Drug Midterm Clinical Pearls

Regular Insulin

Indication(s): Hyperglycemia, hyperkalemia (administer with
dextrose unless blood glucose is elevated)

Warning(s): High-alert medication; verify insulin type, concentration, dose, and route.

Dextrose Injection

Indication(s): Severe hypoglycemia; administered with IV regular insulin for hyperkalemia

Calcium Gluconate

Indication(s): stabilization of the myocardium in hyperkalemia with ECG changes

Warning(s): Not used to lower serum potassium

Calcium Chloride

Warning(s): Vesicant; administer via central line whenever possible due to risk of severe tissue necrosis if extravasation occurs.

Magnesium Sulfate

Indication(s): torsades de pointes; seizure prevention in preeclampsia/eclampsia

Sodium Bicarbonate

Indication(s): Severe metabolic acidosis, sodium channel blocker toxicity (e.g., tricyclic antidepressant overdose)

Warning(s): Not recommended for routine use during cardiac arrest

Potassium Chloride

Warning(s): High-alert medication; NEVER administer IV push or IV bolus

Potassium Phosphate

Warning(s): Contains both phosphorus and potassium

Note(s): Consider serum potassium when choosing between potassium phosphate and sodium phosphate

Sodium Phosphate

Warning(s): Contains both phosphorus and sodium

Note(s): May be preferred over potassium phosphate when additional potassium is undesirable.

Glucagon

Indication(s): Severe hypoglycemia, antidote for beta-blocker toxicity

Lipid emulsion 20%

Indication(s): antidote for local anesthetic systemic toxicity (LAST)

Side effect(s): Hypertriglyceridemia

bumetanide

Note(s): Dose Conversion: furosemide 40 mg = bumetanide 1 mg

furosemide

Note(s): Furosemide IV:PO ratio 1:2 (furosemide 20mg IV = furosemide 40mg PO

chlorothiazide

Note(s): Only thiazide available IV

nicardipine

Warning(s): Hypotension (especially with severe aortic stenosis), nicardipine should not be used in advanced
aortic stenosis

diltiazem, verapamil

Indication(s): Atrial fibrillation/other arrhythmias (rate control)
Warning(s): May worsen symptoms of HF; bradycardia

Side effect(s): Constipation (more with verapamil than diltiazem), gingival hyperplasia

enalaprilat

BBW: Fetal toxicity, avoid in pregnancy

Warning(s): Angioedema

Side effect(s): cough, hyperkalemia

Note(s): Do not use within 36 hours of sacubitril/valsartan (Entresto)

esmolol

Warning(s): Caution in pts with diabetes; can worsen hyperglycemia or hypoglycemia and mask hypoglycemic
conditions. Caution in bronchospastic diseases (asthma and COPD) and Raynaud’s

Note(s): Ultra-short-acting IV beta-1 selective blocker. Effects usually resolve within 10–20 minutes after
stopping the infusion; commonly used for rapid heart rate control and perioperative hypertension/tachycardia

metoprolol

BBW: Do not discontinue abruptly

Warning(s): Caution in pts with diabetes; can worsen hyperglycemia or hypoglycemia and mask hypoglycemic
conditions. Caution in bronchospastic diseases (asthma and COPD) and Raynaud’s

Note(s): Metoprolol tartrate IV is not equivalent to PO (IV:PO ratio is 1:2.5)

propranolol

BBW: Do not discontinue abruptly

Contraindication(s): Asthma

Warning(s): Caution in pts with diabetes; can worsen hyperglycemia or hypoglycemia and mask hypoglycemic
conditions. Caution in Raynaud’s

Note(s): High lipid solubility, crosses BBB, associated with more CNS side effects, but makes it useful for other
conditions (migraine prophylaxis). Non-selective BBs are used in portal HTN

labetalol

BBW: Do not discontinue abruptly

Contraindication(s): Asthma

Warning(s): Caution in pts with diabetes; can worsen hyperglycemia or hypoglycemia and mask hypoglycemic
conditions. Caution in Raynaud’s.

Note(s): Commonly used IV agent for acute severe hypertension in pregnancy

hydralazine

Indication(s): Chronic hypertension, hypertensive emergency (off-label), HFrEF (off-label)

Warning(s): Drug-induced lupus erythematosus (DILE - dose and duration related)

nitroglycerin

Contraindication(s): SBP <90 mmHg, DO NOT USE in combination with PDE5 inhibitors

Note(s): MOA: low doses: venous vasodilator, high doses: arterial vasodilator.
Requires non-PVC container (e.g. glass bottle).

nitroprusside

BBW: Metabolism produces cyanide

Warning(s): Increased intracranial pressure

Note(s): Requires light protection during administration

dobutamine

Note(s): may turn slightly pink due to oxidation but potency is not lost

digoxin

Note(s): Narrow therapeutic index (monitor digoxin level)

