Cardiac Medications Used in the Critical Care Unit | PEDS 602 Cardiac_Drip_Presentation_2020 - Chamberlain College of Nursing

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Cardiac Medications Used in the Critical Care Unit PEDS 602 Cardiac_Drip_Presentation_2020 - Chamberlain College of Nursing Cardiac Medications Used in the Critical Care Unit ALEXANDRA ANGEL, P... HARM.D. PHARMACY RESIDENT WEST KENDALL BAPTIST HOSPITALObjectives  Provide an overview for the management of vasoactive medications  Apply knowledge and concepts in the initiation, administration, and monitoring of therapy for patients receiving vasoactive medications  Discuss overall rationale and management for vasoactive medicationsOutline  Adrenergic receptor physiology  Medication therapy in:  Hypotension (i.e., shock)  Hypertension Emergencies  Acute Decompensated Heart Failure  Arrhythmias  Review of:  Vasopressors and Inotropes  Vasodilators  Anti-arrhythmics  Other Cardiac medicationsVasoactive Therapy CO: Cardiac Output SVR: Systemic Vascular ResistanceVasopressorsVasopressors  Norepinephrine (NE) – Levophed®  Epinephrine (Epi) – Adrenalin®  Dopamine (DA) – Intropin®  Phenylephrine – Neosynephrine  Dobutamine – Dobutrex®  Vasopressin – Vasostrict®Vasopressors  Induce vasoconstriction → ↑ mean arterial pressure (MAP)  Some agents may have both vasopressor and inotropic effects  Inotropes that ↑ cardiac contractility  Dopamine  DobutamineAdrenergic Receptor Physiology Receptor Location Physiologic Effect Alpha-1 (α1) Vascular walls • Vasoconstriction (significant) • Heart: ↑ duration of contraction without ↑ chronotropic effects Beta-1 (β1) Heart • ↑ inotropic & chronotropic effects with minimal vasoconstriction - - - - - - - - - - - - - - - - - - - - - -  Alternative to NE or used in addition to NE to maintain adequate MAP (2B)  Dose: 0.04units/min (fixed rate) in conjunction with a vasopressor to ↓ vasopressor load  No tapering required  Administration:  Central line preferred  Refer to BHSF titration guidelinesVasopressin (Vasostrict®)  Monitor  Blood pressure, heart rate (MAP), EKG  Urine Output  Na (hyponatremia)  Peripheral ischemiaIsoproterenol (Isuprel®)  MOA: β1 and β2 agonist (non-selective)  B1 → prominent chronotropic  B2 → vasodilation and a decrease in MAP  Primarily has inotropic & chronotropic effects rather than a vasopressor  Place in Therapy:  Limited to situations in which hypotension results from bradycardia  Chemical pacemaker (until permanent is done)  Brugada syndrome  Dose: 0.5 -10mcg/min; titrate and taper by 0.5mcg/min to maintain HR > 60bpm (unless otherwise specified)  Administration:  Standard concentration: 8mcg/mL  Refer to BHSF titration guidelines UpToDate and Inotropes/Vasopressors ArticleIsoproterenol (Isuprel®)  Monitor  HR, RR, MAP  Blood glucose  Magnesium  PotassiumAntihypertensive AgentsHow they work.. Mixed • Calcium antagonists • Alpha-adrenergic Blockers • ACE-I, ARBs • Nitroprusside Arterial • Hydralazine • Minoxidil Venous • Nitrates Arterial Vasodilation Venous VasodilationIndications for Vasodilators  Hypertensive Crisis  Severe elevations in BP (> 180/120mmHg)  Hypertensive Emergency - evidence of impending or progressive target organ damage  Goal: reduce MAP by no more than 10-20% within 1 hour  Heart Failure  Speeds symptom relief  Improves efficiency of cardiac workNitroglycerin  MOA: Vasodilator (↓ Preload, some ↓ afterload)  Place in therapy: acute relief of chest pain (CP), but not the best agent for BP control  ADHF, ACS, & Hypertensive Crisis  Dose: 