MICP- 12 Common Infusions

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

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  • MICP- 12 Common Infusions

    1. 1. 12 Infusions You Need To Know Mobile Intensive Care Paramedic Series
    2. 3. Focus Statement <ul><li>Focus Statement: This module will introduce the participant to the 12 most common infusions encountered in CCT, their indications, contraindications, dosing regimens, and practical concerns. </li></ul>
    3. 4. Presentation Information <ul><li>Last revised 04/20/08 </li></ul><ul><li>For more information contact the education department </li></ul><ul><ul><li>208-287-2972 </li></ul></ul><ul><ul><li>[email_address] </li></ul></ul>
    4. 5. Where this fits in the big picture? <ul><li>This lecture discusses material in Section 9 of the Idaho EMS Critical Care Curricula Guide </li></ul><ul><li>Initial lecture on common infusions only. </li></ul><ul><li>Many, many, more hours forthcoming over next few months. </li></ul>
    5. 6. Why? <ul><li>The goal of dedicated critical care transport and specialty care transport is to continue the same level of care during transport as the patient was receiving and may be receiving. </li></ul><ul><li>This involves using medication infusions out of our comfort zone. </li></ul><ul><ul><li>Turning them off NOT an option. </li></ul></ul><ul><li>These meds are essential knowledge of the Mobile Intensive Care Paramedic (MICP) </li></ul>
    6. 7. Other important things… <ul><li>Decreasing Medical Errors </li></ul>
    7. 8. The Dirty Dozen <ul><li>Dopamine </li></ul><ul><li>Dobutamine </li></ul><ul><li>Nitroprusside </li></ul><ul><li>Nor-epinephrine </li></ul><ul><li>Nitro </li></ul><ul><ul><li>Standard composition </li></ul></ul><ul><ul><li>VAMC Composition </li></ul></ul><ul><li>Insulin </li></ul><ul><li>Diltiazem </li></ul><ul><li>Heparin </li></ul><ul><li>GIIb-IIIa Inhibitors </li></ul><ul><li>Amiodarone </li></ul><ul><li>Propofol </li></ul><ul><li>Retavase </li></ul>We also will discuss what IV Fluid you may run!!!
    8. 9. Some thoughts about the Route….
    9. 10. What route ? <ul><li>Central </li></ul><ul><li>May also be used for Hemodynamic Monitoring </li></ul><ul><li>Many types: </li></ul><ul><ul><ul><li>PICC-inserted into antecubital vein and advanced into Superior Vena Cava </li></ul></ul></ul><ul><ul><ul><li>Examples: Triple lumen, Hickman, Broviac, and Groshong </li></ul></ul></ul><ul><li>PROS: </li></ul><ul><ul><li>Good for drug concentrates in fluid restricted patients </li></ul></ul><ul><ul><li>Good for drugs too irritant to be used peripherally </li></ul></ul><ul><li>CONS: </li></ul><ul><ul><li>Slow and risky to gain access </li></ul></ul><ul><ul><li>needs experience & practice </li></ul></ul><ul><ul><li>Many different types </li></ul></ul><ul><ul><li>Sterility a MUST </li></ul></ul><ul><ul><li>Heparinization </li></ul></ul><ul><li>Peripheral </li></ul><ul><li>PROS: </li></ul><ul><ul><li>Easy and safer access </li></ul></ul><ul><ul><li>Large volumes </li></ul></ul><ul><ul><li>Familiar route </li></ul></ul><ul><li>CONS: </li></ul><ul><ul><li>Not suitable for all meds </li></ul></ul><ul><ul><li>Typically not multi-lumen </li></ul></ul><ul><ul><li>Easier to displace </li></ul></ul><ul><ul><li>Infiltration </li></ul></ul>
