Post on 28-Mar-2015
CORDARON – AMIODARON
ACTION Anti arrhythmic properties Reduce sinus automaticity Anti angina properties
INDICATONS Treatment of severe rhythm disorders not responding to other therapies both
atrial and ventricular rhythm disorders Tachycardia associated with Wolff Parkinson White Syndrome Ventricular rhythm disorders
DOSE IV infusion loading dose 5 mg/kg administed in 250 mls of 5% Dextrose over
a period of 20 minutes – 2 hours Rate of infusion is adjusted on basis of results Maintenance dose : 10 – 20 mg/kg/24 hours
(usually 600 – 800 mg/24 hours and up to 1200 mg/kg/24 hours) IV close is usually followed up with oral dose
ROUTE IV Oral
PRECAUTIONS Patients must be monitored when given IV Amiodaron Hypotension Severe Respiratory insufficiency Hyperthyroidism
GTN – NITROCINE
ACTION Veno dilation
INDICATONS Angina Pectoris Rapid control of hypertension during cardiac surgery Maintain controlled hypotension during surgical procedures
DOSE Dilution 10 mg in Normal Saline or 5% Dextrose in 50 mls Peri Operative myocardial ischemia 15 – 20 mcg/min UAP : 10 mcg/min
ROUTE IV
PRECAUTIONS/SIDE EFFECTS Headache Hypotension Tachycardia Palpitation
DOPAMINE
ACTION Stimulate β1 adrenergic cardiac receptors Stimulate α adrenergic effect Increase Cardiac Output (medium to high dose)
INDICATONS Hypotension Septic shock
DOSE 50 mls Dextrose with 200 mg Dopamine 1 – 20 mcg/kg/min
ROUTE IV CVP access preferred
PRECAUTIONS Increased Heart Rate Arrhythmia Nausea and Vomiting
DOBUTAMINE
ACTION Synthetic sympathomimetic amine Stimulate β1 and α1 adrenergic receptors Increase Cardiac Output Minimize myocardial oxygen demand
INDICATONS Decreased Cardiac Output Pulmonary congestion Hypotension
DOSE 50 mls 5% Dextrose or Normal Saline with 250 mg Dobutamine 1 mcg – 20 mcg/kg/min
ROUTE IV
PRECAUTIONS Tachycardia Myocardial ischemia Nausea and Vomiting Headache
LIDOCAINE
ACTION Suppress ventricular arrhythmias by decreasing automaticity It’s local anesthetic properties help to suppress ventricular ectopy after AMI
INDICATONS Treatment of VT and VF that is refractory to electrical DC shocks
DOSE 1 – 2 mg/kg start then 1 – 4 mg/min Infusion 500 mg in 500 mls Normal Saline – ICCU Infusion 500 mg in 50 mls Normal Saline - ICU
ROUTE IV ETT use 2 – 2,5 times the IV dose (emergency use only)
PRECAUTIONS Excessive dose can cause neurological changes
o e.g. Fittingo Drowsinesso Psychosiso Twitching
NOR ADRENALIN
ACTION Stimulate β1 adrenergic cardiac receptors Stimulate α adrenergic effect Arterial and venous vasoconstriction Increase myocardial contractibility
INDICATONS Hypotension Septic shock
DOSE 50 mls Dextrose or Normal Saline with 8 mgs Nor Adrenaline: 50 mls with 8
mgs (160 mcs/ml)o Infusion 0,005 – 0,5 mcg/kg/min
ROUTE IV Must have CVP inserted
PRECAUTIONS Peripheral vasoconstriction Increased myocardial oxygen demand Arrhythmia
ATROPINE
ACTION Is a parasympatholytic drug. That enhances both sinus node automaticity and
atroventricular conduction via it’s direct vagolytic action
INDICATONS Symptomatic bradycardia
DOSE Cardiac arrest 0,5 – 1,0 mg IV
Repeat approximately every 3 – 5 minutes
ROUTE IV ETT 1 -2 mg diluted with approximately 5 mls Normal Saline
SIDE EFFECTS ↑ pulse Flushed and panus skin Blurred vision Dilated pupils
FENTANYL
ACTION Is a potent, lipid soluble synthetic opioid that is rapidly and widely
distributed to tissues
INDICATONS Pain relief Sedation
DOSE Infusion dilution: 50 mls Normal Saline with 500 mcg Fentanyl 1 – 4 mcg/kg/dose (adult 200 mcg) IM or IV Infuse 2 – 4 mcg/kg/hr
o < 25 kg: 100 mcg/kg in 50 mlo > 25 kg: 50 mcg/ml at 0,04 – 0,08 ml/kg in 50 ml/hr
