HIGH ALERT

MEDICATIONS
Presented by:
Dr. AYESHA HANIF
 HIGH ALERT MEDICATIONS

High-alert medications are defined as medications that are most likely to

cause significant patient harm, even when used correctly. These
medications are associated with harm due to issues such as narrow
therapeutic ranges (increasing the potential for a prescribing error),
and an error cause more harm due to significant nature of potential
adverse effects.
 HIGH ALERT MEDICATIONS
Classes/Categories of Medications
• Adrenergic agonists, IV (e.g., Epinephrine, dopamine, dobutamine)
• Adrenergic antagonists, IV (e.g., propranolol, metoprolol, labetalol)
• Anesthetic agents, general, inhaled and IV (e.g., propofol, ketamine)
• Anticoagulants (e.g., warfarin, low molecular weight heparin)
• Chemotherapeutic agents, (parenteral and oral)
• Inotropic medications, IV (e.g., digoxin, milrinone)
• Anticonvulsant and sedatives (Phenytoin, diazepam)
• Blood coagulating agents (Vitamin K)
• Electrolytes (e.g Sodium chloride, KCL)
ADRENERGIC AGONISTS

 Dopamine
 Dobutamine
 Epinephrine
 Nor-epinephrine
 ADRENERGIC AGONISTS
DOPAMINE:
Indications:
Treatment of hypotension, low cardiac output,
poor perfusion of vital organs; used to increase
mean arterial pressure in septic shock patients
who remain hypotensive after adequate volume
expansion.
 ADRENERGIC AGONISTS
DOPAMINE:
Mechanism of action:
mechanism of action is dose dependent
0.5-2mcg/kg/ ACTS ON DOPAMINE RECEPTOR
min • Vasodilation
• ↑ Renal BF
2-10mcg/kg/min ACTS ON BETA1 RECEPTORS
• ↑ myocardial Contractility

10-20mcg/kg/
min
ACTS ON ALPHA 1 RECEPTORS
• ↑ heart rate
• vasoconstriction
 ADRENERGIC AGONISTS
Adverse effects:
• Tachycardia.
• Headache
• Nausea vomiting
Toxicity symptom:
• Severe hypertension
• Cardiac arrhythmia
• Acute renal failure
 ADRENERGIC AGONISTS
DOPAMINE:
DILUENT:
Transfer contents of one or more ampule or vials by aseptic technique
to 100 ml of one of the following sterile intravenous solutions:
• Sodium Chloride Injection, USP
• Dextrose (5%) Injection, USP

INCOMPATIBILITIES:
Acyclovir, aminophylline, amphotericin B,
sodium bicarbonate
 ADRENERGIC AGONISTS
DOPAMINE:
METHOD OF ADMINISTRATION:
DOPAMINE, after dilution, is administered intravenously through a
suitable intravenous catheter or needle in large vein. An i.v. drip
chamber or other suitable metering device is essential for controlling
the rate of flow in drops/minute.
When discontinuing the infusion, gradually decrease the dose of
dopamine (sudden discontinuation can cause hypotension.)
WARNING: NOT FOR DIRECT INTRAVENOUS INJECTION, MUST
BE DILUTED BEFORE USE.

MONITORING PARAMETER:
Blood pressure, ECG, Heart rate.
 ADRENERGIC AGONISTS
NURSING FOCUS:
• Monitor vitals, renal status and tissue integrity
• Correct hypovlemia if possible
• Monitor infusion continuously for free flow, and
take care to avoid extravasation, which can
result in tissue sloughing and gangrene
• Antidote for extravasation: phentolamine
 ADRENERGIC AGONISTS
DOBUTMINE:
Indication:
Dobutamine used to increase cardiac output in
congestive heart failure.

Strong beta1 and weak beta2/alpha effects,

resulting in increased cardiac output, blood
pressure, and heart rate, as well as decreased
peripheral vascular resistance.
 ADRENERGIC AGONISTS
Adverse effects:
 Hypertension
 Tachycardia
 Arrhythmia
 Angina
 ADRENERGIC AGONISTS
Dose of Dobutamine:
2.5-15mcg/kg/min. MONITORING
PARAMETER:
Max: 40mcg/kg/min Blood pressure, ECG, Heart
rate.