    10. 11. Peripheral Line Safety <ul><li>IVs flow by gravity pressure, and the higher the solution bag, the faster the IV will infuse. </li></ul><ul><ul><li>The average height for an adult IV solution bag is 3 feet above heart level. </li></ul></ul><ul><ul><li>When the “height” changes, so does the infusion rate (unless on a pump). </li></ul></ul><ul><li>Secondary solution bags must hang higher than the primary bag to infuse first. </li></ul><ul><ul><li>Even when on a pump </li></ul></ul><ul><li>Flush with confidence? : SIS- saline, IV med/infusion, saline </li></ul>
    11. 12. Piggy Back? <ul><li>Secondary Lines </li></ul><ul><ul><li>Attach to primary IV at injection ports </li></ul></ul><ul><ul><li>Used primarily to infuse meds or other IV fluids on intermittent basis if compatible with fluid on the primary line </li></ul></ul><ul><ul><li>IV piggybacks – IVPB </li></ul></ul><ul><ul><li>IVPB higher than primary – greater pressure and causes it to infuse first </li></ul></ul><ul><ul><li>When IVPB empty primary line will automatically resume its flow </li></ul></ul>
    12. 13. Central Line Safety <ul><li>Sterility </li></ul><ul><li>Medication Safety </li></ul><ul><ul><li>SASH for Central lines- saline, Additive (IV Med/infusion), saline, heparin </li></ul></ul><ul><ul><ul><li>Recommend ASPIRATE on all central lines PRIOR to flushing with saline as well. </li></ul></ul></ul><ul><ul><ul><li>Some lines have high concentration heparin. </li></ul></ul></ul><ul><ul><ul><li>Someone else may not have flushed the line and their may be IV meds in it. </li></ul></ul></ul>
    13. 14. SOME THOUGHTS ABOUT STAYING OUT OF TROUBLE….
    14. 15. GENERAL CONCEPTS <ul><li>Check transfer order carefully to be sure that you are comfortable with all medications ordered. </li></ul><ul><li>Be sure that order specifies: </li></ul><ul><ul><li>Dosage information </li></ul></ul><ul><ul><li>Times of administration (where applicable) </li></ul></ul><ul><ul><li>Indications for changes or discontinuance. </li></ul></ul><ul><ul><ul><li>Eg. Nitroglycerin dosage is often altered based on pain and/or BP. </li></ul></ul></ul>
    15. 16. <ul><li>Ask the physician or RN to review medication if it is one that you are not familiar with. </li></ul><ul><ul><li>Discuss potential adverse reactions and how to deal with them. </li></ul></ul><ul><ul><li>Use resources to double check </li></ul></ul><ul><ul><ul><li>Drug References </li></ul></ul></ul>GENERAL CONCEPTS
    16. 17. GENERAL CONCEPTS <ul><li>Determine how long it will take to reach receiving facility and calculate the amount of the drug you will need to reach your destination. </li></ul><ul><ul><li>Allow for unforeseen delays. </li></ul></ul><ul><ul><li>Boy Scout Firewood Rule </li></ul></ul><ul><ul><ul><li>2 times what you think you will need, and then some more. </li></ul></ul></ul>
    17. 18. <ul><li>Check to be sure that you have the right drug and the right concentration. </li></ul><ul><li>Make sure it is hooked up to the right pump channel. </li></ul>GENERAL CONCEPTS
    18. 19. <ul><li>Consider using the hospitals IV Pump </li></ul><ul><ul><li>Good for short transfers. </li></ul></ul><ul><ul><li>Limits chance of errors or runaway lines during transfers. </li></ul></ul><ul><ul><li>Be sure you able to troubleshoot potential problems with the pump! </li></ul></ul><ul><li>Check IV site for patency, redness, etc. </li></ul><ul><li>Poor Line Management will cause problems, even on short transfers. </li></ul>GENERAL CONCEPTS
    19. 20. <ul><li>Be sure to have a drug reference book available in your ambulance </li></ul><ul><li>Review drug reference for detailed information about the drug. </li></ul><ul><ul><li>Review side effects, adverse reactions, dosing, interactions, etc. </li></ul></ul><ul><li>STRONGLY consider calling medical control if it becomes necessary to administer another drug to ascertain possible interaction problems </li></ul>GENERAL CONCEPTS
