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Commonly Used Medications

Commonly Used Medications. Constipation Diarrhea Dyspepsia Nausea. Cough Wheezing Headache Pain Insomnia. Common Complaints. Common Challenges. VTE prophylaxis Stress ulcer prophylaxis Insulin sliding scale Heparin nomogram Patient controlled analgesia CIWA “protocol”.

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Commonly Used Medications

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  1. Commonly Used Medications

  2. Constipation Diarrhea Dyspepsia Nausea Cough Wheezing Headache Pain Insomnia Common Complaints

  3. Common Challenges • VTE prophylaxis • Stress ulcer prophylaxis • Insulin sliding scale • Heparin nomogram • Patient controlled analgesia • CIWA “protocol”

  4. Docusate (Surfak) 240 mg po qd-bid Psyllium (Metamucil) 1-2 tsp po qd-tid Bisacodyl (Dulcolax) 10 mg po qhs prn Lactulose 15-30 ml po qd-bid Magnesium citrate 120-240 ml po prn Milk of magnesia 30-60 ml po prn Fleets enema 1 enema PR prn Constipation

  5. Diarrhea • Bismuth subsalicylate (Kaopectate) • 2 tab po q1h prn • max 15 tab/day • Loperamide (Immodium) • 4 mg po x 1, then 2 mg po after each loose BM • max 16 mg/day • Atropine/Diphenoxylate (Lomotil) • 0.025/2.5mg • 1-2 tab po tid-qid prn

  6. Dyspepsia / Heartburn • Maalox / Mylanta • Aluminum hydroxide / magnesium hydroxide • 15-30 ml PO qid prn • Tums • Calcium carbonate • 1-2 tabs po qid prn • “GI Cocktail” • Maalox + viscous Lidocaine + Donnatal

  7. Nausea / Vomiting • Promethazine (Phenergan) • 12.5-25 mg PO/IV q4-6h prn • Prochlorperazine (Compazine) • 5-10 mg PO q6-8h prn • Ondansetron (Zofran) • 4 mg PO/IV bid-tid prn • Dexamethasone (Decadron) • 4 mg PO/IV q6h prn

  8. Cough • Guaifenesin (Robitussin) • 10 ml PO q4h prn • Guaifenesin (Humabid LA) • 600 mg po bid • Dextromethorphan/Guaifenesin • Robitussin-DM • 10 ml PO q4h prn • Chlorpheniramine/hydrocodone • Tussionex • 5 ml PO bid

  9. Dyspnea / Wheezing • Albuterol (Proventil) • MDI: 2 puffs q4-6h prn • NEB: 2.5 mg q6-8h prn • Levalbuterol (Xopenex) • NEB: 1.25 mg q6-8h prn • Ipratropium (Atrovent) • MDI: 2-3 puffs tid-qid • NEB: 500 mcg q6-8h • Albuterol / Ipratropium • Combivent MDI 1-2 puffs qid • DuoNeb 3 ml q6h

  10. Headache • Nonsteroidals • Tylenol, Motrin, or Naprosyn • Combination analgesics • Fioricet or Midrin • Triptans • Zomig (Zolmitriptan) • Antiemetics • Compazine or Reglan • Caffeine • 500 mg in 1000 ml of NS over 90 minutes

  11. Pain • Acetaminophen (Tylenol) • 325-975 mg po q4-6h prn • Ibuprofen (Motrin) • 400-800 mg po tid-qid prn • Naproxen (Naprosyn) • 250-500 mg po bid prn • Ketorolac (Toradol) • 15-30 mg IV q6h prn

  12. Pain, cont. • Acetaminophen/hydrocodone (Vicodin) • 500/5 mg • 1-2 tab po q4-6h prn • Acetaminophen/oxycodone (Percocet) • 325/5 mg • 1-2 tab po q4-6h prn • Morphine • 2-4 mg IV q4-6h prn • Hydromorphone (Dilaudid) • 1-2 mg IV q4-6h prn

  13. Insomnia • Diphenhydramine (Benadryl) • 25-50 mg po qhs • Zolpidem (Ambien) • 5-10 mg po qhs • Temazepam (Restoril) • 7.5-30 mg po qhs • Amitriptyline (Elavil) • 10-50 mg po qhs

  14. VTE Prophylaxis • Graduated compression stockings • Intermittent leg compression • Heparin • 7500 units SC bid • Enoxaparin (Lovenox) • 30 mg SC bid • 40 mg SC qd Chest 2004; 126: 338S-400S.

  15. Stress Ulcer Prophylaxis • Major Indications • Mechanical ventilation > 48 hours • Coagulopathy • Minor Indications • Sepsis or shock • Hepatic or renal failure • Trauma or burns • Prior history of PUD or UGIB J Intensive Care Med 1999; 14: 1-8.

  16. Ranitidine Zantac 150 mg PO bid 50 mg IV q8h Famotidine Pepcid 20-40 mg PO qhs 20 mg IV q12h Lansoprazole Prevacid 15-30 mg PO qd 30 mg IV q24h Pantoprazole Protonix 40 mg IV q24h Stress Ulcer Prophylaxis

  17. Insulin Sliding Scale Check fingerstick glucose and apply insulin sliding scale QACHS or Q6H if NPO.

  18. Insulin Sliding Scale • Low-dose: for patients who are NPO, thin, or elderly • Medium-dose: for patients who are eating and are of average weight • High-dose: for patients who are eating and are overweight • Very high-dose: for patients with severe infection or those receiving high-dose steroids

  19. Heparin Nomogram

  20. Heparin Nomogram • Initial bolus = 80 units/kg • Initial rate = 18 units/kg/hour • Maximum bolus = 5,000 units • Check PTT q6h and adjust Heparin drip accordingly • Nurses in CCU/ICU and on 4W can adjust Heparin drip independently • Nurses on 5N, 5E, and 4E require an order from MO before adjusting Heparin drip

  21. Patient Controlled Analgesia (PCA) • PCA Variables • Drug • Concentration • Loading dose • Basal rate • Bolus dose • Lockout interval • Hourly limit

  22. Morphine PCA • Concentration 5 mg/ml • Loading dose 2-4 mg • Basal rate None (or 1 mg/hr) • Bolus dose 1.5 mg • Lockout 6-10 minutes • 4-hour limit 30 mg

  23. PCA Considerations • Monitor respiratory rate • Avoid use of sedatives • Narcan for respiratory depression • Benadryl for pruritis • Phenergan for nausea • Bowel regimen for constipation

  24. CIWA “Protocol” • Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) • Quantifies 10 symptoms and signs of alcohol withdrawal • Severity of withdrawal according to score: • CIWA-Ar score < 8 minor • CIWA-Ar score 8-15 moderate • CIWA-Ar score > 15 severe N Engl J Med 2003; 348: 1786-1795.

  25. CIWA “Protocol” • Sample CIWA orders: • CIWA-Ar scale q4h • Ativan 1 mg IV q4h prn for CIWA-Ar score >8 • Ativan 2mg IV q4h prn for CIWA-Ar score >15 • If Ativan given, then repeat CIWA-Ar scale in 1h and call MO for score >8

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