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General Pharmacology. 205b. Neuromuscular Blocking Agents (NMBAs). Cause skeletal muscle weakness or paralysis for purpose of preventing movement. Neuromuscular Blocking Agents (NMBAs). Cause skeletal muscle weakness or paralysis for purpose of preventing movement Two types

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neuromuscular blocking agents nmbas
Neuromuscular Blocking Agents (NMBAs)
  • Cause skeletal muscle weakness or paralysis for purpose of preventing movement
neuromuscular blocking agents nmbas1
Neuromuscular Blocking Agents (NMBAs)
  • Cause skeletal muscle weakness or paralysis for purpose of preventing movement

Two types

  • Depolarizing agents
  • Non-depolarizing agents
slide5

Non-Depolarizing Agents

  • Produce paralysis and muscle weakness by competing with acetylcholine for binding at the receptor site
  • Prevention of the binding of acetylcholine prevents depolarization of the site, thereby preventing muscle contraction
  • Action
  • Competitive inhibition of acetylcholine at muscle post-synaptic receptor site
    • Effects felt in 2 to 10 minutes and last for 30 to 60 minutes
    • May be reversed by cholinesterase inhibitors, e.g., Neostigmine
  • Generic Name Proprietary Name
  • Tubocurarine d-tubocurarine
  • PancuroniumPavulon
  • MetocurineMetubine
  • VecuroniumNorcuron
  • RocuroniumZemuron, Esmeron
  • Indications
    • - Need for longer term paralysis
    • - Patient-ventilator synchrony
    • - Muscle relaxation during surgery
  • - Indications
    • - Reduction of intracranial pressure
    • - Immobility in trauma patients-
    • - Minimize oxygen consumption

Depolarizing Agents

  • Bind to acetylcholine receptor sites causing a post-synaptic membrane depolarization
  • Prevention of repolarization causes the post-synaptic ending to become refractory and unexcitable, resulting in muscle flaccidity

Action

  • Prevents acetylcholine from binding at the receptor site
  • Shorter acting than non-depolarizing agents
  • Will cause total muscle paralysis in 60 to 90 seconds that lasts from 10 to 15 minutes
  • Do not have reversing agents

