Transcript RT Pandemic Education Pharmacology Oct 2009

2009 Pandemic Education Package
Pharmacology Review
Common Medications for H1N1/SRI
• Antiviral
– Tamiflu
• Antibiotics
– Ceftriaxone
– Zithromycin
– Pip/Tazocin
• Sedation
– Propofol
– Versed
• Analgesic
– Morphine
– Fentanyl
• Vasopressors
– Dopamine
– Epinephrine
– Norepinephrine
– Vasopressin
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Antiviral Medication
Oseltamivir (Tamiflu)
•
Dose 75 mg PO/NG BID for at least 7 days, current experience is showing
it could be needed up to 3-4 weeks
•
The treatment of influenza infection in patients who have been
symptomatic for no more than 2 days, or as prophylaxis once exposure
has occurred. Alleviates symptoms and decreases duration of symptoms.
•
Adverse Effects: Nausea and Vomiting
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Antibiotics
•
These medications are commonly given for the prevention and treatment
of pneumonia/bacterial infections associated with the severe respiratory
illness aspect of H1N1.
•
It is important to start these medications IMMEDIATELY after they
have been ordered by the Physician, as they may be fighting a larger
scale bacterial infection on top of the H1N1 viral infection.
•
Common antibiotics that may be administered to a H1N1/SRI patient –
Ceftriaxone, Azithromycin, Piperacillin/Tazobactam due to the broad
spectrum.
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Antibiotics
Piperacillan/Tazobactam
•
Usual dose is 3.375 to 4.5 Grams every 6 or 8 hours based on renal
function.
•
Administration – I.V over at least 30 minutes
•
Adverse Effects may include Diarrhea, nausea and vomiting.
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Antibiotics
Ceftriaxone
•
Usual Dose is 1-2 Gram daily via IV route
•
Administration – I.V or intermittent does
•
Adverse Effects – Thrombophlebitis (pain at injection site)
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Antibiotics
Azithromycin
•
Usual dose is 500 mg IV daily for 5 days
•
Administration – Intermittent IV only
•
Adverse Effects: nausea, vomiting, diarrhea, pain at injection site
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Sedation/Analgesia
• Recent experiences in other areas of the country and
world have reported that H1N1/SRI patients require a
significantly large amount of sedation and analgesic.
• Routine assessments of your patient including
respiratory status, level of consciousness, and agitation
level will help determine the need for further sedation.
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Sedation/Analgesia
• Routinely in a critical care setting, the order for sedation
and analgesia will be written with no time frame other
than PRN.
i.e. Morphine 5 mg IV PRN
• The ICU RN must use knowledge, experience and
judgment to decide how much or how little of the
specific drug is needed for the patient.
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Sedation/Analgesia
• Assessments to determine need for
sedation/analgesia are:
• Neurologic
• Determine LOC and level of agitation or sedation
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Sedation/Analgesia
• Respiratory
• Current mode of ventilation (full support [AC],
partial support [PS], no support or not ventilated)
• Respiratory rate ( if too slow and not on full
ventilatory support use caution with amount of
drug)
• Asynchronous with ventilator – may need more
sedation or neuromuscular blocking agent
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Sedation/Analgesia
• Cardiovascular
• Blood Pressure and Heart Rate – Will patient’s BP
and HR support the administration of sedation
and/or analgesic? These drugs tend to drop BP.
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Sedation
Propofol
•
Supplied in a concentration of 10 mg/mL
•
0-350 mg is the dose range for sedation
•
Main adverse effects are HYPOTENSION and Respiratory
Depression/Failure.
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Sedation
Versed (Midazolam)
•
Can be given Direct IV, Intermittent or Continuous infusion
•
Direct IV dose is 1-2 mg over 2-3 minutes
•
Continuous infusion is 1-2 mg/hr and then titrated to desired effect
•
Adverse Effects include hypotension, respiratory depression/failure
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Analgesia
Morphine
•
Can be given Direct IV, Intermittent or Continuous Infusion as well as SC
and IM
•
Usual dose for Direct IV/Intermittent administration seen in ICU is 5 mg IV
PRN (No time limit)
– decision on how much drug to give is left to the ICU RN or MD
•
Usual dose for Continuous infusion is 1-10 mg/hr
•
Adverse Effects – Respiratory and cardiovascular depression
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Analgesia
Fentanyl
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Can be given Direct IV, Intermittent or Continuous infusion
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Usual dose for direct IV/Intermittent is 25-100 mcg
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Usual dose for Continuous infusion is 100-200 mcg/hr and titrated to effect.
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Adverse Effects are respiratory depression and cardiovascular depression.
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Vasopressors
Dopamine
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•
•
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Indication
– Hypotension (SBP <70-100)
Route
– IV infusion
Dose
– Titrate to effect
• Increase in increments of 1-4 mcg/kg/min
Adverse Effects
– Tachycardia, tachyarrhythmias, angina, palpitations, nausea
– At high dose - ↓ renal function, ↓ peripheral perfusion
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Vasopressors
Norepinephrine
•
•
•
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Indication
– Hemodynamically significant hypotension
Route of Administration
– IV infusion
Dose
– 0.5-30 mcg/min titrated to effect
Adverse Reactions
– Reflex bradycardia, hypertension, angina, ↓ renal function, ↓ peripheral
perfusion
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Vasopressors
Epinephrine
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Indication – Severe hypotension, bradycardia
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Route of Administration – Continuous IV infusion
• Can be given Direct IV push in cardiac arrest situation (1mg)
Dose
– 1-30 mcg/min titrated to effect
•
•
Adverse Effects
– Reflex bradycardia, hypertension, angina, ↓ renal function, ↓
peripheral perfusion
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Vasopressors
Vasopressin
•
Indication – treatment of shock and hypotension, used for vasoconstrictive
purposes
•
Route of Administration – Continuous IV infusion
– Can be given Direct IV in cardiac arrest situation (40u)
•
Dose - 0.02 – 0.06 units/min
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Adverse Effects: Peripheral vasoconstriction and bronchial constriction
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Neuromuscular Blocking Agents
• NMBAs must be given with sedation and analgesic
• Patient must be on Full Support ventilation [i.e. AC
Mode] prior to receiving NMBA
• Patient must be monitored continuously
– cardiac
– respiratory
• Ventilator alarms are tightened
• ETCO2 placed in-line (alarms set)
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Care of a Paralyzed Patient
• Be diligent with airway maintenance
– Patient unable to cough and will therefore will need
regular bronchial hygiene
• ETCO2 monitoring
– Trending
– Assessing for spontaneous respirations (signs of
distress/dyschrony)
• “Curare cleft”
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