5-200mcg/min, titrate every 5 minutes to desired effect (CP relief, dyspnea relief, target MAP)  Venous > arterial (at > 100mcg/min)  Administration:  Verify concentration for pump  Standard concentration: 100mcg/mL  Refer to BHSF titration guidelines Kaplan et al. Drug treatment of hypertensive emergencies Accessed February 1, 2013. www.uptodate.comNitroglycerin  Monitor  Headache  MAP  Reflex tachycardia  Tachyphylaxis (within 24-48 hours)  Nitrate free interval  Pain (headache)  BP & HR  Phosphodiesterase inhibitors are contraindicated Lacy CF et al. Drug Information Handbook. 19th edition. 2011 – 2012. Caution in brain injury due to ↑ ICPNitroprusside (Nipride®)  MOA: Vasodilator  Place in therapy: acute relief of chest pain (CP), but not the best agent for BP control  ADHF  Hypertensive Crisis  Dose: 0.3-10mcg/kg/min, titrate every 3-5 min to desired MAP goal  Dose ≥ 10mcg/kg/min should be limited to < 10 min  Administration:  Standard concentration: 200mcg/mL  Refer to BHSF titration guidelines Colucci et al. Overview of the therapy of heart failure due to systolic dysfunction. Accessed February 1, 2013. www.uptodate.comNitroprusside (Nipride®)  Monitor  MAP  Arterial Blood Gases (ABGs)  Physical bag for blue color changes  Cyanide (hepatic insufficiency)  Thiocyanate (renal insufficiency) toxicity (if using > 4 days)  “Almond” breath Lacy CF et al. Drug Information Handbook. 19th edition. 2011 – 2012. Caution in brain injury due to ↑ ICPLabetalol (Trandate®)  MOA: Non-selective Beta-blocker with alpha-1 activity  Place in therapy:  Hypertensive Crisis (including pregnancy)  Dose: 1-6mg/min; titrate by 1mg every 5 minutes to maintain HR or SBP  10-20mg Q 10 minutes (increase by 20-40mg to a max 300mg)  Administration:  Standard concentration: 200mg/200mL  Refer to BHSF titration guidelines Lacy CF et al. Drug Information Handbook. 19th edition. 2011 – 2012.Labetalol (Trandate®)  Monitor  MAP  HR  EKG  LFTs  Glucose (hypoglycemia)Nicardipine (Cardene®)  MOA: Calcium channel blocker  Place in therapy:  Hypertensive Crisis (including pregnancy)  Drug of choice for hypertension in acute ischemic stroke  Dose: 5-15mg/hour, titrate by 2.5mg every 5-15 minutes intervals  Avoid abrupt discontinuation → rebound angina (CAD) and tachycardia  Administration:  Central line preferred  Standard concentration: 0.1mg/mL  Refer to BHSF titration guidelines Lacy CF et al. Drug Information Handbook. 19th edition. 2011 – 2012.Nicardipine (Cardene®)  Monitor  HR, MAP  HF & renal patients may experience more flushing and peripheral edema  Drug interaction with Fentanyl® → hypotension Lacy CF et al. Drug Information Handbook. 19th edition. 2011 – 2012.Hydralazine (Apresoline®)  MOA: Arterial vasodilator  Place in therapy:  Hypertensive Crisis  Dose: 10-20mg IV/IM every 4-6 hours as needed, may increase by 5-10mg every 20-30 minutes  Maximum dose: 40mg/dose  IV Push over 1 minute  Renal adjustment required  Administration:  Pregnancy category: C Lacy CF et al. Drug Information Handbook. 19th edition. 2011 – 2012.Hydralazine (Apresoline®)  Monitor  BP  HR  Complete blood count (CBC)  Antinuclear antibody (ANA) titerOptions for Hypertension Crisis Agent Onset Duration Advantage Disadvantage Nitroprusside Immediate 1 – 2 min Potent Cyanide, Thiocyanate, ↑ ICP Nitroglycerin 2 – 5 min 3 – 5 min Coronary Perfusion Tolerance, Variable efficacy, ↑ICP Nicardipine 5 – 15 min 1 – 4 hrs CNS Protection Avoid in HF or cardiac ischemia Enalaprilat 15 – 30 min 6 – 12 hrs IV/IM push Avoid in acute MI Esmolol 1 – 2 min 10 – 30 min Aortic dissection, preoperative Hypotension, nausea, asthma, 1° heart block, HF Hydralazine 10–20 min IV 20–30 min IM 1–4 hrs IV 4–6 hrs IM Eclampsia vomiting, ↑ HR, flushing, HA, ↑ angina Labetalol 2 – 5 min 3 – 6 hrs Most HTN except acute heart failure bronchoconstriction, dizziness, nausea, heart block, orthostatic hypotension JNC 7. National High Blood Pressure Education Program. The7th report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. 