Pharmacology and Critical Care Medications (copy)

Angiotensin Converting Enzyme (ACE) Inhibitors

• Indications

  • Heart Failure

  • s/p MI

  • Diabetes

  • CKD

• MOA: Inhibits ACE

  • Preserves renal function

  • CO and HR do not change

• Medications

  • Capoten (captopril)

  • Listril, Zestril (lisinopril)

  • Vasotec (enalapril)

• Common adverse reactions

  • Hypotension, chronic cough, hyperkalemia, high incidence of angioedemaIndications

    • Heart Failure

    • s/p MI

    • Diabetes

    • CKD

  • MOA: Inhibits ACE

    • Preserves renal function

    • CO and HR do not change

  • Medications

    • Capoten (captopril)

    • Listril, Zestril (lisinopril)

    • Vasotec (enalapril)

  • Common adverse reactions

    • Hypotension, chronic cough, hyperkalemia, high incidence of angioedema

Beta Blockers

• Indications: Decrease heart rate

  • Dysrhythmia

  • Tachycardia

  • Hypertension

  • Conditions: Heart failure, MI, angina

• MOA

  • Sympathetic inhibition

  • Decreases myocardial contractility

• Medications

  • Atenolol

  • Metoprolol (Lopressor)

  • Labetalol

  • Propranolol

• Common adverse reactions

  • Bradycardia

  • Hypotension

  • Fatigue

  • Reduced exercise performance

• PT Implications: Should use Borg RPE to track intensity

Calcium (Ca2+) Channel Blockers

• Indications: Decrease muscle contractility

  • Tachycardia

  • Angina

  • Afib with RVR

• MOA: block calcium channels in arteriole smooth muscle and cardiac muscle

• Conditions treated

  • Dysrhythmia

  • Tachycardia

• Medications

  • Dilitazem (Cardizem)

  • Norvasc (amlodipine)

• Common adverse reactions

  • Bradycardia

  • Hypotension

  • AV block

  • LE edema

• PT Implications

  • Usually a contraindication if on a continuous infusion

Antiarrhythmics

• Purpose

  • Convert irregular heart rhythm to normal sinus rhythm (NSR)

  • Prevent relapse to arrhythmia

• Conditions treated

  • Life-threatening arrhythmia

• Medications

  • Amiodarone (K+ channel blocker)

  • Adenosine (slows conduction through AV node)

• Precautions

  • Limit strenuous activity, monitor HR

Diuretics

• Purpose

  • Increase urine output

• Conditions treated

  • Heart failure

  • Peripheral edema

  • Volume overload

• Medications

  • Furosemide (Lasix)

  • Mannitol

  • Bumetanide (Bumex)

  • Torsemide (Demadex)

• Precautions

  • Hypotension

• PT Implications

  • Patient will need to urinate A LOT

  • Cautious use of whirlpool, exercise that may cause excessive dilation

Thrombolytic Therapy

• Purpose: Break down blood clots

• Conditions treated

  • Acute ischemic stroke

  • PE

  • MI

• Medications

  • Tissue Plasminogen Activator (tPA)

  • Tenecteplase (TNKase)

• PT Implications

  • Facility specific, can be up to 24 hour bed rest

Nitric Oxide

• Indications

  • Pulmonary hypertension

  • ARDS

  • Cor pulmonale

  • Bridge to ECMO

• MOA: Naturally occurring vasodilator produced by endothelial cells

  • Regulates vascular tone

  • Enhances blood flow

  • Supports mitochondrial function

  • Modulates inflammation

  • Can also be inhaled therapeutically

• PT Implications

  • Promotes exercise tolerance, wound healing, muscle recovery

  • Supports pulmonary rehabilitation

• Common adverse reactions: Hypotension

Vasopressors and Inotropes

• Purpose

  • V: Cause constriction of peripheral vasculature leading to increase in blood pressure

    • Will hear in clinic called “pressors”

  • I: increase heart’s contractility, increasing CO

• Conditions treated: acute shock resulting in impaired organ perfusion

  • ex: sepsis, MI, valve disease, arrhythmia, PE pulmonary HTN

• Medications

  • Dopamine (Intropin)

  • Norepinephrine (Levophed)

  • Phenylephrine (Neo-Synephrine) (Neo)

  • Antidiuretic hormone (Vasopressin)

  • Epinephrine

  • Ephedrine

• Precautions

  • Monitor vitals closely, especially with position changes

• PT Contraindication

  • Increasing doses

  • MAPs < 60

  • Patient on multiple pressors

Dopamine

• Combination Vasopressor & Inotrope

• Indication: hypotension due to sepsis or cardiac failure

• Side effects

  • Increased HR with increased dosage

• PT Implications

  • Dyspnea

  • HA

Norepinephrine (Levophed)