Generic name Proprietary name

SuccinylcholineAnectine

Indications

- Short acting paralytic ideal for intubation or similar procedures

indications for nmbas
Indications for NMBAs
  • Endotracheal intubation
  • Muscle relaxation during surgery
  • Enhancement of patient-ventilator synchrony
  • Reduction of intracranial pressure in intubated patients
  • Minimizes oxygen consumption
  • Facilitation of procedures or diagnostic studies
  • Maintenance of immobility, e.g., trauma patients (Flail Chest)
depolarizing agents
Depolarizing Agents
  • Bind to acetylcholine receptor sites causing a post-synaptic membrane depolarization
depolarizing agents1
Depolarizing Agents
  • Prevention of repolarization causes the post-synaptic ending to become refractory and unexcitable, resulting in muscle flaccidity
non depolarizing agents
Non-Depolarizing Agents
  • Produce paralysis and muscle weakness by competing with acetylcholine for binding at the receptor site
non depolarizing agents1
Non-Depolarizing Agents
  • Prevention of the binding of acetylcholine prevents depolarization of the site, thereby preventing muscle contraction
indications for nmbas1
Indications for NMBAs
  • Endotracheal intubation
  • Muscle relaxation during surgery
  • Enhancement of patient-ventilator synchrony
  • Reduction of intracranial pressure in intubated patients
indications for nmbas2
Indications for NMBAs
  • Minimize oxygen consumption
  • Facilitation of procedures or diagnostic studies
  • Maintenance of immobility, e.g., trauma patients
depolarizing agents2
Depolarizing Agents
  • Generic name
    • Succinylcholine
  • Proprietary name
    • Anectine
depolarizing agents3
Depolarizing Agents
  • Action
    • Prevents acetylcholine from binding at the receptor site
    • Shorter acting than non-depolarizing agents
depolarizing agents4
Depolarizing Agents
  • Action
    • Will cause total muscle paralysis in 60 to 90 seconds that lasts from 10 to 15 minutes
    • Do not have reversing agents
depolarizing agents5
Depolarizing Agents
  • Indications
    • Short acting paralytic ideal for intubation or similar procedures
depolarizing agents6
Depolarizing Agents
  • Side effects and hazards
    • May induce sympathomimetic response
      • Tachycardia
      • Increase in blood pressure
      • Vagal response in repeated dosages leading to bradycardia and hypotension
depolarizing agents7
Depolarizing Agents
  • Side effects and hazards
    • May induce sympathomimetic response
      • Make provoke release of histamines
      • Increase in intracranial pressure in patients with cerebral edema or head trauma
depolarizing agents8
Depolarizing Agents
  • Side effects and hazards
    • May induce sympathomimetic response
      • Malignant hyperthermia – caused by genetic defect of muscle metabolism
    • Hypoventilation
depolarizing agents9
Depolarizing Agents
  • Route of administration
    • Intravenous administration
  • Dosage
    • 1.0 to 1.5 mg/kg
non depolarizing agents3
Non-Depolarizing Agents
  • Action
    • Competitive inhibition of acetylcholine at muscle post-synaptic receptor site
    • Effects felt in 2 to 10 minutes and last for 30 to 60 minutes
    • May be reversed by cholinesterase inhibitors, e.g., Neostigmine
non depolarizing agents4
Non-Depolarizing Agents
  • Indications
    • Need for longer term paralysis
    • Patient-ventilator synchrony
    • Muscle relaxation during surgery
non depolarizing agents5
Non-Depolarizing Agents
  • Indications
    • Reduction of intracranial pressure
    • Immobility in trauma patients
    • Minimize oxygen consumption
non depolarizing agents6
Non-Depolarizing Agents
  • Side effects and hazards
    • Vagolytic effects including tachycardia, increase in mean blood pressure, and increase in release of norepinephrine; seen most with Pancuronium
non depolarizing agents7
Non-Depolarizing Agents
  • Side effects and hazards
    • Release of histamine from mast cells
      • Vasodilation leading to flushed appearance
      • Reflex tachycardia
      • Bronchospasm
    • Hypoventilation
non depolarizing agents8
Non-Depolarizing Agents
  • Route of administration
    • Intravenous
non depolarizing agents9
Non-Depolarizing Agents
  • Dosage
    • Tubocurarine
      • 0.5 – 0.6 mg/kg infused at 0.08 – 0.12 mg/kg/hr
    • Pancuronium
      • 0.08 – 0.1 mg/kg infused at 1 µg/kg/min
    • Vecuronium
      • 0.1 – 0.2 mg/kg infused at 1 µg/kg/min
narcotics and analgesics
Narcotics and Analgesics
  • Used for the relief of severe pain
narcotics and analgesics1
Narcotics and Analgesics
  • Opioid analgesics – high potency
    • Morphine
      • Route of administration
        • Oral: (Adults > 50 kg) – 30 mg q3 – q4 hours
        • Intravenous: (Adults > 50 kg)
          • Single Dose: 4 – 10 mg q3 – q4 hours
          • Continuous: 0.8 – 10 mg/hr
        • Intramuscular: 4 – 10 mg q3 – q4 hours
narcotics and analgesics2
Narcotics and Analgesics
  • Opioid Analgesics – high potency
    • Oxymorphone - (proprietary name – Numorphan)
      • Route of administration
        • Intravenous: 0.5 mg q3 – 6 hours
        • Intramuscular: 1.0 – 1.5 mg q3 – 6 hours
narcotics and analgesics3
Narcotics and Analgesics
  • Opioid analgesics – high potency
    • Fentanyl - (proprietary name – Sublimaze)
      • Route of administration
        • Intravenous: 2 mcg/kg (moderate); 2 – 20 mcg/kg (high)
        • Intramuscular: same as IV
        • LOLLYPOP
narcotics and analgesics4
Narcotics and Analgesics
  • Opioid analgesics – high potency
    • Methadone - (proprietary name – Dolophine)
    • Used to overcome Heroine addiction also
      • Route of administration
        • Oral: 10 mg
        • Intravenous: 5 mg
slide35