METHOD OF ADMINISTRATION:
At the time of administration, dobutamine must be further
diluted in an IV container to at least a 50 mL solution
using one of the following intravenous solutions as a
diluent: D5W, 0.9%NS, etc. Use infusion device to
control rate of flow.
 ADRENERGIC AGONISTS
ADRENALINE:
It is used to prevent death because of
anaphylactic shock (severe allergic reaction) or
cardiac arrest (when the heart stops beating). It
has a very rapid effect on the heart, blood
vessels and the lungs.

0.03 mics to 0.3 mics/kg/minute

 ADRENERGIC AGONISTS
Mechanism of action of Adrenaline:
1. Bind with alpha & beta receptors:

• Vasoconstriction, so hypotension is relieve.

• Relaxation of the bronchial smooth muscles, so relieves
bronchoconstriction.
2. Down regulate the release of histamine from mast cells:

• Relieves from allergic reactions

 ADRENERGIC AGONISTS
Adverse effects of adrenaline:
• Dangerously high blood pressure
(severe headache, blurred vision, buzzing in
your ears, anxiety, confusion, chest pain,
shortness of breath, uneven heartbeats,
seizure).
• Difficult breathing
 ADRENERGIC AGONISTS
Adrenaline Administration STABILITY
Epinephrine is sensitive to
And Dilution: light and air, protection
from light is
recommended.

 Epinephrine can be administered SubQ, I.M.,

I.V. Intranasal
 Intravenous infusions require an infusion pump
 Diluent: NS aur D5W can be use.
 ADRENERGIC AGONISTS
INCOMPATIBILITIES : Aminophylline, ampicillin, sodium
bicarbonate, warfarin
NURSING FOCUS:
• Assess for presence/history of anaphylactic shock,
asthma,cardiopulmonary resuscitation glaucoma,
ventricular fibrillation,septic shock, wheezing .
• Monitor vital signs, Input and Output, Blood glucose levels
• Advise patient to report bronchial irritation,
nervousness, or sleeplessness.Dosage should be reduced
ADRENERGIC ANTAGONISTS

Propranolol
Metoprolol
Labetalol
ADRENERGIC ANTAGONISTS
LABETALOL:

Used to treat high blood pressure. Use to

treat mild to severe hypertension, I.V. for
hypertensive emergencies
ADRENERGIC ANTAGONISTS
Mechanism of action:
Labetalol blocks the Alpha 1, Beta1 and Beta 2
receptors

Decreases systemic arterial pressure and

systemic vascular resistance

Reducing high blood pressure

ADRENERGIC ANTAGONISTS
Adverse effects:
• I.V. use may causes hypotension (58%)
• Hepatotoxicity
• Drowsiness, Fatigue , Weakness
• Scalp tingling
ADRENERGIC ANTAGONISTS

Dose of Labetalol:
Child:
Hypertensive emergencies:
0.4-1mg/kg/hr Max: 3mg/kg/hr.
Adult:
Infusion: 2mg/min. Max 300mg total dose.
ADRENERGIC ANTAGONISTS
Method of Administration:
Patients should always be kept in a supine position during
the period of intravenous drug administration. A
substantial fall in blood pressure on standing should be
expected in these patients.
Either of two methods of administration of labetalol
hydrochloride injection may be used: a) repeated
intravenous injections, b) slow continuous infusion.
DILUENT: NS & D5W , Do not mix with sodium
bicarbonate.
 INOTROPIC AGENTS
An inotrope is an agent that alters the force
or energy of muscular contractions.
NEGATIVE INOTRPIC Weaken the force of
muscular contractions.
POSITIVE INOTROPIC Increase the strength
of muscular contraction.
 DIGOXIN
 MILRINONE
 INOTROPIC AGENTS
DIGOXIN:
 Use to treat heart failure.
 Use to treat certain type of irregular
heartbeat (arrhythmia )
 INOTROPIC AGENTS
Mechanism of Action:
1.Inhibit Na/K ATPase pump.
2.This increases intracellular sodium-
calcium exchange.
3.Intracellular calcium increases.
4.Increased contractility of cardiac muscles.
 INOTROPIC AGENTS
Adverse effects:
Digoxin have low therapeutic index,
Toxicity produces because of this.