Toxicity: s/sx blurred/double vision, greenish-yellow halos signs of toxicity

Antidote: DigiFab

amiodarone

BBW: Pulmonary toxicity, hepatotoxicity; proarrhythmic effects. is used for life-threatening arrhythmias only

Note(s): Infusions >2 hours require a non-PVC container. Use 0.22 micron filter. Antiarrhythmic drug of choice
in heart failure. Very long half-life; numerous drug interactions.

procainamide

BBW: Potentially fatal blood dyscrasias (agranulocytosis). Long term use leads to positive antinuclear antibody
(ANA) in 50% of patients, which can result in drug-induced lupus erythematosus (DILE) in 20-30% of patients

lidocaine

Indication(s): Ventricular arrhythmias (refractory VT/ cardiac arrest)

adenosine

Indication(s): Supraventricular re-entrant tachycardias

Note(s): Half-life <10 seconds.

atropine

Indication(s): Bradycardia, inhibition of salivation and secretions, organophosphate poisoning

dopamine

Warning(s): Vasopressors are vesicants; central access is preferred for prolonged administration. If administered peripherally, closely monitor the IV
site for extravasation. Note(s): MOA is dose dependent

epinephrine

Warning(s): Vasopressors are vesicants; central access is preferred for prolonged administration. If administered peripherally, closely monitor the IV
site for extravasation. Epi for IV push is 0.1 mg/mL, Epi for IM injection and compounding IV products is 1 mg/mL

norepinephrine, phenylephrine

Warning(s): Vasopressors are vesicants; central access is preferred for prolonged administration. If administered peripherally, closely monitor the IV
site for extravasation.

vasopressin

Warning(s): Vasopressors are vesicants; central access is preferred for prolonged administration. If administered peripherally, closely monitor the IV
site for extravasation. Note(s): Known as arginine vasopressin (AVP) and antidiuretic hormone (ADH)

epoprostenol

Indication(s): Pulmonary arterial hypertension. Note(s): Very potent vasodilator. Continuous IV infusion, avoid interruptions and sudden large dose reductions. Protect from light during infusion.

treprostinil

Indication(s): Pulmonary arterial hypertension. Note(s): Very potent vasodilator. Continuous IV infusion, avoid interruptions and sudden large dose reductions.

eptifibatide, tirofiban

Side effect(s): Bleeding, thrombocytopenia

alteplase

Indication(s):
Activase- Acute ischemic stroke, pulmonary embolism, ST-elevation myocardial infarction (STEMI)
Cathflo Activase- IV line clearance

Contraindication(s): Active internal bleed, history of recent stroke, severe uncontrolled hypertension (BP cutoff >185/110mmHg), glucose <50

tenecteplase

Indication(s): ST-elevation myocardial infarction (STEMI), acute ischemic stroke in adults. Contraindication(s): Active internal bleed, history of recent stroke, severe uncontrolled hypertension (BP cutoff >185/110mmHg)

heparin sodium

Contraindication(s): Uncontrolled active bleed, history of HIT, Warning(s): Fatal medication error; verify correct concentration is chosen, *High Alert Medication, Monitor: anti-Xa levels and aPTT, Note(s): Heparin lock flush solution is intended only to maintain patency of IV devices and is NOT to be used for systemic anticoagulant
therapy. UFH is often preferred in severe renal impairment because it does not require the same renal dose adjustment as LMWH and has
a short half-life with rapid reversibility. Use total body weight for dosing., Antidote: Protamine

enoxaparin sodium

BBW: Risk of hematomas and subsequent paralysis in patients receiving neuraxial anesthesia (epidural, spinal), Contraindication(s): History of HIT (heparin-induced thrombocytopenia), active major bleed, Note(s): Common Adult Dosing:
Prophylaxis of VTE- 40 mg SC daily
Treatment of VTE- 1 mg/kg SC Q12H
Antidote: Protamine

argatroban, bivalirudin

Note(s): Safe for use with active HIT or history of HIT; no antidote

fondaparinux

BBW: Risk of hematomas and subsequent paralysis in patients receiving neuraxial anesthesia (epidural, spinal), Contraindication(s): Severe renal impairment (CrCl <30mL/min)

4-factor prothrombin
complex concentrate

Indication(s): Bleeding, Note(s): Contains factors II, VII, IX and X and Protein C and Protein S. Administer with vitamin K

phytonadione (vitamin
K1)

Indication(s): Warfarin reversal, vitamin K deficiency, BBW: Fatal hypersensitivity reactions, including anaphylaxis, Note(s): Protect from light

protamine

Indication(s): UFH/LMWH reversal
Heparin neutralization: 1 mg of protamine will reverse 100 units of heparin, Low-molecular-weight heparin neutralization: 1 mg protamine per 1 mg of enoxaparin

idarucizumab

Dabigatran reversal

desmopressin

BBW: Life threatening hyponatremia

octreotide

Indication(s): Acute esophageal variceal bleeding, Side effect(s): bradycardia, hyperglycemia or hypoglycemia, cholelithiasis, biliary sludge