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Meropenem 220 mg q8h IV Action Inhibits bacterial cell-wall synthesis and penetrates gram-negative and gram-positive bacteria Availability

Powder for injection:500-mg and 1-g vials 1Indications and dosages Intra-abdominal infections Adults: 1 g I.V.q 8 hours over 15 to 30 minutes by infusion or over 3 to 5 minutes as a bolus injection Children weighing 50 kg (110 lb) or more: 1 g I.V.q 8 hours over 15 to 30 minutes by infusion or over 3 to 5 minutes as a bolus injection Children ages 3 months and older weighing less than 50 kg (110 lb): 20 mg/kg q 8 hours over 15 to 30 minutes by infusion or over 3 to 5 minutes as a bolus injection Bacterial meningitis Children weighing 50 kg (110 lb) or more: 2 g I.V.q 8 hours over 15 to 30 minutes by infusion or over 3 to 5 minutes as a bolus injection Children ages 3 month and older weighing less than 50 kg (110 lb): 40 mg/kg q 8 hours over 15 to 30 minutes by infusion or over 3 to 5 minutes as a bolus injection,to a maximum of 2 g q 8 hours Complicated skin and skinstructure infections Adults: 500 mg I.V.q 8 hours Dosage adjustment Renal impairment Off-label uses Acute pulmonary exacerbation caused by respiratory tract infection with susceptible organisms in cystic fibrosis patients Contraindications Hypersensitivity to drug,its components,or other beta-lactams Precautions Use cautiously in: sulfite sensitivity,renal disease, seizure disorder pregnant or breastfeeding patients children. Administration For I.V.bolus,add 10 or 20 ml of sterile water to 500-mg or 1-g vial,respectively,to yield a concentration of 50 mg/ml.Shake until clear.Administer single dose over 3 to 5 minutes. For intermittent I.V.infusion,piggyback vials can be reconstituted with compatible I.V.solution (0.9% sodium chloride or 5% dextrose) to yield a concentration of 2.5 to 50 mg/ml.Or vials can be reconstituted as for direct I.V.injection and added to compatible I.V.solution for further dilution.To

reconstitute and administer ADDVantage systems,follow manufacturers instructions.Infuse drug over 15 to 30 minutes. Use diluted solution immediately,if possible. Route Onset Peak Duration I.V. Unknown 1 hr Unknown Adverse reactions CNS: headache,insomnia,dizziness, drowsiness,weakness,seizures CV: hypotension,phlebitis,palpitations,heart failure, cardiac arrest, myocardial infarction GI: nausea,vomiting,diarrhea,constipation,tongue discoloration,oral candidiasis,glossitis,pseudomembranous colitis GU: vaginal candidiasis Hematologic: anemia,eosinophilia, leukopenia,bone marrow depression, thrombocytopenia,neutropenia Musculoskeletal:myoclonus Respiratory: chest discomfort,dyspnea,hyperventilation Skin: rash,urticaria,pruritus,erythema at injection site Other: altered taste,fever,pain,fungal infection,anaphylaxis Interactions Drug-drug.Probenecid: increased meropenem blood level Drug-diagnostic tests.Alanine aminotransferase, alkaline phosphatase, amylase, aspartate aminotransferase, bilirubin, blood urea nitrogen, eosinophils, gamma-glutamyl transpeptidase, lactate dehydrogenase, lipase: increased values Hematocrit, hemoglobin, platelets, neutrophils, white blood cells: decreased values International Normalized Ratio, partial thromboplastin time, prothrombin time: increased or decreased values Patient monitoring Collect specimens for culture and sensitivity testing as needed.However, be aware that drug therapy may start pending results. 2Monitor patient for hypersensitivity reaction or anaphylaxis.If either occurs,stop infusion immediately and initiate emergency treatment. Monitor for CNS irritability and seizures. In prolonged therapy,evaluate hematopoietic,renal,and hepatic function and watch for overgrowth of nonsusceptible organisms. If diarrhea occurs,check for pseudo-

membranous colitis and obtain stool cultures. Obtain hearing tests in child being treated for bacterial meningitis. Patient teaching Advise patient to report such adverse reactions as CNS irritability,diarrhea, rash,shortness of breath,or pain at infusion site. As appropriate,review all other significant and life-threatening adverse reactions and interactions,especially those related to the drugs and tests mentioned above. Furosemide 1.5 mg q 8h IV furosemide Apo-Furosemide?,Bio-Furosemide?, Dom-Furosemide?,Frusol , Lasix, Lasix Special?, Novosemide?, Nu-Furosemide?,PMS-Furosemide? Pharmacologic class: Sulfonamide loop diuretic Therapeutic class: Diuretic,antihypertensive Pregnancy risk category C Action Unclear.Thought to inhibit sodium and chloride reabsorption from ascending loop of Henle and distal renal tubules.Increases potassium excretion and plasma volume,promoting renal excretion of water,sodium, chloride,magnesium,hydrogen,and calcium. Availability Injection: 10 mg/ml Oral solution: 10 mg/ml,40 mg/5 ml Tablets: 20 mg,40 mg,80 mg 1Indications and dosages Acute pulmonary edema Adults: 40 mg I.V.given over 1 to 2 minutes.If adequate response doesnt occur within 1 hour,give 80 mg.I.V. over 1 to 2 minutes. Edema caused by heart failure,hepatic cirrhosis,or renal disease Adults: Initially, 20 to 80 mg/day P.O. as a single dose; may increase in 20to 40-mg increments P.O. q 6 to 8 hours until desired response occurs. Thereafter, may give once or twice daily. For maintenance, dosage may be reduced in some patients or carefully titrated upward to 600 mg P.O. daily in severe edema. Usual I.M. or I.V. dosage is 20 to 40 mg as a single injection; if response inadequate, second and each succeeding dose may be increased in 20-mg increments and given no more often than q 2 hours until desired response occurs. Single dose may then be given once or twice daily. Infants and children: 2 mg/kg P.O. (oral solution) as a single dose.As nec-

essary,increase in increments of 1 or 2 mg/kg q 6 to 8 hours to a maximum of 6 mg/kg/dose.For maintenance,give minimum effective dosage. Hypertension Adults: 40 mg P.O.b.i.d.If satisfactory response doesnt occur,other antihypertensives may be added before furosemide dosage is increased.However,dosage may be titrated upward as needed and tolerated to a maximum of 240 mg P.O.daily in two or three divided doses. Off-label uses Hypercalcemia associated with cancer Contraindications Hypersensitivity to drug or other sulfonamides Anuria Precautions Use cautiously in: diabetes mellitus,severe hepatic disease elderly patients pregnant or breastfeeding patients neonates. Administration Know that I.V.or I.M.injection is given when patient requires rapid onset of diuresis or cant receive oral doses. Be aware that I.V.dose may be given by direct injection over 1 to 2 minutes. For I.V.infusion,dilute in dextrose 5% in water,normal saline solution,or lactated Ringers solution. 2Dont infuse more than 4 mg/ minute. Give oral doses in morning with food.If second dose is prescribed,give in afternoon. Route Onset Peak Duration P.O. 30-60 min 1-2 hr 6-8 hr I.V. 5 min 20-60 min 2 hr I.M. 10-30 min 30 min 4-8 hr Adverse reactions CNS: dizziness,headache,vertigo, weakness,lethargy,paresthesia,drowsiness,restlessness,light-headedness CV: hypotension,orthostatic hypotension,tachycardia,volume depletion, necrotizing angiitis,thrombophlebitis,arrhythmias EENT:blurred vision,xanthopsia,