Methadone is mainly used in the treatment of opioid dependence. It has cross-tolerance with other opioids including heroin and morphine, offering very similar effects and a longer duration of effect. Oral doses of methadone can stabilise patients by mitigating opioid withdrawal syndrome. Higher doses of methadone can block the euphoric effects of heroin, morphine, and similar drugs. As a result, properly dosed methadone patients can reduce or stop altogether their use of these substances.

narcotics and analgesics5
Narcotics and Analgesics
  • Opioid Analgesics – high potency
    • Hydromorphone - (proprietary name – Dilaudid)
      • Route of administration
        • Oral: 4 – 8 mg q3 – 4 hours
        • Intravenous
          • Single dose – 1.5 mg q3 – 4 hours
          • Continuous – 0.2 – 30 mg/hr
        • Intramuscular: 1.5 mg q3 – 4 hours
narcotics and analgesics6
Narcotics and Analgesics
  • Opioid analgesics – intermediate potency
    • Meperidine - (proprietary name – Demerol)
      • Route of administration
        • Oral: 50 – 150 mg q3 – 4 hours
        • Intravenous
          • Single dose: 50 – 150 mg q3 – 4 hours
          • Continuous: 15 – 35 mg/hr
        • Intramuscular: 50 – 150 mg q3 – 4 hours
narcotics and analgesics7
Narcotics and Analgesics
  • Opioid analgesics – intermediate potency
    • Oxycodone - (proprietary names – Percolone, Oxycontin; with acetaminophen – Percocet
      • Route of administration
        • Oral: 5 – 10 mg q3 – 4 hours
        • Oral: time release capsule – q12 hours
narcotics and analgesics8
Narcotics and Analgesics
  • Opioid analgesics – low potency
    • Codeine - (proprietary name – Paveral)
      • Route of administration
        • Oral
          • Analgesic: 15 – 60 mg q3 – 6 hours
          • Antitussive: 10 – 20 mg q4 – 6 hours
        • Intravenous: 15 – 60 mg q4 – 6 hours
        • Intramuscular: 15 – 60 mg q4 – 6 hours
narcotics and analgesics9
Narcotics and Analgesics
  • Opioid analgesics – low potency
    • Diphenoxylate - (proprietary name – Lomotil)
      • Route of administration
        • Oral: 5 mg 3 to 4 times daily initially, then 5 mg once Daily as needed
narcotics and analgesics10
Narcotics and Analgesics
  • Opioid analgesics
    • Action – not completely understood, but affect neurotransmission at specific sites in the CNS, affect autonomic nervous system transmission
narcotics and analgesics11
Narcotics and Analgesics
  • Opioid analgesics
    • Indications
      • Relief of pain
      • Fentanyl used as analgesic supplement to general anesthesia
      • Methadone used as substitute for heroin, etc
narcotics and analgesics12
Narcotics and Analgesics
  • Opioid analgesics
    • Side effects and hazards
      • Hypotension
      • Transient hyperglycemia
      • Depression of respiratory system
      • Cough reflex decreased
      • Nausea and vomiting
narcotics and analgesics13
Narcotics and Analgesics
  • Opioid analgesics
    • Contraindications
      • Hypersensitivity/allergy to agent
      • Head trauma
narcotics and analgesics14
Narcotics and Analgesics
  • Opioid analgesics
    • Route of administration
      • Oral (PO)
      • Intravenous (IV)
      • Intramuscular (IM)
      • Subcutaneous (SubQ)
narcotic antagonists
Narcotic Antagonists
  • Action
    • Competitive replacement of narcotic from receptor site
  • Indication
    • Reversal of the effects of a narcotic
    • http://www.youtube.com/watch?v=U1frPJoWtkw
narcotic antagonists1
Narcotic Antagonists
  • Partial antagonists
    • Side effects
      • Cause narcotic-like effects in absence of a narcotic
      • Increased respiratory depression in non-narcotic overdose
narcotic antagonists2
NarcoticAntagonists
  • Partial antagonists
