Drugs found in the drug tray:
Albuterol 17 gm (Proventil)
Drugs: albuterol & levabuterol (R-isomer of albuterol)
Drug Category: quick-relief medication for asthma
Mode of Action: bronchodilation by adenylate cyclase activation & cAMP
Uses: relief of acute symptoms/bronchospasm, preventive treatment prior to exercise induced asthma (2 hrs duration; 80% patients)
Adverse Effects: acute: have not been able to separate tremor from bronchodilation; chronic: no impact on chronic airway inflammation traditionally because of desensitization (but may be due to inducing phosphodiesterase, PDE3B & PDE4D, gene products)
Therapeutic comment:
- drugs achieve 75% of max effect w/in 5 minutes
- 90 g/puff exercise
- emergency 6-12 puffs or nebulizer—3 treatments every 20 minutes
Calcium Chloride 10 % in 10 ml syringe
Indications: Hypocalcemia;Cardiac arrest;Hyperkalemia;Toxicity, magnesium;Tetany, neonatal;Tetany, secondary to parathyroid deficiency;Tetany, secondary to vitamin D deficiency;Hypocalcemia, secondary to exchange transfusion;Colic, secondary to lead toxicity;Toxicity, lead, adjunct
Off-label Indications: Not clinically relevant:Carcinoma, Medullary Thyroid (diagnosis);Neuromuscular Blockade (antagonize);Zollinger-Ellison (diagnosis)
•In the treatment of hypocalcemia in conditions requiring a prompt increase in plasma calcium levels (e.g., neonatal tetany and tetany due to parathyroid deficiency, vitamin D deficiency and alkalosis) and for the prevention of hypocalcemia during exchange transfusions.
•As adjunctive therapy in the management of acute symptoms in lead colic.
•In the treatment of magnesium intoxication due to overdosage of magnesium sulfate.
•In severe hyperkalemia, to combat deleterious effects on electrocardiographic (ECG) funtion, pending correction of the potassium level in the extracellular fluid.
•In cardiac resuscitation, particularly after open heart surgery, when epinephrine fails to improve weak or ineffective myocardial contractions.
Calciumchloride injection, 10% is irritating to veins and must not be injected into tissues, since severe necrosis and sloughing may occur. Great care should be taken to avoid extravasation or accidental injection into perivascular tissues.
Solutions should be warmed to body temperature. Injections should be made slowly through a small needle into a large vein to minimize venous irritation and avoid undesirable reactions. It is particularly important to prevent a high concentration of calcium from reaching the heart because of the danger of cardiac syncope. If injected into the ventricular cavity in cardiac resuscitation care must be taken to avoid injection into the myocardial tissue.
Cefazolin 1 gm vial (Ancef)
1st Generation Cephalosporin
-Superior 1st gen for parenteral use; longest t½ (90min.; most others are 60 min).
-1st generation are most active cephalosporins for infections caused by Gram (+) bacteria, especially sensitive staphylococci and streptococci; Gram (-) usually effective against Proteus sp., E. coli, and Klebsiella, but - lactamase producing strains may be resistant.
-least irritating after I.M. injection but all the cephalosporins are irritating after injection
-has the smallest volume of distribution (therefore giving highest blood levels).
-Used for urinary tract and skin infections; not much ABX difference with other 1st generations.
Dexamethasone 20 mg/ 5 ml vial (Decadron)
Anti-inflammatory potency: high
Na+ retention potency: none
Duration of action: long
Given: PO, IM, IV
– Hydrocortisone; prednisone; prednisolone; methylprednisolone; triamcinolone; betamethasone; dexamethasone
– ADME: given IV, PO, applied to skin, nose, and airways; highly PP bound to albumin and corticosteroid binding proteins; highly metabolized in liver (reduction of double bond at 4,5 position leads to inactive compound; 3-ketone is reduced to alcohol which can be sulfated or glucuronidated and excreted in urine)
– Special concerns: w/drawal releases (-) feedback on CRH & ACTH acute adrenal insufficiency; W/drawal syndrome – due to lack of feedback on adrenal (fever, myalgia, arthralgia, malaise; usually occurs w/ continuous high dose tx)
– Carbohydrate metabolism: gluconeogenesis; glycogen formation; OVERALL: formation and storage of glucose
– Lipid metabolism: lipolysis; redistribution of fat (Cushing’s – buffalo hump, moon face, loss of fat in arms and legs)
– CNS effects: affect behavior, mood balance, brain excitability; high dose can cause irritability, insomnia, restlessness, psychosis; maintaining glucose balance has indirect effects
– Blood effects: RBC’s and neutrophils; lymphocytes, eosinophils, monocytes, basophils (amt of T cells > amt of B cells); high levels lead to lymphoid tissue mass and vice-versa
– Anti-inflammatory effects: synthesis/release of pro-inflammatory factors (eicosanoids, PG’s, HETE’s, LT’s)
– Other effects: chronic use suppresses pituitary release of ACTH, GH, TSH, LH; large doses antagonize effect of vitD on Ca2+ absorption; important for fetal lung development
Doxapram 400 mg/ 20 ml vial (Dopram)
DRUG CLASS: Analeptics;Stimulants, central nervous system
Indications: Pulmonary disease, chronic;Chronic obstructive pulmonary disease;Apnea, post-anesthetic;Hypercapnia, acute;Respiratory depression, postoperative;Toxicity, central nervous system depressants
Doxapram HCl produces respiratory stimulation mediated through the peripheral carotid chemoreceptors. As the dosage level is increased, the central respiratory centers in the medulla are stimulated with progressive stimulation of other parts of the brain and spinal cord.
