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AMINOCAPROIC ACID (Amicar)

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AMINOCAPROIC ACID (Amicar) Powered By Docstoc
					Commonly Used IV Medications in CVRU

A guide for Nurses caring for post-operative CV Surgery Patients at Presbyterian hospital

Timothy E. McMurry RN, BSN, CCRN-CSC
2006

AMINOCAPROIC ACID (Amicar)

Amicar is used to decrease bleeding after cardiopulmonary bypass. It is usually used in low risk surgeries as a cheaper alternative to Aprotinin. Currently at Presbyterian, Amicar is being used more often because of some recent data that has related Aprotonin with stroke and renal failure. This is a controversial subject and many physicians do not fully rely that the data from the study is dependable. Amicar will always be started in the operating room and the dose will finish in CVRU. In rare instances additional doses have been ordered in CVRU for continued bleeding after the initial dose has completed.
“Aminocaproic acid competitively inhibits activation of plasminogen, thereby reducing conversion of plasminogen to plasmin (fibrinolysin), an enzyme that degrades fibrin clots as well as fibrinogen and other plasma proteins including the procoagulant factors V and VIII. Aminocaproic acid also directly inhibits plasmin activity, but higher doses are required than are needed to reduce plasmin formation. In vitro, the antifibrinolytic potency of Amicar is approximately one-fifth to one-tenth that of tranexamic acid.” 3

Dosage: Initial dose is 4-5 gm IV, diluted in 250 mL of D5W or NS, infuse over 1 hr, followed by 1 g/hr (50
mL/hr) for about 8 hr or until bleeding is controlled.3 “Maximum doses 30 grams daily.”1

When obtaining the initial post-op ACT, a black top tube should be used

Precautions
Hypotension, seizures, acute renal failure, nausea, rash, blurred vision or other changes in vision; dizziness or lightheadedness; unusual tiredness or weakness, blood clotting.  May cause significant hematuria.



May increase BUN, creatinine, CK, AST and ALT levels.



Use cautiously in patients with renal or liver disease, and any patient with hematuria, or DIC.

If a patient has renal insufficiency or failure after surgery, assure that the nephrologist knows the received Amicar.

Aprotonin - (Trasylol)

Aprotinin is commonly used in CV surgery to decrease the inflammatory response caused by the bodies reaction to the cardiopulmonary bypass machine. Its action is unclear but it decreases platelet dysfunction and reduces the amount of fibrinolysis. It is preferred by many practitioners over Amicar and thought to be far superior to Amicar for the reasons listed above. It is a much more expensive.
“The antiinflammatory effects occur by inhibition of the complement system, the fibrinolytic system, tumor necrosis factor, neutrophil activation, and protease-activated receptor effects.”4 Aprotinin is a protease inhibitor used in cardiac surgery and beyond to reduce blood loss and the need for perioperative blood transfusion. Through inhibition of serine proteases such as plasmin, aprotinin significantly reduces fibrinolysis, thereby aiding hemostasis during surgical procedures. In addition, aprotinin interacts with other factors in the coagulation and fibrinolytic cascade, creating a hemostatic balance, without increasing the risk of thrombosis. These proven benefits are supplemented by the anti-inflammatory properties of aprotinin, which may help curb some of the deleterious effects of cardiopulmonary bypass.4

Dosage:
Aprotinin is always started in the operating room and the dose is usually completed in CVRU. Infuse at 50cc/hr until completed.
    10,000 kallikrein inhibitory units IV (10 minutes prior to the loading dose) Coronary artery bypass graft - Hemorrhage, Perioperative; Prophylaxis: loading dose: 1 million-2 million kallikrein inhibitory units IV (over 20-30 minutes and prior to sternotomy) Coronary artery bypass graft – Hemorrhage, Perioperative; Prophylaxis: pump prime: 1 million-2 million kallikrein inhibitory units added to the recirculating priming fluid of the coronary artery bypass circuit Coronary artery bypass graft - Hemorrhage, Perioperative; Prophylaxis: constant infusion: 250,000-500,000 kallikrein inhibitory units/hr IV for duration of surgery

When obtaining the initial post-op ACT, a gold top tube should be used

Precautions
  Heart failure, Myocardial infarction, Shock (<1%), Thrombotic disorder (1%), Cerebral artery occlusion (stroke), Renal failure A test dose is usually given prior to dosing, especially is the patient has received aprotinin before.

“Anaphylactic or anaphylactoid reactions are possible when aprotinin is administered. Hypersensitivity reactions are rare in patients with no prior exposure to aprotinin. The risk of anaphylaxis is increased in patients who are re-exposed to aprotinin-containing products. The benefit of aprotinin to patients undergoing primary CABG surgery should be weighed against the risk of anaphylaxis should a second exposure to aprotinin be required.”3
- Anaphylaxis risk: 2.7% with reexposure, 5% for reexposure within 6 months, 0.9% for reexposure time greater than 6 months, 0.1% with no prior exposure, - Hypersensitivity reaction, 2.7% with reexposure, 5% for reexposure within 6 months, 0.9% for reexposure time greater than 6 months, 0.1% with no prior exposure

Amiodarone - (Cordarone)
Amiodarone is used in postoperative cardiac surgery patients to treat atrial fibrillation and ventricular arrhythmias and is typically ordered by cardiology. Amiodarone has been associated with a wide array of side effects in including pulmonary and liver toxicity and is not typically our first line drug for postop arrhythmias. However, due to current AHA recommendations, it is being seen more commonly. Actions:
“Amiodarone is an antiarrhythmic drug with predominant class III effects of lengthening cardiac action potential and blocking myocardial potassium channels leading to slowed conduction and prolonged refractoriness.” It rapidly blocks sodium channels like a class I drug (3).

