2009 Pandemic Education Package

1. 2009 Pandemic Education Package Pharmacology Review

2. Antiviral Tamiflu Antibiotics Ceftriaxone Zithromycin Pip/Tazocin Sedation Propofol Versed Analgesic Morphine Fentanyl Vasopressors Dopamine Epinephrine Norepinephrine Vasopressin Common Medications for H1N1/SRI

3. Antiviral Medication Oseltamivir (Tamiflu) • Dose 75 mg PO/NG BID for at least 7 days, current experience is showing it could be needed up to 3-4 weeks • The treatment of influenza infection in patients who have been symptomatic for no more than 2 days, or as prophylaxis once exposure has occurred. Alleviates symptoms and decreases duration of symptoms. • Adverse Effects: Nausea and Vomiting

4. Antibiotics • These medications are commonly given for the prevention and treatment of pneumonia/bacterial infections associated with the severe respiratory illness aspect of H1N1. • It is important to start these medications IMMEDIATELY after they have been ordered by the Physician, as they may be fighting a larger scale bacterial infection on top of the H1N1 viral infection. • Common antibiotics that may be administered to a H1N1/SRI patient – Ceftriaxone, Azithromycin, Piperacillin/Tazobactam due to the broad spectrum.

5. Antibiotics Piperacillan/Tazobactam • Usual dose is 3.375 to 4.5 Grams every 6 or 8 hours based on renal function. • Administration – I.V over at least 30 minutes • Adverse Effects may include Diarrhea, nausea and vomiting.

6. Antibiotics Ceftriaxone • Usual Dose is 1-2 Gram daily via IV route • Administration – I.V or intermittent does • Adverse Effects – Thrombophlebitis (pain at injection site)

7. Antibiotics Azithromycin • Usual dose is 500 mg IV daily for 5 days • Administration – Intermittent IV only • Adverse Effects: nausea, vomiting, diarrhea, pain at injection site

8. Sedation/Analgesia • Recent experiences in other areas of the country and world have reported that H1N1/SRI patients require a significantly large amount of sedation and analgesic. • Routine assessments of your patient including respiratory status, level of consciousness, and agitation level will help determine the need for further sedation.

9. Sedation/Analgesia • Routinely in a critical care setting, the order for sedation and analgesia will be written with no time frame other than PRN. i.e. Morphine 5 mg IV PRN • The ICU RN must use knowledge, experience and judgment to decide how much or how little of the specific drug is needed for the patient.

10. Sedation/Analgesia • Assessments to determine need for sedation/analgesia are: • Neurologic • Determine LOC and level of agitation or sedation

11. Sedation/Analgesia • Respiratory • Current mode of ventilation (full support [AC], partial support [PS], no support or not ventilated) • Respiratory rate ( if too slow and not on full ventilatory support use caution with amount of drug) • Asynchronous with ventilator – may need more sedation or neuromuscular blocking agent

12. Sedation/Analgesia • Cardiovascular • Blood Pressure and Heart Rate – Will patient’s BP and HR support the administration of sedation and/or analgesic? These drugs tend to drop BP.

13. Sedation Propofol • Supplied in a concentration of 10 mg/mL • 0-350 mg is the dose range for sedation • Main adverse effects are HYPOTENSION and Respiratory Depression/Failure.

14. Sedation Versed (Midazolam) • Can be given Direct IV, Intermittent or Continuous infusion • Direct IV dose is 1-2 mg over 2-3 minutes • Continuous infusion is 1-2 mg/hr and then titrated to desired effect • Adverse Effects include hypotension, respiratory depression/failure

15. Analgesia Morphine • Can be given Direct IV, Intermittent or Continuous Infusion as well as SC and IM • Usual dose for Direct IV/Intermittent administration seen in ICU is 5 mg IV PRN (No time limit) • decision on how much drug to give is left to the ICU RN or MD • Usual dose for Continuous infusion is 1-10 mg/hr • Adverse Effects – Respiratory and cardiovascular depression

16. Analgesia Fentanyl • Can be given Direct IV, Intermittent or Continuous infusion • Usual dose for direct IV/Intermittent is 25-100 mcg • Usual dose for Continuous infusion is 100-200 mcg/hr and titrated to effect. • Adverse Effects are respiratory depression and cardiovascular depression.

17. Vasopressors Dopamine • Indication • Hypotension (SBP <70-100) • Route • IV infusion • Dose • Titrate to effect • Increase in increments of 1-4 mcg/kg/min • Adverse Effects • Tachycardia, tachyarrhythmias, angina, palpitations, nausea • At high dose - ↓ renal function, ↓ peripheral perfusion

18. Vasopressors Norepinephrine • Indication • Hemodynamically significant hypotension • Route of Administration • IV infusion • Dose • 0.5-30 mcg/min titrated to effect • Adverse Reactions • Reflex bradycardia, hypertension, angina, ↓ renal function, ↓ peripheral perfusion

19. Vasopressors Epinephrine • Indication – Severe hypotension, bradycardia • Route of Administration – Continuous IV infusion • Can be given Direct IV push in cardiac arrest situation (1mg) • Dose • 1-30 mcg/min titrated to effect • Adverse Effects • Reflex bradycardia, hypertension, angina, ↓ renal function, ↓ peripheral perfusion

20. Vasopressors Vasopressin • Indication – treatment of shock and hypotension, used for vasoconstrictive purposes • Route of Administration – Continuous IV infusion • Can be given Direct IV in cardiac arrest situation (40u) • Dose - 0.02 – 0.06 units/min • Adverse Effects: Peripheral vasoconstriction and bronchial constriction

21. Neuromuscular Blocking Agents • NMBAs must be given with sedation and analgesic • Patient must be on Full Support ventilation [i.e. AC Mode] prior to receiving NMBA • Patient must be monitored continuously • cardiac • respiratory • Ventilator alarms are tightened • ETCO2 placed in-line (alarms set)

22. Care of a Paralyzed Patient • Be diligent with airway maintenance • Patient unable to cough and will therefore will need regular bronchial hygiene • ETCO2 monitoring • Trending • Assessing for spontaneous respirations (signs of distress/dyschrony) • “Curare cleft”