    • Nalorphine - (proprietary name – Nalline)
      • Route of administration
        • Initial dose: IV 5 to 10 mg
        • IV drip: 5 to 10 mg in 5% glucose solution
narcotic antagonists3
Narcotic Antagonists
  • Partial antagonists
    • Levallorphan - (proprietary name – Lorfan)
      • Route of administration
        • IV 1 mg
        • May be repeated as needed
narcotic antagonists4
Narcotic Antagonists
  • Pure antagonists
    • Does not increase respiratory depression if administered in a non-narcotic overdose
narcotic antagonists5
Narcotic Antagonists
  • Pure antagonists
    • Naloxone - (proprietary name – Narcan)
      • Route of administration
        • Initial dose: 0.4 to 2 mg IV
        • May be repeated at 2 to 3 minute intervals
        • May be given IM or subcutaneously if IV unavailable
sedatives and hypnotics
Sedatives and Hypnotics
  • Causes longer generalized depression of the central nervous system
  • http://www.youtube.com/watch?v=68NagUt9DzY
sedatives and hypnotics1
Sedatives and Hypnotics
  • Anti-anxiety agents
    • Lorazepam - (proprietary name – Ativan) http://www.youtube.com/watch?v=oG-LHYO8ggg
      • Route of administration
        • Oral: 2 to 6 mg/d.
        • Intramuscular: 0.05 mg/kg
        • Intravenous
          • Intermittent dose: 0.02 to 0.06 mg/kg q2 to q6 hours
          • Infusion rate: 0.01 to 0.10 mg/kg/h
sedatives and hypnotics2
Sedatives and Hypnotics
  • Anti-anxiety agents
    • Midazolam - (proprietary name – Versed)
      • Route of administration
        • Intramuscular: 0.07 to 0.08 mg/kg
        • Intravenous (for conscious sedation)
          • Intermittent dose: 0.02 to 0.08 mg/kg q30 minutes to q2 hours
          • Infusion rate: 0.04 to 0.2 mg/kg/hr
sedatives and hypnotics3
Sedatives and Hypnotics
  • Anti-anxiety agents
    • Haloperidol - (proprietary name – Haldol)
      • Oral: 0.5 to 2 mg BID
      • Intramuscular: 2 to 5 mg q4 to q8 hours as needed
      • Intravenous
        • Intermittent dose: 0.03 to 0.15 mg/kg q30 minutes to q6 hours
        • Infusion rate: 0.04 to 0.15 mg/kg/hr
        • Haloperidolis a dopamine inverse agonist of the typical antipsychotic/Schizophrenic/Delerium
sedatives and hypnotics4
Sedatives and Hypnotics
  • Anti-anxiety agents
    • Propofol - (proprietary name – Diprivan)
      • Induction – 40 mg q10 seconds until induction achieved
      • Maintenance – 5 to 80 µg/kg/min
      • http://www.youtube.com/watch?v=i1GdGMOJw4c
sedatives and hypnotics5
Sedatives and Hypnotics
  • Barbiturates
    • Thiopental - (proprietary name – Pentothal)
      • Route of administration
        • Intravenous: 3 to 7 mg/kg
        • Used in some states for lethal injection
sedatives and hypnotics6
Sedatives and Hypnotics
  • Barbiturates
    • Pentobarbital - (Proprietary Name – Nembutal)
      • Route of Administration
        • Oral: 20 mg tid
        • Intramuscular: 150 to 200 mg
        • Intravenous: 50 mg/min (Initial Dose: 100 mg in 70 kg Adult)
sedatives and hypnotics7
Sedatives and Hypnotics
  • Barbiturates
    • Secobarbital - (proprietary name – Seconal)
      • Route of administration
        • Pre-operative sedation: 200 to 300 mg 1 to 2 hours Before surgery
        • At night: 100 mg PO at hs
sedatives and hypnotics8
Sedatives and Hypnotics
  • Barbiturates
    • Amobarbital - (proprietary name – Amytal)
      • Route of administration
        • Intramuscular: 65 to 500 mg; no more than 5 ml in one injection
        • Intravenous: 65 to 500 mg at rate ≤ 1 ml/min
sedatives and hypnotics9
Sedatives and Hypnotics
  • Barbiturates
    • Phenobarbital
      • Route of administration
        • Oral
          • Sedation – 30 to 120 mg/d in two to three divided doses
          • Hypnotic – 100 to 200 mg

