12 Common Infusions

7/18/2019 12 Common Infusions

http://slidepdf.com/reader/full/12-common-infusions 1/62

2 Infusions You

2 Infusions You

Need To Knoweed To Know

Mobile Intensive Care ParamedicMobile Intensive Care ParamedicSeriesSeries





Focus Statement

ocus Statement

Focus Statement: This module willFocus Statement: This module will

introduce the participant to the 12 mostintroduce the participant to the 12 most

common infusions encountered in CCT,common infusions encountered in CCT,their indications, contraindications,their indications, contraindications,

dosin reimens, and practical concerns!dosin reimens, and practical concerns!



Presentation Information

resentation Information

"ast revised #$%2#%#&"ast revised #$%2#%#&

For more information contact theFor more information contact the

education departmenteducation department 2#&'2&('2)(22#&'2&('2)(2

[email protected] rcol

[email protected]



Where this fits in the big

here this fits in the big

picture?icture?

This lecture discusses material in SectionThis lecture discusses material in Section

) of the) of the Idaho EMS Critical CareIdaho EMS Critical Care

Curricula GuideCurricula Guide Initial lecture on common infusions onl*!Initial lecture on common infusions onl*!

Man*, man*, more hours forthcominMan*, man*, more hours forthcomin

over ne+t few months!over ne+t few months!



Wh?

h?

The oal of dedicated critical care transportThe oal of dedicated critical care transport

and specialt* care transport is to continue theand specialt* care transport is to continue the

same level of care durin transport as thesame level of care durin transport as thepatient was receivin and ma* be receivin!patient was receivin and ma* be receivin!

This involves usin medication infusions out ofThis involves usin medication infusions out of

our comfort one!our comfort one!

Turnin them off -.T an option!Turnin them off -.T an option!

These meds are essential /nowlede of theThese meds are essential /nowlede of the

Mobile Intensive Care Paramedic 0MICPMobile Intensive Care Paramedic 0MICP



!ther important things"

ther important things"

ecreasin Medical 3rrorsecreasin Medical 3rrors



The #irt #o$en

he #irt #o$en

opamineopamine

obutamineobutamine

-itroprusside-itroprusside -or'epinephrine-or'epinephrine

-itro-itro

Standard compositionStandard composition 45MC Composition45MC Composition

InsulinInsulin

iltiaemiltiaem

6eparin6eparin

7IIb'IIIa Inhibitors7IIb'IIIa Inhibitors 5miodarone 5miodarone

PropofolPropofol

8etavase8etavase

9e also will discuss what I4 Fluid *ou ma* run



Some thoughts about

ome thoughts about

the %oute"&he %oute"&



What route ?

hat route ?

Central Central Ma* also be used for 6emod*namicMa* also be used for 6emod*namic

MonitorinMonitorin Man* t*pes:Man* t*pes:

PICC'inserted into antecubital vein andPICC'inserted into antecubital vein and

advanced into Superior 4ena Cavaadvanced into Superior 4ena Cava 3+amples: Triple lumen, 6ic/man,3+amples: Triple lumen, 6ic/man,

;roviac, and 7roshon;roviac, and 7roshon

P8.S:P8.S: 7ood for dru concentrates in fluid7ood for dru concentrates in fluid

restricted patientsrestricted patients 7ood for drus too irritant to be used7ood for drus too irritant to be used

peripherall*peripherall*

C.-S:C.-S: Slow and ris/* to ain accessSlow and ris/* to ain access needs e+perience < practiceneeds e+perience < practice Man* different t*pesMan* different t*pes Sterilit* a M=STSterilit* a M=ST 6epariniation6epariniation

Peripheral Peripheral P8.S:P8.S:

3as* and safer access3as* and safer access "are volumes"are volumes

Familiar routeFamiliar route C.-S:C.-S:

-ot suitable for all meds-ot suitable for all meds T*picall* not multi'lumenT*picall* not multi'lumen 3asier to displace3asier to displace InfiltrationInfiltration



Periphera' (ine Safet

eriphera' (ine Safet

I4s flow b* ravit* pressure, and the hiher theI4s flow b* ravit* pressure, and the hiher thesolution ba, the faster the I4 will infuse!solution ba, the faster the I4 will infuse! The averae heiht for an adult I4 solution ba is > feetThe averae heiht for an adult I4 solution ba is > feet

above heart level!above heart level! 9hen the ?heiht@ chanes, so does the infusion rate9hen the ?heiht@ chanes, so does the infusion rate

0unless on a pump!0unless on a pump!

