Drugs used in RICU

Drug Indications Adult Dosage & Administration Precautions Atropine sulfate First-line therapy for symptomatic bradycardia Second-line therapy for asystole or bradycardic pulseless electrical activity (after epinepherine) For asystole or PEA - 1 mg IVP; may repeat every 3 - 5 minutes to maximum dose of 0.03 - 0.04 mg/kg For bradycardia - 0.05 - 1 mg IVP; may repeat every 3 - 5 minutes to maximum dose of 0.03 - 0.04 mg/kg Endotracheal administration - 2 - 3 mg diluted in 10 ml NS Use cautiously in patients with myocardial ischemia and/or hypoxia; increases myocardial oxygen demand.   Avoid in hypothermic patients. Calcium Chloride Hyperkalemia Hypocalcemia Antidote for overdose of calcium channel blocker 8-16 mg/kg IV slowly Not routinely used for cardiac arrest.   Do not mix with sodium bicarbonate. Digoxin To slow ventricular response in atrial fibrillation or atrial flutter PSVT refractory to other therapy (i.e. vagal maneuvers, adenosine, diltiazem, verapamil) Loading dose: 10-15 mcg/kg given over at least 5 minutes;   Maintenance dose: affected by body size & renal function Toxic effects are common & may precipitate arrhythmias.   Avoid electrical cardioversion (and lower current settings) for patients receiving digoxin.   Antidote = digibind. Dobutamine CHF or pulmonary congestion with hypotension 2-20 mcg/kg/minute titrated so that heart rate doesn't exceed 10% of baseline   (amp. 250mg/5ml) May cause tachyarrhythmias, fluctuations in BP.   Cardiac & hemodynamic monitoring is recommended. Dopamine Hypotension with signs & symptoms of shock Symptomatic bradycardia (after atropine) Low (renal) dose - 1-5 mcg/kg/minute Moderate - 5-10 mcg/kg/minute High - 10-20 mcg/kg/minute (amp. 200mg/5ml) Use only after volume replacement in hypovolemic patient.   May cause tachyarrhythmias, excessive vasoconstriction.   Avoid extravasation administer phentolamine SQ in area of extravasation to minimize tissue necrosis. Epinepherine Ventricular fibrillation, pulseless ventricular tachycardia, asystole, pulseless electrical activity Symptomatic bradycardia after atropine & transcutaneous pacing Severe allergic reactions, anaphylaxis Cardiac arrest - 1.0 mg IVP; may repeat q 3-5 minutes Endotracheal administration - 2.0-2.5 mg diluted in 10 ml. NS Profound bradycardia - 2-10 mcg/minute   If administration causes rapid, marked rise in BP, can see aortic rupture, cerebral hemorrhage, or angina pectoris.   ADMINISTRATION OF SC PREPARATION BY IV ROUTE MAY CAUSE SEVERE OR FATAL HYPERTENSION OR CEREBROVASCULAR HEMORRHAGE. Furosemide Acute pulmonary edema without signs/symptoms of shock Hypertensive emergencies Increased intracranial pressure 0.5-1.0 mg/kg IV over 1-2 minutes; if no response, may double the dose to 1.0 mg/kg IV over 1-2 minutes Monitor serum electrolytes.   May cause dehydration, hypovolemia, hypotension, & electrolyte imbalance. Magnesium sulfate Cardiac arrest related to torsades de pointes or low serum magnesium VF refractory to lidocaine & bretylium Torsades de pointes with a pulse Ventricular arrhythmias associated with digitalis toxicity or tricyclic overdose Resistant BS Cardiac arrest -1-2 Gm IVP Acute myocardial infarction -1-2 Gm. diluted in 50-100 ml 5% dextrose in water IV over 5-60 minutes; follow with 0.5-1.0 Gm/hour IV for up to 24 hours Torsades de pointes -1-2 Gm. diluted in 50-100 ml 5% dextrose in water IV over 5-60 minutes; follow with 1-4 Gm/hour IV titrated to control the torsades Rapid IV administration may cause hypotension.   Use with caution in patient with renal disease.   May cause respiratory failure.  Do not administer if patient has absent patellar reflexes, respiratory depression, or oliguria.    Causes hypotonia. Morphine sulfate Chest pain & anxiety associated with acute MI or cardiac ischemia Acute cardiogenic pulmonary edema 1-3 mg IV over 1-5 minutes; may repeat every 5-30 minutes Use cautiously in patients with respiratory compromise.   May cause hypotension in patients with hypovolemia.   