DRUG STUDY

INTENSIVE CARE UNIT

Nitroglycerin Antianginal agent, vasodilator

Dosing: Adult Note: Hemodynamic and antianginal tolerance often develop within 24-48 hours of continuous

nitrate administration. Nitrate-free interval (1012 hours/day) is recommended to avoid tolerance development; gradually decrease dose in patients receiving NTG for prolonged period to avoid withdrawal reaction.

Angina/coronary artery disease: Oral: 2.5-6.5 mg 3-4 times/day (maximum dose: 26 mg 4 times/day) I.V.: 5 mcg/minute, increase by 5 mcg/minute every 3-5 minutes to 20 mcg/minute. If no response at 20 mcg/minute, may increase by 1020 mcg/minute every 3-5 minutes (generally accepted maximum dose: 400 mcg/minute) Topical ointment: 1/2 upon rising and 1/2 6 hours later; if necessary, the dose may be doubled to 1 and subsequently doubled again to 2 if response is inadequate. Doses of 1/2 to 2 were used in clinical trials. Recommended maximum: 2 doses/day; include a nitrate freeinterval ~10-12 hours/day.

Topical patch, transdermal: 0.2-0.4 mg/hour initially and titrate to doses of 0.4-0.8 mg/hour. Tolerance is minimized by using a patch-on period of 12-14 hours/day and patch-off period of 10-12 hours/day. Sublingual: 0.3-0.6 mg every 5 minutes for maximum of 3 doses in 15 minutes; may also use prophylactically 5-10 minutes prior to activities which may provoke an attack. Translingual: 1-2 sprays onto or under tongue every 35 minutes for maximum of 3 doses in 15 minutes, may also be used prophylactically 5-10 minutes prior to activities which may provoke an angina attack

INDICATION
Treatment or prevention of angina pectoris Intravenous (I.V.) administration: Treatment or prevention of angina pectoris; acute decompensated heart failure (especially when associated with acute myocardial infarction);

perioperative hypertension (especially during cardiovascular surgery); induction of intraoperative hypotension Intra-anal administration (Rectiv ointment): Treatment of moderate-to-severe pain associated with chronic anal fissure

CONTRAINDICATION
Hypersensitivity to organic nitrates or any

component of the formulation (includes adhesives for transdermal product); concurrent use with phosphodiesterase-5 (PDE-5) inhibitors (sildenafil, tadalafil, or vardenafil); increased intracranial pressure; severe anemia Additional contraindications for I.V. product: Constrictive pericarditis; pericardial tamponade; restrictive cardiomyopathy

SIDE EFFECT
Cardiovascular: Flushing, hypotension, peripheral edema, postural hypotension,

syncope, tachycardia Central nervous system: Headache (common), dizziness, lightheadedness Gastrointestinal: Nausea, vomiting, xerostomia Neuromuscular & skeletal: Paresthesia, weakness Respiratory: Dyspnea, pharyngitis, rhinitis Miscellaneous: Diaphoresis

NURSING CONSIDERATION
Evaluate cardiac status and monitor for

hypotension and GI disturbances. Teach patient importance of drug-free intervals. Monitor patient for tachycardia and syncopal episodes.

Dobutamine ( dobutrex)
INDICATION :

Increased the cardiac output in short term treatment of cardiac decompensation caused by depressed contractility, such as during refractory heart failure: adjunctive therapy in cardiac surgery. DOSAGE : Adults: 0.5mcg/kg/min IV infusion, titrating to optimal dosage of 2 to 20mcg/kg/min.