    20. 21. Some thoughts about IV fluid
    21. 22. Types of IV solution <ul><li>4 classes of IV sol </li></ul><ul><ul><li>Crystalloids – Dextrose, saline, LR </li></ul></ul><ul><ul><li>Colloids – volume expanders such as Dextran, Hetastarch </li></ul></ul><ul><ul><li>Bld & Bld products – whole bld,packed RBCs, plasma & albumin </li></ul></ul><ul><ul><li>Lipids – fat emulsion sol – indicated if on IVs more than 5 days </li></ul></ul>
    22. 23. What IV fluid ? <ul><li>Crystalloid? </li></ul><ul><li>PROS: </li></ul><ul><ul><li>Most familiar </li></ul></ul><ul><ul><li>Cheap </li></ul></ul><ul><li>CONS: </li></ul><ul><ul><li>May need large volumes </li></ul></ul><ul><ul><li>Relatively slow increase in CVP </li></ul></ul><ul><ul><li>Will move out of vascular space </li></ul></ul><ul><ul><li>Over 200 diff IV fluids being manufactured </li></ul></ul><ul><li>Colloid? </li></ul><ul><li>PROS: </li></ul><ul><ul><li>Rapid increase in CVP </li></ul></ul><ul><ul><li>Small volumes </li></ul></ul><ul><ul><li>Water redistribution out of tissues </li></ul></ul><ul><ul><ul><li>AKA: Colloid Pulling Power </li></ul></ul></ul><ul><li>CONS: </li></ul><ul><ul><li>Only for Critically ill </li></ul></ul><ul><ul><li>Expensive </li></ul></ul><ul><ul><li>Water redistribution out of tissues </li></ul></ul>
    23. 24. Fluid balance <ul><li>A simple question of input equal to output </li></ul><ul><li>Goal: 1ml/kg/hr urine output </li></ul><ul><li>A complex balance of forces to achieve a urine output of about 1ml/kg/hr (assuming normal renal function) without causing heart failure, pulmonary or peripheral edema </li></ul>
    24. 25. The Drugs….
    25. 26. Dopamine <ul><li>IV Infusions (Titrate to Effect) </li></ul><ul><ul><ul><li>Low Dose “Renal Dose&quot; </li></ul></ul></ul><ul><ul><ul><ul><li>1 to 5 µg/kg per minute </li></ul></ul></ul></ul><ul><ul><ul><li>Moderate Dose “Cardiac Dose&quot; </li></ul></ul></ul><ul><ul><ul><ul><li>5 to 10 µg/kg per minute </li></ul></ul></ul></ul><ul><ul><ul><li>High Dose “Vasopressor Dose&quot; </li></ul></ul></ul><ul><ul><ul><ul><li>10 to 20 µg/kg per minute </li></ul></ul></ul></ul>
    26. 27. Dopamine <ul><li>Precautions (Watch Out!) </li></ul><ul><ul><li>May use in patients with hypovolemia but only after volume replacement </li></ul></ul><ul><ul><li>May cause tachyarrhythmias, excessive vasoconstriction </li></ul></ul><ul><ul><li>DO NOT mix with sodium bicarbonate </li></ul></ul><ul><ul><li>Watch for s/s for fluid overload and hypertension. </li></ul></ul><ul><ul><li>Doses higher than 20/mcg/kg may compromise peripheral circulation </li></ul></ul>
    27. 28. Dobutamine <ul><li>Consider for pump problems (congestive heart failure, pulmonary congestion) with systolic blood pressure of 70 to 100 mm Hg and no signs of shock </li></ul><ul><ul><li>Increases Inotropy </li></ul></ul><ul><li>Dosing </li></ul><ul><ul><li>Usual infusion rate is 2 to 20 µg/kg per minute, </li></ul></ul><ul><ul><ul><li>Absolute max of 40 mck/kg/min </li></ul></ul></ul><ul><ul><li>Titrate so heart rate does not increase by more than 10% of baseline </li></ul></ul><ul><ul><li>Hemodynamic monitoring is recommended for optimal use </li></ul></ul>
