been significant.
• Hyperkalemia
None required. Available as 8.4% sodium bicarbonate solution, 25 mL vial.
Stability in D5W and NS for at least 24 hours at room temperature.
• Incompatible with Ringer's and lactated Ringer's solutions.
Direct Into IV Tubing, Intermittent Infusion, Continuous Infusion
Blood gases and serum electrolyte concentrations.
• Urine pH.
Dosage is determined by severity of acidosis, laboratory tests, age, weight
and clinical condition.
ADULT
• Cardiac arrest: 1 mmol/kg.
• Acidosis (less urgent): 2 - 5 mmol/kg/dose 1 typically given over 4-8
hours
• Urinary alkalinisation: 50-100 mmol/L 0.45% NaCl or 100-150 mmol/L
D5W at 150-200 mL/h.
RENAL IMPAIRMENT ADJUSTMENTS
• Excessive sodium loading should be avoided.
HEPATIC IMPAIRMENT ADJUSTMENTS
• Excessive sodium loading should be avoided.
EXTRAVASATION
• 8.4% sodium bicarbonate is hypertonic: may cause tissue inflammation
and necrosis at IV site and surrounding infiltrated area.
• Treatment: Discontinue drug immediately and notify physician. Apply
cold intermittent compresses.
ENDOCRINE/METABOLIC
• Excessive alkalosis, hypocalcemic tetany, paradoxical intracellular
acidosis, hypokalemia.
• Hypernatremia (oedema, CHF), hyperosmolality.
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
Reconstitution
Compatibility-&
Stability.
Route of Administration
Administration Policy.
Dosage.
Potential Hazards Of
Administration.
Important Implications
Drug Interactions
SUCCINYLCHOLINE CHLORIDE
Depolarising neuromuscular blocker
As an adjunct to general anaesthesia, to facilitate endotracheal intubation
and to provide skeletal muscle relaxation during surgery, or mechanical
ventilation.
None required. Available as succinylcholine 20 mg/mL - 20 mL ampoule.
Compatible in D5, NS, DNS, RL.
• Unstable and decomposes in sodium bicarbonate, barbiturates.
• Ampoules should be refrigerated.
Direct Into IVTubing
• ECG monitoring required
• Observe for signs of malignant hyperthermia (jaw muscle spasm,
increased ETCO2, lack of laryngeal relaxation, and unresponsive
tachycardia).
ADULT
• Initially: 0.3 - 1.5 mg/kg for short-term muscle relaxation
• Maintenance: 0.04 - 0.07 mg/kg at 5 to 10 minutes intervals.
• Elderly: allow more time for drug to achieve maximum effect due to a
delayed onset of action.
• Electroshock therapy: 10 to 30 mg, 1 minute prior to shock.
HEPATIC IMPAIRMENT ADJUSTMENTS
• Decrease dose in severe hepatic disease or cirrhosis since plasma
pseudocholinesterase activity may be decreased.
Hypersensitivity: flushing, skin rash, bronchospasm and shock.
• Malignant hyperthermia (jaw muscle spasm, increased end-tidal CO2
concentration, rigidity, lack of laryngeal relaxation, and unresponsive
tachycardia). Dantrolene IV required.
• Respiratory depression and apnoea: associated with repeated or prolonged
administration and conversion to a nondepolarising block or in those with
decreased pseudocholinesterase activity.
NEUROMUSCULAR
• Transient muscle fasciculations: transient rise in intra-gastric and intraocular pressure.
• Muscle pain: commonly muscles of neck, shoulders, and upper abdomen.
CARDIOVASCULAR
• Bradycardia (more common in children), other arrhythmias, and
hypotension. Premedicate with atropine if possible.
• Tachycardia (more common in adults) and hypertension.
ELECTROLYTE
• Immediate transient increase in serum potassium (0.5 to 1 mmol/L). Rise
in serum potassium may be significant in certain medical conditions:
Potentiated by aminoglycosides, metoclopramide and anticholinesterases
67
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
Reconstitution
Compatibility -&
Stability.
Routes Of
Administration.
Administration Policy.
Dosage.
Potential Hazards Of
Administration.
Important Implications
Drug Interactions
THIOPENTAL SODIUM
Barbiturate anaesthetic
In anaesthesia: for induction in anaesthesia.
