Drugs in ICU 1.pdf

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1. DrugsIn
ICU

2. Introductio
n
▶ Drugas“achemicalsubstanceusedinthetreatment,cure,prevention,or
diagnosisofdiseaseorusedtootherwiseenhancephysicalormentalwell-
being“.

▶ Drugsmaybeprescribedforalimitedduration,oronaregularbasisfor
chronicdisorders.

▶ edrugsinI.C.Uisve?impo?antasfastintervention.

▶ MostofI.C.Ucasesarelifethreatingsoweneeddrugsthatdecrease
fatalchance&
improvingthehea?&lungsfunction.

3. Outlin
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1.
2.
3.
4.
5.
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Introduction

eClassi?cationOfDrugsinICUrelatedtheir
a?ect:
CardiovascularSystemDrugs.
RespiratorySystemDrugs.
Ne?ousSystemDrugs.
UrinarySystemDrugs.
G.I.TSystemDrugs.

Documentation

4. A)Cardiovascular
Drugs1
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Vasopressors:
Adrenalin (GenericName:EpinephrineInjection)
α-adrenergice?ectscanincreasecoronary&cerebralperfusionpressureby
vasoconstriction
β-adrenergiccanincreasemyocardialcontractility
Indication:
Itisachemicalthatnarrowsbloodvessels&opensairwaysinthelungs.
esee?ectscanreverseseverelowbloodpressure.
Epinephrineinjectionisusedtotreatsevereallergicreactions(anaphylaxis).

Contraindication:
Heartdiseaseorhighbloodpressure
AheartrhythmdisorderVTVFiB.
Coronaryarterydisease.
Athyroiddisorder(storm).

5. Con
t.
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Epinephrinesideeffects:
Fast,poundingoruneven
hea?beats.
Sweating.
Nausea&vomiting.
Paleskin.
Dizziness.
Weaknessortremors.
Headache.
Feelingne?ousoranxious.

Dose&routeofadministration
1mg/ml injectionq3-5min

6. Other
Vasopressors:
1
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2
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Levophed(norepinephrinebitartrate)
Vasoconstrictor,similartoadrenaline,usedtotreatlife-threateninglowblood
pressure
(hypotension).
DoseinAcuteHypotensionInitial:0.05-0.1mcg/kg/minIVinfusion;titrateto
e?ect
Maximum:1-2mcg/kg/min

Dobutamine
SympathomimeticwithBeta1increasemyocardialcontractility&strokevolume,
resultingin increasedcardiacoutput.
Usedinthetreatmentofcardiogenicshock&severeheartfailure.3-Dopamine

Sympathomimetic
Usedforhypotension(shock)&hea?blocktoincreaseheartratewhenatropine
hasnot
beene?ective
Dose:1-20mcg/kg/min(in250mlD5W)

7. 2-Anti-Arrhythmic
drugs:
1
2
3
Cordarone
GenericName:Amiodarone
Itworksoncardiaccellmembranes.
Itrelaxesthesmoothmuscles.
Indication
Hemodynamicallyunstableventricular
tachycardia,supraventriculartachycardia,
ventricular?brillation.
Contraindication
AllergictoanyingredientinCordarone,
includingiodine.
Complete,2
ND
degree,3
RD
degree,orsevere
sinoatrialheartblock;anabnormallyslow
heartbeat;orshockduetoserioushea?
problems.
Cardiogenicshock.

8. Cont.
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Sideeffects
CNS:
Headache,dizziness,involunta?movement,tremors,peripheral
neuropathy,
ataxia,malaise.
CVS:
Hypotension,bradycardia,sinusarrest,CHF,SAnodedysfunction,
AVblock.
Eye:blurredvision,photophobia,d?eyes.
Endocrine:hypo/hype?hyroidism
Resp:
Pulmona??brosis/toxicity,pulmona?in?ammation,ARDS.
Gastrointestinal:
nausea,vomiting,diarrhea,abdominalpain,anorexia,hepatotoxicity.
Rash,photosensitivity,blue-grayskindiscoloration,alopecia,
u?icaria.
Weakness,paininextremities.

9. Anti-Arrhythmic
Medication

10. 3-
Digitalis
•
•
Digitalismedicinesareusedtoimprovethestrength&e?ciencyoftheheart,ortocontrolthe
rate&
rhythmofhea?beat.
isleadstobetterbloodcirculation&reducedswellingofhandsandanklesinpatientswith
heartproblems.
DigoxinGenericName:DigoxinInjection

11. ATROPIN
E
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Tertiaryamine.
Canrapidlycrosstheblood–brainbarrier.
Dosage&Packaging
Intravenouslyorintramuscularlyinarangeof0.01–0.02mg/kg,uptotheusual
adultdoseof0.4–0.6mg.
ClinicalConsiderations
emoste?caciousanticholinergic(parasympatholytic)fortreating
bradyarrhythmias.
Patientswithcorona?a?e?diseasemaynottoleratetheincreasedmyocardial
oxygendemand&decreasedoxygensupplyassociatedwiththetachycardia
causedbyatropine.
Ipratropiumbromide,isavailableinametered-doseinhalerforthetreatmentof
bronchospasm.
Providesanantisialagoguee?ect.
Atropineshouldbeusedcautiouslyinpatientswithnarrow-angleglaucoma,
prostatic
hypertrophy,orbladder-neckobstruction.

