Our Lady of Fatima University College of Nursing ACUTE GLOMERULONEPHRITIS A Group Case Study

Submitted to: Ms. Feliciano, RN In Partial Fulfillment of the Requirement for the Course NCM102 RLE

Pasay City General Hospital Pedia Ward Submitted by: Macatangay Jan Alex Madriaga, Merry Grace Marquez, Carmina Martinez, Ricky Navarro Jr., Noel Palompon, Ma. Rafaela Plaza, Jeanine Louise 2Y4-2D JANUARY 2010

Table of Contents Chapter I -Introduction -Patient¶s Profile -Nursing History of Illness Chapter II -Anatomy and Physiology -Pathophysiology Chapter IV -Laboratory Examinations Chapter V -Drug Study Chapter VI -Nursing Care Plan

Chapter VII -News/Trends Bibliography Narratives

The common signs and symptoms of AGN are as follows: Periorbital and facial edema (more prominent in the morning). Glomeruli itself has functions to help filter waste and fluids from the blood. abdominal or flank pain. cloudy. irritability and lethargy. smoky. azotemia. proteinuria. . headaches. pallor. dysuria. inflammation and sclerosis of the glomeruli of both kidneys. destruction. This disease leads to proliferative and inflammatory changes within glomerular structure. hypertension. anorexia. as well as. increased blood urea nitrogen and creatinine levels and Antistreptolysin O titer. and brown-colored urine.decreased urinary output.INTRODUCTION Acute Glomerulonephritis (AGN) is an inflammation of the internal kidney structures (glomeruli).

and to orient one of the appropriate nursing interventions that could be offered to patients. hence. this case study aims to help understand the disease process of AGN.The group encountered a patient with a condition as such and their clinical instructor gave them the opportunity to study the case. Patrick Lleva Age: 4 years old Gender: Male Address: 668 D. 2005 Civil Status: Single Religion: Roman Catholic . Pasay City Date of Birth: April 23. PATIENT¶S PROFILE Patient¶s Name: Ajanun. Bautista St.

Nationality: Filipino Dialect: Tagalog Date of Admission: Time Admitted: Attending Physician: Chief Complaint: Admitting Diagnosis: Final Diagnosis: .

History of Present Illness -Present illness started at nine months prior to admission. After a few hours he had seizure with loss of sight and was admitted to Pasay City General Hospital (PCGH). Past Medical History -Pneumonia C. B. Family History of Past Illness -Positive Maternal Asthma -Positive PTB grandmother .the patient had on and off headache in the temporal area.NURSING HISTORY OF ILLNESS A. After one week prior to admission the patient had cough without fever and was given Salbutamol Syrup and nebulization which afforded temporary relief. He was brought to a private clinic and was diagnosed with sinusitis and was given phenypropanolamine.

Medical Birth History -full term -G2P0 via Normal SD E.D. Nutritional History -Breastfed for one month -Bottle-fed for two months .

The kidneys are protected by three highly specialized layers of protective tissues.ANATOMY AND PHYSIOLOGY The Kidneys The kidneys are two bean shaped organs of the renal system located on the posterior wall of the abdomen one on each side of the vertebral column at the level of the twelfth rib. The kidneys measure about 10cm in length and. The technical name for this layer is the renal capsule. This layer is often called the renal fascia or fibrous membrane. The left kidney is slightly higher than the right. The outer layer consists mainly of connective tissue which protects the kidneys from trauma and infection.5 cm in thickness. Human kidneys are richly supplied with blood vessels which give them their reddish brown color. 5cm in breadth and about 2. The next layer (second .

and the renal capsule (fibrous sac) surrounds the kidney and protects it from trauma and infection. Blockage of the drainage system can cause the kidney to become congested. and one . This layer connects the kidneys to the abdominal wall. stretched. macromolecules. and pH balance of the body by filtering ions. electrolyte.layer from the exterior) is called the fascia and it makes a fibrous capsule around the kidneys. and potentially scarred. and nitrogenous wastes from the blood based on the body¶s condition. Kidney Function The main function of the kidney is to maintain the fluid. Wastes filtered out of the blood drains from canals in the kidney into the bladder as urine. The inner most layer is made up of adipose tissue and is essentially a layer of fatty tissue which forms a protective cushions the kidney. water. Functioning kidneys are necessary to maintain life.

measure of their function is the glomerular filtration rate. Cross-section of a kidney   . which is an artificial method of removing wastes from the blood by running the blood from the body. A loss of ki ney function results in the need for dialysis. through an artificial kidney. and then back into the body.

which forms the outer stratum Each part of the capsule links to its explanation.PARTS OF KIDNEY Capsule The enal apsule is he memb anous overing of he i ney. The cortex is visible near the ¡ ¥£ £ ¥ ¥¤ £ ¢ ¡ ¢ . Cortex The cortex of the ki ney is the outer section which covers the internal medulla. I irectly covers the renal cortex.

They are composed of lines of blood vessels and urinary tubes and a fibrous. They are used to subdivide the sections of the kidney anatomically. cortical material. with distinction being made between major calyces and minor calyces.outer edge of the cross-sectioned kidney. Pyramid The renal pyramids are conical segments within the internal medulla . Renal Column The renal columns are lines of the kidney matrix which support the cortex of the kidney. It is composed of blood vessels and urine tubes and is supported by a fibrous matrix. Calyx The calyces (plural for calyx) are the recesses in the internal medulla of the kidney which enclose the pyramids.

Renal Sinus The renal sinus is the cavity within the kidney which houses the renal pyramid. Nerves and blood vessels .of the kidney. The pyramids contain the secreting apparatus and tubules and are also known as the malphighian pyramids.

The incoming artery divides into four or five branches. each of which leads to the compact ball of capillaries called the glomerulus.pass into the renal sinus through the hilus. Hilus The hilus is the slit-like opening in the middle of the concave medial border of the kidney. eventually forming arterioles. Nerves and blood vessels pass through the hilus into the renal sinus within. Two renal arteries arise from the abdominal section of the aorta. Renal Vein Cell waste is discharged in the veins for . each artery supplies a lobe of the kidney. Renal Artery One quarter of the total blood output from the heart comes to the kidneys along the renal artery.

. The remainder goes back into circulation through the renal arteries.excretion through the kidneys. There are two renal veins. The body circulates about 425 gallons of blood through the kidneys on a daily basis. From the Bowman's capsule. the blood is carried through the compact network of capillaries that forms the glomerulus within the capsule. and opening into the vena cava. but only about a thousandth of this is converted in urine. one extending from each lobe of the kidney. The capillaries eventually reconverge into small venules which lead to the larger renal veins.

THE NEPHRON The nephron is the functional unit of the kidney. The renal tubule consists of the convoluted tubule and the loop of Henle. diabetics have trouble reaborbing the glucose in their body and hence a . urea and other minerals in your body. responsible for the actual purification and filtration of the blood. One side note. The nephron is a filtration system located in your kidney that is responsible for the reaborption of water. The nephron is part of the homeostatic mechanism of your body. This system helps regulate the amount of water. salts. About one million nephrons are in the cortex of each kidney. salts. This is where glucose eventually is absorbed in your body. and each one consists of a renal corpuscle and a renal tubule which carry out the functions of the nephron. glucose.

nutrients flow in through the left and exit through the right. The liquid begins at the Bowman's capsule (upper left) and then flows through the proximal convoluted tubule (that mess of tangled stuff up top). Essentially. water. salts. carbohydrates. . As it approaches the top again." But that's another topic. Along the way.hence the name "diabetic" or "sweet urine. On the way it passes a major bend called the Loop Of Henle. This is located in the medulla of the kidney. The filtrate then flows down the descending limb and then back up.lot of it comes out in the urine . hydrogen ions (waste) flow into the tube and down the collecting duct. and water pass through and are reabsorbed. It is here that Sodium. amino acids. and glucose get reabsorbed. The Loop of Henle is the part of the nephron that contains the basic pathway for liquid.

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into the circulation Antibody Formation Immune complex reaction in the glomerular capillary Inflammatory response Proliferation of epithelial cells lining glomerolus & cells between endothelium & epithelium of capillary membrane Swelling capillary membrane & infiltration with leukocytes . beta hemolytic) Release of material from the organism.PATHOPHYSIOLOGY Post-streptococcal infection (group-A.

(CONTINUED) Permeability of base membrane Occlusion of the capillaries of the glomeruli vasospasm of afferent ventrioles Glomerular filtration rate Ability to form filtrate from glomeruli plasma flow Retention of H2O & Na. circulatory congestion Edema Hypertension urinary output Urine dark in color Anorexia Irritability lethargy ACUTE GLOMERULONEPHRITIS . hypovolemia.

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14 Increased. 2009 PARAMETER NORMAL VALUES ACTUAL VALUES ANALYSIS BUN/ Urea 1. indicates infection BLOOD CHEMISTRY REPORT December 28.3 Mmol/L 10.250.550.LABORATORY EXAMINATIONS HEMATOLOGY REPORT December 24.86 Lymphocytes 0. . indicate high glucose level in the blood Increased.35 0.65 0.7-8. 2009 PARAMETER NORMAL VALUES ACTUAL VALUES ANALYSIS Segmenters 0.10 Increased BUN levels suggest impaired kidney function.

URINALYSIS REPORT December 28.030 Negative Negative Few Few Few Few ACTUAL VALUES Light yellow Slightly turbid 6.This may be due to acute or chronic kidney disease.5-8 1.0 1.010 trace +2 Few 2-7 1-3 Few ANALYSIS normal normal normal normal Reaction Specific Gravity Sugar Protein Squamous Epithelial Cells Red Blood Cells Pus Cells Mucus . 2009 PARAMETER Color Transparency NORMAL VALUES Yellow Amber Clear to slightly turbid 4.0051. or failure. damage.

Bacteria Amorp. Urates/Phosphates

Few Few

Few moderate

DRUG STUDY Nifedipine Brand Names: Adalat® CC; AfeditabŒ; NifediacŒ NifedicalŒ XL; Procardia®; Procardia XL® Use: Angina and hypertension (sustained release only), pulmonary hypertension Contraindications: Hypersensitivity to nifedipine or any component of the formulation; immediate release preparation for treatment of urgent or emergent hypertension; acute MI Adverse Reactions: >10%: CC;

Cardiovascular: Flushing (10% to 25%), peripheral edema (dose related 7% to 10%; up to 50%) Central nervous system: Dizziness/lightheadedness/giddiness (10% to 27%), headache (10% to 23%) Gastrointestinal: Nausea/heartburn (10% to 11%) Neuromuscular & skeletal: Weakness (10% to 12%) 1% to 10%: Cardiovascular: Palpitations (2% to 7%), transient hypotension (dose related 5%), CHF (2%) Central nervous system: Nervousness/mood changes (2% to 7%), shakiness (2%), jitteriness (2%), sleep disturbances (2%), difficulties in balance (2%), fever (2%), chills (2%) Dermatologic: Dermatitis (2%), pruritus (2%), urticaria (2%) Endocrine & metabolic: Sexual difficulties (2%)

thrombocytopenia. purpura. gynecomastia. dyspnea (2%) Miscellaneous: Diaphoresis (2%) <1% (Limited to important or life-threatening): Syncope. transient blindness. paranoid syndrome.Gastrointestinal: Diarrhea (2%). nocturia. anemia. chest congestion (2%). exfoliative dermatitis. bezoars (sustained-release preparations). angioedema. tinnitus. fever. depression. ischemia. gingival hyperplasia (10%) Neuromuscular & skeletal: Muscle cramps/tremor (2% to 8%). weakness (10%). gingival hyperplasia. constipation (2%). joint stiffness (2%) Ocular: Blurred vision (2%) Respiratory: Cough/wheezing (6%). polyuria. leukopenia. arthritis with positive ANA. memory dysfunction. photosensitivity. inflammation (2%). flatulence (2%). angina. allergic hepatitis. erythromelalgia. myoclonus Overdosage/Toxicology: . cramps (2%). reflux. myalgia. nasal congestion/sore throat (2% to 6%). myoclonus.

Try an antifungal like terbinafine (if appropriate) or monitor closely for altered effect of the calcium channel blocker. nausea. . 3A4 (weak) Azole antifungals may inhibit the calcium channel blocker's metabolism. 3A4 (major). Drug Interactions: Substrate of CYP2D6 (minor). and hyperglycemia. avoid this combination. Noncardiac symptoms include confusion. 2D6 (weak). stupor. treat symptomatically. metabolic acidosis. Inhibits CYP1A2 (moderate). particularly hypotension.Primary cardiac symptoms of calcium blocker overdose include hypotension and bradycardia. Calcium may reduce the calcium channel blocker's effects. vomiting. 2C8/9 (weak). Following initial gastric decontamination. Beta-blockers may have increased pharmacokinetic or pharmacodynamic interactions with nifedipine.

. nevirapine. and verapamil. watch for a greater hypotensive effect. mexiletine. mirtazapine. ropinirole. protease inhibitors. quinidine. phenobarbital. monitor blood pressure. erythromycin. and trifluoperazine. Example inducers include aminoglutethimide. nafcillin. Cisapride increases nifedipine's effects. isoniazid. CYP3A4 inducers: CYP3A4 inducers may decrease the levels/effects of nifedipine. nefazodone. CYP3A4 inhibitors: May increase the levels/effects of nifedipine. phenytoin. CYP1A2 substrates: Nifedipine may increase the levels/effects of CYP1A2 substrates. propofol. theophylline. diclofenac. Ethanol increased nifedipine's AUC by 53%.Cimetidine: Cimetidine may increase nifedipine serum concentrations. clarithromycin. Example substrates include aminophylline. and rifamycins. imatinib. Example inhibitors include azole antifungals. nicardipine. ciprofloxacin. carbamazepine. doxycycline. fluvoxamine.

avoid grapefruit juice. avoid this combination. . Use another calcium channel blocker or monitor tacrolimus trough levels and renal function closely. Quinidine's serum concentration is reduced and nifedipine's is increased. Sildenafil. Nafcillin decreases plasma concentration of nifedipine. tadalafil. May require much higher dose of nifedipine. adjust doses as needed. Rifampin increases the metabolism of the calcium channel blocker. Phenobarbital reduces the plasma concentration of nifedipine.Grapefruit juice increases the bioavailability of nifedipine. Protease inhibitor like amprenavir and ritonavir may increase nifedipine's serum concentration. adjust the dose of the calcium channel blocker to maintain efficacy. avoid the combination. use caution Tacrolimus's serum concentrations are increased by nifedipine. vardenafil: Blood pressurelowering effects may be additive.

Ethanol/Nutrition/Herb Interactions: Ethanol: Avoid ethanol (may increase CNS depression). Avoid garlic (may have increased antihypertensive effect). yohimbe. including severe hypotension and myocardial ischemia. Food may decrease the rate but not the extent of absorption of Procardia XL®. monitor closely for vincristine dose adjustment.Vincristine's half-life is increased by nifedipine. Avoid ephedra. Avoid dong quai if using for hypertension (has estrogenic activity). Food: Nifedipine serum levels may be decreased if taken with food. Increased therapeutic and vasodilator side effects. may occur if nifedipine is taken by patients ingesting grapefruit. Herb/Nutraceutical: St John's wort may decrease nifedipine levels. ginseng (may worsen hypertension). Mechanism of Action: Inhibits calcium ion from entering the "slow channels" or select voltage-sensitive areas of .

