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Appendix

Introduction

The drugs listed in this section are those that are commonly used or encountered by anesthetists during perioperative patient care. Anesthetics and muscle relaxants are not included and are covered in respective chapters.

I. Abciximab (Reopro) (see Appendix I)

II. Adenosine

  1. Indications: Paroxysmal supraventricular tachycardia.
  2. Dosage: Adult: 6- to 12-mg peripheral intravenous (IV) bolus followed by rapid 20-mL saline IV flush. Central line: initial dose, 3 mg. Pediatric: 50 μg/kg IV.
  3. Effect: Slows or temporarily blocks atrioventricular (AV) node conduction and conduction through reentrant pathways (especially those involving the AV node).
  4. Comments:
    1. Contraindicated in patients with second- or third-degree heart block or sick sinus syndrome.
    2. Not effective in terminating atrial flutter or fibrillation but may aid in diagnosis by slowing ventricular response.
    3. Asystole for 3 to 6 seconds after administration is common and resolves spontaneously.
    4. May cause bronchospasm or hypotension.
    5. Use with caution in patients with preexcitation syndromes (eg, Wolff-Parkinson-White).

III. Albuterol

  1. Indications: Bronchospasm.
  2. Dosage: Aerosolized: 2.5 mg in 3 mL saline via nebulizer; 180 or 200 μg (two puffs) via metered dose inhaler (MDI). By mouth (PO): 2.5 mg. Pediatric: 0.1 mg/kg (syrup 2 mg/5 mL).
  3. Effect: β2-Receptor agonist, causing bronchial smooth muscle relaxation.
  4. Comments: Possible β-adrenergic overload, tachydysrhythmias. Increased dose required when using MDI for intubated patients (four to six puffs).

V. Alteplase (see Appendix I)

VI. Aminocaproic Acid (Amicar)

  1. Indications: Prevention of bleeding due to fibrinolysis.
  2. Dosage: 5 g/100 to 250 mL of normal saline (NS) IV to load, followed by 1 g/h infusion.
  3. Effect: Stabilizes the formed clot by inhibiting plasminogen activators and plasmin.
  4. Comments: Contraindicated in disseminated intravascular coagulation.

VII. Amiodarone

  1. Indications: Refractory or recurrent atrial and ventricular tachydysrhythmias.
  2. Dosage: 150 mg for Advanced Cardiac Life Support algorithm (ACLS 300 mg) intravenous push (IVP), then 1 mg/min for 6 hours (360 mg), then 0.5 mg/min for 18 hours (540 mg).
  3. Effect: Depresses the sinoatrial node and prolongs the PR, QRS, and QT intervals; produces α- and β-adrenergic blockade.
  4. Comments:
    1. May cause severe sinus bradycardia, ventricular arrhythmias, AV block, liver and thyroid function test abnormalities, hepatitis, and cirrhosis.
    2. Pulmonary fibrosis can result from long-term use.
    3. Increases serum levels of digoxin, oral anticoagulants, diltiazem, quinidine, procainamide, and phenytoin.

IX. Atenolol

  1. Indications: Hypertension, angina, and postmyocardial infarction (post-MI).
  2. Dosage: Oral (PO) 50 to 100 mg/d. IV: 5 mg as needed (prn).
  3. Effect: β1-Selective adrenergic receptor blockade.
  4. Comments:
    1. Relatively contraindicated in acute congestive heart failure and heart block.
    2. Caution in patients on calcium channel blockers and other agents prolonging AV conduction.

X. Atropine

  1. Indications: Antisialagogue; bradycardia; cardiac arrest (ACLS protocol).
  2. Dosage:
    1. Antisialagogue, adult, 0.2 to 0.4 mg IV; 0.4 to 1.0 mg IV; pediatric, 0.01 mg/kg/dose IV/intramuscular (IM) (<0.4 mg).
    2. Bradycardia, adult, 0.2 to 0.4 mg IV; pediatric, 0.02 mg/kg/dose IV (<0.4 mg).
    3. Cardiac arrest, adult, 1 mg IV, pediatric, 0.01 to 0.02 mg/kg/dose IV.
  3. Effect: Competitive blockade of acetylcholine at muscarinic receptors.
  4. Comments:
    1. Low doses may cause paradoxical bradycardia.
    2. May cause tachydysrhythmias, AV dissociation, premature ventricular contractions, dry mouth, or urinary retention.
    3. Central nervous system (CNS) effects occur at high doses.

XI. Bicarbonate, Sodium (NaHCO3)

  1. Indications: Metabolic acidosis; urinary alkalinization.
  2. Dosage: IV dose in mEq NaHCO3 = (base deficit × weight [kg] × 0.3) (subsequent doses titrated against patient’s pH).
  3. Effect: H+ neutralization.
  4. Comments:
    1. Not compatible with many IV medications.
    2. May cause metabolic alkalosis, hypercarbia, and hyperosmolality.
    3. In neonates, can cause intraventricular hemorrhage.
    4. Crosses placenta.
    5. An 8.4% solution is approximately 1.0 mEq/mL; a 4.2% solution is approximately 0.5 mEq/mL.

XIII. Calcium Chloride; Calcium Gluconate

  1. Indications: hypocalcemia, hyperkalemia, and hypermagnesemia.
  2. Dosage:
    1. Calcium chloride: 5 to 10 mg/kg IV prn (10% CaCl2 = 1.36 mEq Ca2+/mL).
    2. Calcium gluconate: 15 to 30 mg/kg IV prn (10% calcium gluconate = 0.45 mEq Ca2+/mL).
  3. Effect: Maintains cell membrane integrity, muscular excitation-contraction coupling, glandular stimulation-secretion coupling, and enzyme function. Increases blood pressure.
  4. Comments:
    1. May cause bradycardia or arrhythmia (especially with digitalis).
    2. Irritating to veins. Ca2+ less available with calcium gluconate than with calcium chloride owing to binding of gluconate.
    3. Rapid infusion may cause coronary vasoconstriction.

XIV. Carboprost (Prostaglandin F2 α ; Hemabate)

  1. Indications: Refractory postpartum hemorrhage.
  2. Dosage: 250 μg IM; may repeat every (q)15-90 min, maximum total dose 2 mg.
  3. Effect: Causes uterine muscle contraction.
  4. Comments: May cause significant bronchospasm, especially in patients with reactive airways, or hypertension.

