MICP- 12 Common Infusions

12 Infusions You 12 Infusions You Need To KnowNeed To Know

Mobile Intensive Care Paramedic Mobile Intensive Care Paramedic SeriesSeries

Focus StatementFocus Statement

Focus Statement: This module will Focus Statement: This module will introduce the participant to the 12 most introduce the participant to the 12 most common infusions encountered in CCT, common infusions encountered in CCT, their indications, contraindications, their indications, contraindications, dosing regimens, and practical concerns. dosing regimens, and practical concerns.

Presentation InformationPresentation Information

Last revised 04/20/08Last revised 04/20/08 For more information contact the For more information contact the

education department education department 208-287-2972208-287-2972 [email protected]@adaweb.net

Where this fits in the big Where this fits in the big picture?picture?

This lecture discusses material in Section This lecture discusses material in Section 9 of the 9 of the Idaho EMS Critical Care Idaho EMS Critical Care Curricula GuideCurricula Guide

Initial lecture on common infusions only. Initial lecture on common infusions only. Many, many, more hours forthcoming Many, many, more hours forthcoming

over next few months.over next few months.

Why?Why?

The goal of dedicated critical care transport The goal of dedicated critical care transport and specialty care transport is to continue the and specialty care transport is to continue the same level of care during transport as the same level of care during transport as the patient was receiving and may be receiving. patient was receiving and may be receiving.

This involves using medication infusions out of This involves using medication infusions out of our comfort zone.our comfort zone. Turning them off NOT an option.Turning them off NOT an option.

These meds are essential knowledge of the These meds are essential knowledge of the Mobile Intensive Care Paramedic (MICP)Mobile Intensive Care Paramedic (MICP)

Other important things…Other important things…

Decreasing Medical ErrorsDecreasing Medical Errors

The Dirty DozenThe Dirty Dozen

DopamineDopamine DobutamineDobutamine NitroprussideNitroprusside Nor-epinephrineNor-epinephrine NitroNitro

Standard compositionStandard composition VAMC CompositionVAMC Composition

InsulinInsulin

DiltiazemDiltiazem HeparinHeparin GIIb-IIIa InhibitorsGIIb-IIIa Inhibitors AmiodaroneAmiodarone PropofolPropofol RetavaseRetavase

We also will discuss what IV Fluid you may run!!!

Some thoughts about the Some thoughts about the Route….Route….

What route ?What route ?

CentralCentral May also be used for Hemodynamic May also be used for Hemodynamic

MonitoringMonitoring Many types:Many types:

PICC-inserted into antecubital vein PICC-inserted into antecubital vein and advanced into Superior Vena and advanced into Superior Vena CavaCava

Examples: Triple lumen, Hickman, Examples: Triple lumen, Hickman, Broviac, and GroshongBroviac, and Groshong

PROS:PROS: Good for drug concentrates in fluid Good for drug concentrates in fluid

restricted patientsrestricted patients Good for drugs too irritant to be used Good for drugs too irritant to be used

peripherallyperipherally CONS:CONS:

Slow and risky to gain accessSlow and risky to gain access needs experience & practiceneeds experience & practice Many different typesMany different types Sterility a MUSTSterility a MUST HeparinizationHeparinization

PeripheralPeripheral PROS:PROS:

Easy and safer accessEasy and safer access Large volumesLarge volumes Familiar routeFamiliar route

CONS: CONS: Not suitable for all medsNot suitable for all meds Typically not multi-lumenTypically not multi-lumen Easier to displaceEasier to displace InfiltrationInfiltration

Peripheral Line SafetyPeripheral Line Safety

IVs flow by gravity pressure, and the higher the IVs flow by gravity pressure, and the higher the solution bag, the faster the IV will infuse.solution bag, the faster the IV will infuse. The average height for an adult IV solution bag is 3 The average height for an adult IV solution bag is 3

feet above heart level.feet above heart level. When the “height” changes, so does the infusion rate When the “height” changes, so does the infusion rate

(unless on a pump).(unless on a pump). Secondary solution bags must hang higher than Secondary solution bags must hang higher than

the primary bag to infuse first.the primary bag to infuse first. Even when on a pumpEven when on a pump

Flush with confidence? : SIS- saline, IV Flush with confidence? : SIS- saline, IV med/infusion, salinemed/infusion, saline

Piggy Back?Piggy Back?

