treating hemodynamic disturbances and threats to tissue oxygenation: a review of commonly used...
TRANSCRIPT
![Page 1: Treating Hemodynamic Disturbances and Threats to Tissue Oxygenation: A Review of Commonly Used PIC/NIC Medications Julie Warren RN, MSN, CCRN Pediatric](https://reader036.vdocument.in/reader036/viewer/2022062409/56649d765503460f94a574a7/html5/thumbnails/1.jpg)
Treating Hemodynamic Disturbances and Threats to
Tissue Oxygenation:
A Review of Commonly Used PIC/NIC Medications
Julie Warren RN, MSN, CCRNPediatric CNS
4/2013-Current
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Intravenous Infusion GuidelinesIntravenous Infusion Guidelines
• Most hemodynamic drugs have a rapid onset and are almost all given intravenously
• Understand how long it will take for new dose to clear IV tubing containing an old dose: Don’t “treat” the line, treat the patient!
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Alteration in the Autonomic Nervous System Responses
• Contractile state = inotropy
• Heart rate = chronotropy
• Speed of conduction = dromotropy
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Inotropes• An increased intracellular calcium concentration
is the central cellular event that enhances contractility of the myocardium
• Inotropes work in one of two ways:– Stimulate receptors to increase cAMP (cyclic
adenosine monophosphate) which ultimately increases intracellular calcium
– Inhibit phosphodiesterase (PDE) which then increases cAMP
• Digitalis glycosides also enhance contractility but don’t use the cAMP “route”
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Increasing Cardiac Strength
• Use of inotropes and preload reducers
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Dopamine: Dopamine: • Dose varies based on intent:
• 0.5-2 mcg/kg/min: renal perfusion/diuresis• 2-5 mcg/kg/min: increased contractility and
C.O. (little HR inc)• 5-6 mcg/kg/min: HR and BP increase plus
increased C.O.• 10-20 mcg/kg/min: increased SVR/BP and
HR
• Primary side effects:• tachycardia• increased myocardial oxygen consumption
(MVO2)
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Dobutamine• Improves contractility followed by CVP,
SVR, PVR• Dose:
• 2-5 mcg/kg/min to start• Maximum effects at 10-15 mcg/kg/min• Max dose not known
• Primary side effects:• tachycardia• increased myocardial oxygen consumption
(MVO2)• potential hypotension• arrhythmias
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• Dose varies based on intent:– 0.05-0.3 mcg/kg/min: Improves contractility and
C.O. through peripheral vasodilation, HR, SVR, PVR– 0.01-1mcg/kg/min: for asystole or pulseless
arrest– > 0.3 mcg/kg/min: SVR and BP; but
vasoconstricts renal arteries• Primary side effects:
• tachycardia• increased myocardial oxygen consumption (MVO2)• arrhythmias• hypertension• CNS excitation: restlessness/dread/fear
Epinephrine:
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Norepinephrine • Its hemodynamic effects limit its use in
pediatrics almost exclusively to treatment of septic shock; used to improve vascular tone after numerous boluses and other inotropes fail
• Dose varies based on intent:• 0.05-0.1 mcg/kg/min: Sharp in SVR;
improves contractility and C.O.if the increase in afterload can be tolerated
• 1-2 mcg/kg/min maximum• Primary side effects:
• profound hypertension• ischemic injury of the extremities• CNS excitation: restlessness/dread/fear
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Milrinone (Primacor) • A Bipyridine that works as a
Phosphodiasterase (PDE) inhibitor/ “Inodilator”
• Increases cAMP content for an inotropic effect with reduced O2 demand
CO, SV, SVR, PVR, CVP• Mix in NS or 5% Dextrose• Dose:
– Loading dose of 50 mcg/kg over 10 minutes – 0.275-0.75 mcg/kg/min infusion
• Side Effects: hypotension and arrhythmias
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RECEPTOR LOCATIONS PRIMARY ACTION
ALPHA-ADRENERGICAlpha 1
Vascular smooth muscleArterioles and venules