12. OtherCommon
Drugs:
DRUG CLASSIFIED AFFECT
CALCIUM
CHLORIDE
Antidotes DisturbancesOfHyperkalemia,OrHypocalcemia
Magnesiumsulfateoverdose
Cardiacarrest
•
•
•
SODIUM
NITROPRUSSIDE
ANTIHYPERTENSVE
VASODILATOR
UsedToManagementOfhype?ensiveCrisis
CongestiveHea?Failure.
•
•
ANGITENSIN-
CONVERTINGENZYME
INHIBITOR
ANTIHYPERTENSVE Hype?ension
CongestiveHea?Failure
•
•
ADENOSIINE
(ADENOCARD)
ANTI-ARRHYTHMICAGENT
ANTI-ARRHYTHMIC
ParoxysmalSupraVentricularTachycardia•

13. B)Respirato?
Drugs:
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Bronchodilators:
1)AtroventGenericName:ipratropiuminhalation
Isaderivativeofatropinebutisaquaterna?amineandthereforedoes
notcross
theblood–brainbarrier
Indication:
Usedtopreventbronchospasm,ornarrowingairwaysinthelungs,
bronchitis,emphysema,orCOPD(chronicobstructivepulmona?
disease).
Contraindication:
Narrow-angleglaucoma
Anenlargedprostateorabladderobstruction(increaseretention).
Sideeffects:
Headache,dizziness.
Nausea,upsetstomach.
Blurredvision

14. Ventolin
GenericName:albuterol
inhalation
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Indication
Ventolinisasympathomimetic(betaagonist)bronchodilatorthatrelaxesthe
smooth
muscleintheairwayswhichallowsairto?owinandoutofthelungsmore
easily.
Usedtotreatorpreventbronchospasminpeoplewithreversibleobstructive
airwaydisease
Contraindication:
Allergictoalbuterol.
Hea?disease,highbloodpressure,orcongestivehea?failureahea?rhythm
disorder
Sideeffects:
Chestpain&fast,pounding,orunevenhea?beats.
Tremor&ne?ousness.
Lowpotassium(confusion,unevenhea?rate,extremethirst,legdiscomfo?,
muscle
weaknessorlimpfeeling)

15. C)Ne?ousSystem
Drugs:
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Narcotics:(ANALGESIA)
1)MORPHINE

Morphineisaμopioidwithintermediateonset&durationofaction.
Extensiveclinicalexperiencemakesmorphineavaluable?rst-lineopioid.
Activemetabolitesincludemorphine-3-glucuronide(toxic,nonanalgesic)&
morphine-6-glucuronide(potentanalgesic).
Neuraxiallyadministeredmorphinehasadurationofactionof12to24hours.
eequianalgesicoralmorphinedoseisthreetofourtimestheIVdose.
(Iv:Oral)(1:3)
Totreatmoderatetoseverepain.
Itworksbydullingthepainperceptioncenterinthebrain.
Extended-releaseformulationsareusedwhenaround-the-clockpainreliefis
needed.

16. Con
t.

17. Con
t.
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Sideeffect:
Shallowbreathing,slowhea?beat.
Seizure(convulsions).
Cold,clammyskin.
Confusion.
Severeweaknessordizziness;orFeelinglight-headed,
fainting.
Lessseriousmorphinesideeffectsaremorelikelytooccur,
suchas:
Constipation.
Warmth,tingling,orrednessunderyourskin.
Nausea,vomiting,stomachpain,diarrhea,lossof
appetite.
Dizziness,headache,anxiety.
Memo?problems;orSleepproblems(insomnia).

18. 2)REMIFENTANIL(ULTIVA)
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Remifentanilisasyntheticμagonist,approximatelyequipotentwith
fentanyl.
Itisrapidlymetabolizedbyblood&tissueesterases.
Hasaconstantcontext-sensitivehalf-timeof±3.5min,independentofage,
weight,
organfunction,&durationofinfusion.
Bolus-doseadministrationcarriestheriskofacutebradycardia,
hypotension,&
respirato?depression.

MEPERIDINE(PETHIDINE)
Meperidineisaphenylpiperidineopioidwithadditionalantimuscarinergic&
serotoninreuptake-inhibitinge?ects.

