9. drugs used in critical

Prof. Dr. RS Mehta, BPKIHS 1

DRUGS USED IN CRITICAL SETTINGS:

ICU, CCU, OT, Emergency


COMMON DRUGS USED IN EMERGENCY

Life Saving Drugs: • Adrenaline• Atropine• Xylocard• Calcium Gluconate• Sodabicarbonate

Other Emergency Drugs are:•Midazolam

Common drugs used for OP poisoning.•Atropine•PAM•Diazepam.


Common drugs used for cardiac arrest:

• Epinephrine• Vasopressors• Antiarrythmic- amiodarone, lidocaine.• Other drugs- atropine, calcium, sodium

bicarbonate, thrombolytic Agents (STK, tPA)

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COMMONLY USED DRUGS IN ICU AND CCU

The main groups of drugs used in ICU are as follows:OPOIDS:• Morphine• Fentanyl• Pethidine• NaloxoneBENZODIAZEPINES:• Diazepam• Midazolam• Lorazepam• Flumazenil

SEDATIVES:Propofol.The main groups of drugs used in CCU are as follows:LignocainePropanololAmiodaroneDigoxinVerapamilAdenosineAspirinAtrovastinGTNStreptokinaseIsosorbide di-nitrateSodium bicarbonateNicorandil Prof. Dr. RS Mehta, BPKIHS


Common drugs used in MI:• Pain relief : Morphine• Vasodilators: Nitroglycerine• Anticoagulant: heparin• Antiplatelet: aspirin• Stool softner: cremaffin• Vasopressor: dopamine, dobutamine


Drugs used in Angina• Glyceryl trinitrate(GTN)• Isosrbide dinitrate• Propanolol• Verapamil• Amlodipine.


Drugs used in CCF:• Diuretics• ACE inhibitors: captopril, enalapril• ARBS: losartan. Candesartan• Digoxin• Beta blockers• vasodilators


NARCOTIC DRUG LAW:• The law was authenticated and published for the first time in 2033

B.S. under Narcotic Drug Control Act.• In this act the narcotic drug means (1) Cannabis/ marijuana(2) Medicinal cannabis/ marijuana(3) Opium (4) Processed opium(5) Medicinal opium(6) Plants and leaves of coca, and(6A) Any substances to be prepared by mixing opium and extract coca, including mixture or salt.(7) Any natural or synthetic narcotic drug or psychotropic substances and their salts,


• Chemical substance to be used for preparation of narcotic drugs may be exported, imported, stored, sold, distributed and used only in the quantity as prescribed by the Chief Narcotic Drugs Control Officer.

• For such procedures one must have license.• Consumption of narcotic drugs by persons falling under the

following categories in the following circumstances shall not be deemed to have been prohibited:-

(a) Purchase and consumption of narcotic drug by any person in the recommended dose from any licensed shop on the recommendation of any recognized medical practitioner for the purpose of medical treatment.(b) Consumption of narcotic drugs by persons belonging to the prescribed categories in prescribed doses.


Responsibility of the Medical Practitioner: While prescribing narcotic drugs,• the medical practitioner shall not prescribe it to those who do

not need it. OR

• prescribe more than what the requirement is even to those to whom it is required.


DRUGS COMMONLY USED IN OPERATION THEATER:

ANESTHETICS:• Local: lignocaine/ lidocaine HCL , bupivacaine HCL• Regional: spinal, epidural• General: ether, nitrous oxide, halothene, isoflurane,

sevoflurane(inhalation), thiopentone sodium, propofol (injection)

MUSCLE RELAXANT:• Succinyl choline• Vecuronium• Atracurium• Mivacurium


Details of some common drugs:


XYLOCARD

Generic name: Lignocaine hydrochloride Trade name: xylocard, xylocaine, octacaine, anestacon,

dilocaine. Classification: anti-arrythmic, local anesthetic.