Secondar* solution bas must han hiher thanSecondar* solution bas must han hiher than

the primar* ba to infuse first!the primar* ba to infuse first! 3ven when on a pump3ven when on a pump

Flush with confidenceA : SIS' saline, I4Flush with confidenceA : SIS' saline, I4med%infusion, salinemed%infusion, saline



Pigg )ac*?

igg )ac*?

Secondar* "inesSecondar* "ines 5ttach to primar* I4 at inBection ports 5ttach to primar* I4 at inBection ports

=sed primaril* to infuse meds or other I4 fluids=sed primaril* to infuse meds or other I4 fluidson intermittent basison intermittent basis if compatible with fluid onif com patible with fluid onthe primary linethe primary line

I4 pi*bac/s I4P;I4 pi*bac/s I4P;

I4P; hiher than primar* reater pressureI4P; hiher than primar* reater pressureand causes it to infuse firstand causes it to infuse first

9hen I4P; empt* primar* line will automaticall*9hen I4P; empt* primar* line will automaticall*resume its flowresume its flow



+entra' (ine Safet

entra' (ine Safet

Sterilit*Sterilit*

Medication Safet*Medication Safet*

S5S6 for Central lines' saline, 5dditive 0I4S5S6 for Central lines' saline, 5dditive 0I4

Med%infusion, saline, heparinMed%infusion, saline, heparin

8ecommend 5SPI85T3 on all central lines8ecommend 5SPI85T3 on all central lines

P8I.8 to flushin with saline as well!P8I.8 to flushin with saline as well!

Some lines have hih concentration heparin!Some lines have hih concentration heparin!

Someone else ma* not have flushed the line andSomeone else ma* not have flushed the line and

their ma* be I4 meds in it!their ma* be I4 meds in it!



S!,- T.!/0.TS 1)!/T

!,- T.!/0.TS 1)!/T

ST1YIN0 !/T !F

T1YIN0 !/T !F

T%!/)(-"&

%!/)(-"&



0-N-%1( +!N+-PTS0-N-%1( +!N+-PTS

Chec/ transfer order carefull* to be sure thatChec/ transfer order carefull* to be sure that

*ou are comfortable with all medications*ou are comfortable with all medications

ordered!ordered! ;e sure that order specifies:;e sure that order specifies:

Dosage informationDosage information

imes of administration !where applicable"imes of administration !where applicable"

Indications for changes or discontinuance.Indications for changes or discontinuance.

Eg. #itroglycerin dosage is often altered based onEg. #itroglycerin dosage is often altered based on

pain and$or %P. pain and$or %P.



5s/ the ph*sician or 8- to review 5s/ the ph*sician or 8- to review

medication if it is one that *ou are notmedication if it is one that *ou are not

familiar with!familiar with!

iscuss potential adverse reactions andiscuss potential adverse reactions and

how to deal with them!how to deal with them!

=se resources to double chec/=se resources to double chec/

ru 8eferencesru 8eferences

0-N-%1( +!N+-PTS0-N-%1( +!N+-PTS



0-N-%1( +!N+-PTS0-N-%1( +!N+-PTS

etermine how lon it willetermine how lon it willta/e to reach receivin facilit*ta/e to reach receivin facilit*

and calculate the amount ofand calculate the amount of

the dru *ou will need tothe dru *ou will need toreach *our destination!reach *our destination!

&llow for unforeseen delays. &llow for unforeseen delays.

%oy Scout 'irewood (ule%oy Scout 'irewood (ule

) times what you thin* you will) times what you thin* you will

need+ and then some more.need+ and then some more.



Chec/ to be sure that *ou have theChec/ to be sure that *ou have the

riht dru and the riht concentration!riht dru and the riht concentration! Ma/e sure it is hoo/ed up to the rihtMa/e sure it is hoo/ed up to the riht

pump channel!pump channel!

0-N-%1( +!N+-PTS0-N-%1( +!N+-PTS



Consider usin the hospitals I4 PumpConsider usin the hospitals I4 Pump 7ood for short transfers!7ood for short transfers!

