MICP- 12 Common Infusions

**** Draft *****
Focus Statement: This module will introduce the participant to the 12 most common infusions encountered in CCT, their indications, contraindications, dosing regimens, and practical concerns

1. 12 Infusions You Need 12 Infusions You Need
To KnowTo Know
Mobile Intensive Care Paramedic Mobile Intensive Care Paramedic
SeriesSeries

3. Focus StatementFocus Statement
Focus Statement: This module will Focus Statement: This module will
introduce the participant to the 12 most introduce the participant to the 12 most
common infusions encountered in CCT, common infusions encountered in CCT,
their indications, contraindications, their indications, contraindications,
dosing regimens, and practical concerns. dosing regimens, and practical concerns.

4. Presentation InformationPresentation Information
Last revised 04/20/08Last revised 04/20/08
For more information contact the For more information contact the
education department education department
208-287-2972208-287-2972
[email protected]@adaweb.net

5. Where this fits in the big Where this fits in the big
picture?picture?
This lecture discusses material in Section This lecture discusses material in Section
9 of the 9 of the Idaho EMS Critical Care Idaho EMS Critical Care
Curricula GuideCurricula Guide
Initial lecture on common infusions only. Initial lecture on common infusions only.
Many, many, more hours forthcoming Many, many, more hours forthcoming
over next few months.over next few months.

6. Why?Why?
The goal of dedicated critical care transport The goal of dedicated critical care transport
and specialty care transport is to continue the and specialty care transport is to continue the
same level of care during transport as the same level of care during transport as the
patient was receiving and may be receiving. patient was receiving and may be receiving.
This involves using medication infusions out of This involves using medication infusions out of
our comfort zone.our comfort zone.
Turning them off NOT an option.Turning them off NOT an option.
These meds are essential knowledge of the These meds are essential knowledge of the
Mobile Intensive Care Paramedic (MICP)Mobile Intensive Care Paramedic (MICP)

7. Other important things…Other important things…
Decreasing Medical ErrorsDecreasing Medical Errors

8. The Dirty DozenThe Dirty Dozen
DopamineDopamine
DobutamineDobutamine
NitroprussideNitroprusside
Nor-epinephrineNor-epinephrine
NitroNitro
Standard compositionStandard composition
VAMC CompositionVAMC Composition
InsulinInsulin
DiltiazemDiltiazem
HeparinHeparin
GIIb-IIIa InhibitorsGIIb-IIIa Inhibitors
AmiodaroneAmiodarone
PropofolPropofol
RetavaseRetavase
We also will discuss what IV Fluid you may run!!!

9. Some thoughts about the Some thoughts about the
Route….Route….

10. What route ?What route ?
CentralCentral
May also be used for Hemodynamic May also be used for Hemodynamic
MonitoringMonitoring
Many types:Many types:
PICC-inserted into antecubital vein and PICC-inserted into antecubital vein and
advanced into Superior Vena Cavaadvanced into Superior Vena Cava
Examples: Triple lumen, Hickman, Examples: Triple lumen, Hickman,
Broviac, and GroshongBroviac, and Groshong
PROS:PROS:
Good for drug concentrates in fluid Good for drug concentrates in fluid
restricted patientsrestricted patients
Good for drugs too irritant to be used Good for drugs too irritant to be used
peripherallyperipherally
CONS:CONS:
Slow and risky to gain accessSlow and risky to gain access
needs experience & practiceneeds experience & practice
Many different typesMany different types
Sterility a MUSTSterility a MUST
HeparinizationHeparinization
PeripheralPeripheral
PROS:PROS:
Easy and safer accessEasy and safer access
Large volumesLarge volumes
Familiar routeFamiliar route
CONS: CONS:
Not suitable for all medsNot suitable for all meds
Typically not multi-lumenTypically not multi-lumen
Easier to displaceEasier to displace
InfiltrationInfiltration