• Emergency treatment of certain acute convulsive episodes.
Available as 1 g vial and 5 g/vial combination kit. Reconstitute 1 g vial
with 40 mL sterile water, D5W or NS for 25 mg/mL (2.5%).
Compatible with D5W, saline, dextrose-saline combination solutions.
• Incompatible with D10W, D50W, RL
Direct Into IV Tubing, Intermittent Infusion, Continuous Infusion
• Direct IV or Infusion: Baseline and continously monitor BP, HR and RR
• Haemodynamic monitoring, Fluid balance.
• Serum thiopental concentrations every 24 - 48 hours.
• Seizures: 75 to 125 mg. Up to 250 mg may be required.
• Status epilepticus: loading dose 5 mg/kg, followed by 1 - 3 mg/kg/hr.
• Acutely elevated ICP: 1.5 to 5 mg/kg intermittently.
• Therapeutic coma for persistently elevated ICP: 10 - 30 mg/kg loading
dose.
RENAL IMPAIRMENT ADJUSTMENTS
• For creatinine clearance less than 0.2 mL/s (10 mL/min) decrease dose
by 25%.
HEPATIC IMPAIRMENT ADJUSTMENTS
• Decrease dose required.
Massive diuresis.
• Hypersensitivity reactions, skin rash or hives, swelling of eyelids, face
or lips, wheezing or chest tightness.
• Emergence delirium: anxiety, confusion, excitement, hallucinations,
nervousness, restlessness.
• Immunosuppression.
• GI motility is inhibited; avoid enteral feeding.
RESPIRATORY
• Apnoea, laryngospasm, respiratory depression, if administered too
rapidly.
• Loss of spontaneous respirations.
CARDIOVASCULAR
• Severe hypotension, due to vasodilation of the systemic arterial system.
• Cardiac arrhythmias.
LOCAL REACTIONS
• Phlebitis, tissue irritation at injection site, necrosis if extravasated.
Administration with other CNS depressants may result in potentiation of
effects.
• Thiopental, when given as an infusion, induces hepatic microsomal
enzymes and increases the clearance of many hepatically metabolised
drugs
68
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
Reconstitution
Compatibility-&
Stability.
Route Of
Administration
Administration Policy.
Dosage.
Potential Hazards Of
Administration.
Important Implications
Drug Interactions
TICARCILLIN / CLAVULANATE
Antibiotic - β lactamase inhibitor
Treatment of various infections due to organisms.
• Gram positive: β lactamase producing strains of S aureus.
• Gram negative: β lactamase producing strains of E coli, Klebsiella, and Ps
aeruginosa. Excluding, inducible chromosomal Type I β lactamase.
Available as 3.1 g vials
• Reconstitute each vial with sterile water for injection or NS.
Stable in D5W for at least 16 hours at room temperature and 24 hours in the
refrigerator.
• Stable in NS for at least 24 hours at room temperature and in the
refrigerator.
• Compatible with D5W, NS and lactated Ringer’s solution
Intermittent Infusion
• Monitor peripheral IV site for pain, redness or swelling prior to initiating
and on completion of infusion.
• Monitor serum potassium, renal, hepatic and haematopoietic systems
during prolonged therapy.
• Over 60 kg: 3 g every 4 to 6 hours.
• Under 60 kg: 200-300 mg/kg/24 hours in divided doses every 4 to 6 hours.
HEPATIC IMPAIRMENT ADJUSTMENTS
• Reduced dose.
HEMO/PERITONEAL DIALYSIS
• Haemodialysis: 2 g q12h, supplement with 3 g post dialysis.
• CAPD: 3 g q12h.
Thrombophlebitis, pain at injection site.
• Hypokalemia, hypernatraemia
• Increased bleeding time, leucopenia, thrombocytopenia, neutropenia.
HYPERSENSITIVITY
• Urticaria, Rash and drug fever, wheezing, and anaphylaxis.
GASTROINTESTINAL
• Nausea, vomiting, diarrhoea and loose stools.
• Pseudomembranous colitis, (rare).
CENTRAL NERVOUS SYSTEM
• Headache, dizziness, fatigue.
• Myoclonia, convulsive seizures and/or depressed consciousness, occur
with high CNS concentrations.
