2009 Pandemic Education Package

Pharmacology Review

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Common Medications for H1N1/SRI• Antiviral

– Tamiflu• Antibiotics

– Ceftriaxone– Zithromycin– Pip/Tazocin

• Sedation– Propofol– Versed

• Analgesic– Morphine– Fentanyl

• Vasopressors– Dopamine– Epinephrine– Norepinephrine– Vasopressin

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Antiviral MedicationOseltamivir (Tamiflu)

• Dose 75 mg PO/NG BID for at least 7 days, current experience is showing it could be needed up to 3-4 weeks

• The treatment of influenza infection in patients who have been symptomatic for no more than 2 days, or as prophylaxis once exposure has occurred. Alleviates symptoms and decreases duration of symptoms.

• Adverse Effects: Nausea and Vomiting

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Antibiotics

• These medications are commonly given for the prevention and treatment of pneumonia/bacterial infections associated with the severe respiratory illness aspect of H1N1.

• It is important to start these medications IMMEDIATELY after they have been ordered by the Physician, as they may be fighting a larger scale bacterial infection on top of the H1N1 viral infection.

• Common antibiotics that may be administered to a H1N1/SRI patient – Ceftriaxone, Azithromycin, Piperacillin/Tazobactam due to the broad

spectrum.

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AntibioticsPiperacillan/Tazobactam

• Usual dose is 3.375 to 4.5 Grams every 6 or 8 hours based on renal function.

• Administration – I.V over at least 30 minutes

• Adverse Effects may include Diarrhea, nausea and vomiting.

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AntibioticsCeftriaxone

• Usual Dose is 1-2 Gram daily via IV route

• Administration – I.V or intermittent does

• Adverse Effects – Thrombophlebitis (pain at injection site)

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AntibioticsAzithromycin

• Usual dose is 500 mg IV daily for 5 days

• Administration – Intermittent IV only

• Adverse Effects: nausea, vomiting, diarrhea, pain at injection site

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Sedation/Analgesia

• Recent experiences in other areas of the country and world have reported that H1N1/SRI patients require a significantly large amount of sedation and analgesic.

• Routine assessments of your patient including respiratory status, level of consciousness, and agitation level will help determine the need for further sedation.

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Sedation/Analgesia• Routinely in a critical care setting, the order for sedation

and analgesia will be written with no time frame other than PRN.

i.e. Morphine 5 mg IV PRN

• The ICU RN must use knowledge, experience and judgment to decide how much or how little of the specific drug is needed for the patient.

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Sedation/Analgesia

• Assessments to determine need for sedation/analgesia are:

• Neurologic

• Determine LOC and level of agitation or sedation

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Sedation/Analgesia

• Respiratory • Current mode of ventilation (full support [AC],

partial support [PS], no support or not ventilated)• Respiratory rate ( if too slow and not on full

ventilatory support use caution with amount of drug)

• Asynchronous with ventilator – may need more sedation or neuromuscular blocking agent

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Sedation/Analgesia

• Cardiovascular

• Blood Pressure and Heart Rate – Will patient’s BP and HR support the administration of sedation and/or analgesic? These drugs tend to drop BP.

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SedationPropofol

• Supplied in a concentration of 10 mg/mL

• 0-350 mg is the dose range for sedation

• Main adverse effects are HYPOTENSION and Respiratory Depression/Failure.

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SedationVersed (Midazolam)• Can be given Direct IV, Intermittent or Continuous infusion

• Direct IV dose is 1-2 mg over 2-3 minutes

• Continuous infusion is 1-2 mg/hr and then titrated to desired effect

• Adverse Effects include hypotension, respiratory depression/failure

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AnalgesiaMorphine• Can be given Direct IV, Intermittent or Continuous Infusion as well as SC

and IM

• Usual dose for Direct IV/Intermittent administration seen in ICU is 5 mg IV PRN (No time limit)

– decision on how much drug to give is left to the ICU RN or MD

• Usual dose for Continuous infusion is 1-10 mg/hr

• Adverse Effects – Respiratory and cardiovascular depression

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AnalgesiaFentanyl

• Can be given Direct IV, Intermittent or Continuous infusion

• Usual dose for direct IV/Intermittent is 25-100 mcg

• Usual dose for Continuous infusion is 100-200 mcg/hr and titrated to effect.

• Adverse Effects are respiratory depression and cardiovascular depression.

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VasopressorsDopamine • Indication

– Hypotension (SBP <70-100)

• Route

– IV infusion

• Dose

– Titrate to effect

• Increase in increments of 1-4 mcg/kg/min

• Adverse Effects

– Tachycardia, tachyarrhythmias, angina, palpitations, nausea

– At high dose - ↓ renal function, ↓ peripheral perfusion

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VasopressorsNorepinephrine• Indication

– Hemodynamically significant hypotension

• Route of Administration

– IV infusion

• Dose

– 0.5-30 mcg/min titrated to effect

• Adverse Reactions

– Reflex bradycardia, hypertension, angina, ↓ renal function, ↓ peripheral perfusion

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VasopressorsEpinephrine• Indication – Severe hypotension, bradycardia

• Route of Administration – Continuous IV infusion

• Can be given Direct IV push in cardiac arrest situation (1mg)

• Dose

– 1-30 mcg/min titrated to effect

• Adverse Effects

– Reflex bradycardia, hypertension, angina, ↓ renal function, ↓ peripheral perfusion

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VasopressorsVasopressin• Indication – treatment of shock and hypotension, used for vasoconstrictive

purposes

• Route of Administration – Continuous IV infusion

– Can be given Direct IV in cardiac arrest situation (40u)

• Dose - 0.02 – 0.06 units/min

• Adverse Effects: Peripheral vasoconstriction and bronchial constriction

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Neuromuscular Blocking Agents• NMBAs must be given with sedation and analgesic

• Patient must be on Full Support ventilation [i.e. AC Mode] prior to receiving NMBA

• Patient must be monitored continuously– cardiac – respiratory

• Ventilator alarms are tightened• ETCO2 placed in-line (alarms set)

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Care of a Paralyzed Patient• Be diligent with airway maintenance

– Patient unable to cough and will therefore will need regular bronchial hygiene

• ETCO2 monitoring– Trending – Assessing for spontaneous respirations (signs of

distress/dyschrony)• “Curare cleft”