Dosage:
In atrial arrhythmias 150mg IV over 10 minutes followed by a 24 hour infusion. First 6 hours 1mg/min (33cc/min) followed by 18 hours of 0.5mg/min (17cc/min). The patient should be changed to PO or an order must be written to continue IV use after 24 hours (See amiodarone orders on the intranet).

Admixture: 900mg in 500cc.

Precautions: (3)
             
Acute myocardial infarction particularly with IV administration AV block, particularly with IV administration Bradycardia, particularly with IV administration Cardiomegaly, particularly with IV administration Concomitant QTc-prolonging drugs Electrolyte imbalance or concomitant use of drugs that may cause electrolyte imbalance Hepatic disease Hypotension, particularly with IV administration Left ventricular dysfunction Post-myocardial infarction patients with asymptomatic or minimally symptomatic non-life threatening ventricular arrhythmias Photosensitivity Proarrhythmic events, new or worsened arrhythmias, effects are prolonged when they occur Pulmonary disease Surgery (hypotension post-bypass, adult respiratory distress syndrome)

Side effects: (3)
     Cardiovascular: Cardiac dysrhythmia (2.4%), Congestive heart failure (2.1%), Shock (less than 2%) Dermatologic: Stevens-Johnson syndrome (less than 2%) Endocrine metabolic: Disease of thyroid gland Hematologic: Thrombocytopenia (less than 2%) Hepatic: Hepatotoxicity Respiratory: Pulmonary toxicityPreoperative low-dose amiodarone therapy does not seem to be related to significant postoperative lung toxicity, but it is associated with various cardiac complications and an increased need for more intense inotropic support after cardiac operations. These findings may be related to the drug's depressant effect on the myocardium



Cardizem - Diltiazem HCL
Cardizem is used in CVRU to reduce the heart rate in atrial fib and flutter. Uncontrolled atrial fib/flutter is defined as a having a rate over 100. The initial goal is to reduce the heart rate to less than 100. A bolus is typically given followed by an IV drip. Cardizem should only be used if the heart rate is over 100. Occasionally, you will see a conversion to sinus rhythm with Cardizem alone. An oral agent, such as rhythmol, is typically ordered along with cardizem. The two drugs work together to treat A-fib/flutter, Cardizem to control the rate, and rhythmol to convert the rhythm. Low or moderately low blood pressures are commonly seen with rapid atrial fibrillation/flutter. Cardizem can be safely administered to patients with marginal blood pressures if given slowly. Reducing the heart rate will help with diastolic filling and will theoretically raise the blood pressure, improve cardiac output and reduce workload after rate control is achieved. Slowing the heart rate reduces myocardial oxygen demand. Consider lowering the dose of vasodilators, such as Nipride or Corlopam, prior to administering Cardizem. Coadministration may potentiate a hypotensive effect. Also, anticipate an increased need for vasopressors, such as Neo or levo, or a fluid bolus. Slowing the administration rate or stopping the bolus will usually result in a steady rise in the blood pressure. Be cautious of the rhythm as well as the rate when giving Cardizem to post-op patients. If an AV block is seen, Cardizem should be placed on hold and the MD updated immediately with vital signs and patient presentation. AV block will be more common in patients that have had valve operations. Cardizem is also used to prevent vasospasm in patients with internal mammary grafts by relaxing vascular smooth muscle. 5mg/hr is the typically dose seen for this purpose.

Action:
“Diltiazem hydrochloride is a slow calcium channel blocker that blocks calcium ion influx during depolarization of cardiac and vascular smooth muscle. It decreases peripheral vascular resistance and causes relaxation of the vascular smooth muscle resulting in a decrease of both systolic and diastolic blood pressure” (3).

Admixture:
Cardizem is available premixed as 100mg/100cc. it is typically always mixed in a 1:1 concentration resulting in 1cc/hr = 1mg/hr. Dosage: Bolus doses can be given slowly from the premixed bag by setting the infusion pump rate and limit accordingly. Vials are available and are a 5mg/cc concentration. Bolus doses can be given over 2 minutes in patients with a stable blood pressure (1). A slower bolus would be given if hypovolemia is suspected, any recent hypotension has been seen, or when a patient is on any other vasoactive medication (Neo, Levo, Epi, Nipride, NTG, Corlopam, etc).

Precautions:
When administering Cardizem, continuously monitor the heart rate and blood pressure. Boluses can be slowed or stopped for any drop in blood pressure or if the desired effect is seen prior to completing the total bolus dose. The total bolus dose is usually, but not always required. Be cautious not to lower the heart rate too much. 90 bpm is a good goal rate for the post-op patient unless otherwise directed by the physician. A patient with rapid atrial fib that responds well to Cardizem bolus will almost always be maintained with a drip. The drip rate will be ordered by the physician and may need to be titrated to maintain the target heat rate after an order is received to do so.

Cardizem can increase the effects of anesthetics. Patients may not awaken as quickly or may be more difficult to arouse after receiving it during the first 24 hours post-op.

Side effects:


Atrioventricular block, Bradyarrhythmia, Congestive heart failure, Exacerbation (rare),
Peripheral edema, Syncope, Drug-induced gingival hyperplasia, Dizziness, and/or Headache (1).