Increases intracellular CA++; Muscle contraction; Constriction; Inhibits
insulin secretion
Alpha 2 Presynaptic nerve terminals Decreases cAMP; Inhibits norepi release;
vasodilation; Negative chronotropy (HR)
BETA ADRENERGICBeta 1
Heart innervation:SA nodeAV node
Increases contractility;Increases heart rate;Increases automaticity;
Increases cAMP;Enhances renin secretion
Beta 2 Vascular smooth muscleArterioles and venules
Pulmonary smooth muscle
Dilation; RelaxationIncreases cAMP; Bronchodilation;
Enhanced glucagon secretion
DOPAMINERGIC Vascular smooth muscle:renal, coronary, mesenteric
Dilation
Review of Receptor Sites
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Agent Dose
(mcg/kg/min)
Peripheral Vascular Effects
Alpha(+) = ConstrictingBeta 2 (-) = Dilating
Cardiac Effects
Beta 1 (+) = ↑contractilityBeta 2 (+) = ↑contractility
Alpha (+)
Beta 2 (-) DA Beta 1 Beta 2
Dopamine 2-5 0 0 2+ 0 0
5-10 0 2+ 2+ 1-2+ 2+
> 10 2-3+ 0 0 1-2+ 2+
Dobutamine 2-10 1+ 2+ 0 3+ 1-2+
Epinephrine 0.05-0.1 1-2+ 1-2+ 0 2-3+ 2+
Norepinephrine 0.05-0.5 3+ 0 0 2+ 0
Effects of Commonly Used Inotropes
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DiureticsDiuretics
• Furosemide– Dose 1-2 mg/kg q 6-12 hrs, given at max rate of 0.5
mg/kg/min; If larger doses required (>120 mg), the infusion rate should not exceed 4 mg/min
• Can dilute to 1-2 mg/ml and give over 10-15 mins
– Continuous IV infusion:• 0.05 mg/kg/hr titrated for clinical effectiveness
• Side Effects:– Hypovolemia/hypotension– Hypokalemia/hyponatremia/hypochloremia– Ototoxicity– Metabolic alkalosis
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Other DiureticsOther Diuretics
Spirinolactone 1-3 mg/kg/day PO
Ethacrinic Acid 1 mg/kg/dose diluted to concentration of 1 mg/ml infused over 20-30 mins
Bumetanide (Bumex)
Neonates:0.01-0.05 mg/kg/dose q 24-48 hrs Infants/kids: 0.015-0.1 mg/kg/dose q 6-24 hrs (max 10 mg/day)
Metolazone (Zaroxolyn)
0.2-0.4 mg/kg/day PO
Chlorothiazide
20 mg/kg/day po in two divided doses; Infants up to 6 mos: 40mg/kg/day PO
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Cautions with DiureticsCautions with Diuretics
• Used cautiously in patients who are hypotensive– due to potential to further reduce BP
• Can cause fluid and electrolyte abnormalities– altered potassium and magnesium– dehydration/hypovolemia
• Urine output is not always a reliable method of estimating preload reduction
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Afterload Reducers
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Nitroprusside (Nipride)Nitroprusside (Nipride)• Balanced vasodilator: equal effects on venous and arterial
circulation– If SVR is not elevated, SV and CO/CI decline and BP is reduced; HR
increases as result– When SVR is high and contractility is depressed, the reduction in preload
and afterload result in increased SV and CO/CI; the increase in SV is proportional to the decrease in SVR; HR declines and BP is unchanged
• Dose: Given in 5% Dextrose- bag and tubing must be opaque or covered
• 0.5 mcg/kg/min starting dose• 1.5-2 mcg/kg/min usually reduce SVR; highest dose is 10 mcg/kg/min• very rapid onset of action; effects stop 3 mins after infusion d/c’d
• Side Effects:– byproduct of breakdown is NO and cyanide (toxic)
• use only for short periods (< 72 hrs)• measure cyanide levels by measuring lactate levels• hypotension
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Afterload Reducers• The other key afterload reducer is
Milrinone• Nitroglycerine is rarely used in children• Calcium channel blockers rarely used:
– Nifedipine has been tried in hypertensive emergencies and to treat patients with hypertrophic cardiomyopathy (BP lowering effect in kids is not predictable however)
– Diltiazem-has emerged as an effective agent for SVT and atrial fib/flutter
• ACE inhibitors: Captopril/Enalopril – Also reduce preload
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Other Key Drugs• Digoxin (increases contractility and has antiarrhythmic
properties)