Secondary Lines Secondary Lines Attach to primary IV at injection portsAttach to primary IV at injection ports Used primarily to infuse meds or other IV Used primarily to infuse meds or other IV

fluids on intermittent basis fluids on intermittent basis if compatible with if compatible with fluid on the primary linefluid on the primary line

IV piggybacks – IVPBIV piggybacks – IVPB IVPB higher than primary – greater pressure IVPB higher than primary – greater pressure

and causes it to infuse firstand causes it to infuse first When IVPB empty primary line will When IVPB empty primary line will

automatically resume its flowautomatically resume its flow

Central Line SafetyCentral Line Safety

SterilitySterility Medication SafetyMedication Safety

SASH for Central lines- saline, Additive (IV SASH for Central lines- saline, Additive (IV Med/infusion), saline, heparinMed/infusion), saline, heparin Recommend ASPIRATE on all central lines Recommend ASPIRATE on all central lines

PRIOR to flushing with saline as well. PRIOR to flushing with saline as well. Some lines have high concentration heparin. Some lines have high concentration heparin. Someone else may not have flushed the line and Someone else may not have flushed the line and

their may be IV meds in it. their may be IV meds in it.

SOME THOUGHTS ABOUT SOME THOUGHTS ABOUT STAYING OUT OF STAYING OUT OF TROUBLE….TROUBLE….

GENERAL CONCEPTSGENERAL CONCEPTS

Check transfer order carefully to be sure Check transfer order carefully to be sure that you are comfortable with all that you are comfortable with all medications ordered.medications ordered.

Be sure that order specifies:Be sure that order specifies: Dosage informationDosage information Times of administration (where applicable)Times of administration (where applicable) Indications for changes or discontinuance.Indications for changes or discontinuance.

Eg. Nitroglycerin dosage is often altered based on Eg. Nitroglycerin dosage is often altered based on pain and/or BP.pain and/or BP.

Ask the physician or RN to review Ask the physician or RN to review medication if it is one that you are not medication if it is one that you are not familiar with. familiar with. Discuss potential adverse reactions and Discuss potential adverse reactions and

how to deal with them.how to deal with them. Use resources to double checkUse resources to double check

Drug ReferencesDrug References


GENERAL CONCEPTSGENERAL CONCEPTS Determine how long it will Determine how long it will

take to reach receiving take to reach receiving facility and calculate the facility and calculate the amount of the drug you will amount of the drug you will need to reach your need to reach your destination. destination. Allow for unforeseen delays.Allow for unforeseen delays. Boy Scout Firewood RuleBoy Scout Firewood Rule

2 times what you think you will 2 times what you think you will need, and then some more. need, and then some more.

Check to be sure that you have the Check to be sure that you have the right drug and the right concentration. right drug and the right concentration.

Make sure it is hooked up to the right Make sure it is hooked up to the right pump channel. pump channel.


Consider using the hospitals IV PumpConsider using the hospitals IV Pump Good for short transfers. Good for short transfers. Limits chance of errors or runaway lines Limits chance of errors or runaway lines

during transfers. during transfers. Be sure you able to troubleshoot potential Be sure you able to troubleshoot potential

problems with the pump!problems with the pump! Check IV site for patency, redness, etc.Check IV site for patency, redness, etc. Poor Line Management Poor Line Management willwill cause cause

problems, even on short transfers. problems, even on short transfers.


Be sure to have a drug reference book Be sure to have a drug reference book available in your ambulanceavailable in your ambulance

Review drug reference for detailed information Review drug reference for detailed information about the drug. about the drug. Review side effects, adverse reactions, dosing, Review side effects, adverse reactions, dosing,

interactions, etc.interactions, etc.