barbiturate and the most widely used anticonvulsant worldwide, and the oldest still commonly used

sedatives and hypnotics10
Sedatives and Hypnotics
  • Barbiturates
    • Phenobarbital
      • Route of administration
        • Intramuscular
          • Sedation – 30 to 120 mg 60 to 90 minutes before surgery
          • Hypnotic – 100 to 320 mg
sedatives and hypnotics11
Sedatives and Hypnotics
  • Barbiturates
    • Phenobarbital
      • Route of administration
        • Intravenous
          • Same as intramuscular
sedatives and hypnotics12
Sedatives and Hypnotics
  • Hypnotics
    • Methaqualone - (proprietary name – Quaalude)
      • Route of administration
        • Oral: 75 to 300 mg
        • More common as a street drug
sedatives and hypnotics13
Sedatives and Hypnotics
  • Hypnotics
    • Flurazepam - (proprietary name – Dalmane)
      • Administered orally
        • 15 to 30 mg at hs
        • In geriatric patients, 15 mg initially, but may be increased
sedatives and hypnotics14
Sedatives and Hypnotics
  • Hypnotics
    • Diazepam - (proprietary name – Valium)
      • Route of administration
        • Oral: 2 to 10 mg bid to qid
        • Intramuscular: 2 to 20 mg repeated in three to four hours
        • Intravenous: 0.03 to 0.01 mg/kg q30 minutes to q6 hours
sedatives and hypnotics15
Sedatives and Hypnotics
  • Action
    • Depression of ascending reticular activating system resulting in loss of consciousness
sedatives and hypnotics16
Sedatives and Hypnotics
  • Indications
    • Sleep induction
    • Relief of anxiety
    • Relief of depression
sedatives and hypnotics17
Sedatives and Hypnotics
  • Indications
    • Anticonvulsant
    • Voluntary muscle relaxation
sedatives and hypnotics18
Sedatives and Hypnotics
  • Side effects
    • Drowsiness
    • Impaired performance and judgment
    • Potential for abuse
    • Hangover effect
sedatives and hypnotics19
Sedatives and Hypnotics
  • Contraindications
    • Hypothyroidism
    • Hypoadrenalism
sedatives and hypnotics20
Sedatives and Hypnotics
  • Routes of administration
    • Oral (PO)
    • Intravenous (IV)
    • Intramuscular (IM)
    • Subcutaneous (SubQ)
diuretic agents
Diuretic Agents
  • Osmotic diuretics are solutes that oppose the passive movement of water during sodium transport. The rapid loss of sodium and water occurs by inhibiting their reabsorption in the proximal tubule. These low-molecular-weight substances create an opposing osmotic force and contribute to a decreased fluid reabsorption and increased urine volume. Osmotic diuretics also cause sodium excretion to increase because of significant back diffusion. Because water reabsorption is inhibited and sodium transport is occurring, a sodium concentration gradient develops. As a result of the high concentration gradient back diffusion occurs.
  • Alteration of the re-absorption of water within the nephron system
slide77