11. Peripheral Line SafetyPeripheral Line Safety
IVs flow by gravity pressure, and the higher the IVs flow by gravity pressure, and the higher the
solution bag, the faster the IV will infuse.solution bag, the faster the IV will infuse.
The average height for an adult IV solution bag is 3 The average height for an adult IV solution bag is 3
feet above heart level.feet above heart level.
When the “height” changes, so does the infusion rate When the “height” changes, so does the infusion rate
(unless on a pump).(unless on a pump).
Secondary solution bags must hang higher Secondary solution bags must hang higher
than the primary bag to infuse first.than the primary bag to infuse first.
Even when on a pumpEven when on a pump
Flush with confidence? : SIS- saline, IV Flush with confidence? : SIS- saline, IV
med/infusion, salinemed/infusion, saline

12. Piggy Back?Piggy Back?
Secondary Lines Secondary Lines
Attach to primary IV at injection portsAttach to primary IV at injection ports
Used primarily to infuse meds or other IV Used primarily to infuse meds or other IV
fluids on intermittent basis fluids on intermittent basis if compatible with if compatible with
fluid on the primary linefluid on the primary line
IV piggybacks – IVPBIV piggybacks – IVPB
IVPB higher than primary – greater pressure IVPB higher than primary – greater pressure
and causes it to infuse firstand causes it to infuse first
When IVPB empty primary line will When IVPB empty primary line will
automatically resume its flowautomatically resume its flow

13. Central Line SafetyCentral Line Safety
SterilitySterility
Medication SafetyMedication Safety
SASH for Central lines- saline, Additive (IV SASH for Central lines- saline, Additive (IV
Med/infusion), saline, heparinMed/infusion), saline, heparin
Recommend ASPIRATE on all central lines Recommend ASPIRATE on all central lines
PRIOR to flushing with saline as well. PRIOR to flushing with saline as well.
Some lines have high concentration heparin. Some lines have high concentration heparin.
Someone else may not have flushed the line and Someone else may not have flushed the line and
their may be IV meds in it. their may be IV meds in it.

14. SOME THOUGHTS ABOUT SOME THOUGHTS ABOUT
STAYING OUT OF STAYING OUT OF
TROUBLE….TROUBLE….

15. GENERAL CONCEPTSGENERAL CONCEPTS
Check transfer order carefully to be sure Check transfer order carefully to be sure
that you are comfortable with all that you are comfortable with all
medications ordered.medications ordered.
Be sure that order specifies:Be sure that order specifies:
Dosage informationDosage information
Times of administration (where applicable)Times of administration (where applicable)
Indications for changes or discontinuance.Indications for changes or discontinuance.
Eg. Nitroglycerin dosage is often altered based on Eg. Nitroglycerin dosage is often altered based on
pain and/or BP.pain and/or BP.

16. Ask the physician or RN to review Ask the physician or RN to review
medication if it is one that you are not medication if it is one that you are not
familiar with. familiar with.
Discuss potential adverse reactions and Discuss potential adverse reactions and
how to deal with them.how to deal with them.
Use resources to double checkUse resources to double check
Drug ReferencesDrug References
GENERAL CONCEPTSGENERAL CONCEPTS

17. GENERAL CONCEPTSGENERAL CONCEPTS
Determine how long it will Determine how long it will
take to reach receiving take to reach receiving
facility and calculate the facility and calculate the
amount of the drug you will amount of the drug you will
need to reach your need to reach your
destination. destination.
Allow for unforeseen delays.Allow for unforeseen delays.
Boy Scout Firewood RuleBoy Scout Firewood Rule
2 times what you think you will 2 times what you think you will
need, and then some more. need, and then some more.

18. Check to be sure that you have the Check to be sure that you have the
right drug and the right concentration. right drug and the right concentration.
Make sure it is hooked up to the right Make sure it is hooked up to the right
pump channel. pump channel.
GENERAL CONCEPTSGENERAL CONCEPTS

19. Consider using the hospitals IV PumpConsider using the hospitals IV Pump
Good for short transfers. Good for short transfers.
Limits chance of errors or runaway lines Limits chance of errors or runaway lines
during transfers. during transfers.
Be sure you able to troubleshoot potential Be sure you able to troubleshoot potential
problems with the pump!problems with the pump!
Check IV site for patency, redness, etc.Check IV site for patency, redness, etc.
Poor Line Management Poor Line Management willwill cause cause
problems, even on short transfers. problems, even on short transfers.
GENERAL CONCEPTSGENERAL CONCEPTS