XV. Clevidipine (Cleviprex)

  1. Indications: Treatment of acute hypertension when oral therapy is undesirable/unavailable.
  2. Dosage: IV infusion: 1 to 2 mg/h; double the dose q90 seconds until approaching goal, then adjust q5-10 minutes. Maximum dose 32 mg/h.
  3. Effect:
    1. Dihydropyridine calcium channel blocker; causes blood pressure reduction ± reflex tachycardia via decreased systemic vascular resistance.
    2. May have negative inotropic effects. Does not affect preload.
    3. No dose adjustments for hepatic/renal dysfunction.
  4. Effect: Lasts 5 to 15 minutes after discontinuation.
  5. Comments:
    1. Rapidly titratable. In lipid emulsion.
    2. Discard unused portion after 4 hours.
    3. Contraindicated in soy/egg allergic patients, defective lipid metabolism, or severe aortic stenosis.
    4. Risk of rebound hypertension with prolonged infusion; risk of atrial fibrillation.

XVI. Clopidogrel (Plavix)

  1. Indications: Antiplatelet agent.
    1. Acute coronary syndrome.
    2. Percutaneous coronary intervention (PCI).
    3. Recent myocardial infarction (MI), recent thromboembolic stroke, or established arterial disease.
    4. Coronary stent stenosis prophylaxis.
  2. Dosage: Load, 300 to 600 mg PO; maintenance, 75 mg every day (qd).
  3. Effect: Irreversible platelet ADP receptor blockade.
  4. Comments:
    1. Major side effect is bleeding.
    2. Reduce dose in hepatic insufficiency.
    3. Proton pump inhibitors may reduce clopidogrel efficacy.
    4. Recommend discontinuing 7 days prior to neuraxial anesthesia.

XVII. Dalteparin (Fragmin)

  1. Indications: Prophylaxis of acute coronary syndromes (ACSs), deep venous thrombosis (DVT).
  2. Dosage:
    1. DVT prophylaxis, 2500 to 5000 units subcutaneously (SC) qd.
    2. ACS, 120 units/kg (maximum dose 10,000 units) SC q12h × 5 to 8 days with concurrent aspirin therapy.
    3. DVT, 100 units/kg SC twice a day (bid) or 200 units/kg SC qd.
  3. Effect: Anticoagulant; inhibits both factor Xa and factor IIa. See Heparin.
  4. Comments:
    1. Reduce dose for Cr clearance less than 30 mL/min.
    2. Equally effective as unfractionated heparin; more predictable dose-response characteristics.
    3. Spinal and epidural hematomas have been associated with spinals/lumbar punctures, or epidural catheter placement or removal. Use with caution when placing or removing neuraxial blockade in patients on Fragmin.
    4. Only partially reversed by protamine.

XVIII. Dantrolene

  1. Indications: Malignant hyperthermia (MH); neuroleptic malignant syndrome.
  2. Dosage: Mix 20 mg in 60 mL of sterile water. At first signs of MH, 2.5-mg/kg IV bolus; repeat dose, up to 10 mg/kg. Prophylactic IV treatment is not recommended.
  3. Effect: Reduces Ca2+ release from sarcoplasmic reticulum; relaxes skeletal muscles.
  4. Comments: Dissolves slowly into solution. Avoid extravasation as it is a tissue irritant.

XIX. Desmopressin Acetate (DDAVP)

  1. Indications:
    1. Treatment of coagulopathy in von Willebrand disease, hemophilia A (but contraindicated if factor VIII > 5% activity), renal failure.
    2. Central diabetes insipidus.
  2. Dosage: Coagulopathy, 0.3 μg/kg IV (diluted 50 mL NS), infused over 15 to 30 minutes. Central DI, 5 to 20 μg intranasally qd/bid.
  3. Effect: Increases plasma levels of factor VIII activity by causing release of von Willebrand factor from endothelial cells; increases renal water reabsorption (antidiuretic hormone [ADH] effect).
  4. Comments: Chlorpropamide, carbamazepine, and clofibrate potentiate the antidiuretic effect. Repeat doses q12-24h will have diminished effect compared with initial dose. Has no vasopressor effect.

XX. Dexamethasone (Decadron)

  1. Indications: Cerebral edema; airway edema; prophylaxis of postoperative nausea and vomiting.
  2. Dosage:
    1. Edema: 10 mg IV, 4 mg IV q6h (tapered over 6 days).
    2. N/V: 4 mg IV.
  3. Effect: See Hydrocortisone. Has 20 to 25 times the glucocorticoid potency of hydrocortisone. Minimal mineralocorticoid effect.
  4. Comments: See Hydrocortisone.

XXI. Dextran 40 (Rheomacrodex)

  1. Indications: Inhibition of platelet aggregation and improvement of blood flow in low-flow states (eg, vascular surgery).
  2. Dosage: 15 to 30 mL/h IV (10% solution); a load of 30 to 50 mL IV over 30 minutes is optional.
  3. Effect: Immediate, short-lived (1.5 hours) plasma volume expansion; decreases platelet adhesion.
  4. Comments: May cause volume overload, anaphylaxis, bleeding tendency, thrombocytopenia, interference with blood cross-matching, or false elevation of blood sugar.

XXII. Diltiazem (Cardizem)

  1. Indications: Angina pectoris, variant angina from coronary artery spasm, atrial fibrillation/flutter, paroxysmal supraventricular tachycardia, hypertension.
  2. Dosage: 20-mg IV bolus then 10-mg/h infusion; PO 30 to 60 mg q6h.
  3. Effect: Calcium channel antagonist that slows conduction through sinoatrial and AV nodes, dilates coronary and peripheral arterioles, and reduces myocardial contractility.
  4. Comments:
    1. May cause bradycardia and heart block.
    2. Possible impairment of contractility by interaction with β-blockers and digoxin.
    3. Causes transiently elevated liver function tests.
    4. Avoid use in patients with accessory conduction tracts, AV block, IV β-blockers, or ventricular tachycardia.

