SODIUM BICARBONATE

Generic Name:
Sodium Bicarbonate

Brand Name:
Sodium Bicarbonate

Contents (Drug Classification):

Alkalinizing Agents

Availability (preparations, dosage availability, presentation)

Injectable solution
• 4%
• 4.2%
• 7.5%
• 8.4%

Tablet
• 325mg
• 650mg

Indication and Dosage

Intravenous
• Metabolic acidosis
 Adult: Severe cases: Usual dose: 1 mmol/kg (1 mL/kg of 8.4% Na bicarbonate
solution) via inj, followed by 0.5 mmol/kg given at 10-minute intervals depending
on individual arterial blood gases. Less urgent cases: 2-5 mmol/kg given via
infusion over 4-8 hours based on the severity of acidosis as judged by the
decrease of total CO2 content, blood pH, and clinical condition of patient.
Dosage recommendations may vary in the country of use (refer to local treatment
protocol and guidelines).
Child: Severe cases: Usual dose: 1 mmol/kg (1 mL/kg of 8.4% Na bicarbonate
solution) via slow inj. In premature infants and neonates up to 2 years: Dilute the
8.4% solution with 5% dextrose (1:1 ratio) or use the 4.2% solution. Give dose
via slow inj. Max: 8 mmol/kg/day. Dosage recommendations may vary in the
country of use (refer to local treatment protocol and guidelines).

Oral
• Metabolic acidosis
Adult: Dosage calculation is individualized according to acid-base balance and
electrolyte status of the patient.
Oral
• Dyspepsia
Adult: 1-5 g 4-6 hourly as necessary. Alternatively, 0.65-2.6 g 4 hourly.

Mode of Action:
Description: Sodium bicarbonate is a systemic alkalinizing agent. It increases blood
and urinary pH by dissociation to provide bicarbonate ions, which neutralizes the
hydrogen ion concentration.
Onset: 15 minutes (oral); rapid (IV).
Duration: 1-3 hours (oral); 8-10 minutes (IV).
Pharmacokinetics:
Absorption: Readily and well absorbed from the gastrointestinal tract.
Distribution: Present in all body fluids.
Metabolism: Not significantly metabolized.
Excretion: Via urine (<1%).

Administration:
should be taken on an empty stomach

Contraindication:
Metabolic or respiratory alkalosis, hypocalcemia, hypochlorhydria, severe
pulmonary oedema, unknown abdominal pain. IV: Conditions with Na intake
restrictions, hypoventilation, history of urinary calculi, coexisting K depletion,
hypernatremia. Patient with chloride loss due to vomiting or continuous
gastrointestinal suction. IV: Concomitant use with diuretics known to produce
hypochloremia alkalosis.

Special Precaution:
Patient with CHF, hypertension, cirrhosis, on low Na diet; eclampsia, oedema,
aldosteronism or other conditions associated with Na retention; oliguria or anuria.
Avoid extravasation (IV). Renal and hepatic impairment. Children. Pregnancy
and lactation.

Adverse Reaction:
• Significant: Metabolic alkalosis, hypernatremia; fluid and/or solute overload (IV);
tissue necrosis, vascular irritation or sloughing (IV extravasation); decreased
CSF pressure and intracranial hemorrhage (rapid IV inj in neonates).
• Gastrointestinal disorders: Abdominal pain, flatulence, spontaneous stomach
rupture, nausea, vomiting, unpleasant taste.
• General disorders and administration site conditions: unusual tiredness or
weakness.
• Metabolism and nutrition disorders: Fluid retention, hypocalcemia,
exacerbated hypokalemia, loss of appetite.
• Musculoskeletal and connective tissue disorders: Muscle spasms or cramps.
• Nervous system disorders: Headache, restlessness.
• Psychiatric disorders: Mood or mental changes, nervousness, extreme
irritability.
• Renal and urinary disorders: Frequent urge to urinate.
• Respiratory, thoracic and mediastinal disorders: Pulmonary oedema,
breathing difficulty, fluid in the lungs.
• Vascular disorders: Hypertension.