http://www.youtube.com/watch?v=6Wc4f2KnbYo

  • http://www.youtube.com/watch?v=JJAMYHAwCMs&feature=related
classification of diuretics
Classification of Diuretics
  • Osmotic diuretics
    • Interfere with the water re-absorption in the descending loop of Henle and in the proximal tubule
    • Used to treat or prevent acute renal failure
classification of diuretics1
Classification of Diuretics
  • Osmotic diuretics
    • Mannitol
      • Route of administration - IV
        • Reduction of intracranial pressure – 1.5 to 2 g/kg as a 15% to 25% solution over 30 to 60 minutes
mannitol
Mannitol
  • Mannitol is used to reduce acutely raised intracranial pressure until more definitive treatment can be applied, e.g., after head trauma. It is also used to treat patients with oliguric renal failure. It is administered intravenously, and is filtered by the glomeruli of the kidney, but is incapable of being resorbed from the renal tubule, resulting in decreased water and Na+ reabsorption via its osmotic effect. Consequently, mannitol increases water and Na+ excretion, thereby decreasing extracellular fluid volume.
  • Mannitol can also be used as a facilitating agent for the transportation of pharmaceuticals directly into the brain.
classification of diuretics2
Classification of Diuretics
  • Carbonic anhydrase inhibitors
    • Prevent re-absorption of sodium and bicarbonate ions in the proximal tubule
    • Weak agents used to lower intraocular pressure in glaucoma
carbonic anhydrase inhibitors
Carbonic anhydrase inhibitors
  • suppress the activity of carbonic anhydrase. Their clinical use has been established as antiglaucoma agents, diuretics, antiepileptics, in the management of mountain sickness, gastric and duodenal ulcers, neurological disorders, or osteoporosis
classification of diuretics3
Classification of Diuretics
  • Carbonic anhydrase inhibitors
    • Acetazolamide (proprietary name – Diamox)
      • Route of administration - orally
        • Diuresis in CHF – 250 to 375 mg (5 mg/kg) qd in the morning
        • May be used for severe metabolic alkalosis
classification of diuretics4
Classification of Diuretics
  • Carbonic anhydrase inhibitors
    • Methazolamide - (proprietary name – Neptazane)
      • Route of administration - orally
        • Reduction of intraocular pressure – 50 to 100 mg bid
classification of diuretics5
Classification of Diuretics
  • Loop diuretics
    • Inhibit absorption of chloride ions in the ascending loop of Henle
    • Used to treat hypertension, acute CHF, chronic renal failure, ascites
classification of diuretics6
Classification of Diuretics
  • Loop diuretics
    • Furosemide - (proprietary name – Lasix)
      • Route of administration - orally or IV
        • Acute pulmonary edema – 40 mg IV over 1 to 2 minutes
lasix
Lasix
  • Furosemide, a 'water pill,' is used to reduce the swelling and fluid retention caused by various medical problems, including heart or liver disease. It is also used to treat high blood pressure. It causes the kidneys to get rid of unneeded water and salt from the body into the urine.
lasix1
Lasix
  • The tendency, as for all loop diuretics, to cause low potassium levels (hypokalemia) has given rise to combination products, either with potassium itself (e.g. Lasix-K) or with the potassium sparing diuretic of amiloride
classification of diuretics7
Classification of Diuretics
  • Loop diuretics
    • Furosemide
      • Administered orally
        • Chronic edema – 20 to 80 mg/d PO initially; may be given q6 to q8 hrs
        • Hypertension – 40 mg PO bid
classification of diuretics8
Classification of Diuretics
  • Loop diuretics
    • Ethacrynic acid - (proprietary name – Edecrin)
      • Administered orally or IV
        • Edema – initial dose of 50 to 100 mg/d PO; 0.5 to 1.0 mg/kg IV administered slowly over several minutes
classification of diuretics9
Classification of Diuretics
  • Thiazide diuretics
    • Block sodium and chloride ion re-absorption in the distal tubule
    • Used to treat hypertension and CHF
classification of diuretics10
Classification of Diuretics
  • Thiazide diuretics
    • Chlorothiazide - (proprietary name – Diuril)
      • Administered orally or IV
        • Edema – 0.5 to 2.0 g PO or IV qd to bid
        • Hypertension – 0.5 to 2 g/d PO; IV not recommended
classification of diuretics11
Classification of Diuretics
  • Thiazide diuretics
    • Chlorthalidone - (proprietary name – Thalitone)
      • Administered orally
        • Edema – 50 to 100 mg/d PO
        • Hypertension – 25 – 100 mg/d based on patient response
classification of diuretics12