"imits chance of errors or runawa* lines"imits chance of errors or runawa* linesdurin transfers!durin transfers!

;e sure *ou able to troubleshoot potential;e sure *ou able to troubleshoot potentialproblems with the pumpproblems with the pump

Chec/ I4 site for patenc*, redness, etc!Chec/ I4 site for patenc*, redness, etc! Poor "ine ManaementPoor "ine Manaement will will causecause

problems, even on short transfers!problems, even on short transfers!

0-N-%1( +!N+-PTS0-N-%1( +!N+-PTS



;e sure to have a dru reference boo/;e sure to have a dru reference boo/

available in *our ambulanceavailable in *our ambulance

8eview dru reference for detailed information8eview dru reference for detailed informationabout the dru!about the dru!

(e,iew side effects+ ad,erse reactions+ dosing+(e,iew side effects+ ad,erse reactions+ dosing+

interactions+ etc.interactions+ etc.

S(-#G/ S(-#G/ consider callin medical control ifconsider callin medical control ifit becomes necessar* to administer anotherit becomes necessar* to administer another

dru to ascertain possible interaction problemsdru to ascertain possible interaction problems

0-N-%1( +!N+-PTS0-N-%1( +!N+-PTS



Some thoughts about I

ome thoughts about I

f'uid

'uid



Tpes of I so'ution

pes of I so'ution

$ classes of I4 sol$ classes of I4 sol

Cr*stalloids e+trose, saline, "8Cr*stalloids e+trose, saline, "8

Colloids volume e+panders such asColloids volume e+panders such ase+tran, 6etastarche+tran, 6etastarch

;ld < ;ld products whole bld,pac/ed;ld < ;ld products whole bld,pac/ed

8;Cs, plasma < albumin8;Cs, plasma < albumin

"ipids fat emulsion sol indicated if on I4s"ipids fat emulsion sol indicated if on I4s

more than D da*smore than D da*s



What I f'uid ?

hat I f'uid ?

Crystalloid0Cr ystalloid0

P8.S:P8.S: Most familiar Most familiar

CheapCheap

C.-S:C.-S: Ma* need lare volumesMa* need lare volumes

8elativel* slow increase in8elativel* slow increase in

C4PC4P

9ill move out of vascular9ill move out of vascular

spacespace

.ver 2## diff I4 fluids bein.ver 2## diff I4 fluids bein

manufacturedmanufactured

Colloid0Colloid0

P8.S:P8.S: 8apid increase in C4P8apid increase in C4P

Small volumesSmall volumes 9ater redistribution out of9ater redistribution out of

tissuestissues

5E5: Colloid Pullin Power 5E5: Colloid Pullin Power

C.-S:C.-S: .nl* for Criticall* ill.nl* for Criticall* ill

3+pensive3+pensive

9ater redistribution out of9ater redistribution out of

tissuestissues



F'uid ba'ance

'uid ba'ance

5 simple uestion of input eual to output 5 simple uestion of input eual to output 7oal: 1ml%/%hr urine output7oal: 1ml%/%hr urine output 5 comple+ balance of forces to achieve a urine output 5 comple+ balance of forces to achieve a urine output

of about 1ml%/%hr 0assumin normal renal functionof about 1ml%/%hr 0assumin normal renal functionwithout causin heart failure, pulmonar* or peripheralwithout causin heart failure, pulmonar* or peripheraledemaedema



The #rugs"&

he #rugs"&



#opamine

opamine

I4 Infusions 0Titrate to 3ffectI4 Infusions 0Titrate to 3ffect "ow ose"ow ose “Renal Dose" “Renal Dose"

1 to D G%/ per minute1 to D G%/ per minute

Moderate oseModerate ose “Cardiac Dose" “Cardiac Dose" D to 1# G%/ per minuteD to 1# G%/ per minute

6ih ose6ih ose “Vasopressor Dose" “Vasopressor Dose" 1# to 2# G%/ per minute1# to 2# G%/ per minute



#opamine

opamine

PrecautionsPrecautions (Watch Out!)(Watch Out!)