STRONGLYSTRONGLY consider calling medical control if consider calling medical control if it becomes necessary to administer another it becomes necessary to administer another drug to ascertain possible interaction problemsdrug to ascertain possible interaction problems


Some thoughts about IV Some thoughts about IV fluidfluid

Types of IV solutionTypes of IV solution

4 classes of IV sol4 classes of IV sol Crystalloids – Dextrose, saline, LRCrystalloids – Dextrose, saline, LR Colloids – volume expanders such as Colloids – volume expanders such as

Dextran, HetastarchDextran, Hetastarch Bld & Bld products – whole bld,packed Bld & Bld products – whole bld,packed

RBCs, plasma & albuminRBCs, plasma & albumin Lipids – fat emulsion sol – indicated if on IVs Lipids – fat emulsion sol – indicated if on IVs

more than 5 daysmore than 5 days

What IV fluid ?What IV fluid ?

Crystalloid?Crystalloid? PROS:PROS:

Most familiarMost familiar CheapCheap

CONS:CONS: May need large volumesMay need large volumes Relatively slow increase in Relatively slow increase in

CVPCVP Will move out of vascular Will move out of vascular

spacespace Over 200 diff IV fluids Over 200 diff IV fluids

being manufacturedbeing manufactured

Colloid?Colloid? PROS:PROS:

Rapid increase in CVPRapid increase in CVP Small volumesSmall volumes Water redistribution out of Water redistribution out of

tissuestissues AKA: Colloid Pulling PowerAKA: Colloid Pulling Power

CONS: CONS: Only for Critically ill Only for Critically ill ExpensiveExpensive Water redistribution out of Water redistribution out of

tissuestissues

Fluid balanceFluid balance

A simple question of input equal to outputA simple question of input equal to output Goal: 1ml/kg/hr urine outputGoal: 1ml/kg/hr urine output A complex balance of forces to achieve a urine output A complex balance of forces to achieve a urine output

of about 1ml/kg/hr (assuming normal renal function) of about 1ml/kg/hr (assuming normal renal function) without causing heart failure, pulmonary or peripheral without causing heart failure, pulmonary or peripheral edemaedema

The Drugs….The Drugs….

DopamineDopamine

IV Infusions (Titrate to Effect)IV Infusions (Titrate to Effect) Low Dose Low Dose “Renal Dose"“Renal Dose"

1 to 5 µg/kg per minute1 to 5 µg/kg per minute

Moderate Dose Moderate Dose “Cardiac Dose"“Cardiac Dose" 5 to 10 µg/kg per minute 5 to 10 µg/kg per minute

High Dose High Dose “Vasopressor Dose"“Vasopressor Dose" 10 to 20 µg/kg per minute 10 to 20 µg/kg per minute

DopamineDopamine

Precautions Precautions (Watch Out!)(Watch Out!) May use in patients with hypovolemia but only after May use in patients with hypovolemia but only after

volume replacementvolume replacement May cause tachyarrhythmias, excessive May cause tachyarrhythmias, excessive

vasoconstrictionvasoconstriction DO NOTDO NOT mix with sodium bicarbonate mix with sodium bicarbonate Watch for s/s for fluid overload and hypertension.Watch for s/s for fluid overload and hypertension. Doses higher than 20/mcg/kg may compromise Doses higher than 20/mcg/kg may compromise

peripheral circulation peripheral circulation

DobutamineDobutamine

Consider for pump problems (congestive heart failure, Consider for pump problems (congestive heart failure, pulmonary congestion) with systolic blood pressure pulmonary congestion) with systolic blood pressure of 70 to 100 mm Hg and no signs of shockof 70 to 100 mm Hg and no signs of shock Increases InotropyIncreases Inotropy

DosingDosing Usual infusion rate is 2 to 20 µg/kg per minute, Usual infusion rate is 2 to 20 µg/kg per minute,

Absolute max of 40 mck/kg/minAbsolute max of 40 mck/kg/min Titrate so heart rate does not increase by more than 10% of Titrate so heart rate does not increase by more than 10% of

baselinebaseline Hemodynamic monitoring is recommended for optimal useHemodynamic monitoring is recommended for optimal use

DobutamineDobutamine

Precautions Precautions Avoid when systolic blood pressure <100 Avoid when systolic blood pressure <100

mm Hg with signs of shock, consider mm Hg with signs of shock, consider dopamine instead. dopamine instead.