CONTRAINDICATION
Hypersensitivity to dobutamine or sulfites

(some contain sodium metabisulfate), or any component of the formulation; idiopathic hypertrophic subaortic stenosis (IHSS)

SIDE EFFECTS
Cardiovascular: Increased heart rate, increased blood

pressure, increased ventricular ectopic activity, hypotension, premature ventricular beats (5%, dose related), anginal pain (1% to 3%), nonspecific chest pain (1% to 3%), palpitation (1% to 3%) Central nervous system: Fever (1% to 3%), headache (1% to 3%), paresthesia Endocrine & metabolic: Slight decrease in serum potassium Gastrointestinal: Nausea (1% to 3%) Hematologic: Thrombocytopenia (isolated cases) Local: Phlebitis, local inflammatory changes and pain from infiltration, cutaneous necrosis (isolated cases) Neuromuscular & skeletal: Mild leg cramps Respiratory: Dyspnea (1% to 3%)

NURSING CONSIDERATION
Use cautiously in patients with history of

hypertension. Monitor ECG, blood pressure, cardiac output and urine output. Monitor electrolyte levels, it may lower potassium level.

ATROPINE SULFATE
INDICATION: Preoperative medication to inhibit salivation and secretions; treatment of symptomatic sinus bradycardia, AV block (nodal level); antidote for anticholinesterase poisoning (carbamate insecticides, nerve agents, organophosphate insecticides); adjuvant use with anticholinesterases (eg, edrophonium, neostigmine) to decrease their side effects during reversal of neuromuscular blockade

DOSAGE
Inhibit salivation and secretions (preanesthesia): I.M., I.V., SubQ: 0.4-0.6 mg 30-

60 minutes preop and repeat every 4-6 hours as needed. Bradycardia (Note: Atropine may be ineffective in heart transplant recipients): I.V.: 0.5 mg every 3-5 minutes, not to exceed a total of 3 mg or 0.04 mg/kg (ACLS, 2010) Neuromuscular blockade reversal: I.V.: 25-30 mcg/kg 30-60 seconds before neostigmine or 710 mcg/kg 30-60 seconds before edrophonium

Organophosphate or carbamate insecticide or nerve agent poisoning: Note: The dose of atropine required varies considerably with the severity of poisoning. The total amount of atropine used for carbamate poisoning is usually less than with organophosphate insecticide or nerve agent poisoning. Severely poisoned patients may exhibit significant tolerance to atropine; 2 times the suggested doses may be needed. Titrate to pulmonary status (decreased bronchial secretions); consider administration of atropine via continuous I.V. infusion in patients requiring large doses of atropine. Once patient is stable for a period of time, the dose/dosing frequency may be decreased.

Mild symptoms (2 mild symptoms): Administer 2 mg as soon as an exposure is known or strongly suspected. If severe symptoms develop after the first dose, 2 additional doses should be repeated in rapid succession 10 minutes after the first dose; do not administer more than 3 doses. If profound anticholinergic effects occur in the absence of excessive bronchial secretions, further doses of atropine should be withheld. Severe symptoms (1 severe symptoms): Immediately administer three 2 mg doses in rapid succession.

CONTRAINDICATION
Hypersensitivity to atropine or any component

of the formulation; narrow-angle glaucoma; adhesions between the iris and lens (ophthalmic product); pyloric stenosis; prostatic hypertrophy Note: No contraindications exist in the treatment of life-threatening organophosphate or carbamate insecticide or nerve agent poisoning.

SIDE EFFECTS
Severity and frequency of adverse reactions are

dose related and vary greatly; listed reactions are limited to significant and/or life-threatening. Cardiovascular: Arrhythmia, flushing, hypotension, palpitation, tachycardia Central nervous system: Ataxia, coma, delirium, disorientation, dizziness, drowsiness, excitement, fever, hallucinations, headache, insomnia, nervousness Dermatologic: Anhidrosis, urticaria, rash, scarlatiniform rash Gastrointestinal: Bloating, constipation, delayed gastric emptying, loss of taste, nausea, paralytic ileus, vomiting, xerostomia, dry throat, nasal

Genitourinary: Urinary hesitancy, urinary retention Neuromuscular & skeletal: Weakness Ocular: Angle-closure glaucoma, blurred vision, cycloplegia, dry eyes, mydriasis, ocular tension increased Respiratory: Dyspnea, laryngospasm, pulmonary edema Miscellaneous: Anaphylaxis

NURSING CONSIDERATIONS
Monitor for tachycardia and

hypotension, especially if cardiac problems are present. Be alert to the potential of heat prostration in the presence of high temperatures.