XXIII. Dobutamine

  1. Indications: Inotropy for heart failure.
  2. Dosage: Begin infusion at 2 μg/kg/min and titrate to effect.
  3. Effect: β1-Adrenergic agonist.
  4. Comments: May cause hypotension, arrhythmias, or myocardial ischemia. Can increase ventricular rate in atrial fibrillation.

XXIV. Dopamine

  1. Indications: Hypotension, heart failure.
  2. Dosage: 5 to 20 μg/kg/min IV titrate to effect.
  3. Effect: dopaminergic; α- and β-adrenergic agonist.
  4. Comments:
    1. May cause hypertension, dysrhythmias, or myocardial ischemia.
    2. Primarily dopaminergic effects (increased renal blood flow) at 1 to 5 μg/kg/min.
    3. Primarily α- and β-adrenergic effects at greater than or equal to 10 μg/kg/min.

XXV. Enoxaparin (Lovenox)

  1. Indications:
    1. Prophylaxis of DVT.
    2. Treatment of DVT.
    3. Acute coronary syndromes.
  2. Dosage:
    1. DVT prophylaxis, 30 mg SC bid or 40 mg SC qd.
    2. DVT treatment, 1 mg/kg SC q12h or 1.5 mg/kg SC qd.
    3. ACS, 1 mg/kg SC bid for a minimum of 2 days, in conjunction with aspirin therapy.
  3. Effect: Anticoagulant; inhibits both factor Xa and factor IIa. See Heparin.
  4. Comments:
    1. Equally effective as unfractionated heparin with more predictable dose-response characteristics.
    2. Spinal and epidural hematomas have been associated with spinals/lumbar punctures, or epidural catheter placement or removal.
    3. Only partially reversed by protamine.

XXVI. Ephedrine

  1. Indication: Treatment of hypotension.
  2. Dosage: 5 to 10 mg IV.
  3. Effect: α- and β-adrenergic stimulation; norepinephrine release at sympathetic nerve endings.
  4. Comments:
    1. May cause hypertension, dysrhythmias, myocardial ischemia, CNS stimulation, decrease in uterine activity, and mild bronchodilation.
    2. Minimal effect on uterine blood flow. Crosses the placenta.
    3. Avoid in patients taking monoamine oxidase inhibitors (MAOI).
    4. Tachyphylaxis with repeated dosing.

XXVII. Epinephrine

  1. Indications:
    1. Heart failure.
    2. Cardiac arrest (ACLS).
    3. Bronchospasm, anaphylaxis.
    4. Airway edema.
  2. Dosage:
    1. Heart failure, 1 to 12 μg/min titrated to effect.
    2. ACLS, 0.1 to 1 mg IV or 1 mg intratracheal q5min prn. Pediatric, 0.01 mg/kg IV up to 0.5 mg. 0.01 mg/kg SC q15min × 2 doses up to 1 mg/dose.
    3. Bronchospasm, anaphylaxis, 0.1 to 0.5 mg SC, 0.1 to 0.25 mg IV, or 0.25 to 1.5 μg/min IV infusion.
    4. Airway edema, nebulized: 0.5 mL of 2.25% solution in 2.5 to 3.5 mL of NS q1-4h prn.
  3. Effect: α- and β-adrenergic agonist.
  4. Comments: May cause hypertension, arrhythmias, or myocardial ischemia. Topical or local injection (1:80,000-1:500,000) causes vasoconstriction. Crosses the placenta.

XXVIII. Epoprostenol (Flolan) (see Appendix I)

XXIX. Eptifibatide (Integrilin) (see Appendix I)

XXX. Ergonovine (Ergotrate) (see also Methylergonovine)

  1. Indication: Postpartum hemorrhage due to uterine atony.
  2. Dosage: For postpartum hemorrhage: IV (emergency only), 0.2 mg in 5 mL of NS greater than or equal to 1 minute; IM, 0.2 mg q2-4h prn for less than or equal to 5 doses, then PO, 0.2 to 0.4 mg q6-12h for 2 days or prn.
  3. Effect: Constriction of uterine and vascular smooth muscle.
  4. Comments: May cause hypertension from systemic vasoconstriction (especially in eclampsia and hypertension), dysrhythmias, coronary spasm, uterine tetany, or gastrointestinal (GI) upset. Overdosage may cause convulsions or stroke.

XXXI. Esmolol (Brevibloc)

  1. Indications: Supraventricular tachydysrhythmias and myocardial ischemia.
  2. Dosage: Start with 5- to 10-mg IV bolus and increase q3min prn to total 100 to 300 mg; infusion 1 to 15 mg/min.
  3. Effect: Selective β1-adrenergic blockade.
  4. Comments: May cause bradycardia, AV conduction delay, hypotension, congestive heart failure; β2 activity at high doses.

XXXII. Fenoldopam

  1. Indications: Hypertension.
  2. Dosage: 0.03 to 0.1 μg/kg/min (most common dose); increase to 0.05 to 0.1 μg/kg/min every 15 minutes.
  3. Effect: Selective postsynaptic dopamine-1 receptor agonist.
  4. Comments:
    1. Evidence does not indicate that it will prevent contrast-induced nephropathy.
    2. May cause hyperkalemia.
    3. Tachycardia possible at higher doses.
    4. May increase intraocular pressure.

XXXIII. Flumazenil (Mazicon)

  1. Indications: Reversal of benzodiazepine overdose.
  2. Dosage: 3 to 5 mg IV at 0.5 mg/min.
  3. Effect: Competitive antagonism of CNS benzodiazepine receptor.
  4. Comments:
    1. Duration of action shorter than midazolam and other agonists.
    2. May induce CNS excitation including seizures, acute withdrawal, nausea, dizziness, and agitation.
    3. Only partial reversal of midazolam-induced ventilatory depression.