7 hours Excretion: Urine .vascular smooth muscle and myocardium during depolarization. Cirrhosis: 7 hours. Elderly: 6. Sustained release: 65% to 86% Half-life elimination: Adults: Healthy: 2-5 hours. increases myocardial oxygen delivery in patients with vasospastic angina Pharmacodynamics/Kinetics: Onset of action: ~20 minutes Protein binding (concentration dependent): 92% to 98% Metabolism: Hepatic to inactive metabolites Bioavailability: Capsules: 45% to 75%. producing a relaxation of coronary vascular smooth muscle and coronary vasodilation.

to 14-day intervals Hemodialysis: Supplemental dose is not necessary. 10 mg 3 times/day as capsules Usual dose: 10-30 mg 3 times/day as capsules or 30-60 mg once daily as sustained release Maximum dose: 120-180 mg/day Increase sustained release at 7.Dosage: Oral: Children: Hypertrophic cardiomyopathy: 0.6-0. total daily dose will start the same) Initial: 30 mg once daily as sustained release formulation.9 mg/kg/24 hours in 3-4 divided doses Adolescents and Adults: (Note: When switching from immediate release to sustained release formulations. . or if indicated.

Dosing adjustment in hepatic impairment: Reduce oral dose by 50% to 60% in patients with cirrhosis. administration with low-fat meals may decrease flushing. signs and symptoms of CHF. do not crush or chew. but may result in vasodilator side effects. Monitoring Parameters: Heart rate.Peritoneal dialysis effects: Supplemental dose is not necessary. peripheral edema Dietary Considerations: Capsule is rapidly absorbed orally if it is administered without food. blood pressure. Avoid grapefruit juice. Administration: Extended release tablets should be swallowed whole. .

nervousness or mood change. or herbal products you are taking. May cause orthostatic hypotension (change position slowly from sitting or lying to standing. and grapefruit juice. or nausea or heartburn (small. swelling of extremities. frequent meals. respiratory difficulty. and frequent mouth rinses). or fatigue (use caution when driving or engaging in tasks that require alertness until response to drug is known).Patient Education: Inform prescriber of all prescriptions. alcohol. Avoid caffeine. Do not crush or chew sustained release forms. and any allergies you have. do not alter dose or decrease without consulting prescriber. difficulties in balance. dizziness. palpitations. rapid heartbeat. frequent mouth care. or . Report chest pain. Do not take any new medication during therapy unless approved by prescriber. OTC medications. chewing gum.use soft toothbrush. swallow whole. or when climbing stairs). muscle weakness or pain. Take with nonfatty food. Consult prescriber before increasing exercise routine (decreased angina does not mean it is safe to increase exercise). rash. or sucking lozenges may help). Take as directed. sore mouth (inspect gums for swelling or redness . waxed dental floss.

treatment of convulsive disorders Restrictions: C-IV Contraindications: Hypersensitivity to diazepam or any component of the formulation (cross-sensitivity with other benzodiazepines may exist). Diazepam Intensol®. Diazepam Brand Names: Diastat®. Pregnancy precaution: Inform prescriber if you are or intend to become pregnant. narrow-angle . Valium® Use: Management of anxiety disorders. skeletal muscle relaxant. ethanol withdrawal symptoms.vision changes.

not for use in children <6 months of age (oral) or <30 days of age (parenteral). and cardiac arrest have occurred with parenteral administration. pregnancy Warnings/Precautions: Diazepam has been associated with increasing the frequency of grand mal seizures. coma. Acute hypotension. Avoid use of the injection in patients with shock. or renal impairment. Active metabolites with extended half-lives may lead to delayed accumulation and adverse effects. patients with hepatic disease (including alcoholics). Acute effects may be more prevalent in patients receiving concurrent barbiturates. . or ethanol. muscle weakness. Use with caution with drugs which may decrease diazepam metabolism.glaucoma. narcotics. or acute ethanol intoxication. apnea. Withdrawal has also been associated with an increase in the seizure frequency. Use with caution in patients with respiratory disease or impaired gag reflex. Use with caution in elderly or debilitated patients. Appropriate resuscitative equipment and qualified personnel should be available during administration and monitoring.

Parenteral formulation contains propylene glycol. Use with caution in patients with a history of drug dependence. Patients must be cautioned about performing tasks which require mental alertness (eg. Benzodiazepines have been associated with falls and traumatic injury and should be used with extreme caution in patients who are at risk of these events (especially the elderly). confusion. operating machinery or driving). Effects with other sedative drugs or ethanol may be potentiated.Intra-arterial injection or extravasation of the parenteral formulation should be avoided. dizziness. The dosage of narcotics should be reduced by approximately 1/3 when diazepam is added. particularly if suicidal risk may be present. Use with caution in patients receiving other CNS depressants or psychoactive agents. or ataxia which may impair physical and mental capabilities. Causes CNS depression (dose-related) resulting in sedation. Benzodiazepines have been associated with dependence and acute withdrawal symptoms on discontinuation or reduction in dose. Use caution in patients with depression. including seizures. Acute withdrawal. which has been associated with toxicity when administered in high dosages. may be precipitated in patients after administration of .

flumazenil to patients receiving long-term benzodiazepine therapy. Diazepam has been associated with anterograde amnesia. Paradoxical reactions, including hyperactive or aggressive behavior, have been reported with benzodiazepines, particularly in adolescent/pediatric or psychiatric patients. Does not have analgesic, antidepressant, or antipsychotic properties. Adverse Reactions: Frequency not defined. Cardiovascular: Hypotension Central nervous system: Drowsiness, ataxia, amnesia, slurred speech, paradoxical excitement or rage, fatigue, insomnia, memory impairment, headache, anxiety, depression, vertigo, confusion Dermatologic: Rash Endocrine & metabolic: Changes in libido

Gastrointestinal: Changes in salivation, constipation, nausea Genitourinary: Incontinence, urinary retention Hepatic: Jaundice Local: Phlebitis, pain with injection Neuromuscular & skeletal: Dysarthria, tremor Ocular: Blurred vision, diplopia Respiratory: Decrease in respiratory rate, apnea Overdosage/Toxicology: Symptoms of overdose include somnolence, confusion, coma, hypoactive reflexes, dyspnea, hypotension, slurred speech, or impaired coordination. Treatment for benzodiazepine overdose is supportive. Flumazenil has been shown to selectively block the binding of benzodiazepines to CNS receptors, resulting in a

reversal of benzodiazepine-induced CNS depression, but not respiratory depression. Drug Interactions: Substrate of CYP1A2 (minor), 2B6 (minor), 2C8/9 (minor), 2C19 (major), 3A4 (major); Inhibits CYP2C19 (weak), 3A4 (weak) CNS depressants: Sedative effects and/or respiratory depression may be additive with CNS depressants; includes ethanol, barbiturates, narcotic analgesics, and other sedative agents; monitor for increased effect CYP2C19 inducers: May decrease the levels/effects of diazepam. Example inducers include aminoglutethimide, carbamazepine, phenytoin, and rifampin. CYP2C19 inhibitors: May increase the levels/effects of diazepam. Example inhibitors include delavirdine, fluconazole, fluvoxamine, gemfibrozil, isoniazid, omeprazole, and ticlopidine. CYP3A4 inducers: CYP3A4 inducers may decrease the levels/effects of diazepam. Example

ciprofloxacin. Example inhibitors include azole antifungals. erythromycin. protease inhibitors. and verapamil. and rifamycins. quinidine.inducers include aminoglutethimide. may require higher doses for sedation . phenytoin. nefazodone. nevirapine. carbamazepine. nicardipine. Levodopa: Therapeutic effects may be diminished in some patients following the addition of a benzodiazepine. limited/inconsistent data Oral contraceptives: May decrease the clearance of some benzodiazepines (those which undergo oxidative metabolism). diclofenac. monitor for increased benzodiazepine effect Theophylline: May partially antagonize some of the effects of benzodiazepines. propofol. imatinib. clarithromycin. CYP3A4 inhibitors: May increase the levels/effects of diazepam. phenobarbital. doxycycline. nafcillin. monitor for decreased response. isoniazid.

kava kava.V. hydrolysis occurs at pH <3. product with other medications Rectal gel: Store at 25°C (77°F). Stability: Protect parenteral dosage form from light. Diazepam effect/toxicity may be increased by grapefruit juice. Food: Diazepam serum levels may be increased if taken with food. Herb/Nutraceutical: St John's wort may decrease diazepam levels. potency is retained for up to 3 months when kept at room temperature. avoid concurrent use.Ethanol/Nutrition/Herb Interactions: Ethanol: Avoid ethanol (may increase CNS depression). most stable at pH 4-8. do not mix I. gotu kola (may increase CNS depression). excursion permitted to 15°C to 30°C (59°F to 86°F). St John's wort. Avoid valerian. .

meropenem. NS Y-site administration: Compatible: Dobutamine. vecuronium. diltiazem. potassium chloride. ranitidine Compatibility when admixed: Compatible: Verapamil. vitamin B complex with C. Incompatible: Doxapram. nafcillin. sufentanil. cefepime. furosemide . linezolid. foscarnet. heparin with hydrocortisone sodium succinate. quinidine gluconate. Variable (consult detailed reference): Ketorolac. doxorubicin. heparin. hydromorphone. buprenorphine. gatifloxacin. Variable (consult detailed reference): Cisatracurium. heparin. Incompatible: Bleomycin. fluconazole. glycopyrrolate.Compatibility: Variable stability (consult detailed reference) in D5W. nalbuphine. atracurium. sufentanil. LR. floxacillin. hydromorphone. propofol. dobutamine. Incompatible: Amphotericin B cholesteryl sulfate complex. fluorouracil. pancuronium. remifentanil Compatibility in syringe: Compatible: Cimetidine.

Protein binding: 98% .M. Pharmacodynamics/Kinetics: I. This shift in chloride ions results in hyperpolarization (a less excitable state) and stabilization.Mechanism of Action: Binds to stereospecific benzodiazepine receptors on the postsynaptic GABA neuron at several sites within the central nervous system. including the limbic system. Enhancement of the inhibitory effect of GABA on neuronal excitability results by increased neuronal membrane permeability to chloride ions. more reliable than I.V.: Status epilepticus: Onset of action: Almost immediate Duration: 20-30 minutes Absorption: Oral: 85% to 100%. reticular formation.

M.8 mg/kg/day in divided doses every 68 hours I.2-0.V. increased half-life in neonates.3 mg/kg (maximum: 10 mg) 45-60 minutes prior to procedure Sedation/muscle relaxant/anxiety: Oral: 0.3 mg/kg/dose every 2-4 hours to a maximum of 0. may be prolonged in neonates Dosage: Oral absorption is more reliable than I.Metabolism: Hepatic Half-life elimination: Parent drug: Adults: 20-50 hours.12-0.M.. Children: Conscious sedation for procedures: Oral: 0. elderly. I.: 0. and those with severe hepatic disorders.6 mg/kg within an 8-hour period if needed .04-0. Active major metabolite (desmethyldiazepam): 50-100 hours.

3 mg/kg/dose given over 2-3 minutes. then 0.Status epilepticus: Infants 30 days to 5 years: I.V.05-0. every 15-30 minutes to a maximum total dose of 5 mg.3 mg/kg/dose given over 2-3 minutes every 15-30 minutes to a maximum total dose of 10 mg.: 0.5 mg/dose every 2-5 minutes to a maximum total dose of 5 mg >5 years: I.5 mg/kg.5 mg/kg .05-0.: 0.V.25 mg/kg in 10 minutes if needed Anticonvulsant (acute treatment): Rectal gel formulation: Infants <6 months: Not recommended Children <2 years: Safety and efficacy have not been studied Children 2-5 years: 0. repeat in 2-4 hours as needed or 1 mg/dose given over 2-3 minutes.2-0. every 2-5 minutes to a maximum total dose of 10 mg Rectal: 0. repeat in 2-4 hours as needed or 0.

3 mg/kg Children 12 years and Adults: 0. 15. 2.V. 5.V. dose may be repeated in 4-12 hours if needed. may repeat with /2 dose if needed Adults: Anxiety/sedation/skeletal muscle relaxant: Oral: 2-10 mg 2-4 times/day I.. 10. do not use more than 5 times per month or more than once every 5 days Adolescents: Conscious sedation for procedures: Oral: 10 mg I.M. may repeat in 3-4 hours if needed 1 .: 5 mg.2 mg/kg Note: Dosage should be rounded upward to the next available dose. and 20 mg/dose.: 2-10 mg.5.Children 6-11 years: 0. I.

average total dose for tranquilization: 20-60 mg Elderly: Oral: Initial: Anxiety: 1-2 mg 1-2 times/day.: 5-10 mg every 10-20 minutes. up to 30 mg in an 8-hour period.1 mg/kg every 30 minutes to 6 hours Status epilepticus: I.V.: 0.V. may repeat in 2-4 hours if necessary Rapid tranquilization of agitated patient (administer every 30-60 minutes): Oral: 5-10 mg.Sedation in the ICU patient: I.03-0. supplemental dose is not necessary Dosing adjustment in hepatic impairment: Reduce dose by 50% in cirrhosis and avoid in severe/acute liver disease . rarely need to use >10 mg/day (watch for hypotension and excessive sedation) Skeletal muscle relaxant: 2-5 mg 2-4 times/day Hemodialysis: Not dialyzable (0% to 5%). increase gradually as needed.

5 mcg/mL (SI: 0.35-1.75.2-1.3 mol/L). cardiovascular. do not exceed 1-2 mg/minute IVP. check for orthostasis Reference Range: Therapeutic: Diazepam: 0.8 mol/L) Test Interactions: False-negative urinary glucose determinations when using Clinistix® or Diastix® .1-0. N-desmethyldiazepam (nordiazepam): 0.5 mcg/mL (SI: 0.Administration: Intensol® should be diluted before use. diazepam does not have any analgesic effects In children. adults 5 mg/minute Monitoring Parameters: Respiratory. and mental status.

do not use alcohol and other prescription or OTC medications (especially pain medications. muscle . respiratory difficulty or shortness of breath. dizziness. Maintain adequate hydration (2-3 L/day of fluids) unless instructed to restrict fluid intake. increased sedation. frequent meals. dizziness. sedatives. loss of appetite. headache. agitation. or impaired coordination) or changes in cognition. depression. changes in sexual activity. fruit. constipation (increased exercise. vomiting. insomnia or nightmares. You may experience drowsiness. changes in urinary pattern. nausea. or dry mouth (small. wear identification that you are taking an antiepileptic medication. or sucking lozenges may help). While using this medication. excitation. fluids.Patient Education: Take exactly as directed. or hypnotics) without consulting prescriber. or fiber may help). do not increase dose or frequency. Drug may cause physical and/or psychological dependence. Report CNS changes (confusion. antihistamines. or blurred vision (use caution when driving or engaging in tasks requiring alertness until response to drug is known). frequent mouth care. chewing gum. If medication is used to control seizures. fatigue.

cramping, weakness, tremors, or rigidity; ringing in ears or visual disturbances; excessive perspiration; excessive GI symptoms (cramping, constipation, vomiting, anorexia); or worsening of seizure activity or loss of seizure control. Pregnancy/breast-feeding precautions: Do not get pregnant while taking this medication; use appropriate contraceptive measures. Do not breast-feed. Mannitol Brand Names: Osmitrol®; Resectisol® Synonyms: D-Mannitol Use: Reduction of increased intracranial pressure associated with cerebral edema; promotion of diuresis in the prevention and/or treatment of

oliguria or anuria due to acute renal failure; reduction of increased intraocular pressure; promoting urinary excretion of toxic substances; genitourinary irrigant in transurethral prostatic resection or other transurethral surgical procedures Contraindications: Hypersensitivity to mannitol or any component or the formulation; severe renal disease (anuria); dehydration; active intracranial bleeding; severe pulmonary edema or congestion Warnings/Precautions: Should not be administered until adequacy of renal function and urine flow is established; cardiovascular status should also be evaluated; do not administer electrolyte-free mannitol solutions with blood Adverse Reactions: Frequency not defined.

