ADVERSE EFFECTS

FINALS COVERAGE
• FIRST TO BE NOTED:
I. Emergency Medications
◦ Headache (monitor for ruptured blood vessel)
II. Anti-Tuberculosis Medications
III. Respiratory Medications ◦ Restlessness
IV. GI Medications ◦ Tremors
V. Anti-Diabetic Medications • Digestive:
VI. Pain and Inflammation (Analgesics & Steroids)
◦ Nausea
◦ Vomiting
EMERGENCY MEDICATIONS • Cardiovascular:
EPINEPHRINE ◦ Palpitations
(Adrenalin, Auvi-Q, EpiPen, EpiPen Jr., Symjepi) ◦ Hypertension
➙Naturally occurring catecholamine ◦ Myocardial Infarction
➙Improves perfusion of the heart and brain in cardiac arrest ◦ Tachyarrhythmias + ventricular fibrillation
states • Respiratory:
◦ stimulate the heart and brain
◦ the blood flow will compensate ◦ Bronchial edema
➙Increases the chance of electrical countershock in ventricular ◦ Pulmonary edema
fibrillation • Urogenital:
➙ Especially given when patient is on cardiac arrest in order to ◦ Urinary retention
reverse and counteract it • Skin:
➙ Always dilute, especially for hypertensive patients
◦ Tissue necrosis (with repeated injections)
➙ It is an alpha-adrenergic receptor: increases myocardial and
cerebral blood flow during CPR • Metabolic:
➙ Bolus is given during cardiac arrest for a rapid effect, and then ◦ Metabolic Acidosis
flushed afterwards ◦ Elevated Serum Lactic Acid
➙ It is always administered intravenously (no oral form) ◦ Transient Elevations of Blood Glucose
➙ Contraindicated to pregnant and lactating • Nervous System:
◦ Altered state of perception and thought
• Pharmacologic class - Sympathomimetic
◦ Psychosis
↦ tend to raise the bp of the patient to
an extent that it becomes alarming
↦ always check bp! (before, during, DRUG INTERACTIONS
and after administration)
+ Phenothiazines, oxytocin, entacapone
• Therapeutic class - Anti-Anaphylactic → (increases hypotension)
↦ for allergies → Will reverse or counteract the effect of epinephrine
↦ relieves signs of respiratory distress + Other sympathomimetics
due to bronchospasms
→ (additive toxicities)
- Bronchodilator
→ ex. Dobutamine, Dopamine, Norepinephrine,
- Cardiac Stimulant
Phenylepinephrine
- Vasopressor
→ Might lead to hypertensive crisis
+ MAO inhibitors, Tricyclic Anti-depressants, Alpha- and
PHARMACOKINETICS
Beta-Adrenergic Blockers
• Absorption: Inactivated in the GI tract → (antagonize effects of epinephrine)
⁃ Onset: 3-5 mins. → Antagonize the effect of epinephrine, and thus the desired
⁃ Peak: 20 mins. effect will not be achieved
⁃ Duration: 12-24 hrs. + General Anesthetics
• Distribution: widely distributed; does not cross the blood-brain → (increases cardiac irritability)
barrier; crosses the placenta → Monitor and do counteractions
• Metabolism: metabolized in tissue and liver → Only given in the OR if really needed
• Elimination: urine; excreted in breastmilk