• Antiarryhthmics– Adenosine (SVT)– Procainamide (SVT/JET/atrial ectopic tachycardia)– Lidocaine (Vtach/Vfib)– Amiodorone (Vtach/Vfib)– Esmolol (tachyarrhythmias)– Sotalol (refractory SVT/VT)
• Triiodothyronine (T3) -increases CO/decreases SVR
• Ca++ (increases contractility)
• Nesiritide /Natrecor (diuretic/natriuretic/vasodilator)
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Other Key Drugs• Pulmonary Bed Vasodilators:
– Oxygen– Prostaglandins (also dilates PDA)– iNO – Prostacyclins:
• Epoprostenol (Flolan)– Endothelin Receptor Antagonists:
• Bosentan (Tracleer)– Phosphodiesterase Inhibitors:
• Sildenafil (Viagra) - oral
• Pulmonary Bed Vasoconstrictors: – Nitrogen– CO2
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Miscellaneous Drugs
• Insulin Infusions for DKA: Refer to DKA Protocol
• Heparin infusions: Refer to Heparin Protocol (pilot)
• Propofol/Diprivan: Short term use only!!!!
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Nursing Responsibilities in Checking Drips
• At the start of each shift, you must check each pump for the correct infusion rate and medication - calculate the rate, don’t trust the pump!
• For each new medication infusion order or rate change, you must manually calculate the drip rate and have it independently double-checked by a second nurse
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Let’s Shift Gears:
Drip Calculations
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Calculating Drips
• Two methods can be used:
– Use / memorize formulas and plug in your numbers
– Use conversion ratios: extremely useful if you forget formulas! Plus, there isn’t a formula for everything we calculate
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Calculating Drips• Try to remember that there is more than one
step. With either method, start with what you know– You will need to know the patient’s weight in
kilograms (# lbs divided by 2.2)– You will need the # milligrams of medication in the
solution– You will need the amount of solution in milliliters
(ml’s)– You will need to know the infusion rate ordered
(mcg/kg/min)
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Calculation: Example #1
• Epi drip is ordered at .05 mcg/kg/min
• Pt weighs 4.1 kg
• Your epi syringe comes labeled .064 mg/ml
• How fast do you run the pump (ml/hr)?
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Calculation: Example #1• Use/ memorize the formula:
cc/hr = (mcg/kg/min) x (60 mins) x (wt in kg) syringe/drip concentration in mcg
• Fill in the “knowns” and do the math:
cc/hr = (.05) x (60) x (4.1) = 12.3 = .19 cc/hr
64 64
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Calculation: Example #2
• Dopamine drip ordered at 5 mcg/kg/min
• Pt weighs 11 kg• Your dopamine syringe comes
labeled 80 mg/ 50ml• How fast do you run the pump
(ml/hr)?
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Calculation: Example #2A• Use/memorize the formula:
cc/hr = (mcg/kg/min) x (60 mins) x (wt in kg)syringe/drip concentration in mcg
• Fill in the “knowns” and do the math:
cc/hr= (5) x (60) x (11) = 3300 = 2.1 cc/hr
1600 1600
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Calculation: Example #2BUse the formula but place the syringe med
concentration in the denominator; if it’s already in mcg you are all set; if it’s in mg, do the math and then move the decimals after you get your answer
cc/hr = (mcg/kg/min) x (60 mins) x (wt in kg)_________________________________________________________________________________________________________________________
syringe/drip concentration in mg
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Calculation: Example #2BThe easiest way??
Med concentration: 80 mg/50 mls= 1.6 mg/ml
cc/hr= (5) x (60) x (11) = 3300 = 2062______________________________________________________________ _____________
1.6 1.6
Now move the decimal because the denominator was in mg not mcg
Answer: 2.062 or 2.1 cc/hr
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What if you know the infusion rate but don’t know the mcg/kg/min?
