Common ICU Medications PDF

Common ICU Medications INTENDED LEARNING OUTCOMES (ILOs) A. Knowledge and understanding ▪ Demonstrate an understanding of the action of different ICU medications ▪ Explain the mechanism of action of ICU medications ▪ Relate between actions of ICU medications an...

Common ICU Medications INTENDED LEARNING OUTCOMES (ILOs) A. Knowledge and understanding ▪ Demonstrate an understanding of the action of different ICU medications ▪ Explain the mechanism of action of ICU medications ▪ Relate between actions of ICU medications and patients' responses ▪ Mention the most significant side effects of each ICU medication ▪ State the nursing role for each ICU medication ▪ Demonstrate an awareness of the difference between different medications having the same action ▪ State different routes for administering emergency medications ▪ Describe impact of diluting solutions on the action of different medications B. Professional and practical skills: ▪ Apply safety measures in administering ICU medications ▪ Manipulate IV medications infusion rates according to patients' responses ▪ Utilize nursing care plan for providing nursing care for patients taking high alert medications C. Intellectual skills ▪ Rationalize use of different ICU medications for different patients ▪ Differentiate between different medications having the same actions ▪ Assess medication administration sites for local complications D. General and transferable skills: ▪ Communicate effectively with critically ill patients regarding the actions, side effects of different ICU medications ▪ Use critical thinking skills in early recognition of ICU medications side effects ▪ Assume responsibility in adherence to safety principles in administration of high alert medications Main goals of ICU drugs administration: 1- Relieve life threatening conditions. 2- Support vital functions. Common routes of ICU drugs administration: 1 1- IV is the most common method used for administration in critically ill patient because it's rapid effect. 2- Transdermal that is absorbed from the skin for example nitroglycerin patch 3- Through ETT (followed by 5 inflation to distribute medication through lung & the dose higher (2-2.5) times than IV). 4- Intraosseous access can be used for the delivery of resuscitation drugs. It is safe and effective for fluid resuscitation as well as drug delivery and it can achieve adequate plasma concentration. Common tips of ICU drugs: o Finding an emergency access for medication is crucial. o Some of critical medications when diluted never to shack the bottle such as streptokinase. o Flush with 20 ml Normal saline after administration. o Be sure when preparing medication you choose appropriate solution for dilution. Drug dilution in ICU: Drugs never to be diluted; Nitroglycerine, Propofol (Diprivan) & Neuril. Drugs may be diluted only in 10 ml NS; Calcium gluconate & Morphine. Drugs diluted & given over specific period of time: - Amikacin diluted in ns, d5% [0-1000 mg] in[100 ml] over[30 minutes] - Theophylline diluted in d5%, ns [500 mg] in [500 ml] - Cordarone diluted in d5% [150 mg / 100 ml] over [10 minutes] - Phenytoin sodium diluted in ns [0 -100 mg] [50 ml] [5-15 min] or use undiluted (loading dose). - Doubtamine diluted in d5%, ns [500 mg] in [250 ml] - Dopamine diluted in d5%, ns (200 to 800 mg/ 250 to 500 ml) - Epinephrine diluted in d5%, ns [1 to 5 mg] [250 ml] 2 MONA therapy: M: morphine O: oxygen N: nitroglycerin A: aspirin used in acute coronary syndrome (ACS). Oxygen (O2): Indication Any medical emergency where hypoxemia is present as (cardiopulmonary arrest, chest pain & asthma). Action O2 elevates the arterial O2 tension, which in turn improves oxygenation of peripheral tissues "maximizes O2 delivery to cells". Side effect Drying of mucous membranes & O2 toxicity Nursing Monitor O2 saturation regularly using pulse oximeter. consideration Avoid excessive administration in patients with concurrent COPD. Humidification, the delivered oxygen. Monitor for signs of oxygen toxicity (visual changes, tinnitus, nausea, irritability, personality changes, anxiety, confusion, dizziness, seizure, bradycardia or palpitations). Aspirin: Indication Treat ACS, headache, fever & cold. Action Antipyretic (decreases temperature), a non-opioid analgesic (reduces pain) & anti-platelets (slows platelet aggregation, reducing the risk of further occlusion or re-occlusion of the coronary artery or a recurrent ischemic event). Nursing Instruct patient to chew the tablet not to swallow. consideration Monitor for bleeding signs (hematuria, ecchymosis, bleeding from