XXXIV. Fosphenytoin

  1. Indication: Seizure prophylaxis, treatment of seizures (see Phenytoin).
  2. Dosage:
    1. It is a prodrug; active metabolite is phenytoin.
    2. 1.5 mg fosphenytoin is equivalent to 1 mg phenytoin and is referred to as 1 mg phenytoin equivalent (PE).
    3. Dilute fosphenytoin in 5% dextrose or 0.9% saline solution for injection to a concentration ranging from 1.5 to 25 mg PE/mL.
    4. The loading dose of fosphenytoin is 10 to 20 mg PE/kg given IV.
    5. Maximum rate, 150 mg PE/min.
  3. Effect: Anticonvulsant.
  4. Comments:
    1. Intravenous bolus may cause bradycardia, hypotension, respiratory arrest, cardiac arrest, or CNS depression.
    2. Determination of unbound phenytoin levels may be helpful in patients with renal failure or hypoalbuminemia 2 hours after infusion has been completed.
    3. Multiple drug interactions that may change the effective concentration of phenytoin.

XXXV. Furosemide (Lasix)

  1. Indications: Edema, hypertension, intracranial hypertension, renal failure, and hypercalcemia.
  2. Dosage: 2 to 40 mg IV (initial dose, dosage individualized).
  3. Effect: Increases excretion of Na+, Cl−, K+, PO43−, Ca2+, and H2O by inhibiting reabsorption in loop of Henle.
  4. Comments: May cause electrolyte imbalance, dehydration, transient hypotension, deafness, hyperglycemia, or hyperuricemia. Sulfa-allergic patients may exhibit hypersensitivity to furosemide.

XXXVI. Glucagon

  1. Indications:
    1. Duodenal or choledochal relaxation.
    2. Refractory β-adrenergic blocker toxicity.
  2. Dosage:
    1. GI effects, 0.25 to 0.5 mg IV q20min prn.
    2. β-Blocker toxicity, 5-mg IV bolus, with 1 to 10 mg/h titrated to patient response.
  3. Effect: Catecholamine release. Positive inotrope and chronotrope.
  4. Comments:
    1. May cause anaphylaxis, nausea, vomiting, hyperglycemia, or positive inotropic chronotropic effects.
    2. High doses potentiate oral anticoagulants.
    3. Use with caution in the presence of insulinoma or pheochromocytoma.

XXXVII. Glycopyrrolate

  1. Indications: Decrease GI motility, antisialagogue. Bradycardia.
  2. Dosage: 0.1 to 0.2 mg IV/IM/SC
  3. Effect: Competitive blockade of acetylcholine at muscarinic receptors.
  4. Comments: Longer duration, possibly less chronotropic effect than atropine. Does not cross the blood-brain barrier or placenta.

XXXVIII. Haloperidol (Haldol)

  1. Indications: Psychosis, delirium, agitation, and postoperative nausea and vomiting.
  2. Dosage: 0.5 to 10 mg IM/IV prn (dosage individualized); antiemetic, 1 mg IV.
  3. Effect: Antipsychotic effects due to dopamine (D2) receptor antagonism. CNS depression.
  4. Comments:
    1. May cause mild α-adrenergic antagonism.
    2. Can prolong QT interval and produce ventricular arrhythmias, notably torsade de pointes, and lower seizure threshold.
    3. May precipitate neuroleptic malignant syndrome.
    4. Contraindicated in Parkinson disease.

XXXIX. Heparin—Unfractionated

  1. Indications: Anticoagulation for:
    1. Thrombosis, thromboembolism.
    2. Cardiopulmonary bypass.
    3. Disseminated intravascular coagulation.
    4. Thromboembolism prophylaxis.
  2. Dosage:
    1. Thrombosis, load: 50 to 150 units/kg IV; maintenance: 15 to 25 units/kg/h IV; titrate dosage with activated partial thromboplastin time.
    2. CPBP, load: 300 units/kg IV; maintenance: 100 units/kg/h IV; titrate with activated clotting time (ACT).
    3. Disseminated intravascular coagulopathy (DIC), load: 50 to 100 units/kg IV; maintenance: 15 to 25 units/kg/h IV; titrate with coagulation tests.
    4. DVT prophylaxis, 5000 units q8-12h SC.
  3. Effect: Potentiates action of antithrombin III; blocks conversion of prothrombin and activation of other coagulation factors.
  4. Comments:
    1. May cause thrombocytopenia, allergic reactions.
    2. Half-life increased in renal failure and decreased in thromboembolism and liver disease.
    3. Does not cross the placenta.
    4. Reversed by protamine.
    5. Spinal and epidural hematomas have been associated with neuraxial anesthesia (single-shot, or catheter placement or removal) and lumbar punctures in patients on heparin infusions.

XL. Hydralazine

  1. Indication: Hypertension.
  2. Dosage: 2.5 to 5 mg IV. Repeat as needed up to total dose of 20 mg.
  3. Effect: Reduces arterial smooth muscle tone; diastolic more effected than systolic.
  4. Comments: May cause reflex tachycardia, systemic lupus erythematosus syndrome. Increases coronary, splanchnic, cerebral, and renal blood flows.

XLI. Hydrocortisone (Solu-Cortef)

  1. Indications:
    1. Adrenal insufficiency.
    2. Inflammation and allergic reaction.
    3. Cerebral edema from CNS tumors.
    4. Asthma.
  2. Dosage: 10 to 100 mg IV q8h. Physiologic replacement: IV: 0.25 to 0.35 mg/kg/d; PO: 0.5 to 0.75 mg/kg/d.
  3. Effect:
    1. Anti-inflammatory.
    2. Mineralocorticoid effect.
    3. Stimulates gluconeogenesis.
    4. Inhibits peripheral protein synthesis.
    5. Has membrane stabilizing effect.
  4. Comments:
    1. May cause adrenocortical insufficiency (Addisonian crisis) with abrupt withdrawal.
    2. Delayed wound healing.
    3. CNS disturbances, osteoporosis, or electrolyte disturbances.

XLII. Indigo Carmine

  1. Indications: Evaluation of urine output. Localization of ureteral orifices during cystoscopy.
  2. Dosage: 40 mg IV slowly (5 mL of 0.8% solution).
  3. Effect: Rapid glomerular filtration produces blue urine.
  4. Comments: Hypertension from α-adrenergic stimulation with rapid administration, lasts 15 to 30 minutes after IV dose. Dye color may interfere with pulse oximetry.