Meperidinemayproduceintenseeuphoria,butnotalwayssedationor
anxiolysis.
Itsanalgesice?ectisnotsuperiortothatofmorphine.

Meperidineshouldnotbeco-administeredwithMAOinhibitors.

19. Sedative(Hypnosis):
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Midazolamisa(benzodiazepine).
BenzodiazepinebindingtotheGABA-Areceptor
Midazolam(pH3.5)isawater-solubledrugthatisconve?edtoalipid-solubledrugwhenexposed
totheblood’s.
elipid-solubleformofmidazolamcanreadilycrosstheblood-brainbarrier&exertits
pharmacologice?ects.
Itworksinthecentralne?oussystem(brain)tocausesedation,sho?-termmemo?loss&to
reduceanxiety.
Highlylipidsolubleunionizedring,accountingforitsrapidonsetofaction.
ItdoesnotcausepainoninjectionIVbutpainfultoIMroute.
Indication:
Givencontinuouslytomaintainsedation
Usedforgeneralanesthesia.
eyaree?ectiveinpreventing&controllinggrandmalseizures
Contraindication:
Patientwithknownhypersensitivity.
Narrowangelglaucoma.

20. Con
t.
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Sideeffect
Benzodiazepinesgivenalonedecreasearterialbloodpressure,
cardiacoutput&peripheralvascularresistanceslightly,and
sometimesincreaseheartrate.
Depresstheventilato?responsetoCO2.
Benzodiazepinesreducecerebraloxygenconsumption,
cerebralblood?ow,&intracranialpressure.

Caution
CRF,CHF,COPD&severhypotension.

21. Propofol(2,6–diisopropylphenyl)
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Propofolisextremelylipid-soluble.
Ampoulesofthedrugcontain200mgofpropofolin20mL(10mgmL−1)&100mL
bottlescontaining1%solution,areavailableforinfusion
Infusionrateisapproximately2mg/kg/hinconjunctionwithaslowinfusionof
morphine
(2mg/h)forsedationofpatientsinICU&recoveryisrapid(usually<30min)..
ItisisotonictoplasmaandhasapHof7.0-8.5Anesthesiaisinducedwithin20–40
safterI.V.administration
Propofolcrossestheplacenta.
Indication
Forinductionofgeneralanesthesia
SedationinICUforpt.onMV
Sedationfordiagnosticprocedures(endoscopies).
Propofolreducesthedurationofseizures
Cerebralmetabolicrate,CBF&intracranialpressurearereduced.

22. Cont.
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Sideeffect
Profoundhypotensionafterinductionofanesthesia
Afterinduction,apneaoccursmorecommonly
Lowincidenceofpostoperativenausea&vomiting(anti-emetic)
Plasmaconcentrationsofco?isolaredecreasedafteradministrationof
propofol
Transientdecreaseinrenalfunction.
Hepaticblood?owisdecreased.
erehavebeenoccasionalreportsofconvulsions&myoclonusduring
recove?
Skinrashesoccuroccasionally.
Painoninjection.
Propofolinfusionsyndromeisanadversedrugeventassociatedwithhigh
doses(>4
mg/kgperhour&long-term(>48hours)use.
Causes(Cardiomyopathywithacutecardiacfailure,Myopathy,Metabolic
acidosis,
h kl hbd l l)

23. Dexmedetomidin
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Selectivealpha-2adrenergicagonist
Hassedative,amnestic&mildanalgesice?ects,yetdoesnotdepress
ventilation
Uniquebecausearousalismaintained,despitedeeplevelsofsedation
Patientscanbearousedfromsedationwithoutdiscontinuingthedrug
infusion&
whenawake,patientsareabletocommunicateandfollowcommands.
Lowerprevalenceofdelirium

Sideeffect:
Hypotensionandbradycardia

24. Haloperid
ol
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First-generationantipsychotic
Blocksdopaminereceptorsinthecentralne?oussystem.
FollowinganIVbolusdoseofhaloperidol:
Sedationin10–20minutes(Notappropriatewhenrapidsedationis
required)
E?ectlasts3–4hours
Norespiratorydepression
Suitedforsedationduringweaningfrommechanicalventilation.

Adverseeffects
Extrapyramidalreactions(Rigidityandspasmodicmovement)
NeurolepticMalignantsyndrome(Hyperpyrexia,severemusclerigidity
&
rhabdomyolysis)
ProlongationofQTinterval(TriggerpolymorphicVT)

25. D)G.I.Tsystem
drugs
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ProtonPumpInhibitor
Omeprazole
Indication
Decreasesgastricjuice.
Usedtotreatsymptomsofgastroesophagealrefluxdisease(GERD)
&To
preventVAP(VentilatorAssociatedPneumonia).
Itisalsousedtopromotehealingoferosiveesophagitis
Contraindication:
Diarrheafromaninfectionwithclostridiumdi?cilebacteria
InadequatevitaminB12
Lowamountofmagnesiumintheblood
Liverproblems
Atypeofkidneyin?ammationcalledinterstitialnephritis
Subacutecutaneouslupuse?thematosus
Systemiclupuse?thematosus
Anautoimmunedisease
Osteoporosis

26. METOCLOPRAMID
E
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Metoclopramideantagonizestheeffectofdopamineinthegut.
Increasesloweresophagealsphinctertone.
Speedsgastricemptying,andlowersgastric?uidvolume.

eeliminationhalf-lifeis4to6hours.