Mechanism of action: It decreases the automaticity, and excitability in the

ventricles during the diastolic phase by a direct action on the tissues, especially the Purkinje network.

Produces local anesthesia by reducing sodium permeability of sensory nerves, which blocks impulse generation and conduction

Uses: ventricular arrythmias resulting from MI, digitalis toxicity, cardiac surgery or cardiac cathterization, general anesthesia in susceptible patients.


Doses: Arrythmia– Dosing should be individualized.– Treatment for ventricular arrhythmias begins with an intravenous injection followed by an intravenous infusionPre-infusion:– initially, 50-100 mg iv bolus given at rate of 25-50 mg/min. if desired response doesn’t occur , give repeat dose at 25-50 mg/min; max dose is 300 mg given over hour


Infusion:– A drip rate of 2-4mg/min is recommended– Infusion duration is normally 2 or more days (at least 24 hours after the last signs of ventricular arrhythmia is evident). Anesthetic Uses Adult: Infiltration 0.5–1% solution, Nerve Block 1–2%

solution, Epidural 1–2% solution, Caudal 1–1.5% solution, Spinal 5% with glucose, Saddle Block 1.5% with dextrose Topical 2.5–5% jelly, ointment, cream, or solution


Side effects:• CNS: light headedness, euphoria, confusion, dizziness,

drowsiness, tinnitus, blurred vision, vomiting, tremors, twitching.

• Cardiovascular: bradycardia, hypotension, cardiovascular collapse which may lead to cardiac arrest.

• Integumentary: cutaneous lesions, urticaria, edema. Contraindication: hypersensitivity, severe degree of

sino-atrial, atrio-ventricular or intra-ventricular block, Adams-stokes syndrome.

Precaution: pregnancy, breastfeeding, pediatric, geriatric.


Nursing consideration: When it is administered as an antiarrhythmic the nurse should

monitor the ECG continuously. Blood pressure and respiratory status should be monitored

frequently during the drug administration. When administered as an anesthetic, the numbness of the

affected part should be assessed. Serum Lidocaine levels should be monitored frequently during

prolonged use. Therapeutic serum lidocaine levels range from 1.5 to 5 mcg/ml.

If signs of overdose occur, stop the infusion immediately and monitor the patient closely


For throat sprays, make sure that the patient’s gag reflex is intact before allowing the patient to eat or drink.

When IM injections are used, the medication should be administered in the deltoid muscle.

For direct IV injection only 1% and 2% solutions are used.

Donot breast feed while taking this drug without physicians consultation


PROPOFOL


• Functional class: general anesthetic• Generic name: propofol• Trade name: diprivan, propoven, fresenius MECHANISM OF ACTION:It produces dose dependent CNS depression by activation of GABA receptors.


USES:induction or maintenance of anesthesia, sedation in mechanically ventilated patients, status epilepticus, migraine

DOSES:Induction of Anesthesia• Adult: IV 2–2.5 mg/kg q10sec until induction onset• Geriatric: IV 1–1.5 mg/kg q10sec until induction onset.


Maintenance of Anesthesia• Adult: IV 100–200 mcg/kg/min• Geriatric: IV 50–100 mcg/kg/minSedation• Adult: IV 5 mcg/kg/min for at least 5 min, may

increase by 5–10 mcg/kg/min q5–10 min until desired level of sedation is achieved (may need maintenance rate of 5–50 mcg/kg/min


AVAILABLE FORMS:Inj 10 mg/ml in 20 ml ampoule, 50 ml and 100 ml vials.

SIDE EFFECTS:CNS= involuntary movement, headache, somnolence, paresthesia, increased ICP, impaired cerebral flow, seizures.

CV= bradycardia, bradydysrhythmia, asystole, ST segment depression.