Page | 1
NURSING ACTIONS
1. Cardiac hemodynamic status monitoring NURSING ACTIONS
→ monitor vital signs and urinary retention 1. BRADYCARDIA: administer IV 0.5-1.0 mg doses at 3-5
→ epinephrine can widen pulse pressure along with bp minutes interval until the desired heart rate is achieved
→ there could also be irritability in the cardiac rhythm → Encourage deep breathing exercise for stimulation if
he/she is coherent
2. Use extreme caution when calculating and preparing → Dilute 1 ampule in 4 mL of normal saline or sterile
doses; a very potent drug; small errors in dosage can cause water
serious adverse effects
→ 1 ampule of epinephrine : 9 mL normal saline 2. ASYSTOLE: administer 1 mg bolus dose IV followed by a
20 mL IV fluid bolus and elevation of extremities
3. Protect drug solutions from light, extreme heat, and → flushed with saline
freezing
→ keep at room temperature to maintain the potency of 3. Adult doses should never be less than 0.5 mg (paradoxical
the drug bradycardia)
→ A form of bradycardia associated with slow beating of
4. Keep a rapidly-acting alpha-adrenergic blocker the heart (increased interval between the “lub” and “dub”)
(phentolamine) or vasodilator (nitrate) readily available in
case of excessive hypertensive reaction 4. Given IV or ETT – dilute 1 mg to 2 mg in 10 mL of sterile
water or normal saline before administration
5. Not administered in the same site with alkaline solution (ex.
sodium bicarbonate) → Given ETT especially when there is no axis line for IV
→ will deactivate epinephrine, therefore, it will have no 5. Cardiac and blood pressure monitoring
effect
6. Presence of metabolic and respiratory acidosis decreases DOPAMINE HCL
the effectiveness (Intropin, Dopamine)
source: https://www.rxlist.com/dopamine-drug.htm

➙ It is also a sympathomimetic drug

ATROPINE SULFATE
(Tropin, Atroealth, Atrorays, Atrop, Atropine, Atropen) ➙ Usually given to severe heart failure patients and patients
➙ Given to patients having bradycardia who are experiencing cardiogenic shock

➙ Indicated in the treatment of significant bradycardia and some ➥ Cardiogenic shock: heart is not capable of pumping
types of heart block enough blood supply to the organs as well as the brain

➙ Increase heart rate by inhibiting the action of the vagus nerve ➙ For hypotension and severe bradycardia (enhance the
(parasympathetic affect) contractility of the myocardium)

➙ Given prior to receiving general anesthesia to suppress ➙ Given intravenously through a burette (separate IV line, not a
production of saliva and mucus (prevents aspiration) side drip)

➙ Administered to reverse general anesthesia brought about by ➙ Common in ICU patients

muscle relaxation ➙ No significant study shows that it can have adverse reactions
➥ This is given when operating due to the body’s to a fetus for pregnant women, but still minimal and regulated
compensation mechanism of muscle contraction when doses are given
being opened up during surgery (muscles need to
relax) • Pharmacologic class - Adrenergic
➥ When nearing the end of the operation, patient is
given a reversal (atropine sulfate + neostigmine) • Therapeutic class - Vasopressor
➙ Mainly given when general anesthesia is administered - Catecholamines
↦ it is a natural catecholamine
➙ Contraindicated for pregnant and lactating
↦ improves the hemodynamic status of
the patient especially if the patient is
• Pharmacologic class - Anticholinergic experiencing shock due to low cardiac
output
• Therapeutic class - Antiarrhythmic - Inotropic Agents
- Antimuscarinic
INDICATIONS
PHARMACOKINETICS Correction of hemodynamic imbalances present in:
• Absorbed after intramuscular administration ◦ Shock Syndrome due to Myocardial Infarction
→ mainly administered intravenously ◦ Trauma
• Metabolized by enzymatic hydrolysis, particularly in the liver ◦ Endotoxic Septicemia
• Excreted in the urine and the breastmilk ◦ Open-heart surgery
• Crosses the placental barrier and enters the fetal circulation ◦ Renal failure

Page | 2
 ◦ Chronic Cardiac Decompensation (congestive failure) → may cause maternal hypertension to the pregnant
PHARMACODYNAMICS (oxytocin)
NURSING ACTION
• Absorption: effects are dosage dependent
1. Lowest possible effective dose should be used (2-20
⁃ Action: 5 mins. (IV administration) mcg/kg/minute)
⁃ Duration of action: <10 mins → considered as the “safe dose”
DOSAGE EFFECT → given through infusion pump and dose is calculated in
Dopamine HCl activates dopamine calibrated cylinder or burette
D1 and D2 receptors in the renal, DOSAGE EFFECT
At <5 mcg/kg/minute mesenteric, and coronary
vasculature causing vasodilation 5-10 mcg/kg/minute Increased cardiac output and renal
(relaxation purpose) (Inotropic Dose) flow