2004Acute Decompensated Heart FailureProfiles and Therapies of Advanced Heart Failure R. Bourge, UAB Cardiology (adapted from L. Stevenson) Stevenson LW. Eur J Heart Failure 1999;1:251-257Acute Decompensate Heart Failure (ADHF)  Goals of Therapy  Relief of symptoms (i.e., fluid overload) – oxygenation and diuretics  Decrease of overload – vasodilators  Low ejection fraction (EF) – inotropic support  Restore normal oxygenation  Identify and address precipitating factors  Optimize chronic oral therapy  Minimize side effects Colucci et al. Overview of the therapy of heart failure due to systolic dysfunction. Accessed February 1, 2013. www.uptodate.comPharmacological Treatment – Diuretics  Loop Diuretics – GOLD STANDARD  Furosemide (Lasix®)  Bumetanide (Bumex®)  Torsemide (Demadex®)  Place in Therapy:  2017 Update on Heart Failure Guidelines  Relief of symptoms due to volume overload  Administration  Refer to BHSF Guidelines Lacy CF et al. Drug Information Handbook. 19th edition. 2011 – 2012.Pharmacological Treatment – Diuretics  Dosing  Oral: Ethacrynic Acid 50mg = Furosemide 40mg = Torsemide 20mg = Bumetanide 1mg  IV: all are 1:1, except Furosemide (IV → PO) 1:2  Furosemide 20mg IV = Furosemide 40mg PO  Fixed rate per MD but changed based on urine output  If no response, can transition to continuous infusion  Furosemide ceiling doses up to 240mg/24 hours  Refer to BHSF Guidelines Lacy CF et al. Drug Information Handbook. 19th edition. 2011 – 2012.Pharmacological Treatment – Diuretics  Monitor  I/Os  Chemistry  Weight  BP  Caution with other nephrotoxins  Ex: ACEIs, NSAIDs Lacy CF et al. Drug Information Handbook. 19th edition. 2011 – 2012.Vasodilators  Place in Therapy  ADHF unresponsive to diuretic treatment  Function is to reduce symptoms and volume overload  Cold & wet  Agents used:  Nitroglycerin  Nitroprusside Overgaard CB et al. Inotropes and Vasopressors: Review of Physiology and Clinical Uses in Cardiovascular Disease. Circulation; 2008; 118: 1047-1056Inotropes  Place in Therapy  First line agents in “cold” presentations  Restore perfusion & forward flow to body tissues through (+) inotropy → serve to directly ↑ CO  Salvage therapy in end-stage failure  Agents used  Dobutamine  MilrinoneDobutamine (Dobutrex®)  MOA: stimulates both alpha and beta receptors  β-1 receptors – produces strong inotropic effect  Dose: 2-20 mcg/kg/min, titrate by 2.5mcg/kg every 15 minutes to desired effect (MAP or CI)  Administration:  Standard concentration: 2mg/mL  Central lines preferred  Refer to BHSF Guidelines  No renal adjustment Lacy CF et al. Drug Information Handbook. 19th edition. 2011 – 2012.Dobutamine (Dobutrex®)  Monitor  BP, EKG, HR, MAP, CI, CO  Glucose  Renal function  Urine output  Electrolytes (K+/Mg+)  Drip may turn pink → potency not altered Lacy CF et al. Drug Information Handbook. 19th edition. 