Toxicity sign and symptoms are:

• Heart block, tachycardia, dysrhythmia.
• Hyperkalemia.
• Visual disturbance, dizziness, headache.
• Nausea, vomiting.
 INOTROPIC AGENTS
Digoxin Administration:
 May be administered undiluted.
 May also dilute 1 mL of digoxin in 4 mL of sterile
water for injection, D5W, or 0.9% NaCl.
 Less diluent will cause precipitation. Use diluted
solution immediately.
Concurrent ingestion of a high-fiber
meal may ↓ absorption. Administer
digoxin 1 hour before or 2 hours after
such a meal.
 INOTROPIC AGENTS
Monitoring parameters:
 Monitor BP periodically in patients receiving IV
digoxin.
 Monitor ECG throughout IV administration and 6
hr after each dose.
 Observe IV site for redness or infiltration;
extravasation can lead to tissue irritation and
sloughing.
 Evaluate serum electrolyte levels and renal and
hepatic functions periodically during therapy.
 ANTICAOGULANTS

Anticoagulants are a class of drugs that

work to prevent the coagulation (clotting)
of blood.
 Enoxparin (low molecular weight
heparin)
 Warfarin
 ANTICAOGULANTS
ENOXAPARIN:
DVT (deep vein thrombosis) , Pulmonary
Embolism, Unstable coronary artery disease
and for the prevention of clotting.
Mechanism Of Action:
Enoxaparin binds to the anti-thrombin (a circulating
anticoagulant)
a complex formed that irreversibly inactivates
clotting factor Xa.
 ANTICAOGULANTS

Adverse Effects Of Enoxaparin:

 Local reactions: local irritation, pain.

 Bleeding
 Hemorrhage
 ANTICAOGULANTS

Administration:
 Pre-filled syringes administered sub-
Q(subcutaneously)
 Not for IM administration.
 Enoxaparin-induced thrombocytopenia, monitor
platelet count closely.
 ANTICONVULSANTS
A medication used to control (prevent)
seizures (convulsions) or stop an ongoing
series of seizures.

 Phenytoin
 Diazepam
 ANTICONVULSANTS
PHENYTOIN
Management of generalized tonic clonic
complex partial seizure prevention of
seizure following head trauma /
neurosurgery.
Stabilizes neuronal membranes and
decreases seizure activity.
 ANTICONVULSANTS
Phenytoin Doses:
I.V. :
Loading dose: 15-20mg/kg
Maintenance Dose: 5-7mg/kg/day divided in
2 doses.
 ANTICONVULSANTS
Phenytoin Administration:
For administration by intravenous infusion
phenytoin injection should be diluted in 50
- 100 ml of normal saline.
WARNING!!!
Risk of hypotension and arrhythmias
with infusion rates that exceed 50
mg/min in adults and 1-3 mg/kg/min
(or 50 mg/min, whichever is slower)
for pediatric patients
Careful cardiac monitoring is needed
during and after IV administration
 ANTICONVULSANTS
DIAZEPAM
Belongs to the class of benzodiazepine.
INDICATIONS:
1. Seizures
2. Anxiety
3. Alcohol withdrawal symptoms
4. Pre-operative and pre-procedural sedation and
amnesia.
 ANTICONVULSANTS
Benzodiazepine Works in following steps:

1. Bind to specific site on GABA receptor

2. Potentiate inhibitory effect of GABA
3. Increase in frequency of opening of Cl channels
4. Increase in chloride conductance
5. Membrane hyperpolarization CNS
depression
 ANTICONVULSANTS

Side Effects of Diazepam:

•Drowsiness
•Fatigue
•Blurred vision.
•Headache
•constipation
 ANTICONVULSANTS
DOSE:
INFANTS AND CHILD:
I.V.: 0.05-0.3mg/kg/dose every 15-30min to
a max total dose of 10mg (repeat in 2-4hrs
as needed)
ADULTS:
I.V. : 5-10mg every 10-20min, upto 30mg in
an 8 hrs period.
 ANTICONVULSANTS
Diazepam I.V Administration:
 Administer over 3 min; no more than 5 mg/min
 Monitor respiration q5-15min and before each IV
dose
 Administer directly into a large vein to avoid
thrombosis
 Do not use small veins such as those of wrist
 CONSCIOUS SEDATION
DRUGS