Caution should be used in the following situations:
        Coadministration with other drugs known to decrease peripheral resistance, intravascular volume, or myocardial contractility or conduction (IV only) Hepatic impairment; increased risk of toxicity Hypotension Renal impairment; increased risk of toxicity Supraventricular arrhythmias with hemodynamic compromise (IV only) Ventricular function, impaired; worsening congestive heart failure has been reported May increase digoxin levels (1). Contraindicated in patients with history of sick sinus syndrome, short PR interval syndrome and WolfParkinson-White disease.

Do not confuse Cardizem with Cardene, another IV calcium channel blocker that is commonly used to control hypertension postoperatively

Corlopam - (Fenoldopam Mesylate)
Corlopam is a dopamine agonist used to treat hypertension. It has become the first line drug for many partly due the adverse pulmonary effects of nipride and because it is less volatile (see nipride precautions). Corlopam also has a positive effect on the kidneys, increasing renal blood flow (some recent literature disputes this effect but the jury is still out on this one). Corlopam does increase urine output in most patients. Pulmonary shunting has been rarely seen with corlopam, but keep in mind that it can happen. Systemic and pulmonary vascular resistances are lowered, resulting in enhanced cardiac output, and it is sometimes used specifically for this effect. Abrupt hypotension can be seen when Corlopam is started, especially in hypertensive patients that are hypovolemic. A fluid bolus may be required and is sometimes all that is needed to correct this problem.

Action:
Fenoldopam mesylate is a dopamine D(1)-like receptor agonist and moderately binds to alpha(2) adrenoreceptors. It acts rapidly as a vasodilator and increases renal blood flow.

Admixture: typically 10mg / 250cc 0.9% NACL yielding 40mcg/ml Dosing:
0.05-1.7mcg/kg/min (some texts say 1.6mcg is a maximum rate) (3). Corlopam should be started at the lower end of the dose range, then titrated every 5-10 minutes to effect. Extremely hypertensive patients that tolerate initial doses may be titrated more rapidly to attain quick control in the immediate postoperative period. Should not be used in excess of 48 hours

Precautions:

Concomitant use with beta blockers, glaucoma/intraocular hypertension, hypokalemia, hypotension, liver disease, and/or tachycardia.



Potassium levels should be closely monitored (3).

Possible adverse effects:
 Hypotension, Tachyarrhythmia, Flushing, Nausea, Vomiting, Dizziness, Headache, Angina, Cardiac dysrhythmia, Heart failure, Myocardial infarction, Serum creatinine elevation

DDAVP -

(Desmopressin Acetate)

DDAVP is given frequently in CVRU to patients with coagulopathy associated with postoperative bleeding. It is typically useful when platelet dysfunction is suspected.

Action:
Increases circulating levels of factor VIII and von Willebrand factor which increases platelet aggregation.

Dosage:
0.3mcg/kg mixed in 50cc 0.9% NACL given over 30-60 minutes. Supplied as 4mcg/ml in a 10cc vial.

Precautions:
Closely monitor blood pressure, renal function, and heart rate during administration
Watch for tachyphylaxis with repeated administration more frequently than every 48 hours

Other side effects:
Anaphylaxis, coronary artery insufficiency and/or hypertensive cardiovascular disease; possible changes in blood pressure and/or heart rate, extreme decrease in plasma osmolality; rare, may result in seizures and coma, flushing, nausea, and headache

Diprivan - Propofol
Diprivan is hypnotic used for sedation when ventilator weaning is not anticipated or when Precedex is contraindicated. At therapeutic doses it provides adequate sedation, but provides no analgesia. It will usually lower the blood pressure and dose adjustments may be needed to stabilize hemodynamics. Many times patients are changed to Diprivan if it is known that they will need to be intubated for a day or longer. Otherwise, Precedex may be used for up to 24 hours.
Propofol has antiemetic properties and is useful when patients have a propensity for nausea after anesthesia.

Action:
Propofol is a short-acting hypnotic and its mechanism of action has not been well-defined (3).

Dose:
Sedation for a mechanically ventilated patient: 5-100 mcg/kg/min. Titrate to achieve desired level of sedation. Usual maintenance rates range from 20 to 50 mcg/kg/min. Admixture: The only bottle we use in CVRU is a 100cc bottle with 1000mg (10mg/ml) yielding a concentration of 10,000mcg/ml. Wean Diprivan over at least 30 minutes and provide pain medicine as appropriate for the particular situation. The patient emerging from sedation from Diprivan, that has not also received pain medicine, will typically experience pain immediately when they show signs of arousal. This may result in hypertension, tachycardia, fever and extreme agitation.

Possible side effects:
Injection site pain, Nausea, Vomiting, Involuntary movement, Bradyarrhythmia, Hypertension, Hypotension, Anaphylaxis, Priapism, Apnea, and/or Respiratory acidosis.

Drug interactions:
 Major

  

Bupivacaine (probable) Lidocaine (probable) St John's Wort (probable)

 Moderate



Succinylcholine (probable) (3).