Drug Interaction:
Increased excretion of lithium, aspirin, methotrexate. Reduced excretion of
quinidine, amphetamines, methadone, quinine, and ephedrine. Reduced
absorption of tetracycline, rifampicin, ketoconazole, dipyridamole, chloroquine,
phenothiazines, phenytoin, penicillamine. May increase the renal tubular
reabsorption of mecamylamine. May reduce the serum K concentration with K
supplements.
Nursing Considerations:
➢ Assess the client’s fluid balance throughout the therapy. This assessment
includes intake and output, daily weight, edema and lung sounds.
➢ Symptoms of fluid overload should be reported such as hypertension, edema,
difficulty breathing or dyspnea, rales or crackles and frothy sputum.
➢ Sigs of acidosis should be assessed such as disorientation, headache,
weakness, dyspnea and hyperventilation.
➢ Assess for alkalosis by monitoring the client for confusion, irritability, paresthesia,
tetany and altered breathing pattern.
➢ Hypernatremia clinical manifestations should be assessed and monitored which
includes: edema, weight gain, hypertension, tachycardia, fever, flushed skin and
mental irritability.
➢ Hypokalemia should also be assessed by monitoring signs and symptoms such
as: weakness, fatigue, U wave on ECG, arrhythmias, polyuria and polydipsia.
➢ IV sites should be observed closely. Extravasation should be avoided as tissue
irritation or cellulitis may occur when taking sodium bicarbonate.
➢ If infiltration occurs, the physician should be notified immediately. Confer with the
doctor or other health care staff regarding warm compresses and infiltration site
with lidocaine or hyaluronidase.
➢ Monitor the client’s serum calcium, sodium, potassium, bicarbonate
concentrations, serum osmolarity, acid-base balance and renal function before
and throughout the therapy.
➢ Tablets must be taken with a full glass of water.
➢ For clients taking the medication as a treatment for peptic ulcers it may be
administered 1 and 3 hours after meals and at bedtime.

FDA Pregnancy Category:

• IV/Parenteral/PO: C
TRAMADOL

Generic Name:
- Tramadol

Brand Name:
- Ultram, Ultram ER, ConZip

Contents (Drug Classification):

- Opioid Analgesics

Availability (preparations, dosage availability, presentation, packaging)

- 50mg tablets oral

Packaging

Indication and Dosage

Oral
Moderate to severe pain
Adult: As conventional tab/cap/Oro dispersible or dispersible tab: 50-100 mg 4-6
hourly. Max: 400 mg daily. As modified release (12-hourly) cap: Initially, 50-100
mg bid, may be titrated to 150 mg or 200 mg bid if necessary. Max: 400 mg daily.
As modified release (24-hourly) tab/cap: Initially, 100 mg or 150 mg once daily.
Max: 300 mg or 400 mg daily. Use the lowest effective dose for the shortest
possible treatment duration. Adjust dose based on the severity of pain and
 individual sensitivity. Dosage recommendations may vary among countries and
individual product (refer to detailed product guideline).
Child: ≥12 years Same as adult dose.
Elderly: >75 years Dosage interval may be prolonged according to individual
requirements. Treatment recommendations may vary among countries and
individual products (refer to detailed product guideline).

Parenteral
Postoperative pain
Adult: Initially, 100 mg via slow IV, IM, or SC inj, followed by 50 mg every 10-20
minutes up to a total of 250 mg (including the initial dose) in the 1st hour.
Subsequent doses of 50 mg or 100 mg 4-6 hourly may be given. Max: 600 mg
daily.
Child: ≥12 years Same as adult dose.
Elderly: >75 years Dosage interval may be prolonged according to individual
requirements.

