Critical Care Pharm

adverse effects of analgesic

• dysphoria

• euphoria

• sedation

• rsp depression

• constipation

• suppression of endocrine systems

• cardiovascular effects

• convulsion

• nausea

• vomiting

fentanyl is _____ _______ than morphine

100x stronger

fentanyl monitoring

• low therapeutic drug concentration

• liquid chromatography-mass spectrometry

fentanyl indications

chronic pain

• > 3 months time

often used for mechanically ventilated pts

fentanyl contraindications

• acute postoperative pain period for short term pain control

• intermittent pain control

• mild pain

• hypoventilation/respiratory compromised pts

fentanyl effect on rsp system

respiratory depression

what is used to reverse fentanyl in severe cases

Nalaxone

Hydromorphone “Dilaudid” monitoring

• closely monitor rsp depression 24-72 hrs initially

• pain relief

• BP

• mental conditions

• bowel functionality

• indications of hypogonadism or hypoadrenalism

Hydromorphone “Dilaudid” indications

• mod-severe acute and chronic pain

• off label

  • cough suppression

  • provide sedation for critically ill pts

hydromorphone “dilaudid” contraindications

• known allergies to drug

• bronchial asthma

• clinical rsp compromise

• gastrointestinal obstruction or hypomotility

• risk of prolonged ileus

• CNS depression

• hypotension

• hypovolemia

hydromorphone “dilaudid” effect on rsp system

rsp depression and cough suppression

hydromorphone

dilaudid

dexmedetomidine “precedex” adverse effects

• hypotension

• bradycardia

• hypertension

pt pop/indications for precedex

• FDA approved for sedation of intubated pts AND peri-operative sedation of non-intubated pts

• off label

  • delirium

  • adjunctive analgesia

  • therapy for insomnia

  • tx of alc withdrawl

dexmedetomidine “precedex” effect on rsp system

none

dexmedetomidine

precedex

propofol “diprivan” common side effects/adverse reactions

• transient local pain at the injection site

• hypotension

• myoclonus

how can the transient local pain at the injection site or propofol be fixed

w/ IV lidocaine before propofol bolus

what is myoclonus

sudden short-lived involuntary twitching of a muscle/group or muscles

propofol “diprivan” indications

general anesthesia and sedation of mech vent pts

propofol “diprivan” contraindications

• known hypersensitivity

• allergy to egg or soy products

propofol “diprivan” monitoring

• rr

• cyanosis

• assess for rsp depression

propofol “diprivan” effect on rsp system

rsp depression

propofol

diprivan

midazolam common side effects/adverse reactions

• hiccups

• cough

• nausea/vomiting

• thrombosis

• pain at injection site

midazolam indications

• induction of anesthesia

• management of acute seziures

midazolam contraindications

• hypotension

• angle closure glaucoma

• shock

• alc/drug dependent individuals

• kidney and liver diseases

midazolam monitoring

• blood and plasma levels

• cardiac function

• rsp function

midazolam effects on rsp system

• rsp depression bc

  • increased pulmonary resistance

neuromuscular blockers indications

• endotracheal intubations

• surgery

• severe ARDS

• ventilator dyssynchrony

don’t use ___ if going to be a challenging intubation. why?

neuromuscular blockers bc don’t want them to loose their drive to breathe, want their help

what do you not want to give overly obese pts

neuromuscular blockers bc gravity

neuromuscular blockers monitoring

• hemodynamics

• SpO2

• train of four - prevents overdosing

• sedation levels

neuromuscular blockers effect on rsp system

complete cessation

all neuromuscular blocker drugs end in

-ium

Cistracurium common side effects

• flushing

• hypotension

• bronchospasm (rare)