hearing loss,tinnitus GI: nausea,vomiting,diarrhea,constipation,dyspepsia,oral and gastric irritation,cramping,anorexia,dry mouth,acute pancreatitis GU: excessive and frequent urination, nocturia,glycosuria,bladder spasm, oliguria,interstitial nephritis Hematologic: anemia,purpura,leukopenia,thrombocytopenia,hemolytic anemia Hepatic: jaundice Metabolic: hyperglycemia,hyperuricemia,dehydration,hypokalemia,hypomagnesemia,hypocalcemia,hypochloremic alkalosis Musculoskeletal: muscle pain,muscle cramps Skin: photosensitivity,rash,diaphoresis,urticaria,pruritus,exfoliative dermatitis,erythema multiforme Other:fever,transient pain at I.M.injection site Interactions Drug-drug. Aminoglycosides, ethacrynic acid, other ototoxic drugs: increased risk of ototoxicity Amphotericin B, corticosteroids, corticotropin, potassium-wasting diuretics, stimulant laxatives: additive hypokalemia Antihypertensives, diuretics, nitrates: additive hypotension Cardiac glycosides: increased risk of glycoside toxicity and fatal arrhythmias Clofibrate: exaggerated diuretic response,muscle pain and stiffness Hydantoins, nonsteroidal anti-inflammatory drugs, probenecid: diuresis inhibition Insulin, oral hypoglycemics: decreased hypoglycemic effect Lithium: decreased lithium excretion, possible toxicity Norepinephrine: decreased arterial response to norepinephrine Propranolol: increased propranolol blood level Salicylates: increased risk of salicylate toxicity at lower dosages than usual Succinylcholine: potentiation of succinylcholine effect Sucralfate: decreased naturietic and antihypertensive effects of furosemide Sulfonylureas: decreased glucose tolerance,resulting in hyperglycemia Theophyllines: altered,enhanced,or inhibited theophylline effects Tubocurarine: antagonism of tubocurarine effects Drug-diagnostic tests. Blood urea nitrogen (BUN): transient increase Calcium, magnesium, platelets, potassium, sodium: decreased levels Cholesterol, creatinine, glucose, nitrogenous compounds: increased levels

Drug-herbs. Dandelion: interference with drugs diuretic effect Ephedra (ma huang),ginseng: decreased furosemide efficacy Licorice: rapid potassium loss Drug-behaviors. Acute alcohol ingestion: additive hypotension Sun exposure: increased risk of photosensitivity Patient monitoring Watch for signs and symptoms of ototoxicity. 2Assess for other evidence of drug toxicity (arrhythmias,renal dysfunction,abdominal pain,sore throat,fever). Monitor CBC,BUN,and electrolyte, uric acid,and CO2levels. Monitor blood pressure,pulse,fluid intake and output,and weight. Assess blood glucose levels in patients with diabetes mellitus. Monitor dietary potassium intake. Watch for signs and symptoms of hypokalemia. Patient teaching Instruct patient to take in morning with food (and second dose,if prescribed,in afternoon),to prevent nocturia. Tell patient that drug may cause serious interactions with many common drugs.Instruct him to tell all prescribers hes taking it. Instruct patient to report signs and symptoms of ototoxicity (hearing loss, ringing in ears,vertigo) and other drug toxicities. Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration and alertness. Instruct patient to move slowly when rising,to avoid dizziness from sudden blood pressure decrease. Encourage patient to discuss need for potassium and magnesium supplements with prescriber. Caution patient to avoid alcohol and herbs while taking this drug. Inform patient that hell undergo regular blood testing during therapy. As appropriate,review all other significant and life-threatening adverse reactions and interactions,especially those related to the drugs,tests,herbs, and behaviors mentioned above. VITAMIN K Classification Vitamins Indications Hypoprothrombinemia secondary to vitamin K malabsorption, drug therapy, or excessive vitamin A dosage; hypoprothrombinemia secondary to

effect of oral anticoagulants; prevention of hemorrhagic disease of newborn prevention of hypoprothrombonemia related to vitamin K deficiency for longterm parenteral nutrition; prevention of hypoprothrombinemia in infants receiving less than 0.1 mg/liter vitamin K in breast milk or milk substitute. Action An antihemorrhagic actor that promotes hepatic formation of active prothrombin. Adverse Reactions dizziness, transient hypotension after IV administration, rapid and weak pulse, diaphoresis,flushing, erythema, pain, swelling and hematoma at injection site. Nursing Considerations

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IV use: Dilute with 0.9% sodium chloride for injection, D5W, or D5W in 0.9% sodium chloride for injection. Give IV by slow infusion over 2 to 3 hours. Rate shouldnt exceed 1 mg/minute in adults or 3 mg/m2/minute in children. Effects of IV injection are more rapid but shorter-lived than SC or IM injections. Protect parenteral products from light. Wrap infusion container with aluminum foil. For IM administration in adults and older children, administer in upper outer quadrant of buttocks; for infants, administer in the anterolateral aspect of thigh or deltoid region. Anticipate order of weekly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solutions. Monitor PT to determine dosage effectiveness as ordered. If severe bleeding occurs, dont delay other measures, such as fresh frozen plasma or whole blood. Alert: watch for signs of flushing, weakness, tachycardia and hypotension; may progress to shock. Be aware that phytonodione therapy for hemorrhagic disease in infants causes fewer adverse reactions than

Failure to respond to vitamin K may indicate coagulation defects. Calcium glusconate + equal diluents q6h IV Action Increases serum calcium level through direct effects on bone,kidney,and GI tract.Decreases osteoclastic osteolysis by reducing mineral release and collagen breakdown in bone. Availability Calcium acetate Gelcaps: 667 mg Tablets: 667 mg Calcium carbonate Capsules: 1,250 mg Lozenges: 600 mg Oral suspension: 1,250 mg Powder: 6.5 g Tablets: 650 mg,1,250 mg,1,500 mg Tablets (chewable): 750 mg,1,000 mg, 1,250 mg Tablets (gum): 300 mg,450 mg,500 mg Calcium chloride Injection: 10% solution Calcium citrate Tablets: 950 mg Calcium glubionate Syrup: 1.8 g/5 ml (contains 115 mg of elemental calcium) Calcium gluceptate Injection: 22% solution Calcium gluconate Injection: 10% solution Tablets: 500 mg,650 mg,975 mg Calcium lactate Tablets: 325 mg,500 mg,650 mg Tricalcium phosphate Tablets: 600 mg 1Indications and dosages Hypocalcemic emergency Adults: 7 to 14 mEq I.V.of 10% calcium gluconate solution,2% to 10% calcium chloride solution,or 22% calcium gluceptate solution Children: 1 to 7 mEq calcium gluconate I.V. Infants: Up to 1 mEq calcium gluconate I.V. Hypocalcemic tetany Adults: 4.5 to 16 mEq calcium gluconate I.V.,repeated as indicated until tetany is controlled Children: 0.5 to 0.7 mEq/kg calcium gluconate I.V.three to four times daily as indicated until tetany is controlled Neonates: 2.4 mEq/kg calcium gluconate I.V.daily in divided doses Cardiac arrest Adults: 0.027 to 0.054 mEq/kg calcium chloride I.V.,4.5 to 6.3 mEq calcium gluceptate I.V.,or 2.3 to 3.7 mEq calci-