The onset of respiratory stimulation following the recommended single IV injection of doxapram HCl usually occurs in 20-40 seconds with peak effect at 1-2 minutes. The duration of effect may vary from 5-12 minutes.
The respiratory stimulant action is manifested by an increase in tidal volume associated with a slight increase in respiratory rate.
A pressor response may result following doxapram administration. Provided there is no impairment of cardiac function, the pressor effect is more marked in hypovolemic than in normovolemic states. The pressor response is due to the improved cardiac output rather than peripheral vasoconstriction. Following doxapram administration, an increased release of catecholamines has been noted.
When the possibility of airway obstruction and/or hypoxia have been eliminated, doxapram may be used to stimulate respiration in patients with drug-induced postanesthesia respiratory depression or apnea other than that due to muscle relaxant drugs.
To pharmacologically stimulate deep breathing in the postoperative patient. (A quantitative method of assessing oxygenation, such as pulse oximetry, is recommended.)
Diphenhydramine 50 mg/ 1 ml vial
DRUG CLASS: Antihistamines, H1
Indications: Parkinson's disease;Conjunctivitis, allergic;Transfusion reaction;Anaphylaxis, adjunct;Motion sickness;Angioedema;Urticaria;Dermatographism
Diphenhydramine HCl is an antihistamine with anticholinergic (drying) and sedative effects. Antihistamines appear to compete with histamine for cell receptor sites on effector cells.
Diphenhydramine is widely distributed throughout the body, including the CNS.
Diphenhydramine HCl has an atropine-like action and therefore should be used with caution in patients with a history of lower respiratory disease including asthma, increased intraocular pressure, hyperthyroidism, cardiovascular disease or hypertension.
Droperidol 5 mg/ 2 ml vial(Inapsine)
DRUG CLASS: Anesthetics, general;Antiemetics/antivertigo;Anxiolytics;Sedatives/hypnotics
Indications: Nausea;Vomiting
Off-label Indications: Clinically relevant:Anesthesia, General;Anesthesia, Regional (adjunct);Psychotic Disorder;Sedation, Conscious;Not clinically relevant:Delirium
Cases of QT prolongation and/or torsades de pointes have been reported in patients receiving droperidol at doses at or below recommended doses. Some cases have occurred in patients with no known risk factors for QT prolongation and some cases have been fatal.
Cases of QT prolongation and serious arrhythmias (e.g., torsades de pointes) have been reported in patients treated with droperidol. Based on these reports, all patients should undergo a 12-lead ECG prior to administration of droperidol to determine if a prolonged QT interval (i.e., QTc greater than 440 milliseconds for males or 450 milliseconds for females) is present. If there is a prolonged QT interval, droperidol should NOT be administered. For patients in whom the potential benefit of droperidol treatment is felt to outweigh the risks of potentially serious arrhythmias, ECG monitoring should be performed prior to treatment and continued for 2-3 hours after completing treatment to monitor for arrhythmias.
Droperidol produces marked tranquilization and sedation. It allays apprehension and provides a state or mental detachment and indifference while maintaining a state of reflex alertness.
Droperidol produces an antiemetic effect as evidenced by the antagonism of apomorphine in dogs. It lowers the incidence of nausea and vomiting during surgical procedures and provides antiemetic protection in the postoperative period.
Droperidol potentiates other CNS depressants. It produces mild alpha-adrenergic blockade, peripheral vascular dilatation and reduction of the pressor effect of epinephrine. It can produce hypotension and decreased peripheral vascular resistance and may decrease pulmonary arterial pressure (particularly if it is abnormally high). It may reduce the incidence of epinephrine-induced arrhythmias, but it does not prevent other cardiac arrhythmias.
The onset of action of single intramuscular and intravenous doses is from 3-10 minutes following administration, although the peak effect may not be apparent for up to 30 minutes. The duration of the tranquilizing and sedative effects generally is 2-4 hours, although alteration of alertness may persist for as long as 12 hours.