• Combination vasopressor & inotrope

• Indication: hypotension

• First choice pressor for septic shock

• PT Implications

  • HR: Mild increase or no change

  • Tissue necrosis

  • Confusion

  • Headache (HA)

  • Tremor

  • Anxiety

  • Restlessness

Phenylephrine/Neo

• Vasopressor

• Indication: hypotension, neurologic disorders, anesthesia-induced hypotension

• Side effects

  • Severe bradycardia

  • V-Tach

  • HA

  • Metabolic acidosis

  • Restlessness

Vasopressin

• Vasopressor

• Indication: vasodilatory shock/septic shock

• Side effects

  • **More notable for contribution to distal tissue necrosis

  • Decreased HR

  • Arrhythmias

  • Cardiac arrest

  • Angina

  • Myocardial ischemia

  • Peripheral constriction

Epinephrine

• Combination vasopressor & inotrope

• Indication: anaphylaxis, second-line agent in septic shock, hypotension s/p CABG

• Side effects

  • Increased CO with decreased SVR

  • Variable effects on MAP

  • Increased HR, dysrhythmias HTN, V-fib

  • Asthenia (weakness)

  • Dizziness

  • HA

  • Tremor

  • Difficulty breathing, pulmonary edema

  • Cerebral hemorrhage

Paralytics and Neuromuscular Blocking Agents

• Purpose: chemical paralysis during intubation to improve ventilator synchrony

• Uses:

  • Skeletal muscle paralysis

  • surgery

  • ET intubation

• Medications

  • Propofol (dipivan)

  • cisatracurium (nimbex)

  • Rocuronium (Zemuron)

  • commonly have “-ium” suffix

• PT implications

  • pt. Cannot communicate, minimal muscle tone

  • if doing PROM watch for hyperextension, subluxation, impingement

• Side effects

  • Unrecognizable signs of distress

  • Skin breakdown

  • Nausea

  • Hiccups

  • Tachycardia

  • Bradycardia

  • Apnea

  • Hypotension

  • Bronchospasm

Versed (Midazolam)

• Continuous infusion for anesthesia, sedation, and severe agitation

• Conditions treated

  • Seizure management

  • ETOH withdrawal

  • Fall back option if Propofol or Precedex are contributing to hypotension or bradycardia

• Onset: 1-3 min, Duration: 30-60 mins

• PT Implications

  • Unpredictable awakening and time to extubation with prolonged use

  • Associated with longer ventilation times and longer ICU stay

• Side effects

  • Excessive somnolence

  • Cardiac arrest

  • Involuntary movement

  • Apnea

Propofol

• Purpose

  • CNS Depressant

  • Amnesiac

  • Used in mechanical ventilation

• Onset: 10 seconds

• Duration: varies

  • Patients can becomes aroused within 10 mins for neuro checks

• PT Implications

  • Assess ability to follow commands

• Side effects

  • Dystonic movements

  • Bradycardia

  • Hypotension

  • Decreased CO

  • HLD

  • Apnea that can last longer than 60 seconds

  • Respiratory acidosis

Precedex

• Purpose

  • Sedation

  • Analgesic without respiratory depression

  • Can help preserve sleep/wake cycle

• Onset: 10-15 mins

• Duration: 1-2 hrs

• Side effects

  • Initial

    • Bradycardia

    • HTN

  • Continuous

    • Hypotension

    • Afib

    • Tachycardia

• PT Implications

  • Apnea

  • Bronchospasm

Barbiturates

• Purpose

  • Sedation

• Conditions treated

  • Difficulty sleeping

  • Anxiety

  • Drug Withdrawal

• Medications

  • Phenobarbital (Luminal)

• Precautions

  • Can heighten pain intensity/awareness

• Side effects

  • Cardiovascular depression

  • Cerebrovascular vasoconstrictors

  • High potential for dependence

Narcotics

• Can come in PO, IV, patch, patient-controlled analgesia (PCA)