Precautions:
              
Abrupt discontinuation; may result in anxiety, agitation, tremulousness, and hyperirritability Duration of infusion longer than 5 days; theoretically may lead to zinc deficiency Elderly, debilitated: rapid bolus administration during general anesthesia may aggravate cardiorespiratory depression

Epileptic patients; risk of seizure during recovery phase
patients at risk for renal toxicity; increased risk of renal tubule toxicity

IV tubing and bottle should be changed every 12 hours to avoid infection. Typically given via central line when possible. May cause fluctuations in blood pressure Avoid discontinuing the drug suddenly as this will cause the patient to abruptly arouse, commonly resulting in combativeness and pain.
Propofol decreases cerebral blood flow, cerebral metabolic oxygen consumption, and intracranial pressure, and increases cerebrovascular resistance Contraindicated in people hypersensitive to soybean oil, glycerol, egg lecithin, or disodium edetate STRICT ASEPTIC TECHNIQUE MUST ALWAYS BE MAINTAINED DURING HANDLING. A lower induction dose and a slower maintenance rate of administration should be used in elderly or debilitated patient

Patients should be monitored for early signs of significant hypotension and/or cardiovascular depression, which may be profound. These effects are responsive to discontinuation of DIPRIVAN, IV fluid administration, and/or vasopressor therapy.
Since DIPRIVAN is formulated in an oil-in-water emulsion, elevations in serum triglycerides may occur when DIPRIVAN is administered for extended periods of time. Slower rates of administration should be utilized in premedicated patients, geriatric patients, patients with recent fluid shifts, or patients who are hemodynamically unstable. Any fluid deficits should be corrected prior to administration of DIPRIVAN. In those patients where additional fluid therapy may be contraindicated, other measures, eg, elevation of lower extremities or use of pressor agents, may be useful to offset the hypotension which is associated with the induction of anesthesia with DIPRIVAN.

Dobutrex - (Dobutrex HCL)
Dobutrex is used postoperatively to increase cardiac output. It can increase or decrease blood pressure and the effect is dose dependent in most patients. Particularly useful in low cardiac output states where filling pressures are elevated (5). Dobutrex has a vasodilatory effect. It will most commonly be ordered at a dose of 2.55mcg/kg/min, but therapeutic doses vary widely by patient (1-20mcg). To avoid extremes in blood pressure and tacharrhythmias, Dobutrex should be started at 1mcg and titrated up to the ordered dose, using the lowest dose needed to accomplish the desired effect. Higher doses are sometimes used in refractory cardiogenic shock. Action: “Dobutamine hydrochloride is a synthetic catecholamine and a direct-acting inotropic agent. It stimulates the beta-receptors of the heart which produces hypertensive, mild chronotropic, vasodilative, and arrhythmogenic effects.”(3)

Dosage: Decreased cardiac output: initial, 0.5-1 mcg/kg/min IV; maintenance, 2.5-20 mcg/kg/min IV; titrate according to response; MAX dose, 40 mcg/kg/min IV

Admixture: typically, 250mg/250ml yielding 1000mcg/ml but it may be concentrated

Precautions:
     Contraindicated in patients with Idiopathic hypertrophic subaortic stenosis (IHSS) Arrhythmias Hypovolemia – Volume resuscitate prior to giving dobutrex Myocardial infarction Severe coronary artery disease

Adverse effects:
Chest Pain, Hypertension, Palpitations, Tachyarrhythmia, Hypokalemia, Nausea, Headache, Dyspnea, and Cardiac dysrhythmia



Severe hypertension and tachycardia are frequently seen when starting Dobutrex. This is typically as result of starting at too large a dose or not adequately volume resuscitating the patient prior to initiating the drug.

Dopamine
Dopamine is used commonly in CVRU as an inotrope to increase cardiac output by stimulating the beta receptors in the heart. In many patients 1.0-3mcg/kg/min of dopamine is all that is needed to resolve post-operative cardiogenic shock and is typically weaned in 24-72 hours. It is rarely used as a vasopressor in CVRU at doses over 5mcg/kg/min due to its negative effects on renal and mesenteric blood flow. It should never be titrated to a higher than ordered dose without consent of the attending physician. Dosage:
Therapeutic doses vary widely by patient and can be seen as low as 0.5mcg/kg/min. There is an ongoing
debate in the literature about the “renal effect” of low dose dopamine or whether the positive effects exerted on the kidneys is a result of an increased cardiac output.

Dose dependant effects: 0.5-2.0mcg - Mainly stimulates dopamine receptors resulting in vasodilatation of the renal Vasculature. 2-5mcg – Stimulates beta receptors resulting in a positive inotropic effect. Doses over 5mcg results in alpha stimulation and raises blood pressure by vasoconstricting. Dopamine should be started at a low dose and titrated upward for effect. As opposed to simply starting it at 3-5mcg and titrating downward if negative effects are seen. The lowest dose needed to reach the desired effect should be continued.

Precautions:
   Dopamine has been known to cause profound reflex hypotension in post cardiac surgery patients, especially when used prior to adequate volume resuscitation. Pulmonary shunting may also be seen when dopamine is initiated resulting in a sharp drop in oxygen saturations. Dopamine can raise pulmonary pressures, monitor these closely

Dopamine extravasations can cause severe tissue sloughing and necrosis. It should be given via central line hen possible.
“To prevent sloughing and necrosis in ischemic areas, the area should be infiltrated as soon as possible with 10 to 15 mL of saline solution containing from 5 to 10 mg of phentolamine”3 (Regitine). Phentolamine should be given as soon as possible after the extravasation is noted.3 Follow Presbyterian protocol for Regitine.



Carefully monitor for atrial arrhythmias after starting dopamine in this population.