nose). Nitroglycerin (Tridil or Nitrol) Indication Treat ACS, angina, hypertension. Action Anti-angina, vasodilator & anti-hypertensive. It acts on coronary arteries, improving blood flow to ischemic areas. Decreases myocardial oxygen consumption. In peripheral vascular beds, it causes vasodilation & reduces preload and afterload, resulting in decreased cardiac workload. Side effect CNS: Headache, restlessness, weakness, dizziness, faintness. CVS: Tachycardia, retrosternal discomfort, palpitations, hypotension, syncope, collapse, orthostatic hypotension. GIT: Nausea, vomiting, abdominal pain 3  Nursing ▪ Diluted in compatible solution is preferred than given undiluted for safe titration consideration of the drug with minimal side effects. ▪ Assess patient’s anginal pain. ▪ Patients on IV nitroglycerin require continuous ECG & B.P monitoring. ▪ Be alert for overdose symptoms: Hypotension, tachycardia; warm, flushed skin becoming cold & cyanotic; headache, palpitations, confusion, vomiting. Morphine Indication Pain in myocardial infarction & post-operative sever pain. Action Narcotic analgesic. Respiratory depressant action. Pain relieve immediately & last for 2 hours. Inhibit transmission of pain impulse. Relieve pulmonary congestion, lower myocardial oxygen demands and reduce anxiety. Side effect Respiratory depression, bradycardia, palpitations, hypotension, loss of consciousness & cardiopulmonary arrest. Nursing Obtain baseline RR, depth, rhythm, SPO2, HR, B.P, LOC & size of pupils. consideration Put the patient on O2 therapy & continuous cardiac monitoring. Monitor fluid balance. Report oliguria or urinary retention. Monitor (RR, B.P, HR, LOC & SPO2) + pain intensity. Ensure the availability of resuscitation equipment at bedside. Adenosine: Indication Narrow-complex paroxysmal supra ventricular tachycardia Action Anti-dysrhythmic, restores normal sinus rhythm (NSR) by slowing conduction time through the atrioventricular (AV) node Side effect Flushing, chest pain/tightness, a systole or bradycardia. Nursing Monitor for side effects. consideration Patient monitoring: B.P & HR. Avoid adenosine with the following medical problems : (AV) block, pre- existing 2nd or 3rd degree without pacemaker, risk of complete heart block 4 Amiodarone (Cordarone): Indication Atrial and ventricular tachy dysrhythmias. Action Anti-dysrhythmic, Multichannel blocker (sodium, potassium, calcium, and noncompetitive ∞ &β blocker) Class III Antiarrhythmic. Side effect Bradycardia, hypotension, phlebitis. Nursing Diluted in G5% & administer through central line. consideration Monitor cardiac rhythm continuously & V/S. Monitor for safe and effective serum levels (0.5–2.5 mcg/ mmol). Doses of dioxin, quinidine, procainamide, phenytoin, & warfarin may need to be reduced one-third to one-half when amiodarone is started. Give drug with meals to decrease GI problems (with tablets). Arrange for ophthalmologic exams; reevaluate any sign of optic neuropathy. Arrange for regular periodic exam of liver enzymes, thyroid hormone levels Atropine: Indication Symptomatic bradycardia (first choice) N.B (Atropine is not recommended for 2nd degree AV heart block Mobitz Type II or 3rd degree AV block with wide QRS complexes. Immediate pacing is recommended for these patients. According to the 2010 guidelines, atropine is no longer recommended for routine use in the management of PEA or a systole. Antidote for poisoning e.g. organ phosphorus insecticides) Action Anti-cholinergic, Increases the heart through the anticholinergic effect (increases the HR due to a parasympathetic action accelerating the rate of the sinus node discharge & improving AV conduction) Side effect Most of the side effects of atropine are directly related to its anti-muscarinic action: (Dryness of the mouth, blurred vision, photophobia, tachycardia, constipation, difficulty in micturition may occur in elderly patients, flushed hot skin, delirium, coma, and death.) Nursing ▪ Monitor vital signs / intake and output in elderly patient. consideration ▪ Flush with NS after administration. ▪ If atropine given over more than 1 minute may cause paradoxical bradycardia which will resolve in 2 minutes. 