XLIII. Isoproterenol

  1. Indications: Heart failure; bradycardia.
  2. Dosage: 2 μg/min titrated up to 20 μg/min.
  3. Effect: β-Adrenergic agonist; positive chronotrope and inotrope.
  4. Comments: May cause dysrhythmias, myocardial ischemia, hypertension, or CNS excitation.

XLIV. Ketorolac (Toradol)

  1. Indications: Nonsteroidal anti-inflammatory drug (NSAID) for moderate pain. Useful adjunct for severe pain when used with parenteral or epidural opioids.
  2. Dosage: 30 to 60 mg, then 15 to 30 mg q6h.
  3. Effect: Limits prostaglandin synthesis by cyclooxygenase inhibition.
  4. Comments:
    1. Adverse effects are similar to those with other NSAIDs: peptic ulceration, bleeding, decreased renal blood flow.
    2. Duration of treatment not to exceed 5 days.
    3. Caution when used in the elderly or in patients with preexisting renal dysfunction or significant hypovolemia.

XLV. Labetalol

  1. Indications: Hypertension, controlled hypotension.
  2. Dosage: 5 to 10 mg IV increments at 5-minute intervals, to 40 to 80 mg/dose. Infusion: titrate to desired response, 10 to 180 mg/h.
  3. Effect: Selective α1-adrenergic blockade with nonselective β-adrenergic blockade. Ratio of α/β-blockade = 1:7.
  4. Comments: May cause bradycardia, AV conduction delays, and postural hypotension. Crosses the placenta.

XLVI. Levetiracetam (Keppra)

  1. Indication: Seizure prophylaxis; treatment of seizures.
  2. Dosage: 500 to 1000 mg IV.
  3. Effect: Suppression of seizure activity.
  4. Comments: Adjustment for renal insufficiency.

XLVII. Lidocaine (Xylocaine)

  1. Indications:
    1. Ventricular dysrhythmias.
    2. Cough suppression.
    3. Local anesthesia.
  2. Dosage:
    1. Dysrhythmias, 1 mg/kg IV × 2 (second dose 20 to 30 minutes after first dose) followed by 15 to 50 μg/kg/min IV (1 to 4 mg/min).
    2. Cough 1 mg/kg IV.
  3. Effect: Decreases conductance of sodium channels. Antiarrhythmic effect, sedation, neural blockade.
  4. Comments:
    1. May cause dizziness, seizures, disorientation, heart block (with myocardial conduction defect), or hypotension.
    2. Crosses the placenta.
    3. Caution in patients with Wolff-Parkinson-White syndrome.

XLVIII. Low-Molecular-Weight Heparin

Please see individual entries for dalteparin (Fragmin) and enoxaparin (Lovenox).

XLIX. Magnesium Sulfate

  1. Indications:
    1. Preeclampsia/eclampsia.
    2. Hypomagnesemia.
    3. Polymorphic ventricular tachycardia (torsade de pointes).
  2. Dosage:
    1. Obstetrics, 1 to 8 g IV, then 1 to 4 g/h.
    2. Hypomagnesemia, 1 to 2 g q6-8h, prn.
    3. VT, 1 to 2 g in 10 mL D5W over 1 to 2 minutes; 5 to 10 g may be administered for refractory arrhythmias.
  3. Effect: Treatment and prevention of hypomagnesemia; prevents and treats seizures or hyperreflexia associated with preeclampsia/eclampsia.
  4. Comments:
    1. Potentiates neuromuscular blockade.
    2. Potentiates CNS effects of anesthetics, hypnotics, and opioids.
    3. Toxicity occurs with serum concentration greater than or equal to 10 mEq/L.
    4. May alter cardiac conduction in digitalized patients. Avoid in patients with heart block.
    5. Caution in patients with renal failure.

L. Mannitol

  1. Indications:
    1. Increased intracranial pressure.
    2. Oliguria or anuria associated with acute renal injury.
  2. Dosage:
    1. ICP, 0.25 to 1.0 g/kg IV as 20% solution over 30 to 60 minutes (in acute situation, can give bolus of 1.25 to 25.0 g over 5 to 10 minutes).
    2. Renal, 0.2 g/kg test dose over 3 to 5 minutes, then 50 to 100 g IV over 30 minutes if adequate response.
  3. Effect: Increases serum osmolality, which reduces cerebral edema and lowers intracranial and intraocular pressure; also causes osmotic diuresis and transient expansion of intravascular volume.
  4. Comments:
    1. Rapid administration may cause vasodilation and hypotension.
    2. May worsen or cause pulmonary edema, intracranial hemorrhage, systemic hypertension, or rebound intracranial hypertension.

LI. Methylene Blue

  1. Indications:
    1. Surgical marker for genitourinary surgery.
    2. Methemoglobinemia.
    3. Vasoplegic syndrome.
  2. Dosage:
    1. Genitourinary, 100 mg (10 mL of 1% solution) IV.
    2. Methemoglobinemia, 1 to 2 mg/kg IV of 1% solution over 10 minutes; repeat q1h, prn.
    3. Vasoplegia, 2 mg/kg IV.
  3. Effect: Low dose promotes conversion of methemoglobin to hemoglobin. High dose promotes conversion of hemoglobin to methemoglobin.
  4. Comments:
    1. May cause red blood cell destruction (prolonged use), hypertension, bladder irritation, nausea, diaphoresis.
    2. May inhibit nitrate-induced coronary artery relaxation.
    3. Interferes with pulse oximetry for 1 to 2 minutes.
    4. Can cause hemolysis in patients with glucose-6-phosphate dehydrogenase deficiency.

LII. Methylergonovine (Methergine)

  1. Indication: Postpartum hemorrhage due to uterine atony.
  2. Dosage:
    1. IV (emergency only, after delivery of placenta): 0.2 mg in 5 mL of NS, dose over greater than or equal to 1 minute.
    2. IM: 0.2 mg q2-4h, prn (<5 doses).
  3. Comments: See Ergonovine. Caution in patients with hypertension, although the hypertensive response is less marked than with ergonovine.