Parenteral
Moderate to severe pain
Adult: 50-100 mg 4-6 hourly via slow IV over 2-3 minutes, IM, or SC inj. Max:
600 mg daily.
Child: ≥12 years Same as adult dose.
Elderly: >75 years Dosage interval may be prolonged according to individual
requirements.

Mode of Action:
Description: Tramadol is a centrally acting analgesic that has opioid agonist
properties. It binds to μ-opiate receptors in the CNS resulting in inhibition of
ascending pain pathways, thus altering the perception of and response to pain.
Its inhibition of neuronal uptake of norepinephrine and enhancement of serotonin
release may also contribute to its analgesic effect.
Onset: Analgesia: Oral (immediate release): Within 1 hour (peak effect: 2-3
hours).
Duration: Analgesia: Oral: 3-6 hours (peak effect: 1-4 hours post-dosing).

Pharmacokinetics:
Absorption: Rapidly and completely absorbed following oral administration.
Bioavailability: Oral: Approx 75% (immediate release); approx. 85-90% (modified
release; as compared to immediate release); IM: 100%. Time to peak plasma
concentration: Tramadol: Approx 2 hours (immediate release); approx. 4-12
hours (modified release).
Distribution: Widely distributed in the body. Crosses the placenta; enters breast
milk (small amounts). Volume of distribution: IV: 2.9 L/kg (females); 2.6 L/kg
(males). Plasma protein binding: Approx 20%.
 Metabolism: Extensively metabolized in the liver mainly via N- and O-
demethylation by CYP2D6 and CYP3A4 isoenzyme, glucuronidation, and
sulfation into several metabolites; O-desmethyltramadol (M1) is the only active
metabolite.
Excretion: Via urine (60% as metabolites, approx. 30% as unchanged drug).
Elimination half-life: Oral: Immediate release: 6.3 ± 1.4 hours (tramadol); 7.4 ±
1.4 hours (M1). Modified release: Cap: Approx 10 hours (tramadol); approx. 11
hours (M1); Tab: Approx 7.9 hours (tramadol); 8.8 hours (M1).

Administration:
- May be taken with or without food.

Contraindication:
- Acute intoxication with centrally acting analgesics, hypnotics, psychotropic
drugs, alcohol, or other opioids; uncontrolled epilepsy, significant respiratory
depression, acute or severe bronchial asthma (in unmonitored setting or lack
of resuscitative equipment), known or suspected gastrointestinal obstruction
(including paralytic ileus). Children <12 years and in children <18 years who
have undergone tonsillectomy and/or adenoidectomy. CYP2D6 ultrarapid and
poor metabolizers. Concomitant use or within 14 days after MAOI therapy.
Use for narcotic withdrawal treatment or during light planes of anesthesia.

Special Precaution:
- Patient with history of epilepsy or those with susceptibility to seizures (e.g.
alcohol or drug withdrawal, metabolic disorders, CNS infection, malignancy),
head injury, intracranial lesions, increased intracranial pressure, mental
health conditions, hypovolemia, CV disease, acute abdominal conditions,
adrenal insufficiency (e.g. Addison's disease), delirium tremens, toxic
psychosis, prostatic hyperplasia and/or urinary stricture, significant COPD or
core pulmonale, substantially decreased respiratory reserve, hypoxia,
hypercapnia, pre-existing respiratory depression, thyroid dysfunction, biliary
tract disease (including acute pancreatitis), history of drug abuse or acute
alcoholism. Morbidly obese, cachectic, or debilitated patients. Avoid use in
suicidal patients and in patients with circulatory shock, impaired
consciousness or coma. Not recommended in children in whom respiratory
function may be compromised (e.g., neuromuscular disorders, upper
respiratory or lung infections, multiple trauma or extensive surgical
procedures). Not recommended in patients with severe renal impairment.
Avoid abrupt withdrawal following prolonged use. Renal and hepatic
impairment. Children ≥12 years (particularly when used for post-operative
pain relief) and elderly. Pregnancy and lactation. Concomitant use with other
serotonergic agents, CNS depressant drugs; CYP3A4 inducers and CYP3A4
or CYP2D6 inhibitors.