May cause tachyarrhythmiasMay cause tachyarrhythmias DO NOT mix with sodium bicarbonateDO NOT mix with sodium bicarbonate

NorepinephrineNorepinephrine Brand Name:Brand Name: Levophed Levophed

Generic Name:Generic Name: Norepinephrine Bitartrate Norepinephrine Bitartrate Indications Indications

For severe cardiogenic shock and hemodynamic For severe cardiogenic shock and hemodynamic significant hypotension (systolic blood pressure < 70 significant hypotension (systolic blood pressure < 70 mm/Hg) with low total peripheral resistancemm/Hg) with low total peripheral resistance

NorepinephrineNorepinephrine

Many Various infusions in use.Many Various infusions in use. Typically 1 mg in 250 cc or 2 mg in 500 ccTypically 1 mg in 250 cc or 2 mg in 500 cc DosageDosage (initial): 8 to 12 mcg/min -titrate to BP (initial): 8 to 12 mcg/min -titrate to BP

(Usual target: SB:80-100 or MAP=80). Usual (Usual target: SB:80-100 or MAP=80). Usual maintenance: 2 to 4 mcg/min. maintenance: 2 to 4 mcg/min. Note: doses as high as 0.5 to 1.5 mcg/kg/min for 1-Note: doses as high as 0.5 to 1.5 mcg/kg/min for 1-

10days have been used in septic shock. 10days have been used in septic shock. Poison/drug-induced hypotension (i.e. Poison/drug-induced hypotension (i.e.

TCAs) may require higher doses to achieve TCAs) may require higher doses to achieve adequate perfusionadequate perfusion

NorepinephrineNorepinephrine

Precautions Precautions (Watch Out!)(Watch Out!) Increases myocardial oxygen requirementsIncreases myocardial oxygen requirements Good vasculature required (i.e. Central or large peripheral)Good vasculature required (i.e. Central or large peripheral) DO NOTDO NOT administer is same IV line as alkaline infusions (i.e. Bicarb) administer is same IV line as alkaline infusions (i.e. Bicarb) May induce arrhythmiasMay induce arrhythmias Extravasation causes tissue necrosisExtravasation causes tissue necrosis Should be administered in dextrose containing solutions (i.e. Should be administered in dextrose containing solutions (i.e.

D5W or D5/0.45% NS). D5W or D5/0.45% NS). These dextrose containing fluids are protection against significant These dextrose containing fluids are protection against significant

loss of potency due to oxidation. loss of potency due to oxidation. Administration in saline solution alone is not recommended.Administration in saline solution alone is not recommended. Blood products should be administered in separate line.Blood products should be administered in separate line.

Sodium Nitroprusside Sodium Nitroprusside (Nitropress)(Nitropress)

Sodium nitroprusside is indicated for the Sodium nitroprusside is indicated for the immediate reduction of blood pressure of immediate reduction of blood pressure of patients in hypertensive crises. patients in hypertensive crises.

Sodium nitroprusside is also indicated for Sodium nitroprusside is also indicated for producing controlled hypotension in order producing controlled hypotension in order to reduce bleeding during surgery. to reduce bleeding during surgery.

Sodium nitroprusside is also indicated for Sodium nitroprusside is also indicated for the treatment of acute congestive heart the treatment of acute congestive heart failure.failure.