Aminoglycoside (e.g. gentamicin, tobramycin): ticarcillin may chemically
inactivate the aminoglycoside and reduce serum levels in patients with
severe renal failure.
• Probenecid: concomitant administration may prolong the half life of
ticarcillin.
69
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
Reconstitution
Compatibility &
Statbility.
Route of Administration
Administration Policy.
Dosage.
Important Implications
Drug Interactions
TOBRAMYCIN
Aminoglycosides
Therapy of gram negative organisms that are resistant to gentamicin but
susceptible to tobramycin
Gram positive: Staphylococci-including methicillin sensitive S.aureus
• Gram negative: Aerobic bacilli including Pseudomonas aeruginosa
None required.
Available as 40 mg/mL – 2, 4 and 30 mL vials
Compatible with dextrose, NS, Ringer's and DNS
Intermittent infusion
• Serum creatinine prior to start of therapy and at least twice weekly during
therapy
• Serum tobramycin as indicated levels (See therapeutic drug monitoring)
• Vestibular and auditory function as indicated
ADULT
Conventional dosing 3 - 5 mg/kg/day, divided every 8 hours
• Used for those who have a tendency to eliminate tobramycin rapidly.
• Endocarditis, pregnancy and renal failure.
ELDERLY Dosage adjustment may be required based on renal function
PEDIATRIC
• 7.5 mg/kg/day divided every 8 hours
• Cystic fibrosis: 7.5 – 10 mg/kg/day divided every 8 hours
• Endocarditis, osteomyelitis and renal failure
Once daily dosing
• 7.5 mg/kg every 24 hours
• Cystic fibrosis: 10 mg/kg every 24 hours
RENAL
• Nephrotoxicity – dose related; more frequent during prolonged therapy.
NEUROLOGIC
• Ototoxicity - May be irreversible
• Neuromuscular blockade: Calcium may help to reverse
Loop diuretics (eg ethacrynic acid, furosemide) - additive ototoxicity
• Nephrotoxic drugs (eg amphotericin B, cyclosporine and NSAIDS) increased risk of nephrotoxicity
• Neuromuscular blocking agents and general anaesthetics - possible
prolonged action and/or respiratory paralysis
• Extended spectrum penicillins (eg ticarcillin, piperacillin) may chemically
inactivate the tobramycin and reduce serum levels. Usually only clinically
significant in patients with severe renal impairment
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Indications..
Reconstitution
Compatibility -& Stability.
Routes Of Administration.
Administration Policy.
Dosage.
Potential Hazards Of
Administration.
Important Implications
TRANEXAMIC ACID
Haemostatic agent
None required. Available as tranexamic acid 100 mg/mL – 10 mL vial.
Compatible in dextrose, normal saline, dextrose-saline combinations
and Ringer's solution.
Direct Into IV Tubing, Intermittent Infusion, Continuous Infusion
• In repeated or > 2 to 3days treatment, a complete ophthalmologic
examination (visual acuity, color vision, eye ground, visual fields)
should be done before and at regular intervals during treatment.
Haemorrhage, hyperfibrinolysis-induced
• 15 mg/kg or 1 g every 6 to 8 hours.
Theoretical risk of thrombophlebitis if given undiluted via a peripheral
line.
All side effects may subside with reduced dosage or rate of
administration.
CARDIOVASCULAR
• Hypotension, primarily when IV injection of the drug is too rapid, (i.e.,
administered at a rate greater than 100 mg/min).
• Thromboembolic events (e.g. central retinal artery and vein
obstruction, pulmonary embolism), a theoretical concern, rarely
reported in the literature.
GASTROINTESTINAL
• Nausea, cramping, diarrhoea
CENTRAL NERVOUS SYSTEM
• Dizziness, primarily when intravenous injection of the drug is too
rapid, (i.e., administered at a rate greater than100 mg/min).
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
Reconstitution
Compatibility -&
Stability.
Routes Of
Administration.
Administration Policy.
Dosage.
Potential Hazards Of
Administration.
Important Implications
VANCOMYCIN
Antibiotic - irritant
Serious infections due to beta-lactam resistant gram positive
microorganisms
Available as vancomycin 500 mg and 1 g vials
Reconstitute vials with SW, NS or D5W. .
