1. 2009 Pandemic Education Package Pharmacology Review

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

3. 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. 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. 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. 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. 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. 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. 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. 10 Sedation/Analgesia Assessments to determine need for sedation/analgesia are: Neurologic Determine LOC and level of agitation or sedation

11. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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 ETCO 2 placed in-line (alarms set)

22. 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”