Dopamine HCl activates beta-1 10-20 mcg/kg/min Cause vasoconstriction and

At 5-10 mcg/kg/min
At >10 mcg/kg/minute
receptors enhancing heart rate and (Higher Dose) decreased renal perfusion
contractility (used for patients
Increased blood pressure,
experiencing hypotension and
stimulate vasoconstriction, and
severe bradycardia)
>20 mcg/kg/min may not have beneficial effects in
Dopamine HCl activates alpha-1 the blood pressure (can cause
receptors causing vasoconstriction tachyarrhythmias)
and increased blood pressure
(given after resuscitation)

PHARMACOKINETICS
• Distribution: widely distributed in the body but does not cross
the blood-brain barrier to a significant extent
• Metabolism: 75% metabolized by monoamine oxidase (MAO)
and catechol O-methyl transferase (COMT) in the liver, kidney,

INFUSION PUMP
and plasma & 25% is metabolized to norepinephrine in the
adrenergic nerve terminals
• Excretion: 80% of dopamine is renally excreted as inactive

BURETTE
metabolites within 24 hours

DRUG INTERACTIONS
+ Halogenated Anesthetics
(desflurane, enflurane, isoflurane, and sevoflurane)
→ Withhold dopamine at least 2 weeks prior to an operation 2. Weaned gradually
since it might lead to ventricular arrhythmias and → abrupt stopping of intake may cause hypotension
hypertension. Cardiac arrest might occur during operation
→ may sensitize the myocardium, thus increasing cardiac 3. Administer through infusion pump; not with alkaline solution
autonomic irritability → alkaline solution (ex. sodium bicarbonate) will
→ should be administered with EXTREME CAUTION inactivate the dopamine
→ propranolol has been reported to reverse dopamine-
induced ventricular arrhythmias 4. Continuous heart rate and blood pressure monitoring;
intake and output
+ MAO Inhibitors
(isocarboxazid, phenelzine, tranylcypromine, rasagiline, selegiline, linezolid) 5. IV site checked hourly for signs of drug infiltration
→ prolongs and potentiates the effects of dopamine, leading → NOTE: produce tissue necrosis (surgical debridement
to severe hypertension and cardiac arrhythmia and skin grafting)
→ patients treated with MAO inhibitors within 2-3 weeks prior
to the administration of dopamine should receive no greater
than 1/10 of the usual dose
+ Tricyclic Antidepressants
(amitriptyline, desipramine, doxepin, imipramine, nortriptyline)
→ may potentiate cardiovascular defects and the pressor
response to adrenergic agents
+ Vasopressors
(norepinephrine, epinephrine, oxytocin)
→ may result in persistent hypertension
→ may contribute or alleviate the possibility of having severe
hypertension

Page | 3
6. + Extravasation: site should be injected in multiple areas • Beta 2 effect: mild vasodilation
with phentolamine (Regitine), 5-10 mg diluted in 10-15 mL → Dobutamine have some beta-2 activity, which contributes to
of normal saline to prevent tissue damage the reduction in the systemic vascular resistance, whose
vasoconstrictive effects are negated by the baroreceptor
mediated response and beta-2 activity.
• Temporary intravenous inotropic support
→ Dobutamine can be used as temporary intravenous inotropic
support until the patient receives more definitive treatment, such
as coronary revascularization, mechanical circulatory support,
or heart transplant.