Cardiovascular: Circulatory overload, CHF Central nervous system: Headache, convulsions, headache, chills, dizziness Dermatologic: Rash Endocrine & metabolic: Fluid and electrolyte imbalance, water intoxication, dehydration and hypovolemia secondary to rapid diuresis, hyponatremia Gastrointestinal: Nausea, vomiting, xerostomia Genitourinary: Polyuria, dysuria Local: Tissue necrosis Ocular: Blurred vision Respiratory: Pulmonary edema Miscellaneous: Allergic reactions

cardiovascular collapse. pulmonary edema.Overdosage/Toxicology: Symptoms of overdose include polyuria. Increased electrolyte excretion and fluid overload can occur. crystallization may occur at low temperatures. do not use solutions that contain crystals. Hemodialysis will clear mannitol and reduce osmolality. hyponatremia. and seizures. heating in a hot water bath and vigorous shaking may be utilized for resolubilization. hypokalemia. cool solutions to body temperature before using . oliguria. Drug Interactions: Lithium toxicity (with diuretic-induced hyponatremia) Stability: Should be stored at room temperature (15°C to 30°C) and protected from freezing. hypotension.

thiotepa. which inhibits tubular reabsorption of water and electrolytes and increases urinary output Pharmacodynamics/Kinetics: Onset of action: Diuresis: Injection: 1-3 hours. cisatracurium. idarubicin.Compatibility: Y-site administration: Compatible: Allopurinol. amphotericin B cholesteryl sulfate complex. teniposide. remifentanil. fludarabine. doxorubicin liposome. ondansetron. fluorouracil. paclitaxel. gatifloxacin. cladribine. gemcitabine. sargramostim. Reduction in intracerebral pressure: ~15 minutes Duration: Reduction in intracerebral pressure: 3-6 hours . docetaxel. vinorelbine. etoposide. amifostine. Incompatible: Cefepime. propofol. aztreonam. piperacillin/tazobactam. filgrastim Mechanism of Action: Increases the osmotic pressure of glomerular filtrate. linezolid. melphalan.

does not penetrate the blood-brain barrier Metabolism: Minimally hepatic to glycogen Half-life elimination: 1.Distribution: Remains confined to extracellular space (except in extreme concentrations).5 g/kg given every 4-6 hours .1-1.V.6 hours Excretion: Primarily urine (as unchanged drug) Dosage: I.5-1 g/kg Maintenance: 0.25-0.: Children: Test dose (to assess adequate renal function): 200 mg/kg over 3-5 minutes to produce a urine flow of at least 1 mL/kg for 1-3 hours Initial: 0.

5-1 g/kg Maintenance: 0.5-2 g/kg/dose I. maintain serum osmolality 310-320 mOsm/kg Preoperative for neurosurgery: 1.5 g/kg every 4-6 hours.25-0. as a 15% to 20% solution over 30 minutes.5-2 g/kg administered 1-1.5 hours prior to surgery Transurethral irrigation: Use urogenital solution as required for irrigation . usual adult dose: 20-200 g/24 hours Intracranial pressure: Cerebral edema: 1.5 g (200 mg/kg) over 3-5 minutes to produce a urine flow of at least 30-50 mL of urine per hour over the next 2-3 hours Initial: 0.Adults: Test dose (to assess adequate renal function): 12.V.

for treatment of elevated intracranial pressure. eye pain. avoid extravasation. crenation and agglutination of red blood cells may occur if administered with whole blood Monitoring Parameters: Renal function. serum and urine osmolality. blurred vision. serum electrolytes. for cerebral edema or elevated ICP.Administration: In-line 5-micron filter set should always be used for mannitol infusion with concentrations 20%.V. maintain serum osmolality 310-320 mOsm/kg Patient Education: This medication can only be given by infusion. respiratory difficulty. dizziness. Pregnancy/breast-feeding precautions: Inform . tingling. push over 35 minutes. Report immediately any muscle weakness. numbness. acute headache. administer over 20-30 minutes. nausea. chest pain. daily fluid I & O. administer test dose (for oliguria) I. or pain at infusion site.

skin and skin structure infections. pelvic inflammatory disease (PID). used in surgical prophylaxis . Consult prescriber if breast-feeding. uncomplicated gonorrhea. Ceftriaxone Brand Names: Rocephin® Synonyms: Ceftriaxone Sodium Use: Treatment of lower respiratory tract infections.prescriber if you are pregnant. bacterial septicemia. intraabdominal and urinary tract infections. bone and joint infections. acute bacterial otitis media. and meningitis.

especially IgEmediated reactions (eg. Discontinue in patients with signs and symptoms of gallbladder disease. anaphylaxis. difficile.Contraindications: Hypersensitivity to ceftriaxone sodium. do not use in hyperbilirubinemic neonates. urticaria). Adverse Reactions: 1% to 10%: Dermatologic: Rash (2%) . any component of the formulation. prolonged use may result in superinfection. or other cephalosporins. particularly those who are premature since ceftriaxone is reported to displace bilirubin from albumin binding sites Warnings/Precautions: Modify dosage in patients with severe renal impairment. Use with caution in patients with a history of penicillin allergy. May cause antibiotic-associated colitis or colitis secondary to C.

leukocytosis. prolonged or decreased PT. renal precipitations . renal stones. allergic pneumonitis. tightness. induration (5% to 17%) following I. pseudomembranous colitis. vaginitis. vomiting. diaphoresis. colitis. leukopenia (2%) Hepatic: Transaminases increased (3. hematuria. gallstones. thrombocytosis (5%). seizure. bronchospasm. nausea. phlebitis. headache. neutropenia. hemolytic anemia. urinary casts. dizziness. pruritus. lymphocytosis.3%) Local: Pain. anaphylaxis. thrombocytopenia. monocytosis. 1%). serum sickness. increased alkaline phosphatase. lymphopenia. basophilia. glycosuria. flushing.Gastrointestinal: Diarrhea (3%) Hematologic: Eosinophilia (6%).M. chills. and creatinine Postmarketing and/or case reports: Nephrolithiasis.V. warmth.1% to 3. induration at injection site (I. injection Renal: BUN increased (1%) <1%: Agranulocytosis. bilirubin. jaundice. anemia. candidiasis. dysgeusia.

toxic epidermal necrolysis. superinfection. treatment is supportive or symptom-directed. sulfinpyrazone): Uricosuric agents may decrease . neuromuscular excitability. Hemodialysis may be helpful to aid in removal of the drug from blood. toxic nephropathy Overdosage/Toxicology: Symptoms of overdose include neuromuscular hypersensitivity and convulsions. dicumarol. otherwise. cholestasis. asterixis. Drug Interactions: Coumarin derivative (eg. renal dysfunction. erythema multiforme. Stevens-Johnson syndrome. warfarin): Cephalosporins may increase the anticoagulant effect of coumarin derivatives. probenecid. interstitial nephritis. Uricosuric agents (eg. aplastic anemia. paresthesia. Many betalactam containing antibiotics have the potential to cause neuromuscular hyperirritability or convulsive seizures. hemorrhage.Reactions reported with other cephalosporins include angioedema. encephalopathy. pancytopenia.

100 mg/mL: Reconstituted in D5W or NS: Stable for 2 days at room temperature of 25°C (77°F) or for 10 days when refrigerated at 5°C (41°F).the excretion of cephalosporin. Premixed solution (manufacturer premixed): Store at -20°C. Stability of reconstituted solutions: 10-40 mg/mL: Reconstituted in D5W or NS: Stable for 2 days at room temperature of 25°C (77°F) or for 10 days when refrigerated at 5°C (41°F). solutions are stable for 2 days at room . protect from light. solutions are stable for 3 days at room temperature of 25°C (77°F) or for 21 days refrigerated at 5°C (41°F). Stability: Powder for injection: Prior to reconstitution. Once thawed. monitor for toxic effects. Do not refreeze. Stable for 26 weeks when frozen at -20°C. once thawed. store at room temperature of 25°C (77°F).

Reconstitution: I. Do not refreeze. 250-350 mg/mL: Reconstituted in D5W.9 mL 500 mg vial: 1. injection: Vials should be reconstituted with appropriate volume of diluent (including D5W. lidocaine 1% solution. Reconstituted in lidocaine 1% solution: Stable for 24 hours at room temperature of 25°C (77°F) or for 10 days when refrigerated at 5°C (41°F).temperature of 25°C (77°F) or for 10 days when refrigerated at 5°C (41°F).6 mL . Volume to add to create a 250 mg/mL solution: 250 mg vial: 0. or 1% lidocaine) to make a final concentration of 250 mg/mL or 350 mg/mL.M. NS. does not apply to manufacturer's premixed bags.8 mL 1 g vial: 3. NS. or SWFI: Stable for 24 hours at room temperature of 25°C (77°F) or for 3 days when refrigerated at 5°C (41°F).

0 mL 1 g vial: 2.2 mL I.V.2 mL .V. infusion: Infusion is prepared in two stages: Initial reconstitution of powder.2 g vial: 7. D5W.1 mL 2 g vial: 4.8 mL 1 g vial: 9. Vials: Reconstitute powder with appropriate I.6 mL 2 g vial: 19.4 mL 500 mg vial: 4. followed by dilution to final infusion solution. NS) to create an initial solution of ~100 mg/mL.2 mL Volume to add to create a 350 mg/mL solution: 500 mg vial: 1. Recommended volume to add: 250 mg vial: 2. diluent (including SWFI.

Recommended initial volume to add: 1 g bottle:10 mL 2 g bottle: 20 mL Note: After reconstitution.V. 50-100 mL of D5W or NS) is recommended. variable stability (consult detailed reference) in LR. Compatibility: Stable in D5W with KCl 10 mEq. further dilution to 50 mL or 100 mL volumes with the appropriate I. bacteriostatic water. sodium bicarbonate 5%. mannitol 5%. sterile water for injection. mannitol 10%. diluent (including D5W or NS) is recommended. D10W. D5 /4NS with KCl 1 20 mEq. to prepare the final infusion solution.V. peritoneal dialysis solutions 1 . NS. D5W. Piggyback bottle: Reconstitute powder with appropriate I.Note: After reconstitution of powder. further dilution into a volume of compatible solution (eg. diluent (D5W or NS) to create a resulting solution of ~100 mg/mL. D5 /2 NS.

Variable (consult detailed reference): Metronidazole. aztreonam. amphotericin B cholesteryl sulfate complex. cisatracurium. Incompatible: Aminophylline. amifostine. sodium bicarbonate. vancomycin Mechanism of Action: Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins . fludarabine. labetalol. fluconazole. etoposide phosphate. propofol. gemcitabine. linezolid. warfarin. theophylline. famotidine. docetaxel. zidovudine. doxorubicin liposome. meperidine. theophylline. melphalan. remifentanil. linezolid.Y-site administration: Compatible: Acyclovir. pentamidine. gatifloxacin. paclitaxel. filgrastim. amsacrine. thiotepa. Incompatible: Alatrofloxacin. diltiazem. Variable (consult detailed reference): Vancomycin Compatibility in syringe: Variable (consult detailed reference): Lidocaine Compatibility when admixed: Compatible: Metronidazole. morphine. vinorelbine. tacrolimus. foscarnet. allopurinol. methotrexate. sargramostim. granisetron. teniposide. heparin. clindamycin.

: 1-2 hours . Bacteria eventually lyse due to ongoing activity of cell wall autolytic enzymes (autolysins and murein hydrolases) while cell wall assembly is arrested. CSF (higher concentrations achieved when meninges are inflamed). thus inhibiting cell wall biosynthesis. bile.M. lungs.M. serum: I. enters amniotic fluid and breast milk Protein binding: 85% to 95% Half-life elimination: Normal renal and hepatic function: 5-9 hours Time to peak. bone. Pharmacodynamics/Kinetics: Absorption: I.(PBPs) which in turn inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell walls. crosses placenta.: Well absorbed Distribution: Widely throughout the body including gallbladder.

I. complicated (unlabeled use): I.M.V.: Mild-to-moderate infections: 50-75 mg/kg/day in 12 divided doses every 12-24 hours (maximum: 2 g/day).M.: <45 kg: 50 mg/kg in a single dose (maximum: 1 g) >45 kg: 1 g in a single dose .M.Excretion: Urine (33% to 65% as unchanged drug). continue until at least 2 days after signs and symptoms of infection have resolved Serious infections: 80-100 mg/kg/day in 1-2 divided doses (maximum: 4 g/day) Gonococcal infection.: 125 mg in a single dose Gonococcal conjunctivitis. uncomplicated: I.. feces Dosage: Infants and Children: Usual dose: I.

for at least 28 days Gonococcal infection.M. complicated: .: 1-2 g every 12 hours. I.V.: <45 kg: 25-50 mg/kg once daily (maximum: 1 g) >45 kg: 1 g once daily for 7 days Meningitis: I. usual duration of treatment is 7-14 days Gonococcal. I.M.: Uncomplicated: Loading dose of 100 mg/kg (maximum: 4 g). disseminated (unlabeled use): I..V.M. followed by 100 mg/kg/day divided every 12-24 hours (maximum: 4 g/day). I.Gonococcal endocarditis (unlabeled use): <45 kg: I..V.: 50 mg/kg/day every 12 hours (maximum: 2 g/day) for at least 28 days >45 kg: I.V..

usual duration of treatment is 10-14 days >45 kg: I.: 1-2 g every 12 hours.M.M.. acute: I.V. Children >15 years: Refer to Adults dosing.M.V. usual duration of treatment is 10-14 days Otitis media: I. sexual assault (unlabeled uses): 125 mg in a single dose Children >8 years (45 kg) and Adolescents (unlabeled use): Epididymitis.: Acute: 50 mg/kg in a single dose (maximum: 1 g) Persistent or relapsing (unlabeled use): 50 mg/kg once daily for 3 days STD.: 125 mg in a single dose.<45 kg: 50 mg/kg/day given every 12 hours (maximum: 2 g/day).: 125 mg in a single dose Children 15 years: Chemoprophylaxis for high-risk contacts and persons with invasive meningococcal disease (unlabeled use): I. . I.

..: 250 mg in a single dose Surgical prophylaxis: I. complicated (unlabeled use): I.V.M. uncomplicated: I.: 1-2 g every 12 hours for at least 28 days Gonococcal infection.M.M. disseminated (unlabeled use): I. acute (unlabeled use): I. depending on the type and severity of infection Gonococcal conjunctivitis.V.: 125250 mg in a single dose PID: I.: 250 mg in a single dose Chemoprophylaxis for high-risk contacts and persons with invasive meningococcal disease (unlabeled use): I. I. I.: 1-2 g every 12-24 hours.: 1 g once daily for 7 days Gonococcal infection.M.M.V.V.M.M..: 1 g in a single dose Gonococcal endocarditis (unlabeled use): I. I.M.: 250 mg in a single dose .: 1 g 30 minutes to 2 hours before surgery Epididymitis.Adults: Usual dose: I.