Potential side effects:
Chest pain, Hypertension, Palpitations, Tachyarrhythmia, Injection site reaction, Piloerection, Nausea, Vomiting, Headache, Mydriasis, Anxiety, Oliguria, Dyspnea, Ectopic beats, gangrenous disorder, Ventricular arrhythmia, and Wide QRS complex.3

Epinephrine
Epinephrine is a powerful catecholamine used to improve cardiac function and as a vasopressor for refractory hypotension. While on Epi, the patient must be monitored closely for tachycardia, signs of myocardial ischemia and increased oxygen demand. Sympathetic nervous system reflexes, such as piloerection, dilated pupils, sweating, increased saliva and mucous production, tachycardia, decreased urine output, decreased peristalsis, increased blood glucose levels, and tachypnea can be activated. Epinephrine can raise the blood sugar so profoundly that insulin drips have become synonymous with its use and higher than normal doses may be needed to maintain adequate glycemic control. Be prepared to quickly wean the dose of insulin if the Epinephrine drip is reduced or discontinued. Epinephrine may be given via nebulizer (racemic Epi) to treat bronchospasm or stridor post-extubation.

Action
Epinephrine is a sympathomimetic catecholamine that acts on both alpha- and beta-adrenergic receptors. The drug effectively causes vasoconstriction through its effect on alpha-adrenergic receptors and it induces relaxation of the bronchial smooth muscle by acting on beta-adrenergic receptors (3).

Dosage:
We dose Epinephrine in mcg/min. The lowest possible dose should be used to achieve the desired effect. There is no defined upper limit; however, the doctor may wish to set one. Drips should be started at 1mcg/min and slowly titrated upwards. The higher the dose the more likely you will see negative side effects such as atrial or ventricular ectopy and tachyarrhythmias.



When increasing doses are required or if the drug appears to become ineffective, acidosis should be considered and ruled out. If present, acidosis should be corrected prior to increasing the infusion rate.

Admixture:
You will see Epi mixed as 1, 2 or 4 mg in 250cc NACL.

Precautions:
Epinephrine increases myocardial oxygen demand and puts the patient at much higher risk for tachyarrhythmias including ventricular tachycardia.

Tissue necrosis secondary to epinephrine vasoconstriction has been reported. It should only be given via central line to limit this risk in case of extravasation.

Potential side effects:
 Palpitations, Tachyarrhythmia, Body pale, Sweating symptom, Nausea, Vomiting, Asthenia, Dizziness, Headache, Tremor, Anxiety, Apprehension, Nervousness, Dyspnea, Cardiac dysrhythmia, hypertensive crisis, Pulmonary edema, and/or tissue necrosis.

Inocor - Inamrinone lactate
Inocor is a positive inotropic agent used to increase cardiac output postoperatively. It is a direct phosphodiesterase inhibitor and smooth muscle relaxer.

Action
Inamrinone lactate is a positive inotropic agent with vasodilator activity. Its exact mechanism is unknown. However, it is thought that its inotropic activity is due to the inhibition of phosphodiesterase and increasing cellular levels of cAMP while its vasodilator activity is due to the reduction of afterload and preload through its direct relaxant effect on vascular smooth muscle (3).

Dosage:
 Bolus - 0.75 – 2.0 mg/kg IV bolus over 2-3 minutes and may be given undiluted via central line, may repeat in 30 minutes.

Closely monitor vital signs during the bolus. The vasodilatory effects can cause a sharp drop in blood pressure. Be prepared to administer a fluid bolus if necessary. Ideally, volume resuscitation will take place prior to initiating Inocor in order to optimize preload and raise cardiac output.  maintenance, 5-15 mcg/kg/min IV infusion

Inocor should be weaned slowly due to its long half life. Effects aren’t thought to be seen until approximately 4 hours after dose adjustments. The attending physician should be consulted before weaning Inocor off.

Admixture:
300mg/250ml 0.9% NACL yielding a concentration of 1200mcg/ml Inocor is a clear yellow solution

Potential adverse effects:

Hypotension, Hyperthermia, Abdominal pain, Diarrhea, Loss of appetite, Nausea, Vomiting, Cardiac

dysrhythmia, Thrombocytopenia, and Hepatotoxicity.

Hypotension caused by Inocor can be dose related and is treated with a combination of fluid boluses and vasoactive drugs. Follow the MD’s recommendation for treating related hypotension.

Levophed Bitartrate (Norepinephrine)
Levophed is a powerful vasopressor that is typically used when high doses of NeoSynephrine are ineffective. Some practitioners prefer it over Neo-Synephrine and use it first line. Adequate volume resuscitation should be assured prior to initiating Levophed.
Dosage: In CVRU Levophed is dosed as mcg/min. Initially started at 2-10mcg/min and titrated for response. When doses are required over 10mcg/min be sure to update the MD and consider other problems that may cause hypotension: low circulating volume, pneumothorax, hemothorax, etc. Notify the MD immediately if urine output drops after starting Levophed.

Admixture: In CVRU you will see Levophed mixed in 0.9% saline in different concentrations 4mg/250 (16mcg/ml) 8mg/250 (32mcg/ml) 16mg/250 (64mcg/ml)

Effects: Stimulates alpha and beta1 receptors causing vasoconstriction and cardiac stimulation. Adverse reactions/Precautions:
Bradyarrhythmia, Hypertension, Necrosis, Nausea, Vomiting, Confusion, Headache, Tremor, Anxiety, Restlessness, Urinary retention, asthma attack, severe hypertension.1 Extravasation injury can be severe so it should only be given through a central line when possible.