20. Be sure to have a drug reference book Be sure to have a drug reference book
available in your ambulanceavailable in your ambulance
Review drug reference for detailed information Review drug reference for detailed information
about the drug. about the drug.
Review side effects, adverse reactions, dosing, Review side effects, adverse reactions, dosing,
interactions, etc.interactions, etc.
STRONGLYSTRONGLY consider calling medical control if consider calling medical control if
it becomes necessary to administer another it becomes necessary to administer another
drug to ascertain possible interaction problemsdrug to ascertain possible interaction problems
GENERAL CONCEPTSGENERAL CONCEPTS

21. Some thoughts about IV Some thoughts about IV
fluidfluid

22. Types of IV solutionTypes of IV solution
4 classes of IV sol4 classes of IV sol
Crystalloids – Dextrose, saline, LRCrystalloids – Dextrose, saline, LR
Colloids – volume expanders such as Colloids – volume expanders such as
Dextran, HetastarchDextran, Hetastarch
Bld & Bld products – whole bld,packed Bld & Bld products – whole bld,packed
RBCs, plasma & albuminRBCs, plasma & albumin
Lipids – fat emulsion sol – indicated if on IVs Lipids – fat emulsion sol – indicated if on IVs
more than 5 daysmore than 5 days

23. What IV fluid ?What IV fluid ?
Crystalloid?Crystalloid?
PROS:PROS:
Most familiarMost familiar
CheapCheap
CONS:CONS:
May need large volumesMay need large volumes
Relatively slow increase in Relatively slow increase in
CVPCVP
Will move out of vascular Will move out of vascular
spacespace
Over 200 diff IV fluids Over 200 diff IV fluids
being manufacturedbeing manufactured
Colloid?Colloid?
PROS:PROS:
Rapid increase in CVPRapid increase in CVP
Small volumesSmall volumes
Water redistribution out of Water redistribution out of
tissuestissues
AKA: Colloid Pulling PowerAKA: Colloid Pulling Power
CONS: CONS:
Only for Critically ill Only for Critically ill
ExpensiveExpensive
Water redistribution out of Water redistribution out of
tissuestissues

24. Fluid balanceFluid balance
A simple question of input equal to outputA simple question of input equal to output
Goal: 1ml/kg/hr urine outputGoal: 1ml/kg/hr urine output
A complex balance of forces to achieve a urine output of A complex balance of forces to achieve a urine output of
about 1ml/kg/hr (assuming normal renal function) about 1ml/kg/hr (assuming normal renal function)
without causing heart failure, pulmonary or peripheral without causing heart failure, pulmonary or peripheral
edemaedema

25. The Drugs….The Drugs….

26. DopamineDopamine
IV Infusions (Titrate to Effect)IV Infusions (Titrate to Effect)
Low Dose Low Dose “Renal Dose"“Renal Dose"
1 to 5 µg/kg per minute1 to 5 µg/kg per minute
Moderate Dose Moderate Dose “Cardiac Dose"“Cardiac Dose"
5 to 10 µg/kg per minute 5 to 10 µg/kg per minute
High Dose High Dose “Vasopressor Dose"“Vasopressor Dose"
10 to 20 µg/kg per minute 10 to 20 µg/kg per minute

27. DopamineDopamine
Precautions Precautions (Watch Out!)(Watch Out!)
May use in patients with hypovolemia but only after May use in patients with hypovolemia but only after
volume replacementvolume replacement
May cause tachyarrhythmias, excessive May cause tachyarrhythmias, excessive
vasoconstrictionvasoconstriction
DO NOTDO NOT mix with sodium bicarbonate mix with sodium bicarbonate
Watch for s/s for fluid overload and hypertension.Watch for s/s for fluid overload and hypertension.
Doses higher than 20/mcg/kg may compromise Doses higher than 20/mcg/kg may compromise
peripheral circulation peripheral circulation

28. DobutamineDobutamine
Consider for pump problems (congestive heart failure, Consider for pump problems (congestive heart failure,
pulmonary congestion) with systolic blood pressure pulmonary congestion) with systolic blood pressure
of 70 to 100 mm Hg and no signs of shockof 70 to 100 mm Hg and no signs of shock
Increases InotropyIncreases Inotropy
DosingDosing
Usual infusion rate is 2 to 20 µg/kg per minute, Usual infusion rate is 2 to 20 µg/kg per minute,
Absolute max of 40 mck/kg/minAbsolute max of 40 mck/kg/min
Titrate so heart rate does not increase by more than 10% of Titrate so heart rate does not increase by more than 10% of
baselinebaseline
Hemodynamic monitoring is recommended for optimal useHemodynamic monitoring is recommended for optimal use