: Infuse intermittent infusion over 30 minutes .Dosage adjustment in renal/hepatic impairment: No adjustment necessary Hemodialysis: Not dialyzable (0% to 5%).M.V. can be diluted with 1:1 water and 1% lidocaine for I. I. administration I. into large muscle mass.: Inject deep I. administer dose postdialysis Peritoneal dialysis effects: Administer 750 mg every 12 hours Continuous arteriovenous or venovenous hemofiltration: Removes 10 mg of ceftriaxone of liter of filtrate per day Administration: Do not admix with aminoglycosides in same bottle/bag.M. a concentration of 250 mg/mL or 350 mg/mL is recommended for all vial sizes except the 250 mg size (250 mg/mL is suggested).M.

Do not take any new medication during therapy unless approved by prescriber. OTC medications. Report immediately any . and any allergies you have. falsepositive serum or urine creatinine with Jaffé reaction Dietary Considerations: Sodium contents: 83 mg (3. Fehling's solution). or herbal products you are taking.6 mEq) per ceftriaxone 1g Patient Education: Inform prescriber of all prescriptions. This medication is administered by infusion or injection. false-positive urinary glucose test using cupric sulfate (Benedict's solution. Clinitest®.Monitoring Parameters: Observe for signs and symptoms of anaphylaxis Test Interactions: Positive direct Coombs'.

Maintain adequate hydration (2-3 L/day of fluids) unless instructed to restrict fluid intake. May cause false test results with Clinitest®. Breast-feeding precaution: Consult prescriber if breast-feeding. boiled milk. itching. rash. unusual fever or chills. pus. sores in mouth. rash. or hives. easy bleeding or bruising.redness. May cause diarrhea (yogurt. burning or pain at injection/infusion site. or difficulty swallowing or breathing. swelling. blood. Report unresolved diarrhea. Dental Health: Effects on Dental Treatment: No significant effects or complications reported Dental Health: Vasoconstrictor/Local Anesthetic Precautions: No information available to require special precautions Mental Health: Effects on Mental Status: . opportunistic infection (vaginal itching or drainage. or respiratory difficulty. or buttermilk may help). or mucus in stool or urine). use of another type of glucose testing is preferable.

and depersonalization with cephalosporins Midazolam Synonyms: Midazolam Hydrochloride Brand Names: Apo-Midazolam® Use: Preoperative sedation and provides conscious sedation prior to diagnostic or radiographic procedures. ICU sedation (continuous infusion).Dental: Sedation component in I. conscious sedation in oral surgery patients. delusion. intravenous anesthesia (maintenance) Use . syrup formulation is used for . intravenous anesthesia (induction).V. illusions.Case reports of euphoria.

status epilepticus Contraindications: Hypersensitivity to midazolam or any component of the formulation. pregnancy Warnings/Precautions: May cause severe respiratory depression.Unlabeled/Investigational: Anxiety. parenteral form is not for intrathecal or epidural injection. Appropriate resuscitative equipment and qualified personnel must be available for administration and monitoring. including benzyl alcohol (crosssensitivity with other benzodiazepines may exist). or ritonavir). Use with extreme caution.children to help alleviate anxiety before a dental procedure Use . atazanavir. respiratory arrest. narrow-angle glaucoma. Initial dosing must be cautiously . or apnea. concurrent use of potent inhibitors of CYP3A4 (amprenavir. particularly in noncritical care settings.

Parenteral form contains benzyl alcohol . particularly in elderly or debilitated patients. Should not be used in shock. Use during upper airway procedures may increase risk of hypoventilation. Use with caution in patients with respiratory disease or impaired gag reflex. patients with hepatic impairment (including alcoholics).titrated and individualized.avoid rapid injection in neonates or prolonged infusions. coma.5 mg.hemodynamic events are more common in pediatric patients or patients with hemodynamic instability. or in renal impairment. or acute alcohol intoxication. Prolonged responses have been noted following extended administration by continuous infusion (possibly due to metabolite accumulation) or in the presence of drugs which inhibit midazolam metabolism. particularly if other CNS depressants (including opiates) are used concurrently. Use with caution in obese patients. Avoid intra-arterial . Hypotension and/or respiratory depression may occur more frequently in patients who have received narcotic analgesics. chronic renal failure. and CHF. Does not protect against increases in heart rate or blood pressure during intubation. May cause hypotension . Initial doses in elderly or debilitated patients should not exceed 2.

particularly in adolescent/pediatric or psychiatric patients. Causes CNS depression (dose-related) resulting in sedation. Paradoxical reactions. or ataxia which may impair physical and mental capabilities. Patients must be cautioned about performing tasks which require mental alertness (eg.administration or extravasation of parenteral formulation. dizziness. A minimum of 1 day should elapse after midazolam administration before attempting these tasks. Use with caution in patients receiving other CNS depressants or psychoactive agents. or antipsychotic properties. confusion. operating machinery or driving). Benzodiazepines have been associated with dependence and acute withdrawal symptoms on . including hyperactive or aggressive behavior have been reported with benzodiazepines. Benzodiazepines have been associated with falls and traumatic injury and should be used with extreme caution in patients who are at risk of these events (especially the elderly). antidepressant. Does not have analgesic. Effects with other sedative drugs or ethanol may be potentiated. Midazolam causes anterograde amnesia.

Adverse Reactions: As reported in adults unless otherwise noted: >10%: Respiratory: Decreased tidal volume and/or respiratory rate decrease. may be precipitated after administration of flumazenil to patients receiving long-term benzodiazepine therapy. including seizures. seizure-like activity (1% children) Gastrointestinal: Nausea (3%).V.discontinuation or reduction in dose.. headache (1%). vomiting (3%) Local: Pain and local reactions at injection site (4% I. severity less than diazepam) .M. apnea (3% children) 1% to 10%: Cardiovascular: Hypotension (3% children) Central nervous system: Drowsiness (1%). oversedation. Acute withdrawal.. 5% I.

Flumazenil has been shown to selectively block the binding of benzodiazepines to its receptor. 1% children). hypotension. . hallucinations. bradycardia. hyperventilation. hiccups (4%. coma. amnesia. excessive salivation. paradoxical reaction (2% children) <1%: Acid taste. stupor. resulting in reversal of CNS depression but not always respiratory depression. bronchospasm. wheezing Overdosage/Toxicology: Symptoms of overdose include respiratory depression. confusion. confusion.Ocular: Nystagmus (1% children) Respiratory: Cough (1%) Miscellaneous: Physical and psychological dependence with prolonged use. agitation. euphoria. laryngospasm. PVC. emergence delirium. bigeminy. tachycardia. Treatment for benzodiazepine overdose is supportive. and apnea. dyspnea. rash.

or by at least 50% if >65 years of age. carbamazepine. doxycycline. 3A4 (weak) CNS depressants: Sedative effects and/or respiratory depression may be additive with CNS depressants. protease inhibitors. nefazodone. Example inducers include aminoglutethimide. includes ethanol. nevirapine. clarithromycin. ciprofloxacin. . the midazolam dose should be reduced by 30% if <65 years of age. Inhibits CYP2C8/9 (weak). Example inhibitors include azole antifungals. and verapamil. phenobarbital. CYP3A4 inducers: CYP3A4 inducers may decrease the levels/effects of midazolam. monitor for increased effect. CYP3A4 inhibitors: May increase the levels/effects of midazolam. nicardipine. quinidine. phenytoin. imatinib. and rifamycins. propofol. and other sedative agents. nafcillin. diclofenac. erythromycin. narcotic analgesics. 3A4 (major). isoniazid. If narcotics or other CNS depressants are administered concomitantly.Drug Interactions: Substrate of CYP2B6 (minor). barbiturates.

Levodopa: Therapeutic effects may be diminished in some patients following the addition of a benzodiazepine; limited/inconsistent data Oral contraceptives: May decrease the clearance of some benzodiazepines (those which undergo oxidative metabolism); monitor for increased benzodiazepine effect Saquinavir: A 56% reduction in clearance and a doubling of midazolam's half-life were seen with concurrent administration with saquinavir. Theophylline: May partially antagonize some of the effects of benzodiazepines; monitor for decreased response; may require higher doses for sedation Ethanol/Nutrition/Herb Interactions: Ethanol: Avoid ethanol (may increase CNS depression). Food: Grapefruit juice may increase serum concentrations of midazolam; avoid concurrent use with oral form.

Herb/Nutraceutical: Avoid concurrent use with St John's wort (may decrease midazolam levels, may increase CNS depression). Avoid concurrent use with valerian, kava kava, gotu kola (may increase CNS depression). Stability: Stable for 24 hours at room temperature/refrigeration; at a final concentration of 0.5 mg/mL, stable for up to 24 hours when diluted with D5W or NS, or for up to 4 hours when diluted with lactated Ringer's; admixtures do not require protection from light for short-term storage Compatibility: Stable in D5NS, D5W, NS; incompatible in LR Y-site administration: Compatible: Alatrofloxacin, amikacin, amiodarone, atracurium, calcium gluconate, cefazolin, cefotaxime, cimetidine, ciprofloxacin, cisatracurium, clindamycin, digoxin, diltiazem, dopamine, epinephrine, erythromycin lactobionate, esmolol, etomidate, famotidine, fentanyl, fluconazole, gatifloxacin, gentamicin, haloperidol, heparin,

hydromorphone, insulin (regular), ketanserin, labetalol, linezolid, lorazepam, methylprednisolone sodium succinate, metronidazole, milrinone, morphine, nicardipine, nitroglycerin, norepinephrine, pancuronium, piperacillin, potassium chloride, ranitidine, remifentanil, sodium nitroprusside, sufentanil, theophylline, tobramycin, vancomycin, vecuronium. Incompatible: Albumin, amphotericin B cholesteryl sulfate complex, ampicillin, bumetanide, butorphanol, ceftazidime, cefuroxime, clonidine, dexamethasone sodium succinate, floxacillin, foscarnet, fosphenytoin, furosemide, hydrocortisone sodium succinate, imipenem/cilastatin, methotrexate, nafcillin, omeprazole, sodium bicarbonate, thiopental, trimethoprim/sulfamethoxazole. Variable (consult detailed reference): Dobutamine, propofol Compatibility in syringe: Compatible: Alfentanil, atracurium, atropine, buprenorphine, butorphanol, chlorpromazine, cimetidine, diamorphine, diphenhydramine, droperidol, fentanyl, glycopyrrolate, hydromorphone, hydroxyzine, meperidine, metoclopramide, morphine, nalbuphine, ondansetron, promazine, promethazine, scopolamine, sufentanil, thiethylperazine, trimethobenzamide. Incompatible: Dimenhydrinate, pentobarbital, perphenazine, prochlorperazine edisylate, ranitidine

V. I.M. reticular formation.: Up to 6 hours. This shift in chloride ions results in hyperpolarization (a less excitable state) and stabilization.: 1-5 minutes Peak effect: I.M.: 0.Compatibility when admixed: Compatible: Hydromorphone Mechanism of Action: Binds to stereospecific benzodiazepine receptors on the postsynaptic GABA neuron at several sites within the central nervous system.5-1 hour Duration: I. Mean: 2 hours Absorption: Oral: Rapid . including the limbic system.M. Pharmacodynamics/Kinetics: Onset of action: I.: Sedation: ~15 minutes. Enhancement of the inhibitory effect of GABA on neuronal excitability results by increased neuronal membrane permeability to chloride ions.

5 L/kg. underlying diseases. and elderly Excretion: Urine (as glucuronide conjugated metabolites).8-2. and concurrent medications. Decrease dose (by ~30%) if narcotics or other CNS depressants are administered concomitantly. prolonged with cirrhosis. feces (~2% to 10%) Dosage: The dose of midazolam needs to be individualized based on the patient's age. Personnel and equipment needed for standard respiratory . obesity. increased with congestive heart failure (CHF) and chronic renal failure Protein binding: 95% Metabolism: Extensively hepatic via CYP3A4 Bioavailability: Mean: 45% Half-life elimination: 1-4 hours.Distribution: Vd: 0. congestive heart failure.

4 mg/kg in some studies). administer 30-45 minutes prior to procedure. maximum total dose: 10 mg . calculate dose on ideal body weight Conscious sedation for procedures or preoperative sedation: Oral: 0.M. Intranasal (not an approved route): 0. up to a maximum of 20 mg. Children <6 years may require higher doses and closer monitoring than older children.2 mg/kg (up to 0. doses up to 0.: 0.05-0.15 mg/kg.5 mg/kg have been used in more anxious patients. Children <6 years or less cooperative patients may require as much as 1 mg/kg as a single dose. may be administered 30-45 minutes prior to procedure I. to a maximum of 15 mg. 0. range 0.1-0.25 mg/kg may suffice for children 6-16 years of age.15 mg/kg 30-60 minutes before surgery or procedure.resuscitation should be immediately available during midazolam administration.25-0.5 mg/kg as a single dose preprocedure.

titrate dose in small increments to desired effect. usual maximum total dose: 10 mg Children 12-16 years: Dose as adults. total dose of 0. infants <6 months are at higher risk for airway obstruction and hypoventilation. usual range: 0.12 mg/kg/hour (1-2 mcg/kg/minute).2 mg/kg.I.4-6 mcg/kg/minute .V.4 mg/kg may be required. titrate to the desired effect.6 mg/kg may be required.05-0.06-0. dosing recommendations not clear. titrate dose carefully.: Infants <6 months: Limited information is available in nonintubated infants. followed by initial continuous infusion: 0.025-0. usual maximum total dose: 10 mg Conscious sedation during mechanical ventilation: Children: Loading dose: 0. total doses of 0. monitor carefully Infants 6 months to Children 5 years: Initial: 0.05 mg/kg. titrate dose carefully.050.1 mg/kg. usual maximum total dose: 6 mg Children 6-12 years: Initial: 0.

: 0.07-0.Status epilepticus refractory to standard therapy (unlabeled use): Infants >2 months and Children: Loading dose: 0.02-0.5-2 mg slow I.2 mg/kg Intranasal (not an approved route): 0.V.2 mg/kg (up to 0.4 mg/kg in some studies). mean infusion rate required in 24 children was 2.: Initial: 0.15 mg/kg followed by a continuous infusion of 1 mcg/kg/minute. high-risk patients. titrate dose upward every 5 minutes until clinical seizure activity is controlled. and patients receiving other narcotics or CNS depressants I.1-0.M. over at least 2 minutes.3 mcg/kg/minute with a range of 1-18 mcg/kg/minute Adults: Preoperative sedation: I.04 mg/kg. Note: Reduce dose in patients with COPD. patients 60 years of age.: 0.08 mg/kg 30-60 minutes prior to surgery/procedure. administer 30-45 minutes prior to surgery/procedure Conscious sedation: I. usual dose: 5 mg.V.V. repeat every 5 minutes as needed to desired effect or up to 0. slowly titrate to effect by .