Ventilated 5 – 10 mcg/kg start or 50 mcg/kg IV over 1 hourInfusion 5 – 10 mcg/kg/hr (amp. 50 mcg/ml at 0,1 – 0,2 ml/kg/hr)
ROUTE IV
PRECAUTIONS Respiratory depression Hypotension
PENTHOTAL
ACTION Acts on the brain and CNS to cause drowsiness
INDICATONS Assist to reduce intracranial pressure
DOSE Infusion dilution: 50 mls Normal Saline with 1000 mg Penthotal 3 – 5 mg/kg slowly start Then 1 – 5 mg/kg/hr
ROUTE IV
PRECAUTIONS Hypotension
MUSCLE RELAXANTS
TRACRIUM
IMPORTANT NO PATIENT SHOULD BE PARALYSED WITHOUT FIRST BEING
SEDATED TOM THE POINT OF UNROUSABILITY PATIENT MUST BE VENTILATED
DOSE Infusion dilution: 50 mls Normal Saline with 500 mg Tracrium 0,3 – 0,6 mg start, then 5 – 10 mcg/kg/min IV
INDICATIONS To facilitate ventilation when adequate sedation alone is unable to:
o Increase chest wall complianceo Reduce peak airway pressureo Reduce the risk of barotraumaso Allow optimal gas exchangeo Facilitate permissive hypercapnia
To ensure physiological control in patient with raised intracranial pressure To control muscle spasm in Tetanus
PRECAUTIONS Histamine release, producing vasodilatation or bronchospasm (bolus dose
only) not seen with infusion of atracurium Protective reflexes abolished, risk of corneal abrasions, deep vein thrombosis Prolonged muscle weakness Neurological assessment is unreliable
MIDAZOLAM
ACTION Produce sleepiness or drowsiness and to relieve anxiety Used to maintain unconscious state in ICU
INDICATIONS Hypnotic Sedation
DOSE Infusion dilution: 50 mls Dextrose or Normal Saline with 90 mg Midazolam Sedation: 0,01 – 0,2 mg/kg/IV or IM up to 0,5 mg/kg Anesthesia: 0,5 mg/kg, then 2 mcg/kg/min
ROUTE IV
PRECAUTIONS Respiratory depression and over sedation Hypotension May impair verbal contact and cooperation
MORPHINE
ACTION Analgesic effect Reduces systemic vascular resistance Reduces myocardial oxygen requirement
INDICATIONS Treatment of cardiac related pain and anxiety Useful in treating acute cardiogenic pulmonary oedema
DOSE Infusion dilution: 50 mls Normal Saline with 20 mg Morphine Administered in small incremental doses slowly over 1 -5 minutes until
desired effect achieved 0,1 – 0,2 mg/kg dose (adult 5 – 10 mg) IV 0,2 mg/kg/dose (10 – 20 mg adult) IM Infusion: 10 – 60 mcg/kg/hr
ROUTE IV
PRECAUTIONS Respiratory depression Hypotension
PRECEDEX – Dexmedetomedine HCL
ACTION Provide sedation and analgesia without respiratory depression Additional symphatolytic properties include less anxiety hemodynamic
stability Alpha 2 adrenoreceptor agonist
INDICATIONS Sedation with analgesic
DOSE Infusion dilution: 200 mcg Precedex in 48 mls of Normal Saline or water for
injection Loady dose I mcg/kg over 10 minutes Then followed by maintenance infusions : 0,2 to 0,7 mcg/kg/hr
ROUTE IV
PRECAUTIONS Hypotension Bradycardia
LASIX
ACTION Rapidly acting diuretic that inhibits reabsorption of sodium and chloride in
ascending loop of Henle Promotes a diuresis
INDICATIONS Treatment of acute renal failure Treatment of pulmonary congestion associated with left ventricle dysfunction
DOSE Infusion dilution: 50 mls Normal Saline with 400 mg Lasix Initial dose usually is: 0,5 – 1 mg/kg (adult 20 – 40 mg) IV 6 – 24 hr IV infusion at rate of 0,25 – 0,75 mg/kg/hr
ROUTE IV
PRECAUTIONS Dehydration Hypotension Electrolyte imbalance Metabolic alkalosis
SUXAMETHOIMUM
ACTION Paralysis short acting
INDICATIONS For intubation inductive
DOSE 1 – 2 mg/kg BW bolus
o Neonate 3 mg/kg doseo Child 2 mg/kg doseo Adult 1 mg/kg doseo IM: double IV dose
ROUTE IV or IM
PRECAUTIONS Increase potassium Tachycardia
ACTRAPID (BIOSYNTHETIC HUMAN INSULIN)
ACTION Reduction of blood glucose level Time of onset ½ hour. For maximal effect 1 – 3 hours with duration of action
8 hours
INDICATIONS Treatment for Insulin Dependent Diabetes Mellitus