Regitine should be used per hospital policy for ANY amount of extravasation.
Antidote for Extravasation Ischemia: To prevent sloughing and necrosis in areas in which extravasation has taken place, the area should be infiltrated as soon as possible with 10 mL to 15 mL of saline solution containing from 5 mg to 10 mg of phentolamine mesylate for injection USP, an adrenergic blocking agent. A syringe with a fine hypodermic needle should be used, with the solution being infiltrated liberally throughout the area, which is easily identified by its cold, hard, and pallid appearance. Sympathetic blockade with phentolamine causes immediate and conspicuous local hyperemic changes if the area is infiltrated within 12 hours. Therefore, phentolamine should be given as soon as possible after the extravasation is noted.3

To calculate dose being given: If the pump rate is 15ml/hr

(Concentration x rate) / 60

(16mcg/ml x 15ml/hr)/60gtt = 4mcg/min is the dose being given

To calculate drip rate for a desired dosage: (Pump rate x 60) / concentration

To give 5mcg/min

(5mcg/min x 60gtt)/16mcg/ml = 18.75cc/hr is the desired pump rate

Consider acidosis when large or escalating doses are required Be sure to assess the skin in distal areas for signs of decreased circulation

Natrecor - Nesiritide
Natrecor can be used to reduce preload after cardiac surgery. Too much preload depresses cardiac output and causes pulmonary edema that can lead to respiratory failure. It is mainly used outside CVRU to treat decompensated heart failure.
Natrecor is a recombinant brain-type natriuretic peptide (BNP), which decreases pulmonary arterial (PA) pressures and myocardial oxygen consumption while increasing coronary flow and urine output. Natrecor can block cardiac sympathetic nervous system activity, inhibit the renin-angiotension-aldosterone system, has a relaxing (lusitropic) effect on the myocardium, and has antiproliferative and antifibrotic effects in the vascular tissue (3).

Action
Human BNP increases intracellular concentrations of guanosine 3'5'-cyclic monophosphate (cGMP) and smooth muscle cell relaxation by binding to the particulate guanylate cyclase receptor of vascular smooth muscle and endothelial cells. Cyclic GMP serves as a second messenger to dilate veins and arteries. In human studies in patients with heart failure, nesiritide has been shown to reduce pulmonary capillary wedge pressure (in a dose-dependent manner) and systemic arterial pressure (3).

Dosage:
2 mcg/kg IV bolus over 10-15 minutes followed by a maintenance infusion 0.3750.75 mcg/kg/min IV

Precautions:
 Major precautions are hypotension and arrhythmias. Natrecor may need to be discontinued or the dose reduced for significant hypotension.

Potential side effects:


Hypotension (11%-35%), Lightheadedness, Pruritus, Facial, Nausea, Confusion, Headache,
Paresthesia, Somnolence, Tremor, Cardiac dysrhythmia, Atrial/ventricular.

Natrecor Cont.

Chemical/Physical Interactions
Natrecor is physically and/or chemically incompatible with injectable formulations of heparin, insulin, ethacrynate sodium, bumetanide, enalaprilat, hydralazine, and furosemide. These drugs should not be co-administered as infusions with Natrecor through the same IV catheter. The preservative sodium metabisulfite is incompatible with Natrecor. Injectable drugs that contain sodium metabisulfite should not be administered in the same infusion line as Natrecor. The catheter must be flushed between administration of Natrecor and incompatible drugs. 1

 Natrecor binds to heparin and therefore could bind to the heparin lining of a heparin-coated catheter, decreasing the amount of Natrecor delivered to the patient for some period of time.

 Therefore, Natrecor must not be administered through a central heparin-coated catheter. Regular PA catheters are heparin coated.

Concomitant administration of a heparin infusion through a separate catheter is acceptable. 1

Neostigmine Bromide
Used for the reversal of neuromuscular blockade. It should always be given with Robinul to prevent bradycardia and hypotension (vagotonia).

Action
Neostigmine bromide is an anticholinesterase agent that competes with acetylcholine for binding to acetylcholinesterase at cholinergic transmission sites. It facilitates impulse transmission across neuromuscular junctions thus, improving cholinergic action. It is also exerts direct effects on skeletal muscle, autonomic ganglion cells and nerve cells of the central nervous system.

Dosage:
A weight based dose is used in CVRU.

 Robinul and neostigmine are mixed in a single syringe and given IVP over one minute.
Neostigmine and Robinul will be given after bleeding is controlled and after hemodynamics are stabilized. It should be given no sooner than two hours after admission per our current standing orders.

Precautions/Potential side effects:
Diaphoresis, Diarrhea, Excessive salivation, Flatulence, Increased peristalsis, Nausea and vomiting, Muscle twitch, Anaphylaxis, Seizure, Bronchospasm,   Cardiac dysrhythmia Respiratory arrest, Respiratory depression

Nipride - (Nitroprusside Sodium)
Nipride is used to control hypertension and reduce afterload. Due to its untoward side effects, great care must be taken when it is used.

Action:
life is brief.

Nipride lowers blood pressure by increasing levels nitrous oxide. Its action is rapid and half-

Dosage:
0.1 – 8.0mcg/kg/min titrated to the desired effect. The smallest dose possible should be used.

Admixture:

The standard CVRU concentration is 100mg in 250cc D5W.

Other units mix the drug 50mg/250cc D5W. The concentration should always be double checked when admitting a patient from other units.

Precautions:
 Abrupt hypotension can be seen when Nipride is started, especially in hypertensive patients that are hypovolemic. A fluid bolus may be required and is sometimes all that is needed to correct this problem.



Care should be taken not to flush lines that contain Nipride, as abrupt life threatening hypotension can ensue. Whenever Nipride is discontinued, the line should be aspirated then flushed to avoid this from occurring. Starting fluid in a line that contains any amount of retained Nipride can result in abrupt hypotension.
Nipride should be avoided in postop CV patients with a history of renal insufficiency.