um gluconate I.V. Children: 0.27 mEq/kg calcium chloride I.V.,repeated in 10 minutes if needed.Check calcium level before giving additional doses. Magnesium intoxication Adults: Initially,7 mEq I.V.;subsequent dosages based on patient response Exchange transfusions Adults: 1.35 mEq calcium gluconate I.V.with each 100 ml of citrated blood Hyperphosphatemia in patients with end-stage renal disease Adults:Two tablets P.O.daily,given in divided doses t.i.d.with meals.May increase gradually to bring serum phosphate level below 6 mg/dl,provided hypercalcemia doesnt develop. Dietary supplement Adults:500 mg to 2 g P.O.daily Off-label uses Osteoporosis Contraindications Hypersensitivity to drug Ventricular fibrillation Hypercalcemia and hypophosphatemia Cancer Renal calculi Pregnancy or breastfeeding Precautions Use cautiously in: renal insufficiency,pernicious anemia,heart disease,sarcoidosis,hyperparathyroidism,hypoparathyroidism history of renal calculi children. Administration 2When infusing I.V.,dont exceed a rate of 200 mg/minute. Keep patient supine for 15 minutes after I.V.administration to prevent orthostatic hypotension. Administer P.O.doses 1 to 112 hours after meals. Know that I.M.or subcutaneous administration is never recommended. Be aware that I.V.route is preferred in children. Be alert for extravasation,which causes tissue necrosis. Route Onset Peak Duration P.O. Unknown Unknown Unknown I.V. Immediate Immediate 0.5-2 hr Adverse reactions CNS: headache,weakness,dizziness, syncope,paresthesia CV: mild blood pressure decrease,

bradycardia,arrhythmias,cardiac arrest (with rapid I.V.injection) GI: nausea,vomiting,diarrhea,constipation,epigastric pain or discomfort GU: urinary frequency,renal calculi Metabolic: hypercalcemia Musculoskeletal: joint pain,back pain Respiratory: dyspnea Skin: rash Other: altered or chalky taste,excessive thirst,allergic reactions (including facial flushing,swelling,tingling,tenderness in hands,and anaphylaxis) Interactions Drug-drug. Atenolol, fluoroquinolones, tetracycline: decreased bioavailability of these drugs Calcium channel blockers: decreased calcium effects Cardiac glycosides: increased risk of cardiac glycoside toxicity Iron salts: decreased iron absorption Sodium polystyrene sulfonate: metabolic alkalosis Verapamil: reversal of verapamil effects Drug-diagnostic tests.Calcium: increased level Drug-food. Foods containing oxalic acid (such as spinach), phytic acid (such as whole grain cereal), or phosphorus (such as dairy products): interference with calcium absorption Patient monitoring Monitor calcium levels frequently, especially in elderly patients. Patient teaching Instruct patient to consume plenty of milk and dairy products during therapy. Refer patient to dietitian for help in meal planning and preparation. As appropriate,review all other significant and life-threatening adverse reactions and interactions,especially those related to the drugs,tests,and foods mentioned above Citicoline 85 mg q12 IV Citicoline is a brain chemical that occurs naturally in the body. As a medicine, it is taken by mouth as a supplement or given by IV or as a shot. Citicoline is used for Alzheimer's disease and other types of dementia, head trauma, cerebrovascular disease such as stroke, age-related memory loss, Parkinson's disease, attention deficit-hyperactive disorder (ADHD), and glaucoma. Citicoline was originally developed in Japan for stroke. It was later introduced as a prescription drug in many European countries. In these countries it is now frequently prescribed for thinking

problems related to circulation problems in the brain. In the US, citicoline is marketed as a dietary supplement. How does it work? Citicoline seems to increase a brain chemical called phosphatidylcholine. This brain chemical is important for brain function. Citicoline might also decrease brain tissue damage when the brain is injured.

Age-related memory problems. Citicoline seems to help memory loss in people aged 50 to 85 years. Stroke recovery. Stroke patients who take citicoline by mouth within 24 hours of having the kind of stroke that is caused by a clot (ischemic stroke) are more likely than other ischemic stroke patients to have a complete recovery within 3 months. Long-term blood circulation problems in the brain (cerebrovascular diseases). There is some evidence that citicoline taken by mouth or given by IV or as a shot might improve memory and behavior in patients with long-term cerebrovascular diseases, such as stroke.

Insufficient Evidence for:

Alzheimer's disease and other types of dementia. Some evidence suggests that taking citicoline by mouth might improve learning, memory and information processing (cognitive function) in people with mild to moderate Alzheimer's disease. Parkinson's disease. There is some evidence that citicoline given as a shot along with usual treatment might improve some of the symptoms of Parkinsons disease, but not tremor. Attention deficit-hyperactive disorder (ADHD). Glaucoma. Developing evidence suggests that citicoline might improve visionin some people with glaucoma. Vascular dementia. Taking citicoline does not seem to improve symptoms in people with vascular dementia. Head trauma. Other conditions.

Citicoline seems to be safe when taken short-term (up to 90 days). The safety of long-term use is not known. Most people who take citicoline don't experience problematic side effects. But some people can have side effects such as trouble sleeping (insomnia), headache, diarrhea, low or high blood pressure, nausea, blurred vision, chest pains, and others. Special Precautions & Warnings: Pregnancy and breast-feeding: Not enough is known about the use of citicoline during pregnancy and breastfeeding. Stay on the safe side and avoid use. omeprazole Heartburn Relief , Losec? , Mepradec , Prilosec, Prilosec OTC, Ratio-Omeprazole?, Sandoz Omeprazole?, Zanprol , Zegerid Pharmacologic class: Proton pump inhibitor Therapeutic class: Antiulcer drug Pregnancy risk category C Action Reduces gastric acid secretion and increases gastric mucus and bicarbonate production,creating protective coating on gastric mucosa and easing discomfort from excess gastric acid Availability Capsules (delayed-release):10 mg, 20 mg,40 mg Powder for oral suspension: 20 mg Tablets (delayed-release): 20 mg 1Indications and dosages Gastroesophageal reflux disease Adults: 20 mg P.O.(capsules,powder) daily for 4 weeks Erosive esophagitis Adults: 20 mg P.O.(capsules,powder) daily for 4 to 8 weeks Short-term treatment of active duodenal ulcer Adults: 20 mg P.O.(capsules,powder) daily for 4 weeks.Some patients may need 4 additional weeks of therapy. To reduce risk of duodenal ulcers caused by Helicobacter pylori Adults:40 mg P.O.(capsules) daily in morning,given with clarithromycin t.i.d. for 2 weeks;then 20 mg daily for 2 weeks Gastric ulcers Adults: 40 mg P.O.(capsules) daily for 4 to 8 weeks Pathologic hypersecretory conditions,including Zollinger-Ellison syndrome Adults: Initially,60 mg P.O.(capsules) daily; may increase up to 120 mg t.i.d. Divide daily dosages above 80 mg.