Adverse Reaction:
 Significant: Sleep-related breathing disorders (e.g., sleep-related hypoxemia,
central sleep apnea), withdrawal symptoms, convulsions, reversible adrenal
insufficiency, severe hypotension (including syncope and orthostatic
hypotension), hyponatremia (including severe cases), CNS depression, spasm of
the sphincter of Oddi. Rarely, drug dependence (prolonged use) and abuse;
hypoglycemia (including severe cases).
Cardiac disorders: Palpitations, tachycardia.
Gastrointestinal disorders: Nausea, vomiting, dry mouth, constipation,
abdominal discomfort, dyspepsia.
General disorders and administration site conditions: Fatigue, asthenia.
Musculoskeletal and connective tissue disorders: Muscle spasticity.
Nervous system disorders: Dizziness, drowsiness, headache, tremor.
Psychiatric disorders: Anxiety, agitation, emotional lability, euphoria,
hallucinations, nervousness.
Reproductive system and breast disorders: Menopausal symptoms.
Skin and subcutaneous tissue disorders: Pruritus, urticaria, rash,
hyperhidrosis, toxic epidermal necrolysis, Stevens-Johnson syndrome.

Drug Interaction:
- Increased risk of INR elevation and ecchymoses with coumarin derivatives
(e.g., warfarin). Increased risk of convulsions with SSRIs, serotonin-
norepinephrine reuptake inhibitors (SNRIs), anorectics, TCAs, antipsychotics,
and other seizure-threshold lowering agents (e.g., bupropion, mirtazapine).
Concomitant use with mixed agonist/antagonist analgesics (e.g.,
buprenorphine, butorphanol, nalbuphine, pentazocine) may precipitate
withdrawal symptoms and/or diminish analgesic effect in patients after
prolonged therapy with tramadol. Concomitant use with CYP2D6 inhibitors
(e.g., paroxetine, fluoxetine, quinidine, bupropion) may increase plasma
levels of tramadol and decrease plasma concentration of M1 (active
metabolite). Concomitant use with CYP3A4 inhibitors (e.g., erythromycin,
ketoconazole, ritonavir) may increase tramadol plasma concentration which
may result in greater amount of metabolism by CYP2D6 isoenzyme and
increased levels of M1. May decrease plasma levels with CYP3A4 inducers

Nursing Considerations:
Assessment
History: Hypersensitivity to tramadol; pregnancy; acute intoxication with
alcohol, opioids, psychotropic drugs or other centrally acting analgesics;
lactation; seizures; concomitant use of CNS depressants or MAOIs; renal
or hepatic impairment; past or present history of opioid addiction
Physical: Skin color, texture, lesions; orientation, reflexes, bilateral grip
strength, affect; P, auscultation, BP; bowel sounds, normal output; LFTs,
renal function tests

Interventions
 Control environment (temperature, lighting) if sweating or CNS effects
occur.
WARNING: Limit use in patients with past or present history of addiction to
or dependence on opioids.

Teaching points
You may experience these side effects: Dizziness, sedation, drowsiness,
impaired visual acuity (avoid driving or performing tasks that require
alertness); nausea, loss of appetite (lie quietly, eat frequent small meals).
Report severe nausea, dizziness, severe constipation.
FDA Pregnancy Category:
- PO: C
VASOPRESSIN

Generic Name:
- Pitressin

Brand Name:
- Vasopressin

Contents (Drug Classification):

- Antidiuretics / Hemostatic

Availability (preparations, dosage availability, presentation, packaging)

• 20 units/mL injection solution

Packaging:

Indication and Dosage

Intramuscular, Subcutaneous
Diabetes insipidus
Adult: In non-nephrogenic origin: 5-20 units (0.25-1 mL) via SC or IM inj 4
hourlies.