5  ▪ Assess the patient routinely for abdominal distention & auscultate for bowel sound Dopamine: Indication Increase cardiac output, treat shock, correct hemodynamic imbalances & improve perfusion to vital organs. Action Sympathomimetic, vasopressor, inotropic. Stimulates dopaminergic, alpha & beta receptors of the sympathetic nervous system. Action is dose dependent. Dosage At low rates of infusion (10 mcg/kg/min) (Vasopressor): It stimulates alpha-adrenoceptors, resulting in systemic vasoconstriction and improvement of blood pressure. N.B (At very high rates of infusion (above 20 mcg/kg/min), stimulation of alpha-adrenoceptors predominates & vasoconstriction may compromise the circulation of the limbs). Side effect ventricular arrhythmia (at very high doses), angina pain, palpitation, cardiac conduction abnormalities, widened QRS complex, hypertension, dyspnea, nausea, vomiting, headache & limb ischemia. Nursing 1. Monitor B.P, pulse, RR, ECG & hemodynamic parameters. consideration 2. Monitor urine output frequently throughout administration. 3. Palpate peripheral pulses and asses color and temperature of extremities. 4. Correct the following before giving dopamine infusion : 6  Acidosis as acidosis decrease effectiveness of dopamine. Hypovolemia. 5. Observe for adverse reactions 6. Use large vein, check vein frequently for blanching or pallor which may indicate extravasations 7. Weaning infusion gradually to prevent sudden hypotension. 8. Can be diluted in: Sodium Chloride (0.9%) and 5% Dextrose. N.B (It must be diluted before administration to patient, Do not add to Sodium Bicarbonate or other alkaline intravenous solutions, since the drug is inactivated in alkaline solution). Doubtamine (dobutrex): Indication Heart failure, cardiac deconsumption. Avoid in shock without adequate fluid replacement. Action Inotropic , β1-agonist 1. Increase myocardial contractility & cardiac output without significant change in blood pressure, it increase coronary blood flow & myocardial O2 consumption. 2. Positive chronotropic & inotropic effects which are balanced by a mild degree of vasodilatation so that myocardial oxygen demand is generally not increased. 3. Doubtamine is generally considered the inotrope of choice in patients with myocardial ischemia. Side effect CNS: headache, musculoskeletal: mild leg cramps or tingling sensation. Nursing Hemodynamic monitoring is recommended for optimal effect. consideration Fluid deficit ( Hypovolemia) should be corrected before infusion Use large vein for administration; an infusion pump should be used on regulate flow rate. Monitor urine output continuously during administration 7  Observe for adverse effects. Epinephrine (adrenaline): Indication Cardiac arrest, hypersensitivity reaction, anaphylaxis, acute asthma at attacks, symptomatic bradycardia, sever hypotension Action Cardiac stimulant, vasopressor, bronchodilator, Beta 2 Adrenergic agonists. (Increase myocardial contractility, HR, SBP, CO & relaxes bronchial smooth muscles). Side effect Nervousness, tremor, vertigo, pain, widened pulse pressure, hypertension, nausea, headache Nursing 1. Monitor continuous ECG & hemodynamics. consideration 2. Use an infusion device via CVC & avoid giving any drug in the lumen of epinephrine to avoid giving bolus dose that may cause dysrhythmia. 3. Use extreme caution when calculating doses; epinephrine is a very potent drug; small errors in dosage can cause serious adverse effects. 4. Monitor blood glucose for loss of glycemic control if diabetic. 5. Auscultate breathe sound before and after administration. Noradrenaline (nor-epinephrine, levophed): Indication Severe shock Action Sympathomimetic, vasopressor. Produce vasoconstriction, increase myocardial contractility and dilate coronary arteries so increase blood flow to all vital organs without increasing the workload or output of the heart Side effect Hypertension, Severe peripheral & visceral vasoconstriction, Decreased renal perfusion (decreased urine output), palpitations, tachycardia, ventricular arrhythmias & increased myocardial O2 consumption (may lead to chest pain). Headache, weakness, dizziness, tremors, restless, anxiety, insomnia. Tissue necrosis (peripheral) and sloughing at the site of IVI. Nursing It should be given in infusion pump and through large vein. consideration Patient should be on cardiac monitor. Check flow rate and injection site continuously. 