Ma* use in patients with h*povolemia but onl* afterMa* use in patients with h*povolemia but onl* aftervolume replacementvolume replacement

Ma* cause tach*arrh*thmias, e+cessiveMa* cause tach*arrh*thmias, e+cessivevasoconstrictionvasoconstriction

DO NOT DO NOT mi+ with sodium bicarbonatemi+ with sodium bicarbonate

9atch for s%s for fluid overload and h*pertension!9atch for s%s for fluid overload and h*pertension!

oses hiher than 2#%mc%/ ma* compromiseoses hiher than 2#%mc%/ ma* compromiseperipheral circulationperipheral circulation



#obutamine

obutamine

Consider for pump problems 0conestive heart failure,Consider for pump problems 0conestive heart failure,pulmonar* conestion with s*stolic blood pressurepulmonar* conestion with s*stolic blood pressureof (# to 1## mm 6 and no sins of shoc/of (# to 1## mm 6 and no sins of shoc/

Increases Inotrop*Increases Inotrop* osinosin

=sual infusion rate is 2 to 2# G%/ per minute,=sual infusion rate is 2 to 2# G%/ per minute, 5bsolute ma+ of $# mc/%/%min 5bsolute ma+ of $# mc/%/%min

Titrate so heart rate does not increase b* more than 1#H ofTitrate so heart rate does not increase b* more than 1#H of

baselinebaseline 6emod*namic monitorin is recommended for optimal use6emod*namic monitorin is recommended for optimal use



#obutamine

obutamine

PrecautionsPrecautions

5void when s*stolic blood pressure 1## 5void when s*stolic blood pressure 1##

mm 6 with sins of shoc/, considermm 6 with sins of shoc/, considerdopamine instead!dopamine instead!

Ma* cause tach*arrh*thmiasMa* cause tach*arrh*thmias

. -.T mi+ with sodium bicarbonate. -.T mi+ with sodium bicarbonate



Norepinephrine

orepinephrine

Brand Name:Brand Name: "evophed"evophedGeneric Name:Generic Name: -orepinephrine ;itartrate-orepinephrine ;itartrate

IndicationsIndications

For severe cardioenic shoc/ and hemod*namicFor severe cardioenic shoc/ and hemod*namic

sinificant h*potension 0s*stolic blood pressure (#sinificant h*potension 0s*stolic blood pressure (#

mm%6 with low total peripheral resistancemm%6 with low total peripheral resistance



Norepinephrine

orepinephrine

Man* 4arious infusions in use!Man* 4arious infusions in use!

T*picall* 1 m in 2D# cc or 2 m in D## ccT*picall* 1 m in 2D# cc or 2 m in D## cc

DosageDosage 0initial: & to 12 mc%min 'titrate to ;P0initial: & to 12 mc%min 'titrate to ;P0=sual taret: S;:&#'1## or M5PJ&#! =sual0=sual taret: S;:&#'1## or M5PJ&#! =sualmaintenance: 2 to $ mc%min!maintenance: 2 to $ mc%min! -ote: doses as hih as #!D to 1!D mc%/%min for 1'-ote: doses as hih as #!D to 1!D mc%/%min for 1'

1#da*s have been used in septic shoc/!1#da*s have been used in septic shoc/!

Poison%dru'induced h*potension 0i!e! TC5sPoison%dru'induced h*potension 0i!e! TC5sma* reuire hiher doses to achievema* reuire hiher doses to achieveadeuate perfusionadeuate perfusion



Norepinephrine

orepinephrine

PrecautionsPrecautions (Watch Out!)(Watch Out!) Increases m*ocardial o+*en reuirementsIncreases m*ocardial o+*en reuirements Good vasculature required (i.e. Central or large peripheral)Good vasculature required (i.e. Central or large peripheral)

DO NOT DO NOT

administer is same I4 line as al/aline infusions 0i!e! ;icarbadminister is same I4 line as al/aline infusions 0i!e! ;icarb

Ma* induce arrh*thmiasMa* induce arrh*thmias

3+travasation causes tissue necrosis3+travasation causes tissue necrosis

Should be administered in de+trose containin solutions 0i!e!Should be administered in de+trose containin solutions 0i!e!D9 or D%#!$DH -S!D9 or D%#!$DH -S!

These de+trose containin fluids are protection aainst sinificantThese de+trose containin fluids are protection aainst sinificantloss of potenc* due to o+idation!loss of potenc* due to o+idation!

Administration in saline solution alone is not recommended.Administration in saline solution alone is not recommended.

;lood products should be administered in separate line!;lood products should be administered in separate line!



