Critical Care Pharm

What does inotropic mean?

A substance that affects myocardial contractility.

(+) Inotropic effect

Increases the force of myocardial contraction.

(-) Inotropic effect

Decreases the force of myocardial contraction.

What does chronotropic mean?

A substance that affects heart rate.

(+) Chronotropic effect

Increases heart rate.

(-) Chronotropic effect

Decreases heart rate.

What is the main idea to remember about alpha receptors?

Think vasoconstriction and increased contractility.

Where are alpha-1 receptors located?

In vascular smooth muscle.

What happens when alpha-1 receptors are stimulated?

Profuse, body-wide vasoconstriction occurs. Increase BP

Where are alpha-2 receptors located?

Centrally and peripherally.

What is the central alpha-2 effect described in the slides?

It causes removal of norepinephrine at neuronal synaptic junctions, leading to hypotension. Decreases BP / sedation

What is the peripheral alpha-2 effect described in the slides?

A non-significant platelet aggregation action; most medications stimulate alpha-2 receptors peripherally.

Where are beta-1 receptors located?

In the heart.

What happens when beta-1 receptors are stimulated?

Heart rate, conduction, and contractility increase.

Where are beta-2 receptors located?

In smooth muscle of the bronchi and skeletal blood vessels.

What happens when beta-2 receptors are stimulated?

Vasodilation and relaxation of bronchial, uterine, and GI smooth muscle occur.

What metabolic effect is associated with beta-2 stimulation?

Activation of glycogenolysis, converting glycogen to glucose in the liver.

Where are dopaminergic receptors located according to the slides?

In the coronary, renal, mesenteric, and visceral blood vessels.

When studying an ICU vasoactive drug, what five hemodynamic variables should you think about?

Preload, afterload, cardiac output, heart rate, and blood pressure.

What two questions should guide titration of a critical-care medication?

Why is the patient receiving the medication, and how will you know when to stop titrating?

Which major drug groups are listed for pain management?

Opioids and non-opioid analgesics.

Which opioids are listed in the slides?

Morphine, fentanyl, hydromorphone, and oxycodone.

Which non-opioid analgesic is listed separately?

Acetaminophen.

Which NSAIDs are listed?

Ibuprofen, aspirin, and ketorolac.

What is the opioid reversal agent?

Naloxone is the standard opioid antagonist used to reverse opioid-induced respiratory/CNS depression. This was not named on the slide, which only asks 'Reversal agent?'

What is ketamine's drug class in the slides?

An NMDA receptor antagonist and non-barbiturate general anesthetic.

How does ketamine work according to the slides?

It interrupts association pathways and produces sensory blockade.

What are the listed uses of ketamine?

Acute pain and procedures.

What are important ketamine adverse effects listed in the slides?

Hypertension, respiratory depression, nausea/vomiting, possible hallucinations, and increased ICP.

What should the nurse monitor with ketamine?

Vital signs and for effects such as hallucinations and increased ICP.

What are benzodiazepines used for in critical care according to the slides?

Anxiety and sedation.

Which benzodiazepines are listed?

Midazolam (Versed) and lorazepam (Ativan).

How may midazolam and lorazepam be administered according to the slides?

IV push or continuous infusion; doses vary.

What key assessment question should be asked when a sedated patient becomes restless?

Is the patient experiencing agitation or delirium?

How do you recognize too much versus too little sedation?

Use a sedation scale such as RASS and compare the patient's score with the prescribed/desired goal.

What is the usual RASS goal listed in the slides?

Usually -2 to 0; -4 and -5 may be used for patients receiving neuromuscular blocking agents.

What is the benzodiazepine reversal agent?

Flumazenil is the standard benzodiazepine antagonist. It was not named on the slide, which asks for the reversal agent.

What is propofol's action?

A general anesthetic and sedative-hypnotic.

What makes propofol useful for ICU sedation?

It has a rapid onset of sedation and rapid awakening.

What is propofol used for?

Conscious or unconscious sedation.

What propofol infusion range is listed?

5-50 mcg/kg/min, titrated until the desired effect.

What are major propofol adverse effects listed?

Hypotension, respiratory depression, CNS depression, and green discoloration of urine.

What airway precaution is listed for continuous propofol infusion?

Patients should be intubated if receiving a continuous infusion because of respiratory-depression risk.

What tubing precaution is listed for propofol?

Change the tubing every 12 hours.

What laboratory value should be monitored with propofol?

Triglycerides.

What infection-related issue should be monitored with propofol?

Infection risk.

What is dexmedetomidine's action?

Sedative-hypnotic with some analgesic effect.

What is a benefit of dexmedetomidine?

It may decrease the amount of other sedation needed.

Who is dexmedetomidine used for according to the slides?

Intubated ICU patients; the slides also note it may be used in non-intubated patients.

What dexmedetomidine dose range is listed?

0.2-0.7 mcg/kg/hr, titrated for desired sedation; maximum listed is 1.5 mcg/kg/hr.

What are major dexmedetomidine adverse effects?

Bradycardia, nausea, and hypotension.

Which medications are listed for agitation associated with delirium?

Haloperidol, quetiapine, and risperidone.

What does RASS assess?

The patient's level of agitation and sedation.

A patient on propofol has RASS -4 with a goal of -2 and BP 86/48. What is the priority action?

Decrease the propofol and reassess sedation and blood pressure.