8  Monitor and prevent the occurrence of adverse events.. Monitor fluid balance. Urinary output is a sensitive indicator of the degree of renal perfusion. The infusion rate should be slowed incrementally and abrupt withdrawal avoided. Titrate off in same manner as was started. Calcium chloride: Indication Acute hyperkalemia, acute hypocalcaemia, calcium channel blocker (Nifedipine, Verapamil) overdose, antidote for magnesium sulfate. Action Increases cardiac contractility. Calcium replacement therapy. Side effect Arrhythmias (bradycardia and a systole), hypotension. Nursing IV line should be flushed between calcium chloride and sodium bicarbonate consideration administration. Extravasations may cause tissue necrosis. Administer calcium through central line slowly. Monitor BP because peripheral vasodilatation will occur Monitor serial serum (Ca, K, Mg) levels Continuously monitor ECG for onset of dysrhythmia Observe & prevent for adverse effect. Digoxin (Lanoxin): Indication Congestive heart failure, cardiogenic shock , rapid atrial arrhythmias, especially atrial flutter and atrial fibrillation and PVST Action Cardiac glycoside, inotropic, anti dysrhythmic. Increases cardiac contractile force, decrease HR, increases CO, which improves renal blood flow & increase urine output, reduces edema associated with CHF, slow AV conduction. Side effect Nausea , vomiting , anorexia , epigastric pain, unusual fatigue , blurred or yellow of vision , irritability , confusion , prolonged PR interval Nursing Check Serum K & Mg levels before administration because hypokalemia and consideration hypomagnesaemia are associated with in increases risk of digitals toxicity Check Serum Ca level because hypercalcemia can increase the risk of digitalis toxicity and hypocalcaemia can nullify the effects of digoxin Count apical pulse before administration if < 60 beats /min 9  Monitor & prevent digital toxicity. Be prepared to treat overdose with IV magnesium sulfate or digoxin immune fab ( Digibind ) if the patient has sever , life threaten refractory dysrhythmia Magnesium sulfate: Indication Seizure associated with eclampsia, preeclampsia, hypomagnesaemia, torsade de points, life threaten ventricular dysrhythmia secondary to digitals toxicity Action Electrolyte, anti-dysrhythmia, anti-convulsant. It replaces & maintains Mg levels in body. It depress the CNS , producing anti convulsion effects , decrease incidence of dysrhythmia Side effect Absent patellar reflex , flushing , hypotension , sweating , flaccid paralysis , prolonged PR ,QRS and QT interval ; respiratory depression and cardiac arrest Nursing - Continuous monitor ECG for dysrhythmia, HR, RR and BP. consideration - Evaluate presence of patellar reflexes before each dose if they absent, magnesium should not be given until they return. - Monitor renal status , urine output should be at least 25ml/hr - Have emergency equipment available in case of respiratory or cardiac arrest - CaCl2 (5-10) mEq can be given to reverse respiratory depression & heart block - Observe & prevent for adverse effect. Manitol: Indication Increased intracranial pressure N.B (Contraindicated in active intracranial bleeding, anuria, sever pulmonary congestion; sever heart failure, fluid and electrolyte depletion and renal dysfunction). Action Osmotic diuretic. Increase osmotic pressure of fluid (due to its hyper osmotic action to draw water from the edematous brain. This osmotic property usually takes effect in 15-30 minutes when it sets up an osmotic gradient and draws water out of neurons ), decrease reabsorption of water and electrolyte, increase urine output and Na and Cl excretion 10  Nursing ▪ Monitor HR , BP, CVP and ICP ( if available ) consideration ▪ Monitor urine output every hour & hydration status. ▪ Monitor serum electrolyte, BUN, Creatinine levels and ABG. ▪ Observe for adverse effect: seizure, rebound increase ICP, pulmonary congestion, hypotension, fluid & electrolyte imbalance & fluid overload. Nitroprusside (nipride): Indication Hypertensive crisis, acute heart failure, pulmonary edema Action Anti-hypertensive, vasodilator. Decrease B.P & peripheral resistance & usually increase cardiac output, relaxes arterial & venous smooth muscle to decrease afterload & preload, enhanced renal blood flow, enhanced coronary blood flow, decreases pulmonary artery pressure. Side effect Hypotension, hypovolemia, Cyanide Toxicity Nursing ▪ Continuous blood pressure, HR, ECG monitoring. consideration ▪ Should be protected from light by wrapping the container with opaque material. Must be administered via central line, infusion pump. ▪ Hypovolemia should be corrected concurrently with initiation of therapy. ▪ Continuous monitoring for ABG & urine output ▪ Assess for Cyanide Toxicity: (thiocyanate levels > 1.7 um/L) Each Nitroprusside molecule contains 5 cyanide molecules. It Breaks down into Cyanide. Toxicity occurs when the total dose of Nitroprusside exceeds the ability to eliminate the cyanide (total dose of 68 mg), Toxicity (inhibits O2 utilization by tissues): increased HR, metabolic acidosis, increased lactate despite normal SPO2 , decreased response to drug, increased mixed venous O2 saturation, decreased oxygen extraction. Antidote: Sodium Thiosulfate