and blood level,possible digoxin Frequent heartburn (two or more Effective for toxicity episodes a week) Helping to prevent crusting in people with a tube in their windpipe (people who have undergone a tracheostomy). Drugs metabolized by CYP450 system: Adults ages 18 and older: 20 mg P.O. Acetaminophen (Tylenol) poisoning. N-acetyl cysteine is effective in reducing the death rate and preventing the permanent har competitive metabolism (OTC tablets) daily for 14 days use, N-acetyl cysteine given by mouth is as effective as N-acetyl cysteine given intravenously (by IV). Drug-diagnostic tests. Alanine phosOff-label uses Reducing mucus and helping breathing in various phatase, alkalinewith aminotransferase, as- lung conditions. Posterior laryngitis . partate aminotransferase, bilirubin: in To enhance pancreatin efficacy in Cystic fibrosis creased levels Possibly Effective for treating steatorrhea in cystic fibrosis Gastrin: increased level during first patients Preventing problems such as heart attack and stroke in people with serious kidney disease. The risk reduction can be as much 1 to 2risk weeks of therapy Contraindications reduce the overall of death or death from heart disease in these people. Patient Hypersensitivity to drug or its Chest pain (angina) . monitoring Assess vital signs. components Preventing complications of chronic bronchitis. Check for abdominal pain,emesis, Precautions Preventing complications of lung disease (chronic obstructive pulmonary disease, COPD). diarrhea,or constipation. Use cautiously in: Preventing side effects of ifosfamide (Ifex), which is used for certain types of cancer. Evaluate fluid intake and output. hepatic disease Preventing kidney problems with dyes during Watch for elevated liver used function testsome X-ray exams. pregnant or breastfeeding patients Reducing homocysteine levels, a possible risk factor for heart disease. results (rare). children (safety not established). Patient teaching Administration Reducing symptoms of the flu. Tell patient to take 30 Give 30 to 60 minutes before a meal, Reducing symptoms of hair pulling . to 60 minutes before a meal,preferably in morning. preferably in morning. Treating some types of epilepsy seizures. Instruct patient to swallow capsules If desired,give concurrently with Treating a lung disease called fibrosing alveolitis. or tablets whole and not to chew or antacids. Possibly forthem.If he cant swallow capcrush Know that if patient has ulcer at start Ineffective Preventing side effects ofhe doxorubicin for treating certain types of cancer). sule,tell him may open (used it,carefully of therapy,treatment may be extended. sprinkle and mix sclerosis entire contents into 1 When giving through nasogastric Treating amyotrophic lateral (ALS, Lou Gehrigs disease). tbsp of cool applesauce,and swallow tube,use powder for oral suspension, Likely Ineffective for immediately with glass of water. or separate capsule and mix pellets Preventing new tumors in people with head and neck cancer, or lung cancer. Inform patient taking OTC delayedwith water.Agitate syringe while Treating Alzheimers disease. release tablets for heartburn that full injecting.After administration,flush Improving how the may body responds to nitroglycerin effect take 1 to 4 days.Advise him (Nitrostat). with 30 to 60 ml of water. Treating organ failure . not to take tablets for more than 14 Dont crush capsules. days consulting healthcare Be aware that symptomatic response Insufficient Evidence towithout Rate Effectiveness for professional. doesnt rule out gastric cancer. Colon cancer. Taking N-acetyl cysteine may reduce the likelihood of colon and rectal cancer in patients with a history of adenom Caution patient to avoid and Route Heart attack. Early evidence shows that driving N-acetyl cysteine given by IV along with nitroglycerin and another drug called streptokin Onset heart attack. other hazardous activities until he knows how drug affects concentration Peak Carbon monoxide poisoning. and alertness. Duration Allergic reactions to phenytoin (Dilantin) . As appropriate,review all other sigP.O. Ear infections . nificant adverse reactions and interacWithin 1 hr Within 2 hr 72-96 hr Hay fever. tions,especially those related to the P.O. drugs and tests mentioned above. Unknown Removing heavy metals such as mercury, lead, and cadmium from the body . 10-90 min Chronic fatigue syndrome (CFS). Unknown Preventing alcoholic liver damage. (delayed) Protecting against environmental pollutants. omeprazole 857 -ACETYL CYSTEINE Other conditions. o What is it? More evidence is needed to rate the effectiveness of N-acetyl cysteine for these uses. Reactions bold are life-threatening. N-acetyl cysteine comes fromin the amino acid L-cysteine. Amino acids are the building blocks of proteins. N-acetyl cysteine has many uses as medicine.N-acetyl cysteine is used to How does it poisoning. work? 2Clinical (Tylenol) alert counteract acetaminophen and carbon monoxide It is also used for chest pain (unstable angina), bile duct blockage in infants, amyotrophic lateral sclerosis (ALS, Lou N-acetyl cysteine treats drug acetaminophen (Tylenol) poisoning by binding called the poisonous forms of acetaminophen that formed in the Adverse reactions Gehrigs disease), Alzheimers disease, allergic reactions to the anti-seizure phenytoin (Dilantin), and an eye infection keratoconjunctivitis. It is also used for are reducing levels of l preventing cancer. dizziness,headache,asthenia type of cholesterol CNS: called lipoprotein (a), homocysteine levels (a possible risk factor for heart disease) and the risk of heart attack and stroke in patients with serious kidney disease.Some Are there safety concerns? GI: nausea,vomiting,diarrhea,constipeople use N-acetyl cysteine for chronic bronchitis, chronic obstructive pulmonary disease (COPD), hay fever, a lung condition called fibrosing alveolitis, head and neck cancer, and lung N-acetyl cysteine is LIKELY SAFE for of most adults, whenchronic used asfatigue a prescription medication. It can cause nausea, vomiting, and diarrhea o pation,abdominal pain cancer. It is also used for treating some forms of epilepsy; ear infections; complications kidney dialysis; syndrome (CFS); an autoimmune disorder called Sjogrens headache, drowsiness, low blood pressure, liver problems.When inhaled (breathed into the lungs), it can causelead, swelling Musculoskeletal: back pain syndrome; preventing sports injury complications; radiation treatment; increasing immunity to and flu and H1N1 (swine) flu; and for detoxifying heavy metals such asalso mercury, and in the chest tightness.N-acetyl cysteine has an unpleasant odor that may make it hard to take. Respiratory:cough,upper respiratory cadmium. Special Precautions & Warnings: infection N-acetyl cysteine istract also used for preventing alcoholic liver damage; for protecting against environmental pollutants including carbon monoxide, chloroform, urethanes and certain Pregnancy or breast-feeding : N-acetyl cysteine is POSSIBLY SAFE when taken bypreventing mouth, delivered hole the windpipe, or b Skin:rash herbicides; for reducing toxicity of ifosfamide and doxorubicin, drugs that are used for cancer treatment; as a hangover remedy; for kidney through damage a due toin certain X-ray dyes; but there is no evidence so far linking it with harm to the unborn child or mother. However, N-acetyl cysteine should only be used in p Interactions virus (HIV). and for human immunodeficiency cases of acetaminophen toxicity. overdose, acrylonitrile poisoning, amyotrophic lateral sclerosis (ALS, Lou Gehrigs disea se), kidney Drug-drug. Ampicillin, cyanocobalHealthcare providers give N-acetyl cysteine intravenously (by IV) for acetaminophen Allergy : Dont use pain N-acetyl cysteine if you are allergic to acetyl amin, ketoconazole: reduced failure in the presence of iron liver salts, disease (hepatorenal syndrome), chest in combination with nitroglycerin, heart cysteine. attack in combination with nitroglycerin and streptokinase, and for Asthma: There is a concern that N-acetyl cysteine might cause bronchospasm in people with asthma if inhaled or taken by mouth or th absorption of theseleading drugs to death. helping to prevent multi-organ failure cysteine and or have asthma, you should bein monitored by your healthcare provider. increased omeprazole N-acetyl cysteine isClarithromycin: sometimes inhaled (breathed into the lungs) delivered through a tube the throat to treat certain lung disorders such as pneumonia, bronchitis, emphysema, cyst Are there any interactions with medications? blood level fibrosis, and others. Activated charcoal Diazepam, phenytoin, warfarin: proit Effective? Interaction Rating = Moderate Be cautious with this combination. longed elimination and increased efNatural Medicines Comprehensive Database rates effectiveness based on scientific evidence according to the following scale: Effective, Likely Effective, Possibly Effective, Possibly Talk with yourto health provider. fects of these drugs and Insufficient Ineffective, Likely Ineffective, Ineffective, Evidence Rate.The effectiveness ratings for N-ACETYL CYSTEINE are as follows: Digoxin: increased digoxin absorption Activated charcoal is sometimes used to prevent poisoning in people who take too much acetaminophen and other medications. Activ