Stable in D5, NS, DNS, RL
Intermittent Infusion
• Monitor peripheral IV site for pain, redness or swelling prior to
initiating infusion and every 30 minutes until completion of infusion
• Advise patients to report burning/stinging/pain at IV site promptly
• Serum creatinine prior to start of therapy and once or twice weekly
during therapy
15 mg/kg (total body weight) - interval based on renal function.
Bacterial endocarditis prophylaxis: 1 g, completed within 30 minutes of
starting procedure
Surgical prophylaxis in patients allergic to beta-lactams: 1 g pre-op and q
12 h x 1 dose
Ototoxicity (ie vertigo, dizziness, tinnitus) is usually associated with
renal impairment, peak serum levels exceeding 80 mcg/mL, pre-existing
hearing loss, or concomitant ototoxic drugs.
Renal impairment characterised by increased serum creatinine or urea
Reversible neutropenia, after 1 week or more of therapy or with
cumulative doses greater than 25 g
Usually Associated With Infusion Times Of Less Than 1 Hour
• "Red-man syndrome" characterised by hypotension, chills, fever,
flushing, feeling of warmth, erythematous rash over face, neck and upper
body, generalised tingling. Reaction usually resolves within 20 minutes or
longer, is not an true anaphylactic reactions, ie hypotension, wheezing,
dyspnea, urticaria or pruritus are rare.
• Pain and thrombophlebitis - can be minimised by increasing dilution
to 2.5 mg/mL and rotating administration sites.
Irritating to tissues may cause necrosis. Consider a central line for long
term therapy
72
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications.
Reconstitution
Compatibility-&
Stability.
Route of
Administration.
Administration Policy.
Dosage.
Potential Hazards Of
Administration.
Important Implications
Drug Interactions
VASOPRESSIN
Antidiuretic hormone
Acute post-traumatic or post-operative diabetes insipidus.
Hypotension due to septic shock or vasodilatory shock.
Cardiac arrest (ventricular fibrillation/ pulseless ventricular tachycardia).
None required.
Available as vasopressin 20 unit/ mL aq. Sol. – 1 mL vial and 2 mL
ampoule.
Normal saline preferred diluent.
Compatible with dextrose and normal saline solutions.
Direct Into IV Tubing, Continuous Infusion
Cardiac arrest: ECG monitoring
Continuous infusions of rates less than 1 unit/hour or 10 mUnit/kg/hour
Baseline BP and heart rate, then q 5 minutes, Urine output hourly.
Continuous infusions of rates of 1 unit/hour (10 mUnit/kg/hour) or
greater
Continuous ECG monitoring and continuous BP, Urine output hourly
Baseline serum electrolytes, then every 2 – 4 hours.
Urine osmolality every 12 – 16 hours
DIABETES INSIPIDUS
4 - 10 Units / hour as required based on serum electrolytes, osmolality and
urine specific gravity
GI BLEED -0.1 to 0.4 units / min
Hypotension related to spesis –0.01 - 0.04 units/min
Shock refactory VF/pulsless VT -40 units IV push x1
Tremor, sweating, Water retention with hyponatremia, drowsiness,
listlessness or headaches may signal onset of water intoxication.
HYPERSENSITIVITY
Urticaria, angioedema, bronchoconstriction and anaphylaxis.
CARDIOVASCULAR
Increased blood pressure
Angina in patients with coronary artery disease
Peripheral vasoconstriction, such as coronary or mesenteric vessels.
Drugs which increase antidiuretic effect e.g., carbamazepine,
chlorpropamide, indomethacin and oxcarbazine.
73
ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
Reconstitution
Compatibility -& Stability.
Routes Of Administration.
Administration Policy.
Dosage.
Potential Hazards
Important Implications
Drug Interactions
VORICONAZOLE
Anti-fungal
Treatment of invasive aspergillosis.
Available as voriconazole 200 mg vial. Reconstitute 200 mg vial with 19
mL of sterile water for injection for voriconazole 10 mg/mL.
Compatible with D5W, NS, D5-1/2S, D5S, 1/2NS, RL and 20 mEq KCl
Intermittent Infusion
• Observe for signs of anaphylactoid reaction (i.e., chest tightness,
dyspnea, faintness, flushing, nausea, sweating) for 10 minutes after the
start of each dose.
• Baseline serum electrolytes, creatinine, liver function tests and ECG.