15-0.5 mcg/kg/minute .repeating doses every 2-3 minutes if needed. or continuous infusion 0.V. Additional doses of midazolam may be administered after a 2-minute waiting period and evaluation of sedation after each dose increment.3 mg/kg as needed. use decreased doses in elderly Healthy Adults <60 years: Some patients respond to doses as low as 1 mg.05-0.5-5 mg.5 mg should be administered over a period of 2 minutes.25-1.6 mg/kg in resistant cases) Premedicated patients: 0. Anesthesia: I. no more than 2.: Induction: Unpremedicated patients: 0.35 mg/kg Maintenance: 0. usual total dose: 2.35 mg/kg (up to 0.3-0. A total dose >5 mg is generally not needed. the midazolam dose should be reduced by 30%. If narcotics or other CNS depressants are administered concomitantly.

V.5 mg slow I.. may concentrate up to a maximum of 0.5 mg in a 2-minute period.2 mg/kg/hour and titrate to reach desired level of sedation Elderly: I. if additional titration is needed.04-0.02-0.V. give no more than 1.5 mg is rarely necessary Dosage adjustment in renal impairment: Hemodialysis: Supplemental dose is not necessary Peritoneal dialysis: Significant drug removal is unlikely based on physiochemical characteristics . waiting another 2 or more minutes to evaluate sedative effect.Sedation in mechanically-ventilated patients: I. give no more than 1 mg over 2 minutes.5 mg/mL).08 mg/kg (~1 mg to 5 mg in 70 kg adult) initially and either repeated at 5-15 minute intervals until adequate sedation is achieved or continuous infusion rates of 0.V. continuous infusion: 100 mg in 250 mL D5W or NS (if patient is fluid-restricted. a total dose of >3.: Conscious sedation: Initial: 0. initial dose: 0.

V. Monitoring Parameters: Respiratory and cardiovascular status.M.V. blood pressure.: Administer by slow I. /2 of the dose may be administered to each nare Oral: Do not mix with any liquid (such as grapefruit juice) prior to administration Parenteral: I. I.V. infusion.Administration: Intranasal: Administer using a 1 mL needleless syringe into the nares over 15 seconds. Continuous infusions should be administered via an infusion pump. blood pressure monitor required during I. injection over at least 2-5 minutes at a concentration of 1-5 mg/mL or by I. into large muscle.: Administer deep I. use the 5 1 mg/mL injection.V. administration Dietary Considerations: .M.

in patients with hypoalbuminemia. Pregnancy/breast-feeding precautions: Advise prescriber if you are pregnant. Midazolam may accumulate in obesity. The ACCM/SCCM task force does not recommend midazolam use for ongoing sedation in the . Avoid driving or engaging in any tasks that require alertness for 24 hours following administration. Anesthesia and Critical Care Concerns/Other Considerations: Agitation in the ICU Patient: Diazepam or midazolam is recommended for rapid sedation of the acutely-agitated patient. or renal failure.14 mEq Patient Education: Avoid use of alcohol or prescription or OTC sedatives or hypnotics for a minimum of 24 hours after administration. You may experience some loss of memory following administration. Concurrent use of CYP3A4 inhibitors may inhibit midazolam's metabolism and prolong its sedative effects. this medication is contraindicated for pregnant women.Injection: Sodium content of 1 mL: 0. Breastfeeding is not recommended.

DexPak® TaperPak®. Maxidex® Synonyms: Dexamethasone Sodium Phosphate Use: Systemically and locally for chronic swelling. may be used in management of cerebral . Dexamethasone Brand Names: Decadron®. combativeness) have been successfully treated with flumazenil. Decadron® Phosphate [DSC]. agitation. Paradoxical reactions associated with midazolam use in children (eg. and autoimmune diseases.practice guidelines for sustained use of sedatives and analgesics in the critically-ill adult. Midazolam is 3-4 times as potent as diazepam. restlessness. hematologic. Dexamethasone Intensol®. allergic. neoplastic.

fungal.edema. ophthalmic use in viral. active untreated infections. or tuberculosis diseases of the eye Warnings/Precautions: Use with caution in patients with hypothyroidism.Unlabeled/Investigational: General indicator consistent with depression. or thromboembolic disorders. cirrhosis. antiemetic Use . Corticosteroids should . inflammatory or autoimmune origin Use .Dental: Treatment of a variety of oral diseases of allergic. CHF. diagnosis of Cushing's syndrome Contraindications: Hypersensitivity to dexamethasone or any component of the formulation. ulcerative colitis. as a diagnostic agent. septic shock. hypertension.

Fatalities have occurred due to adrenal insufficiency in asthmatic patients during and after transfer from systemic corticosteroids to aerosol steroids. Patients receiving 20 mg/day of prednisone (or equivalent) may be most susceptible. Symptoms of adrenocortical insufficiency in suppressed patients may result from rapid discontinuation/withdrawal. glaucoma. including an increase in allergic symptoms. Particular care is required when patients are transferred from systemic corticosteroids to inhaled products due to possible adrenal insufficiency or exacerbation of underlying disease. cataracts. deficits in HPA response may persist for months following discontinuation and require supplementation during metabolic stress. peptic ulcer. aerosol steroids do not provide the . Because of the risk of adverse effects. osteoporosis. Use caution following acute MI (corticosteroids have been associated with myocardial rupture). May cause suppression of hypothalamic-pituitaryadrenal (HPA) axis. Use caution in hepatic impairment. particularly in younger children or in patients receiving high doses for prolonged periods.be used with caution in patients with diabetes. systemic corticosteroids should be used cautiously in the elderly in the smallest possible effective dose for the shortest duration. or tuberculosis.

8 cm per year] and appears to be related to dose and duration of exposure). each patient should be titrated to the lowest effective dose. patients may be more susceptible to infection. To minimize the systemic effects of orally-inhaled and intranasal corticosteroids.3-1. or infections.systemic steroid needed to treat patients having trauma. Avoid exposure to chickenpox and measles. May suppress the immune system. via stadiometry). the mean reduction in growth velocity was ~1 cm per year [range 0. (In studies of orally-inhaled corticosteroids. The growth of pediatric patients receiving inhaled corticosteroids. . Dexamethasone does not cross-react with cortisol assays. surgery. Use with caution in patients with systemic infections or ocular herpes simplex. should be monitored routinely (eg. Controlled clinical studies have shown that orallyinhaled and intranasal corticosteroids may cause a reduction in growth velocity in pediatric patients. Dexamethasone does not provide adequate mineralocorticoid activity in adrenal insufficiency (may be employed as a single dose while cortisol assays are performed).

psychosis. myocardial rupture (post-MI). sodium and water retention. nervousness. seizure. Cushing's syndrome. gynecomastia. thrombophlebitis. mood swings. injection).Adverse Reactions: Frequency not defined. Cardiovascular: Edema. glucose intolerance. alkalosis. hallucinations. amenorrhea. perianal pruritus (following I. vasculitis Central nervous system: Insomnia. bruising. hypertension. syncope. hyperglycemia. urticaria Endocrine & metabolic: Diabetes mellitus. weight gain . headache. euphoria Dermatologic: Hirsutism. growth suppression. delirium. pseudotumor cerebri (usually following discontinuation). skin atrophy. adrenal suppression. thromboembolism. hypercalciuria. hypokalemia. vertigo. hyperlipidemia. arrhythmia. pituitary-adrenal axis suppression.V. cardiomyopathy. hyperpigmentation. pruritus (generalized). acne.

moon face . vomiting. exophthalmos. angioedema. abnormal fat deposition. indigestion. secondary malignancy. intestinal perforation Genitourinary: Altered (increased or decreased) spermatogenesis Hematologic: Transient leukocytosis Hepatic: Transaminases increased.Gastrointestinal: Appetite increased. muscle weakness. vertebral compression fractures. tendon rupture. pancreatitis. fractures. abdominal distention. neuropathy. myopathy (particularly in conjunction with neuromuscular disease or neuromuscular blocking agents). avascular necrosis. Kaposi's sarcoma. glaucoma. hepatomegaly Neuromuscular & skeletal: Arthralgia. anaphylaxis. intraocular pressure increased Miscellaneous: Infections. anaphylactoid reaction. osteoporosis. neuritis. intractable hiccups. nausea. impaired wound healing. parasthesia Ocular: Cataracts. ulcerative esophagitis. peptic ulcer.

hypertrichosis. discontinuation of the corticosteroid should be done judiciously. allergic contact dermatitis. Induces CYP2A6 (weak). acneiform eruptions. hypopigmentation. 2B6 (weak). systemic hypercorticism and adrenal suppression may occur. perioral dermatitis. dryness. folliculitis. striae. separate administration by 2 hours. skin atrophy. miliaria. local burning. 2C8/9 (weak). likely via induction of microsomal isoenzymes. In these cases. 3A4 (weak) Aminoglutethimide: May reduce the serum levels/effects of dexamethasone. secondary infection Overdosage/Toxicology: When consumed in high doses over prolonged periods. . Drug Interactions: Substrate of CYP3A4 (minor). skin maceration.Topical:<1%: Itching. Antacids: May increase the absorption of corticosteroids. irritation.

Fluoroquinolones: Concurrent use may increase the risk of tendon rupture.Anticholinesterases: Concurrent use may lead to severe weakness in patients with myasthenia gravis. monitor. monitor. monitor. . Azole antifungals: May increase the serum levels of corticosteroids. In addition. particularly in elderly patients (overall incidence rare). Bile acid sequestrants: May reduce the absorption of corticosteroids. Calcium channel blockers (nondihydropyridine): May increase the serum levels of corticosteroids. Cyclosporine: Corticosteroids may increase the serum levels of cyclosporine. separate administration by 2 hours. cyclosporine may increase levels of corticosteroids Estrogens: May increase the serum levels of corticosteroids.

use caution. use caution Vaccines. In patients receiving high doses of systemic corticosteroids for 14 days. Thalidomide: Concurrent use with corticosteroids may increase the risk of selected adverse effects (toxic epidermal necrolysis and DVT). monitor. The use of live vaccines is contraindicated in immunosuppressed patients. Neuromuscular-blocking agents: Concurrent use with corticosteroids may increase the risk of myopathy. toxoids: Corticosteroids may suppress the response to vaccinations. Salicylates: Salicylates may increase the gastrointestinal adverse effects of corticosteroids. Phenytoin: Dexamethasone may decrease serum levels/effects of phenytoin. wait at least . Nonsteroidal anti-inflammatory drugs (NSAIDs): Concurrent use with corticosteroids may lead to an increased incidence of gastrointestinal adverse effects.Isoniazid: Serum concentrations may be decreased by corticosteroids.

Limit caffeine. Stability of injection of parenteral admixture at room temperature (25°C): 24 hours . protect from light and freezing. Warfarin: Corticosteroids may lead to a reduction in warfarin effect. Herb/Nutraceutical: Avoid cat's claw. Food: Dexamethasone interferes with calcium absorption. monitor.1 month between discontinuing steroid therapy and administering immunization. echinacea (have immunostimulant properties). Ethanol/Nutrition/Herb Interactions: Ethanol: Avoid ethanol (may enhance gastric mucosal irritation). Stability: Injection solution: Store at room temperature.

foscarnet. filgrastim. theophylline. gemcitabine. melphalan. levofloxacin. vinorelbine. piperacillin/tazobactam. sargramostim. zidovudine. aztreonam. NS Y-site administration: Compatible: Acyclovir. doxorubicin liposome. linezolid. allopurinol. sufentanil. paclitaxel. cyclophosphamide. thiotepa. meropenem. amikacin. amsacrine. idarubicin. fludarabine. doxorubicin. tacrolimus. fluconazole. morphine. cefpirome. famotidine. granisetron. amphotericin B cholesteryl sulfate complex. vitamin B complex with C. ondansetron. heparin. cisplatin. Incompatible: Ciprofloxacin. amifostine. .Stability of injection of parenteral admixture at refrigeration temperature (4°C): 2 days. meperidine. protect from light and freezing Injection should be diluted in 50-100 mL NS or D5W. lorazepam. remifentanil. cisatracurium. etoposide phosphate. docetaxel. cefepime. sodium bicarbonate. heparin with hydrocortisone sodium succinate. potassium chloride. cladribine. gatifloxacin. cytarabine. propofol. teniposide. Compatibility: Stable in D5W.

glycopyrrolate. verapamil. and reversal of increased capillary permeability. . vancomycin. ranitidine. granisetron. Dexamethasone's mechanism of antiemetic activity is unknown. mitomycin. Variable (consult detailed reference): Amikacin Mechanism of Action: Decreases inflammation by suppression of neutrophil migration. ranitidine. floxacillin. Incompatible: Doxapram. hydromorphone. sufentanil. bleomycin. diphenhydramine with lorazepam and metoclopramide. ondansetron. suppresses normal immune response. Variable (consult detailed reference): Diphenhydramine. furosemide. netilmicin. lidocaine. Incompatible: Daunorubicin. metaraminol.midazolam. decreased production of inflammatory mediators. cimetidine. prochlorperazine edisylate. metoclopramide. nafcillin. topotecan. ondansetron Compatibility when admixed: Compatible: Aminophylline. meropenem. Variable (consult detailed reference): Methotrexate Compatibility in syringe: Compatible: Granisetron.

Biological half-life: 36-54 hours Time to peak.Pharmacodynamics/Kinetics: Onset of action: Acetate: Prompt Duration of metabolic effect: 72 hours.M. I. (should be given as sodium phosphate): 5-20 mg given 15-30 minutes before treatment . acetate is a long-acting repository preparation Metabolism: Hepatic Half-life elimination: Normal renal function: 1.8-3.: ~8 hours Excretion: Urine and feces Dosage: Children: Antiemetic (prior to chemotherapy): I.V.5 hours. serum: Oral: 1-2 hours.

M. I. maintenance: 1-1. (injections should be given as sodium phosphate): 0. I. start dexamethasone at the time of the first dose of antibiotic Physiologic replacement: Oral.5-2 mg/kg/day in divided doses every 6 hours beginning 24 hours prior to extubation and continuing for 4-6 doses afterwards Cerebral edema: I.V...08-0. I. (should be given as sodium phosphate): Loading dose: 1-2 mg/kg/dose as a single dose.6-0.V.V.M. then discontinue Bacterial meningitis in infants and children >2 months: I.V.03-0.5-10 2 mg/m /day in divided doses every 6-12 hours Extubation or airway edema: Oral.V. (injections should be given as sodium phosphate): 0. I.15 2 mg/kg/day or 0..3 mg/kg/day or 2. I. I.5 mg/kg/day (maximum: 16 mg/day) in divided doses every 4-6 hours for 5 days then taper for 5 days.M.75 mg/m /day in divided doses every 6-12 hours .6 mg/kg/day in 4 divided doses every 6 hours for the first 4 days of antibiotic treatment.Anti-inflammatory immunosuppressant: Oral.: 0. (should be given as sodium phosphate): 0.