29. DobutamineDobutamine
Precautions Precautions
Avoid when systolic blood pressure <100 Avoid when systolic blood pressure <100
mm Hg with signs of shock, consider mm Hg with signs of shock, consider
dopamine instead. dopamine instead.
May cause tachyarrhythmiasMay cause tachyarrhythmias
DO NOT mix with sodium bicarbonateDO NOT mix with sodium bicarbonate

30. NorepinephrineNorepinephrine
Brand Name:Brand Name: Levophed Levophed
Generic Name:Generic Name: Norepinephrine Bitartrate Norepinephrine Bitartrate
Indications Indications
For severe cardiogenic shock and hemodynamic For severe cardiogenic shock and hemodynamic
significant hypotension (systolic blood pressure < 70 significant hypotension (systolic blood pressure < 70
mm/Hg) with low total peripheral resistancemm/Hg) with low total peripheral resistance

31. NorepinephrineNorepinephrine
Many Various infusions in use.Many Various infusions in use.
Typically 1 mg in 250 cc or 2 mg in 500 ccTypically 1 mg in 250 cc or 2 mg in 500 cc
DosageDosage (initial): 8 to 12 mcg/min -titrate to BP (initial): 8 to 12 mcg/min -titrate to BP
(Usual target: SB:80-100 or MAP=80). Usual (Usual target: SB:80-100 or MAP=80). Usual
maintenance: 2 to 4 mcg/min. maintenance: 2 to 4 mcg/min.
Note: doses as high as 0.5 to 1.5 mcg/kg/min for 1-Note: doses as high as 0.5 to 1.5 mcg/kg/min for 1-
10days have been used in septic shock. 10days have been used in septic shock.
Poison/drug-induced hypotension (i.e. Poison/drug-induced hypotension (i.e.
TCAs) may require higher doses to achieve TCAs) may require higher doses to achieve
adequate perfusionadequate perfusion

32. NorepinephrineNorepinephrine
Precautions Precautions (Watch Out!)(Watch Out!)
Increases myocardial oxygen requirementsIncreases myocardial oxygen requirements
Good vasculature required (i.e. Central or large peripheral)Good vasculature required (i.e. Central or large peripheral)
DO NOTDO NOT administer is same IV line as alkaline infusions (i.e. Bicarb) administer is same IV line as alkaline infusions (i.e. Bicarb)
May induce arrhythmiasMay induce arrhythmias
Extravasation causes tissue necrosisExtravasation causes tissue necrosis
Should be administered in dextrose containing solutions (i.e. Should be administered in dextrose containing solutions (i.e.
D5W or D5/0.45% NS). D5W or D5/0.45% NS).
These dextrose containing fluids are protection against significant These dextrose containing fluids are protection against significant
loss of potency due to oxidation. loss of potency due to oxidation.
Administration in saline solution alone is not recommended.Administration in saline solution alone is not recommended.
Blood products should be administered in separate line.Blood products should be administered in separate line.

33. Sodium Nitroprusside Sodium Nitroprusside
(Nitropress)(Nitropress)
Sodium nitroprusside is indicated for the Sodium nitroprusside is indicated for the
immediate reduction of blood pressure of immediate reduction of blood pressure of
patients in hypertensive crises. patients in hypertensive crises.
Sodium nitroprusside is also indicated for Sodium nitroprusside is also indicated for
producing controlled hypotension in order producing controlled hypotension in order
to reduce bleeding during surgery. to reduce bleeding during surgery.
Sodium nitroprusside is also indicated for Sodium nitroprusside is also indicated for
the treatment of acute congestive heart the treatment of acute congestive heart
failure.failure.