Sodium Nitroprusside

odium Nitroprusside

3Nitropress4

Nitropress4

Sodium nitroprusside is indicated for theSodium nitroprusside is indicated for the

immediate reduction of blood pressure ofimmediate reduction of blood pressure of

patients in hypertensive crises.patients in hypertensive crises.

Sodium nitroprusside is also indicated forSodium nitroprusside is also indicated for

producing controlled hypotension in orderproducing controlled hypotension in order

to reduce bleeding during surgery.to reduce bleeding during surgery.

Sodium nitroprusside is also indicated forSodium nitroprusside is also indicated forthe treatment of acute congestive heartthe treatment of acute congestive heart

failure.failure.




odium Nitroprusside

Initial 0#!> G%/%minInitial 0#!> G%/%min Titrated to 1#Titrated to 1#

G%/%min ma+G%/%min ma+




odium Nitroprusside

PrecautionsPrecautions (Watch Out!)(Watch Out!) -itroprusside must be reconstituted for each use! It is ood for 2$ hours-itroprusside must be reconstituted for each use! It is ood for 2$ hours

afterward!afterward! The diluted solution should be protected from liht! It is not necessar* to coverThe diluted solution should be protected from liht! It is not necessar* to cover

the infusion drip chamber or the tubin!the infusion drip chamber or the tubin!

-itroprusside can be deactivated inadvertentl* b* contaminates! -ormal-itroprusside can be deactivated inadvertentl* b* contaminates! -ormal-itroprusside is a faint brownish color!-itroprusside is a faint brownish color! Contaminated nitroprusside will often be blue, reen, or red, much brihter colorsContaminated nitroprusside will often be blue, reen, or red, much brihter colors Particulate ma* be visible!Particulate ma* be visible! iscard if this is noted!iscard if this is noted!

o not mi+ with an* other drus in same line!o not mi+ with an* other drus in same line! Severe 6*potension ma* develop even at normal rates!Severe 6*potension ma* develop even at normal rates!

8is/ of C*anide To+icit*8is/ of C*anide To+icit* Total dose K D## mc%/ ! 7reater ris/ with impaired renal functionTotal dose K D## mc%/ ! 7reater ris/ with impaired renal function 7reater than 2 mc%/%min7reater than 2 mc%/%min Treat with Sodium Thiosulfate 0increased 6*potension ris/Treat with Sodium Thiosulfate 0increased 6*potension ris/



Nitro5 Standard

itro5 Standard

composition6s4

omposition6s4

7lass ;ottles7lass ;ottles

Standard Half-strength concentrationStandard Half-strength concentration

!"" mcg#ml$ %ost common at !"" mcg#ml$ %ost common at !RC#!C !RC#!C &' mg#&'" ml( or '" mg#'"" ml&' mg#&'" ml( or '" mg#'"" ml

Standard )ull-strength concentrationStandard )ull-strength concentration

%ost common used at%ost common used at $RC#$%C $RC#$%C

&"" mcg#ml$&"" mcg#ml$ '" mg#&'" ml'" mg#&'" ml

Multiple other wa*s to mi+L!!Multiple other wa*s to mi+L!!



Nitro5 1,+

itro5 1,+

+omposition

omposition

;a;a #- & %-E #- & %-E

># M7%D## CC># M7%D## CC

1 MC7%M"1 MC7%M"

C.-C3-T85TI.-C.-C3-T85TI.-

1 MCG$MI# 2 11 MCG$MI# 2 1

CC$3-4( CC$3-4( E5ample+ you want toE5ample+ you want to

run #G at )6run #G at )6

mcg$min+mcg$min+ R&N 'T $TR&N 'T $T

G#*O&R. G#*O&R.



Nitro

itro


CON+'R CONC%NTR$T'ON CON+'R CONC%NTR$T'ON ;eware 8unawa* lines;eware 8unawa* lines 5 separate line should be used when possible, or at 5 separate line should be used when possible, or at

least pi*bac/ed!least pi*bac/ed! 5 patient with a nitro drip reuires blood pressure 5 patient with a nitro drip reuires blood pressure

monitorin with either non'invasive blood pressuremonitorin with either non'invasive blood pressureor arterial line, at least ever* five 0D minutes untilor arterial line, at least ever* five 0D minutes until

stabilied!stabilied! The patient should have continuous 3E7 monitorinThe patient should have continuous 3E7 monitorin

while receivin the dru!while receivin the dru!



