11. drugs used in critical

DRUGS USED IN
CRITICAL SETTINGS:
ICU, CCU, OT, Emergency
1
Prof. Dr. RS Mehta, BPKIHS

COMMON DRUGS USED IN
EMERGENCY
Life Saving Drugs:
• Adrenaline
• Atropine
• Xylocard
• Calcium Gluconate
• Sodabicarbonate
Other Emergency Drugs are:
•Midazolam
Common drugs used for OP
poisoning.
•Atropine
•PAM
•Diazepam.
2

Common drugs used for cardiac arrest:
• Epinephrine
• Vasopressors
• Antiarrythmic- amiodarone, lidocaine.
• Other drugs- atropine, calcium, sodium
bicarbonate, thrombolytic Agents (STK, tPA)
3

COMMONLY USED DRUGS IN ICU AND CCU
The main groups of drugs used in ICU are as follows:
OPOIDS:
• Morphine
• Fentanyl
• Pethidine
• Naloxone
BENZODIAZEPINES:
• Diazepam
• Midazolam
• Lorazepam
• Flumazenil
SEDATIVES:
Propofol.
The main groups of drugs used in
CCU are as follows:
Lignocaine
Propanolol
Amiodarone
Digoxin
Verapamil
Adenosine
Aspirin
Atrovastin
GTN
Streptokinase
Isosorbide di-nitrate
Sodium bicarbonate
Nicorandil
4

Common drugs used in MI:
• Pain relief : Morphine
• Vasodilators: Nitroglycerine
• Anticoagulant: heparin
• Antiplatelet: aspirin
• Stool softner: cremaffin
• Vasopressor: dopamine, dobutamine
5

Drugs used in Angina
• Glyceryl trinitrate(GTN)
• Isosrbide dinitrate
• Propanolol
• Verapamil
• Amlodipine.
6

Drugs used in CCF:
• Diuretics
• ACE inhibitors: captopril, enalapril
• ARBS: losartan. Candesartan
• Digoxin
• Beta blockers
• vasodilators
7

NARCOTIC DRUG LAW:
• The law was authenticated and published for the first time in
2033 B.S. under Narcotic Drug Control Act.
• In this act the narcotic drug means
(1) Cannabis/ marijuana
(2) Medicinal cannabis/ marijuana
(3) Opium
(4) Processed opium
(5) Medicinal opium
(6) Plants and leaves of coca, and
(6A) Any substances to be prepared by mixing opium
and extract coca, including mixture or salt.
(7) Any natural or synthetic narcotic drug or psychotropic
substances and their salts,
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• Chemical substance to be used for preparation of narcotic drugs
may be exported, imported, stored, sold, distributed and used
only in the quantity as prescribed by the Chief Narcotic Drugs
Control Officer.
• For such procedures one must have license.
• Consumption of narcotic drugs by persons falling under the
following categories in the following circumstances shall not
be deemed to have been prohibited:-
(a) Purchase and consumption of narcotic drug by any person in
the recommended dose from any licensed shop on the
recommendation of any recognized medical practitioner for the
purpose of medical treatment.
(b) Consumption of narcotic drugs by persons belonging to
the prescribed categories in prescribed doses.
9

Responsibility of the Medical Practitioner:
While prescribing narcotic drugs,
• the medical practitioner shall not prescribe it to those who do
not need it.
OR
• prescribe more than what the requirement is even to those to
whom it is required.
10

DRUGS COMMONLY USED IN
OPERATION THEATER:
ANESTHETICS:
• Local: lignocaine/ lidocaine HCL , bupivacaine HCL
• Regional: spinal, epidural
• General: ether, nitrous oxide, halothene, isoflurane,
sevoflurane(inhalation), thiopentone sodium, propofol
(injection)
MUSCLE RELAXANT:
• Succinyl choline
• Vecuronium
• Atracurium
• Mivacurium
11

Details of some common drugs:
Prof. Dr. RS Mehta, BPKIHS 12

XYLOCARD
 Generic name: Lignocaine hydrochloride
 Trade name: xylocard, xylocaine, octacaine, anestacon,
dilocaine.
 Classification: anti-arrythmic, local anesthetic.
13