• confusion

cistracurium contraindications

known hypersensitivity

atracurium side effects

• flushing

• hypotension

• tachycardia

• bronchospasm

• laudanosine accumulation → CNS excitation, possible seizures

atracurium contraindications

• seizure disorders

• neuromuscular disease

vecuronium side effects

prolonged use causes hepatic or renal impairment

vecuronium contraindications

• known hepatic or renal impairment

• known hypersensitivity

• neuromuscular disease

what neuromuscular blocker is used most often at bedside

rocuronium “roc”

rocuronium typically used for what type of intubation

rapid sequence intubation (RSI)

rocuronium side effects

painful at injection site

rocuronium contraindications

• hepatic impairment

• neuromuscular disease

amiodarone common side effects

• cough or spitting up blood

• fatigue

• cracks in the skin

• bluish gray skin

• change in vision such as blurry vision

• decreased urine output

• general body swelling

amiodarone indications

• ventricular tachycardia

• ventricular fibrillation

• atrial fibrillation

• atrial flutter

amiodarone contraindications

• severe sinus node dysfunction

• cardiogenic shock

• known allergy

amiodarone monitoring

• skin color

• EKG

• HR

amiodarone effect on rsp system

• ARDS

• pulmonary toxicity - long term use

lidocaine common side effects

• mostly CNS due to it crossing the blood-brain barrier

  • drowsiness, confusion, paresthesias

• tremors, seizures

• cardiovascular: hypotension, bradycardia, arrhythmias if overdose

lidocaine indications

• acute ventricular arrhythmias, of myocardial infarction or cardiac surgery

• ventricular tachycardia - particularly ischemia-induced VT

• ventricular fibrillation - alternative to amiodarone of unavailable or contraindicated

lidocaine contraindications

• known hypersensitivity to amide-type local anesthetics

• severe SA node dysfunction, 2nd/3rd degree AV block or Adams-Stokes syndrome (unless pacemaker present)

• Wolff-Parkinson-White (WPW) with atrial fibrillation

lidocaine monitoring

• BP

• EKG

• neurologic status

lidocaine effect on rsp system

respiratory depression

alpha receptor stimulation causes

vasoconstriction and vasopressor effect

• increased BP

beta 1 receptor stimulation causes

increased HR and myocardial contractility

beta 2 receptor stimulation

• relaxes bronchial smooth muscle

• stimulates mucociliary activity

• some inhibitory action on inflammatory mediator release

epinephrine side effects

• tachycardia

• hypertension

• headache

• heart palpitations

• nausea

epinephrine indications

• post cardiac surgery

• anaphylaxis

• septic shock

• cardiogenic shock w/ hypotension

• cardiac arrest

epinephrine contraindications

known sensitivity

epinephrine monitoring

• EKG

• BP

• rr

epinephrine effect on rsp system

relaxes the smooth muscle around airways

norepinephrine side effects

• hypertension

• peripheral ischemia

norepinephrine indications

• septic shock

• vasodilatory shock states

• acute hypotension

norepinephrine contraindications

• tachyarrhythmias

• tissue ischemia

norepinephrine monitoring

• target MAP

• BP/HR and rhythym

• urine output

norepinephrine effect on rsp system

none

methylprednisolone side effects

fluid retention - short term

methylprednisolone indications

• inflammatory/autoimmune

• severe asthma and COPD exacerbations

• septic shock

• ARDS

• spinal cord injury

methylprednisolone contraindications

• untreated systemic fungal infections

• uncontrolled diabetes

methylprednisolne monitoring

• BP

• bone mass density

• signs infection

• glucose - diabetics

methylprednisolone effect on rsp system

• decrease airway inflammation

• reduces mucus production in inflamed airways

dexamethasone (salumeterol) side effects

• hyperglycemia

• immunosuppression

• fluid retention

• hypertension

dexemethasone (salumeterol) indications

• severe allergic reactions

• asthma and COPD exacerbations

• cerebral edema

• angioedema

dexamethasone (salumeterol) contraindications

• uncontrolled diabetes

• systemic fungal infections

• known hypersensitivity

dexamethasone (salumeterol) monitoring

• BP

• glucose levels

dexamethasone (salumeterol) effects on rsp system

• reduces airway inflammation

• can improve oxygenation in severe inflammatory lung disease

conscious sedation purpose

medicines combined to block pain and relax during a medical procedure

conscious sedation monitoring

• BP (may drop)

• breathing (may slow or stop)

what must you have at bedside for conscious sedation

• end tidal on NC

• suction

• bag

• crash cart

when to use conscious sedation

• biopsy

• minor bone fracture repair

• minor skin surgery

pharmaceuticals used for conscious sedation

• ketamine

• propofol

• midazolam and fentanyl