Intravenous
Initial control of variceal bleeding
Adult: 20 units in 100 mL of dextrose 5% infused over 15 minutes.
Intravenous
Shock
Adult: In hypotensive patients with vasodilatory shock who remain hypotensive
despite fluids and catecholamines: Post cardiotomy shock: Initially, 0.3 unit/min.
Max: 0.1 unit/min. Septic shock: Initially, 0.01 unit/min. Max: 0.07 unit/min. All
doses are titrated up by 0.005 unit/min at 10-15 minutes intervals until the target
blood pressure is reached.

Mode of Action:
Description: Vasopressin is a posterior pituitary hormone which may be
synthetically prepared or extracted from animals. It stimulates V1 receptor and
increases systemic vascular resistance and mean arterial blood pressure
resulting in decreased heart rate and cardiac output. It also stimulates V2
receptor which increases cyclic adenosine monophosphate (cAMP) thus
increasing water permeability at the renal tubule resulting in increased osmolality
and decreased urine volume. At pressor doses, vasopressin causes smooth
muscle contraction in the gastrointestinal tract by stimulating V1 receptors, and
release of prolactin and ACTH via V3 receptors.
Onset: Antidiuretic: 1-2 hours. Vasopressor effect: Within 15 minutes (IV).
Duration: Antidiuretic: 2-8 hours (SC). Vasopressor: Within 20 minutes (IV).

Pharmacokinetics:
Distribution: Volume of distribution: 140 mL/kg.
Metabolism: Metabolized in the liver and kidney into inactive metabolites.
Excretion: Via urine (approx. 5% as unchanged drug [SC]; approx. 6% as
unchanged drug [IV]). Elimination half-life: 10-20 minutes.

Contraindication:
Hypersensitivity to vasopressin and chlorobutanol. Coronary artery disease, -
chronic nephritis with nitrogen retention.

Adverse Reaction:
Significant: Reversible diabetes insipidus (following discontinuation of
treatment), water intoxication; extravasation; decreased cardiac output.
Blood and lymphatic system disorders: Decreased platelet count, intractable
bleeding.
Cardiac disorders: Angina, cardiac arrest, atrial fibrillation, bradycardia,
myocardial ischemia, right heart failure.
Gastrointestinal disorders: Nausea, vomiting, diarrhea, flatulence, abdominal
pain, mesenteric ischemia.
General disorders and admin site conditions: non-cardiac chest pain.
Immune system disorders: Hypersensitivity, anaphylaxis.
 Investigations: Increased serum bilirubin Metabolism and nutrition disorders:
Hyponatremia.
Nervous system disorders: Headache, vertigo, tremor.
Renal and urinary disorders: Fluid retention, acute renal insufficiency.
Respiratory, thoracic and mediastinal disorders: Bronchospasm.
Skin and subcutaneous tissue disorders: Gangrene, hyperhidrosis, urticaria,
ischemic lesions.
Vascular disorders: Hypertension, pallor, peripheral ischemia, hemorrhagic
shock.

Drug Interaction:
- Enhanced therapeutic effect with indomethacin specifically on cardiac
index and systemic vascular resistance. Enhanced effect on means
arterial blood pressure with ganglionic blocking agents. Increased pressor
and antidiuretic effects with drugs suspected of causing SIADH Decreased
pressor and antidiuretic effects with drugs suspected of causing diabetes
insipidus

Nursing Considerations:
• use caution with HF and CV disease
• contraindicated in renal failure and hypersensitivity to pork
• monitor BP, HR, and EKG during therapy
• monitor urine specific gravity and osmolality
• weigh patient and assess for edema
• monitor electrolyte panel
• do not use with alcohol

FDA Pregnancy Category:

- IM/IV/Parenteral/SC: C
VERAPAMIL

Generic Name:
Calan / Calan SR

Brand Name:
Veralan PM / Veralan

Contents (Drug Classification):

