MEDICATIONS & CONSIDERATIONS IN PACU SETTINGKP RIVERSIDE INPATIENT PHARMACY

ABBA R. BASCARA PHARM.D.

INPATIENT PHARMACY SUPERVISOR

TOPICS

General process of order flow in KPHC

Medications in PACU

•Antiemetics

•BP control

•Antibiotics

•Miscellaneous meds

Controlled substance/pain

management in PACU

•Titratable doses & documentation

•Narcotic patches

•Narcotic PCA

Opioid Med Safety Alert

•Opioid crisis

•What have we done?

Medication

ordering process

in KPHC

MD orders medication in KPHC

Needs to be released timely and appropriately

Needs to be phased appropriately

Order verification by RPH

Health Connect interfaces with Pyxis allowing medication removal

Medications in PACU - AntiemeticsMedication Considerations Side Effects

Ondansetron 4mg/2ml (Zofran) - Gold standard antiemetic for prevention and treatment of PONV

- T½ life = 4 hours- Dose should not exceed 16 mg

HeadacheDiarrheaConstipation

Higher doses are more likely to cause QT-prolongation

Metoclopramide10mg/5ml (Reglan)

- IV doses should be given over 1-2 min

- Non-inferior to Zofran but more sedating

SedationDizzinessEPS

QT prolongation is likely with IV

Promethazine 25mg/ml(Phenergan)

- Limited evidence for efficacy for prevention of PONV

- IM is the preferred route- BBB: tissue damage such as

thrombophlebitis, gangrene and amputation

- SC administration is contraindicated, and IV injection should be avoided if possible. If given IV, concentration should not exceed 25 mg/mL; Administration rate should not exceed 25 mg/minute

Dry mouthConstipationParesthesiaIrritability

Beers Criteria – avoid in elderly

Medications in PACU- BP ControlMedication Considerations Side effects

Metoprolol 50mg/ml - Hepatic elimination- Monitor BP/HR- Proven to reduce risk of death post-op

DizzinessBradycardiaHeadacheHypotension

Labetalol2mg/ml

- Bolus administered 10mg/min- Caution with hepatic impairment- MDV only

Orthostatic HTNDizzinessNausea

Hydralazine20mg/ml

- Renal adjustment- No effect on HR

HeadacheN/VDiarrhea

Medications in PACU – Pain ControlMedication Considerations Side Effects

Fentanyl 100mcg/ml

(Sublimaze)- IVP over 1-2 min- Onset of action = immediate- DUA = 30-60 min- 0.1mg Fentanyl = 10mg Morphine

Confusion

DizzinessDyspnea

Morphine 2mg/ml - IVP over 4-5 min- Onset of Action = 30 min- Peak = 20 min- DUA = 3-5 hours- 1.5mg Dilaudid = 10mg Morphine

Dizziness

HeadacheN/V

Hydromorphone 2mg/ml

(Dilaudid)- IVP over 2-3 min- Onset of action: 5 min- Peak effect: 30-60 min- DUA = 3-4 hours - 1.5mg Dilaudid = 0.1mg Fentanyl

BradycardiaFlushingPalpitations

Ketorolac 30mg/ml

(Toradol)- BBB: renal risk, GI bleed- IVP over 15 seconds- Onset of action = 30 min- Peak = 2-3 hours- DUA = 4-6 hours

HeadacheDyspepsia

Acetaminophen 1000mg/100ml

(Ofirmev)- Administer over - Onset of action = 5-10, 30 min- Peak = 1 hour- DUA = 4-6 hours, > 6 hours- Once bottle punctured, only good

for 6 hours

NauseaVomitingInsomnia

Medications in PACU – MISC MedsMedication Considerations Side Effects

Tranexamic Acid - Administer IV over 10 minutes (100mg/min) usually 3-12 hours post-op

- to avoid hypotension- Renally adjusted- Commonly used post-op ortho, spine,

and C-section procedures

HeadacheAbdominal painBack painMusculoskeletal pain

Dexmedetomidine(Precedex)

- LD administer over 10-20 min to reduce vasoconstrictive effects

- Onset of action = 5 to 10 min- Peak = 15 to 30 min- DUA = 1-2 hours

HypotensionBradycardiaTachycardiaRespiratory depression

Handling narcotic medications in PACU

Titratable narcotic medications (ie Fentanyl, Midazolam)

Ensure medication is removed from the correct patient

Dose removed must be accounted for both in Pyxis and KPHC

Ensure proper documentation in KPHC

Pyxis medication waste

Undocumented waste

Handling narcotic medications in PACU

FENTANYL TRANSDERMAL PATCHES

BBB: serious or life threatening hypoventilation/ respiratory depression and

death

Patient evaluation is absolutely necessary

awareness of s/sx of fentanyl overdose

must be removed before surgery or MRI

must not be placed on open/broken skin

must not be cut before application

must not be opioid-naïve or for management of acute pain post-op

Discard patches by folding sticky side together, cut in small pieces and

dispose in pharmaceutical waste bin

Documentation in KPHC of the sequence of events

WHAT HAVE WE DONE?

4) Just Say NO to Soma® (carisoprodol)• Drug of abuse esp when combined with

opioids and/or benzos

WHAT HAVE WE DONE?

WHAT HAVE WE DONE?

QUESTIONS????