 Mechanism of action:
 It decreases the automaticity, and excitability in the
ventricles during the diastolic phase by a direct action
on the tissues, especially the Purkinje network.
 Produces local anesthesia by reducing sodium
permeability of sensory nerves, which blocks impulse
generation and conduction
 Uses:
ventricular arrythmias resulting from MI, digitalis
toxicity, cardiac surgery or cardiac cathterization, general
anesthesia in susceptible patients.
14

 Doses:
Arrythmia
– Dosing should be individualized.
– Treatment for ventricular arrhythmias begins with an
intravenous injection followed by an intravenous infusion
Pre-infusion:
– initially, 50-100 mg iv bolus given at rate of 25-50 mg/min. if
desired response doesn’t occur , give repeat dose at 25-50
mg/min; max dose is 300 mg given over hour
15

Infusion:
– A drip rate of 2-4mg/min is recommended
– Infusion duration is normally 2 or more days (at least 24 hours
after the last signs of ventricular arrhythmia is evident).
Anesthetic Uses
 Adult: Infiltration 0.5–1% solution, Nerve Block 1–2%
solution, Epidural 1–2% solution, Caudal 1–1.5% solution,
Spinal 5% with glucose, Saddle Block 1.5% with dextrose
Topical 2.5–5% jelly, ointment, cream, or solution
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Side effects:
• CNS: light headedness, euphoria, confusion,
dizziness, drowsiness, tinnitus, blurred vision,
vomiting, tremors, twitching.
• Cardiovascular: bradycardia, hypotension,
cardiovascular collapse which may lead to cardiac
arrest.
• Integumentary: cutaneous lesions, urticaria, edema.
 Contraindication: hypersensitivity, severe degree of
sino-atrial, atrio-ventricular or intra-ventricular block,
Adams-stokes syndrome.
 Precaution: pregnancy, breastfeeding, pediatric,
geriatric.
17

Nursing consideration:
 When it is administered as an antiarrhythmic the nurse should
monitor the ECG continuously.
 Blood pressure and respiratory status should be monitored
frequently during the drug administration.
 When administered as an anesthetic, the numbness of the
affected part should be assessed.
 Serum Lidocaine levels should be monitored frequently during
prolonged use. Therapeutic serum lidocaine levels range from
1.5 to 5 mcg/ml.
 If signs of overdose occur, stop the infusion immediately and
monitor the patient closely
18

For throat sprays, make sure that the patient’s
gag reflex is intact before allowing the patient
to eat or drink.
When IM injections are used, the medication
should be administered in the deltoid muscle.
For direct IV injection only 1% and 2%
solutions are used.
Donot breast feed while taking this drug
without physicians consultation
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PROPOFOL
20

• Functional class: general anesthetic
• Generic name: propofol
• Trade name: diprivan, propoven, fresenius
MECHANISM OF ACTION:
It produces dose dependent CNS depression by
activation of GABA receptors.
21

USES:
induction or maintenance of anesthesia, sedation in mechanically
ventilated patients, status epilepticus, migraine
DOSES:
Induction of Anesthesia
• Adult: IV 2–2.5 mg/kg q10sec until induction onset
• Geriatric: IV 1–1.5 mg/kg q10sec until induction onset.
22

Maintenance of Anesthesia
• Adult: IV 100–200 mcg/kg/min
• Geriatric: IV 50–100 mcg/kg/min
Sedation
• Adult: IV 5 mcg/kg/min for at least 5 min, may
increase by 5–10 mcg/kg/min q5–10 min until desired
level of sedation is achieved (may need maintenance
rate of 5–50 mcg/kg/min
23

AVAILABLE FORMS:
Inj 10 mg/ml in 20 ml ampoule, 50 ml and 100 ml vials.
SIDE EFFECTS:
CNS= involuntary movement, headache, somnolence,
paresthesia, increased ICP, impaired cerebral flow, seizures.
CV= bradycardia, bradydysrhythmia, asystole, ST segment
depression.
EENT= blurred vision, tinnitus, eye pain, diplopia
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GI= nausea, vomiting, abdominal cramp, pancreatitis, hyper
salivation.
GU= urine retention, green urine, cloudy urine, oliguria.
INTEG= flushing, phlebitis, hives burning/ stinging at inj site,
rash.
RESP= apnea, cough, hypoventilation, wheezing, hypoxia,
respiratory acidosis.
SYS= propofol infusion syndrome
CONTRAINDICATION:
hypersensitivity to the product or soyabean oil, egg, benzyl
alcohol.
25