EENT= blurred vision, tinnitus, eye pain, diplopia


GI= nausea, vomiting, abdominal cramp, pancreatitis, hyper salivation.GU= urine retention, green urine, cloudy urine, oliguria.INTEG= flushing, phlebitis, hives burning/ stinging at inj site, rash.RESP= apnea, cough, hypoventilation, wheezing, hypoxia, respiratory acidosis.SYS= propofol infusion syndrome

CONTRAINDICATION:hypersensitivity to the product or soyabean oil, egg, benzyl alcohol.


PRECAUTION:pregnancy (B), brest feeding, children, geriatric, respiratory depression, cardiac dysrhythmias

NURSING CONSIDERATION: Patient must be Intubated and ventilated Monitor: HR, ECG, oxygen saturation, BP Abrupt discontinuation of infusion may result in rapid

awakening with agitation, anxiety.


. Discard tubing/bottle after 12 hours (contains

lipids) Do not use if emulsion appears separated. If hypotension or bradycardia occurs, decrease

or stop and monitor BP & HR, notify to doctor. Document neuro assessment on awakening.


AMIODARONE


AMIODARONE

Functional class: antidysrrhythmicChemical class: iodinated benzofuran derivative.Generic name: Amiodarone hydrochlorideTrade name: pacerone, cordarone, nexterone.MECHANISM OF ACTION: It works on cardiac cell membranes . It relaxes the smooth muscles, the myocardial blood flow is also ensured to be at its height of function.


USES:hemodynamically unstable ventricular tachycardia, supraventricular tachycardia, ventricular fibrillation.UNLABELED USES:cardiac arrest, cardiac surgery, CPR, heart failure, artial flutter.DOSES:Adult:• Oral Loading dose is between 800 to 1,600 mg for 1-3 weeks.

Maintenance dosage may range between 600 to 800 mg per day. It is advised to use the possible lowest dose in reaching cardiac stability.


• I.V. Infusion: A 150 mg loading dose must be given with 10 minutes slowly. For maintenance dose, a 540 mg amiodarone must be run with 18 hours. The rate on the first day of therapy can be increased depending on the situation.

Child:• PO Loading Dose 10–15 mg/kg/d in 1–2 divided

doses for 4–14 d cycle or until adequate control of arrhythmia

• PO Maintenance Dose 5 mg/kg/d once daily, may be able to reduce to 2–5 mg/kg/d 5 d per week


SIDE EFFECTS:CNS: headache, dizziness, involuntary movement, tremors, pheripheral neuropathy, ataxia, malaise.CV: hypotension, bradycardia, sinus arrest, CHF, SA node dysfunction, AV block.EENT: blurred vision, photophobia, dry eyes.ENDO: hypo/hyperthyroidismGI: nausea, vomiting, diarrhea, abdominal pain, anorexia, hepatotoxicity.INTEG: rash, photosensitivity, blue-gray skin discoloration, alopecia, phlebitis(IV), urticaria


RESP: pulmonary fibrosis/toxicity, pulmonary inflammation, ARDS; gasping syndrome if used in neontes.MS: weakness, pain in extrimities.

CONTRAINDICATIONhypersensitivity, pregnancy(D), breastfeeding, neonates, infants, severe sinus node dysfunction, cardiogenic shock, bradycardia, 2nd and 3rd degree AV block.

PRECAUTIONchildren, goiter, hashimoto’s thyroiditis, respiratory disease.


NURSING CONSIDERATION: Before the therapy, assess the patient’s vital signs and put

more focus on the cardiac activity. For patients with cardiac device implants, check its condition

and if it works properly before during and after administration. Monitor also the pulmonary, liver and thyroid function tests as

it may infer with the expected results. Watch out for adverse drug interactions such as: peripheral

neuropathy, abnormal gait, ataxia, dizziness, headache, fatigue.


Check pulse daily once stabilized, or as prescribed. Report a pulse <60.

Take oral drug consistently with respect to meals. Become familiar with potential adverse reactions and

report those that are bothersome to the physician. Use dark glasses to ease photophobia; some patients

may not be able to go outdoors in the daytime.