Sodium NitroprussideSodium Nitroprusside

Initial (0.3 µg/kg/min) Initial (0.3 µg/kg/min) Titrated to 10 Titrated to 10

µg/kg/min maxµg/kg/min max

Sodium NitroprussideSodium Nitroprusside

Precautions Precautions (Watch Out!)(Watch Out!) Nitroprusside must be reconstituted for each use. It is good for 24 hours Nitroprusside must be reconstituted for each use. It is good for 24 hours

afterward. afterward. The diluted solution should be protected from light. It is not necessary to cover The diluted solution should be protected from light. It is not necessary to cover

the infusion drip chamber or the tubing. the infusion drip chamber or the tubing. Nitroprusside can be deactivated inadvertently by contaminates. Normal Nitroprusside can be deactivated inadvertently by contaminates. Normal

Nitroprusside is a faint brownish color. Nitroprusside is a faint brownish color. Contaminated nitroprusside will often be blue, green, or red, much brighter colorsContaminated nitroprusside will often be blue, green, or red, much brighter colors Particulate may be visible.Particulate may be visible. Discard if this is noted. Discard if this is noted.

Do not mix with any other drugs in same line. Do not mix with any other drugs in same line. Severe Hypotension may develop even at normal rates. Severe Hypotension may develop even at normal rates. Risk of Cyanide ToxicityRisk of Cyanide Toxicity

Total dose > 500 mcg/kg . Greater risk with impaired renal function Total dose > 500 mcg/kg . Greater risk with impaired renal function Greater than 2 mcg/kg/minGreater than 2 mcg/kg/min Treat with Sodium Thiosulfate (increased Hypotension risk)Treat with Sodium Thiosulfate (increased Hypotension risk)

Nitro: Standard Nitro: Standard composition's)composition's)

Glass BottlesGlass Bottles Standard Half-strength concentrationStandard Half-strength concentration

( 100 mcg/ml) Most common at ( 100 mcg/ml) Most common at SLRMC/SLMMCSLRMC/SLMMC 25 mg/250 ml, or 50 mg/500 ml25 mg/250 ml, or 50 mg/500 ml

Standard Full-strength concentrationStandard Full-strength concentration Most common used at Most common used at SARMC/SAEMCSARMC/SAEMC

(200 mcg/ml)(200 mcg/ml) 50 mg/250 ml50 mg/250 ml

Multiple other ways to mix…..Multiple other ways to mix…..

Nitro: VAMC CompositionNitro: VAMC Composition

Bag Bag NOT A BOTTLENOT A BOTTLE 30 MG/500 CC30 MG/500 CC 1 MCG/ML 1 MCG/ML

CONCENTRATIONCONCENTRATION 1 MCG/MIN = 1 1 MCG/MIN = 1

CC/HOURCC/HOUR Example, you want to Example, you want to

run NTG at 20 run NTG at 20 mcg/min, mcg/min, RUN IT AT RUN IT AT 20 MG/HOUR. 20 MG/HOUR.

NitroNitro

Precautions Precautions (Watch Out!)(Watch Out!) CONFIRM CONCENTRATIONCONFIRM CONCENTRATION Beware Runaway linesBeware Runaway lines A separate line should be used when possible, or at A separate line should be used when possible, or at

least piggybacked. least piggybacked. A patient with a nitro drip requires blood pressure A patient with a nitro drip requires blood pressure

monitoring with either non-invasive blood pressure monitoring with either non-invasive blood pressure or arterial line, at least every five (5) minutes until or arterial line, at least every five (5) minutes until stabilized.stabilized.

The patient should have continuous EKG monitoring The patient should have continuous EKG monitoring while receiving the drug.while receiving the drug.

InsulinInsulin

Commonly used for diabetic and non Commonly used for diabetic and non diabetic patients in the Critical Care diabetic patients in the Critical Care settingsetting

May be included in TPN mixtures. If it is May be included in TPN mixtures. If it is not, it is administered as well.not, it is administered as well.