LIII. Methylprednisolone (Solu-Medrol)

  1. Indications: See Hydrocortisone. Spinal cord injury; status asthmaticus.
  2. Dosage:
    1. 40 to 60 mg IV q6h. Higher doses in transplant patients.
    2. Status asthmaticus, 2 mg/kg; then 0.5 to 1 mg/kg q6h.
    3. Spinal cord injury, 30 mg/kg IV over 15 minutes; after 45 minutes begin 5.4 mg/kg/h × 23 or 47 hours.
  3. Effect: See Hydrocortisone; has five times the glucocorticoid potency of hydrocortisone with almost no mineralocorticoid activity.
  4. Comments: See Hydrocortisone.

LIV. Metoclopramide (Reglan)

  1. Indications: Gastroesophageal reflux, diabetic gastroparesis, pulmonary aspiration prophylaxis, and antiemetic.
  2. Dosage: 10 mg IV q6-8h.
  3. Effect:
    1. Facilitates gastric emptying by increasing gastric motility; relaxes pyloric sphincter and increases peristalsis in the duodenum and jejunum.
    2. Increases resting tone of the lower esophageal sphincter.
    3. Weak antiemetic effects appear secondary to antagonism of central and peripheral dopamine receptors.
    4. Case causes neuroleptic malignant syndrome.
  4. Comments:
    1. Avoid in patients with GI obstruction, pheochromocytoma, or Parkinson disease.
    2. Extrapyramidal reactions occur in 0.2% to 1% of patients.

LV. Metoprolol (Lopressor)

  1. Indications: Hypertension, angina pectoris, dysrhythmia, hypertrophic cardiomyopathy, MI, and pheochromocytoma.
  2. Dosage: 2.5 to 5 mg IV q2min, prn, up to 15 mg.
  3. Effect: β1-Adrenergic blockade (β2-adrenergic antagonism at high doses).
  4. Comments:
    1. May cause symptomatic bradycardia.
    2. Can increase the risk of heart block.

LVI. Milrinone

  1. Indication: Myocardial depressing requiring inotropy.
  2. Dosage: 50 μg/kg IV over 10 minutes, then titrate 0.375 to 0.75 μg/kg/min to effect.
  3. Effect: Phosphodiesterase inhibition causing positive inotropy and vasodilation.
  4. Comments:
    1. May increase ventricular ectopy.
    2. Possible worsening of outflow tract obstruction in hypertrophic obstructive cardiomyopathy (HOCM).
    3. Hypotension is common.

LVII. Naloxone (Narcan)

  1. Indication: Reversal of systemic opioid effects.
  2. Dosage: Adult: 0.04- to 0.4-mg doses IV, titrated q2-3min. Pediatric: 1 to 10 μg/kg IV (in increments) q2-3min (up to 0.4 mg).
  3. Effect: Antagonizes effects of opioids by competitive inhibition.
  4. Comments:
    1. May cause hypertension, dysrhythmias, rare pulmonary edema, and delirium usually if given in high doses.
    2. Reversal of analgesia.
    3. Withdrawal syndrome in opioid-dependent patients.
    4. Renarcotization may occur because antagonist has shorter duration than opiates.

LVIII. Nicardipine (Cardine)

  1. Indication: Hypertension.
  2. Dosage: 2.5-5 mg/h
  3. Effect: IV antihypertensive calcium channel blocker.
  4. Comments:
    1. Steady state achieved in 3 to 5 hours.
    2. Maximum dose limit: 15 mg/h.
    3. My cause hypoxemia secondary to inhibition of hypoxic pulmonary vasoconstriction.

LIX. Nitroglycerin

  1. Indications:
    1. Angina, myocardial ischemia, or infarction.
    2. Hypertension.
    3. Congestive heart failure.
    4. Controlled hypotension.
    5. Esophageal spasm.
  2. Dosage:
    1. Initial IV infusion at 50 μg/min, then titrate to effect.
    2. Sublingual (SL): 0.15 to 0.6 mg/dose.
    3. Topical: 2% ointment, 0.5 to 2.5 in q6-8h.
  3. Effect:
    1. Produces smooth muscle relaxation by enzymatic release of NO, causing systemic, coronary, and pulmonary vasodilatation (veins more than arteries).
    2. Bronchodilation, biliary, GI, and genitourinary tract relaxation.
  4. Comments:
    1. May cause reflex tachycardia, hypotension, or headache.
    2. Tolerance with chronic use may be avoided with a 10- to 12-hour nitrate-free period.
    3. May be adsorbed by plastic in IV tubing.

LVIII. Nitroprusside (Nipride)

  1. Indications: Hypertension, controlled hypotension, and congestive heart failure.
  2. Dosage: IV infusion initially at 0.1 μg/kg/min, then titrated to patient response to maximum 10 μg/kg/min.
  3. Effect: Direct NO donor causing smooth muscle relaxation in both arterioles and veins.
  4. Comments:
    1. May cause excessive hypotension if not titrated slowly.
    2. Reflex tachycardia.
    3. Accumulation of cyanide with liver dysfunction; thiocyanate with kidney dysfunction. Cyanide/thiocyanate buildup with prolonged infusion.
    4. Avoid with Leber hereditary optic atrophy, hypothyroidism, or vitamin B12 deficiency.
    5. Solution and powder are light-sensitive and must be wrapped in opaque material.

LXI. Norepinephrine (Levophed)

  1. Indication: Hypotension, myocardial depression.
  2. Dosage:
    1. 1 to 30 μg/min IV, titrated to desired effect.
    2. Administered through central venous catheter.
  3. Effect: Both α- and β-adrenergic activity, with α-adrenergic activity predominating.
  4. Comments:
    1. May cause tachycardia and dysrhythmias in some patients.
    2. Increased uterine contractility.
    3. Constricted microcirculation.

LXII. Octreotide (Sandostatin)

  1. Indications:
    1. Upper GI tract bleeding and acute variceal hemorrhage.
    2. Treatment of symptomatic carcinoid.
  2. Dosage: 25- to 50-μg IV bolus followed by continuous IV infusion of 25 to 50 μg/h.
  3. Effect: Somatostatin analogue that suppresses the release of serotonin, gastrin, vasoactive intestinal peptide, insulin, glucagon, and secretin.
  4. Comments: May cause nausea, decreased GI motility, and transient hyperglycemia.