PRECAUTION:
pregnancy (B), brest feeding, children, geriatric, respiratory
depression, cardiac dysrhythmias
NURSING CONSIDERATION:
 Patient must be Intubated and ventilated
 Monitor: HR, ECG, oxygen saturation, BP
 Abrupt discontinuation of infusion may result in rapid
awakening with agitation, anxiety.
26

.
 Discard tubing/bottle after 12 hours (contains
lipids)
 Do not use if emulsion appears separated.
 If hypotension or bradycardia occurs, decrease
or stop and monitor BP & HR, notify to doctor.
 Document neuro assessment on awakening.
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AMIODARONE
28

AMIODARONE
Functional class: antidysrrhythmic
Chemical class: iodinated benzofuran derivative.
Generic name: Amiodarone hydrochloride
Trade name: pacerone, cordarone, nexterone.
It works on cardiac cell membranes . It relaxes the
smooth muscles, the myocardial blood flow is also
ensured to be at its height of function.
29

USES:
hemodynamically unstable ventricular tachycardia,
supraventricular tachycardia, ventricular fibrillation.
UNLABELED USES:
cardiac arrest, cardiac surgery, CPR, heart failure, artial flutter.
DOSES:
Adult:
• Oral Loading dose is between 800 to 1,600 mg for 1-3 weeks.
Maintenance dosage may range between 600 to 800 mg per
day. It is advised to use the possible lowest dose in reaching
cardiac stability.
30

• I.V. Infusion: A 150 mg loading dose must be given
with 10 minutes slowly. For maintenance dose, a 540
mg amiodarone must be run with 18 hours. The rate
on the first day of therapy can be increased depending
on the situation.
Child:
• PO Loading Dose 10–15 mg/kg/d in 1–2 divided
doses for 4–14 d cycle or until adequate control of
arrhythmia
• PO Maintenance Dose 5 mg/kg/d once daily, may be
able to reduce to 2–5 mg/kg/d 5 d per week
31

SIDE EFFECTS:
CNS: headache, dizziness, involuntary movement, tremors,
pheripheral neuropathy, ataxia, malaise.
CV: hypotension, bradycardia, sinus arrest, CHF, SA node
dysfunction, AV block.
EENT: blurred vision, photophobia, dry eyes.
ENDO: hypo/hyperthyroidism
GI: nausea, vomiting, diarrhea, abdominal pain, anorexia,
hepatotoxicity.
INTEG: rash, photosensitivity, blue-gray skin discoloration,
alopecia, phlebitis(IV), urticaria
32

RESP: pulmonary fibrosis/toxicity, pulmonary inflammation,
ARDS; gasping syndrome if used in neontes.
MS: weakness, pain in extrimities.
CONTRAINDICATION
hypersensitivity, pregnancy(D), breastfeeding, neonates, infants,
severe sinus node dysfunction, cardiogenic shock, bradycardia,
2nd and 3rd degree AV block.
PRECAUTION
children, goiter, hashimoto’s thyroiditis, respiratory disease.
33

 Before the therapy, assess the patient’s vital signs and put more
focus on the cardiac activity.
 For patients with cardiac device implants, check its condition
and if it works properly before during and after administration.
 Monitor also the pulmonary, liver and thyroid function tests as
it may infer with the expected results.
 Watch out for adverse drug interactions such as: peripheral
neuropathy, abnormal gait, ataxia, dizziness, headache, fatigue.
34

 Check pulse daily once stabilized, or as prescribed.
Report a pulse <60.
 Take oral drug consistently with respect to meals.
 Become familiar with potential adverse reactions and
report those that are bothersome to the physician.
 Use dark glasses to ease photophobia; some patients
may not be able to go outdoors in the daytime.
35