M. then .: 10-20 mg 15-30 minutes before treatment on each treatment day Continuous infusion regimen: Oral or I. then 4 mg every 12 hours for 2 days or 20 mg 1 hour before chemotherapy. then 8 mg every 12 hours for 4 doses.: 4 mg every 4-6 hours Delayed nausea/vomiting: Oral: 4-10 mg 1-2 times/day for 2-4 days or 8 mg every 12 hours for 2 days. then 10 mg 12 hours after chemotherapy.: 10 mg every 12 hours on each treatment day Mildly emetogenic therapy: Oral.V. I.V. I.. I.Adults: Antiemetic: Prophylaxis: Oral.V.

if no improvement is seen. (injections should be given as sodium phosphate): 0. I. intralesional.4-6 mg/day Ophthalmic: Ointment: Apply thin coating into conjunctival sac 3-4 times/day.V.75-9 mg/day in divided doses every 6-12 hours Intra-articular. reassessment of diagnosis may be necessary. I.M.4 mg every 12 hours for 4 doses Anti-inflammatory: Oral. then to 3-4 times/day Topical: Apply 1-4 times/day. . gradually taper dose to discontinue Suspension: Instill 2 drops into conjunctival sac every hour during the day and every other hour during the night.. Therapy should be discontinued when control is achieved. or soft tissue (as sodium phosphate): 0. gradually reduce dose to every 34 hours.

then switch to oral regimen.V.M. I. diagnostic: Oral: 1 mg at 11 PM. greater accuracy for Cushing's syndrome may be achieved by the following: Dexamethasone 0./I. 4 mg I. 10 mg stat.Chemotherapy: Oral.5 mg by mouth every 6 hours for 48 hours (with 24-hour urine collection for 17hydroxycorticosteroid excretion) Differentiation of Cushing's syndrome due to ACTH excess from Cushing's due to other causes: Oral: Dexamethasone 2 mg every 6 hours for 48 . draw blood at 8 AM the following day for plasma cortisol determination Cushing's syndrome.: 40 mg every day for 4 days. dosage may be reduced after 24 days and gradually discontinued over 5-7 days Dexamethasone suppression test (depression indicator) (unlabeled use): Oral: 1 mg at 11 PM. (should be given as sodium phosphate) every 6 hours until response is maximized.V. repeated every 4 weeks (VAD regimen) Cerebral edema: I. draw blood at 8 AM.V. then taper off if appropriate.

hours (with 24-hour urine collection for 17hydroxycorticosteroid excretion) Multiple sclerosis (acute exacerbation): 30 mg/day for 1 week.6-0.M.03-0. followed by 4-12 mg/day for 1 month Physiological replacement: Oral.V. which may be repeated if necessary Unresponsive shock (ie. I. (should be given as sodium phosphate): 0..75 mg/m /day in divided doses every 6-12 hours Treatment of shock: Addisonian crisis/shock (ie. adrenal insufficiency/responsive to steroid therapy): I.V. (given as sodium phosphate): 1-6 mg/kg as a single I. I. unresponsive to steroid therapy): I. (given as sodium phosphate): 4-10 mg as a single dose.V.15 2 mg/kg/day or 0. dose or up to 40 mg initially followed by repeat doses every 2-6 hours while shock persists Hemodialysis: Supplemental dose is not necessary .V.

and glucose . occult blood loss. use.Peritoneal dialysis: Supplemental dose is not necessary Administration: Oral: Administer with meals to decrease GI upset. I. serum potassium. rapid injection is associated with a high incidence of perianal discomfort.V. Topical: For external use. Apply sparingly to occlusive dressings. Should not be used in the presence of open or weeping lesions.: Administer as a 5-10 minute bolus.V. Monitoring Parameters: Hemoglobin. Do not use on open wounds. I.: Acetate injection is not for I.M.

OTC medications. . vitamin D. Do not take any new medication during therapy unless approved by prescriber. and phosphorus. do not increase dose or discontinue abruptly without consulting prescriber. overnight: 8 AM cortisol <6 mcg/100 mL (dexamethasone 1 mg). vitamin C. plasma cortisol determination should be made on the day after giving dose Dietary Considerations: May be taken with meals to decrease GI upset. or herbal products you are taking. Patient Education: Inform prescriber of all prescriptions. Take exactly as directed. pyridoxine. folate. and any allergies you have.Reference Range: Dexamethasone suppression test. May need diet with increased potassium. calcium.

Some forms of this medication may cause GI upset (small. frequent meals and frequent mouth care may help). Prescriber may recommend increased dietary vitamins. Lie down or tilt your head back and look upward. excessive growth of body hair or loss of skin color.Oral: Take with or after meals. swelling of face or extremities. Ophthalmic: For use in eyes only. Pregnancy/breast-feeding precautions: Inform prescriber if you are or intend to become pregnant. monitor glucose levels closely (antidiabetic medication may need to be adjusted). minerals. Wash hands before using. Consult prescriber if breastfeeding. persistent abdominal pain. respiratory difficulty. If you have diabetes. tarry stool. Inform prescriber if you are experiencing greater-than-normal levels of stress (medication may need adjustment). unhealed injuries). or iron. Put drops of suspension or apply thin . vision changes. muscle weakness. Avoid alcohol and limit intake of caffeine or stimulants. signs of infection (eg. excessive or sudden weight gain (>3 lb/week). You may be more susceptible to infection (avoid crowds and persons with contagious or infective conditions and do not have any vaccinations unless approved by prescriber). worsening of condition or failure to improve. sore throat. Report promptly excessive nervousness or sleep disturbances.

mucous membranes. fails to improve. Do not use occlusive dressing unless so advised by prescriber. irritation. Do not blink for /2 minute. Do not use any other eye preparation for at least 10 minutes. wash and dry area gently. do not contaminate tip of applicator (may cause eye infection. Use exactly as directed and for no longer than the period prescribed. Inform prescriber if condition worsens (swelling.ribbon of ointment inside lower eyelid. Apply in thin layer (may rub in lightly). Do not let tip of applicator touch eye. or open wounds. you may be more sensitive to bright light. . Close eye 1 and roll eyeball in all directions. pain. redness. or other adverse eye response. Inform prescriber if condition worsens. or if you experience eye pain. Before using. Do not use for eyes. Apply gentle pressure to inner corner of eye for 30 seconds. Do not share medication with anyone else. eye damage. disturbances of vision. open sores) or fails to improve. Wear sunglasses when in sunlight. Apply light dressing (if necessary) to area being treated. Topical: For external use only. or vision loss). Avoid exposing treated area to sunlight (severe sunburn may occur).

adjunct to treatment of acute toxicity from isoniazid.Pyridoxine Brand Names: Aminoxin® [OTC] Synonyms: Pyridoxine Hydrochloride. pyridoxine-dependent seizures in infants. cycloserine. Vitamin B6 Use: Prevention and treatment of vitamin B6 deficiency. or hydralazine overdose Contraindications: Hypersensitivity to pyridoxine or any component of the formulation Warnings/Precautions: .

seizure (following very large I.Dependence and withdrawal may occur with doses >200 mg/day Adverse Reactions: Frequency not defined.V. doses). Central nervous system: Headache. sensory neuropathy Endocrine & metabolic: Decreased serum folic acid secretions Gastrointestinal: Nausea Hepatic: Increased AST Neuromuscular & skeletal: Paresthesia Miscellaneous: Allergic reactions Overdosage/Toxicology: .

Symptoms of overdose include ataxia and sensory neuropathy with doses of 50 mg to 2 g daily over prolonged periods. and phenytoin Stability: Protect from light Compatibility: Stable in fat emulsion 10% Compatibility in syringe: Compatible: Doxapram Mechanism of Action: Precursor to pyridoxal. pyridoxal also aids in the release of liver and . which functions in the metabolism of proteins. phenobarbital. carbohydrates. Drug Interactions: Decreased serum levels of levodopa. and fats.

muscle-stored glycogen and in the synthesis of GABA (within the central nervous system) and heme Pharmacodynamics/Kinetics: Absorption: Enteral.9 mg 4-6 years: 1.3 mg . parenteral: Well absorbed Metabolism: Via 4-pyridoxic acid (active form) and other metabolites Half-life elimination: 15-20 days Excretion: Urine Dosage: Recommended daily allowance (RDA): Children: 1-3 years: 0.

M. isoniazid. SubQ: 10-100 mg Dietary deficiency: Oral: Children: 5-25 mg/24 hours for 3 weeks. then 1.7-2.6 mg Pyridoxine-dependent Infants: Oral: 2-100 mg/day I.7-10 years: 1. hydralazine.. cycloserine): Oral: . I.V..5 mg/day in multiple vitamin product Adults: 10-20 mg/day for 3 weeks Drug-induced neuritis (eg.6 mg Adults: Male: 1.0 mg Female: 1. penicillamine.52.4-1.

has been used .V.V.V./I. a dose of pyridoxine hydrochloride equal to the amount of INH ingested can be given I.M.M. in divided doses together with other anticonvulsants. pyridoxine Treatment of acute hydralazine toxicity.Children: Treatment: 10-50 mg/24 hours Prophylaxis: 1-2 mg/kg/24 hours Adults: Treatment: 100-200 mg/24 hours Prophylaxis: 25-100 mg/24 hours Treatment of seizures and/or coma from acute isoniazid toxicity. administer 5 g I. if the amount INH ingested is not known. a pyridoxine dose of 25 mg/kg in divided doses I./I.

You may experience burning or pain at .5-18 ng/mL (SI: 17-88 nmol/L). red meat.V. administration of very large doses Reference Range: Over 50 ng/mL (SI: 243 nmol/L) (varies considerably with method). bananas. seizures have occurred following I. potatoes. and whole grain cereals). lima beans. or SubQ administration. A broad range is ~2580 ng/mL (SI: 122-389 nmol/L).Administration: Burning may occur at the injection site after I. Test Interactions: Urobilinogen Patient Education: Take exactly as directed.M. HPLC method for pyridoxal phosphate has normal range of 3. Do not take more than recommended. yeast. Do not exceed recommended intake of dietary B6 (eg.

Rifampin Brand Name: Rifadin® Synonyms: Rifampicin Use: Management of active tuberculosis in combination with other agents. Legionella pneumonia. Pregnancy precaution: Inform prescriber if you are pregnant.injection site.Unlabeled/Investigational: Prophylaxis of Haemophilus influenzae type b infection. elimination of meningococci from the nasopharynx in asymptomatic carriers Use . used in combination with other anti-infectives in the . notify prescriber if this persists.

Use with caution in patients receiving concurrent medications associated with hepatotoxicity (particularly with pyrazinamide). porphyria exacerbation is possible. leprae infections Contraindications: Hypersensitivity to rifampin. discontinue therapy if this in conjunction with clinical symptoms or any signs of significant hepatocellular damage develop. since rifampin has enzyme-inducing properties. do not use for meningococcal disease. saquinavir/ritonavir (possibly other protease inhibitors) Warnings/Precautions: Use with caution and modify dosage in patients with liver impairment. observe for hyperbilirubinemia. any rifamycins. or in patients with .treatment of staphylococcal infections. treatment of M. only for short-term treatment of asymptomatic carrier states. or any component of the formulation. concurrent use of amprenavir. use with caution in patients with porphyria.

numbness. form via I. headache. confusion.a history of alcoholism (even if ethanol consumption is discontinued during therapy). drowsiness. saliva. tears. flushing Central nervous system: Ataxia. sweat. concentration impaired. remove soft contact lenses during therapy since permanent staining may occur. thrombocytopenia in patients on intermittent therapy. and CSF may be discolored to red/orange. feces. dizziness. fatigue.V. Monitor for compliance and effects including hypersensitivity. behavioral changes. restart infusion at another site if extravasation occurs. psychosis . urine. or SubQ routes. do not administer I.M. regimens of 600 mg once or twice weekly have been associated with a high incidence of adverse reactions including a flu-like syndrome Adverse Reactions: Frequency not defined: Cardiovascular: Edema. fever.

hemolysis. heartburn. urticaria Endocrine & metabolic: Adrenal insufficiency. hemoglobin decreased.Dermatologic: Pemphigoid reaction. nausea. osteomalacia. pruritus. epigastric distress. DIC. visual changes 1% to 10%: Dermatologic: Rash (1% to 5%) Gastrointestinal (1% to 2%): Anorexia. weakness Ocular: Exudative conjunctivitis. pancreatitis vomiting . thrombocytopenia (especially with high-dose therapy) Hepatic: Hepatitis (rare). pseudomembranous colitis. menstrual disorders Hematologic: Agranulocytosis. eosinophilia. jaundice Neuromuscular & skeletal: Myalgia. hemolytic anemia. cramps. leukopenia. diarrhea. flatulence.

Reconstitute powder for injection with SWFI. and CNS depression. lethargy. Stability: Rifampin powder is reddish brown.Hepatic: LFTs increased (up to 14%) Overdosage/Toxicology: Symptoms of overdose include nausea. Plasma rifampin concentrations are not significantly affected by hemodialysis or peritoneal dialysis. dilute in appropriate volume of compatible diluent (eg. vomiting. hepatotoxicity. Treatment is supportive. Intact vials should be stored at room temperature and protected from excessive heat and light. Reconstituted vials are stable for 24 hours at room temperature Stability of parenteral admixture at room temperature (25°C) is 4 hours for D5W and 24 hours for NS Compatibility: . prior to injection. 100 mL D5W).

crosses blood-brain barrier well .Variable stability (consult detailed reference) in D5W. blocking RNA transcription Pharmacodynamics/Kinetics: Duration: 24 hours Absorption: Oral: Well absorbed. food may delay or slightly reduce peak Distribution: Highly lipophilic. NS Y-site administration: Incompatible: Diltiazem Compatibility when admixed: Incompatible: Minocycline Mechanism of Action: Inhibits bacterial RNA synthesis by binding to the beta subunit of DNA-dependent RNA polymerase.

serum: Oral: 2-4 hours Excretion: Feces (60% to 65%) and urine (~30%) as unchanged drug Dosage: Oral (I. . prolonged with hepatic impairment.811 hours Time to peak. infusion dose is the same as for the oral route): Tuberculosis therapy (drug susceptible):Note: A four-drug regimen (isoniazid. undergoes enterohepatic recirculation Half-life elimination: 3-4 hours. rifampin.V. End-stage renal disease: 1.Relative diffusion from blood into CSF: Adequate with or without inflammation (exceeds usual MICs) CSF:blood level ratio: Inflamed meninges: 25% Protein binding: 80% Metabolism: Hepatic.

and ethambutol) is preferred for the initial. empiric treatment of TB. the regimen should be altered as appropriate. Infants and Children <12 years: Daily therapy: 10-20 mg/kg/day usually as a single dose (maximum: 600 mg/day) Twice weekly directly observed therapy (DOT): 1020 mg/kg (maximum: 600 mg) Adults: Daily therapy: 10 mg/kg/day (maximum: 600 mg/day) Twice weekly directly observed therapy (DOT): 10 mg/kg (maximum: 600 mg).pyrazinamide. When the drug susceptibility results are available. 3 times/week: 10 mg/kg (maximum: 600 mg) Latent tuberculosis infection (LTBI): As an alternative to isoniazid: Children: 10-20 mg/kg/day (maximum: 600 mg/day) for 6 months .

Aug 8. Note: Combination with pyrazinamide should not generally be offered (MMWR. H.Adults: 10 mg/kg/day (maximum: 600 mg/day) for 4 months. influenzaeprophylaxis (unlabeled use): Infants and Children: 20 mg/kg/day every 24 hours for 4 days. 2003). not to exceed 600 mg/dose Adults: 600 mg every 24 hours for 4 days Leprosy (unlabeled use): Adults: Multibacillary: 600 mg once monthly for 24 months in combination with ofloxacin and minocycline Paucibacillary: 600 mg once monthly for 6 months in combination with dapsone Single lesion: 600 mg as a single dose in combination with ofloxacin 400 mg and minocycline 100 mg Meningococcal meningitis prophylaxis: .