Centraladversee?ects,includingsedation,extrapyramidal
symptoms.

Relativelycontraindicatedinpatientswithepilepsybecauseithas
beenrepo?edtoelicitseizures.

27. E)Urina?system
drugs
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DIURETIC
Lasix
ismedicineisaloopdiuretic.
Loopdiureticsmakethekidneyseliminatelargeramountsof
electrolytes(especiallysodiumandpotassiumsalts)andwater
thannormal(diuretice?ect).
Loopdiureticsareusefulfortreatingmanyconditionsinwhich
saltand
waterretention(e.g.,edema,swelling)areaproblem.

Contraindication:
Anuricpatient
Allergytosulfadrugs
Sideeffects
D?mouth,thirst,nausea,vomiting
Feelingweak,drowsy,restless,orlight-headed
Fastorunevenheartbeat
Musclepainorweakness

28. Muscle
Relaxant
Blocking
AgentsDepolarizing Nondepolarizing
Short-acting
Succinylcholine
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Short-acting
Gantacurium
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Intermediate-acting
Atracurium
Cisatracurium
Vecuronium
Rocuronium
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Long-acting
Pancuronium
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29. Succinylcholine
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ConsistsoftwojoinedAChmolecules
Rapidonsetofaction(30–60s)andshortduration
Mechanismofaction:
esedrugsactlikeacetylcholinebutpersistatthesynapseathigh
concentration&
forlongerduration&constantlystimulatethereceptor.

First,openingoftheNa+channeloccursresultingindepolarization,thisleads
totransienttwitchingofthemuscle,continuedbindingofdrugsmakethe
receptorincapabletotransmittheimpulses,paralysisoccurs.
Indication
Whenrapidendotrachealintubationsisrequired.
ElectroconvulsiveshocktherapyECT.
Sideeffects:
Bradycardiaandsinusarrest.(Muscarinicstimulationofthesinus
node)
Increaseintraocularpressureduetocontractureofextraocular
muscles.
Increaseinloweresophagealsphinctertone.
Fasciculations
Musclepains
Postoperativemyalgias
Hyperkalemiainpatientswithtraumaorburns

30. 
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Unwantedeffects:

ProlongedParalysis–scolineapnea(reducedlevelsofnormal
pseudocholinesterase)
IntracranialPressure
HistamineRelease.
MasseterMuscleRigidity-transientlyincreasesmuscletoneinthe
masseter
muscles.
MalignantHyperthermia-potenttriggeringagentinpatients
susceptibleto
malignanthype?hermia
Cont.

31. NondepolarizingMuscle
Relaxants
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1.
2.
3.
4.
5.
ATRACURIUM
ClinicalConsiderations
Atracuriumtriggersdose-dependenthistaminereleasethat
becomessigni?cantatdosesabove0.5mg/kg.
Slowlyadministartionreducesthehistaminerelease.
Itmustbestoredat2–8°C,asitloses5%to10%ofitspotency
foreachmonthitisexposedtoroomtemperature.
Atroomtemperature,itshouldbeusedwithin14daysto
prese?epotency.

SideE?ects:
HypotensionandTachycardia.
Bronchospasm
LaudanosineToxicity(Laudanosineisametaboliteofthe
neuromuscular-blockingdrugsatracurium&cisatracurium
withpotentiallytoxicsystemice?ects.Itcrossestheblood-
brainbarrierandmaycauseexcitementandseizureactivity.)
TemperatureandpHSensitivity
AllergicReactions–rare

32. NondepolarizingMuscle
Relaxants
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CISATRACURIUM(NIMBEX)

ClinicalConsiderations

Cisatracuriumisastereoisomerofatracuriumthatisfourtimesmorepotent.
Cisatracuriumshouldbestoredunderrefrigeration(2–8°C)
Shouldbeusedwithin21daysafterremovalfromrefrigerationandexposuretoroom
temperature.
Cisatracuriumshareswithatracuriumtheproductionoflaudanosine,pHandtemperature
sensitivity(hofmannelimination)&chemicalincompatibility.
Dose-dependentincreaseinplasmahistaminelevelsfollowingadministration.
Cisatracuriumdoesnotalterhea?rateorbloodpressure.