 Wear protective clothing and a barrier-type sunscreen
that physically blocks penetration of skin by
ultraviolet light (e.g., titanium oxide or zinc
formulations) to prevent a photosensitivity reaction
(erythema, pruritus); avoid exposure to sun and
sunlamps.
 Do not breast feed while taking this drug without
consulting physician.
36

STREPTOKINASE
37

STREPTOKINASE
Classification:
therapeutic= thrombolytics.
pharmacologic= plasminogen activator.
Generic name: Streptokinase
Trade name: straptase
 Combines with plasminogen to form activator complexes, then
converts plasminogen to plasmin, which is then able to degrade clot-
bound fibrin.
Therapeutic Effects:
 Lysis of thrombi in coronary arteries, with preservation of
ventricular function. Lysis of pulmonary emboli and subsequent
restoration of blood flow. Restoration of cannula patency and
function.
38

USES:
acute myocardial infarction (MI), pulmonary embolism (PE).
deep vein thrombosis(DVT), acute peripheral arterial thrombosis,
occluded arterio-venous cannula.
DOSES:
Myocardial Infarction:
• IV (Adults): 1.5 million IU given as a continuous infusion over up
to 60 minutes.
• Intracoronary (Adults): 20,000 IU bolus followed by 2000 IU/min
infusion for 60 min.
DVT, Pulmonary Emboli, Arterial Emboli, or Other Thrombosis:
• IV (Adults): 250,000 IU loading dose, followed by 100,000 IU/hr
for 24 hr for pulmonary emboli, 72 hr for recurrent pulmonary
emboli or deep vein thrombosis.
39

Occluded Arterio-venous Cannula:
• IV (Adults): 250,000 IU/2 mL instilled into occluded catheter.
SIDE EFFECTS:
CNS: intracranial hemorrhage.
EENT: epistaxis, gingival bleeding.
RESP: bronchospasm, hemoptysis.
CV: reperfusion arrhythmias, hypotension, recurrent
ischemia/ thromboembolism.
GI: GI bleeding, hepatotoxicity, nausea,
retroperitonial bleeding, vomiting.
40

GU: GU tract bleeding.
INTEG: ecchymoses, flushing, urticaria.
HEMAT: bleeding,
LOCAL: hemorrhage at injection site, phlebitis at
injection site.
MS: musculoskeletal pain.
MISC: allergic reactions including anaphylaxis, fever.
CONTRAINDICATION:
active internal bleeding; history of cerebrovascular accident;
recent (within 2 mo) intracranial or intra-spinal injury or trauma;
Intracranial neoplasm, severe uncontrolled hypertension, known
bleeding tendencies; hypersensitivity.
41

PRECAUTION:
recent (within 10 days) major surgery, trauma, GI or GU
bleeding; severe hepatic or renal disease; recent
streptococcal infection or previous therapy with
anistreplase or streptokinase (within 5 days– 6 mo);
geriatric patients (75 yr; increased risk of intracranial
bleeding); pregnancy, lactation, or children (safety not
established).
Extreme Caution: patients receiving warfarin therapy;
early postpartum period.
42

• Monitor vital signs, continuously for myocardial infarction.
• Do not use lower extremities to monitor BP. Notify health care
professional if systolic BP 180 mm Hg or diastolic BP 110 mm
Hg. Thrombolytic therapy should not be given if hypertension
is uncontrolled. Inform health care professional
if hypotension occurs.
• Assess patient carefully for bleeding every 15 min during the
1st hr of therapy, every 15– 30 min during the next 8 hr, and at
least every 4 hr for the duration of therapy. Frank bleeding
may occur from sites of invasive procedures or from body
orifices.
43

• If uncontrolled bleeding occurs, stop medication and
notify health care professional immediately. Inquire
about previous reaction to streptokinase therapy.
• Assess patient for hypersensitivity reaction (rash,
dyspnea, fever, changes in facial color, swelling
around the eyes, wheezing). If these occur, inform
health care professional promptly. Keep
epinephrine, an antihistamine, and resuscitation
equipment close by in the event of an anaphylactic
reaction.
• Inquire about recent streptococcal infection.
Streptokinase may be less effective if administered
between 5 days and 12 mo of a streptococcal infection.
44