Infants <1 month: 10 mg/kg/day in divided doses every 12 hours for 2 days Infants 1 month and Children: 20 mg/kg/day in divided doses every 12 hours for 2 days (maximum: 600 mg/dose) Adults: 600 mg every 12 hours for 2 days Nasal carriers ofStaphylococcus aureus(unlabeled use): Children: 15 mg/kg/day divided every 12 hours for 5-10 days in combination with other antibiotics Adults: 600 mg/day for 5-10 days in combination with other antibiotics Synergy forStaphylococcus aureusinfections (unlabeled use): Adults: 300-600 mg twice daily with other antibiotics Dosing adjustment in hepatic impairment: Dose reductions may be necessary to reduce hepatotoxicity .

or 2 hours after meals or antacids) to increase total absorption. 1 hour prior to. The compounded oral suspension must be shaken well before using. Administration: I. sputum culture. Oral: Administer on an empty stomach (ie. preparation once daily by slow I. hepatic status and mental status.V.: Administer I.Hemodialysis or peritoneal dialysis: Plasma rifampin concentrations are not significantly affected by hemodialysis or peritoneal dialysis. bilirubin). May mix contents of capsule with applesauce or jelly. Monitoring Parameters: Periodic (baseline and every 2-4 weeks during therapy) monitoring of liver function (AST. infusion over 30 minutes to 3 hours at a final concentration not to exceed 6 mg/mL.V. ALT. CBC. chest x-ray 2-3 months into treatment .V.

Report persistent vomiting or diarrhea. Stains on clothing or contact lenses are permanent.Test Interactions: Positive Coombs' reaction [direct]. 1 hour before or 2 hours after meals. unusual bruising or bleeding. Patient Education: Inform prescriber of all prescriptions. or other persistent adverse . transient increase in LFTs and decreased biliary excretion of contrast media Dietary Considerations: Rifampin should be taken on an empty stomach. and other body fluid a red-brown color. do not skip doses. or flu-like symptoms. or herbal products you are taking. sweat. Do not take any new medication during therapy without consulting prescriber. stool. and any allergies you have. tears. OTC medications. on an empty stomach. rash. rifampin inhibits standard assay's ability to measure serum folate and B12. chills. saliva. fever. Complete full course of therapy. Will discolor urine. Take as per recommended schedule.

Pregnancy precaution: Inform prescriber is you are or intend to become pregnant.effects. Use with caution in patients receiving concurrent medications associated with hepatotoxicity . chronic gout. acute gout. severe hepatic damage Warnings/Precautions: Use with caution in patients with renal failure. consult prescriber for alternative contraceptive measures. or porphyria. Pyrazinamide Use: Adjunctive treatment of tuberculosis in combination with other antituberculosis agents Contraindications: Hypersensitivity to pyrazinamide or any component of the formulation. diabetes mellitus. This drug may interfere with effectiveness of oral contraceptives.

anorexia Neuromuscular & skeletal: Arthralgia. photosensitivity. Treatment is supportive. dysuria. Adverse Reactions: 1% to 10%: Central nervous system: Malaise Gastrointestinal: Nausea. Drug Interactions: . acne. myalgia <1%: Fever. gastric upset. porphyria. vomiting. thrombocytopenia. rash.(particularly with rifampin). and hepatic damage (mild). hepatotoxicity. interstitial nephritis Overdosage/Toxicology: Symptoms of overdose include gout. itching. gout. or in patients with a history of alcoholism (even if ethanol consumption is discontinued during therapy).

lung. Mechanism of Action: Converted to pyrazinoic acid in susceptible strains of Mycobacterium which lowers the pH of the environment. and CSF Relative diffusion from blood into CSF: Adequate with or without inflammation (exceeds usual MICs) CSF:blood level ratio: Inflamed meninges: 100% . exact mechanism of action has not been elucidated Pharmacodynamics/Kinetics: Bacteriostatic or bactericidal depending on drug's concentration at infection site Absorption: Well absorbed Distribution: Widely into body tissues and fluids including liver.Combination therapy with rifampin and pyrazinamide has been associated with severe and fatal hepatotoxic reactions.

Children: Daily therapy: 15-30 mg/kg/day (maximum: 2 g/day) .Protein binding: 50% Metabolism: Hepatic Half-life elimination: 9-10 hours Time to peak. followed by a continuation phase of 4 or 7 additional months. frequency of dosing may differ depending on phase of therapy. Treatment regimens consist of an initial 2-month phase. serum: Within 2 hours Excretion: Urine (4% as unchanged drug) Dosage: Oral: Treatment of tuberculosis: Note: Used as part of a multidrug regimen.

5 g) .Twice weekly directly observed therapy (DOT): 50 mg/kg/dose (maximum: 4 g/dose) Adults (dosing is based on lean body weight): Daily therapy: 15-30 mg/kg/day 40-55 kg: 1000 mg 56-75 kg: 1500 mg 76-90 kg: 2000 mg (maximum dose regardless of weight) Twice weekly directly observed therapy (DOT): 50 mg/kg 40-55 kg: 2000 mg 56-75 kg: 3000 mg 76-90 kg: 4000 mg (maximum dose regardless of weight) Three times/week DOT: 25-30 mg/kg (maximum: 2.

and peritoneal dialysis as well as continuous arteriovenous or venovenous hemofiltration. sputum culture. Dosing adjustment in hepatic impairment: Reduce dose Monitoring Parameters: Periodic liver function tests.40-55 kg: 1500 mg 56-75 kg: 2500 mg 76-90 kg: 3000 mg (maximum dose regardless of weight) Elderly: Start with a lower daily dose (15 mg/kg) and increase as tolerated. serum uric acid. chest x-ray 2-3 months into treatment and at completion . Dosing adjustment in renal impairment: Clcr<50 mL/minute: Avoid use or reduce dose to 12-20 mg/kg/day Avoid use in hemo.

or unresolved nausea or vomiting. You will need regular medical follow-up and laboratory tests while taking this medication. unusual fever. serum uric acid . Pregnancy precaution: Inform prescriber if you are or intend to become pregnant. pale stools. easy bruising or bleeding. May cause nausea or loss of appetite (small. extreme joint pain. frequent meals. yellowing of skin or eyes. frequent mouth care. with food. or chewing gum may help). blood in urine or difficulty urinating.Test Interactions: Reacts with Acetest® and Ketostix® to produce pinkish-brown color Patient Education: Take as directed. Report change in color of urine. It is imperative to take for full length of therapy. Nursing Implications: Monitor periodic liver function tests. sucking lozenges. do not miss doses and do not discontinue without consulting prescriber.

tularemia. and brucellosis Contraindications: Hypersensitivity to streptomycin or any component of the formulation. Cardiovascular: Hypotension . mycobacterial infections. pregnancy Adverse Reactions: Frequency not defined. used in combination with other agents for treatment of streptococcal or enterococcal endocarditis. plague.Streptomycin Synonyms: Streptomycin Sulfate Use: Part of combination therapy of active tuberculosis.

vomiting Hematologic: Eosinophilia. ototoxicity (vestibular) Renal: Nephrotoxicity Respiratory: Difficulty in breathing Overdosage/Toxicology: Symptoms of overdose include ototoxicity. drug fever. tremor Otic: Ototoxicity (auditory). headache. paresthesia Dermatologic: Skin rash Gastrointestinal: Nausea. anemia Neuromuscular & skeletal: Arthralgia. and neuromuscular toxicity.Central nervous system: Neurotoxicity. drowsiness. nephrotoxicity. The treatment of choice following a single acute overdose appears to be maintenance of urine output of at least 3 mL/kg/hour during the acute . weakness.

If required. Dialysis is of questionable value in enhancing aminoglycoside elimination. exposure to light causes darkening of solution without apparent loss of potency Compatibility: Y-site administration: Compatible: Esmolol . Drug Interactions: Increased/prolonged effect: Depolarizing and nondepolarizing neuromuscular blocking agents Increased toxicity: Concurrent use of amphotericin may increase nephrotoxicity Stability: Depending upon manufacturer. reconstituted solution remains stable for 2-4 weeks when refrigerated. hemodialysis is preferred over peritoneal dialysis in patients with normal renal function. Chelation with penicillins is experimental.treatment phase.

pleural. Variable (consult detailed reference): Ampicillin Compatibility when admixed: Compatible: Bleomycin. methohexital. phenobarbital. phenytoin. chlorothiazide.: Well absorbed Distribution: To extracellular fluid including serum. abscesses. sodium bicarbonate Mechanism of Action: Inhibits bacterial protein synthesis by binding directly to the 30S ribosomal subunits causing faulty peptide sequence to form in the protein chain Pharmacodynamics/Kinetics: Absorption: I. crosses placenta. Incompatible: Heparin. ascitic. lymphatic. norepinephrine. Incompatible: Amobarbital. synovial.M. small amounts enter breast milk Protein binding: 34% .Compatibility in syringe: Compatible: Penicillin G sodium. pentobarbital. pericardial. amphotericin B. heparin. and peritoneal fluids.

and tears (<1%) Dosage: Children: Tuberculosis: Daily therapy: 20-40 mg/kg/day (maximum: 1 g/day) Directly observed therapy (DOT): Twice weekly: 20-40 mg/kg (maximum: 1 g) DOT: 3 times/week: 25-30 mg/kg (maximum: 1 g) Adults: . saliva. sweat.7 hours.Half-life elimination: Newborns: 4-10 hours. feces. prolonged with renal impairment Time to peak: Within 1 hour Excretion: Urine (90% as unchanged drug). Adults: 2-4.

not to exceed 750 mg/day. some authors suggest not to give more than 5 days/week or give as 20-25 mg/kg/dose twice weekly . 500 mg every 12 hours for 1 week Tularemia: 1-2 g/day in divided doses for 7-10 days or until patient is afebrile for 5-7 days Plague: 2-4 g/day in divided doses until the patient is afebrile for at least 3 days Elderly: 10 mg/kg/day.Tuberculosis: Daily therapy: 15 mg/kg/day (maximum: 1 g) Directly observed therapy (DOT): Twice weekly: 25-30 mg/kg (maximum: 1.5 g) DOT: 3 times/week: 25-30 mg/kg (maximum: 1 g) Enterococcal endocarditis: 1 g every 12 hours for 2 weeks. 500 mg every 12 hours for 4 weeks in combination with penicillin Streptococcal endocarditis: 1 g every 12 hours for 1 week. dosing interval should be adjusted for renal function.

sense of fullness in ears.V.Dosing interval in renal impairment: Clcr 10-50 mL/minute: Administer every 24-72 hours Clcr<10 mL/minute: Administer every 72-96 hours Removed by hemo and peritoneal dialysis: Administer dose postdialysis Administration: Inject deep I. eighth cranial nerve damage is usually preceded by high-pitched tinnitus. roaring noises. may be administered I.M. creatinine. over 30-60 minutes Monitoring Parameters: Hearing (audiogram). into large muscle mass. serum concentration of the drug should be monitored in all patients. or impaired hearing and may persist for weeks after drug is discontinued . BUN.

Trough: <5 mcg/mL. May cause headache or dizziness (use caution when driving or engaging in tasks requiring alertness until response to drug is known). This medication can only be given by intramuscular injection. Trough: >10 mcg/mL Test Interactions: False-positive urine glucose with Benedict's solution or Clinitest®. frequent meals. or loss of appetite (small. penicillin may decrease aminoglycoside serum concentrations in vitro Patient Education: Inform prescriber of all prescriptions.Reference Range: Therapeutic: Peak: 20-30 mcg/mL. or nausea. vomiting. Do not discontinue even if you are feeling better. frequent . or herbal products you are taking. Maintain adequate hydration (2-3 L/day of fluids) unless instructed to restrict fluid intake. and any allergies you have. Therapy for TB may last several months. Toxic: Peak: >50 mcg/mL. OTC medications.

unusual clumsiness or change in strength or altered gait. Pregnancy precaution: Do not get pregnant while taking this medication. or numbness in muscles. weakness. pain. or respiratory difficulty or chest pain. Consult prescriber for appropriate barrier contraceptive measures. change in urinary pattern or back pain. sucking lozenges.mouth care. or chewing gum may help). Report immediately change in hearing or sense of fullness in ears. Furosemide Brand Names: Lasix® Use: Management of edema associated with congestive heart failure and hepatic or renal disease. tremors. alone or in combination with antihypertensives in treatment of hypertension Contraindications: .

patients with hepatic coma or in states of severe electrolyte depletion until the condition improves or is corrected Adverse Reactions: Frequency not defined. erythema multiforme.V. photosensitivity. hyperglycemia. hypochloremia. Cardiovascular: Orthostatic hypotension. hyperuricemia. purpura.Hypersensitivity to furosemide. hypocalcemia. anuria. xanthopsia . dizziness. chronic aortitis. necrotizing angiitis. acute hypotension. or sulfonylureas. hypomagnesemia. thrombophlebitis. administration) Central nervous system: Paresthesias. any component. sudden death from cardiac arrest (with I. hypokalemia. vertigo. pruritus. lightheadedness. rash. hyponatremia. headache. or I. fever.M. blurred vision. restlessness Dermatologic: Exfoliative dermatitis. urticaria. metabolic alkalosis . cutaneous vasculitis Endocrine & metabolic: Gout.

hemolytic anemia. ischemia hepatitis Genitourinary: Urinary bladder spasm. weakness Otic: Hearing impairment (reversible or permanent with rapid I. glycosuria. transient rise in BUN Miscellaneous: Anaphylaxis (rare). administration).V.Gastrointestinal: Nausea. agranulocytosis (rare). intrahepatic cholestatic jaundice. leukopenia. constipation.M. diarrhea. tinnitus. allergic interstitial nephritis. anemia. vomiting. purpura Neuromuscular & skeletal: Muscle spasm. reversible deafness (with rapid I. exacerbate or activate systemic lupus erythematosus . thrombocytopenia. fall in glomerular filtration rate and renal blood flow (due to overdiuresis). urinary frequency Hematological: Aplastic anemia (rare). or I.M. anorexia. oral and gastric irritation. or I. pancreatitis.V. cramping. administration) Renal: Vasculitis.

and circulatory collapse.Overdosage/Toxicology: Symptoms of overdose include electrolyte depletion. Cephaloridine or cephalexin: Nephrotoxicity may occur. Monitor potassium. Treatment is supportive. Antihypertensive agents: Hypotensive effects may be enhanced. Antidiabetic agents: Glucose tolerance may be decreased. Drug Interactions: ACE inhibitors: Hypotensive effects and/or renal effects are potentiated by hypovolemia. Digoxin: Furosemide-induced hypokalemia may predispose to digoxin toxicity. hypotension. dehydration. . Cholestyramine or colestipol may reduce bioavailability of furosemide. volume depletion.

Metformin may decrease furosemide concentrations. Ototoxic drugs (aminoglycosides. monitor for increased effect/toxicity. . Indomethacin (and other NSAIDs) may reduce natriuretic and hypotensive effects of furosemide. Limited documentation.Fibric acid derivatives: Blood levels of furosemide and fibric acid derivatives (ie. Lithium: Renal clearance may be reduced. cis-platinum): Concomitant use of furosemide may increase risk of ototoxicity. clofibrate and fenofibrate) may be increased during concurrent dosing (particularly in hypoalbuminemia). Metformin blood levels may be increased by furosemide. monitor lithium levels. Isolated reports of lithium toxicity have occurred. NSAIDs: Risk of renal impairment may increase when used in conjunction with furosemide. especially in patients with renal dysfunction.