by the body. Taking N-acetyl cysteine at the same time as activated charcoal pates might heat decrease and lowers how body well it works for preventing 4-11 poisoning. months 80 mg q 4 hr temperature. 5 doses in 24 hr Availability 0-3 months bination. Caplets, capsules: 160cause mg,500 mg, chance of side 40 mg q 4 hr se blood flow. Taking N-acetyl cysteine seems to increase the effects of nitroglycerin. This could increased effects 650 mg (extended-release) 5 doses in 24 hr ess. Drops: 100 mg/ml Rectal use nts? Elixir: 80 mg/2.5 ml,80 mg/5 ml, Age supplements. 120 mg/5 ml,160 mg/5 ml Usual Gelcaps: 500 mg Maximum Liquid: 160 mg/5 ml,500 mg/15 ml dosage Solution: 80 mg/1.66 ml,100 mg/1 ml, dosage fic research:BY MOUTH: 120 mg/2.5 ml,160 mg/5 ml,167 mg/5 12 years he beginning of treatment, a first high dose of 140 mg/kg of a 5% solution of N-acetyl cysteine is given. The commercially available 10% ml 325-650 mg er, carbonated, or non-carbonated beverages, and given through a straw to lessen the unpleasant odor of N-acetyl cysteine. Seventeen Suppositories: 80 mg,120 mg,125 mg, 4,000 mg/day on are given every 4 hours, for a total dose of 1330 mg/kg over 72 hours. 300 mg,325 mg,650 mg and older unstable angina): 600 mg of N-acetyl cysteine three times daily with a nitroglycerin patch. Suspension: 32 mg/ml,160 mg/5 ml q 4 hr c bronchitis: doses of 200 mg twice daily, 200 mg three times daily, 300 mg slow-release twice Syrup: 160 mg/5 ml daily, and 600 mg controlled-release 11-12twice years 320-480 mg Tablets (chewable): 80 mg,160 mg 2,880 mg/day disease (COPD): 600 mg of N-acetyl cysteine once daily, in addition to standard care, has been used for up mg, to 6 months. Tablets (extended-release): 160 q 4 hr 325daily. mg,500 mg,650 mg 6-11 years g alveolitis that makes breathing difficult: 600 mg of N-acetyl cysteine 3 times (film-coated): 160 mg,325 mg, 325 mg q 4 hr to treatment with a cancer drug called ifosfamide: 1 to 2 grams of N-acetylTablets cysteine every 6 hours. 500 mg 2,600 mg/day blood: 1.2 grams of N-acetyl cysteine daily. 1Indications and dosages 3-6 years 120-125 mg Mild to moderate pain caused by aily. 720 mg/day headache,muscle ache,backache,mitrokes in patients with end-stage kidney disease: 600 mg twice daily. q 6 hr nor arthritis,common cold,toothache, ment: 200 mg four times daily or 600 mg twice daily. 1-3 years or menstrual cramps or fever with the use of iopromide (Ultravist-300) for diagnostic tests: 400 to 600 mg of N-acetyl cysteine daily on the day before and on q the 80 mg 4 hr Adults: 325 to 650 mgtwice P.O.q4 to 6 line (0.45%) 1 mL/kg body weight per hour for 12 hours before and 12 hours after iopromide administration. 3-11 months 80 mg q 6 hr hours,or 1,000 mg three or four times Dosage adjustment daily.Or two extended-release caplets cysteine 1200 mg to 2400 mg daily has been used. Renal or hepatic impairment or tablets P.O.q 8 hours,to a maxiContraindications mum dosage of 4,000 mg/day.Or intravenously (by IV) for acetaminophen poisoning. Hypersensitivity to drug 650 mg P.R.q 4 to 6 hours,to a maxiPrecautions mum dosage of 4,000 mg/day. Actylcystine, Chlorhydrate de Cystine, Cysteine, Cystine, Cysteine Hydrochloride, Cystine, Hydrochlorure de Cystine, L-Cysteine, LUse cautiously in: Children: 10 to 15 mg/kg,or as indiAcetil Cistena, N-Acetyl-B-Cysteine, N-Actyl Cystine, N-Acetyl-L-Cysteine, N-Actyl-L-Cystine, N-Acetylcysteine, N-Actylcystine. anemia,hepatic or renal disease cated below: elderly patients Oral use cetaminophen pregnant or breastfeeding patients Age Abenol?,Acephen,Anadin children younger than age 2. Usual Paracetamol ,Apo-Acetaminophen?, Administration Maximum Aspirin Free Anacin,Atasol?,Calpol , Be aware that although most patients dosage Cetaphen,Childrens Tylenol Soft tolerate drug well,toxicity can occur dosage Chews,Disprol ,Feverall,Galpamol , with a single dose. 11-12 years Genapap,Genebs,Little Fevers, Know that acetylcysteine may be or480 mg q 4 hr Mandanol ,Mapap,Nortemp, dered to treat acetaminophen toxicity, 5 doses in 24 hr Nortemp Children's,Novo-Gesic?, depending on patients blood drug level. 9-10 years Pain Eze,Panadol ,Pediatrix?, Activated charcoal is used to treat 400 mg q 4 hr Silapap,Tempra?,Tycolene,Tylenol 8 acute,recent acetaminophen overdose 5 doses in 24 hr Hour,Tylenol,Tylenol Arthritis,Valorin (within 1 hour of ingestion). Oral use (continued) Pharmacologic class: Synthetic nonacetaminophen 15 Age opioid p-aminophenol derivative a Usual Therapeutic class:Analgesic,antipyretic Reactions in bold are life-threatening. Maximum Pregnancy risk category B 2Clinical alert dosage 14 (continued) dosage acetaminophen Determine overdose severity by 6-8 years ?Canada measuring acetaminophen blood level 320 mg q 4 hr UK no sooner than 4 hours after overdose 5 doses in 24 hr Hazardous drug ingestion (to ensure that peak concen4-5 years High alert drug tration has been reached). 240 mg q 4 hr Action Route 5 doses in 24 hr Unclear.Pain relief may result from inhiOnset 2-3 years bition of prostaglandin synthesis in CNS, Peak 160 mg q 4 hr with subsequent blockage of pain imDuration 5 doses in 24 hr pulses.Fever reduction may result from P.O. 1 year vasodilation and increased peripheral 0.5-1 hr 120 mg q 4 hr blood flow in hypothalamus,which dissi10-60 min 5 doses in 24 hr