Classification of Diuretics
  • Thiazide diuretics
    • Hydrochlorothiazide - (proprietary name – HydroDiuril)
      • Administered orally
        • Edema – 25 – 200 mg qd PO
        • Hypertension – 12.5 – 50 mg PO initially; 25 – 100 mg qd maintenance
classification of diuretics13
Classification of Diuretics
  • Thiazide diuretics
    • Methyclothiazide - (proprietary name – Enduron)
      • Administered orally
        • Edema – 2.5 – 10 mg qd PO
        • Hypertension – 2.5 – 5 mg qd PO
classification of diuretics14
Classification of Diuretics
  • Potassium sparing diuretics
    • Block sodium re-absorption in the distal tubule and collecting duct
    • Used to treat chronic liver disease and in CHF to counteract the hypokalemic effects of other diuretics
classification of diuretics15
Classification of Diuretics
  • Potassium sparing diuretics
    • Spironolactone - (proprietary name – Aldactone)
      • Administered orally
        • Edema – 100 – 200 mg/d PO
        • Essential hypertension – 50 – 100 mg/d PO
classification of diuretics16
Classification of Diuretics
  • Potassium sparing diuretics
    • Triamterene - (proprietary name – Dyrenium)
      • Administered orally
        • Diuresis – 100 mg bid PO
classification of diuretics17
Classification of Diuretics
  • Indications
    • Used for diuresis in patients with excessive fluid such as with congestive heart failure, hypertension, and acute and chronic renal failure
classification of diuretics18
Classification of Diuretics
  • Side effects
    • Hypokalemia
    • Acid-base alterations
    • Hyperglycemia
steroids
Steroids
  • A class of hormonal agents produced naturally by the body to regulate various metabolic functions; artificially produced versions are used to mimic the normal agents
steroids1
Steroids
  • Actions
    • In the context of the ICU, prevention or suppression of inflammatory responses caused by hypersensitivity
    • Decrease capillary permeability in edema
steroids2
Steroids
  • Indications
    • Presence of allergic or non-allergic inflammatory response
      • Asthma
      • Chronic obstructive pulmonary disease
steroids3
Steroids
  • Indications
    • Suppression of immune response in organ transplant patients
steroids4
Steroids
  • Side effects from systemic administration
    • Cushing’s disease
      • Moon face
      • Hirsutism
      • Muscle wasting
      • Hypokalemia
steroids5
Steroids
  • Side effects from systemic administration
    • Hypertension
    • Atrophy of the adrenal glands
    • Obesity
    • Suppression of growth
steroids6
Steroids
  • Side effects from systemic administration
    • Thinning of skin
    • Osteoporosis
    • Immunosuppression
    • Masks infection
steroids7
Steroids
  • Hydrocortisone
    • (proprietary names – Cortaid, Aquacort)
    • Routes of administration – oral, topical, intramuscular, intravenous
      • Intramuscular & intravenous: 100 to 500 mg initially, then q 2 to q10 hours
steroids8
Steroids
  • Cortisone
    • (proprietary name –
    • Cortone)
    • Routes of administration
      • Oral: 25 to 300 mg/d
      • Intramuscular: 20 to 330 mg/d
steroids9
Steroids
  • Prednisone
    • Route of administration
      • Oral: initial dose variable depending upon severity of symptoms; maintenance dose of 5 to 60 mg/d PO
solu medrol
Solu-Medrol
  • Potent IV steroid for COPD/Asthma exacerbations
  • 40, 125, 500 mg doses
anti thrombotic agents
Anti-Thrombotic Agents
  • Anti-coagulant agents
    • Action
      • Potentiates the inhibitory effect of anti-thrombin on Factor Xa and thrombin
      • Prevents the conversion of fibrinogen to fibrin
      • http://www.youtube.com/watch?v=ac_om5HCjvg&feature=related
anti thrombotic agents1
Anti-Thrombotic Agents
  • Anti-coagulant agents
    • Indications
      • Prophylaxis and treatment of thrombo-embolic disorders
      • (Pulmonary emboli, stroke, MI…)
anti thrombotic agents2
Anti-Thrombotic Agents
  • Anti-coagulant agents
    • Side effects
      • Excessive bleeding
      • Hypersensitivity
      • http://www.youtube.com/watch?v=Lt0BjNwF6IU
anti thrombotic agents3
Anti-Thrombotic Agents
  • Anti-coagulant agents
    • Heparin
      • Route of administration
        • Intravenous
          • Bolus – 10,000 units
          • Continuous infusion – 20,000 to 40,000 units infused over 24 hours
anti thrombotic agents4
Anti-Thrombotic Agents
  • Anti-platelet agents
    • Action
      • Inhibits platelet aggregation
    • Indications
      • Reduction of risk of myocardial infarction, stroke, and peripheral vascular disease
      • Artrial fibrillation
slide120