Wear protective clothing and a barrier-type sunscreen that physically blocks penetration of skin by ultraviolet light (e.g., titanium oxide or zinc formulations) to prevent a photosensitivity reaction (erythema, pruritus); avoid exposure to sun and sunlamps.

Do not breast feed while taking this drug without consulting physician.


STREPTOKINASE


STREPTOKINASEClassification:

therapeutic= thrombolytics.pharmacologic= plasminogen activator.

Generic name: StreptokinaseTrade name: straptaseMECHANISM OF ACTION: Combines with plasminogen to form activator complexes, then

converts plasminogen to plasmin, which is then able to degrade clot-bound fibrin.

Therapeutic Effects: Lysis of thrombi in coronary arteries, with preservation of

ventricular function. Lysis of pulmonary emboli and subsequent restoration of blood flow. Restoration of cannula patency and function.


USES:acute myocardial infarction (MI), pulmonary embolism (PE). deep

vein thrombosis(DVT), acute peripheral arterial thrombosis, occluded arterio-venous cannula.

DOSES:Myocardial Infarction:• IV (Adults): 1.5 million IU given as a continuous infusion over up to

60 minutes.• Intracoronary (Adults): 20,000 IU bolus followed by 2000 IU/min

infusion for 60 min.

DVT, Pulmonary Emboli, Arterial Emboli, or Other Thrombosis:• IV (Adults): 250,000 IU loading dose, followed by 100,000 IU/hr for

24 hr for pulmonary emboli, 72 hr for recurrent pulmonary emboli or deep vein thrombosis.


Occluded Arterio-venous Cannula:• IV (Adults): 250,000 IU/2 mL instilled into occluded catheter.

SIDE EFFECTS:CNS: intracranial hemorrhage. EENT: epistaxis, gingival bleeding. RESP: bronchospasm, hemoptysis. CV: reperfusion arrhythmias, hypotension, recurrent ischemia/ thromboembolism.GI: GI bleeding, hepatotoxicity, nausea, retroperitonial bleeding, vomiting.


GU: GU tract bleeding. INTEG: ecchymoses, flushing, urticaria. HEMAT: bleeding,LOCAL: hemorrhage at injection site, phlebitis at

injection site. MS: musculoskeletal pain.MISC: allergic reactions including anaphylaxis, fever.

CONTRAINDICATION:active internal bleeding; history of cerebrovascular accident; recent (within 2 mo) intracranial or intra-spinal injury or trauma; Intracranial neoplasm, severe uncontrolled hypertension, known bleeding tendencies; hypersensitivity.


PRECAUTION:recent (within 10 days) major surgery, trauma, GI or GU bleeding; severe hepatic or renal disease; recent streptococcal infection or previous therapy with anistreplase or streptokinase (within 5 days– 6 mo); geriatric patients (75 yr; increased risk of intracranial bleeding); pregnancy, lactation, or children (safety not established).Extreme Caution: patients receiving warfarin therapy; early postpartum period.


NURSING CONSIDERATION:• Monitor vital signs, continuously for myocardial infarction.• Do not use lower extremities to monitor BP. Notify health care

professional if systolic BP 180 mm Hg or diastolic BP 110 mm Hg. Thrombolytic therapy should not be given if hypertension is uncontrolled. Inform health care professional

if hypotension occurs. • Assess patient carefully for bleeding every 15 min during the

1st hr of therapy, every 15– 30 min during the next 8 hr, and at least every 4 hr for the duration of therapy. Frank bleeding may occur from sites of invasive procedures or from body orifices.


• If uncontrolled bleeding occurs, stop medication and notify health care professional immediately. Inquire about previous reaction to streptokinase therapy.

• Assess patient for hypersensitivity reaction (rash, dyspnea, fever, changes in facial color, swelling around the eyes, wheezing). If these occur, inform health care professional promptly. Keep epinephrine, an antihistamine, and resuscitation equipment close by in the event of an anaphylactic reaction.