Sodium bicarbonate: Indication Severe metabolic acidosis as in (renal disease, uncontrolled DM, shock, extracorporeal circulation of blood, cardiac arrest & severe lactic acidosis. Action An alkalinizing agent by releasing bicarbonate ions. 11  Side effect Edema, Gastric distention, Metabolic alkalosis, Hypernatremia, Hypocalcaemia, Hypokalemia, Sodium and water retention, Irritation at IV site, Tetany. Nursing Assess the client’s fluid balance. consideration Administer via a central line. Obtain ABG, serum calcium, sodium, potassium balance and renal function before and throughout the therapy. Flush line before and after administration sodium bicarbonate Observe & prevent for adverse effect Streptokinase: Indication Acute myocardial infraction, arterial thrombosis and embolism, pulmonary embolism. Action Thrombolytic, fibrinolytic. It dissolves vascular thrombi (Acts with plasminogen to produce a new activator complex which enhances the conversion of of plasminogen to plasmin. Plasmin then beaks down fibrinogen, fibrin clots & other plasma protein promoting the breakdown of insoluble fibrin trapped in intravascular emboli & thrombi) Side effect Bleeding, fever, nausea, headache, breathing difficulties, fever, shivering, bronchospasm, urticaria, itching, flushing, musculoskeletal pain, vasculitis, interstitial nephritis, respiratory depression. Nursing ▪ It should be given by syringe pump. Nacl injection or D5W is the preferred consideration diluents for IV use. Do not add any other medications to the IV line. ▪ Note any redness and or pain at the site. ▪ Record ECG before and after administration, observer dysrhythmia development during infusion ▪ Vital signs monitoring: record /15 minutes for at least 1 hour from onset of infusion until stable. Hourly for a further hour then hourly for 24 hours. ▪ Assess if any contraindications for using the drug ▪ Assess bleeding for: bleeding gums, petechia, ecchymosis, hematuria, epistaxis and hemoptysis, assess neurological careful (intracranial hemorrhage), assess for retroperitoneal bleeding (back pain, leg weakness, 12  diminished pulse) if bleeding occur, stop infusion and notify physician, minimal duration of cuff inflation when recording BP, fine toothbrush). ▪ Report abdominal pain and/or distension. ▪ Avoid any invasive procedures (arterial, IM injection). ICU Drugs cont. Drug Action Aminophylline / Theophylline Bronchodilator Acetaminophen Antipyretic, analgesic Phenytoin Anticonvulsant Ventolin Inhaled β-agonist, bronchodilator Capoten Angiotensin converting enzyme inhibitors Plendil / Nimotop / Norvasc Calcium channel blocker Aldactone Potassium sparing diuretics Fucidin Bacteriostatic Clexan Anticoagulant (Low molecular weight heparin) Diazepam / Dormicum Sedative / Anxiolytic / Hypnotic / Anti- epileptic Solu-Cortef Corticosteroid Konakion Vitamin K, Coagulant Kapron (Tranexamic Acid) Anti-fibrinolytic drug Haemstop ( Dycinon ) To stop bleeding / Coagulant Zofran / Primpriane Antiemetic Succinylcholine Short-term muscle relaxation 13  Atracurium Intermediate-duration non-depolarizing neuromuscular- blocking agent. Fentanyl Rapid onset & Short duration Narcotic analgesic Haloperidol Atypical antipsychotic Inderal Beta blocker Pentobarbital Short acting barbiturate with sedative, hypnotic & anticonvulsant properties Thiopental Decrease ICP; adjunctive therapy for intubation in head injury patients Octreotide (Sandostatin) Splanchnic vasoconstrictor In G.I.T. BLEEDING Carbamazepine (Tegretol) Anticonvulsant and mood-stabilizer Sorbitol Cathartic Clopidogril (Plavix) Platelet aggregation inhibitor Diclofenac Na A non-steroidal anti-inflammatory drug that exhibits anti- inflammatory, analgesic, and antipyretic activities. (Cataflam / Voltaren) Ephedrine Stimulates both alpha & beta receptors, treat dug-induced hypotension Erythromycin Prokinetic agent ( stimulate gut motility ) Haloperidol Tranquilizers / Antipsychotic Hyoscine Butyl bromide Spasmolytic (Buscopan) Diprivan (Propofol) Sedation Lactulose (Duphalac) Colonic acidifier that promotes laxation 14  Ranitidine (Zantac) Histamine H2-receptor antagonist Thyroxine (Eltroxin) Thyroid hormone replacement therapy Protamine Sulphate Reversal of heparin Omeprazole / Pantoprazole Proton pump inhibitor Paracetamol Analgesic and antipyretic Pethidine Hydrochloride Narcotic analgesic Daktarine Antifungal Oracure Healing agent for oral ulcer Oraldine / Hexitol Mouth wash, Antiseptic Thilotears / Eye refresh Artificial tears (Prevent eye dryness) Mebo / Nataria / Dermazine Healing agent for bed sore Warfarin Anticoagulant Naloxone Opioid antagonist 15