34. Sodium NitroprussideSodium Nitroprusside
Initial (0.3 µg/kg/min) Initial (0.3 µg/kg/min)
Titrated to 10 Titrated to 10
µg/kg/min maxµg/kg/min max

35. Sodium NitroprussideSodium Nitroprusside
Precautions Precautions (Watch Out!)(Watch Out!)
Nitroprusside must be reconstituted for each use. It is good for 24 hours Nitroprusside must be reconstituted for each use. It is good for 24 hours
afterward. afterward.
The diluted solution should be protected from light. It is not necessary to cover The diluted solution should be protected from light. It is not necessary to cover
the infusion drip chamber or the tubing. the infusion drip chamber or the tubing.
Nitroprusside can be deactivated inadvertently by contaminates. Normal Nitroprusside can be deactivated inadvertently by contaminates. Normal
Nitroprusside is a faint brownish color. Nitroprusside is a faint brownish color.
Contaminated nitroprusside will often be blue, green, or red, much brighter colorsContaminated nitroprusside will often be blue, green, or red, much brighter colors
Particulate may be visible.Particulate may be visible.
Discard if this is noted. Discard if this is noted.
Do not mix with any other drugs in same line. Do not mix with any other drugs in same line.
Severe Hypotension may develop even at normal rates. Severe Hypotension may develop even at normal rates.
Risk of Cyanide ToxicityRisk of Cyanide Toxicity
Total dose > 500 mcg/kg . Greater risk with impaired renal function Total dose > 500 mcg/kg . Greater risk with impaired renal function
Greater than 2 mcg/kg/minGreater than 2 mcg/kg/min
Treat with Sodium Thiosulfate (increased Hypotension risk)Treat with Sodium Thiosulfate (increased Hypotension risk)

36. Nitro: Standard Nitro: Standard
composition's)composition's)
Glass BottlesGlass Bottles
 Standard Half-strength concentrationStandard Half-strength concentration
( 100 mcg/ml) Most common at ( 100 mcg/ml) Most common at SLRMC/SLMMCSLRMC/SLMMC
25 mg/250 ml, or 50 mg/500 ml25 mg/250 ml, or 50 mg/500 ml
Standard Full-strength concentrationStandard Full-strength concentration
Most common used at Most common used at SARMC/SAEMCSARMC/SAEMC
(200 mcg/ml)(200 mcg/ml)
50 mg/250 ml50 mg/250 ml
Multiple other ways to mix…..Multiple other ways to mix…..

37. Nitro: VAMC CompositionNitro: VAMC Composition
Bag Bag NOT A BOTTLENOT A BOTTLE
30 MG/500 CC30 MG/500 CC
1 MCG/ML 1 MCG/ML
CONCENTRATIONCONCENTRATION
1 MCG/MIN = 1 1 MCG/MIN = 1
CC/HOURCC/HOUR
Example, you want to Example, you want to
run NTG at 20 run NTG at 20
mcg/min, mcg/min, RUN IT AT RUN IT AT 
20 MG/HOUR. 20 MG/HOUR. 

38. NitroNitro
Precautions Precautions (Watch Out!)(Watch Out!)
CONFIRM CONCENTRATIONCONFIRM CONCENTRATION
Beware Runaway linesBeware Runaway lines
A separate line should be used when possible, or at A separate line should be used when possible, or at
least piggybacked. least piggybacked.
A patient with a nitro drip requires blood pressure A patient with a nitro drip requires blood pressure
monitoring with either non-invasive blood pressure or monitoring with either non-invasive blood pressure or
arterial line, at least every five (5) minutes until arterial line, at least every five (5) minutes until
stabilized.stabilized.
The patient should have continuous EKG monitoring The patient should have continuous EKG monitoring
while receiving the drug.while receiving the drug.

39. InsulinInsulin
Commonly used for diabetic and non Commonly used for diabetic and non
diabetic patients in the Critical Care diabetic patients in the Critical Care
settingsetting
May be included in TPN mixtures. If it is May be included in TPN mixtures. If it is
not, it is administered as well.not, it is administered as well.