Insu'in

nsu'in

Commonl* used for diabetic and nonCommonl* used for diabetic and non

diabetic patients in the Critical Carediabetic patients in the Critical Care

settinsettin Ma* be included in TP- mi+tures! If it isMa* be included in TP- mi+tures! If it is

not, it is administered as well!not, it is administered as well!



Tpica' Insu'in Infusion

pica' Insu'in Infusion

'nsulin in,usions are institution speci,ic.'nsulin in,usions are institution speci,ic. 5n initial bolus is iven per M order, t*picall* up to 1# units reular! 5n initial bolus is iven per M order, t*picall* up to 1# units reular! 5 maintenance infusion was then started at 2 units%hr ! 5 maintenance infusion was then started at 2 units%hr !

If follow up ;7 remains at reater than >## m%dl, or did not decrease b* 2D m%d, thenIf follow up ;7 remains at reater than >## m%dl, or did not decrease b* 2D m%d, theninsulin is increased b* 2 u%hour insulin is increased b* 2 u%hour

If the patientNs blood lucose concentration decreased b* 2D m%d" but 1## m%d"If the patientNs blood lucose concentration decreased b* 2D m%d" but 1## m%d"from the previous blood lucose value, the infusion rate was not chanedfrom the previous blood lucose value, the infusion rate was not chaned If the ;7 drops b* 1## m%d", then infusion decreased in half and rechec/ed in oneIf the ;7 drops b* 1## m%d", then infusion decreased in half and rechec/ed in one

hour!hour! 5fter the tareted ;7 is achieved, if the blood lucose level 5fter the tareted ;7 is achieved, if the blood lucose level continued to decrease overcontinued to decrease over

three consecutive measurements(three consecutive measurements( the infusion rate was decreased b* #!D '1 unit%hr,the infusion rate was decreased b* #!D '1 unit%hr, If blood lucose concentrations fell below &# m%d at an* time, the infusion was stopped,If blood lucose concentrations fell below &# m%d at an* time, the infusion was stopped,

and blood lucose levels were rechec/ed hourl* until it returns to &# m%d" or reater!and blood lucose levels were rechec/ed hourl* until it returns to &# m%d" or reater! .nce the blood lucose is &# m%d", the infusion was restarted at D#H of the previous.nce the blood lucose is &# m%d", the infusion was restarted at D#H of the previous

rate!rate! If the blood lucose concentration falls below O# m%d", the infusion was discontinued 0ifIf the blood lucose concentration falls below O# m%d", the infusion was discontinued 0if

not alread* stopped and D#H de+trose inBection was iven!not alread* stopped and D#H de+trose inBection was iven!





Insu'in

nsu'in

PrecautionsPrecautions (Watch Out!)(Watch Out!) 5s/ for a cop* of the institutional protocol 0or the 5s/ for a cop* of the institutional protocol 0or the

one the M wrote for reference!one the M wrote for reference!

5s/ what the oal ;7 is for this patient! 5s/ what the oal ;7 is for this patient! T*picall* between 1## and 1># m%dl but ma* be patientT*picall* between 1## and 1># m%dl but ma* be patient

specific!specific! 9hat is the crisis levelA 0t*picall* &# m%dl9hat is the crisis levelA 0t*picall* &# m%dl

Chec/ lucose atChec/ lucose at

beinnin of transport,beinnin of transport, ># minutes into transport># minutes into transport 3ver* O# minutes unless drops below 1## m%dl, then3ver* O# minutes unless drops below 1## m%dl, then

ever* 1D minutes until normalied!ever* 1D minutes until normalied!



#i'tia$em

i'tia$em

Must be reconstituted and used with inMust be reconstituted and used with in

2$ hours! 0or refrierated used with in >#2$ hours! 0or refrierated used with in >#

da*sda*s ose:ose:

Initial bolus as ordered b* M, followed b* DInitial bolus as ordered b* M, followed b* D

m%hour, titrated to 1D m%hour ma+!m%hour, titrated to 1D m%hour ma+!