Epinephrine 1: 10,000 in 10 ml pre-filled syringe
DRUG CLASS: Adrenergic agonists;Bronchodilators;Inotropes;Ophthalmics
Indications: Rhinitis, allergic;Glaucoma, open-angle;Asthma;Serum sickness;Cardiac arrest;Angioedema;Urticaria;Anaphylaxis;Anesthesia, local, adjunct;Anesthesia, spinal, adjunct;Uterine contraction, inhibition
Off-label Indications: Not clinically relevant:Hemorrhage, Gastrointestinal;Hemorrhage, Renal Arterial
Epinephrine is a sympathomimetic drug, acting on both alpha and beta receptors. It is the drug of choice for the emergency treatment of severe allergic reactions (Type I) to insect stings or bites, foods, drugs, and other allergens. It can also be used in the treatment of idiopathic or exercise-induced anaphylaxis. Epinephrine when given subcutaneously or intramuscularly has a rapid onset and short duration of action. The strong vasoconstrictor action of epinephrine through its effect on alpha adrenergic receptors acts quickly to counter vasodilation and increased vascular permeability which can lead to loss of intravascular fluid volume and hypotension during anaphylactic reactions. Epinephrine through its action on beta receptors on bronchial smooth muscle causes bronchial smooth muscle relaxation which alleviates wheezing and dyspnea. Epinephrine also alleviates pruritis, urticaria, and angioedema and may be effective in relieving gastrointestinal and genitourinary symptoms associated with anaphylaxis.
In general, the most common uses of epinephrine are to relieve respiratory distress due to bronchospasm, to provide rapid relief of hypersensitivity reactions to drugs and other allergens, and to prolong the action of infiltration anesthetics. Its cardiac effects may be of use in restoring cardiac rhythm in cardiac arrest due to various causes, but it is not used in cardiac failure or in hemorrhagic, traumatic, or cardiogenic shock.
Esmolol 100 mg/ 10 ml vial (Brevibloc)
DRUG CLASS: Antiadrenergics, beta blocking;Antiarrhythmics, class II
Indications: Tachycardia, supraventricular;Tachycardia, intraoperative;Tachycardia, postoperative;Hypertension, perioperative
Off-label Indications: Not clinically relevant:Ischemia, Myocardial;Tachyarrhythmia
Esmolol HCl is a beta1-selective (cardioselective) adrenergic receptor blocking agent with rapid onset, a very short duration of action, and no significant intrinsic sympathomimetic or membrane stabilizing activity at therapeutic dosages. Its elimination half-life after intravenous infusion is approximately 9 minutes. Esmolol HCl inhibits the beta1 receptors located chiefly in cardiac muscle, but this preferential effect is not absolute and at higher doses it begins to inhibit beta2 receptors located chiefly in the bronchial and vascular musculature.
Esmolol HCl is rapidly metabolized by hydrolysis of the ester linkage, chiefly by the esterases in the cytosol of red blood cells and not by plasma cholinesterases or red cell membrane acetylcholinesterase. Total body clearance in man was found to be about 20 L/kg/h, which is greater than cardiac output; thus the metabolism of esmolol HCl is not limited by the rate of blood flow to metabolizing tissues such as the liver or affected by hepatic or renal blood flow. Esmolol HCl has a rapid distribution half-life of about 2 minutes and an elimination half-life of about 9 minutes.
Using an appropriate loading dose, steady-state blood levels of esmolol HCl for dosages from 50-300 μg/kg/min (0.05-0.3 mg/kg/min) are obtained within 5 minutes. (Steady-state is reached in about 30 minutes without the loading dose.) Steady-state blood levels of esmolol HCl increase linearly over this dosage range and elimination kinetics are dose-independent over this range. Steady-state blood levels are maintained during infusion but decrease rapidly after termination of the infusion. Because of its short half-life, blood levels of esmolol HCl can be rapidly altered by increasing or decreasing the infusion rate and rapidly eliminated by discontinuing the infusion.
Esmolol HCl has been shown to be 55% bound to human plasma protein, while the acid metabolite is only 10% bound.
Esmolol HCl is indicated for the treatment of tachycardia and hypertension that occur during induction and tracheal intubation, during surgery, on emergence from anesthesia, and in the postoperative period, when in the physician's judgment such specific intervention is considered indicated.
Etomidate 40 mg/ 20 ml syringe (Amidate)
DRUG CLASS: Anesthetics, general
Indications: Anesthesia, adjunct;Anesthesia, general
Etomidate is a hypnotic drug without analgesic activity. Intravenous injection of etomidate produces hypnosis characterized by a rapid onset of action, usually within 1 minute. Duration of hypnosis is dose dependent but relatively brief, usually 3-5 minutes when an average dose of 0.3 mg/kg is employed. Immediate recovery from anesthesia (as assessed by awakening time, time needed to follow simple commands and time to perform simple tests after anesthesia as well as they were performed before anesthesia), based upon data derived from short operative procedures where intravenous etomidate was used for both induction and maintenance of anesthesia, is about as rapid as, or slightly faster than, immediate recovery after similar use of thiopental. These same data revealed that the immediate recovery period will usually be shortened in adult patients by the intravenous administration of approximately 0.1 mg of intravenous fentanyl, 1 or 2 minutes before induction of anesthesia, probably because less etomidate is generally required under these circumstances.