    28. 29. Dobutamine <ul><li>Precautions </li></ul><ul><ul><li>Avoid when systolic blood pressure <100 mm Hg with signs of shock, consider dopamine instead. </li></ul></ul><ul><ul><li>May cause tachyarrhythmias </li></ul></ul><ul><ul><li>DO NOT mix with sodium bicarbonate </li></ul></ul>
    29. 30. Norepinephrine <ul><li>Brand Name: Levophed Generic Name: Norepinephrine Bitartrate </li></ul><ul><li>Indications </li></ul><ul><ul><li>For severe cardiogenic shock and hemodynamic significant hypotension (systolic blood pressure < 70 mm/Hg) with low total peripheral resistance </li></ul></ul>
    30. 31. Norepinephrine <ul><li>Many Various infusions in use. </li></ul><ul><li>Typically 1 mg in 250 cc or 2 mg in 500 cc </li></ul><ul><li>Dosage (initial): 8 to 12 mcg/min -titrate to BP (Usual target: SB:80-100 or MAP=80). Usual maintenance: 2 to 4 mcg/min. </li></ul><ul><ul><li>Note: doses as high as 0.5 to 1.5 mcg/kg/min for 1-10days have been used in septic shock. </li></ul></ul><ul><ul><li>Poison/drug-induced hypotension (i.e. TCAs) may require higher doses to achieve adequate perfusion </li></ul></ul>
    31. 32. Norepinephrine <ul><li>Precautions (Watch Out!) </li></ul><ul><ul><li>Increases myocardial oxygen requirements </li></ul></ul><ul><ul><li>Good vasculature required (i.e. Central or large peripheral) </li></ul></ul><ul><ul><li>DO NOT administer is same IV line as alkaline infusions (i.e. Bicarb) </li></ul></ul><ul><ul><li>May induce arrhythmias </li></ul></ul><ul><ul><li>Extravasation causes tissue necrosis </li></ul></ul><ul><ul><li>Should be administered in dextrose containing solutions (i.e. D5W or D5/0.45% NS). </li></ul></ul><ul><ul><ul><li>These dextrose containing fluids are protection against significant loss of potency due to oxidation. </li></ul></ul></ul><ul><ul><ul><li>Administration in saline solution alone is not recommended. </li></ul></ul></ul><ul><ul><ul><li>Blood products should be administered in separate line. </li></ul></ul></ul>
    32. 33. Sodium Nitroprusside (Nitropress) <ul><li>Sodium nitroprusside is indicated for the immediate reduction of blood pressure of patients in hypertensive crises. </li></ul><ul><li>Sodium nitroprusside is also indicated for producing controlled hypotension in order to reduce bleeding during surgery. </li></ul><ul><li>Sodium nitroprusside is also indicated for the treatment of acute congestive heart failure. </li></ul>
    33. 34. Sodium Nitroprusside <ul><li>Initial (0.3 µg/kg/min) </li></ul><ul><li>Titrated to 10 µg/kg/min max </li></ul>
    34. 35. Sodium Nitroprusside <ul><li>Precautions (Watch Out!) </li></ul><ul><ul><li>Nitroprusside must be reconstituted for each use. It is good for 24 hours afterward. </li></ul></ul><ul><ul><li>The diluted solution should be protected from light. It is not necessary to cover the infusion drip chamber or the tubing. </li></ul></ul><ul><ul><li>Nitroprusside can be deactivated inadvertently by contaminates. Normal Nitroprusside is a faint brownish color. </li></ul></ul><ul><ul><ul><li>Contaminated nitroprusside will often be blue, green, or red, much brighter colors </li></ul></ul></ul><ul><ul><ul><li>Particulate may be visible. </li></ul></ul></ul><ul><ul><ul><li>Discard if this is noted. </li></ul></ul></ul><ul><ul><li>Do not mix with any other drugs in same line. </li></ul></ul><ul><ul><li>Severe Hypotension may develop even at normal rates. </li></ul></ul><ul><ul><li>Risk of Cyanide Toxicity </li></ul></ul><ul><ul><ul><li>Total dose > 500 mcg/kg . Greater risk with impaired renal function </li></ul></ul></ul><ul><ul><ul><li>Greater than 2 mcg/kg/min </li></ul></ul></ul><ul><ul><ul><li>Treat with Sodium Thiosulfate (increased Hypotension risk) </li></ul></ul></ul>
