Objectives. Fluids. Sterile IV Techniques. How many of you have sterile compounding technique procedures at your institution?
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- Bertha Watts
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1 Objectives Intravenous Medications in the Intensive Care Unit Paul Juang, Pharm.D., BCPS Assistant Professor of Pharmacy Practice St. Louis College of Pharmacy April 16, 2011 The speaker has no conflict to disclose. Describe the pharmacology of common intravenous medications used in the Intensive Care Unit (ICU). Explain the potential uses of common intravenous medications used within the ICU. Describe the potential role of pharmacy technicians in the safe medication use process within an ICU. Fluids FLUIDS Crystalloids Normal Saline Lactated Ringer s Dextrose 5% Colloids Albumin 5% Hetastarch 6% Hextend (in lactated electrolyte solution) Hespan, Voluven (in NS) Blood Products Others How many of you have sterile compounding technique procedures at your institution? What are some of these procedures? Sterile IV Techniques USP 797 Sterile Compounding Clean Room Critical Sites Environment Control Environment Control Personnel Increase patient safety! 1
2 Crystalloids Advantages Low cost Widely available Disadvantages Only ~ 25 33% remain in blood vessels Fluids Colloids Advantages Range from ~80 100% remain in blood vessels Disadvantages Very expensive May not be readily available Fluids Blood Products Whole Blood Packed Red Blood Cell (PRBC) Platelets Fresh Frozen Plasma (FFP) Cryoprecipitate Blood Products Oxygen Therapeutic Agents Hemogloblin based oxygen carriers Polyheme (human glutaraldehyde polymerized) Hemopure (hemogloblin glutamer 250[bovine]) Perfluorocarbons Fluids Crystalloids and Colloids Maintain adequate hydration Maintain adequate blood pressure Maintain perfusion of tissues and organs Blood and Blood Products Maintain adequate oxygen delivery to tissues and organs Maintain adequate ability to coagulate VASOACTIVE AGENTS 2
![Hemogloblin based oxygen carriers Polyheme (human glutaraldehyde polymerized) Hemopure (hemogloblin glutamer 250[bovine]) Perfluorocarbons Fluids Crystalloids and Colloids Maintain adequate hydration](/docs-images/47/20980572/images/page_2.jpg "Maintain adequate blood pressure Maintain perfusion of tissues and organs Blood and Blood Products Maintain adequate oxygen delivery to tissues and organs Maintain adequate ability to coagulate")
3 Vasoactive Agents Vasopressor Pharmacology Vasopressors Dopamine Norepinephrine Epinephrine Phenylephrine Vasopressin Inotropes Dopamine Dobutamine Milrinone Stimulation of DA receptors Increase kidney and GI tract blood flow Inhibition of kidney sodium reabsorption Stimulation of β receptors Increase heart contraction and rate Small increase in arterial vasodilatation Stimulation of α 1 receptors Increase arterial vasoconstriction Vasopressors Dopamine Stimulation of DA, β, α 1 receptors Norepinephrine Si Stimulation i of α 1, β receptors Phenylephrine Stimulation of α 1 receptors Epinephrine Stimulation of β, α 1 receptors With the norepinephrine shortage, what vasoactive agent are you using in your institution? Vasopressin Synthetic antidiuretic hormone Stimulation of VP 1 receptors Peripheral vascular constriction Stimulation of VP 2 receptors Sodium and water retention in kidneys Stimulation of VP 3 receptors Increase ACTH and cortisol production Vasopressors Maintain adequate blood pressure Maintain perfusion of tissues and organs 3
4 Inotrope Pharmacology Inotrope Pharmacology Doubtamine Stimulation of β receptors Milrinone Phosphodiesterase h type 3 (PDE 3 ) inhibitor Inhibits breakdown of camp in myocardium and vasculature heart contrac on and arterial vasodilata on Fink, MP ed. Textbook of Critical Care. Philadelphia: Elsevier Saunders; Inotropes Maintain adequate cardiac function Maintain adequate blood pressure (indirectly) Maintain perfusionoftissuesof andorgans Vasoactive Agents Septic Shock (overwhelming infection) Norepinephrine Dopamine Phenylephrine Vasopressin Dobutamine Cardiogenic Shock (heart failure, heart attack) Dopamine Dobutamine Milrinone Vasodilators Venodilator Nitroglycerin Vasodilator Sodium nitroprusside Adrenergic Blockers Labetolol Esomolol (Brevibloc ) Calcium Channel Blockers Nicardipine (Cardene ) Clevidipine (Cleviprex ) Vasodilators Decrease blood pressure Prevention of heart attack, stroke and aneurysms Decrease heart rate Prevention of heart attack 4
5 Vasodilators Prostaglandins Epoprostenol (Flolan ) Pulmonary hypertension Improve oxygenation in patients on mechanical ventilation SEDATIVES, PARALYTICS AND ANALGESICS Sedatives Sedatives Benzodiazepines Midazolam Lorazepam Diazepam Propofol Dexmedetomidine (Precedex ) s Maintain adequate mental status Prevent agitation Neuromuscular Blockers Depolarizing Succinylcholine Non depolarizing Atracurium Cisatracurium (Nimbex ) Mivacurium Pancuronium Pipecuronium Rocuronium (Zemuron ) Vecuronium What neuromuscular blocking agent(s) do you have in your RSI kit? 5