“Conscious sedation is a combination of

medicines to help you relax (a sedative)
and to block pain (an anesthetic) during a
medical or dental procedure.”
 CONSCIOUS SEDATION
DRUGS
Monitoring required:
 Monitor vital signs before, during, and after the
procedure.
 ECG monitoring should be continuous for high-
risk patients, during prolonged procedures.
• Monitor airway patency.
• Monitor response to physical stimuli and verbal
command.
 CONSCIOUS SEDATION
DRUGS
Routes of Administration:
The intravenous (IV) route is preferred for
conscious sedation/analgesia because:
 it has a fast onset of action
 Absorption is more predictable than it is by
the intramuscular, subcutaneous, oral, and
rectal routes.
 It is also easier to titrate doses of IV drugs.
 ANESTHETIC AGENTS

PROPOFOL:

Propofol is an intravenous sedative-hypnotic

agent for use in the induction and
maintenance of anesthesia or sedation.
 ANESTHETIC AGENTS
SIDE EFFECTS:
 Bradycardia
 Arrhythmia
 Apnea
 Rash
 ANESTHETIC AGENTS
Method Of Administration of Propofol:
 It should only be diluted with 5%Dextrose.
 It should not be diluted to a concentration less
than 2 mg/ml
 Don't administer through same i.v cathether with
blood or plasma
 Discard unused portion within 6 hrs
 Monitoring: Patients should be monitored for
early signs of significant hypotension and/or
cardiovascular depression
 ANESTHETIC AGENTS

KETAMINE:
Ketamine, is a medication mainly used for
starting and maintaining anesthesia. It
induces a trance-like state while
providing pain relief, sedation,
and memory loss. Other uses include
for chronic pain and for sedation
in intensive care.
 ANESTHETIC AGENTS
KETAMINE
Onset of action:
(IV): General anesthesia: 1-2 minutes,
Sedation: 1-2 minutes.
(IM): General anesthesia: 3-8 minutes.
Duration:
5-15 minutes IV,
12-25 minutes IM.
 ANESTHETIC AGENTS
SIDE EFFECTS:
• Abnormal heart rhythms, slow heart rate or fast
heart rate, high blood pressure or low blood
pressure
• Disorientation and general confusion due to the
drug's anesthetic nature.
• Drowsiness.
• Nausea or Vomiting
 ANESTHETIC AGENTS

• Administer on an empty stomach to

prevent vomiting and aspiration

Dilution:
• Dilute 100 mg/mL concentration with equal
parts of sterile water for injection, 0.9% NaCl,
or D5W
 ELECTROLYTES
Intravenous Potassium Chloride
• Treatment and Prevention of Potassium
depletion
 ELECTROLYTES
Administration:
• Administration of concentrated intravenous potassium
can lead to death
• Do not administer undiluted. Each single dose must be
diluted and thoroughly mixed in 100–1000 mL of
dextrose, saline, Ringer’s or LR, dextrose/saline,
dextrose/Ringer’s, or LR combinations.
• limited to 80 mEq/L via peripheral line
(200 mEq/L via central line).
 ELECTROLYTES
• Rate:
• Infuse slowly, at a rate up to 10 mEq/hr in adults
or 0.5 mEq/kg/hr in children on general care
areas. Check hospital policy for maximum
infusion rates (maximum rate in monitored
setting 40 mEq/hr in adults or 1 mEq/kg/hr in
children)
 ELECTROLYTES

Toxicity and Overdose:

• Symptoms of toxicity are those of hyperkalemia
(slow, irregular heartbeat; fatigue; muscle
weakness; paresthesia; confusion; dyspnea and
cardiac arrytmias)
 ELECTROLYTES
Intravenous Sodium Chloride:
Hydration and provision of NaCl in deficiency
states. Maintenance of fluid and electrolyte
status in situations in which losses may be
excessive (excess diuresis or severe salt
restriction)
• Infusion of 0.45% NaCl is hypotonic,
0.9% NaCl is isotonic, and 3% and
5% NaCl are hypertonic
 ELECTROLYTES
Administration
• Administer 3% or 5% NaCl via a large vein and prevent
infiltration. After the first 100 mL, sodium, chloride, and
bicarbonate concentrations should be re-evaluated to
determine the need for further administration.
Rate:
• Rate of hypertonic NaCl solutions should not exceed 100
mL/hr or 1 mEq/kg/hr
 THINK SAFE
THINK TWICE
DOUBLE CHECK