40. Typical Insulin InfusionTypical Insulin Infusion
Insulin infusions are institution specific.Insulin infusions are institution specific.
An initial bolus is given per MD order, typically up to 10 units regular. An initial bolus is given per MD order, typically up to 10 units regular.
A maintenance infusion was then started at 2 units/hr .A maintenance infusion was then started at 2 units/hr .
If follow up BG remains at greater than 300 mg/dl, or did not decrease by ≥25 mg/d, then If follow up BG remains at greater than 300 mg/dl, or did not decrease by ≥25 mg/d, then
insulin is increased by 2 u/hourinsulin is increased by 2 u/hour
If the patient's blood glucose concentration decreased by ≥25 mg/dL but <100 mg/dL from If the patient's blood glucose concentration decreased by ≥25 mg/dL but <100 mg/dL from
the previous blood glucose value, the infusion rate was not changedthe previous blood glucose value, the infusion rate was not changed
If the BG drops by ≥100 mg/dL, then infusion decreased in half and rechecked in one hour. If the BG drops by ≥100 mg/dL, then infusion decreased in half and rechecked in one hour.
After the targeted BG is achieved, if the blood glucose level After the targeted BG is achieved, if the blood glucose level continued to decrease over continued to decrease over
three consecutive measurements,three consecutive measurements, the infusion rate was decreased by 0.5 -1 unit/hr, the infusion rate was decreased by 0.5 -1 unit/hr,
If blood glucose concentrations fell below 80 mg/d at any time, the infusion was stopped, If blood glucose concentrations fell below 80 mg/d at any time, the infusion was stopped,
and blood glucose levels were rechecked hourly until it returns to 80 mg/dL or greater. and blood glucose levels were rechecked hourly until it returns to 80 mg/dL or greater.
Once the blood glucose is ≥80 mg/dL, the infusion was restarted at 50% of the previous Once the blood glucose is ≥80 mg/dL, the infusion was restarted at 50% of the previous
rate.rate.
If the blood glucose concentration falls below 60 mg/dL, the infusion was discontinued (if If the blood glucose concentration falls below 60 mg/dL, the infusion was discontinued (if
not already stopped) and 50% dextrose injection was given.not already stopped) and 50% dextrose injection was given.

42. InsulinInsulin
Precautions Precautions (Watch Out!)(Watch Out!)
Ask for a copy of the institutional protocol (or the one Ask for a copy of the institutional protocol (or the one
the MD wrote) for reference. the MD wrote) for reference.
Ask what the goal BG is for this patient. Ask what the goal BG is for this patient.
Typically between 100 and 130 mg/dl but may be patient Typically between 100 and 130 mg/dl but may be patient
specific. specific.
What is the crisis level? (typically 80 mg/dl)What is the crisis level? (typically 80 mg/dl)
Check glucose at Check glucose at
beginning of transport,beginning of transport,
30 minutes into transport30 minutes into transport
Every 60 minutes unless drops below 100 mg/dl, then Every 60 minutes unless drops below 100 mg/dl, then
every 15 minutes until normalized. every 15 minutes until normalized.

43. DiltiazemDiltiazem
Must be reconstituted and used with in Must be reconstituted and used with in
24 hours. (or refrigerated used with in 30 24 hours. (or refrigerated used with in 30
days)days)
Dose: Dose:
Initial bolus as ordered by MD, followed by 5 Initial bolus as ordered by MD, followed by 5
mg/hour, titrated to 15 mg/hour max. mg/hour, titrated to 15 mg/hour max.

44. DiltiazemDiltiazem
Precautions Precautions (Watch Out!) (Watch Out!)
Most common side effect is Most common side effect is
HYPOTENSION (3-5% of patients)HYPOTENSION (3-5% of patients)

45. HeparinHeparin
Used to prevent extension of existing clot or Used to prevent extension of existing clot or
formation of new blood clotsformation of new blood clots
Does not dissolve existing clotsDoes not dissolve existing clots
Patients may be on these drugs for extended Patients may be on these drugs for extended
periods of time periods of time
Most commonly used anticoagulants:Most commonly used anticoagulants:
HeparinHeparin
Lovenox (Enoxaparin) AKA “Low Molecular Lovenox (Enoxaparin) AKA “Low Molecular
Weight Heparin” (SQ)Weight Heparin” (SQ)