#i'tia$em

i'tia$em


Most common side effect isMost common side effect is

HYPOTENSION (3-5% of patients)HYPOTENSION (3-5% of patients)



.eparin

eparin

*sed to prevent e+tension of e+isting clot or*sed to prevent e+tension of e+isting clot orformation of ne, blood clotsformation of ne, blood clots

Does not dissolve e+isting clotsDoes not dissolve e+isting clots

atients may be on these drugs for e+tendedatients may be on these drugs for e+tendedperiods of timeperiods of time

%ost commonly used anticoagulants:%ost commonly used anticoagulants:

6eparin6eparin

"oveno+ 03no+aparin 5E5 ?"ow Molecular"oveno+ 03no+aparin 5E5 ?"ow Molecular

9eiht 6eparin@ 0S9eiht 6eparin@ 0S



.eparin

eparin

4arious protocols' facilit*, ph*sician, patient,4arious protocols' facilit*, ph*sician, patient,and situation dependant!and situation dependant! 8efer to institutional written order!8efer to institutional written order!

', see-s unusual con,ir- ith D.', see-s unusual con,ir- ith D.

Common osinCommon osin Initial bolus O# I=%/Initial bolus O# I=%/

Ma+imum bolus: $### I=Ma+imum bolus: $### I=

.ften forotten.ften forotten

Continue at 12 I=%/%hr 0ma+imum 1### I=%hr forContinue at 12 I=%/%hr 0ma+imum 1### I=%hr forpatients (# /, round to the nearest D# I=patients (# /, round to the nearest D# I=



PrecautionsPrecautions (Watch Out!)(Watch Out!) ::

(un &way I78s(un &way I78s

Signs of bleeding+ either internallySigns of bleeding+ either internally

or e5ternally or e5ternally

Monitor ,itals fre9uently Monitor ,itals fre9uently

Signs and symptoms of shoc* Signs and symptoms of shoc*

&ltered le,el of consciousness &ltered le,el of consciousness

.eparin

eparin



0(Y+!P%!T-IN IIb7IIIa

(Y+!P%!T-IN IIb7IIIa

Inhibitors

nhibitors

Indications:Indications:

Inhibit the interin l*coprotein IIb%IIIaInhibit the interin l*coprotein IIb%IIIa

receptor in the membrane of platelets,receptor in the membrane of platelets,inhibitin platelet areationinhibitin platelet areation

Indicated for 5cute Coronar* S*ndromesIndicated for 5cute Coronar* S*ndromes

ithoutithout ST sement elevationST sement elevation

+requentl/ used ith *eparin+requentl/ used ith *eparin



0(Y+!P%!T-IN0(Y+!P%!T-IN

IIb8IIa P'ate'et InhibitorsIIb8IIa P'ate'et Inhibitors

Three most common 7IIb%IIIa Inhibitors are:Three most common 7IIb%IIIa Inhibitors are:

5bci+imab 08eoPro 5bci+imab 08eoPro

3ptifibitide 0Interilin3ptifibitide 0Interilin

Tirofiban 05rastatTirofiban 05rastat



5bci+imab 08eoPro 5bci+imab 08eoPro

-on wave MI or unstable anina with-on wave MI or unstable anina with

planned PCI within 2$ hoursplanned PCI within 2$ hours

Must use with heparinMust use with heparin

;inds irreversibl* with platelets;inds irreversibl* with platelets

Platelet function recover* reuires $&Platelet function recover* reuires $&

hourshours







3ptifibitide 0Interilin3ptifibitide 0Interilin

-on wave MI, unstable anina manaed-on wave MI, unstable anina manaed

medicall*, and unstable anina % -on wave MImedicall*, and unstable anina % -on wave MI

patients underoin PCIpatients underoin PCI

Platelet function recovers within $ to & hours afterPlatelet function recovers within $ to & hours after

discontinuationdiscontinuation

5dministered with 5S5 0or clopidorel and 6eparin! 5dministered with 5S5 0or clopidorel and 6eparin!

osinosin ;olus 1&# G%/ over 1 to 2 minutes;olus 1&# G%/ over 1 to 2 minutes

I4 Infusion 2 G%/%minuteI4 Infusion 2 G%/%minute





Tirofiban 05rastatTirofiban 05rastat

-on wave MI, unstable anina manaed-on wave MI, unstable anina manaed

medicall*, and unstable anina % -on wave MImedicall*, and unstable anina % -on wave MI

patients underoin PCIpatients underoin PCI

Platelet function recovers within $ to & hoursPlatelet function recovers within $ to & hours

after discontinuationafter discontinuation

oseose ;olus #!$ G%/ and minute for ># minutes!;olus #!$ G%/ and minute for ># minutes!