    35. 36. Nitro: Standard composition's) <ul><li>Glass Bottles </li></ul><ul><li>Standard Half-strength concentration </li></ul><ul><ul><li>( 100 mcg/ml) Most common at SLRMC/SLMMC </li></ul></ul><ul><ul><ul><li>25 mg/250 ml, or 50 mg/500 ml </li></ul></ul></ul><ul><li>Standard Full-strength concentration </li></ul><ul><ul><li>Most common used at SARMC/SAEMC </li></ul></ul><ul><ul><ul><li>(200 mcg/ml) </li></ul></ul></ul><ul><ul><ul><li>50 mg/250 ml </li></ul></ul></ul><ul><li>Multiple other ways to mix….. </li></ul>
    36. 37. Nitro: VAMC Composition <ul><li>Bag NOT A BOTTLE </li></ul><ul><ul><li>30 MG/500 CC </li></ul></ul><ul><ul><li>1 MCG/ML CONCENTRATION </li></ul></ul><ul><ul><li>1 MCG/MIN = 1 CC/HOUR </li></ul></ul><ul><ul><ul><li>Example, you want to run NTG at 20 mcg/min, RUN IT AT 20 MG/HOUR. </li></ul></ul></ul>
    37. 38. Nitro <ul><li>Precautions (Watch Out!) </li></ul><ul><ul><li>CONFIRM CONCENTRATION </li></ul></ul><ul><ul><li>Beware Runaway lines </li></ul></ul><ul><ul><li>A separate line should be used when possible, or at least piggybacked. </li></ul></ul><ul><ul><li>A patient with a nitro drip requires blood pressure monitoring with either non-invasive blood pressure or arterial line, at least every five (5) minutes until stabilized. </li></ul></ul><ul><ul><li>The patient should have continuous EKG monitoring while receiving the drug. </li></ul></ul>
    38. 39. Insulin <ul><li>Commonly used for diabetic and non diabetic patients in the Critical Care setting </li></ul><ul><li>May be included in TPN mixtures. If it is not, it is administered as well. </li></ul>
    39. 40. Typical Insulin Infusion <ul><li>Insulin infusions are institution specific. </li></ul><ul><li>An initial bolus is given per MD order, typically up to 10 units regular. </li></ul><ul><li>A maintenance infusion was then started at 2 units/hr . </li></ul><ul><ul><li>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/hour </li></ul></ul><ul><ul><li>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 changed </li></ul></ul><ul><ul><li>If the BG drops by ≥100 mg/dL, then infusion decreased in half and rechecked in one hour. </li></ul></ul><ul><ul><li>After the targeted BG is achieved, if the blood glucose level continued to decrease over three consecutive measurements, the infusion rate was decreased by 0.5 -1 unit/hr, </li></ul></ul><ul><ul><li>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. </li></ul></ul><ul><ul><li>Once the blood glucose is ≥80 mg/dL, the infusion was restarted at 50% of the previous rate. </li></ul></ul><ul><ul><li>If the blood glucose concentration falls below 60 mg/dL, the infusion was discontinued (if not already stopped) and 50% dextrose injection was given. </li></ul></ul>
    40. 42. Insulin <ul><li>Precautions (Watch Out!) </li></ul><ul><ul><li>Ask for a copy of the institutional protocol (or the one the MD wrote) for reference. </li></ul></ul><ul><ul><li>Ask what the goal BG is for this patient. </li></ul></ul><ul><ul><ul><li>Typically between 100 and 130 mg/dl but may be patient specific. </li></ul></ul></ul><ul><ul><ul><li>What is the crisis level? (typically 80 mg/dl) </li></ul></ul></ul><ul><ul><li>Check glucose at </li></ul></ul><ul><ul><ul><li>beginning of transport, </li></ul></ul></ul><ul><ul><ul><li>30 minutes into transport </li></ul></ul></ul><ul><ul><ul><li>Every 60 minutes unless drops below 100 mg/dl, then every 15 minutes until normalized. </li></ul></ul></ul>