ADULT
Loading dose: 6 mg/kg every 12 hours for 2 doses; followed by
maintenance dose of 4 mg/kg every 12 hours.
P/O - 40 kg or greater: 200 mg every 12 hours; increase to 300 mg every
12 hours if response inadequate.
- less than 40 kg reduce the above dose to half
PAEDIATRIC
Exact paediatric dose not yet determined, but is believed to be greater than
adult dosing.
Loading dose: 6 mg/kg every 12 hours for 2 doses; followed by
maintenance dose of 4 mg/kg every 12 hours has been used.
Increased liver function tests, cholestatic jaundice, ARF
OCULAR : photophobia, color changes, increased or decreased visual
acuity, or blurred vision
INFUSION RELATED HYPERSENSITIVITY REACTIONS
• Anaphylactoid type reactions e.g. chest tightness, dyspnea, faintness,
fever, flushing, nausea, pruritus, rash, sweating,Tachycardia.
CARDIOVASCULAR
• Tachycardia, hypertension, hypotension, vasodilation, peripheral
oedema, • QTc prolongation (rare).
CNS - Fever, chills, headache, hallucinations, dizziness.
DERMATOLOGIC - Rash, pruritus, Photosensitivity – avoid sunlight.
ENDOCRINE - Hypocalcemia, hypokalemia, hypomagnesaemia.
GI - Nausea, vomiting, abdominal pain, diarrhoea, xerostomia
• Interactions are numerous and potentially life threatening. Review drug
profile at time of initiation and with any change in medication regimen.
Contact Drug Information for more information.
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Drug Name.
Classification.
Indications..
Reconstitution
Compatibility -&
Stability.
Routes Of Administration.
Administration Policy.
Dosage.
Potential Hazards Of
Administration.
Important Implications
Drug Interactions
ZIDOVUDINE
Antiretroviral agent
Management of patients with human immunodeficiency virus (HIV)
infection.
• For prophylaxis against HIV transmission to baby during delivery.
None required. Available as zidovudine 10 mg/mL - 20 mL amber vial.
Compatible with D5W, NS, D5-½S and lactated Ringer's solutions.
Stable in above solutions for at least 24 hours at room temperature and in
the refrigerator.
IV
• Baseline CBC with differential then regularly thereafter.
• Baseline serum creatinine.
HIV- 1 - 2 mg/kg every 4 hours around the clock.
Pregnancy: prophylaxis against HIV transmission to baby • 2 mg/kg/hour for 1 hour, then 1 mg/kg/hour up to umbilical cord
clamping.
RENAL IMPAIRMENT ADJUSTMENTS
• For creatinine clearance (GFR) less than 10 mL/min, 1 mg/kg every 6-8
hours.
HEMO/PERITONEAL DIALYSIS
• Haemodialysis and CAPD: 1 mg/kg every 6-8 hours.
• CRRT: 1 mg/kg every 6-8 hours.
Headache, nausea, myalgia, insomnia
Myopathy and myositis with pathologic changes.
Lactic acidosis and severe hepatomegaly with steatosis (sometimes fatal)
has been reported.
HAEMATOLOGICAL - dose-limiting toxicity
• Neutropenia: usually occurs after 6-8 weeks.
• Anaemia: may occur as early as 2-4 weeks.
HYPERSENSITIVITY - Rash, anaphylaxis (rare)
• Any drug metabolised by glucuronidation (e.g. acetaminophen,
diazepam, morphine); toxicity of both drugs may be increased.
• Bone marrow depressants (e.g. dapsone, doxorubicin, flucytosine,
vincristine): May cause additive or synergistic myelosuppression, dosage
reduction may be required.
• Ganciclovir: Synergistic myelosuppression, use combination with
extreme caution.
• Probenecid: Inhibits metabolism and excretion of zidovudine, may
increase risk of toxicity.
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ICU Nurses Drug Index-2011
© Dr. P.K. Jain, Critical Care Education Foundation
Disclaimer: Compiled in good faith for personal non-commercial use only by Drs. P.K. Jain, Meeta Mehta,
Sampat Kumar, Dhiraj Pandey, Barkha Raut and Sunil Gupta. Please refer to product monograms and
standard textbooks.
Feel free to modify and add/delete information as per your individual need. We would however
appreciate your sending the improved version to us for distribution and use by ICU community in
developing countries. (email: [email protected])
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