Nipride can cause shunting in the pulmonary vasculature, resulting in lowered oxygen saturations and a need for a higher FIO2. This effect can usually be seen immediately and can be dose dependent. If this occurs, alert the ordering practitioner immediately.

Potential side effects:
Sodium nitroprusside rapidly reduces blood pressure and is converted in the body to cyanide and then thiocyanate. Its adverse effects can be attributed mainly to excessive hypotension and excessive cyanide accumulation; thiocyanate toxicity may also occur, especially in patients with renal impairment. Intravenous infusion of sodium nitroprusside may produce nausea and vomiting, apprehension, headache, dizziness, restlessness, perspiration, palpitations, retrosternal discomfort, abdominal pain, and muscle twitching, but these effects may be reduced by slowing the infusion rate (3). An excessive amount of cyanide in plasma (more than 80 nanograms/mL), because of overdosage or depletion of endogenous thiosulfate (which converts cyanide to thiocyanate in vivo), may result in tachycardia, sweating, hyperventilation, arrhythmias, and profound metabolic acidosis. Metabolic acidosis may be the first sign of cyanide toxicity. Thiocyanate can be removed by dialysis. Methaemoglobinaemia may also occur (3). Adverse effects attributed to thiocyanate include tinnitus, miosis, and hyperreflexia; confusion, hallucinations, and convulsions have also been reported (3).

Nitroglycerin
Nitroglycerin (NTG) has many uses in the postoperative cardiac surgery patient. It decreases preload and, to a lesser effect, afterload (1). It helps to increase coronary artery perfusion and decrease myocardial oxygen demand. Dr. Howe’s patients should always have NTG started per our standing order set unless otherwise contraindicated. Patients with high preload (particularly high PA pressures) may benefit from IV NTG. It will lower PA pressures and CVP via its vasodilatory action. Anytime ischemia is suspected postoperatively, nitroglycerin may be ordered due to its ability to dilate coronary arteries and increase coronary blood flow. Coronary artery dilatation is dose dependent and the rate is limited only by MD order, blood pressure and hemodynamic status. Nitroglycerin is also used short term (24-48 hours) to prevent spasm of internal mammary arteries in the postoperative environment. Rates may be as low as 10mcg/min and the dose used is dependent upon the blood pressure and hemodynamic status. Cardizem is also used for this purpose and may be chosen when its other effects would be beneficial in the specific patient situation. When the patient is able to take PO, an oral nitrate is started and IV NTG is discontinued. Abrupt discontinuation of NTG can cause coronary vasospasm, so close monitoring of rhythm, blood pressure and hemodynamics are warranted when it is stopped.

Dosage:
10mcg/min initially and then titrated to effect up to 100mcg/min. Dose will be dependent upon blood pressure and hemodynamics, keeping in mind that increasing coronary blood flow may improve cardiac function.

Admixture:
50mg in 250cc D5W glass bottle

Precautions:
Watch for hypotension, which is usually transient. Be prepared to administer fluid bolus or initiate vasopressor therapy for severe hypotension. NTG should not be given to volume depleted patients.
Potential side effects:  Headache, dizziness, weakness, orthostatic hypotension, tachycardia, flushing, palpitations, nausea, vomiting, rash, contact dermatitis, and/or hypersensitivity reactions (3).

Vasopressin
Vasopressin is used in septic and vasodilatory shock along with catecholamines to help raise blood pressure and reduce the duration and dose of them.

Action
The main role of vasopressin is to regulate water balance. In healthy individuals, it does not appear to play a role in blood pressure regulation. Individuals with high vasopressin levels do not necessarily display hypertension (6). “In shock states however, release of endogenous vasopressin is an important vasoconstrictor mechanism” (6). At greater than physiologic doses, vasopressin has a pressor effect due to vasoconstriction and causes contraction of the smooth muscle (3). It increases secretion of
corticotropin, which is a hormone produced by the anterior pituitary gland that stimulates the adrenal cortex. The adrenal cortex produces cortisol which is a major hormone responsible for blood pressure regulation.

Dosage:
Shock; Adjunct: 0.01 - 0.04 unit/min IV infusion; in combination with 1-2 additional catecholamines

Admixture:
At Presbyterian the most common mixture is 40units in 100cc 0.9% NACL.

Precautions:
Abdominal distention: decreased abdominal discomfort, diabetes insipidus: reduction of urine output, electrocardiograms, periodic during therapy, fluid and electrolytes status, periodic during therapy (3). Use caution in the following: any state in which a rapid addition to extracellular water may produce hazard for an already overburdened system, asthma, chronic nephritis with nitrogen retention contraindicates the use of vasopressin until reasonable nitrogen blood levels have been attained, do not use in patients with vascular disease, especially disease of the coronary arteries, except with extreme caution, epilepsy, heart failure, migraine, vasopressin may produce water intoxication; recognize early signs of drowsiness, listlessness and headaches in order to prevent terminal coma and convulsions (3).

Potential side effects:
Gangrenous disorder, Cutaneous, Sweating symptom, Urticaria, Gastrointestinal: Nausea, Passing flatus, Stomach cramps, Vomiting, Neurologic: Throbbing headache, Tremor, Vertigo, Cardiac arrest, Cardiac dysrhythmia, Coronary atherosclerosis, Decreased cardiac output, Gangrenous disorder, Water intoxication syndrome, Anaphylaxis, and/or Stenosis of bronchus (3).