    41. 43. Diltiazem <ul><li>Must be reconstituted and used with in 24 hours. (or refrigerated used with in 30 days) </li></ul><ul><li>Dose: </li></ul><ul><ul><li>Initial bolus as ordered by MD, followed by 5 mg/hour, titrated to 15 mg/hour max. </li></ul></ul>
    42. 44. Diltiazem <ul><li>Precautions (Watch Out!) </li></ul><ul><li>Most common side effect is HYPOTENSION (3-5% of patients) </li></ul>
    43. 45. Heparin <ul><li>Used to prevent extension of existing clot or formation of new blood clots </li></ul><ul><li>Does not dissolve existing clots </li></ul><ul><li>Patients may be on these drugs for extended periods of time </li></ul><ul><li>Most commonly used anticoagulants: </li></ul><ul><ul><li>Heparin </li></ul></ul><ul><ul><li>Lovenox (Enoxaparin) AKA “Low Molecular Weight Heparin” (SQ) </li></ul></ul>
    44. 46. Heparin <ul><li>Various protocols- facility, physician, patient, and situation dependant. </li></ul><ul><ul><li>Refer to institutional written order. </li></ul></ul><ul><ul><li>If seems unusual confirm with MD. </li></ul></ul><ul><li>Common Dosing </li></ul><ul><ul><li>Initial bolus 60 IU/kg </li></ul></ul><ul><ul><ul><li>Maximum bolus: 4000 IU </li></ul></ul></ul><ul><ul><ul><li>Often forgotten </li></ul></ul></ul><ul><ul><li>Continue at 12 IU/kg/hr (maximum 1000 IU/hr for patients < 70 kg), round to the nearest 50 IU </li></ul></ul>
    45. 47. <ul><li>Precautions (Watch Out!) : </li></ul><ul><ul><li>Run Away IV’s </li></ul></ul><ul><ul><li>Signs of bleeding, either internally or externally </li></ul></ul><ul><ul><ul><li>Monitor vitals frequently </li></ul></ul></ul><ul><ul><ul><li>Signs and symptoms of shock </li></ul></ul></ul><ul><ul><ul><li>Altered level of consciousness </li></ul></ul></ul>Heparin
    46. 48. GLYCOPROTEIN IIb-IIIa Inhibitors <ul><li>Indications: </li></ul><ul><ul><li>Inhibit the integrin glycoprotein IIb/IIIa receptor in the membrane of platelets, inhibiting platelet aggregation </li></ul></ul><ul><ul><li>Indicated for Acute Coronary Syndromes without ST segment elevation </li></ul></ul><ul><ul><li>Frequently used with Heparin </li></ul></ul>
    47. 49. GLYCOPROTEIN IIb/IIa Platelet Inhibitors <ul><li>Three most common GIIb/IIIa Inhibitors are: </li></ul><ul><li>Abciximab (ReoPro) </li></ul><ul><li>Eptifibitide (Integrilin) </li></ul><ul><li>Tirofiban (Aggrastat) </li></ul>
    48. 50. <ul><li>Abciximab (ReoPro) </li></ul><ul><ul><li>Non Q wave MI or unstable angina with planned PCI within 24 hours </li></ul></ul><ul><ul><li>Must use with heparin </li></ul></ul><ul><ul><li>Binds irreversibly with platelets </li></ul></ul><ul><ul><li>Platelet function recovery requires 48 hours </li></ul></ul>GLYCOPROTEIN IIb/IIa Platelet Inhibitors
    49. 51. GLYCOPROTEIN IIb/IIa Platelet Inhibitors <ul><li>Eptifibitide (Integrilin) </li></ul><ul><ul><li>Non Q wave MI, unstable angina managed medically, and unstable angina / Non Q wave MI patients undergoing PCI </li></ul></ul><ul><ul><li>Platelet function recovers within 4 to 8 hours after discontinuation </li></ul></ul><ul><ul><li>Administered with ASA (or clopidogrel) and Heparin. </li></ul></ul><ul><ul><li>Dosing </li></ul></ul><ul><ul><ul><li>Bolus 180 µg/kg over 1 to 2 minutes </li></ul></ul></ul><ul><ul><ul><li>IV Infusion 2 µg/kg/minute </li></ul></ul></ul>