LXIII. Ondansetron (Zofran)

  1. Indications: Prophylaxis and treatment of perioperative nausea and vomiting.
  2. Dosage: Adult: 4 mg IV over greater than 30 seconds or 8 mg PO. Pediatric: 4 mg PO.
  3. Effect: Selective 5-HT3 receptor antagonist.
  4. Comments: Used in much higher doses for chemotherapy-induced nausea. Mild side effects include headache and reversible transaminase elevation.

LXIV. Oxytocin (Pitocin)

  1. Indications: Postpartum hemorrhage, uterine atony, and augmentation of labor.
  2. Dosage:
    1. Hemorrhage, 10 units IM or 10 to 40 units in 1000 mL of crystalloid-infused IV at rate necessary to control atony (eg, 0.02 to 0.04 units/min).
    2. Labor induction: 0.0005 to 0.002 units/min, increasing until contraction pattern established or maximum dose of 20 milliunits/min reached.
  3. Effect: Reduces postpartum blood loss by contraction of uterine smooth muscle. Renal, coronary, and cerebral vasodilation.
  4. Comments:
    1. May cause uterine tetany and rupture, fetal distress, or anaphylaxis.
    2. Intravenous bolus can cause hypotension, tachycardia, and dysrhythmia.

LXV. Phenobarbital

  1. Indication: Seizure suppression.
  2. Dosage: 10 to 20 mg/kg IV, additional 5 mg/kg doses q15-30min for control of status epilepticus, then 3 to 5 mg/kg/d PO or IV in divided doses.
  3. Comments:
    1. May cause hypotension.
    2. Multiple drug interactions through induction of hepatic enzyme systems.
    3. Therapeutic anticonvulsant concentration 15 to 40 μg/mL at trough (just before next dose).

LXVI. Phenoxybenzamine

  1. Indication: Preoperative preparation for pheochromocytoma resection.
  2. Dosage: 10 to 40 mg/d PO (start at 10 mg/d and increase dosage by 10 mg/d every 4 days prn).
  3. Effect: Nonselective and noncompetitive α-adrenergic antagonist.
  4. Comments: May cause orthostatic hypotension (which may be refractory to norepinephrine) and reflex tachycardia.

LXVII Phenylephrine

  1. Indication: Hypotension.
  2. Dosage: 10 μg/min IV initially, then titrated to response; IV bolus 40 to 100 μg/dose. Customary mix: 10 to 30 mg in 250 mL of D5W or NS.
  3. Effect: α1-Adrenergic agonist.
  4. Clearance: Hepatic metabolism; renal elimination.
  5. Comments: May cause hypertension, reflex bradycardia, microcirculatory constriction, uterine contraction, or uterine vasoconstriction.

LXVIII. Phenytoin (Dilantin)

  1. Indications: Seizure prophylaxis, treatment of seizures.
  2. Dosage: 10 to 15 mg/kg IV at less than 50 mg/min (up to 1000 mg cautiously, with ECG monitoring); for neurosurgical prophylaxis, then 100 to 200 mg IV q4h (at <50 mg/min).
  3. Effect:
    1. Anticonvulsant effect via membrane stabilization.
    2. Antidysrhythmic effect similar to those of quinidine or procainamide.
  4. Comments:
    1. Intravenous bolus may cause bradycardia, hypotension, respiratory arrest, cardiac arrest, or CNS depression.
    2. Nystagmus, diplopia, ataxia, drowsiness, gingival hyperplasia, GI upset, hyperglycemia, or hepatic microsomal enzyme induction.
    3. Crosses the placenta.
    4. Significant interpatient variation in dose needed to achieve therapeutic concentration of 7.5 to 20.0 μg/mL.
    5. Determination of unbound phenytoin levels may be helpful in patients with renal failure or hypoalbuminemia.

LXIX. Phosphorus (Sodium Phosphate)

  1. Indications:

    Treatment and prevention of hypophosphatemia.

  2. Dosage: 0.15 to 0.25 mmol/kg IV over 6 to 12 hours.
  3. Effect: Electrolyte replacement.
  4. Comments:
    1. Infuse doses of IV phosphate over a 4- to 6-hour period since risks of rapid IV infusion include hypocalcemia, hypotension, muscular irritability, calcium deposition, renal function deterioration, and hyperkalemia.
    2. Use with caution in patients with cardiac disease and renal insufficiency.

LXX. Physostigmine (Antilirium)

  1. Indications: Postoperative delirium, tricyclic antidepressant overdose, and reversal of CNS effects of anticholinergic drugs.
  2. Dosage: 0.5 to 2.0 mg IV q15min prn.
  3. Effect: Central and peripheral cholinergic effects; inhibits cholinesterase.
  4. Comments: Rarely may cause bradycardia, tremor, convulsions, hallucinations, CNS depression, mild ganglionic blockade, or cholinergic crisis.

LXXI. Potassium (KCl) (see Appendix I)

LXXII. Prochlorperazine (Compazine)

  1. Indications: Nausea and vomiting.
  2. Dosage: 5 to 10 mg IV (≤40 mg/d); 5 to 10 mg IM q2-4h prn; 25 mg PR q12h prn.
  3. Effect: Central dopamine (D2) antagonist with neuroleptic and antiemetic effects with antimuscarinic and antihistaminic (H1) actions.
  4. Comments: May cause hypotension (especially when given IV), extrapyramidal reactions, neuroleptic malignant syndrome, leukopenia, and cholestatic jaundice.

LXXIII. Promethazine (Phenergan)

  1. Indications: Nausea and vomiting.
  2. Dosage: Adult: 12.5 to 25 mg IV q4-6h prn. Pediatric: 0.1 to 1 mg/kg IV, IM, PO, PR (per rectum) q4-6h prn.
  3. Effect: Antagonist of H1 and muscarinic receptors.
  4. Comments: Lower doses (3-6 mg) may be effective in the immediate postoperative period for nausea and vomiting. May cause mild hypotension or mild anticholinergic effects.