Antidote: naloxone 0.4-2.0 mg IV. Nitroglycerin Chest pain of suspected cardiac origin Unstable angina Complications of acute myocardial infarction, including CHF & LV failure Hypertensive crisis 10-20 mcg/minute infusion titrated to effect 0.3-0.4 mg sublingually every 5 minutes Monitor VS & EKG during therapy.   Use NTG tubing.   Do not mix with other drugs. Norepinepherine Cardiogenic shock Hemodynamically significant hypotension Start at 0.5-1.0 mcg/minute; titrate to 30 mcg/minute  Increases myocardial oxygen requirements and may induce arrhythmias, therefore use cautiously in patient with cardiac ischemia.   Extravasation causes tissue necrosis. Sodium Bicarbonate Known preexisting hyperkalemia Known preexisting bicarbonate-responsive acidosis Overdosage of tricyclic antidepressants or aspirin May be used in prolonged resuscitation with effective ventilation or upon return of spontaneous circulation after long arrest Initial dose: 1 mEq/kg IV bolus Repeat half of initial dose every 10 minutes thereafter Given dose: 1/6BWt.x deficit ABG analysis of pH, pCO2, and base deficit is helpful in guiding bicarbonate therapy.   Harmful in hypoxic lactic acidosis, i.e. cardiac arrest & CPR without intubation/adequate ventilation. Sodium Nitroprusside Hypertensive crisis To reduce afterload in heart failure, acute pulmonary edema, or acute mitral or aortic valve regurgitation Begin at 0.10 mcg/kg/minute and titrate upward every 3-5 minutes to desired effect (up to 5.0 mcg/kg/minute) Drug is light-sensitive; therefore, wrap drug reservoir in aluminum foil.   May cause thiocyanate toxicity: blurred vision, tinnitis, confusion, hyperreflexia, seizures.   Use with an infusion pump; closely monitor blood pressure during therapy. Verapamil PSVT with narrow QRS complex & adequate blood pressure 2.5-5.0 mg bolus over 1-2 minutes; may administer 5-10 mg if needed 15-30 minutes after initial dose Maximum dose = 30 mg. Expect BP to drop due to peripheral vasodilation.   IV calcium can restore BP; some clinicians recommend administering ca prophylactically prior to Verapamil. Heparin / Cal-heparin Prophylaxis and treatment of PE AF with embolization Diagnosis and treatment of DIC Prevention of clotting in arterial and cardiac surgery Prophylaxis and treatment of peripheral arterial embolism. In blood transfusions, extracorporeal circulation, and dialysis procedures and in blood samples Loading dose: 80 IU/Kg   Maintenance dose: 18 IU/Kg/hr IV   Prophylactic dose: 5000 IU/12hrs Sc   Follow up with PTT aiming to become double normal.   Regular platelet count monitoring.   Antidote= protamine sulphate (1mg neutralizes 1mg heparin or 100 unit)   Not used in bleeding tendencies or recent stroke or active PU.   Clexane PE   DVT   MI   Unstable angina   In dialysis machine Prophylactic dose: 1mg/Kg/d Sc/IV   Therapeutic dose: 1mg/Kg/12hrs Sc/IV Low molecular weight heparin (enoxaparin or fraxiparin).   FU renal function, K+ and platelets.     Aminophylline Acute severe asthma   COPD exacerbation   P. edema   Increase diaphragmatic motility Loading dose: 6mg/Kg/20mins   Maintenance dose: 0.6mg/Kg/hr IV slowly Slowly IV diluted in fluids.   Monitoring dose for side effects and drug interactions.   Trichium Muscle relaxant after ventilation (neuromuscular blocker). Initial dose: 2.5-3 mcg/kg/min   Infusion: 0.1-2 mg/kg   (amp. 25mg/2.5ml or 50mg/5ml) Caution with hypotension and hypotonia. Midazolam (Dormicum)   Procedural sedation   Pre-operative   Acute aggression or delirium   Status epilepticus   After MV Loading dose: 0.02-0.1 mg/Kg (as valium)   Maintenance dose: 0.04-0.2 mg/Kg/hr   1ml, 3ml, 10ml amp. With conc. 5mg/ml and Oral form 7.5mg tab. Relative contraindications in hypotension, hypersensitivity, glaucoma and drug interactions.   Fastest onset, shortest duration. Doxapram (Dopram) Stimulate respiration in:   Post-anesthesia   Drug induced CNS depression   Chronic pulmonary disease with hypercapnea     IV: 0.5-1 mg/Kg single injection with 5 min interval, maximum 2 mg/Kg   Infusion: 1-3 mg/min, maximum 300 mg/d   (400mg amp.) Not with epilepsy, PE, cerebral injuries or ischemia, mechanical disorders of ventilation, severe hypertension.   Slow infusion to prevent hemolysis, seizures.   Monitor ECG.