PHARMACOKINETICS
Extravasation injury due to dopamine infusion • Absorption: administered only intravenously
leading to dermal necrosis and gangrene
• Metabolism: liver and some tissues
CALCULATION • Excretion: kidneys through urine
1. Amount of the drug needed per 50mL solution • Half-life: 2 minutes

= Patient’s body weight (kg) × 3

2. Infusion Preparation
= Needed Dose (mg) × Available Volume (mL)
----------------------------------------------------------------------------------------------------------------------------------------

Available Dose
PRECAUTIONS
3. Dilution preparation • History of hypertension = increased risk of exaggerated
pressor response
50mL = IVF volume + Infusion Preparation
• Avoid giving dobutamine to patients with acute myocardial
4. Drug Concentration infarction because it can intensify or extend myocardial ischemia
• Atrial fibrillation (pretreatment with digoxin recommended)
= Needed Dose (mg) × 100 mcg
----------------------------------------------------------------------------------------------

Diluted Solution Volume • History of ventricular atopic activity (may be exacerbated)

• Hypovolemia (correct before administration)
5. Rate of infusion
• Pregnancy (pregnancy Category B. Dobutamine is not
= Needed Dose (mg) × Body Wt. (kg) × 60 mins. expected to harm an unborn baby, it is not known whether
---------------------------------------------------------------------------------------------------------------------------------------------
dobutamine passes into breast milk or if it could harm a nursing
Available Dose baby.)

DOBUTAMINE ADVERSE REACTIONS/SIDE EFFECTS

➙ Dobutamine stimulates heart muscle and improves blood flow • CV: hypertension, increased heart rate, premature ventricular
by helping the heart pump better. contractions, angina pectoris, arrhythmias, hypotension,
➙ To treat low cardiac output and heart failure short term palpitations
• GI: nausea, vomiting
➙ Dobutamine is a beta-1 agonist used to treat cardiac
decompensation in patients with organic heart disease or from • Local: phlebitis
cardiac surgery. A beta-1 agonist catecholamine that has • Neuro: headache
cardiac stimulant action without evoking vasoconstriction or • Respiratory: shortness of breath
tachycardia.
• Misc.: hypersensitivity reactions, nonanginal chest pain

• Pharmacologic class - Sympathomimetic

INTERACTIONS:
• Therapeutic class - Inotropic + Nitroprusside
→ may have a synergistic effect on increased cardiac output
INDICATIONS + Beta Blockers
• Beta 1 effect: enhance force of myocardial contractility, → may negate the effect of dobutamine
increasing the heart rate + Anesthetics (Cyclopropane, Halothane)
⇾ Dobutamine's ionotropic effect increases contractility, leading → increases risk of arrhythmias or hypertension with some
to decreased end-systolic volume and, therefore, increased anesthetics)
stroke volume. Increase in stroke volume leads to an + MAO Inhibitors, Oxytocin & Tricyclic Antidepressants
augmentation of the cardiac output of the heart.

Page | 4
NURSING CONSIDERATION
1. Monitor hemodynamics: hypertension, increased heart rate,
premature ventricular contractions
2. Skin reactions may occur with hypersensitivity
3. Beta blockers may negate therapeutic effects of dobutamine
4. Monitor cardiac output & peripheral pulses before, during, and
after therapy
5. DO NOT confuse dobutamine with dopamine
6. Monitor potassium concentrations during therapy
7. Monitor urine output hourly

DOSAGE AND PREPARATION

USUAL ADULT DOSE FOR CONGESTIVE HEART FAILURE
DOSE DOSAGE RANGE
Initial Dose 0.5 to 1 mcg/kg/min IV infusion
Maintenance Dose 2 to 20 mcg/kg/min IV infusion
Maximum Dose 40 mcg/kg/min IV infusion

FORMULA FOR DOCUTAMINE COMPUTATION

➮ Rate of Infusion (mL/hour)
= Desired Dose × Quantity × Time (mins.) × Weight (kg)
----------------------------------------------------------------------------------------------------------------------------------------

Available Dose × 1000

Sample Situation:
Patient Juan a 75 years old male was admitted on CCU due to
cardiogenic shock. The doctor ordered to start dobutamine
infusion at 2.5mcg/kg/min. The pt weighs 80kgs. Your available
stock is 250mg/ 250ml. How will you compute for the rate of
infusion?

Solution:
= (2.5mcg X 250 ml X 60 mins X 80 kgs.) ÷ (250 mg X 1000)
= 3000000 ÷ 250000
= 12 mL/hour

Page | 5