46. HeparinHeparin
Various protocols- facility, physician, patient, Various protocols- facility, physician, patient,
and situation dependant. and situation dependant.
Refer to institutional written order. Refer to institutional written order.
If seems unusual confirm with MD. If seems unusual confirm with MD. 
Common Dosing Common Dosing
Initial bolus 60 IU/kg Initial bolus 60 IU/kg
Maximum bolus: 4000 IUMaximum bolus: 4000 IU
Often forgottenOften forgotten
Continue at 12 IU/kg/hr (maximum 1000 IU/hr for Continue at 12 IU/kg/hr (maximum 1000 IU/hr for
patients < 70 kg), round to the nearest 50 IUpatients < 70 kg), round to the nearest 50 IU

47. Precautions Precautions (Watch Out!) (Watch Out!) ::
Run Away IV’sRun Away IV’s
Signs of bleeding, either internally Signs of bleeding, either internally
or externallyor externally
Monitor vitals frequentlyMonitor vitals frequently
Signs and symptoms of shockSigns and symptoms of shock
Altered level of consciousnessAltered level of consciousness
HeparinHeparin

48. GLYCOPROTEIN IIb-IIIa GLYCOPROTEIN IIb-IIIa
InhibitorsInhibitors
Indications: Indications:
Inhibit the integrin glycoprotein IIb/IIIa Inhibit the integrin glycoprotein IIb/IIIa
receptor in the membrane of platelets, receptor in the membrane of platelets,
inhibiting platelet aggregationinhibiting platelet aggregation
Indicated for Acute Coronary Syndromes Indicated for Acute Coronary Syndromes
without without ST segment elevationST segment elevation
Frequently used with HeparinFrequently used with Heparin

49. GLYCOPROTEINGLYCOPROTEIN
IIb/IIa Platelet InhibitorsIIb/IIa Platelet Inhibitors
Three most common GIIb/IIIa Inhibitors Three most common GIIb/IIIa Inhibitors
are:are:
Abciximab (ReoPro)Abciximab (ReoPro)
Eptifibitide (Integrilin)Eptifibitide (Integrilin)
Tirofiban (Aggrastat)Tirofiban (Aggrastat)

50. Abciximab (ReoPro)Abciximab (ReoPro)
Non Q wave MI or unstable angina with Non Q wave MI or unstable angina with
planned PCI within 24 hoursplanned PCI within 24 hours
Must use with heparinMust use with heparin
Binds irreversibly with plateletsBinds irreversibly with platelets
Platelet function recovery requires 48 Platelet function recovery requires 48
hourshours
GLYCOPROTEINGLYCOPROTEIN
IIb/IIa Platelet Inhibitors IIb/IIa Platelet Inhibitors

51. GLYCOPROTEINGLYCOPROTEIN
IIb/IIa Platelet InhibitorsIIb/IIa Platelet Inhibitors
Eptifibitide (Integrilin)Eptifibitide (Integrilin)
Non Q wave MI, unstable angina managed medically, Non Q wave MI, unstable angina managed medically,
and unstable angina / Non Q wave MI patients and unstable angina / Non Q wave MI patients
undergoing PCIundergoing PCI
Platelet function recovers within 4 to 8 hours after Platelet function recovers within 4 to 8 hours after
discontinuationdiscontinuation
Administered with ASA (or clopidogrel) and Heparin. Administered with ASA (or clopidogrel) and Heparin.
DosingDosing
Bolus 180 µg/kg over 1 to 2 minutes Bolus 180 µg/kg over 1 to 2 minutes
 IV Infusion 2 µg/kg/minuteIV Infusion 2 µg/kg/minute

52. GLYCOPROTEINGLYCOPROTEIN
IIb/IIa Platelet InhibitorsIIb/IIa Platelet Inhibitors
Tirofiban (Aggrastat)Tirofiban (Aggrastat)
Non Q wave MI, unstable angina managed Non Q wave MI, unstable angina managed
medically, and unstable angina / Non Q medically, and unstable angina / Non Q
wave MI patients undergoing PCIwave MI patients undergoing PCI
Platelet function recovers within 4 to 8 hours Platelet function recovers within 4 to 8 hours
after discontinuationafter discontinuation
DoseDose
Bolus 0.4 µg/kg and minute for 30 minutes. Bolus 0.4 µg/kg and minute for 30 minutes.
Followed by infusion at 0.1 µg/kg /minute. Followed by infusion at 0.1 µg/kg /minute.