• Inquire about recent streptococcal infection. Streptokinase may be less effective if administered between 5 days and 12 mo of a streptococcal infection.


• Assess neurologic status throughout therapy. Altered sensorium or neurologic changes may be indicative of intracranial bleeding.

• Myocardial Infarction: Monitor ECG continuously. Notify doctor if significant arrhythmias occur. Monitor cardiac enzymes.Myocardial scanning and/or coronary angiography may be ordered 7– 10 days after therapy to monitor effectiveness of therapy.

• Assess intensity, character, location, and radiation of chest pain. Note presence of associated symptoms (nausea, vomiting, diaphoresis). Administer analgesics as directed. Notify doctors if chest pain is unrelieved or recurs.

• Monitor heart sounds and breath sounds frequently. Inform doctor if signs of HF occur (rales/crackles, dyspnea, S3 heart sound, jugular venous distention).


• Deep Vein Thrombosis: Observe extremities and palpate pulses of affected extremities every hour.

• Teach patient and family:

Explain purpose of medication and the need for close monitoring to patient and family.

Instruct patient to report hypersensitivity reactions (rash, dyspnea) and bleeding or bruising.

Explain need for bed rest and minimal handling during therapy to avoid injury. Avoid all unnecessary procedures such as shaving and vigorous tooth brushing


SUCCINYLCHOLINE


SUCCINYLCHOLINE

Functional class: depolarizing skeletal muscle relaxant.Generic name: SuccinylcholineTrade name: Anectine, Sucostrin, Quelicin

MECHANISM OF ACTION:Prevents neuromuscular transmission by blocking the effect of acetylcholine at the myoneural junction. Therapeutic Effects: Skeletal muscle paralysis.


USES:to produce skeletal muscle relaxation as adjunct to anesthesia or during orthopedic manipulation; to facilitate intubation and endoscopy, to increase pulmonary compliance in assisted or controlled respiration.DOSES:Surgical and Anesthetic Procedures. Adult: IV 0.3–1.1 mg/kg administered over 10–30 sec, may

give additional doses .IM 2.5–4 mg/kg up to 150 mg Child: IV 1–2 mg/kg administered over 10–30 sec, may give

additional doses. IM 2.5–4 mg/kg up to 150 mgProlonged Muscle Relaxation. Adult: IV 0.5–10 mg/min by continuous infusion.


SIDE EFFECTS:MS: muscle fasciculations, profound and prolonged muscle relaxation, muscle pain, rhabdomyolysis. CV: bradycardia, tachycardia, hypotension, hypertension, arrhythmias, sinus arrest. RESP: respiratory depression, bronchospasm, hypoxia,

apnea. META: myoglobinemia, hyperkalemia.GI: decreased tone and motility of GI tract (large doses).SYST: angioedema, anaphylaxis.


CONTRAINDICATION:hypersensitivity, malignant hyperthermia, trauma.

PRECAUTION:pregnancy(C), breastfeeding, geriatric or debilitated patients,cardiac/neuromuscular/respiratory/renal/ hepatic disease, children<2 yrs, hyperkalemia, myopathy, rhabdomyolysis.


NURSING CONSIDERATION: Obtain baseline serum electrolytes. Electrolyte imbalance

(particularly potassium, calcium, magnesium) can potentiate effects of neuromuscular blocking agents.

Be aware that transient apnea usually occurs at time of maximal drug effect (1–2 min); spontaneous respiration should return in a few seconds or, at most, 3 or 4 min.

Have immediately available: Facilities for emergency endotracheal intubation, artificial respiration, and assisted or controlled respiration with oxygen.

Monitor vital signs and keep airway clear of secretions..


Patient & Family Education• Patient may experience post-procedural

muscle stiffness and pain (caused by initial fasciculations following injection) for as long as 24–30 hr.

• To be aware that hoarseness and sore throat are common even when pharyngeal airway has not been used.

• To report if muscle weakness to physician.


Thank you

9. drugs used in critical

Health & Medicine