Typical Insulin InfusionTypical Insulin Infusion

Insulin infusions are institution specific.Insulin infusions are institution specific. An initial bolus is given per MD order, typically up to 10 units regular. An initial bolus is given per MD order, typically up to 10 units regular. A maintenance infusion was then started at 2 units/hr .A maintenance infusion was then started at 2 units/hr .

If follow up BG remains at greater than 300 mg/dl, or did not decrease by ≥25 mg/d, then If follow up BG remains at greater than 300 mg/dl, or did not decrease by ≥25 mg/d, then insulin is increased by 2 u/hourinsulin is increased by 2 u/hour

If the patient's blood glucose concentration decreased by ≥25 mg/dL but <100 mg/dL If the patient's blood glucose concentration decreased by ≥25 mg/dL but <100 mg/dL from the previous blood glucose value, the infusion rate was not changedfrom the previous blood glucose value, the infusion rate was not changed

If the BG drops by ≥100 mg/dL, then infusion decreased in half and rechecked in one If the BG drops by ≥100 mg/dL, then infusion decreased in half and rechecked in one hour. hour.

After the targeted BG is achieved, if the blood glucose level After the targeted BG is achieved, if the blood glucose level continued to decrease over continued to decrease over three consecutive measurements,three consecutive measurements, the infusion rate was decreased by 0.5 -1 unit/hr, the infusion rate was decreased by 0.5 -1 unit/hr,

If blood glucose concentrations fell below 80 mg/d at any time, the infusion was stopped, If blood glucose concentrations fell below 80 mg/d at any time, the infusion was stopped, and blood glucose levels were rechecked hourly until it returns to 80 mg/dL or greater. and blood glucose levels were rechecked hourly until it returns to 80 mg/dL or greater.

Once the blood glucose is ≥80 mg/dL, the infusion was restarted at 50% of the previous Once the blood glucose is ≥80 mg/dL, the infusion was restarted at 50% of the previous rate.rate.

If the blood glucose concentration falls below 60 mg/dL, the infusion was discontinued (if If the blood glucose concentration falls below 60 mg/dL, the infusion was discontinued (if not already stopped) and 50% dextrose injection was given.not already stopped) and 50% dextrose injection was given.

InsulinInsulin

Precautions Precautions (Watch Out!)(Watch Out!) Ask for a copy of the institutional protocol (or the Ask for a copy of the institutional protocol (or the

one the MD wrote) for reference. one the MD wrote) for reference. Ask what the goal BG is for this patient. Ask what the goal BG is for this patient.

Typically between 100 and 130 mg/dl but may be patient Typically between 100 and 130 mg/dl but may be patient specific. specific.

What is the crisis level? (typically 80 mg/dl)What is the crisis level? (typically 80 mg/dl) Check glucose at Check glucose at

beginning of transport,beginning of transport, 30 minutes into transport30 minutes into transport Every 60 minutes unless drops below 100 mg/dl, then Every 60 minutes unless drops below 100 mg/dl, then

every 15 minutes until normalized. every 15 minutes until normalized.

DiltiazemDiltiazem

Must be reconstituted and used with in Must be reconstituted and used with in 24 hours. (or refrigerated used with in 30 24 hours. (or refrigerated used with in 30 days)days)

Dose: Dose: Initial bolus as ordered by MD, followed by 5 Initial bolus as ordered by MD, followed by 5

mg/hour, titrated to 15 mg/hour max. mg/hour, titrated to 15 mg/hour max.

DiltiazemDiltiazem

Precautions Precautions (Watch Out!) (Watch Out!) Most common side effect is Most common side effect is

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

HeparinHeparin Used to prevent extension of existing clot or Used to prevent extension of existing clot or

formation of new blood clotsformation of new blood clots Does not dissolve existing clotsDoes not dissolve existing clots Patients may be on these drugs for extended Patients may be on these drugs for extended

periods of time periods of time Most commonly used anticoagulants:Most commonly used anticoagulants:

HeparinHeparin Lovenox (Enoxaparin) AKA “Low Molecular Lovenox (Enoxaparin) AKA “Low Molecular

Weight Heparin” (SQ)Weight Heparin” (SQ)

HeparinHeparin

Various protocols- facility, physician, patient, Various protocols- facility, physician, patient, and situation dependant. and situation dependant. Refer to institutional written order. Refer to institutional written order. If seems unusual confirm with MD. If seems unusual confirm with MD.