53. GLYCOPROTEINGLYCOPROTEIN
IIb/IIa Platelet InhibitorsIIb/IIa Platelet Inhibitors
Route of Administration:Route of Administration:
IV infusion onlyIV infusion only
Small BottlesSmall Bottles
Can lose alot of the drug flushing Can lose alot of the drug flushing
the tubing, be careful not to the tubing, be careful not to
waste. waste.

54. What to watch for during transport:What to watch for during transport:
HYPERTENSION (increased bleeding HYPERTENSION (increased bleeding
risk)risk)
Any signs of bleedingAny signs of bleeding
Signs and symptoms of shockSigns and symptoms of shock
Changes in level of consciousnessChanges in level of consciousness
GLYCOPROTEINGLYCOPROTEIN
IIb/IIa Platelet InhibitorsIIb/IIa Platelet Inhibitors

55. Potential interventions in cases of Potential interventions in cases of
adverse or allergic reactions:adverse or allergic reactions:
Control any external bleedingControl any external bleeding
Treat for shock as neededTreat for shock as needed
Contact OLMC for options of discontinuing Contact OLMC for options of discontinuing
drug, altering dose or diversiondrug, altering dose or diversion
In cases of suspected bleeding, the provider In cases of suspected bleeding, the provider
may also have to D/C heparin if it is also may also have to D/C heparin if it is also
being administeredbeing administered
GLYCOPROTEINGLYCOPROTEIN
IIb/IIa Platelet InhibitorsIIb/IIa Platelet Inhibitors

56. AmiodaroneAmiodarone
Difference between BOLUS infusion and Difference between BOLUS infusion and
24 hour infusion24 hour infusion
Bolus infusion Bolus infusion
150 mg/100 cc150 mg/100 cc
150 mg bolus over 10 min150 mg bolus over 10 min
Maintenance InfusionMaintenance Infusion
450mg /250cc 1.8 mg/ml450mg /250cc 1.8 mg/ml
1 mg/min for 11 mg/min for 1
stst
6 hours 6 hours
Then 0.5 mg/min for remaining 24 hoursThen 0.5 mg/min for remaining 24 hours

57. AmiodaroneAmiodarone
Precautions Precautions (Watch Out!)(Watch Out!)
HypotensionHypotension
Widened QT intervalWidened QT interval
Can’t use if TCA overdose or Procainimide Can’t use if TCA overdose or Procainimide
has been used. has been used.
Can’t use Procainimide for refractory ectopyCan’t use Procainimide for refractory ectopy

58. PropofolPropofol
Fat suspension Fat suspension
(larger vein if (larger vein if
possible)possible)
Standard Standard
concentration 10 concentration 10
mg/mlmg/ml
DosesDoses
5-50 mcg/kg/min 5-50 mcg/kg/min
titrated in 5 mcg titrated in 5 mcg
increments. increments.

59. PropofolPropofol
 Precautions Precautions (Watch Out!)(Watch Out!)
HYPOTENSION is biggest concern. HYPOTENSION is biggest concern.
HyperkalemiaHyperkalemia
Metabolic AcidosisMetabolic Acidosis
Most problems common when using high-Most problems common when using high-
dose (>5 mg/kg/h) and long-term (>48 h)dose (>5 mg/kg/h) and long-term (>48 h)

60. RetavaseRetavase
Rapid , easy to use thrombolyticRapid , easy to use thrombolytic
First bolus of 10 UnitsFirst bolus of 10 Units
30 minutes later 230 minutes later 2
ndnd
bolus of 10 units is given bolus of 10 units is given

61. RetavaseRetavase
Precautions Precautions (Watch Out!)(Watch Out!)
Heparin and Retavase® are incompatible Heparin and Retavase® are incompatible
when combined in solution. Do not when combined in solution. Do not
administer heparin and Retavase® administer heparin and Retavase®
simultaneously in the same intravenous simultaneously in the same intravenous
line. line.
Bleeding Bleeding

62. SummarySummary
Watch for run away IV’s, especially Watch for run away IV’s, especially
during changeoversduring changeovers
ALWAYS DOUBLE CHECK ALWAYS DOUBLE CHECK
CONCENTRATIONSCONCENTRATIONS
Double check MD orders.Double check MD orders.
Don’t mix infusions prior to confirming Don’t mix infusions prior to confirming
compatability. compatability.