• Assess neurologic status throughout therapy. Altered
sensorium or neurologic changes may be indicative of
intracranial bleeding.
• Myocardial Infarction: Monitor ECG continuously. Notify
doctor if significant arrhythmias occur. Monitor cardiac
enzymes.Myocardial scanning and/or coronary angiography
may be ordered 7– 10 days after therapy to monitor
effectiveness of therapy.
• Assess intensity, character, location, and radiation of chest
pain. Note presence of associated symptoms (nausea,
vomiting, diaphoresis). Administer analgesics as directed.
Notify doctors if chest pain is unrelieved or recurs.
• Monitor heart sounds and breath sounds frequently. Inform
doctor if signs of HF occur (rales/crackles, dyspnea, S3 heart
sound, jugular venous distention).
45

• Deep Vein Thrombosis: Observe extremities and
palpate pulses of affected extremities every hour.
• Teach patient and family:
Explain purpose of medication and the need for close monitoring
to patient and family.
Instruct patient to report hypersensitivity reactions (rash,
dyspnea) and bleeding or bruising.
Explain need for bed rest and minimal handling during therapy to
avoid injury. Avoid all unnecessary procedures such as shaving
and vigorous tooth brushing
46

SUCCINYLCHOLINE
47

SUCCINYLCHOLINE
Functional class: depolarizing skeletal muscle relaxant.
Generic name: Succinylcholine
Trade name: Anectine, Sucostrin, Quelicin
Prevents neuromuscular transmission by blocking the
effect of acetylcholine at the myoneural junction.
Therapeutic Effects: Skeletal muscle paralysis.
48

USES:
to produce skeletal muscle relaxation as adjunct to anesthesia or
during orthopedic manipulation; to facilitate intubation and
endoscopy, to increase pulmonary compliance in assisted or
controlled respiration.
DOSES:
Surgical and Anesthetic Procedures.
 Adult: IV 0.3–1.1 mg/kg administered over 10–30 sec, may
give additional doses .IM 2.5–4 mg/kg up to 150 mg
 Child: IV 1–2 mg/kg administered over 10–30 sec, may give
additional doses. IM 2.5–4 mg/kg up to 150 mg
Prolonged Muscle Relaxation.
 Adult: IV 0.5–10 mg/min by continuous infusion.
49

SIDE EFFECTS:
MS: muscle fasciculations, profound and prolonged
muscle relaxation, muscle pain, rhabdomyolysis.
CV: bradycardia, tachycardia, hypotension,
hypertension, arrhythmias, sinus arrest.
RESP: respiratory depression, bronchospasm, hypoxia,
apnea.
META: myoglobinemia, hyperkalemia.
GI: decreased tone and motility of GI tract (large doses).
SYST: angioedema, anaphylaxis.
50

CONTRAINDICATION:
hypersensitivity, malignant hyperthermia, trauma.
PRECAUTION:
pregnancy(C), breastfeeding, geriatric or debilitated
patients,cardiac/neuromuscular/respiratory/renal/
hepatic disease, children<2 yrs, hyperkalemia,
myopathy, rhabdomyolysis.
51

 Obtain baseline serum electrolytes. Electrolyte imbalance
(particularly potassium, calcium, magnesium) can potentiate
effects of neuromuscular blocking agents.
 Be aware that transient apnea usually occurs at time of
maximal drug effect (1–2 min); spontaneous respiration should
return in a few seconds or, at most, 3 or 4 min.
 Have immediately available: Facilities for emergency
endotracheal intubation, artificial respiration, and assisted or
controlled respiration with oxygen.
 Monitor vital signs and keep airway clear of secretions.
.
52

Patient & Family Education
• Patient may experience post-procedural muscle
stiffness and pain (caused by initial
fasciculations following injection) for as long
as 24–30 hr.
• To be aware that hoarseness and sore throat are
common even when pharyngeal airway has not
been used.
• To report if muscle weakness to physician.
53

Thank you
54

11. drugs used in critical

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11. drugs used in critical