2011 – 2012.Milrinone (Primacor®)  MOA: Phosphodiesterase (PDE)3-inhibitor  Selectively inhibits cAMP PDE-2 isoenzyme in cardiac and smooth vascular muscle  Positive (+) Inotrope/Vasodilator  Dose:  Renal adjustment required  Loading dose: 50mcg/kg over 10 minutes  Continuous infusion: 0.375-0.75mcg/kg/min, then titrate  Administration:  Central line preferred  Standard concentration: 20mg/100mL  Refer to BHSF Guidelines Colucci et al. Overview of the therapy of heart failure due to systolic dysfunction. Accessed February 1, 2013. www.uptodate.comMilrinone (Primacor®)  Monitor  EKG, MAP, CI  Urine output  LFTs  Renal function  Platelets for thrombocytopenia  Electrolytes Lacy CF et al. Drug Information Handbook. 19th edition. 2011 – 2012.Digoxin (Lanoxin®)  MOA:  HF: ↑ heart’s force of contraction by inhibiting Na+/K+ ATPase pump (controls movement of calcium)  A-Fib: Direct suppression of AV node  Dose:  HF: 0.125-0.25mg daily (no loading dose)  Renal adjustment: ↓ by 25-75% +/- extending dosing interval (no levels)  A-Fib: up to 1.5mg/24 hours LD, then 0.125-0.5mg/day  Administration:  IV push Lacy CF et al. Drug Information Handbook. 19th edition. 2011 – 2012.Digoxin (Lanoxin®)  Monitor  HR, EKG,  Electrolytes  Renal function  Levels: drawn at least 6-8 hours after initial LD (best 12-24 hours)  Therapeutic levels:  A-Fib: 0.8-2ng/mL  HF: 0.5-0.8ng/mL  Toxic levels: >2ng/mL  Symptoms of Toxicity  Blurred vision, seeing halos around objects  Nausea, vomiting  HA, dizziness, Lacy CF et al. Drug Information Handbook. 19th edition. 2011 – 2012.Anti-arrhythmicsAnti-arrhythmics Effects Class I • Na+ channel blockers Class II • Beta-Blockers Class III • K+ channel blockers Class IV • Ca+ channel blockersLidocaine (Xylocaine®)  MOA: Na+ channel blocker; ↓ automaticity and excitability of ventricles  Place in therapy:  Useful in ventricular arrhythmias  Dose:  Loading dose: 1-1.5mg/kg IV over 2-3 minutes, may repeat in 5 minutes up to 300mg in 1-hour period  Maintenance: 1-4 mg/min  Administration:  Standard concentration: 4mg/mL  Refer to BHSF Guidelines Lacy CF et al. Drug Information Handbook. 19th edition. 2011 – 2012. Class ILidocaine (Xylocaine®)  Monitor  EKG  Liver function test  Electrolytes  Fluids  ABG  Symptoms of Toxicity  Levels >4 mcg/mL  Dizziness, seizures, slurred speech, motor nerve paralysis  Levels >9 mcg/mL  Respiratory depression, heart block, coma, cardiac arrestIV Beta Blockers  MOA:  Block catecholamine’s activity on cardiac pacemaker  Place in Therapy:  Arrhythmias, MI, cardiomyopathy, HF  Dose:  See table  Administration:  Refer to BHSF Guidelines Lacy CF et al. Drug Information Handbook. 19th edition. 2011 – 2012. Class IIIV Beta Blockers Agei i i i i i i i i i i i i i i i i i i i i i i i ii ents (max 15 mg/hour) • PRN; some patients may respond to an initial rate of 5 mg/hour **useful in HFrEF due to less myocardial depression**Vaughan Williams Classification Classes Anti-arrhythmic Agents Effect Class I Na channel blockers IA – Quinidine, Procainamide, Disopyramide ↑ QRS and QT IB – Lidocaine, Mexiletine, Phenytoin ↓ QT IC – Propafenone, Flecainide, Moricizine ↑QRS Class II Beta Blockers Metoprolol, Esmolol, Atenolol ↓ HR and ↑ PR Class III K Channel Blockers Amiodarone, Sotalol, Dofetilide, Dronedarone, or Ibutilide ↑ QT Class IV Ca Channel Blockers Diltiazem and Verapamil ↓ HR and ↑ PRExtravasations  Management:  Stop infusion immediately  DO NOT flush the line  Agents available  Phentolamine (Rogitine®)  Terbutaline  Nitroglycerin ointment (alternative to Phentolamine)  Refer to BHSF extravasation protocol for specific directions Lacy CF et al. Drug Information Handbook. 19th edition. 2011 – 2012.When in doubt… …Call your friendly PharmacistQuestions? ? [Show More]

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