• This calculation is used when you need to work the other way: you’ve been titrating or weaning your drip (turning the rate up/down) or a patient comes to you from the O.R. or from outside transport
• Use the following formula and plug in pump rate, pt wt, and drip concentration:
mcg/kg/min= (rate) x (*drip concentration) (pt wt) x (60)
* in mcg/ml
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Using Conversion Ratios When All Else Fails
• Set up equivalent formulas from what you know such as:– 1 lb = 2.2 kg– 1 mg = 1000 mcg– 1 hour= 60 mins
• Set up your equation so that numerators cancel out with denominators and what you want to find out is set up correctly (cc/hr not hr/cc).
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A Conversion Ratio Example
• 1 gorp = 2.2 burps• 1 dweeb = 1000 mini dweebs• 1 jerp = 60 flibs• 10 burps = 1000 mini dweebs• 6 dweebs= 5 flibs
• How many jerps would you have if you had 20 gorps?
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Start with what you have and what you want
• Have 20 gorps ? Jerps• Set up your conversion ratios so that units cancel
out correctly:
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Let’s Try An Easy One
• Ativan ordered to be given: 1.25 mg
• It comes as 2 mg /ml
• Another nurse has drawn up 0.75 ml and asks you to check his/her math
• Did he/she draw up the correct amount?
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Using Conversion Ratios
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Let’s try using Conversion Ratios with our Epi example
from earlier• Epi drip ordered at .05 mcg/kg/min• Pt weighs 4.1 kg• Epi syringe comes labeled .064
mg/ml• How fast should you set you pump?
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Start with what you have and what you want
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Let’s try Milrinone
• Ordered dose is .5 mcg/kg/min• Pharmacy sends you 50 cc of
Milrinone in a 60 cc syringe labeled 20 mg/100 ml
• Your patient weighs 14 kg• What rate do you set your
pump???
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Using Conversion Ratios
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Let’s see if our Milrinone rate is correct using the “formula”
cc/hr = (mcg/kg/min) x (60 mins) x (wt in kg)*syringe/drip concentration in mcg
• Convert the syringe/drip concentration to mcg/ml:
* 20 mg/100 ml = .2 mg/ml= 200 mcg/ml
• Fill in the “knowns” and do the math:
cc/hr= (.5) x (60) x (14) = 420 = 2.1 cc/hr
200 200
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Now You Try!!
• Your patient is receiving Fentanyl at 1.3 ml/hr
• The syringe is mixed 500 mcg in 50 cc
• How many mcg/hr is your patient receiving?
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Another One!• You’ve just come on duty to find your
patient is on a dobutamine drip at 10cc/hr. You want to check the dose/rate against the original order.
• Your pt weighs 20 kg
• The dobutamine syringe reads “50 mg in 50 cc D5W”
• How many mcg/kg/min is the dobutamine currently infusing at?
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Propofol
• Ordered mcg/kg/min as an infusion
• Ordered mg/kg as incremental doses
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Precedex (mcg/kg/hr)
• Use the following formula:
cc/hr = (dose ordered in mcg/kg/hr) x (wt in kg)
syringe/drip concentration: mcg/ml
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Precedex
• Dose ordered: 0.2mcg/kg/hr • Pt weight: 12 kg• Syringe concentration is: 4 mcg/ml
• How fast would you run the pump?• If you needed to titrate the drip- What
would the rate be for 0.3mcg/kg/hr?• 0.4mcg/kg/hr?
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Almost Done!!• A new “experimental drug” has just been
approved for use on your patient following approval by the IRB
• Drug “x” is mixed as 20 units in a 50 cc syringe
• You are to infuse this new drug at a rate of 3 units/kg/hr
• Your pt weighs 5 kg
• How fast do you set your pump???
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Last One!!!!!!
• You’ve just received an order to begin dopamine at 10 mcg/kg/min
• Your pt weighs 22 lbs
• Pharmacy sends you a syringe labeled “40 mg in 50cc”
• What rate do you set your pump at???