3-8 hr (dose dependent) P.R. 0.5-1 hr 10-60 min 3-4 hr Adverse reactions Hematologic:thrombocytopenia,hemolytic anemia, neutropenia, leukopenia,pancytopenia Hepatic:jaundice,hepatotoxicity Metabolic:hypoglycemic coma Skin: rash,urticaria Other: hypersensitivity reactions (such as fever) Interactions Drug-drug. Activated charcoal, cholestyramine, colestipol: decreased acetaminophen absorption Barbiturates, carbamazepine, diflunisal, hydantoins, isoniazid, rifabutin, rifampin, sulfinpyrazone: increased risk of hepatotoxicity Hormonal contraceptives: decreased acetaminophen efficacy Oral anticoagulants: increased anticoagulant effect Phenothiazines (such as chlorpromazine, fluphenazine, thioridazine): severe hypothermia Zidovudine: increased risk of granulocytopenia Drug-diagnostic tests.Home glucose measurement systems: altered results Urine 5-hydroxyindole acetic acid: falsepositive result Drug-behaviors. Alcohol use: increased risk of hepatotoxicity Patient monitoring 2Observe for acute toxicity and overdose.Signs and symptoms of acute toxicity are as followsPhase 1:Nausea, vomiting,anorexia,malaise,diaphoresis.Phase 2: Right upper quadrant pain or tenderness,liver enlargement, elevated bilirubin and hepatic enzyme levels,prolonged prothrombin time, oliguria (occasional).Phase 3: Recurrent anorexia,nausea,vomiting,and malaise; jaundice; hypoglycemia; coagulopathy; encephalopathy; possible renal failure and cardiomyopathy. Phase 4: Either recovery or progression to fatal complete hepatic failure. Patient teaching Caution parents or other caregivers not to give acetaminophen to children younger than age 2 without consulting prescriber first. Tell patient,parents,or other caregivers not to use drug concurrently with other acetaminophen-containing products. Advise patient,parents,or other caregivers to contact prescriber if fever

or other symptoms persist despite taking recommended amount of drug. Inform patients with chronic alcoholism that drug may increase risk of severe liver damage. As appropriate,review all other significant and life-threatening adverse reactions and interactions,especially those related to the drugs,tests,and behaviors mentioned above. midazolam hydrochloride Apo-Midazolam?, Hypnovel Pharmacologic class: Benzodiazepine Therapeutic class:Anxiolytic,sedativehypnotic,adjunct for general anesthesia induction Controlled substance schedule IV Pregnancy risk category D FDA BOXED WARNING I.V.form is linked to respiratory depression and respiratory arrest,especially when used for sedation in noncritical care settings.In some cases, where this wasnt recognized promptly and treated effectively,death or hypoxic encephalopathy resulted.Use I.V. form only in hospital or ambulatory care setting that provides continuous monitoring of respiratory and cardiac function.Ensure immediate availability of resuscitative drugs and equipment as well as personnel trained in their use and skilled in airway management.For deeply sedated pediatric patient,dedicated individual should monitor patient throughout procedure. Patients who are debilitated,older than age 60,or receiving concurrent opioids or other CNS depressants require lower dosages.Slowly titrate initial dose and all subsequent doses; give over at least 2 minutes and allow 2 or more additional minutes to fully evaluate sedative effect.In pediatric patients, calculate dosage on mg/kg basis,and titrate slowly. Dont give by rapid injection to neonates.Severe hypotension and seizures may result. Action Unknown.Thought to suppress CNS stimulation at limbic and subcortical levels by enhancing the effects of gamma-aminobutyric acid,an inhibitory neurotransmitter. Availability Injection: 1 mg/ml,5 mg/ml Syrup: 2 mg/ml 1Indications and dosages To induce general anesthesia Adults younger than age 55:0.3 to 0.35 mg/kg I.V.over 20 to 30 seconds if patient hasnt received premedication,or 0.15 to 0.35 mg/kg (usual dosage of 0.25

mg/kg) I.V.over 20 to 30 seconds if patient has received premedication.Wait 2 minutes to evaluate effect.Additional increments of 25% of initial dosage may be needed to complete induction. Continuous infusion to initiate sedation Adults:When rapid sedation is required, give loading dose of 0.01 to 0.05 mg/kg I.V.slowly;repeat dose q 10 to 15 minutes until adequate sedation occurs.To maintain sedation,infuse at initial rate of 0.02 to 0.10 mg/kg/hour (1 to 7 mg/ hour).Adjust infusion rate as needed. Preoperative sedation,anxiolysis, and amnesia Adults: 0.07 to 0.08 mg/kg I.M.30 minutes to 1 hour before surgery.For I.V.administration in healthy adults younger than age 60,give initial dose of 1 mg and titrate slowly to effect. 758 midazolam hydrochloride ?Canada UK Hazardous drug High alert drug Some patients may respond adequately to 1-mg dose.Dont give more than 2.5 mg over a 2-minute period.Total dosage above 5 mg is rarely necessary. Wait at least 2 minutes after additional doses to assess effect. Anxiolysis and amnesia before diagnostic,therapeutic,and endoscopic procedures or anesthesia induction Children: 0.25 to 0.5 mg/kg P.O.as a single dose.Maximum dosage is 20 mg. Dosage adjustment Elderly patients Children or neonates Contraindications Hypersensitivity to drug,its components,or other benzodiazepines Acute closed-angle glaucoma Allergy to cherries (syrup preparation) Precautions Use cautiously in: pulmonary disease,heart failure,renal impairment,severe hepatic impairment obese pediatric patients elderly or debilitated patients pregnant or breastfeeding patients children and neonates. Administration 2Keep oxygen and resuscitation equipment at hand in case severe respiratory depression occurs. Inject I.M.deep into large muscle mass. Know that drug may be mixed in same syringe as meperidine,atropine, scopolamine,or morphine. Dilute concentrate for I.V.infusion

to 0.5 mg/ml using dextrose 5% in water or normal saline solution.Infuse over at least 2 minutes; then wait at least 2 minutes before giving second dose.Be aware that excessive dosage or rapid I.V.delivery may cause severe respiratory depression. Give oral form with liquid,but never with grapefruit juice. Route Onset Peak Duration P.O. 10-20 min 45-60 min 2-6 hr I.V. 1.5-5 min Rapid 2-6 hr I.M. 15 min 15-60 min 2-6 hr Adverse reactions CNS: headache,oversedation,drowsiness,agitation and excitement (in children) CV:hypotension,irregular pulse,bradycardia,arrhythmias,cardiac arrest GI: nausea,vomiting Respiratory: decreased respiratory rate,hiccups,apnea,respiratory arrest Other: pain and tenderness at injection site Interactions Drug-drug. CNS depressants (such as some antidepressants, antihistamines, barbiturates, opioids, tranquilizers), respiratory depressants: potentiation of CNS effects of these drugs Diltiazem, verapamil: increased midazolam blood level Erythromycin: decreased midazolam clearance Hormonal contraceptives: prolonged midazolam half-life Rifampin: decreased midazolam blood level Theophylline: increased sedative effect of midazolam Drug-food. Grapefruit juice: increased bioavailability of oral midazolam Drug-herbs. Chamomile, kava, skullcap, valerian: increased CNS depression Drug-behaviors. Alcohol use: potentiation of midazolam effects Patient monitoring Monitor vital signs,ECG,respiratory status,and oxygen saturation. Assess neurologic status closely,especially in pediatric patient. Watch for nausea and vomiting. midazolam hydrochloride 759

m Reactions in bold are life-threatening. 2Clinical alert Patient teaching Advise patient that drug causes perioperative amnesia. If patient will use oral drug at home, instruct him to take it with liquid but never grapefruit juice. Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration and alertness. Tell female patient to inform prescriber is she is pregnant or breastfeeding. As appropriate,review all other significant and life-threatening adverse reactions and interactions,especially those related to the drugs,foods,herbs, and behaviors mentioned above. milrinone lactate Apo-Milrinone? Pharmacologic class: Bipyridine phosphodiesterase inhibitor Therapeutic class: Inotropic Pregnancy risk category C Action Increases cellular levels of cyclic adenosine monophosphate,causing inotropic action that relaxes vascular smooth muscle and increases myocardial contractility Availability Injection: 1 mg/ml in 10-,20-,and 50-ml vials Injection (premixed): 200 mcg/ml in dextrose 5% in water (D5W) 1Indications and dosages Heart failure Adults: Initially,50 mcg/kg I.V.bolus given slowly over 10 minutes,followed by continuous I.V.infusion of 0.375 to 0.75 mcg/kg/minute.Dont exceed total daily dosage of 1.13 mg/kg. Dosage adjustment Renal impairment Contraindications Hypersensitivity to drug Precautions Use cautiously in: atrial flutter or fibrillation,supraventricular and ventricular arrhythmias, renal impairment,electrolyte abnormalities,decreased blood pressure,severe aortic or pulmonic valvular disease,acute phase of myocardial infarction (not recommended),electrolyte abnormalities,abnormal blood digoxin level elderly patients pregnant or breastfeeding patients children (safety and efficacy not established).