6 Neuromuscular Blockers Maintain paralysis Improve ventilation Allow intubation Rapid Sequence Intubation» Midazolam / Propofol» Succinylcholine / Rocuronium Improve outcome in patients with elevated intracranial pressure Opiates Fentanyl Hydromorphone Morphine Analgesics Analgesics Maintain adequate pain control Maintain adequate mental status Patient Controlled Analgesics (PCA) Computerized Ambulatory Drug Dli Delivery (CADD) Pump Safety Mechanism Continuous infusion Patient controlled demand Lock out mechanism Analgesics Antipsychotics Butyrophenone Haloperidol (Haldol ) Atypical Antipsychotics Ai Aripiprazole i (Abilify ) Olanzapine (Zyprexa ) Ziprasidone (Geodon ) Antipsychotics Maintain adequate mental status Alleviate delirium 6
7 Cell Wall Inhibitors ANTIMICROBIALS Inhibits bacterial growth via elongation of peptidoglycan on bacterial cell wall Examples Beta Lactams Glycopeptides Penicillins Penicillin G Ampicillin Ampicillin/sulbactam (Unasyn ) Oxacillin, Nafcillin Piperacillin/tazobactam (Zosyn ) Ticarcillin/clavulanate (Timentin ) Cell Wall Inhibitors Cephalosporins Cefazolin Cefuroxime Cefotetan, Cefoxitin Cefotaxime, Ceftriaxone (Rocephin ) Ceftazidime (Fortaz ) Cefepime (Maxipime ) Ceftaroline (Teflaro ) Carbapenems Imipenem/cilastatin (Primaxin ) Meropenem (Merrem ) Doripenem (Doribax ) Ertapenem (Invanz ) Monobactams Aztreonam (Azactam ) Glycopeptides Vancomycin Telavancin (Vibativ ) Protein Synthesis Inhibitors Inhibit protein synthesis Examples Tetracyclines Macrolides Aminoglycosides Lincosamides Oxazolidinones Streptogramins Sohmen, D. Cell. 2009; 139:212. Protein Synthesis Inhibitors Nucleic Acid Inhibitors Tetracyclines Doxycycline Minocycline Glycylcycline Tigecycline (Tygacil ) Macrolides Clarithromycin Azithromycin Aminoglycosides Gentamicin Tobramycin Amikacin Lincosamides Clindamycin Oxazolidinones Linezolid (Zyvox ) (y Streptogramins Quinupristin/Dalfopristin (Synercid ) Antifolates Inhibits purine metabolism Trimethoprim/Sulfamethoxazole Topoisomerase Inhibitors Inhibits DNA replication Fluoroquinolones Ciprofloxacin Levofloxacin (Levaquin ) Moxifloxacin (Avelox ) DNA Inhibitor Nitro imidazole Metronidazole (Flagyl ) 7
8 Cell Membrane Inhibitors Lipopeptide Daptomycin (Cubicin ) Polymyxin Colistin, i colistimethate i Fungal Cell Wall Inhibitors Polyenes Amphotericin B Amphotericin B dexycholate Amphotericin B Lipid Complex (Abelcet ) Liposomal Amphotericin B (AmBisome ) Imidazoles / Triazoles Fluconazole (Diflucan ) Voriconazole (Vfend ) Echinocandins Caspofungin (Cancidas ) Micafungin (Mycamine ) Anidulafungin (Eraxis ) Antimicrobials Treatment of suspected infections Best outcome when started early Quickdelivery ofantimicrobials What antimicrobials have you been preparing or delivering more often? Heparins ANTICOAGULANTS Unfractionated Heparin (UFH) Low Molecular Weight Heparin (LMWH) Enoxaparin (Lovenox ) l i ( i ) Dalteparin (Fragmin ) Tinzaparin (Innohep ) Pentasaccharide Fondaparinux (Arixtra ) 8
9 Heparins Anticoagulants Blood clots Prevention Treatment Direct Thrombin Inhibitors Agents Argatroban Lepirudin (Refludan ) Bivalrudin (Angiomax ) Role Treatment of blood clots in patients allergic to heparins Anticoagulants Activated Protein C Drotrecogin alfa (Xigris ) Used in patients with sepsis Fibrinolytics Agents Alteplase (Activase ) Reteplase (Retavase ) Tenecteplase (TNKase ) Urokinase (Kinlytic ) Patients with heart attack or stroke Unclogging IV catheter Glycoprotein IIb/IIIa Inhibitors Agents Abciximab (ReoPro ) Eptifibatide (Integrilin ) Tirofiban (Aggrastat ) Patients with heart attack going for stent placement Smart Pumps Drug libraries with standardized concentrations for commonly used drugs Feedback for dosing Especially for high risk medications Insulin Heparin Propofol Vasoactive agents Smart Pump 9
10 ICHP/MSHP 2011 Spring Meeting Technician Session - Intravenous Medications in the Intensive Care Unit Paul Juang, PharmD L01-T Post Test Questions: 1. Which of the following is a potential benefit of crystalloids versus colloids? a. Expensive b. Stays in the blood vessels c. Widely available d. Frequent shortages 2. Which of the following is a potential use of vasopressors? a. Help blood coagulate? b. Help maintain adequate blood pressure c. Help maintain adequate heart function d. Help decrease heart rate 3. Which of the following can technicians help in the safe use of analgesics? a. Ensure sterile preparation of fentanyl solution b. Ensure correct preparation of morphine solution via compounding log c. Ensure appropriate loading of CADD cassettes d. All of the above 4. Which of the following is an agent that works by inhibiting cell wall production of resistance bacteria like methicillin-resistant Staphylococcus aureus (MRSA)? a. Vancomycin b. Levofloxacin c. Azithromycin d. Gentamicin 5. Which of the following is a potential use of heparin? a. Treat bacterial infections b. Prevent agitation c. Treat blood clots d. Maintain blood pressure
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