Why should propofol be decreased in that scenario?

The patient is more deeply sedated than the goal and has significant hypotension, both of which can be worsened by propofol.

A patient on dexmedetomidine is calm and follows commands but has HR 46 and BP 88/52. What is most concerning?

The decreased heart rate and blood pressure.

What are the four ACLS drugs specifically identified as needing dose knowledge in the slides?

Adenosine, atropine, amiodarone, and epinephrine.

What is adenosine's action?

It slows AV-node conduction and interrupts AV-nodal reentry circuits.

What is adenosine used for?

Supraventricular tachycardia (SVT); it is also used in myocardial perfusion/stress testing.

What is the first adenosine dose listed?

6 mg IV push over 1-2 seconds, followed immediately by a rapid 20 mL flush.

What is the next adenosine dose if there is no response?

12 mg rapid IV push followed by a rapid flush; the slides note two doses are now used.

Why must adenosine be pushed rapidly?

Its very short action requires rapid administration so it reaches the heart before being metabolized.

What adverse effects can occur with adenosine?

Flushing, lightheadedness, dizziness, chest pain, bronchospasm, and transient asystole up to about 10 seconds.

A patient briefly shows asystole after adenosine. What should the nurse understand?

Transient asystole can occur because adenosine temporarily slows AV-node conduction; the patient should be monitored closely.

What is amiodarone's action?

It prolongs the action potential to terminate dysrhythmias.

What rhythms are listed as uses for amiodarone?

VT, VF, and rapid atrial rhythms including atrial fibrillation, atrial flutter, and SVT.

What is the amiodarone cardiac-arrest dose listed?

300 mg IV/IO push; an additional 150 mg may follow.

What is the amiodarone loading dose for continuous infusion listed?

150 mg IV over 10 minutes.

What is the listed amiodarone infusion rate for the first 6 hours?

1 mg/min for 6 hours.

What is the listed amiodarone infusion rate for the next 18 hours?

0.5 mg/min for 18 hours.

What are major amiodarone adverse effects listed?

Bradycardia and hypotension.

What is atropine's action?

It is an anticholinergic, antiarrhythmic, and antidote that increases SA-node automaticity and AV-node conduction by decreasing vagal tone.

What is atropine used for in the slides?

Symptomatic bradycardia.

What is the atropine dose listed for bradycardia?

1 mg IV every 3-5 minutes, up to a maximum of 3 mg.

What adverse effect is important with atropine?

Tachycardia and increased myocardial oxygen demand.

Why may atropine not work after a heart transplant according to the slides?

The vagus nerve has been severed, so decreasing vagal tone does not produce the expected effect.

What should be considered if atropine is ineffective for symptomatic bradycardia?

Pacing, dopamine, or epinephrine.

What is epinephrine's action?

It is a vasopressor, cardiac stimulant, and bronchodilator.

What hemodynamic effects does epinephrine produce?

It increases contractility, automaticity, systemic vascular resistance, blood pressure, and heart rate and improves coronary and cerebral perfusion.

When is epinephrine used in cardiac arrest?

VF, pulseless VT, PEA, and asystole; it can also be used as an infusion for symptomatic bradycardia.

What is the epinephrine code dose listed?

1 mg IV/IO.

How often is the epinephrine code dose repeated in the slides?

Every 3-5 minutes.

What are major epinephrine adverse effects?

Tachycardia and hypertension.

What is dopamine's action?

An inotropic agent, cardiac stimulant, and vasopressor.

What does moderate-dose dopamine do according to the slides?

At 2-10 mcg/kg/min, it stimulates beta receptors, increasing contractility and potentially improving cardiac output.

What does high-dose dopamine do according to the slides?

At 10-20 mcg/kg/min, it stimulates alpha receptors, causing vasoconstriction and increased SVR.

When is dopamine used according to the slides?

Hypotension not related to hypovolemia and symptomatic bradycardia after atropine.

What are major dopamine adverse effects?

Tachycardia and excessive vasoconstriction.

What line is recommended for dopamine?

Central line.

Is lidocaine part of the current ACLS protocol according to the slides?

No. The slides state it is not used in the current ACLS protocol.

What is lidocaine's action?

Antiarrhythmic; it suppresses ventricular dysrhythmias.

When may lidocaine be used according to the slides?

As an alternative to amiodarone or for refractory VF/VT.

What is the listed initial lidocaine dose?

1-1.5 mg/kg IV/IO.

What is the listed repeat lidocaine dose?

0.5-0.75 mg/kg every 5-10 minutes, up to 3 doses.

What are major lidocaine adverse effects?

Neurotoxicity, bradycardia, prolonged PR interval, widened QRS complex, and respiratory depression.

What is norepinephrine's action?

A vasopressor that stimulates alpha-1 and alpha-2 receptors to cause peripheral and arterial vasoconstriction and beta-1 receptors to increase myocardial contractility and dilate coronary arteries.

When is norepinephrine used?

Hypotensive states such as trauma, shock, drug reactions, and spinal anesthesia.

How is norepinephrine administered?

IV only and titrated to achieve adequate perfusion.

Why is central access preferred for norepinephrine?

Peripheral extravasation can cause tissue necrosis; the slides state it should be infused through a central line.

What is an important oxygen-demand effect of norepinephrine?

It increases myocardial oxygen requirements.