Administration Dilute 1 mg/ml solution with halfnormal saline solution,normal saline solution,or D5W per manufacturers instructions. 764 milrinone lactate ?Canada UK Hazardous drug High alert drug 2Dont administer through same I.V.line as furosemide or torsemide (precipitate will form). Deliver I.V.slowly over 10 minutes. Expect to titrate infusion rate depending on response. Route Onset Peak Duration I.V. 5-15 min 1-2 hr 3-6 hr Adverse reactions CNS: headache CV: hypotension,chest pain,angina, ventricular or supraventricular arrhythmias,ventricular tachycardia or fibrillation Interactions None significant Patient monitoring Monitor vital signs and ECG.Watch closely for ventricular arrhythmias, sustained tachycardia, and fibrillation. Assess cardiovascular status closely. Stay alert for complaints of chest pain. 2Stop drug and contact prescriber immediately if patients systolic pressure drops 30 mm Hg or more. Patient teaching Instruct patient to change position slowly,to avoid light-headedness or dizziness from hypotension. As appropriate,review all other significant and life-threatening adverse reactions. dobutamine hydrochloride Pharmacologic class: Sympathomimetic,adrenergic Therapeutic class: Inotropic Pregnancy risk category B Action Stimulates beta1-adrenergic receptors of heart,causing a positive inotropic effect that increases myocardial contractility and stroke volume.Also reduces peripheral vascular resistance,decreases ventricular filling pressure,and promotes atrioventricular conduction. Availability Injection: 12.5 mg/ml in 20-ml vials 1Indications and dosages

Short-term treatment of cardiac decompensation caused by depressed contractility (such as during refractory heart failure);adjunct in cardiac surgery Adults: 2.5 to 10 mcg/kg/minute I.V.as a continuous infusion,adjusted to hemodynamic response Dosage adjustment Elderly patients Off-label uses Adjunct in myocardial infarction (MI) and septic shock Diagnosis of coronary artery disease (echocardiography stress test,ventriculography,computed tomography) Contraindications Hypersensitivity to drug 362 dobutamine hydrochloride ?Canada UK Hazardous drug High alert drug Idiopathic hypertrophic subaortic stenosis Precautions Use cautiously in: hypertension,MI,atrial fibrillation, hypovolemia pregnant or breastfeeding patients children. Administration As needed,correct hypovolemia before starting therapy by giving volume expanders,as prescribed. Use infusion pump or microdrip I.V. infusion set. Dilute with dextrose 5% in water or normal saline solution to at least 50 ml of solution. Know that drug is incompatible with alkaline solutions, such as sodium bicarbonate injection. Route Onset Peak Duration I.V. 1-2 min 10 min Brief Adverse reactions CNS: headache CV: hypertension,hypotension,tachycardia,premature ventricular contractions,angina,palpitations,nonspecific chest pain,phlebitis GI: nausea,vomiting Metabolic:hypokalemia Respiratory:dyspnea,asthma attacks Skin: extravasation with tissue necrosis Other: hypersensitivity reactions including anaphylaxis Interactions Drug-drug.Beta-adrenergic blockers: increased alpha-adrenergic effects

Bretylium: potentiation of vasopressor activity Cyclopropane, halothane: serious arrhythmias Guanethidine: decreased hypotensive effects Thyroid hormone: increased cardiovascular effects Tricyclic antidepressants: potentiation of cardiovascular and vasopressor effects Drug-herbs. Rue: increased inotropic potential Patient monitoring Monitor ECG and blood pressure continuously during administration. Monitor cardiac output,pulmonary capillary wedge pressure,and central venous pressure. Monitor fluid intake and output and watch for signs and symptoms of worsening heart failure. 2Assess electrolyte levels.Stay especially alert for hypokalemia. Patient teaching Instruct patient to report anginal pain,headache,leg cramps,and shortness of breath. Explain need for close observation and monitoring. As appropriate,review all other significant and life-threatening adverse reactions and interactions,especially those related to the drugs and herbs mentioned above. dopamine hydrochloride Intropin Pharmacologic class: Catecholamine, adrenergic Therapeutic class: Inotropic, vasopressor Pregnancy risk category C FDA BOXED WARNING Dilute full-strength injection before administering. If extravasation occurs,infiltrate area promptly with 10 to 15 ml of saline solution containing 5 to 10 mg phentolamine to prevent sloughing and necrosis.Use syringe with fine hypodermic needle,and infiltrate solution liberally throughout area.Give phentolamine as soon as possible; its dopamine hydrochloride 369 d Reactions in bold are life-threatening. 2Clinical alert sympathetic blockade causes immediate local hyperemic changes if area is infiltrated within 12 hours. Action Causes norepinephrine release (mainly on dopaminergic receptors),leading to vasodilation of renal and mesenteric arteries.Also exerts inotropic effects on

heart,which increases the heart rate, blood flow,myocardial contractility, and stroke volume. Availability Injection for dilution: 40 mg/ml, 80 mg/ml,160 mg/ml Premixed injection: 0.8 mg/ml,1.6 mg/ ml,3.2 mg/ml in 250 ml and 500 ml of dextrose 5% in water 1Indications and dosages Shock; hemodynamic imbalance; hypotension; heart failure Adults and children: 2 to 5 mcg/kg/ minute by I.V.infusion.Titrate dosage to desired response; may increase infusion by 1 to 4 mcg/kg/minute at 10- to 30-minute intervals.Maximum dosage is 50 mcg/kg/minute. Contraindications Hypersensitivity to drug or bisulfites Tachyarrhythmias,ventricular fibrillation Pheochromocytoma Precautions Use cautiously in: hypovolemia,myocardial infarction, occlusive vascular disease,diabetic endarteritis,atrial embolism concurrent MAO inhibitor use pregnant or breastfeeding patients children. Administration Give I.V.infusion using metered pump or other device that controls flow. Add 200 to 400 mg of dopamine to 250 to 500 ml of normal saline solution, 5% dextrose injection,5% dextrose and half-normal saline solution,or 5% dextrose in lactated Ringers solution. Infuse into large (preferably central) vein to minimize extravasation. 2Dont give concurrently with MAO inhibitors.Reduce dosage if patient has received MAO inhibitor recently. Route Onset Peak Duration I.V. 1-2 min Unknown <10 min Adverse reactions CNS: headache CV:palpitations,hypotension,angina, ECG changes,tachycardia,vasoconstriction,arrhythmias EENT: mydriasis GI: nausea,vomiting Metabolic: azotemia,hyperglycemia Respiratory: dyspnea,asthma attacks Skin: piloerection Other: irritation at injection site,gangrene of extremities (with high doses