Common Dosing Common Dosing Initial bolus 60 IU/kg Initial bolus 60 IU/kg

Maximum bolus: 4000 IUMaximum bolus: 4000 IU Often forgottenOften forgotten

Continue at 12 IU/kg/hr (maximum 1000 IU/hr for Continue at 12 IU/kg/hr (maximum 1000 IU/hr for patients < 70 kg), round to the nearest 50 IUpatients < 70 kg), round to the nearest 50 IU

Precautions Precautions (Watch Out!) (Watch Out!) :: Run Away IV’sRun Away IV’s Signs of bleeding, either internally Signs of bleeding, either internally

or externallyor externallyMonitor vitals frequentlyMonitor vitals frequentlySigns and symptoms of shockSigns and symptoms of shockAltered level of consciousnessAltered level of consciousness

HeparinHeparin

GLYCOPROTEIN IIb-IIIa GLYCOPROTEIN IIb-IIIa InhibitorsInhibitors

Indications: Indications: Inhibit the integrin glycoprotein IIb/IIIa Inhibit the integrin glycoprotein IIb/IIIa

receptor in the membrane of platelets, receptor in the membrane of platelets, inhibiting platelet aggregationinhibiting platelet aggregation

Indicated for Acute Coronary Syndromes Indicated for Acute Coronary Syndromes without without ST segment elevationST segment elevation

Frequently used with HeparinFrequently used with Heparin

GLYCOPROTEINGLYCOPROTEINIIb/IIa Platelet InhibitorsIIb/IIa Platelet Inhibitors

Three most common GIIb/IIIa Inhibitors Three most common GIIb/IIIa Inhibitors are:are:

Abciximab (ReoPro)Abciximab (ReoPro)

Eptifibitide (Integrilin)Eptifibitide (Integrilin)

Tirofiban (Aggrastat)Tirofiban (Aggrastat)

Abciximab (ReoPro)Abciximab (ReoPro) Non Q wave MI or unstable angina with Non Q wave MI or unstable angina with

planned PCI within 24 hoursplanned PCI within 24 hours Must use with heparinMust use with heparin Binds irreversibly with plateletsBinds irreversibly with platelets Platelet function recovery requires 48 Platelet function recovery requires 48

hourshours

GLYCOPROTEINGLYCOPROTEINIIb/IIa Platelet Inhibitors IIb/IIa Platelet Inhibitors


Eptifibitide (Integrilin)Eptifibitide (Integrilin) Non Q wave MI, unstable angina managed Non Q wave MI, unstable angina managed

medically, and unstable angina / Non Q wave MI medically, and unstable angina / Non Q wave MI patients undergoing PCIpatients undergoing PCI

Platelet function recovers within 4 to 8 hours after Platelet function recovers within 4 to 8 hours after discontinuationdiscontinuation

Administered with ASA (or clopidogrel) and Heparin. Administered with ASA (or clopidogrel) and Heparin. DosingDosing

Bolus 180 µg/kg over 1 to 2 minutes Bolus 180 µg/kg over 1 to 2 minutes IV Infusion 2 µg/kg/minuteIV Infusion 2 µg/kg/minute


Tirofiban (Aggrastat)Tirofiban (Aggrastat) Non Q wave MI, unstable angina managed Non Q wave MI, unstable angina managed

medically, and unstable angina / Non Q wave medically, and unstable angina / Non Q wave MI patients undergoing PCIMI patients undergoing PCI

Platelet function recovers within 4 to 8 hours Platelet function recovers within 4 to 8 hours after discontinuationafter discontinuation

DoseDose Bolus 0.4 µg/kg and minute for 30 minutes. Bolus 0.4 µg/kg and minute for 30 minutes. Followed by infusion at 0.1 µg/kg /minute. Followed by infusion at 0.1 µg/kg /minute.