    50. 52. GLYCOPROTEIN IIb/IIa Platelet Inhibitors <ul><li>Tirofiban (Aggrastat) </li></ul><ul><ul><li>Non Q wave MI, unstable angina managed medically, and unstable angina / Non Q wave MI patients undergoing PCI </li></ul></ul><ul><ul><li>Platelet function recovers within 4 to 8 hours after discontinuation </li></ul></ul><ul><li>Dose </li></ul><ul><ul><li>Bolus 0.4 µg/kg and minute for 30 minutes. </li></ul></ul><ul><ul><li>Followed by infusion at 0.1 µg/kg /minute. </li></ul></ul>
    51. 53. GLYCOPROTEIN IIb/IIa Platelet Inhibitors <ul><li>Route of Administration: </li></ul><ul><ul><li>IV infusion only </li></ul></ul><ul><ul><li>Small Bottles </li></ul></ul><ul><ul><ul><li>Can lose alot of the drug flushing the tubing, be careful not to waste. </li></ul></ul></ul>
    52. 54. <ul><li>What to watch for during transport: </li></ul><ul><ul><li>HYPERTENSION (increased bleeding risk) </li></ul></ul><ul><ul><li>Any signs of bleeding </li></ul></ul><ul><ul><li>Signs and symptoms of shock </li></ul></ul><ul><ul><li>Changes in level of consciousness </li></ul></ul>GLYCOPROTEIN IIb/IIa Platelet Inhibitors
    53. 55. <ul><li>Potential interventions in cases of adverse or allergic reactions: </li></ul><ul><ul><li>Control any external bleeding </li></ul></ul><ul><ul><li>Treat for shock as needed </li></ul></ul><ul><ul><li>Contact OLMC for options of discontinuing drug, altering dose or diversion </li></ul></ul><ul><ul><li>In cases of suspected bleeding, the provider may also have to D/C heparin if it is also being administered </li></ul></ul>GLYCOPROTEIN IIb/IIa Platelet Inhibitors
    54. 56. Amiodarone <ul><li>Difference between BOLUS infusion and 24 hour infusion </li></ul><ul><li>Bolus infusion </li></ul><ul><ul><li>150 mg/100 cc </li></ul></ul><ul><ul><ul><li>150 mg bolus over 10 min </li></ul></ul></ul><ul><li>Maintenance Infusion </li></ul><ul><ul><li>450mg /250cc 1.8 mg/ml </li></ul></ul><ul><ul><ul><li>1 mg/min for 1 st 6 hours </li></ul></ul></ul><ul><ul><ul><li>Then 0.5 mg/min for remaining 24 hours </li></ul></ul></ul>
    55. 57. Amiodarone <ul><li>Precautions (Watch Out!) </li></ul><ul><ul><li>Hypotension </li></ul></ul><ul><ul><li>Widened QT interval </li></ul></ul><ul><ul><li>Can’t use if TCA overdose or Procainimide has been used. </li></ul></ul><ul><ul><li>Can’t use Procainimide for refractory ectopy </li></ul></ul>
    56. 58. Propofol <ul><li>Fat suspension (larger vein if possible) </li></ul><ul><li>Standard concentration 10 mg/ml </li></ul><ul><li>Doses </li></ul><ul><ul><li>5-50 mcg/kg/min titrated in 5 mcg increments. </li></ul></ul>
    57. 59. Propofol <ul><li>Precautions (Watch Out!) </li></ul><ul><ul><li>HYPOTENSION is biggest concern. </li></ul></ul><ul><ul><li>Hyperkalemia </li></ul></ul><ul><ul><li>Metabolic Acidosis </li></ul></ul><ul><ul><li>Most problems common when using high-dose (>5 mg/kg/h) and long-term (>48 h) </li></ul></ul>
    58. 60. Retavase <ul><li>Rapid , easy to use thrombolytic </li></ul><ul><ul><li>First bolus of 10 Units </li></ul></ul><ul><ul><li>30 minutes later 2 nd bolus of 10 units is given </li></ul></ul>
    59. 61. Retavase <ul><li>Precautions (Watch Out!) </li></ul><ul><ul><li>Heparin and Retavase® are incompatible when combined in solution.   Do not administer heparin and Retavase® simultaneously in the same intravenous line. </li></ul></ul><ul><ul><li>Bleeding </li></ul></ul>
    60. 62. Summary <ul><li>Watch for run away IV’s, especially during changeovers </li></ul><ul><li>ALWAYS DOUBLE CHECK CONCENTRATIONS </li></ul><ul><li>Double check MD orders. </li></ul><ul><li>Don’t mix infusions prior to confirming compatability. </li></ul>

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