for prolonged periods or in occlusive vascular disease) Interactions Drug-drug.Alpha- or beta-adrenergic blockers: antagonism of dopamine effects Ergot alkaloids: extreme blood pressure increase Guanethidine: decreased cardiostimulatory effects Inhalation anesthetics: increased risk of hypertension,arrhythmias MAO inhibitors: hypertensive crisis Oxytocics: severe,persistent hypotension Phenytoin: seizures,severe hypotension,bradycardia Tricyclic antidepressants: decreased pressor response Drug-diagnostic tests. Glucose, nitrogenous compounds, urine catecholamines: increased levels 370 dopamine hydrochloride ?Canada UK Hazardous drug High alert drug Patient monitoring Monitor blood pressure,pulse,urinary output,and pulmonary artery wedge pressure during infusion. 2Inspect I.V.site regularly for irritation.Avoid extravasation. 2Monitor color and temperature of extremities. 2Never stop infusion abruptly,because this may cause severe hypotension.Instead,taper gradually. Patient teaching Explain the need for close observation during infusion. Instruct patient to report adverse reactions and I.V.site discomfort. As appropriate,review all other significant and life-threatening adverse reactions and interactions,especially those related to the drugs and tests mentioned above. epinephrine Primatene Mist,Twinject epinephrine bitartrate Bronitin Mist epinephrine hydrochloride Adrenalin Chloride?,Anapen , Epi-E-Z Pen?, EpiPen, EpiPen Jr. Pharmacologic class: Sympathomimetic (direct acting) Therapeutic class: Bronchodilator, mydriatic Pregnancy risk category C Action Stimulates alpha- and beta-adrenergic receptors,causing relaxation of cardiac

and bronchial smooth muscle and epinephrine 409 e Reactions in bold are life-threatening. 2Clinical alert dilation of skeletal muscles.Also decreases aqueous humor production, increases aqueous outflow,and dilates pupils by contracting dilator muscle. Availability Aerosol inhaler: 160 mcg,200 mcg, 220 mcg,250 mcg Auto-injector for I.M. injection: 1:2,000 (0.5 mg/ml) Injection: 0.1 mg/ml,0.5 mg/ml, 1 mg/ml Ophthalmic drops: 0.5%,1%,2% 1Indications and dosages Bronchodilation; anaphylaxis; hypersensitivity reaction Adults: 0.1 to 0.5 ml of 1:1,000 solution subcutaneously or I.M.,repeated q 10 to 15 minutes p.r.n.Or 0.1 to 0.25 ml of 1:10,000 solution I.V.slowly over 5 to 10 minutes;may repeat q 5 to 15 minutes p.r.n.or follow with a continuous infusion of 1 mcg/minute,increased to 4 mcg/minute p.r.n.For emergency treatment,EpiPen delivers 0.3 mg I.M. of 1:1,000 epinephrine. Children: For emergency treatment, EpiPen Jr.delivers 0.15 mg I.M.of 1:2,000 epinephrine. Acute asthma attack Adults and children ages 4 and older: 160 to 250 mcg metered aerosol (equivalent to one inhalation); repeat once after 1 minute,if needed.Dont give subsequent doses for at least 3 hours.Or one to three deep inhalations of 1% solution with hand-held nebulizer,repeated q 3 hours p.r.n. To restore cardiac rhythm in cardiac arrest Adults:0.5 to 1 mg I.V.,repeated q 3 to 5 minutes,if needed.If no response, may give 3 to 5 mg I.V.q 3 to 5 minutes. Chronic simple glaucoma Adults:Onedrop in affected eye once or twice daily.Adjust dosage to meet patients needs. To prolong local anesthetic effects Adults and children: 1:200,000 concentration with local anesthetic Contraindications Hypersensitivity to drug,its components,or sulfites Angle-closure glaucoma Cardiac dilatation,cardiac insufficiency Cerebral arteriosclerosis,organic brain syndrome Shock with use of general anesthetics and halogenated hydrocarbons or cyclosporine MAO inhibitor use within past 14 days

Labor Breastfeeding Precautions Use cautiously in: hypertension,hyperthyroidism, diabetes,prostatic hypertrophy elderly patients pregnant patients children. Administration In anaphylaxis,use I.M.route,not subcutaneous route,if possible. 2Inject EpiPen and EpiPen Jr.only into anterolateral aspect of thigh. Dont inject into buttocks or give I.V. 2Be aware that not all epinephrine solutions can be given I.V.Check manufacturers label. For I.V.injection,give each 1-mg dose over at least 1 minute.For continuous infusion,use rate of 1 to 10 mcg/ minute,adjusting to desired response. Use Epi-Pen Jr.for patients weighing less than 30 kg (66 lb). 2Dont give within 14 days of MAO inhibitors. Route Onset Peak Duration I.V. Immediate 5 min Short I.M. Variable Unknown 1-4 hr Subcut. 5-15 min 0.5 hr 1-4 hr Inhalation 1-5 min Unknown 1-3 hr 410 epinephrine ?Canada UK Hazardous drug High alert drug Adverse reactions CNS: nervousness,anxiety,tremor, vertigo,headache,disorientation,agitation,drowsiness,fear,dizziness,asthenia,cerebral hemorrhage,cerebrovascular accident (CVA) CV:palpitations,widened pulse pressure, hypertension,tachycardia,angina,ECG changes,ventricular fibrillation,shock GI: nausea,vomiting GU: decreased urinary output,urinary retention,dysuria Respiratory: dyspnea,pulmonary edema Skin: urticaria,pallor,diaphoresis, necrosis Other: hemorrhage at injection site Interactions

Drug-drug. Alpha-adrenergic blockers: hypotension from unopposed betaadrenergic effects Antihistamines, thyroid hormone, tricyclic antidepressants: severe sympathomimetic effects Beta-adrenergic blockers (such as propranolol): vasodilation and reflex tachycardia Cardiac glycosides, general anesthetics: increased risk of ventricular arrhythmias Diuretics: decreased vascular response Doxapram, mazindol, methylphenidate: enhanced CNS stimulation or pressor effects Ergot alkaloids: decreased vasoconstriction Guanadrel, guanethidine: enhanced pressor effects of epinephrine Levodopa: increased risk of arrhythmias Levothyroxine: potentiation of epinephrine effects MAO inhibitors: increased risk of hypertensive crisis Drug-diagnostic tests.Glucose: transient elevation Lactic acid: elevated level (with prolonged use) Patient monitoring 2Monitor vital signs,ECG,and cardiovascular and respiratory status. Watch for ventricular fibrillation, tachycardia,arrhythmias,and signs and symptoms of shock.Ask patient about anginal pain. Assess drugs effect on underlying problem (such as anaphylaxis or asthma attack), and repeat dose as needed. 2Monitor neurologic status,particularly for decreased level of consciousness and other signs and symptoms of cerebral hemorrhage or CVA. Monitor fluid intake and output, watching for urinary retention or decreased urinary output. Inspect injection site for hemorrhage or skin necrosis. Patient teaching Teach patient who uses auto-injector how to use syringe correctly, when to inject drug, and when to repeat doses. Teach patient who uses hand-held nebulizer correct use of equipment and drug.Explain indications for both initial dose and repeat doses. 2Inform patient that drug may cause serious adverse effects.Tell him which symptoms to report. If patient will self-administer drug outside of health care setting, explain need for prompt evaluation by a health care provider to ensure that

underlying disorder has been corrected. As appropriate,review all other significant and life-threatening adverse reactions and interactions,especially those related to the drugs and tests mentioned above. Nacetylcysteine 550 mg q4h iv