Ethanol/Nutrition/Herb Interactions: Food: Furosemide serum levels may be decreased if taken with food. effects may be significantly decreased.Peripheral adrenergic-blocking drugs or ganglionic blockers: Effects may be increased. . separate oral administration by 2 hours. Succinylcholine: Action may be potentiated by furosemide. Phenobarbital or phenytoin may reduce diuretic response to furosemide. Salicylates (high-dose) with furosemide may predispose patients to salicylate toxicity due to reduced renal excretion or alter renal function. Sucralfate may limit absorption of furosemide. Thiazides: Synergistic diuretic effects occur. Tubocurarine: The skeletal muscle-relaxing effect may be attenuated by furosemide.

Avoid garlic (may have increased antihypertensive effect). resolubilization at room temperature or warming may be performed without affecting the drug's stability Furosemide solutions are unstable in acidic media but very stable in basic media I. yohimbe. Stability: Furosemide injection should be stored at controlled room temperature and protected from light Exposure to light may cause discoloration.V. May also be diluted for infusion 1-2 mg/mL (maximum: .Herb/Nutraceutical: Avoid dong quai if using for hypertension (has estrogenic activity). do not use furosemide solutions if they have a yellow color Refrigeration may result in precipitation or crystallization. Limit intake of natural licorice. Avoid ephedra. infusion solution mixed in NS or D5W solution is stable for 24 hours at room temperature. ginseng (may worsen hypertension). however.

ciprofloxacin.10 mg/mL) over 10-15 minutes (following infusion rate parameters). linezolid. potassium chloride. leucovorin. bleomycin. foscarnet. mitomycin. gentamicin. tolazoline. hydralazine. levofloxacin. fluconazole. epinephrine. doxorubicin liposome. . LR. kanamycin. lorazepam. tacrolimus. Compatibility: Stable in D5LR. docetaxel. NS Y-site administration: Compatible: Allopurinol. cytarabine. amikacin. remifentanil. esmolol. hydrocortisone sodium succinate. propofol. etoposide phosphate. methotrexate. norepinephrine. vitamin B complex with C. sargramostim. gatifloxacin. piperacillin/tazobactam. meropenem. hydromorphone. diltiazem. nitroglycerin. fentanyl. aztreonam. D10W. teniposide. Incompatible: Alatrofloxacin. droperidol. fludarabine. granisetron. mannitol 20%. tobramycin. D5W. cefepime. idarubicin. heparin. paclitaxel. gemcitabine. D5NS. amifostine. cladribine. cyclophosphamide. amphotericin B cholesteryl sulfate complex. chlorpromazine. D20W. indomethacin. clarithromycin. fluorouracil. thiotepa. amsacrine. ranitidine. melphalan. cisplatin. filgrastim.

cefamandole. dobutamine. droperidol. tobramycin. heparin. sodium bicarbonate. potassium chloride. leucovorin. Incompatible: Buprenorphine. sulfadimidine. vinblastine. ranitidine. dopamine. promethazine. netilmicin. atropine. ampicillin. vinorelbine. diazepam. labetalol. meropenem. morphine. netilmicin. meperidine. dexamethasone sodium phosphate. cefuroxime. diamorphine. methotrexate. nicardipine. cefoperazone. theophylline. cimetidine. kanamycin. vecuronium. Incompatible: Doxapram.metoclopramide. metoclopramide. digoxin. vincristine. lidocaine. epinephrine. doxorubicin. vinblastine. doxorubicin. erythromycin lactobionate. metoclopramide. morphine Compatibility in syringe: Compatible: Bleomycin. aminophylline. isoproterenol. fluorouracil. heparin. thiopental. dobutamine. midazolam. isosorbide. penicillin G. Variable (consult detailed . vincristine Compatibility when admixed: Compatible: Amikacin. famotidine. chlorpromazine. quinidine gluconate. cyclophosphamide. Variable (consult detailed reference): Cisatracurium. mitomycin. calcium gluconate. bumetanide. ondansetron. meperidine. milrinone. prochlorperazine edisylate. nitroglycerin. milrinone. scopolamine. cisplatin.

M. I.: ~5 minutes Peak effect: Oral: 1-2 hours Duration: Oral: 6-8 hours.: 30 minutes. and calcium Pharmacodynamics/Kinetics: Onset of action: Diuresis: Oral: 30-60 minutes. sodium.: 2 hours Absorption: Oral: 60% to 67% Protein binding: >98% Metabolism: Minimally hepatic . magnesium.V. gentamicin. I. hydrocortisone sodium succinate. interfering with the chloride-binding cotransport system.V.reference): Amiodarone. chloride. I. verapamil Mechanism of Action: Inhibits reabsorption of sodium and chloride in the ascending loop of Henle and distal renal tubule. thus causing increased excretion of water.

I.V. End-stage renal disease: 9 hours Excretion: Urine (Oral: 50%. I.Half-life elimination: Normal renal function: 0. feces (as unchanged drug). I.V.1 hours. nonrenal clearance prolonged in renal impairment Dosage: Infants and Children: Oral: 1-2 mg/kg/dose increased in increments of 1 mg/kg/dose with each succeeding dose until a satisfactory effect is achieved to a maximum of 6 mg/kg/dose no more frequently than 6 hours. usual maintenance dose interval is twice . increasing by each succeeding dose at 1 mg/kg/dose at intervals of 612 hours until a satisfactory response up to 6 mg/kg/dose.: 80%) within 24 hours..M.5-1. Adults: Oral: 20-80 mg/dose initially increased in increments of 20-40 mg/dose at intervals of 6-8 hours.: 1 mg/kg/dose.

daily or every day.V. over 1-2 minutes.. Continuous I. Usual dosing interval: 6-12 hours.M. the usual dose is 40 mg I.V.V. for acute pulmonary edema.V. may be repeated in 1-2 hours as needed and increased by 20 mg/dose until the desired effect has been obtained. Other studies have used a rate of 4 mg/minute as a continuous I. infusion.1 mg/kg followed by continuous I. may increase dose to 80 mg. If not adequate.V.: 20-40 mg/dose. infusion doses of 0. bolus dose of 0.4 mg/kg/hour if urine output is <1 mL/kg/hour have been found to be effective and result in a lower daily requirement of furosemide than with intermittent dosing. Refractory heart failure: Oral. I.V.: Doses up to 8 g/day have been used. Hypertension (JNC 7): 20-80 mg/day in 2 divided doses I.V. . I. infusion: Initial I. may be titrated up to 600 mg/day with severe edematous states.1 mg/kg/hour doubled every 2 hours to a maximum of 0.

at a maximum rate of 0. I. I. supplemental dose is not necessary.Elderly: Oral.or peritoneal dialysis.V.) have been used to initiate desired response.5 mg/kg/minute for doses <120 mg and 4 mg/minute for doses >120 mg. avoid use in oliguric states.: Initial: 20 mg/day. monitor effects.oral/I. Dosing adjustment/comments in hepatic disease: Diminished natriuretic effect with increased sensitivity to hypokalemia and volume depletion in cirrhosis.V. Administration: Replace parenteral therapy with oral therapy as soon as possible. Dosing adjustment/comments in renal impairment: Acute renal failure: High doses (up to 1-3 g/day . maximum rate of administration for IVPB or infusion: 4 mg/minute. increase slowly to desired response.. I. Dialysis: Not removed by hemo.V.V.M. For continuous infusion . particularly with high doses. injections should be given slowly may be administered undiluted direct I.

do not mix with acidic solutions. especially citrus fruits. or recommend that you eat foods high in potassium.furosemide in patients with severely-impaired renal function. however. ideally. blood pressure. may be administered with food or milk if GI distress. your healthcare provider may prescribe a potassium supplement. in high doses. monitor hearing Dietary Considerations: This product may cause a potassium loss. Sodium content of 1 mL (injection): 0. too much potassium can be as harmful as too little. orthostasis. do not change your diet on your own while taking this medication. should be administered on an empty stomach. another medication to help prevent the potassium loss. serum electrolytes. especially if you are taking potassium supplements or medications to reduce potassium loss. Monitoring Parameters: Monitor weight and I & O daily.162 mEq . do not exceed 4 mg/minute. renal function.

Take as directed with food or milk (to reduce GI distress) early in the day (daily). Do not take potassium supplements without advice of prescriber. Weigh yourself each day. do not use discolored medication. blurred vision. OTC medications. and any allergies you have. postural hypotension (use caution when rising from lying or sitting position or when climbing stairs). or herbal products you are taking. or sensitivity to sunlight (use sunblock or wear protective clothing and sunglasses). Report unusual or unanticipated weight gain or loss. May cause dizziness. include bananas or orange juice or other potassium-rich foods in daily diet. Follow dietary advice of prescriber. at the same time. Keep medication in original container. Report .Patient Education: Inform prescriber of all prescriptions. or if twice daily. in the same clothes when beginning therapy and weekly on long-term therapy. take last dose in late afternoon in order to avoid sleep disturbance and achieve maximum therapeutic effect. away from light. or drowsiness (use caution when driving or engaging in tasks that require alertness until response to drug is known). Do not take any new medication during therapy unless approved by prescriber.

swollen ankles. Genebs® Extra Strength [OTC]. Pregnancy/breast-feeding precautions: Inform prescriber if you are or intend to become pregnant. numbness or fatigue. Genapap® Infant [OTC]. Mapap® Infants [OTC]. Silapap® Infants [OTC]. Tylenol® Children's [OTC]. Mapap® Extra Strength [OTC]. ElixSureŒ Fever/Pain [OTC]. feet or hands). Acetaminophen Brand Names: Acephen® [OTC]. Mapap® [OTC]. Genapap® [OTC]. Redutemp® [OTC]. Mapap® Children's [OTC]. Aspirin Free Anacin® Maximum Strength [OTC]. . palpitations. trembling. Comtrex® Sore Throat Maximum Strength [OTC]. Cetafen Extra® [OTC]. Silapap® Children's [OTC]. FeverALL® [OTC]. weight gains. or change in hearing.signs of edema (eg. Tylenol® 8 Hour [OTC]. Consult prescriber if breast-feeding. Cetafen® [OTC]. Mapap® Arthritis [OTC]. Genebs® [OTC]. Genapap® Extra Strength [OTC]. cramping or muscle weakness. Genapap® Children [OTC]. unresolved nausea or vomiting. Tylenol® [OTC]. Tylenol® Arthritis Pain [OTC].

Tylenol® Extra Strength [OTC]. N-Acetyl-P-Aminophenol. Tylenol® Junior Strength [OTC]. Paracetamol Use: Treatment of mild to moderate pain and fever (antipyretic/analgesic). Tylenol® Infants [OTC]. Valorin [OTC].Dental: Treatment of postoperative pain Contraindications: Hypersensitivity to acetaminophen or any component of the formulation . does not have antirheumatic or anti-inflammatory effects Use . Tylenol® Sore Throat [OTC]. Valorin Extra [OTC] Synonyms: APAP.

bicarbonate. uric acid. nephrotoxicity with chronic overdose.Adverse Reactions: Frequency not defined. Dermatologic: Rash Endocrine & metabolic: May increase chloride. may decrease sodium. transient azotemia. pancytopenia. calcium Hematologic: Anemia. renal tubular necrosis with acute toxicity. and GI disturbances with . analgesic nephropathy Miscellaneous: Hypersensitivity reactions (rare) Overdosage/Toxicology: Symptoms of overdose include hepatic necrosis. leukopenia) Hepatic: May increase bilirubin. anemia. alkaline phosphatase Renal: May increase ammonia. blood dyscrasias (neutropenia. glucose.

Treatment consists of acetylcysteine 140 mg/kg orally (loading) followed by 70 mg/kg every 4 hours for 17 doses. Activated charcoal is very effective at binding acetaminophen.chronic toxicity. Intravenous acetylcysteine should be reserved for patients unable to take oral forms. Mechanism of Action: Inhibits the synthesis of prostaglandins in the central nervous system and peripherally blocks pain impulse generation. Stability: Do not freeze suppositories. therapy should be initiated based upon laboratory analysis suggesting a high probability of hepatotoxic potential. produces antipyresis from inhibition of hypothalamic heat-regulating center Pharmacodynamics/Kinetics: Onset of action: <1 hour .

at toxic doses (as little as 4 g daily) glutathione conjugation becomes insufficient to meet the metabolic demand causing an increase in acetylimidoquinone concentration. this should not affect dosing) Time to peak. which may cause hepatic cell necrosis Half-life elimination: Prolonged following toxic doses Neonates: 2-5 hours Adults: 1-3 hours (may be increased in elderly. serum: Oral: 10-60 minutes. varies by dosage form Protein binding: 8% to 43% at toxic doses Metabolism: At normal therapeutic dosages. may be delayed in acute overdoses . hepatic to sulfate and glucuronide metabolites. however. while a small amount is metabolized by CYP to a highly reactive intermediate (acetylimidoquinone) which is conjugated with glutathione and inactivated.Duration: 4-6 hours Absorption: Incomplete.

55% as glucuronide metabolites. do not exceed 5 doses (2. the following age-based doses may be used. rectal: Children <12 years: 10-15 mg/kg/dose every 4-6 hours as needed.6 g) in 24 hours. 30% as sulphate metabolites) Dosage: Oral.Excretion: Urine (2% to 5% unchanged. see table. alternatively. Note: Acetaminophen Dosing Age Dosage Age (mg) 40 4-5 y 6-8 y Dosage (mg) 240 320 0-3 mo 4-11 mo 80 .

1-2 y 2-3 y 120 160 9-10 y 400 11 y 480 Note: Higher rectal doses have been studied for use in preoperative pain control in children. do not exceed 4 g/day Dosing interval in renal impairment: Clcr 10-50 mL/minute: Administer every 6 hours Clcr<10 mL/minute: Administer every 8 hours (metabolites accumulate) Hemodialysis: Moderately dialyzable (20% to 50%) . The safety and efficacy of alternating acetaminophen and ibuprofen dosing has not been established. specific guidelines are not available and dosing may be product dependent. However. Adults: 325-650 mg every 4-6 hours or 1000 mg 34 times/day.

low-dose therapy usually well tolerated in hepatic disease/cirrhosis. cases of hepatotoxicity at daily acetaminophen dosages <4 g/day have been reported. Administration: Suppositories: Do not freeze Suspension. oral: Shake well before pouring a dose Monitoring Parameters: Relief of pain or fever Reference Range: Therapeutic concentration (analgesic/antipyretic): 10-30 mcg/mL . Limited.Dosing adjustment/comments in hepatic impairment: Use with caution. Avoid chronic use in hepatic impairment. However.

avoid or limit alcohol to <3 drinks/day and avoid other prescription or OTC medications that contain acetaminophen. . mouth. Most adverse effects are related to excessive use. change in elimination patterns. if needed. This medication will not reduce inflammation. consult prescriber for anti-inflammatory. ranges between 3-12 mg/tablet). Maintain adequate hydration (2-3 L/day of fluids) unless instructed to restrict fluid intake. Take with food or milk. While using this medication. or change in color of urine or stool. consult individual product labeling.Toxic concentration (acute ingestion) with probable hepatotoxicity: >200 mcg/mL at 4 hours or 50 mcg/mL at 12 hours after ingestion Dietary Considerations: Chewable tablets may contain phenylalanine (amount varies. urine) or bruising. Patient Education: Take exactly as directed. unusual fatigue and weakness. do not increase dose or frequency. Report unusual bleeding (stool.

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