• Purpose: Analgesia

• Conditions treated: severe pain

• Medications

  • Morphine

  • Fentanyl

  • Hydromorphone

  • Oxycodone

  • Methadone

• Side Effects

  • Sedation

  • Hypotension

  • Gastric hypomobility

  • Respiratory distress

Morphine

• Onset

  • PO

    • IR: 30-60 mins

    • ER: 90 mins

  • IV 2 mins

• Duration

  • PO

    • IR: 3-4 hrs

    • ER: 12 hrs

  • IV 2-4 hrs

• Concerns

  • Respiratory depression

  • Nausea

  • Constipation

  • Hypotension

  • Accumultation in liver and renal failure

  • Seizures

Fentanyl

• IV given as bolus

  • Onset: 7-8 mins

  • Duration: 30-60 mins

• Concerns

  • Respiratory depression

  • Nausea

  • Constipation

  • Bradycardia

  • Hypotension

  • Skeletal muscle rigidity

  • Accumulation in liver failure

  • Confusion

  • Somnolence

• Must be weaned slowly due to withdrawal symptoms

  • Tachycardia

  • HTN

  • Diaphoresis

Hydromorphone (Dilaudid)

• Onset

  • PO: 30 mins

  • IV 1-2 mins

• Duration

  • PO 4 hrs

  • IV ~2 hrs

• Concerns

  • Respiratory depression

  • Bradycardia

  • Hypotension

  • Nausea

  • Constipation

Oxycodone

• Onset

  • IR: 30-60 mins

  • ER: variable

• Duration

  • IR: 3-4 hrs

  • ER: 12 hrs

• Side Effects/Concerns

  • Respiratory depression

  • Nausea

  • Constipation

  • Hypotension

  • Bradycardia

Methadone

• Used to treat Opioid Use Disorder

• Opioid agonist

• Onset

  • PO ~ 1 hr

  • IV 30 mins

• Duration 4-8 hrs

• Side Effects/Concerns

  • Respiratory depression

  • Nausea

  • Constipation

  • Extremely long half life (up to 150 hrs)

  • QTc prolongation

  • Risk of arrhythmias

  • Serotonin syndrome

Ketamine

• Purpose

  • Multimodal pain management

  • Used to take pressure off opioid epidemic

  • Higher doses decrease sedative requirements

  • Lower doses help decrease opioid requirement

• Onset

  • IV: 30 seconds

  • Intramuscular (IM): 3-4 mins

• Duration

  • IV: 5-10 mins

  • IM 12-25 mins

• Side effects

  • HTN

  • Tachycardia

  • Dissociative anesthetic at high doses

  • Hallucinations

  • Apnea

  • Nausea

Benzodiazepines

• Purpose

  • CNS depressant

  • Amnesiac

• Conditions treated

  • Anxiety

  • Agitation

  • Muscle spasm

  • Seizure

  • ETOH withdrawal

• Medications

  • Lorazepam (Ativan)

  • Midazolam (Versed)

  • Diazepam (Valium)

• Precautions

  • Impaired cognition

  • Hypotension

• Side effects

  • Delayed recovery as fat soluble

  • High potential for dependence

  • Hypotension, tachycardia

  • Apnea

  • Hiccups

  • Amnesia

Narcan (Naloxone)

• APTA stance: should have available at PT clinics

  • Before administering, check practice act, insurance policies for hospital/clinic

  • In New Jersey, Governor Murphy set a law you can get without a prescription

• Opioid antagonist

• Will not hurt someone that doesn’t have opioids

Aldosterone Antagonists

• “Potassium sparing” diuretic

• Indications

  • Heart failure

  • HTN

  • CKD

  • Edema

  • Hypokalemia

  • s/p MI

• MOA

  • Blocks aldosterone, hormone produced by adrenal glands

  • Increases sodium and water excretion

  • Decreases potassium loss

  • Reduces blood volume and pressure

• Medications

  • Aldactone, CaroSpir (Spironolactone)

• Common adverse reactions

  • Hyperkalemia

  • Menstrual irregularities

  • Impotence

  • Renal failure

• PT Implications

  • Can cause dizziness and lightheadedness

Alpha Antagonists (Alpha Blockers)

• Indications: lowers BP and improves urinary flow

• MOA

  • Blocks alpha-1 receptors

    • Promotes vasodilation and smooth muscle relaxation

  • If non selective and blocks alpha-1 and alpha-2 receptors

    • Can increase norepinephrine and can raise HR and BP

• Medications

  • Alpha 1 selective

    • Flomax (Tamsulosin)

  • Non selective

    • Dibenzyline (Phenoxybenzamine)

    • Regitine (Phentolamine)

• Common Adverse Reactions and PT Implications

  • Orthostatic hypotension

  • Dizziness and fatigue

  • Reflex tachycardia

Antipsychotics

• Purpose

  • Works to help restore balance of certain neurotransmitters in the brain

  • Used for behavioral management without sedation

• Conditions treated

  • Can decrease hallucinations and agitation

  • Improve concentration

• Medications

  • Seroquel

  • Haldol

  • Geodon

• Precautions

  • Can cause drowsiness, dizziness, lightheadedness