Primacor – (Milrinone Lactate)
Primacor is used to increase cardiac output and lower vascular resistance after cardiac surgery. It is a direct phosphodiesterase in inhibitor and causes smooth muscle relaxation.

Action
Milrinone lactate is an inotropic/vasodilator. It selectively inhibits peak III cAMP phosphodiesterase isozyme found in cardiac and vascular muscle. This activity leads in increase of intracellular ionized calcium and contractile force in heart muscles (3).

Dosage:
Initial loading dose, 50 mcg/kg IV over 10 min

Three IV drip doses are used: 0.375mcg/kg/min, 0.5mcg/kg/min and 0.75mcg/kg/min

Admixture:
40mg in 200cc of 0.9% NACL yields 200mcg/ml

Initial bolus may be given via mini-bag from a separate vial or from the IV drip.

Precautions:
Atrial fibrillation/flutter, concurrent use of disopyramide, electrolyte abnormalities, hypotension, proarrhythmic effects, recent myocardial infarction, renal impairment, severe aortic or pulmonic valvular
disease

Potential side effects:
 Chest pain, Hypotension, Headache, Cardiac dysrhythmia, Thrombocytopenia, Hepatotoxicity.



Hypotension is the most commonly seen side effect. This can occur at any time during therapy, commonly during the initial bolus, and dose adjustments may be required. Due to the stark vasodilatory effect of Primacor, vasopressors and/or fluid therapy are commonly required. Monitor the heart rhythm closely and update the ordering physician of any atrial fibrillation, atrial or ventricular ectopy.



Phenylephrine HCL

(Neo-Synephrine)

Common vasopressor used after cardiac surgery to manage mild to severe hypotension after adequate volume resuscitation. Neo-Synephrine offers little effect other than vasoconstriction and is shunned by some practitioners for its tendency to cause decreased tissue perfusion.

Dosage: Dosed as mcg/min. Neo-Synephrine is started at a dose relative to the clinical situation. The textbook answer is: “To treat severe hypotension: initial IV rate 100-180 mcg/min until BP is stabilized; then may reduce IV rate to 40-60 mcg/min” 3 More realistically it can be started at lower doses unless hypotension is severe. Effects are sometimes seen immediately in the 20-50mcg/min range. Anytime high doses are required, be sure to update the MD. When dosages over 80-100mcg/min are being used a different medicine may be considered as an alternative or the patient may require more aggressive volume resuscitation.  The lowest dosage to meet set blood pressure parameters should be used.

Admixture: 20mg in 250ml of 0.9% saline yielding 80mcg/ml Standard admixture is 10mg/250ml and patients admitted from other units such as PACU will probably have this lower concentration. Be careful to assess the mixture.

Effects: Stimulates alpha receptors to cause vasoconstriction. Minimal effects on beta receptors. Adverse reactions/Precautions: Headache, restlessness, nervousness, dizziness, weakness, bradycardia, arrhythmias (unspecified), asthmatic episodes, decreased organ perfusion, allergic reaction.  Extravasation can cause sloughing of the skin. Neo should always be given in a central line when possible.

For a mixture of 20mg/250cc the concentration is 80mcg/ml

To calculate dose being given: If the pump rate is 60ml/hr

(Concentration x rate) / 60 (80mcg/ml x 60cc/hr) / 60gtt = 80mcg/min is the dose being given

To calculate drip rate for a desired dosage: (Pump rate x 60) / concentration

To give 50mcg/min

(50mcg/ml x 60gtt) / 80mcg/ml = 37.5cc/hr is the desired pump rate

Precedex - Dexmedetomidine
In CVRU, Precedex is used for post-operative sedation and pain management when extubation is anticipated within 24 hours of the drug being started. It does not depress respiratory function and does not need to be turned off prior to extubation. Low dose Precedex can be used to facilitate a smooth weaning from the ventilator. Some patients, particularly elderly, do require the drug to be discontinued to wean. Many of these patients have adequate sedation from the anesthetics and opioids used in the OR and don’t require further narcotics for some time after surgery. The nurse must use sound clinical judgment to identify these patients. Precedex reduces the need for add on morphine to maintain adequate analgesia, its big advantage over Diprivan. It can remain on to assist with pain control for up to 24 hours if needed. After extubation, Precedex may be titrated for effect to relieve pain. Patients will rest soundly and arouse easily allowing aggressive pulmonary toileting and early ambulation. It can cause a labile blood pressure.

Action
 
Alpha-2 Adrenergic Agonist Sedative

Dosage:
Bolus is only given by anesthesia in the operating room. The patient will arrive in CVRU with IV drip infusing at 0.6mcg/kg/hr. Therapeutic doses are achieved between 0.2-0.7 mcg/kg/hr.

Admixture:
400mcg in 100cc saline

Precautions:
     
geriatric: may need to use lower initial doses and increase gradually as needed and tolerated liver disease: may need to use lower initial doses and increase gradually as needed and tolerated renal impairment: may need to use lower initial doses and increase gradually as needed and tolerated Use care when administering to patients with advanced heart block or severe ventricular dysfunction

Watch for bradycardia
Should only be used for 24 hours from time of initial bolus. Since the bolus and drip are stated in the OR, the total CVRU administration time will be less than 24 hours.

Potential side effects:
Nausea, Xerostomia, Atrial fibrillation, Atrioventricular block, Bradyarrhythmia, Cardiac arrest (rare), Hypertension, Hypotension, Supraventricular tachycardia, Ventricular arrhythmia, Ventricular tachycardia


				
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