Antidysrhythmic / Calcium Channel Blocker / Non-dihydropyridine

Availability (preparations, dosage availability, presentation, packaging):

• 2.5 mg/mL injectable solution
• 40, 80, 120 mg tablet

Packaging:

Indication and Dosage:

Intravenous
Supraventricular arrhythmias
 Adult: Initially, 5-10 mg via slow inj over 2-3 minutes then 5 mg via inj after 5-10
minutes if needed.
Child: ≤1 years 0.1-0.2 mg/kg; 1-15 years 0.1-0.3 mg/kg (Max: 5 mg). All doses
to be given over at least 2 minutes, repeat after 30 min if needed.

Oral
Angina pectoris
Adult: 120 mg tid or 80 mg tid in patient’s w/ angina of effort. As modified-
release: Up to 480 mg daily.

Oral
Supraventricular arrhythmias
Adult: 120-480 mg daily in 3-4 divided doses depending on patient's response
and severity of the condition.
Child: ≤2 yr. 20 mg 2-3 times daily; >2 yr. 40-120 mg 2-3 times daily, depending
on age and response.

Oral
Hypertension
Adult: Initially, 240 mg daily in 2-3 divided doses. Max: 480 mg daily.
Child: ≤2 yr. 20 mg 2-3 times daily; >2 yr. 40-120 mg 2-3 times daily, depending
on age and response.

Oral
Secondary prophylaxis of myocardial infarction
Adult: Modified release: Initially, 360 mg daily in divided doses 1 wk. after acute
infarction.

Mode of Action:
Description: Verapamil inhibits entry of Ca ions into the slow channels or select
voltage-sensitive areas of vascular smooth muscle and myocardium during
depolarization. It relaxes coronary vascular smooth muscle and coronary
vasodilation, increases myocardial oxygen delivery, and slows automaticity and
AV node conduction.
Onset: W/in 1-2 hr. (oral); w/in 5 min (IV).
Duration: 6-8 hr. (oral); 10-20 min (IV).

Administration:
- Should be taken with food.

Contraindication:
- Cardiogenic shock, hypotension (systolic pressure <90 mmHg), marked
bradycardia, uncompensated heart failure, 2nd- or 3rd-degree AV block
(unless pacemaker is fitted), sick-sinus syndrome, severe ventricular
dysfunction, atrial flutter or atrial fibrillation and accessory bypass tract
Special Precaution:
- Patient w/ bradycardia or 1st-degree AV block, attenuated neuromuscular
transmission, hypertrophic cardiomyopathy. Avoid abrupt withdrawal. Renal
and hepatic impairment. Child. Pregnancy and lactation.

Adverse Reaction:
- AV block, bradycardia, worsening heart failure, transient asystole,
hypotension, dizziness, flushing, fatigue, headache, dyspnea, peripheral
oedema, constipation, nausea, abnormal liver function, skin reactions,
gingival hyperplasia, extrapyramidal symptoms. Rarely, gynecomastia.

Drug Interaction:
- May increase plasma level w/ CYP3A4 inhibitors, cimetidine. May decrease
plasma level w/ CYP3A4 inducers, phenobarbital, sulfinpyrazone. Increased
risk of bleeding w/ aspirin. May increase bradycardic and hypotensive effect
w/ telithromycin. Increased AV blocking effect w/ clonidine. May increase
plasma level of cardiac glycoside, β-blockers, α-blockers,
immunosuppressants, lipid lowering agents. May potentiate hypotensive
effect w/ diuretics, antihypertensives, vasodilators. May increase neurotoxic
effect of lithium.
Nursing Considerations:
• Monitor cardiac rhythm regularly during stabilization of dosage and
periodically during long-term therapy.
• Administer SR form in the morning with food to decrease GI upset.
• Protect IV solution from light.
• Monitor patients with renal or hepatic impairment carefully for possible
drug accumulation and adverse reactions.

FDA Pregnancy Category:

• IV/Parenteral/PO: C