LXXIV. Propranolol (Inderal)

  1. Indications:
    1. Hypertension, atrial and ventricular dysrhythmias, myocardial ischemia, or infarction.
    2. Junctional rhythm.
    3. Hypertrophic cardiomyopathy.
    4. Thyrotoxicosis.
    5. Migraine headache.
  2. Dosage: 0.5 to 1 mg IV, then titrate to effect; 0.5 mg IV for junctional rhythm.
  3. Effect: Nonspecific β-adrenergic blockade.
  4. Comments: May cause bradycardia, AV dissociation.

LXXV. Prostaglandin E1 (Alprostadil) (see Appendix I)

LXXVI. Protamine

  1. Indication: Reversal of the effects of heparin.
  2. Dosage: 1 mg/100 units of heparin activity IV at less than or equal to 5 mg/min.
  3. Effect: Polybasic compound forms complex with polyacidic heparin.
  4. Comments:
    1. May cause myocardial depression and peripheral vasodilation with sudden hypotension or bradycardia.
    2. May cause severe pulmonary hypertension, particularly in the setting of cardiopulmonary bypass.
    3. Concern for allergic reaction/anaphylaxis for patients taking NPH insulin.
    4. Transient reversal of heparin may be followed by rebound heparinization.
    5. Monitor response with a partial thromboplastin time or ACT.

LXXVII. Scopolamine

  1. Indications: Sedation, nausea/vomiting, motion sickness, amnesia.
  2. Dosage: 0.3 to 0.6 mg IV/IM, 1.5-mg transdermal patch.
  3. Effect: Peripheral and central cholinergic (muscarinic) antagonism.
  4. Comments:
    1. Excessive CNS depression can be reversed by physostigmine.
    2. May cause excitement, delirium, transient tachycardia, hyperthermia, or urinary retention.
    3. Care when handling patch because contact with eyes may cause long-lasting mydriasis and cycloplegia.
    4. Crosses the blood-brain barrier and placenta.

LXXVIII. Tranexamic Acid

  1. Indications: Prevention of bleeding due to fibrinolysis.
  2. Dosage: Intermittent IV infusion: 1000 mg over 10 minutes not to exceed 100 mg/min. Continuous IV infusion: 1 to 16 mg/kg/h not to exceed 100 mg/min.
  3. Effect: Stabilizes the formed clot by inhibiting plasminogen activators and plasmin.
  4. Comments:
    1. May cause hypotension with rapid administration.
    2. Commonly used for trauma, epistaxis, spine surgery, and joint arthroplasty.
    3. Used for management of postpartum hemorrhage.
    4. Cleared by the kidneys. It is contraindicated for patients with renal insufficiency since is may cause seizures.
    5. Contraindications for any prothrombotic state: previous DVT, PE, stroke, recent cardiac, vascular stent.

LXXIX. Vasopressin (Antidiuretic Hormone, Pitressin)

  1. Indications:
    1. Diabetes insipidus.
    2. Upper gastrointestinal (GI) hemorrhage.
    3. Pulseless ventricular tachycardia or ventricular fibrillation.
    4. Shock refractory to fluid and vasopressor therapy.
  2. Dosage:
    1. Diabetes insipidus (DI), 5 to 10 units IM/SC q8-12h.
    2. GI, 0.1 to 0.4 units/min IV infusion.
    3. ACLS, 40 units IV bolus (single dose).
    4. Shock, 0.04 units/min IV infusion titrated as required.
  3. Effect:
    1. Increases urine osmolality and decreases urine volume.
    2. Smooth muscle constriction; vasoconstriction of splanchnic, coronary, muscular, and cutaneous vasculature.
  4. Comments:
    1. May cause oliguria, water intoxication, pulmonary edema; hypertension, arrhythmias, myocardial ischemia; abdominal cramps (from increased peristalsis); contraction of gallbladder, urinary bladder, or uterus; vertigo or nausea.
    2. Patients with coronary artery disease are often treated with concurrent nitroglycerin.
    3. Useful in shock states as the effect of drug is not pH-dependent.

LXXX. Verapamil

  1. Indications: Supraventricular tachycardia, atrial fibrillation or flutter, Wolff-Parkinson-White syndrome.
  2. Dosage: 2.5 to 10 mg IV over ≥2 minutes, repeat once if no response in 30 minutes.
  3. Effect: Blocks slow calcium channels in the heart. Prolongs PR interval. Negative inotrope and chronotrope; systemic and coronary vasodilator.
  4. Comments:
    1. May cause severe bradycardia, AV block (especially with concomitant β-adrenergic blockade), excessive hypotension, or congestive heart failure.
    2. May increase ventricular response to atrial fibrillation or flutter in patients with accessory tracts.
    3. Active metabolite has 20% of the antihypertensive effect of the parent compound.

LXXXI. Vitamin K

  1. Indications: Deficiency of vitamin K–dependent clotting factors, reversal of warfarin anticoagulation.
  2. Dosage: 2.5 to 10 mg IM/SC/PO or 1 to 10 mg IV at less than or equal to 1 mg/min (with caution). If prothrombin time is not improved 8 hours after initial dose, repeat prn.
  3. Effect: Increases the levels of clotting factors II, VII, IX, and X by regeneration of vitamin K–dependent epoxide reductase blocked by warfarin.
  4. Comments:
    1. Excessive doses can make patient refractory to further oral anticoagulation.
    2. Rapid IV bolus can cause profound hypotension, fever, diaphoresis, bronchospasm, anaphylaxis, and pain at the injection site.

LXXXII. Warfarin (Coumadin)

  1. Indication: Anticoagulation.
  2. Dosage: 5 mg PO × 2 to 5 days, then 2 to 10 mg PO, titrated to INR (international normalized ratio should be 2 to 3, based on indication).
  3. Effect: Inhibits vitamin K epoxide reductase effectively lowering vitamin K levels to inhibit synthesis of factors II, VII, IX, and X and proteins C, S, and Z.
  4. Comments:
    1. May be potentiated by ethanol, antibiotics, dextran, thyroxine, diazoxide, ethacrynic acid, glucagon, methyldopa, monoamine oxidase inhibitors, phenytoin, prolonged use of narcotics, quinidine, sulfonamides, congestive heart failure, hyperthermia, liver disease, and malabsorption.
    2. May be antagonized by barbiturates, chlordiazepoxide, haloperidol, oral contraceptives, hypothyroidism, and hyperlipidemia.