The most important antiplatelet drugs are:

  • Cyclooxygenase inhibitors
    • Aspirin
  • Adenosine diphosphate (ADP) receptor inhibitors
    • Clopidogrel (Plavix)
    • Prasugrel (Effient)
    • Ticagrelor (Brilinta)
    • Ticlopidine (Ticlid)
anti thrombotic agents5
Anti-Thrombotic Agents
  • Anti-platelet agents
    • Side effects
      • Increased risk of bleeding
      • Safety not established in pregnancy
anti thrombotic agents6
Anti-Thrombotic Agents
  • Anti-platelet agents
    • Clopidogrel - (proprietary name – Plavix)
      • Route of administration
        • Oral
          • Daily – 75 mg PO
          • Acute coronary syndrome – 300 mg initially, then 75 mg once daily
anti thrombotic agents7
Anti-Thrombotic Agents
  • Anti-platelet agents
    • Acetylsalicylic Acid - (proprietary name – Aspirin)
      • Route of administration
        • Oral: for prevention of myocardial infarction – 300 to 325 mg/d; dosage as low as 80 mg/d may be effective
anti thrombotic agents8
Anti-Thrombotic Agents
  • Thrombolytic agents
    • Action
      • Converts plasminogen to plasmin, which is then able to degrade fibrin in clots
anti thrombotic agents9
Anti-Thrombotic Agents
  • Thrombolytic agents
    • Indications
      • Acute myocardial infarction
      • Massive pulmonary embolism
      • Deep vein thrombosis
      • Acute ischemic stroke
anti thrombotic agents10
Anti-Thrombotic Agents
  • Thrombolytic agents
    • Side effects
      • Intracranial hemorrhage
      • Bleeding
anti thrombotic agents11
Anti-Thrombotic Agents
  • Thrombolytic agents
    • Streptokinase - (proprietary name – Streptase)
      • Route of administration – intravenous
        • Myocardial infarction – 1.5 million units IV
        • Deep vein thrombosis, pulmonary emboli – 250,000 units loading dose, then 100,000 units/hr for 24 hours