Route of Administration:Route of Administration: IV infusion onlyIV infusion onlySmall BottlesSmall Bottles

Can lose alot of the drug Can lose alot of the drug flushing the tubing, be careful flushing the tubing, be careful not to waste. not to waste.

What to watch for during transport:What to watch for during transport: HYPERTENSION (increased bleeding HYPERTENSION (increased bleeding

risk)risk) Any signs of bleedingAny signs of bleeding Signs and symptoms of shockSigns and symptoms of shock Changes in level of consciousnessChanges in level of consciousness


Potential interventions in cases of Potential interventions in cases of adverse or allergic reactions:adverse or allergic reactions: Control any external bleedingControl any external bleeding Treat for shock as neededTreat for shock as needed Contact OLMC for options of discontinuing Contact OLMC for options of discontinuing

drug, altering dose or diversiondrug, altering dose or diversion In cases of suspected bleeding, the provider In cases of suspected bleeding, the provider

may also have to D/C heparin if it is also may also have to D/C heparin if it is also being administeredbeing administered


AmiodaroneAmiodarone

Difference between BOLUS infusion and Difference between BOLUS infusion and 24 hour infusion24 hour infusion

Bolus infusion Bolus infusion 150 mg/100 cc150 mg/100 cc

150 mg bolus over 10 min150 mg bolus over 10 min

Maintenance InfusionMaintenance Infusion 450mg /250cc 1.8 mg/ml450mg /250cc 1.8 mg/ml

1 mg/min for 11 mg/min for 1stst 6 hours 6 hours Then 0.5 mg/min for remaining 24 hoursThen 0.5 mg/min for remaining 24 hours

AmiodaroneAmiodarone

Precautions Precautions (Watch Out!)(Watch Out!) HypotensionHypotension Widened QT intervalWidened QT interval Can’t use if TCA overdose or Procainimide Can’t use if TCA overdose or Procainimide

has been used. has been used. Can’t use Procainimide for refractory ectopyCan’t use Procainimide for refractory ectopy

PropofolPropofol

Fat suspension Fat suspension (larger vein if (larger vein if possible)possible)

Standard Standard concentration 10 concentration 10 mg/mlmg/ml

DosesDoses 5-50 mcg/kg/min 5-50 mcg/kg/min

titrated in 5 mcg titrated in 5 mcg increments. increments.

PropofolPropofol

Precautions Precautions (Watch Out!)(Watch Out!) HYPOTENSION is biggest concern. HYPOTENSION is biggest concern. HyperkalemiaHyperkalemia Metabolic AcidosisMetabolic Acidosis Most problems common when using high-Most problems common when using high-

dose (>5 mg/kg/h) and long-term (>48 h)dose (>5 mg/kg/h) and long-term (>48 h)

RetavaseRetavase

Rapid , easy to use thrombolyticRapid , easy to use thrombolytic First bolus of 10 UnitsFirst bolus of 10 Units 30 minutes later 230 minutes later 2ndnd bolus of 10 units is given bolus of 10 units is given

RetavaseRetavase

Precautions Precautions (Watch Out!)(Watch Out!) Heparin and Retavase® are incompatible Heparin and Retavase® are incompatible

when combined in solution. Do not when combined in solution. Do not administer heparin and Retavase® administer heparin and Retavase® simultaneously in the same intravenous simultaneously in the same intravenous line. line.

Bleeding Bleeding

SummarySummary

Watch for run away IV’s, especially Watch for run away IV’s, especially during changeoversduring changeovers

ALWAYS DOUBLE CHECK ALWAYS DOUBLE CHECK CONCENTRATIONSCONCENTRATIONS

Double check MD orders.Double check MD orders. Don’t mix infusions prior to confirming Don’t mix infusions prior to confirming

compatability. compatability.

MICP- 12 Common Infusions

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Transcript of MICP- 12 Common Infusions