DOSE 50 units Actrapid in 50 mls Normal Saline Infusion 4 units/hr check BLS every 8 hours
SKDIAS SCALE – BOLUS < 100 mg/dL give 8 unit 100 – 150 mg/dL give 4 unit 151 – 200 mg/dL give 8 unit 201 – 250 mg/dL give 12 unit 251 – 300 mg/dL give 16 unit >300 mg/dL call doctor
ROUTE IV, SC
PRECAUTIONS Hypoglicemia
Check BLS every 2 – 4 hours or more frequently as required
CARE OF THE INTUBATED PATIENT
REASONS FOR INTUBATION
Several indication for intubation exist:o Airway obstruction – airway oedema, epiglottiso Secretion management – ETT provides a conduit for suctioningo Airway protection – from regurgitation/aspiration due to decreased
LOC/FICS and,o Need for high concentration oxygenation, ventilation or sedation/general
anesthesia
POSSIBLE COMPLICATION OF INTUBATION
Aspiration Trauma Bradycardia – Vagal stimulation Hypoxaemia (attempts limited to 30 sec) Right main bronchus intubation Oesophageal intubation Tube malposition Tracheal necrosis Pharyngeal oedema Mouth, lip or nare preassure – sore development
CONTINOUS MANDATORY VENTILATION
CMV (assist/control) RR, Vt (8 – 10 mls/kg), FiO2, peak flow and waveform all constant Breaths initiated can be:
o Mandatory: ventilator/operator initiatedo Assist: patient initiated (retains characteristics of mandatory breath)
If Pt ↑ RR = ↑ minute volume
CONTINOUS POSITIVE AIRWAY PRESSURE
CPAP Spontaneous mode Positive pressure applied to airway throughout respiratory cycle useful for alveolar recruitment (↑ FRC) = optimizing oxygenation
PEEP ~ CPAP except CPAP term used for spontaneous mode
SYNCHRONISED INTERMITTENT MANDATORY VENTILATION
SIMV timed to allow for pt effort
o timing divides each breath cycle into mandatory breath phase and spontaneous phase
o @ 12 bpm breath cycle = 5 secs Any breaths taken in excess of RR set, are spontaneous phase Advantages
o Guarantees minimum minute volume in absence of patient efforto Assist + mandatory breath = total RRo Additional respiratory effort = spontaneous breathso ↓ SIMV rate allows weaning
Disadvantageo Can still get pt/ventilator dysynchrony
PRESSURE SUPPORT
Only active in SIMV + CPAP Range = 1 – 70 cmH2O When pt initiates breath gas delivered at rate to achieve and maintain PS level above
PEEP Can be volume or flow triggered
o PS + flowby = flow triggeringo PS (no flowby) = volume triggered
Advantageso Augment tidal volumeo Overcome resistance of artificial airwayo Reduce work of breathing (controversial)
Disadvantageso Static
CARE OF THE ICU PATIENT DURING TRANSPORT
Security of the ETT – to avoid dislodgement we ensure there is sufficient oxygen in bottle
Stability of unstable patient – may require paralyzing/sedative agents prior to transport Haemodynamically unstable patient may require inotropic drugs/fluid challenges, ensure
adequate supply Emergency equipment
PENGENCERAN OBAT TITRASI
Atropine 16 mcg in 50 mls Normal Saline
Diazepam 100 mcg in 50 mls Normal Saline
Dobutamine 250 mg in 50 mls Dextrose or Normal Saline
Dopamine 200 mg in 50 mls Dextrose
Fentanyl 500 mcg in 50 mls Normal Saline
GTN - Nitrocine 10 mg in 50 mls Normal Saline or 5% Dextrose
Lasix 400 mg in 50 mls Normal Saline
Lidocaine 500 mg in 500 mls Normal Saline – ICCU500 mg in 50 mls Normal Saline – ICU
Midazolam 90 mg in 50 mls Dextrose or Normal Saline
Morphine 20 mg in 50 mls Normal Saline
Nor Adrenaline 8 mg in 50 mls Normal Saline or Dextrose
Penthotal 1000 mg in 50 mls Normal Saline
Precedex 200 mcg in 50 mls Normal Saline or water for injection
Soxamethoimum bolus
Tracrium 500 mg in 50 mls Normal Saline
PEDOMAN TERAPI OBAT EMERGENCY
DI RUANG TERAPI INTENSIF
INSTALASI RAWAT INTENSIF TERPADU
RUMAH SAKIT UMUM PUSAT SANGLAH
DENPASAR
2007