Followed b* infusion at #!1 G%/ %minute!Followed b* infusion at #!1 G%/ %minute!





oute of Administration:oute of Administration:

I7 infusion only I7 infusion only

Small %ottlesSmall %ottles

Can lose alot of the drugCan lose alot of the drug

flushing the tubing+ be carefulflushing the tubing+ be carefulnot to waste.not to waste.

0 +! !



/hat to ,atch for during transport:/hat to ,atch for during transport:

3/PE(E#SI-# !increased bleeding3/PE(E#SI-# !increased bleeding

ris*"ris*"

&ny signs of bleeding &ny signs of bleeding

Signs and symptoms of shoc* Signs and symptoms of shoc*

Changes in le,el of consciousnessChanges in le,el of consciousness



0(Y+!P%!T-IN



otential interventions in cases ofotential interventions in cases of

adverse or allergic reactions:adverse or aller gic reactions:

Control any e5ternal bleeding Control any e5ternal bleeding reat for shoc* as needed reat for shoc* as needed

Contact -MC for options of discontinuingContact -MC for options of discontinuing

drug+ altering dose or di,ersiondrug+ altering dose or di,ersion

In cases of suspected bleeding+ the pro,iderIn cases of suspected bleeding+ the pro,ider

may also ha,e to D$C heparin if it is alsomay also ha,e to D$C heparin if it is also

being administered being administered





1miodarone

miodarone

ifference between ;."=S infusion andifference between ;."=S infusion and2$ hour infusion2$ hour infusion

;olus infusion;olus infusion 1D# m%1## cc1D# m%1## cc

1D# m bolus over 1# min1D# m bolus over 1# min

Maintenance InfusionMaintenance Infusion $D#m %2D#cc 1!& m%ml$D#m %2D#cc 1!& m%ml

1 m%min for 11 m%min for 1stst O hoursO hours

Then #!D m%min for remainin 2$ hoursThen #!D m%min for remainin 2$ hours



1miodarone

miodarone


6*potension6*potension

9idened T interval9idened T interval

CanQt use if TC5 overdose or ProcainimideCanQt use if TC5 overdose or Procainimide

has been used!has been used!

CanQt use Procainimide for refractor* ectop*CanQt use Procainimide for refractor* ectop*



Propofo'

ropofo'

Fat suspension 0larerFat suspension 0larer

vein if possiblevein if possible

StandardStandard

concentration 1#concentration 1#

m%mlm%ml

osesoses

D'D# mc%/%minD'D# mc%/%mintitrated in D mctitrated in D mc

increments!increments!



Propofo'

ropofo'


6RP.T3-SI.- is biest concern!6RP.T3-SI.- is biest concern!

6*per/alemia6*per/alemia

Metabolic 5cidosisMetabolic 5cidosis

Most problems common when usin hih'Most problems common when usin hih'

dose 0KD m%/%h and lon'term 0K$& hdose 0KD m%/%h and lon'term 0K$& h



%eta9ase

eta9ase

8apid , eas* to use thrombol*tic8apid , eas* to use thrombol*tic

First bolus of 1# =nitsFirst bolus of 1# =nits

># minutes later 2># minutes later 2ndnd bolus of 1# units is ivenbolus of 1# units is iven



%eta9ase

eta9ase


Heparin and etavase0 are incompatibleHeparin and etavase0 are incompatible

,hen combined in solution. Do not,hen combined in solution. Do notadminister heparin and etavase0administer heparin and etavase0

simultaneously in the same intravenoussimultaneously in the same intravenous

line.line.

BleedingBleeding



Summar

ummar

9atch for run awa* I4Qs, especiall*9atch for run awa* I4Qs, especiall*

durin chaneoversdurin chaneovers

5"95RS .=;"3 C63CE 5"95RS .=;"3 C63CEC.-C3-T85TI.-SC.-C3-T85TI.-S

ouble chec/ M orders!ouble chec/ M orders!

onQt mi+ infusions prior to confirminonQt mi+ infusions prior to confirmincompatabilit*!compatabilit*!

Documents

12 Common Infusions