The most characteristic effect of intravenous etomidate on the respiratory system is a slight elevation in arterial carbon dioxide tension (PaCO2).
Reduced cortisol plasma levels have been reported with induction doses of 0.3 mg/kg etomidate. These persist for approximately 6-8 hours and appear to be unresponsive to ACTH administration.
The intravenous administration of up to 0.6 mg/kg of etomidate to patients with severe cardiovascular disease has little or no effect on myocardial metabolism, cardiac output, peripheral circulation or pulmonary circulation. The hemodynamic effects of etomidate have in most cases been qualitatively similar to those of thiopental sodium, except that the heart rate tended to increase by a moderate amount following administration of thiopental under conditions where there was little or no change in heart rate following administration of etomidate. There are insufficient data concerning use of etomidate in patients with recent severe trauma or hypovolemia to predict cardiovascular response under such circumstances.
Etomidate induction is associated with a transient 20-30% decrease in cerebral blood flow. This reduction in blood flow appears to be uniform in the absence of intracranial space occupying lesions. As with other intravenous induction agents, reduction in cerebral oxygen utilization is roughly proportional to the reduction in cerebral blood flow. In patients with and without intracranial space occupying lesions, etomidate induction is usually followed by a moderate lowering of intracranial pressure, lasting several minutes. All of these studies provided for avoidance of hypercapnia. Information concerning regional cerebral perfusion in patients with intracranial space occupying lesions is too limited to permit definitive conclusions.
Reduced plasma cortisol and aldosterone levels have been reported following induction doses of etomidate. These results persist for approximately 6-8 hours and appear to be unresponsive to ACTH stimulation. This probably represents blockage of 11 beta-hydroxylation within the adrenal cortex.
Furosemide 20 mg/ 2 ml vial (Lasix)
Mode of Action: Actively secreted into PCT; acts on ascending loop of Henle (specifically the Na+,K+,Cl- transporter) to inhibit the reabsorption of chloride
Uses: treatment of CHF (#1 diuretic for CHF), edema—various pathophysiologies (useful in pulmonary edema because they produce short-term in venous capacitance), treatment of hypertension
Adverse Effects: allergy (related to sulfonamides), hypokalemia, hyponatremia & dehydration, hyperglycemia (less common than w/ thiazides), hyperuricemia (excretion of this drug in PCT will interfere w/ uric acid excretiongout), GI upset, ototoxicity (ethacrynic acid especially, loop diuretics + aminoglycosides)
Urine composition: volume , sodium and chloride , potassium , bicarbonate ,
calcium (supports renal calculus formation; negative calcium balance)
*Rapid onset of action (w/in minutes of IV administration), efficacy independent of acid-base balance, effective even w/ poor renal function; furosemide is twice daily & torsemide is longer duration of action—once a day
Heparin 1000 units/ ml in 10 ml vial
Drug Category: heparin subclass of anticoagulants
Mode of Action: attaches to & activates antithrombin III which complexes w/ serum proteases to inactivate their protease activity
ADME: first cleared by initial saturable process (endothelial cell & macrophage clearance) & secondly by slower, non-saturable renal clearance (w/ prolonged admininstration renal predominates); administrated subcutaneous or IV
Adverse Effects: unwanted bleeding function of improper dosing (overdose can be treated w/ protamine a positively charged drug that binds & inactivates heparin), allergic reactions, chronic usage in dialysis patients or those undergoing chronic anticoagulation therapy may develop osteoporosis, immediate re-occlusion of an arterial thrombosis w/ withdrawal of heparin, transient thrombocytopenia, peripheral necrosis in fingers & toes from white clots
Precautions/Contraindications: patients w/ bleeding disturbances, pathologies prone to bleeding (esophageal varices, active TB, or GI ulcerations), or w/ known hypersensitivity
*enoxapirin (Lovenox) similar to heparin w/ small molecular weight
--has longer ½ life: subcutaneous injection once daily
--does not produce thrombocytopenia & less chances of developing osteoporosis
--safe during pregnancy
Hetastarch 6 % in NS 500 ml (Hespan)
DRUG CLASS: Plasma expanders
Indications: Hypovolemia;Leukapheresis, adjunct
Off-label Indications: Not clinically relevant:Cryoprotective Agent (long-term storage of whole blood);Plasma Volume Expander (during cardiopulmonary bypass);Priming Fluid (for perfusion during extracorporeal circulation)